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Intradiscal procedures current evidence


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Percutaneous discectomy is a minimally invasive surgical procedure that treats contained, herniated discs. Specific procedures within the class include: manual percutaneous lumbar discectomy, Automated percutaneous lumbar discectomy (APLD) laser discectomy and nucleoplasty percutaneous intradiscal radiofrequency thermocoagulation is a procedure that allows the controlled delivery of heat to the intervertebral disc via an electrode or coil.

Published in: Health & Medicine

Intradiscal procedures current evidence

  1. 1. Treating Chronic Back Pain: New Knowledge, More Choices MBBS, MD (Anesthesiology), FIPP Director. Interventional Pain and Spine Centre New Delhi ,India
  2. 2.  Normal Architecture of the Disc Pathophysiology of Disc related pain Intradiscal Procedures for  Discogenic pain  Herniated disc
  3. 3. INTERVERTEBRAL DISC Nucleous Pulposus Irregular network of collagen fibers type II (viscocity) > type I and elastin fibers Proteoglycans( Agrrecan)-Osmotic properties to resist compression
  4. 4. ANNULUS FIBROSUS Callagen fibers type I (Thickness) > type II Runs oblique in alternating direction ---Tensile strength Also contains some proteoglycans and Elastin fibers
  5. 5. END PLATE Approx 1 mm thick Considered part of disc rather than body Made up of hyaline cartilage mostly (young) and fibrocartilage (old) The collagen fibers of the inner 2/3rds of the annulus form the fibro cartilaginous component of the VEP
  6. 6. LUMBAR INTERVERTEBRAL DISC - NERVE INNERVATION  Outer 1/3rds of the annulus circumferentially  Posterior plexus - Sinuvertebral nerves stems from Rami Communicans  Anterior plexus formed by bridging of sympathetic trunks and the proximal ends of the GRCs
  7. 7. BLOOD SUPPLY ANDNUTRITION Capillaries arise in Vertebral body Diffusion O 2 and glucose Penetrates Subchondral Bone Lactic acid Terminates at Vertebral End Plates
  8. 8. PathophysiologyDisc Degeneration –Internal Disc Disruption- Discogenic pain- Disc Herniation
  9. 9. Pathophysiology-Disc Degeneration Decrease in end plate Permiability Failure of nutrient supply & Accumulation of waste Low p H Injury
  10. 10. -DISCDEGENERATION  Loss of Proteoglycan & collagen and degradation  Fall in osmotic pressure of disc matrix No longer behaves  hydrostatically under load  Loose height and fluid more rapidly  Stress concentration along End plates and Annulus
  12. 12. PATHOPHYSIOLOGY- INTERNAL DISC DISRUPTION  Normal Disc – Pressure evenly distributed along end plates and annulus • Degenerated disc – Uneven stress across End plates and annulus –Fissures and Tear
  13. 13. INTERNAL DISCDISRUPTION  Annular tear and fissures
  14. 14. PATHOPHYSIOLOGY-DISCOGENIC PAIN Only outer 1/3 is innervated Now the whole disc can feel
  15. 15. RISK FACTORS –DISCDEGENERATION Age: Vascular changes e.g. Atherosclerosis End Plate changes e.g. calcification Sub cortical sclerosis Genetic factors : Aggrecan gene polymorphism
  16. 16. RISKFACTORS Life style: Prolonged sitting Lack of Exercise Obesity Smoking Smoking and IVD Degeneration .Spine 1991: Sep; 16(9): 1015-21 Sally Roberts, Jill P.G. Urban
  17. 17. Aging of Disc Degeneration of Disc• Affects Nucleous • Annulus & End plates• Increased proteoglycan • Concentric or radial tear in the fragmentation and water annulus, Inwards buckling of content is decreased annulus & radial bulging of outer annulus• Nucleus is gradually • Endplate defects & vertical replaced by collagen bulging of endplates into the fibers. adjacent vertebral bodies.• Disc height is maintained. • Reduced disc height• Look black on T2 • Look black on T2 weighted weighted image of MRI image of MRI
  18. 18. Investigations Plain Radiographs
  19. 19. C T SCAN •The vacuum disc phenomenon •Loss of disc height. •Secondary findings of disc degeneration, Endplate sclerosis Osteophyte formation
  20. 20. MRI Test of Choice  Architecture of Disc  Disruption of endplates  Secondary changes  Herniation
  21. 21. MRI HIZ Fibrovascular ingrowth into region of Annular tear The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J. 2005 Jul 27
  22. 22. MRI MODIC CHANGES SECONDARY TO DISC DEGENERATION Type- I  Low signal in T1-weighed sequences and high signal in T2)---edema. Type II  High signal in T1-weighed sequences and either high or intermediate signal in T2) ---fatty replacement Type III  Low signal in T1 and low signal in T2--sclerotic changes.
  23. 23. FACET ARTHROPATHY SECONDARY TO DISCMRI DEGENERATION  Disc bears 80% of weight  Facet joints bears 20 % of weight A change in the intervertebral disc produces Change in the whole motion segment
  24. 24. MRI  Ligamental Buckling Degenerative Changes – Intraspinal Ligaments
  25. 25. GRADES OF DISCDEGENERATION Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration SPINE Volume 26, Number 17, pp 1873–1878
  26. 26. MODIFIED PFIRRMANN GRADINGSYSTEM- 8 GRADES Modified Pfirrmann Grading System for Lumbar Intervertebral Disc Degeneration Spine: 15 November 2007 - Volume 32 - Issue 24 - pp E708-E712
  27. 27. Intradiscal Procedures
  30. 30. PROVOCATIVE DISCOGRAPHY-DERBY’S CLASSIFICATION-PAIN PROVOCATION ANDDISCOMETRY  Pain @ <15 psi - chemically sensitive  Pain @ 15-50 psi - mechanically sensitive  Pain @ 51-90 psi - intermediate  Pain @ >90 psi - normal disc  No Pain - normal disc
  31. 31. POST DISCOGRAPHY CT SCAN-(3RDSTEP)MODIFIED DALLAS GRADES Site and Extent of Tear  Grade 0 – Normal disc, cotton ball appearance  Grade 1 – Radial tear upto inner 1/3 of AF  Grade 2 – Radial tear upto middle 1/3 of AF  Grade 3 – Radial tear upto outer 1/3 of AF, but extends < 30 degrees of disc circumference  Grade 4 – Radial tear upto outer 1/3 of AF & extends > 30 degrees of disc circumference  Grade 5 – Radial tear with extra-annular leakage into epidural space. Disc stimulation + Discography = Provocative Discography Step 1 and 2 Step 3
  32. 32. Interventions for Discogenic pain Contained Disc HerniationLevel of Description ImplicationsEvidence1A + RCT’s( good quality) . Benefit >> Risk1B + RCT’s(methodological weakness). Benefit >> Positive Risk Recommendations2B + RCT’s(methodological weakness). Benefit > Risk Level of Evidence2B + RCT’s(methodological weakness). Considered Contradictory results2C + Observational Studies. No conclusive evidence0 Case reports. Insufficient evidence Only study related2C - Observational studies- no effectiveness Negative
  33. 33. IDET Indication  Mild to moderate Degeneration  Absent radicular symptom  Positive discogram  1week-IDET Contraindication  Large disc herniation  Canal stenosis  Disc height loss > 50% Mechanism of Action  strengthen the collagen fibers,  Seal fissures,  denature inflammatory exudates, or coagulate nociceptors
  34. 34. Temperature- 65 degree to 90 degree 16 min Nerve fiber damageStabilization of fissures
  35. 35.  Saal JS, Saal JA. Management of chronic discogenic low back pain with a thermal intradiscal catheter: a preliminary report. Spine. 2000;25:382-8 Freeman BJ, Fraser RD, Cain CM. et al. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005;30:2369-77 Nunley PD, Jawahar A, Brandao SM. et al. Intradiscal electrothermal therapy (IDET) for low back pain in workers compensation patients: can it provide a potential answer? Long-term results. J Spinal Disord Tech. 2008;21:11-8
  36. 36. POSTERIOR ANNULOPLASTY Electrodes (Disctrode) – Placed in Posterior Annulus
  37. 37. NUCLEOPLASTYORRF COBLATION  Bipolar radiofrequency probe  Coblation (molecular dissociation) technology to ablate tissue  Thermal energy for coagulation Perc-D Spine Wand •125 V of Energy •60-70 degree (Courtesy of Arthrocare Spine, Sunnyvale, CA.)
  38. 38. NUCLEOPLASTYORRF COBLATION  Indication  Discogenic pain with contained disc herniation (No prospective randomized controlled studies for purely Discogenic pain)  Contraindication  Extruded disc  Disc herniation >33 % of sagittal diameter of spinal canal
  39. 39. BIACUPLASTY Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for the treatment of Lumbar Discogenic Pain. PainPractice J. 2007;7:130–135.
  40. 40. Insufficient number of studies about its efficacy andsafety the preliminary findings show that this methodwas effective and safe.Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) forthe Treatment of Lumbar Discogenic Pain. Pain Practice.2007;7:130-4Kapural L, Ng A, Dalton J. et al. Intervertebral disc biacuplasty for thetreatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med. 2008;9:60-7
  41. 41. Intradiscal Injections INTRADISCAL STEROID • Prevent Inflammatory cascade • Modic Type – I •Eur Spine J (2007) 16:925–931 Buttermann GR (2004) The effect of spinal steroid injections for Degenerative disc disease. Spine J 4:495–505
  42. 42. Intradiscal Injections METHYLENE BLUE • Weak Neurolytic effect • Inhibition of Guanylate Cyclase and NO synthesis PAIN: Volume 149, Issue 1 , Pages 124-129, April 2010
  43. 43. Intradiscal Injections INTRADISCAL OZONE  Anti-inflammatory properties  Primary Indicaction is Radicular Pain. Eur J Radiol 2009 Dec; 72(3) :499-504.
  45. 45. INDICATIONS OF PERCUTANEOUSMECHANICAL DISC DECOMPRESSION Unilateral leg pain greater than back pain. Radicular symptoms in a specific dermatomal distribution that correlates with MRI findings. Positive straight leg raising test or positive bowstring sign, or both. No improvement after 6 weeks of conservative therapy. Imaging studies (CT, MRI, discography) indicating a subligamentous contained disc herniation. Well maintained disc height of 60%.
  46. 46. PERCUTANEOUS DISC DECOMPRESSION  Rotating probe is inserted through needle into the disc under X-Ray/ Fluoroscopic guidance  Rotating tip removes small portion of disc material.  Because only enough of the disc is removed to reduce pressure inside the disc, the spine remains stable.
  47. 47. NUCLEOTOMY  The herniation suctioned toward the probe where an integrated knife then cuts it away from the disk. The material is then suctioned away
  48. 48. HYDRODISCECTOMY Cutting with water fluidJet technology  uses the Venturi Effect created by high velocity saline jets to cut and aspirate targeted tissue
  49. 49. OZONE DISCECTOMY/ OZONUCLEOLYSIS  It’s action is due to the active oxygen atom (singlet oxygen) liberated from it.  It attaches with the proteo-glycan bridges in the nucleus pulposus.  They are broken down and they no longer capable of holding water.  As a result disc shrinks and mummified and there is decompression of nerve roots.
  50. 50. Regenerative Therapies  Glucosamine and chondrointin sulphate- Enhance the Repair response of chondrocytes and retard the enzymatic degradation of cartilage.  Cell based Therapies Stimulate the disc cell to produce matrix Direct injection of Growth factor/ Cytokine inhibitor- Unsuccessful Gene of interest is introduced into target cell  Nucleous Pulposus augmentation Injectable Nucleous –Solution of Protein polymer and crosslinking agent
  51. 51.