The document discusses chronic back pain treatment, focusing on the pathophysiology of disc-related pain, including internal disc disruption and herniation. It details risk factors for disc degeneration, diagnostic methods like MRI, and various intradiscal procedures such as discography and percutaneous disc decompression. Lastly, it presents interventions for discogenic pain, including therapeutic injections and regenerative therapies, along with their indications and contraindications.

1. Treating Chronic Back Pain: New Knowledge, More Choices
MBBS, MD (Anesthesiology), FIPP
Director. Interventional Pain and Spine Centre
New Delhi ,India
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2.  Normal Architecture of the Disc
 Pathophysiology of Disc related pain
 Intradiscal Procedures for
 Discogenic pain
 Herniated disc

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
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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. 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. 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. BLOOD SUPPLY AND
NUTRITION
Capillaries arise in
Vertebral body Diffusion
O 2 and glucose
Penetrates Subchondral
Bone
Lactic acid
Terminates at Vertebral End
Plates
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8. Pathophysiology
Disc Degeneration –Internal Disc Disruption-
Discogenic pain- Disc Herniation

9. Pathophysiology-
Disc Degeneration
Decrease in end plate Permiability
Failure of nutrient supply
&
Accumulation of waste
Low p H
Injury

10. -
DISC
DEGENERATION
 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
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11. INTERNAL DISC DISRUPTION

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. INTERNAL DISC
DISRUPTION
 Annular tear and fissures

14. PATHOPHYSIOLOGY-
DISCOGENIC PAIN
Only outer 1/3 is
innervated
Now the whole
disc
can feel
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15. RISK FACTORS –DISC
DEGENERATION
Age:
Vascular changes e.g. Atherosclerosis
End Plate changes e.g. calcification
Sub cortical sclerosis
Genetic factors :
Aggrecan gene polymorphism

16. RISK
FACTORS
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. 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. Investigations
Plain Radiographs

19. C T SCAN
•The vacuum disc phenomenon
•Loss of disc height.
•Secondary findings of disc degeneration,
Endplate sclerosis
Osteophyte formation

20. MRI
 Test of Choice
 Architecture of Disc
 Disruption of endplates
 Secondary changes
 Herniation

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. 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. FACET ARTHROPATHY
SECONDARY TO DISC
MRI 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. MRI
 Ligamental Buckling Degenerative Changes –
Intraspinal Ligaments

25. GRADES OF DISC
DEGENERATION
Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration
SPINE Volume 26, Number 17, pp 1873–1878

26. MODIFIED PFIRRMANN GRADING
SYSTEM-
8 GRADES
Modified Pfirrmann Grading System for Lumbar Intervertebral Disc Degeneration
Spine: 15 November 2007 - Volume 32 - Issue 24 - pp E708-E712

27. Intradiscal Procedures

28. DISCOGRAPHY

29. DISCOGRAPHY -3 COMPONENTS

30. PROVOCATIVE DISCOGRAPHY-
DERBY’S CLASSIFICATION-
PAIN PROVOCATION AND
DISCOMETRY
 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. POST DISCOGRAPHY CT SCAN-(3RD
STEP)
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. Interventions for
Discogenic pain Contained Disc
Herniation
Level of Description Implications
Evidence
1A + RCT’s( good quality) . Benefit >> Risk
1B + RCT’s(methodological weakness). Benefit >> Positive
Risk
Recommendations
2B + RCT’s(methodological weakness). Benefit >
Risk Level of Evidence
2B + RCT’s(methodological weakness). Considered
Contradictory results
2C + Observational Studies. No conclusive
evidence
0 Case reports. Insufficient evidence Only study related
2C - Observational studies- no effectiveness Negative

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. Temperature- 65
degree to 90
degree
16 min
Nerve fiber
damage
Stabilization of
fissures

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 worker's compensation patients: can it provide
a potential answer? Long-term results. J Spinal Disord Tech. 2008;21:11-8

36. POSTERIOR ANNULOPLASTY
 Electrodes (Disctrode) – Placed in Posterior
Annulus

37. NUCLEOPLASTY
OR
RF 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. NUCLEOPLASTY
OR
RF 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. BIACUPLAST
Y
Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for the
treatment of Lumbar Discogenic Pain. PainPractice J. 2007;7:130–135.

40. Insufficient number of studies about its efficacy and
safety the preliminary findings show that this method
was effective and safe.
Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for
the Treatment of Lumbar Discogenic Pain. Pain Practice.
2007;7:130-4
Kapural L, Ng A, Dalton J. et al. Intervertebral disc biacuplasty for the
treatment of lumbar discogenic pain: results of a six-month follow-
up. Pain Med. 2008;9:60-7

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. 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. Intradiscal Injections
INTRADISCAL
OZONE
 Anti-inflammatory properties
 Primary Indicaction is Radicular Pain.
Eur J Radiol 2009 Dec; 72(3) :499-504.

44. INTRADISCAL PROCEDURES FOR DISC
PROLAPSE

45. INDICATIONS OF PERCUTANEOUS
MECHANICAL 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. 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. 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. HYDRODISCECTOMY
 Cutting with water fluidJet technology
 uses the Venturi Effect created by high velocity saline
jets to cut and aspirate targeted tissue

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. 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

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