Intradiscal Therapies for Discogenic Pain

ABSTRACT

Since the first injection of chymopapain in 1963, percutaneous intradiscal therapies have been used to treat discogenic back and leg pain. The percutaneous discectomy techniques treat contained disc herniations not by resecting the prolapsed disc material but rather through central decompression of the disc. By removing a small volume of tissue from the disc nucleus, a large reduction in overall disc pressure is achieved with consequent relief of neural compression. DISC Nucleoplasty™ and Dekompressor™ are the two leading percutaneous discectomy technologies currently. Although rigorous clinical testing of their efficacy is ongoing, there has now been a 40-year history confirming the concept of percutaneous disc decompression, and initial results are very promising. Discogenic low back pain can also arise from annular tears and other forms of internal disc derangement (IDD). Annuloplasty techniques, such as IntraDiscal Electrothermal Therapy (IDET™) and discTRODE™, have been developed over the past decade that thermally treat the lesions of IDD. Although the therapeutic mechanisms of thermal annuloplasty have yet to be fully elucidated, research studies demonstrate that the procedure can be effective for appropriately selected patients with degenerative disc disease characterized by discographically proven painful annular fissures. Other novel intradiscal therapies are emerging for percutaneous treatment of discogenic pain and await more widespread clinical evaluation.

KEYWORDS

Discogenic pain - disc herniation - annular tear - percutaneous discectomy - Nucleoplasty - annuloplasty - Coblation - IDET - Dekompressor

REFERENCES

• 1 Maroon J C. Current concepts in minimally invasive discectomy.  Neurosurgery. 2002;  51(5 Suppl) S137-S145
• 2 Simmons J W, Nordby E J, Hadjipavlou A G. Chemonucleolysis: the state of the art.  Eur Spine J. 2001;  10 192-202
• 3 Nordby E J, Javid M J. Continuing experience with chemonucleolysis.  Mt Sinai J Med. 2000;  67 311-313
• 4 Onik G M, Helms C. Nuances in percutaneous discectomy.  Radiol Clin North Am. 1998;  36 523-532
• 5 Case R B, Choy D S, Altman P. Chance of intradisc pressure versus volume change.  J Clin Laser Med Surg. 1995;  13 143-147
• 6 Singh V, Piryani C, Liao K, Nischulz S. Percutaneous disc decompression using Coblation (Nucleoplasty™) in the treatment of chronic discogenic pain.  Pain Physician. 2002;  5 250-259
• 7 Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K. The natural history of herniated nucleus pulposus with radiculopathy.  Spine. 1996;  21 225-229
• 8 Carragee E J, Han M Y, Suen P W, Kim D. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence.  J Bone Joint Surg Am. 2003;  85 102-108
• 9 Choy D S, Case R B, Fielding W, Hughes J, Liebler W, Ascher P. Percutaneous laser nucleolysis of lumbar disks.  N Engl J Med. 1987;  317 771-772
• 10 Lau E, Date E, Kim B J, Lee S H, Tran D, Lehman N L. An experimental safety study in nucleoplasty (percutaneous disc decompression via coblation)-thermo-mapping in human cadavers. Presented at International Spinal Injection Society, Annual Meeting August 2003 Orlando, FL;
• 11 Chen Y, Lee S H, Lehmen N, Saenz Y. Histology of Disc, Endplate and Neural Elements Post Coblation of Nucleus: An Experimental Nucleoplasty Study. Presented at NASS Meeting of the Americas II April 2002 New York, NY;
• 12 Stadler K R, Woloszko J, Brown I G, Smith C D. Repetitive plasma discharges in saline solutions.  Appl Phys Lett. 2001;  79 4503-4505
• 13 Chen Y, Lee S H, Chen D. Intradiscal pressure study of disc decompression with nucleoplasty in human cadavers.  Spine. 2003;  28 661-665
• 14 Sharps L S, Isaac Z. Percutaneous disc decompression using Nucleoplasty^® .  Pain Physician. 2002;  5 121-126
• 15 Castro W H, Jerosch J, Hepp R et al.. Restriction of indications for automated percutaneous discectomy based on CT discography.  Spine. 1992;  167 1239-1243
• 16 Onik G M, Helms C. Nuances in percutaneous discectomy.  Radiol Clin North Am. 1998;  36 523-532
• 17 Simmons J W, Stavinoha W B, Knodel L C. Update and review of chemonucleolysis.  Clin Orthop Relat Res. 1984;  183 51-60
• 18 Nordby E J. Long term results. In: Brown JE, Nordby EJ, Smith L Chemonucleolysis. Slack Inc Thorofare, NJ; 1985: 217-220
• 19 Mansfield F, Polivy K, Boyd R et al.. Long term results of chymopapain injections.  Clin Orthop Relat Res. 1986;  206 67-69
• 20 Gogan W J, Fraser R D. Chymopapain. A ten-year double-blind study.  Spine. 1992;  17 388-394
• 21 Benoist M, Bonneville J F, Lasalle B et al.. A randomized double-blinded study to compare low-dose with standard-dose chymopapain in the treatment of herniated lumbar intervertebral discs.  Spine. 1993;  18 28-34
• 22 Onik G, Maroon J, Helms C et al.. Automated percutaneous diskectomy: initial patient experience. Work in progress.  Radiology. 1987;  162 129-132
• 23 Revel M, Payan C, Vallee C et al.. Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica. a multicenter trial.  Spine. 1993;  18 1-7
• 24 Chatterjee S, Foy P M, Findlay G F. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation.  Spine. 1995;  20 734-738
• 25 Bonaldi G. Automated percutaneous lumbar discectomy: technique, indications and clinical follow-up in over 1000 patients.  Neuroradiology. 2003;  45 735-743
• 26 Choy D S. Percutaneous laser disc decompression (PLDD): twelve years experience with 752 procedures in 518 patients.  J Clin Laser Med Surg. 1998;  16 325-331
• 27 Chen Y, Lee S H, Chen D. Intradiscal pressure study of disc decompression with nucleoplasty in human cadavers.  Spine. 2003;  28 661-665
• 28 O'Neill C, Lotz J, Liu J et al.. Percutaneous plasma discectomy stimulates repair in injured porcine intervertebral discs.  Spine J. 2004;  4 88-98
• 29 Sharps L S, Isaac Z. Percutaneous disc decompression using Nucleoplasty.  Pain Physician. 2002;  5 121-126
• 30 Singh V, Piryani C, Liao K. Evaluation of percutaneous disc decompression using Coblation in chronic back pain with or without leg pain.  Pain Physician. 2003;  6 273-280
• 31 Slipman C W, Bhat A L, Gilchrist R V et al.. Preliminary results for axial low back pain treated with Coblation: a comparison of patients with and without central focal protrusion.  Eur Spine J. 2002;  11 417 , Abstract
• 32 Singh V, Manchikanti L, Nieschulz S, Piryani C, Liao K. A novel approach in percutaneous disc decompression for back pain. Presented at NASS WorldSpine II August 2003 Chicago, IL;
• 33 Slipman C, Nirschl M, Isaac Z, Gilchrist R, Bhat A. Preliminary data: side effects and complications of lumbar Nucleoplasty. Presented at NASS Spine Across the Sea July 2003 Maui, Kapalua, HI;
• 34 Slipman C W, Bhagia S M, Abd O E, Garvin C. Nucleoplasty procedure for cervical radicular pain-initial case series. Presented at International Spinal Injection Society, Annual Meeting August 2004 Maui, Kapalua, HI;
• 35 Alo K, Wright R, Sutcliffe J, Brandt S. Percutaneous lumbar discectomy: clinical response in an initial cohort of fifty consecutive patients with chronic radicular pain.  Pain Pract. 2004;  4 19-29
• 36 Crock H V. Internal disc disruption. A challenge to disc prolapse fifty years on.  Spine. 1986;  11 650-653
• 37 Lee K S, Doh J W, Bae H G, Yun I G. Diagnostic criteria for the clinical syndrome of IDD.  Br J Neurosurg. 2003;  17 19-23
• 38 Schwarzer A, Aprill C, Derby R et al.. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.  Spine. 1995;  20 1878-1883
• 39 Lam K S, Carlin D, Mulholland R C. Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source.  Eur Spine J. 2000;  9 36-41
• 40 Saal J A, Saal J S. Intradiscal electrothermal therapy for the treatment of chronic discogenic low back pain: a prospective outcome study with minimum 1-year follow-up.  Spine. 2000;  25 2622-2627
• 41 Wall M S, Deng X H, Torzilli P, Doty S, O'Brien S, Warren R F. Thermal modification of collagen.  J Shoulder Elbow Surg. 1999;  8 339-344
• 42 Karasek M, Bogduk N. Intradiscal electrothermal annuloplasty: percutaneous treatment of chronic discogenic back pain.  Tech Reg Anesth Pain Manage. 2001;  5 130-135
• 43 Cosman E R, Nashold B, Ovelman-Levitt J. Theoretical aspects of radiofrequency lesions in the dorsal root entry zone.  Neurosurgery. 1984;  15 945-950
• 44 Kleinstueck F, Diederich C, Nau W, Puttlitz C, Smith J, Bradford D, Lotz J. Acute biomechanical and histologic effects of intradiscal electrothermal therapy on human lumbar discs.  Spine. 2001;  26 2198-2207
• 45 Finch P M. The use of radiofrequency heat lesions in the treatment of lumbar discogenic pain.  Pain Pract. 2002;  2 235-240
• 46 Kleinstueck F S, Diederich C J, Nau W H et al.. Temperature and thermal dose distributions during intradiscal electrothermal therapy in the cadaveric lumbar spine.  Spine. 2003;  28 1700-1709
• 47 Brandt S A, Vilims B D, Bailey D, Wright R E. Formulation and implementation of the Radionics DiscTRODE annuloplasty protocol.  Pain Physician. 2002;  5 468-469
• 48 Pauza K, Howell S, Dreyfuss P et al.. A randomized, placebo controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain.  Spine J. 2004;  4 27-35
• 49 Karasek M, Bogduk N. Twelve-month follow up of controlled trial of intradiscal electrothermal annuloplasty for back pain due to internal disc disruption.  Spine. 2000;  25 2601-2607
• 50 Derby R, Eck B, Chen Y et al.. Intradiscal electrothermal annuloplasty (IDET): a novel approach for treating chronic discogenic back pain.  Neuromodulation. 2000;  3 69-75
• 51 Saal J A, Saal J S. Intradiscal electrothermal treatment for chronic discogenic low back pain-a prospective study with minimum 1-year follow-up.  Spine. 2000;  25 2622-2627
• 52 Freedman B A, Cohen S P, Kuklo T R, Lehman R A, Larkin P, Giuliani J R. Intradiscal electrothermal therapy (IDET) for chronic low back pain in active-duty soldiers: 2-year follow-up.  Spine J. 2003;  3 502-509
• 53 Davis T T, Delamarter R B, Sra P, Goldstein T B. The IDET procedure for chronic discogenic low back pain.  Spine. 2004;  29 752-756
• 54 Andreula C, Muto M, Leonardi M. Interventional spine procedures.  Eur J Radiol. 2004;  50 112-119
• 55 Andreula C F, Simonetti L, de Santis F, Agati R, Ricci R, Leonardi M. Minimally invasive oxygen-ozone therapy for lumbar disk herniation.  AJNR Am J Neuroradiol. 2003;  24 996-1000
• 56 Derby R, Eek B, Lee S H, Seo K S, Kim B J. Comparison of intradiscal restorative injections and intradiscal electrothermal treatment (IDET) in the treatment of low back pain.  Pain Physician. 2004;  7 63-66
• 57 Simmons J W, McMillin J N, Emery S F, Kimmich S J. Intradiscal steroids: a prospective double-blind clinical trial.  Spine. 1992;  17 S172-S175
• 58 Duquesnoy B, Debiais F, Heuline A et al.. Unsatisfactory results of intradiscal injection of triamcinolone hexacetonide in the treatment of sciatica caused by intervertebral disk herniation [in French].  Presse Med. 1992;  21 1801-1804
• 59 Khot A, Bowditch M, Powell J, Sharp D. The use of intradiscal steroid therapy for lumbar spinal discogenic pain: a randomized controlled trial.  Spine. 2004;  29 833-837
• 60 Aoki M, Kato F, Mimatsu K, Iwata H. Histologic changes in the intervertebral disc after intradiscal injections of methylprednisolone acetate in rabbits.  Spine. 1997;  22 127-131
• 61 Privat J M, Finiels P. Neurosurgical treatment of complications of intra-disk injections of triamcinolone hexacetonide. Value of a radio-clinical classification [in French].  Neurochirurgie. 1997;  43 212-219