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.
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Intradiscal procedures current evidence
1. Treating Chronic Back Pain: New Knowledge, More Choices
MBBS, MD (Anesthesiology), FIPP
Director. Interventional Pain and Spine Centre
New Delhi ,India
www.ipscindia.com
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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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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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
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
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
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
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
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