Intradiscal procedures current evidence
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Treating Chronic Back Pain: New Knowledge, More Choices
MBBS, MD (Anesthesiology), FIPP Director. Interventional Pain and Spine Centre
New Delhi ,India
www.ipscindia.com
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Normal Architecture of the Disc
Pathophysiology of Disc related pain
Intradiscal Procedures for
Discogenic pain Herniated disc
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INTERVERTEBRAL DISC
Irregular network of collagen fibers type II (viscocity) > type I and elastin fibers
Proteoglycans( Agrrecan)-Osmotic properties to resist compression
Nucleous Pulposus
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ANNULUS FIBROSUSANNULUS FIBROSUS
Callagen fibers type I (Thickness) > type II
Runs oblique in alternating direction ---Tensile strength
Also contains some proteoglycans and Elastin fibers
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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
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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
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BLOOD SUPPLY AND NUTRITION
Capillaries arise in Vertebral body
Penetrates Subchondral Bone
Terminates at Vertebral End Plates
Diffusion
O 2 and glucose
Lactic acid
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Pathophysiology
Disc Degeneration –Internal Disc Disruption- Discogenic pain- Disc Herniation
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Decrease in end plate Permiability
Failure of nutrient supply&
Accumulation of waste
Low p H
Injury
Pathophysiology-Disc Degeneration
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PATHOPHYSIOLOGY-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 Annuluswww.ipscindia.com
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INTERNAL DISC DISRUPTION
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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
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INTERNAL DISC DISRUPTION
Annular tear and fissures
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PATHOPHYSIOLOGY-DISCOGENIC PAIN
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Only outer 1/3 is innervated
Now the whole disc
can feel
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RISK FACTORS –DISC DEGENERATION
Age:Vascular changes e.g. AtherosclerosisEnd Plate changes e.g. calcificationSub cortical sclerosis
Genetic factors :
Aggrecan gene polymorphism
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RISK FACTORS
Smoking and IVD Degeneration .Spine 1991: Sep; 16(9): 1015-21
Sally Roberts, Jill P.G. Urban
Life style:Life style:
Lack of ExerciseObesity
Smoking
Prolonged sitting
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Aging of Disc Degeneration of Disc
• Affects Nucleous
• Increased proteoglycan fragmentation and water content is decreased
• Nucleus is gradually replaced by collagen fibers.
• Disc height is maintained.
• Look black on T2 weighted image of MRI
• Annulus & End plates
• Concentric or radial tear in the annulus, Inwards buckling of annulus & radial bulging of outer annulus
• Endplate defects & vertical bulging of endplates into the adjacent vertebral bodies.
• Reduced disc height
• Look black on T2 weighted image of MRI
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Plain Radiographs
Investigations
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C T SCAN
•The vacuum disc phenomenon
•Loss of disc height.
•Secondary findings of disc degeneration, Endplate sclerosis
Osteophyte formation
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MRI
Test of Choice
Architecture of Disc Disruption of endplates Secondary changes Herniation
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HIZ
MRI
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
Fibrovascular ingrowth into region of Annular tear
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MODIC CHANGES SECONDARY TO DISC DEGENERATION
MRI
Type III Low signal in T1 and low signal
in T2--sclerotic changes.
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
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FACET ARTHROPATHY SECONDARY TO DISC
DEGENERATION
Disc bears 80% of weight Facet joints bears 20 % of weight
A change in the intervertebral disc producesChange in the whole motion segment
MRI
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Ligamental Buckling Degenerative Changes –Intraspinal Ligaments
MRI
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GRADES OF DISC DEGENERATION
Magnetic Resonance Classification of Lumbar Intervertebral Disc DegenerationSPINE Volume 26, Number 17, pp 1873–1878
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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
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Intradiscal Procedures
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DISCOGRAPHY
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DISCOGRAPHY -3 COMPONENTS
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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
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POST DISCOGRAPHY CT SCAN-(3RD STEP)MODIFIED DALLAS GRADES
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.
Site and Extent of Tear
Disc stimulation + Discography = Provocative DiscographyStep 1 and 2 Step 3
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Interventions for Discogenic pain Contained Disc Herniation
Level of Evidence
Level of Evidence
Description Implications
1A + RCT’s( good quality) . Benefit >> Risk
1B + RCT’s(methodological weakness). Benefit >> Risk
Positive Recommendations
2B + RCT’s(methodological weakness). Benefit > Risk
2B + RCT’s(methodological weakness). Contradictory results
Considered
2C + Observational Studies. No conclusive evidence
0 Case reports. Insufficient evidence Only study related
2C - Observational studies- no effectiveness Negative Recommendations
2B - RCT’s –No effectiveness. Benefit << Risk
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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
IDET
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Nerve fiber damage
Stabilization of fissures
Temperature- 65 degree to 90
degree
16 min
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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
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POSTERIOR ANNULOPLASTY
Electrodes (Disctrode) – Placed in Posterior Annulus
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NUCLEOPLASTY OR RF COBLATION
Bipolar radiofrequency probe Coblation (molecular
dissociation) technology to ablate tissue
Thermal energy for coagulation
•125 V of Energy•60-70 degree
Perc-D Spine Wand
(Courtesy of Arthrocare Spine, Sunnyvale, CA.)
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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
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BIACUPLASTY
Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for the treatment of Lumbar Discogenic Pain. PainPractice J. 2007;7:130–135.
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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
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INTRADISCAL STEROID
•Eur Spine J (2007) 16:925–931Buttermann GR (2004) The effect of spinal steroid injections for Degenerative disc disease. Spine J 4:495–505
• Prevent Inflammatory cascade
• Modic Type – I
Intradiscal Injections
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METHYLENE BLUE
• Weak Neurolytic effect
• Inhibition of Guanylate Cyclase and NO synthesis
Intradiscal Injections
PAIN: Volume 149, Issue 1 , Pages 124-129, April 2010
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INTRADISCAL OZONE
Anti-inflammatory properties
Primary Indicaction is Radicular Pain.
Intradiscal Injections
Eur J Radiol 2009 Dec; 72(3) :499-504.
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INTRADISCAL PROCEDURES FOR DISC PROLAPSE
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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%.
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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.
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NUCLEOTOMY
The herniation suctioned toward the probe where an integrated knife then cuts it away from the disk. The material is then suctioned away
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HYDRODISCECTOMY
Cutting with water fluidJet technology uses the Venturi Effect created by high velocity
saline jets to cut and aspirate targeted tissue
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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.
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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 matrixDirect 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
Regenerative Therapies
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