Treatment of intervertebral disc degenerative disease using percutaneous nucleotomy–an overview of less invasive procedures
Background: Less invasive treatment methods for intervertebral disc disease and decompression of neural structures as a consequence of contained disc herniation represent an alternative to surgical procedure. Percutaneus nucleotomy uses a percutaneous approach to the intervertebral disc. The article presents the evolution of numerous procedureds in clinical practice.
Methods: Percutaneous nucleoplasty is a fluoroscopy-guided procedure which enables controlled and safe entrance into the intervertebral disc. The procedure is performed under strict aseptic conditions, using a local anaesthesia with the patient under analgosedation. Based on the principle of therapeutic intradiscal action, the procedures can be divided into three groups: chemical (chemonucleolysis with chimopapain, alcohol, ozone), mechanical (automated percutaneous lumbar discectomy – APLD, arthroscopic discectomy) and thermical methods (laser, radiofrequency ablation, intradiscal electrothermal annuloplasty – IDET, Coblation®).
Results: Percutaneous nucleotomy by the majority of the mentioned procedures results in a therapeutic effect (reduction of pain and decompression of neural structures). Fast recovery represents a major advantage of less invasive treatment.
Conclusions: Less invasive method (nucleotomy using different procedures) represents a successful alternative approach to surgical discectomy. Proper patient selection and safe technique are mandatory in order to achieve a good clinical outcome.
Nachemson A. The lumbar spine: an orthopedic challenge. Spine 1976; 1: 59–7.
Coppes MH, Marani E, Thomeer RT, Groen GJ. Innervation of ‘‘painful’’ lumbar discs. Spine 1997; 22: 2342–9.
Wetzel FT, McNally TA. New directions and interventions: Intradiscal electrothermal annuloplasty to treat chronic discogenic low back pain. Current Opinion in Orthopedics 2002; 13: 172–7.
Buy X, Gangi A. Percutaneous Treatment of Intervertebral Disc Herniation. Semin Intervent Radiol 2010; 27: 148–59.
Long MD. Decision making in lumbar disc disease. Clin Neurosurg 1991; 39: 36–51.
Chen Y, DerbyR, LeeSH. Percutaneous disc decompression in the management of chronic low back pain. Orthop Clin North Am 2004; 35: 17–23.
Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal New Engl J Med 1934; 211: 210–5.
Smith LW. Enzyme dissolution of the nucleus pulposus in humans. JAMA 1964; 187: 137–40.
Nordby EJ, Wright PH, Schofield SR. Safety of chemonucleolysis. Adverse effects reported in the United States, 1982–1991. Clin Orthop 1993; 293: 122–34.
Postacchini F. Management of herniation of the lumbar disc. J Bone Joint Surg 1999; 81: 567–76.
Agre K, Wilson RR, Brim M, McDermott DJ. Chymodiactin postmarketing surveillance. Demographic and adverse experience data in 29,075 patients. Spine 1984; 9: 479–85.
Hall BB, McCulloch JA. Anaphylactic reactions following the intradiscal injection of chymopapain under local anesthesia. J Bone Joint Surg 1983; 65: 1215–9.
Sasaki M, Takahashi T, Miyahara K, Hirose AT. Effects of chondroitinase ABC on intradiscal pressure in sheep: an in vivo study. Spine 2001; 26: 463–8.
Wittenberg RH, Oppel S, Rubenthaler FA, Steffen R. Five-year results from chemonucleolysis with chymopapain or collagenase: a prospective randomized study. Spine 2001; 26: 1835–41.
Das G, Ray S, Ishwarari S, Roy M. Ghosh P. Ozone Nucleolysis for Management of Pain and Disability in Prolapsed Lumber Intervertebral Disc A Prospective Cohort Study. Interv Neuroradiol 2009; 15: 330–4.
Muto M, Avella F. Percutaneous treatment of herniated lumber disc by intradiscal oxygen-ozone injection. Interv Neuroradiol 1998; 4: 279–86.
Muto M, Andreula C, Leonardi M. Treatment of herniated lumbar disc by intradiscal and intraforaminal oxygen-ozone (O2-O3) injection. J Neuroradiol 2004; 31: 183–9.
Buric J, Molino Lova R. Ozone chemonucleolysis in non-contained lumbar disc herniations: a pilot study with 12 months follow-up. Acta Neurochir Suppl 2005; 92: 93–7.
D’Erme M, Scarchilli A, Artale AM, Pasquali Lasagni M. Ozonetherapy in lumbar sciatic pain. Radiol Med 1998; 95: 21–4.
Andreula CF, Simonetti L, De Santis F, Agati R, Ricci R, Leonardi M. Minimally invasive oxygen-ozone therapy for lumbar disk herniation. Am J Neuroradiol 2003; 24: 996–1000.
Paradiso R, Alexandre A. The different outcomes of patients with disc herniation treated either by microdiscectomy, or by intradiscal ozone injection. Acta Neurochir Suppl 2005; 92: 139–42.
Oder B, Loewe M, Reisegger M, Lang W, Ilias W, Thurnher SA. CT-guided ozone/steroid therapy for the treatment of degenerative spinal disease—effect of age, gender, disc pathology and multi-segmental changes. Neuroradiology 2008; 50: 777–85.
Gallucci M, Limbucci N, Zugaro L, Barile A, Stavroulis E, Ricci A, et al. Sciatica: treatment with intradiscal and intraforaminal injections of steroid and oxygen-ozone versus steroid only. Radiology 2007; 242: 907–13.
Wu Z, Wei LX, Li J, Wang Y, Ni D, Yang P, Zhang Y. Percutaneous treatment of non-contained lumbar disc herniation by injection of oxygen-ozone combined with collagenase. Eur J Radiol 2009; 72: 499–504.
Riquelme C, Musacchio M, Mont’Alverne F, Tournade A. Absolut alcohol: Chemonucleolysis of lumbar disc herniation with ethanol. J Neuroradiol 2001; 28: 219–29.
Theron J, Guimaraens L, Casasco A, Sola T, Cuellar H, Courtheoux P. Percutaneous treatment of lumbar intervertebral disk hernias with radiopaque gelified ethanol: a preliminary study. J Spinal Disord Tech 2007; 20: 526–32.
Guarnieri G, de Dominicis G, Muto M. Intradiscal and Intramuscular Injection of Discogel® Radiopaque Gelified Ethanol: Pathological Evaluation The Neuroradiology Journal 2010; 23: 249–52.
Stagni S, de Santis F, Cirillo L, Dall’olio M, Princiotta C, Simonetti L, et al. A minimally invasive treatment for lumbar disc herniation: DiscoGel® chemonucleolysis in patients unresponsive to chemonucleolysis with oxygen-ozone. Interv Neuroradiol 2012; 18: 97–104.
Theron J, Cuellar H, Sola T, Guimaraens L, Casasco A, Courtheoux P. Percutaneous treatment of cervical disk hernias using gelified ethanol. Am J Neuroradiol 2010; 31: 1454–6.
Yasargil MG. Microsurgical operation of herniated lumbar disc. In: Wullenweber R, Brock M, Hamer J, Klinger M, Spoerri O, eds. Advances in Neurosurgery. Berlin, New York: Springer-Verlag; 1977. p. 81–94.
Hult L. The Munkfors Investigation. Acta Orthop Scand Suppl 1954; 16: 5–76.
Hijikata S, Yamgishi M, Makayama T, Oomori K. Percutaneous discectomy. A new treatment method for lumbar disc herniation. J Toden Hosp 1975; 5: 5–13.
Onik G, Helms CA, Ginsburg L, Hoaglund FT, Morris J. Percutaneous lumbar diskectomy using a new aspiration probe. Am J Roentgenol 1985; 144: 1137–40.
Lierz P, Alo KM, Felleiter P. Percutaneous lumbar discectomy using the Dekompressor System under CT-control. Pain Pract 2009; 9: 216–220.
Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti L. Automated percutaneous lumbar discectomy forthe contained herniated lumbar disc: a systematic assessment of evidence. Pain Physician 2009; 12: 601–20.
Shapiro S. Long-term follow-up of 57 patients undergoing automated percutaneous discectomy. J Neurosurg 1995; 83: 31–33.
Eloqayli H, Al-omari M. Percutaneous discectomy: minimally invasive method for treatment of recurrent lumbar disc herniation. Clin Neurol Neurosurg 2012; 114: 871–5.
Hermantin FU, Peters T, Quartararo L, Kambin P. “A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999; 81: 958–65.
Choy DS, Case RB, Fielding W, Hughes J, Liebler W, Ascher P. Percutaneous laser nucleolysis of lumbar disks. N Engl J Med 1987; 317: 771–2.
Yeung A. Considerations for the use of the KTP laser for disc decompression and ablation. State of the Art Reviews. Spine 1993; 7: 67–93.
Hayashi K, Thabit III G, Bogdanske JJ, Mascio LN, Markel MD. The effect of nonablative laser energy on the ultrastructure of joint capsular collagen. Arthroscopy 1996; 12: 474–81.
Cvitanic OA, Schimandle J, Casper GD, Tirman PF. Subchondral marrow changes after laser diskectomy in the lumbar spine: MR imaging findings and clinical correlation. Am J Roentgenol 2000; 174: 1363–9.
Ohnmeiss DD, Guyer RD, Hochschuler SH. Laser discdecompression. The importance of proper patient selection. Spine 1994; 19: 2054–8.
Menchetti PP, Canero G, Bini W. Percutaneous laser discectomy: experience and long term follow-up. Acta Neurochir Suppl 2011; 108: 117–21.
Barendse GA, van Den Berg SG, Kessels AH, Weber WE, van Kleef M. Randomized controlled trial of percutaneous intradiscal radiofrequency thermocoagulation for chronic discogenic back pain: lack of effect from a 90-second 70 C lesion. Spine 2001; 26: 287–92.
Houpt JC, Conner ES, McFarland EW. Experimental study of temperature distributions and thermal transport during radiofrequency current therapy of the intervertebral disc. Spine 1996; 21: 1808–12.
Barendse GA, van Den Berg SG, Kessels AH, Weber WE, van Kleef M. Randomised controlled trial of percutaneous intradiscal radio-frequency thermo-coagulation for chronic discogenic back pain. Lack of effect from a 90-second 70 0C lesion. Spine 2001; 26: 287–92.
Jung YJ, Lee DG, Cho YW, Ahn SH. Effect of intradiscal monopolar pulsed radiofrequency on chronic discogenic back pain diagnosed by pressure controlled provocative discography: a one year prospective study. Ann Rehabil Med 2012; 36: 648–56.
Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective outcome study with minimum 1-year follow-up. Spine 2000; 25: 2622–7.
Wall MS, Deng XH, Torzilli PA, Doty SB, O’Brien SJ, Warren RF. Thermal modification of collagen. J Shoulder Elbow Surg 1999; 8: 339–44.
Cosman ER, Nashold BS, Ovelman-Levitt J. Theoretical aspects of radiofrequency lesions in the dorsal root entry zone. Neurosurgery 1984; 15: 945–50.
Derby REB, Chen Y, O’Neill C, Ryan D. Intradiscal electrothermal annuloplasty: a novel approach for treating chronic discogenic back pain. Neuromodulation 2000; 3: 82–8.
Lee MS, Cooper G, Lutz GE, Lutz C, Hong HM. Intradiscal electrothermal therapy (IDET) for treatment of chronic lumbar discogenic pain: a minimum 2-year clinical outcome study. Pain Physician 2003; 6: 443–8.
Cohen SP, Larkin T, Abdi S. Risk factors for failure and complications of intradiscal electrothermal therapy: a pilot study Spine 2003; 28: 1142–7.
Djurasovic M, Glassman SD, Dimar JR 2nd, Johnson JR. Vertebral osteonecrosis associated with the use of intradiscal electrothermal therapy. A case report. Spine 2002; 27: 325–8.
Hsia AW, Isaac K, Katz JS. Cauda equina syndrome from intradiscal electrothermal therapy. Neurology 2000; 55: 320.
Wegener B, Rieskamp K, Büttner A, Habiyambere V, von Schultze-Pellangahr C, Schaffer V, et al. Experimental evaluation of the risk of extradiscal thermal damage in intradiscal electrothermal therapy (IDET). Pain Physician. 2012; 15: 99–106.
Singh V, Piryani C, Liao K, Nieschulz S. Percutaneous Disc Decompression Using Nucleoplasty–Annual Meeting of the Florida Pain Society; 2001 June 4–6; Miami, USA.
Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician 2006; 9: 139–46.
Chen YC, Lee SH, Saenz Y, Lehman NL. Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: an experimental nucleoplasty study. Spine J 2003; 3: 466–70.
Sharps LS, Issac Z. Percutaneous disc decompression using nucleoplasty. Pain Phys 2002; 5: 121–6.
Kim PS. Nucleoplasty. Tech Reg Anes Pain Manage 2004; 8: 46–52.
Sinan T, Sheikh M, Buric J, Dashti K, Al-Mukhaimi A. Percutaneous coblation nucleoplasty in patients with contained lumbar disc prolapse: 1 year follow-up in a prospective case series. Acta Neurochir Suppl 2011; 108: 107–12.
Sim SE, Ko ES, Kim DK, Kim HK, Kim YC, Shin HY. The results of cervical nucleoplasty in patients with cervical disc disorder: a retrospective clinical stydy of 22 patients. Korean J Pain 2011 Mar; 24: 36–43.
Grewal H, Grewal BS, Patel R. Nonsurgical interventions for low back pain. Prim Care 2012; 39: 517–23.
König V, Eichen PM, Achilles N, Mösges, R. A Systematic Review of RCTs with Nucleoplasty– An Update. Pain Physician 2013; 16: 45–50.
Kallás JL, Godoy BL, Andraus CF, Carvalho FG, Andraus ME. Nucleoplasty as a therapeutic option for lumbar disc degeneration related pain: a retrospective study of 396 cases. Arq Neuropsiquiatr. 2013; 71: 46–50
Halim W, Wullems JA, Lim T, Aukes HA, van der Weegen W, Vissers KC, et al.. The Long term Efficacy and Safety of Percutaneous Cervical Nucleoplasty in Patients with a Contained Herniated Disk. Pain Pract. 2013; 13: 364–71.
Kasch R, Mensel B, Schmidt F, Ruetten S, Barz T, Froehlich S, et al. Disc volume reduction with percutaneous nucleoplasty in an animal model. PLoS One 2012; 7: 50211.
Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, et al. Compregensive review of therapeutic intervenrions in managing chronic spinal pain. Pain Physician 2009; 12: 123–98.
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