Percutaneous techniques offer effective pain relief

Treatment of back pain and disc herniation is becoming more successful and effective with minimally invasive techniques. As back pain is considered by many doctors, surgeons and radiologists to be one of the major medical conditions that affects people worldwide, it is not surprising that new techniques and less invasive procedures are becoming more popular with not only the medical professional, but also the patient.

At the recent CIRSE meeting, Professor Afshin Gangi from the Department of Radiology, University Hospital in Strasbourg, France, gave a presentation discussing interventional radiology (IR) treatments for disc and facet joint diseases and related problems. He identified a number of IR techniques, including percutaneous laser and radiofrequency (RF) disc decompression, and facet joint injection, that are currently used to treat chronic diseases of the spine, such as discogenic sciatic pain and facet syndrome.

Gangi commented that 100,000 patients per year suffer from discogenic sciatic pain in France alone, with 37,000 surgical interventions performed. Until now, treatment options have been limited. Historically, open surgery has been used to treat sciatica, by removing part of the intervertebral disc to provide 'decompression' and relieve the pressure of the disc on adjacent nerve roots. Disc decompression surgical techniques have advanced and now the entire decompression can be performed interventionally.

Percutaneous techniques
Image guided surgery, involving such modalities as CT fluoroscopy and MRI, has offered new indications in IR for treating back pain. Commonly, discography is performed to view and assess the internal structure of a disc and determine if it is a source of pain. The results of discography can be used to plan treatment options.

"The interventional radiologist with an efficient imaging guided technique (for example, CT-guidance), can increase the precision of the procedures allowing an improvement of the results and reduction of the complications," said Gangi.

In his presentation, Gangi discussed the various percutaneous techniques related to the treatment of low back pain. These can be divided into those techniques that are designed to ablate disc material and therefore decompress the disc, or those that are designed to alter the biomechanics of the disc annulus. The former category includes percutaneous laser disc nucleotomy, and most recently disc decompression using radiofrequency (RF) energy, referred to as nucleoplasty. Techniques that alter the biomechanics of the disc include annuloplasty.

Epidural injections
Epidural/periradicular steroid injections can reduce the inflammation in the target area and relieve pain caused by nerve impingement. According to Gangi, they are helpful, however the pain often recurs if the underlying problem is severe. For acute problems, the only remaining treatments have previously been to surgically remove part of the disc, or to surgically fuse the vertebrae to remove pressure on the disc.

RF nucleoplasty
Percutaneous disc decompression for the treatment of contained herniated discs has been used for almost 40 years, and currently there are a variety of techniques used to decompress discs, which include chemical (eg. ethanol, oxygen-ozone), mechanical (eg. several devices of nucleotomy) and thermal/heat (eg. radiofrequency and laser) methods. According to Gangi, the advantages of such percutaneous techniques are protection of surrounding tissues, no scar, local anaesthesia, outpatient basis and cost. The main disadvantage, as Gangi explained, is that only contained herniations can be treated.

Most recently (since 2000), nucleoplasty, a new, innovative thermal technique has been used to decompress discs. Under fluoroscopic guidance, a small needle is placed into the centre of the desired disc to act as a portal for a wand-like coblation device, eg. SpineWand Company (ArthroCare). The device uses RF energy to both vaporise and remove disc material and seal the channel created by each pass of the wand. These channels decompress the disc and allow for a retraction of any herniation that may be irritating nearby nerve roots. There are a variety of peer reviewed and published studies that have demonstrated both the safety and effectiveness of the procedure (eg Gerszten PC et al 2006 and Erdine S et al 2006). According to studies, it has quickly become a preferred treatment for symptomatic patients with contained herniated discs. However, current data regarding this new technique is insufficient.

Laser nucleotomy
Another PT that Gangi discussed, was laser nucleotomy. Percutaneous Laser Disk Decompression is considered a safe and short procedure for treatment of patients with herniated disc disease. Gangi mentioned that the most critical elements to successful nucleotomy are proper patient selection and correct needle placement. He also compared RF and laser disc decompression, which is seen in Table 1 (bottom of page).