The Neuroradiology Journal 22: 108-121, 2009

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A Comparison of Minimally Invasive Techniques in Percutaneous Treatment of Lumbar Herniated Discs A Review G. GUARNIERI, P. VASSALLO, M.G. PEZZULLO*, F. LAGHI*, F. ZECCOLINI, G. AMBROSANIO, R. GALASSO, M. MUTO, R. IZZO Neuroradiology Service, A.O.R.N. A. Cardarelli Hospital; Naples, Italy * Radiology Service, Second University of Naples; Naples, Italy

Key words: percutaneous, chemodiscolysis, chymopapain, nucleus aspiration, O2-O3 intradiscal therapy

SUMMARY – Low back pain is the commonest spine disease causing absence from work in developed countries. Low back pain with classical irradiation along the course of the nerve root affected is more frequently due to disc disease. In 60-80% of patients with herniated disc, radicular symptoms disappear with conservative treatment after about six weeks, the remainder are treated surgically with a 2-6% of incidence of true recurrence of herniation post-intervention and with failed back surgery syndrome in 15% of cases. Recently minimally invasive techniques have developed as “alternative” treatments to surgical intervention. This review aimed to assess the pathogenesis of low back pain caused by lumbar disc hernia as a basis for action of minimally invasive techniques; to illustrate the techniques already used or currently in use, to compare them in technical guidance, indications and complications, exposing for each of them the inclusion/exclusion criteria in enrolling patients and the imaging guide technique of choice. Minimally invasive techniques can be a valuable alternative to traditional surgery with low cost, low risk of complications, easy feasibility, and in the event of failure they do not exclude subsequent surgery.

Low back pain is one of the most common spine diseases and it is the most frequent cause of absence from work in developed countries. Around 80% of adults suffer from low back pain during a lifetime, and 55% suffer from back pain associated with radicular syndrome 1. The most common cause of low back pain with classical irradiation along the nerve root course is disc herniation. The natural history of disc herniation is characterized by a disappearance of clinical symptoms in up to 60% with conservative treatment through simple rest of patients for about six weeks and shrinkage of the disc herniation revealed by CT or MR scans within eight to nine months after the start of back pain 2-4. Surgery is considered the treatment of choice for extruded, migrated and free fragment herniated disk. The success rate in the short-term 108

for such treatment is around 85-90% 5. This percentage drops to around 80% in long-term (more than six months), related to the appearance of surgical failure syndrome (FBSS) characterized by relapse and/or hypertrophic scar with severe symptoms in 20% of cases and with true FBSS in 15% of patients 6. Currently, the incidence of recurrence of hernia in patients who have already undergone surgery is approximately 2-6% 7. The attitude of neurosurgeons has become increasingly less aggressive and in the United States it is estimated that among all patients suffering from back pain/sciatica only 3-4% undergo surgery. In fact, patients with a small or contained herniated disk, without any benefit from simple medical treatment, can be candidates for one of minimally invasive percutaneous techniques, whose outcome, though, depends on

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A Comparison of Minimally Invasive Techniques in Percutaneous Treatment of Lumbar Herniated Discs

the characteristics of hernia itself and on the chosen technique 8. The pathogenesis of low back pain is multifactorial: it is characterized by mechanical causes – nerve root compression – and by associated inflammatory factors 9. Direct mechanical factors are: 1) Direct compression of herniated disk on the spinal ganglion (intra and extra foraminal herniation); 2) Mechanical deformation of the posterior longitudinal ligament and annulus with nociceptor stimulation of the recurrent nerve of Lutschka. Indirect mechanical factors are: – Ischemia due to compression on afferent arterioles and nerve bundle microcirculation (with consequent anoxic demyelination of nerve fibres); – Venous stasis. Neural and perineural inflammation plays an important role in the pathogenesis of pain from a herniated disk, through: – cell-mediated inflammatory reaction to disc protrusion: the nucleus pulposus is formed by proteoglycans immunologically segregated after birth; a herniated fragment may trigger an inflammatory process with autoimmune cellmediated response, led by macrophages. – bio-humoral immunological response, due to: – phospholipase A2 (inflammatory inductor) that produces prostaglandin (PGE2) and leucotrieni from arachidonic acid; – matrix metalloproteinases (MMP-1, MMP2, MMP-3, MMP-9 ) that degrade discal tissue and increase the inflammatory reaction; – IL-1, IL-6,TNF-alfa that cause matrix degradation. Floowing new knowledge on low back pain pathogenesis and FBSS, many specialists, convinced that conservative treatments offers better results than surgery in long-term follow-up, report that only one third of patients with lumbar pain subjected to conservative treatment then resort to surgery have simulated research into minimally invasive techniques to improve clinical outcome 10. They are: 1) Chemodiscolysis with chymopapain. 2) Automated percutaneous lumbar discectomy according to Onik (APLD). 3) Percutaneous laser disc decompression (PLDD). 4) Intradiscal electrothermal therapy (IDET). 5) Percutaneous coablation nucleoplasty. 6) Decompressor percutaneous discectomy. 7) Chemodiscolysis with O2-O3 mixture with

periradicular and periganglionic infiltration. 8) Jellified ethyl alcohol (Discogel ®). The background for a percutaneous discal treatment is: – A correct and complete clinical evaluation to distinguish radicular pain from articular facet syndrome or piriform syndrome and to discern a discal origin from a spinal origin of pain; – Evaluation with instrumental examinations (XR,CT,MR,NM,EMG); – Team work to assess the best treatment. Discussion: Techniques Minimally invasive percutaneous techniques of lumbar herniated disk introduced in clinical practice are: 1) Chemodiscolysis with chymopapain. 2) Automated percutaneous lumbar discectomy according to Onik (APLD). 3) Percutaneous laser disc decompression (PLDD). 4) Intradiscal electrothermal therapy (IDET). 5) Percutaneous coablation nucleoplasty. 6) Dekompressor percutaneous discectomy. 7) Chemodiscolysis with O2-O3 mixture with periradicular and periganglionic infiltration. 8) Jellified ethyl alcohol (Discogel®). Generally, these treatments offer good results with good patient compliance and low costs. They need a short period of hospitalisation and they reduce the occurrence of post-surgical complications like infections or hypertrophic scar tissue, often responsible for recurrence of pain 6-7. The aim of all percutaneous treatments is to reduce the intradiscal pressure in different ways, creating the space required for retropulsion or digestion of the disc. Chemodiscolysis with chymopapain Chemodiscolysis with chymopapain was the first percutaneous technique for treatment of lumbar herniated disc and the first clinical experience performed by Lyman W. Smith 40 years ago. It consists in intra-discal injection of chymopapain, a proteolytic enzyme derived from papaya fruit catalyzing the hydrolysis of proteoglycans in the nucleus pulposus 11. The aim is based on the poor capability of containing the nucleus pulposus during increasing disc pressure: the loss of water in the nucleus due to chymopapain reduces the pressure on the fibrous annulus creating the space required 109

A Comparison of Minimally Invasive Techniques in Percutaneous Treatment of Lumbar Herniated Discs

for disc “retropulsion”. The food and drug administration (FDA) in the USA confirmed the therapeutic use of chymopapain in 1982. This technique is used only for treatment of contained herniated disc to avoid contact of the proteolytic enzyme with the medulla, dural sac and nerve roots. It was very successful in more than 75,000 cases and was considered a valid alternative to surgery. After a long period of application, it is no longer used due to its risks like anaphylactic shock, discitis, post-op back spasm and acute transverse myelitis that can be prevented by a postero-lateral approach 12-13. Automated percutaneous lumbar discectomy (APLD) During the Seventies Hijkata described a new technique: percutaneous hand-made discectomy with a fenestrated probe 14. On the basis of this experience, Onik introduced “automated percutaneous lumbar discectomy” or “nucleodiscal aspiration” in 1985 using an instrument called a “nucleotom” composed of a pneumatic pump working with compressed air, connected to an “aspirating -cutting” probe with an external diameter of 2 mm. The probe is introduced into the disc through a needle 2.5 mm in diameter under fluoroscopic guidance. The nucleus pulposus is aspirated through a lateral window of the probe while a blade, that moves coaxially in the probe, destroys it and allows it to be drained outside. The success rate is about 70-80% with good results 15-19. However, when exclusion criteria are not considered, the percentage of success drops to 49.4% 18. Supporters of this technique believe that it carries fewers risks than percutaneous laser discectomy and intradiscal electrothermal therapy (IDET) 20. When the procedure is not performed correctly it may damage nerve roots or dura tissue. The greatest complication of this procedure is “cauda equina syndrome” characterized by saddle anaesthesia of the perineal region, retention or urine/fecal incontinence and bilateral hyposthenia 21. APLD has now been abandoned. Percutaneous laser disc decompression (PLDD) Daniel S.J. Choy introduced percutaneous laser discectomy during the Eighties. Then, the technique was performed for the first time in 110

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Graz, Austria in February 1986 and the FDA approved its use in clinical practice in 1991. PLDD is performed under local anaesthesia and consists in introducing a soft needle (0.8mm calibre) inside the nucleus pulposus of a herniated disc under fluoroscopic guidance. Once the correct position of the needle has been checked, the operator introduces a thin optical fibre connected to an Nd-Yag laser, a special laser that works with a solid energy source, the yttrium aluminium garnet crystal supplemented with Neodymium (YAG , an acronym that stands for yttrium aluminium and garnet). The operator goes on using the laser on the nucleus pulposus vaporizing the water of a small part of the nucleus pulposus that allows decompression of disc pressure. The action of PLDD is based on the idea that the vertebral disc is a closed hydraulic system composed of the nucleus pulposus, made of water, surrounded by the fibrous annulus. An increasing water content of the nucleus pulposus causes a disproportionate increase in intra-discal pressure. Vaporizing the nucleus pulposus leads to a reduction of intradiscal pressure and determines a repositioning of the extruded nucleus pulposus in its original position 22. The power of the single laser impulse, the number of impulses, the intervals between each impulse and the total power allocated must be identified 23. Over 100.000 patients underwent this percutaneous technique with good results. At 62 months follow-up Choy showed good results (78.4%) for 261 out of 333 patients who had undergone percutaneous laser discectomy and an immediate reduction of back pain in 160 patients (48%) 24. Literature data report the outcome of this technique successfully in 75% to 87% of cases 23-25. However, the high temperature created by the laser can cause pain and spasms in patients after surgery and is responsible for a high rate of complications 26. Septic and aseptic discitis is the most common complication, with an average recurrence of 0% to 1.2% of cases 27-31. Septic discitis is caused by inoculation of microorganisms during positioning of the needle into the disc. The indispensable condition to prevent this occurrence is to perform the treatment in a sterile environment. Aseptic discitis is caused by the action of the laser itself on the disc and on the adjacent vertebral plate 32. Other uncommon complications are intestinal perforation, cauda equina syndrome, nerve root lesion with consequent impairments that depend on its function

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Figure1 A-C Fluoroscopy control of correct position of electrothermic catheter (IDET) in the disk L4-L5.

. PLDD has evolved and been modified during years and other authors have used new types of lasers, such as: – HO: YAG laser, composed of crystals of YAG (yttrium aluminium garnet) and holmium as the active solid; – KTP laser (potassium-titanium –phosphate, with wavelength of emission of 532 nm); – laser diode (980 nanometres).

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The use of this laser source (Diode 980nm) and of a different kind of optic fibres allows the operator to concentrate the highest power without heat dissipation in surrounding tissues, as occurred in the past. However, there are no blinded or random studies currently available, so there is still no evidence to evaluate the efficacy and safety of one type of laser compared to another 34. 111

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Figure 2 A-D CT at level L5-S1. A-C) Percutaneous coablation nucleoplasty of L5-S1 by postero-lateral approach. D) Control of L5-S1 after percutaneous coablation nucleoplasty.

Intradiscal electrothermal therapy (IDET) IDET is a minimally invasive technique for therapy of low back pain of discal origin, invented by Saal et Al. in 1997. It is indicated in percutaneous treatment of bulging disc or contained herniated disc, as it occurs in young people with positional low back pain or among people with relaxed ligaments. IDET acts on the posterior aspect of fibrous annulus, unlike other techniques that act on nucleus pulposus. It consists in introducing a needle under fluoroscopic guidance into the intervertebral disc that has to be treated. Through the needle, an electrothermic flexible catheter is introduced around the periphery between the nucleus pul112

posus and the annulus. The tip of the catheter has a resistance that, once placed near the posterior margin of the annulus, is warmed at 90° for 16-17 minutes and is then removed (figure 1 A-C). The warming of the fibrous annulus is believed to reduce the symptoms and stabilizes the discal lesion through the reorganization of the collagen fibres, strengthening of the disc, the lesion of ring fissures and the ablation of pain receptors 35. Reports published in the literature on this technique are controversial 36. Pauza et Al 37 evaluated the therapeutic effects of intradiscal electrothermal therapy on pain of discal origin in a randomized trial showing an improvement of pain symptoms in the majority of treated patients. However in the follow-up at six months

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only 40% of patients had a reduction of symptoms of over 50%. Saal 38-40 published their experience with patients who underwent IDET with a follow-up after six, 12 and 24 months reporting a resolution of pain in 71% of cases. Our own analysis from 1998 to 2005 showed that IDET causes a mean reduction of pain of about 2.9 points measured on the visual analogue scale (VAS), and determines a mean improvement in physical activity of an average 21.1 points related to SF -36, an improvement of disability of 7.0 points related to the Oswestry disability index (ODS). The mean incidence of complication was 0.8% and the complication with the poorest prognosis and the highest frequency is osteonecrosis post IDET 41. Percutaneous coablation nucleoplasty Percutaneous coablation nucleoplasty was approved in 1999. It is another minimally invasive technique indicated for treating symptomatic herniated and not extruded disc. This technique is performed at low temperatures (50-70°) unlike traditional radiofrequency that uses high temperatures (150-200°), obtaining the same results in a shorter time (2-3’ versus 15-17’). It is less invasive and carries lower risks for patients than traditional radiofrequency (figure 2 A-D). Radiofrequency ablation with radiofrequency is done by percutaneous introduction under fluoroscopic guidance of a thermic coagulator (Perc-D coablation Probe) in the nucleus pulposus. By application of a bipolar current on the extremity of an electrode it produces a radiofrequency field that breaks collagen bonds in the area it reaches. It creates “an ionic plasma” inside the nucleus that contains simple molecules and ionized gases like O2, H, NO that are removed through the needle used to introduce the electrode. The warmth produced does not exceed 70° and it has a limited diffusion of 2 mm, creating a channel of thermic lesion in the nucleus pulposus. By a manual 360° rotation of the probe for six times, without any other movements of in or outside, it creates six channels of thermic lesion with a rapid dehydration of the nucleus and a following reduction of disc volume of 1020%. The subsequent contraction of the collagen fibres allows the reduction of the protruded portion with decompression of the compressed root 42. An essential condition is the integrity of the fibrous annulus, otherwise the mecha-

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nism of retraction cannot occur. The physical principle for this technique is that of a closed hydraulic system. An intervertebral disc is like a closed hydraulic system where even a small material removal causes a high decrease of internal hydraulic pressure. Results obtained from control trials report the resolution of pain symptoms in 70% of cases with a duration of pain relief for at least six months 43. The risk of complications is very low. The main complications are discitis, anterior disc perforation caused by the probe, and cauda equina syndrome 44-45. This technique has also been extended to cervical disc protrusion. Bonaldi reported a good or excellent outcome in 80% of cases in a series of 55 patients with herniated disc, nerve root compression symptoms and myelopathy at two to six months after treatment with an incidence of discitis of one out of 55 46. Decompressor percutaneous discectomy Discectomy was improved with the introduction of the Dekompressor probe (1.5 mm) that effectively removes the nucleus pulposus of the intervertebral disc through a tiny canal. This technique is performed under CT or fluoroscopic guidance and in local anaesthesia. The patient is in prone position. A scan is done at the level of the disc to be treated. The skin is sterilized and a discography is done through the probe introduced at the level of herniation. After a small cut, the coaxial 17G trocar is introduced at the level of the disc needing treatment; this trocar can be curved manually if the access is difficult, especially when the herniated disc is at level L5-S1. The decompressor probe (Struker, Kalamazoo, Mi, USA) is introduced through the coaxial trocar that, with a continuous movement like a ‘screw’ is inserted into the nucleus pulposus. CT images document the correct positioning of the probe. After switching on the rotating engine, the radiologist moves the probe forward and backward. The tissue removed from the herniated nucleus pulposus goes up through the probe and is expelled (figure 3 A-E). The procedure finishes when there is no more material to extract or when the radiologist feels a satisfactory decompression has been obtained. When it is performed under fluoroscopic guidance a postero-lateral approach is needed with patients in a prone position, and to reach the disc the landmark is the lateral foramen. Dis113

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Figure 3 A-E A,B) Sagittal and axial T1W MRI descending postero-lateral left herniated disc at level L4-L5. C) CT control of correct position of decompressor percutaneous discectomy. D) CT control after decompressor percutaneous discectomy. E) Decompressor percutaneous discectomy probe with discal fragment.

cectomy was introduced by Kennet M. Robert. The technique offers many advantages: – the calibre of the probe is only 16G, 1.5 mm and this reduces the risk of damaging the longitudinal posterior ligament and the annulus; 114

– the probe and the trocar can be curved manually in case of a difficult approach; – the probe rotation system allows the nucleus aspiration not only in case of central or paracentral herniation but also in case of foraminal

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Figure 4 A-D A,B) Sagittal T1W MRI and sagittal T2W MRI of herniated disc at level L4-L5. C) CT at level L4-L5 in patient in prone position, the needle is inserted in the nucleus pulposus L4-L5 by postero-lateral approach. D) CT control after intradiscal infiltration of O2-O3.

and extraforaminal herniated disc. In this way it is possible to decompress the intraforaminal hernia with no risk of root damage; – the removal of a few cm3 of disk material results in a significant pressure decrease on the

peripheral disc portion, resolving the disc-root conflict. A reduction of pain symptoms superior to 70% has been reported among 70-72% of patients treated with this technique 47-48. The location of the hernia is, however, the most im115

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Figure 5 A-C Epidural fibrosis after surgical treatment of hernia L5-S1:intradiscal and epidural infiltration of O2-O3 by trans-laminar approach.

portant parameter for the efficacy of therapy. The reduction of symptoms is over 70% in 79% of foraminal postero-lateral or extraforaminal hernias. Similar results can be obtained in only 50% of patients with middle-posterior hernia 49 . The complications reported in literature are three cases of broken probe 50. The probe can break proximally and caudally. In the first case the probe was removed through a simple surgical incision. Instead, a more complex surgical intervention may be necessary. Chemodiscolysis with O2-O3 mixture with periradicular and periganglionic infiltration Chemodiscolysis with a mixture of O2-O3 and periradicular and perigangliar infiltrations is a recent percutaneous technique for treating of 116

herniated disc widespread in Europe (especially in Italy, Germany and Spain) 9. Ozone is an unstable, colourless, irritating gas with a thorny smell, oxidative power and antiseptic, disinfectant and antiviral properties. It is prepared and used in real time, transforming a small percentage of O2 to O3 by special generators. The O2-O3 mixture is injected into the intradiscal space and foramen: 3-4ml in the disc and 10 ml in the foramen. The administrated dose for treating the disc is 30-40 micron/ml and it is the best concentration to dehydrate the nucleus and reduce inflammation 51. The rational criterion is that the pain is due to mechanical compression on the root with associated inflammatory changes in the perigangliar and periradicular spaces 52-53. In a prone position, the technique is usually performed under CT guidance for better evaluation of gas distribution, with intradiscal and perigangliar treatment. Intra-

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foraminal treatment alone is suggested in not compressed root inflammation. The technique can also be performed under fluoroscopic guidance with a good control of the intradiscal or endocanalar injection and gas distribution into the psoas muscle. If anatomical alterations are present, these are diagnosed by MRI or CT before treatment. After CT scan showing the disc level, a needle is inserted into the nucleus pulposus (18-20 gauge calibre and 7-10 cm length) by oblique paravertebral approach, taking as target the specific articular facet (figure 4 A-D). Sometimes, for anatomical reasons the “classic” oblique approach could be difficult, especially at level L5-S1. So further needle inclination of 30° in a cranio-caudal direction is required to reach the specific disc space. When this approach is still difficult, a translaminar medial approach should be performed without fear of crossing the dural sac to reach the vertebral disc (figure 5 A-C). Once the needle has been positioned in the centre of the disc, the gas mixture is slowly injected into the nucleus pulposus, then into the epidural and intra-foraminal space using a local anti-inflammatory effect. The oxygenozone mechanisms of action are currently being investigated and include 54: – the anti-inflammatory effect due to oxidative action on the chemical pain mediators; – improved capillary blood perfusion and resolution of venous stasis with better tissue oxygenation in the compression site and reduction of ischemic pain and root oedema; – the direct action, through the oxygenation process, on the cross bounds of the nucleus pulposus mucopolysaccharides filled with water with secondary disc dehydration. These effects were confirmed by histological studies on the disc fragments previously treated with O2-O3 therapy and removed by microdiscectomy. If the ozone enters the CSF or subarachnoid space, it does no damage as reported by Tian et Al. in an experimental study on pigs using a high ozone dose 55. Experimental studies have demonstrated that a mixture of O2-O3 at the concentration used by intradiscal injection produced the same results as steroid on cytokine production and so it reduces pain 56. The therapeutic efficacy of O2-O3 in the treatment of root -disc conflict from herniated disc is widely known and a successful percentage of 70- 80% without complications has been reported by randomized studies evaluating conservative treatment versus O2-O3 treatment, also associated with injection of steroid in periradicular and perigangliar spaces 57-64. No early or late

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neurological or infectious complications have been reported following O2-O3 injection 64-67. Jellified ethyl alcohol (Discogel®) Jellified ethyl alcohol (Discogel®) is a new product for mini-invasive, percutaneous treatment of herniated disc. It is a sterile viscous solution containing ethyl alcohol, cellulose derivative product, added to a radio-opaque element, the tungsten, that injected into the vertebral disc, relieves lumbar, radicular or lumboradicular pain. The 96% pure ethyl alcohol produces a local necrosis of the nucleus pulposus. Its action is mechanical via a dehydration of the turgescent and protruding disc compressing the peripheral nerves of the spine causing extreme pain. After asepsis and local anesthesia, the product is injected into the nucleus pulposus under radiological control (CT or fluoroscopy guidance) with a posterolateral approach for thoracic or lumbar level and anterolateral approach as for the cervical level. Preferably the disc is punctured using a small needle of: • 20 gauge for cervical disc ; • 18 gauge for thoracic and lumbar discs, so as to reach the central region of the intraspinal space. The resuspension of the metallic contrast agent must be homogeneous at the time of its injection. The quantity of jellified ethyl alcohol injected per disc varies between 0.2 and 0.8 mL, depending on the size of the disc and extent of the hernia. In general, it is recommended to use: • 0.2 mL of Jellified ethyl alcohol for cervical discs; • 0.3-0.5 mL of Jellified ethyl alcohol for thoracic discs; • 0.6-0.8mL of Jellified ethyl alcohol for lumbar discs. At the beginning of the injection the patient may experience a transitional scalding sensation in the region of injection which disappears in the course of injection. To minimize this risk, the product must be injected very slowly. Once the product has been injected, the needle is left in place two minutes before being withdrawn. The viscosity of jellified ethyl alcohol depends on the temperature. An administration of the product warmed up above room temperature should be avoided because the gel becomes more liquid and is below optimum viscosity. To increase its viscosity jellified ethyl alcohol can be refrigerated just prior to injection. Simultaneous general or local complemen117

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tary treatments can be used in case of facet pain. Additional, complementary intradiscal therapies are also possible in case of treatment of hernias with narrow canal, foraminal, extremely painful and “sleepless” hernias. Jellified ethyl alcohol is not indicated for pregnant woman and for patients known to be allergic to one of the components, patients in severe depression or any other condition making the interpretation of pain difficult 68. However, there are no blinded, random or experimental studies available at this moment, so there is still no evidence to evaluate the efficacy and safety of this product compared to another. Selection of patients: indications and contraindications The selection of patients for minimally invasive treatments is the most important factor for the technique’s success, most of all because it is an alternative treatment to classical surgery, already standardized by world guidelines. The following selection criteria were adopted for enrolment. General exclusion criteria are: – extruded herniated disc; – free herniated fragment; – recent disc or vertebral infection; – high arm deficit; – sphincteral deficit; – hyperalgic sciatalgia; – progressive neurologic deficits of the involved body segment. The last three conditions are absolute indications for surgery. Absolute contraindications to chemodiscolysis with chymopapain are a sensitivity to papaya, cauda equina syndrome and pregnancy, because no studies currently demonstrate the effects of papain on fetal development. Failure in IDET may be due to obesity, wide herniated disc, a significant reduction of intradiscal space and a complex syndrome involving three or more discal spaces. Among all the techniques illustrated, oxygen-ozone therapy has the advantage of no absolute contra-indications. The best results are reported for small and medium size herniations with a normal spinal canal, without calcifications. Prognostic factors for an unsuccessful outcome are the presence of a calcified herniated disc, a high grade of spinal stenosis, presence of a small descending herniated disc in the lateral spinal recess, or the presence of FBSS and recurrent herniation 56. 118

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Inclusion criteria are : – clinical criteria: low back pain and sciatica resistant to conservative medical therapy, physiotherapy and other manipulations such as needle puncture for period not shorter than two to three months. For IDET the indication is for patients with low back pain without root compression symptoms and resistance to pharmacological therapy and physiotherapy for more than six months; – neurological criteria: paresthesia or hypoesthesia over the dermatome involved, mild muscle weakness and signs of root-ganglion irritation; – psychological: a firm resolve on the part of the patient to recover with a commitment to cooperate and undergo subsequent physiotherapy with postural and motor rehabilitation; – neuroradiological (CT, MR) evidence of: a) small and medium-sized herniated discs correlating with the patient’s symptoms with or without degenerative disc-vertebra disease complicated by intervertebral disc changes (protrusion, herniation); b) pain evoked by contrast low pressure injection in the compromised disc during discography for IDET, nucleoplasty and APLD techniques; c) residue of surgical micro-discectomy with herniation recurrence and/or hypertrophic fibrous scarring. Chemodiscolysis with papain is now obsolete and was only indicated for treating contained hernia, to avoid the connection of proteolytic enzyme and medulla, dural sac and nerve roots. Percutaneous discectomy with decompressor is indicated in the central and postero-lateral herniated disc and also in cases of foraminal and extraforaminal herniation. Chemodiscolysis with O2-O3 seems to be easier to perform and less traumatic than other techniques. In fact, its is also useful in: – patients with FBSS because in these patients the ozone action on chronic inflammatory and venous stasis is effective; – patients with large or free fragments of herniated disc without significant symptoms. The choice of radiological guidance: CT or digital angiography and fluoroscopy All techniques need a specific radiological support: CT or fluoroscopic guidance. The choice among different techniques depends on the con-

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fidence of everyone in the technique itself the and local availability of a good quality system. Some procedures are done under fluoroscopic guidance, like IDET, nucleoplasty and APLD, while others are done under CT guidance (O2-O3 therapy). This choice allows the radiologist to evaluate the presence of a bowel segment behind the psoas muscle, and absolute contraindication for treatment and intradiscal gas distribution. In any case these techniques can also be performed by fluoroscopic guidance but any anatomical alterations must be diagnosed by CT or MRI before treatment. If the hernia is still contained, it is possible to perform PLDD under fluoroscopic guidance, releasing laser energy at the vertebral disc centre and in the posterior portion. If the hernia is not contained but still connected to the intervertebral disc, it is better to perform PLDD under CT guidance to better assess the connection of disc and hernia. In this way the laser energy can be released along multiple places of herniated disc, obtaining a better vaporization and a higher retraction of the hernia with root decompression and resolution of symptoms. The lumbar percutaneous discectomy decompressor can be performed under CT or fluoroscopic guidance, without technique limitations. Some techniques (chemodiscolysis with papain, APLD and IDET) need a previous discography to obtain a better evaluation of contained her-

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nia, the disc compression and the disc pressure itself. For O2-O3 therapy, discography is not suggested because it adds no diagnostic information necessary for treatment. The indications for O2-O3 treatment are extended to FBSS patients by chronic inflammation and venous stasis effect, but with minor outcome. CT guidance allows the operator to avoid intradiscal administration of contrast that even at a low dose reduces the ozone absorption and causes obstruction to the intraforaminal injection of the O2-O3 mixture. Conclusion Percutaneous techniques can be a good alternative to surgical treatment for herniated disc for patients with low back pain and sciatica. All techniques have a low rate of complications and easy feasibility. They do not entail a long hospital stay and do not exclude the possibility of surgery in case of failed treatment. Probably, among all techniques, chemodiscolysis with O2-O3 mixture with periradicular and periganglionic infiltration is the best and most competitive technique with good therapeutic results and lower costs, also related to the costbenefit ratio and absence of complications. Surgery is really indicated in emergency cases of neurologic deficit or severe low back pain.

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68 Theron J: “Jellified alcohol” Personal Oral Communication At ESNR XXXIII Congress Cracow - Poland 18-21 September 2008.

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Dipartimento di Neuroradiologia A.O.R.N. A. Cardarelli Via Catullo 30 80100 Naples, Italy Tel.: +39 3473549657 Fax: +39 0815752281 E-mail: [email protected]

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Low back pain is the commonest spine disease causing absence from work in developed countries. Low back pain with classical irradiation along the cour...
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