Percutaneous disc decompression began with chemonucleolysis in 1963. Minimally invasive discectomies began with Hijikata’s report in the 1975 using a prototype cutter in percutaneous nucleotomy. Choy presented clinical results using laser discectomy in 1987, but there still lacks randomized control trial. Percutaneous disc decompression techniques are thought to decompress the nucleus pulposis and thereby decompress pressure in herniated discs. Several decompression techniques have been implemented over the years as a treatment of low back pain due to disc disease. Generally, the different techniques can be broadly divided into those that are designed to remove or ablate disc material and thus decompress the disc, and others that alter the biomechanics of the disc annulus.
The advantages of the minimally invasive percutaneous techniques include less pain, less time missed from work, and decreased scar tissue around the nerve roots as a result of the procedure (compared with open, microdiscectomy, or tube discectomy that always cause scar tissue). The success rates of these techniques range from 55% to 90% depending on the technique. All percutaneous disc decompression techniques are FDA approved except for ozone therapy.
Percutaneous Non-Endoscopic Techniques
Acutherm, involves collagen shrinkage via application of thermal energy. Having been introduced in 2003 it is not widely implemented as of yet. In summary, a catheter is inserted into the disc through a needle and coiled inside the disc until it lies directly adjacent to the disc herniation. The heat energy applied through the coil causes the disc to shrink and thus reduce intrad discal pressure. This method of disc decompression is in its infancy, having only been introduced in 2003, and is not widely used. The active portion of the catheter is shorter than the IDET SpineCath used to treat annular tears of the disc but the insertion into the disc is effectively the same. Reportedly, IDET does not decompress the disc to the same degree as Acutherm but there are no published studies to support this claim or the overall efficacy of Acutherm.
The Disc nucleoplasty™ procedure uses bipolar radiofrequency energy in a process referred to as Coblation technology. This technique uses a fraction of the energy required by traditional RF systems. Instead of heat, a portion of nucleus pulposis is ablated with a low-temperature plasma field of ionized particles. The “wand” is placed through the a needle in the nucleus pulposis and when the wand is retracted , a second portion of the wand acts to provide heat to the sides of the channel created and results in a shrinkage of the channel size. Thus, the nucleus and the periphery are decompressed. The advantage of this Coblation technology is thought to be minimal damage to the surrounding tissue with this highly localized ablation.
Disc Dekompressor is a mechanical disc device where unlike coblation, the needle is situated in the inner annulus while a wand is cycled back and forth through the needle. The rotating tip collects disc material and propels it along the shaft into a collecting chamber. Central disc herniation pressure reduction is achieved by mechanical removal of the disc. Kenneth Alo et al published a one year outcome study of 50 patients that showed a reduction in VAS pain scored from 7.92 to 2.79 at 12 months. Furthermore, this technique allows for a quantifiable amount of disc removed to be measured (they removed between 0.75-2.0 cc with a mean of 1.25 cc) in approximately 3 minutes on average. Follow-up MRI demonstrated postoperative reductions in the treated herniations. They did not find any evidence of tissue injury, increased degeneration, auger fragmentation, or mechanical device failure.
Non-Endoscopic Laser Disc Decompression is a technique that has been used with a variety of lasers since the 1980s. A laser fiber is placed percutaneously through a needle with the aid of fluoroscopy or CT guidance. Laser energy is applied resulting in creation of a cavity behind the disc herniation to provide a passage for the herniation to decompress. A well known study by Choy showed in summary: 500 patients with the following results summary: 752 intervertebral discs in 518 patients over a period of 12 years. The overall success rate ranged from 75% to 89% with a complication rate of less than 1%.
Chemonucleolysis has been used since the 1970s for disc decompression with chymopapain being the most widely used substance. Apparently chymopapain reportedly had an 80% efficacy rate with minimal complications in over 250,000 patients. Unfortunately, malpractice attorneys were the demise of the technique and the active ingredient is no longer manufactured in the US. Effectively chymopapain is an enzyme derived from the papaya fruit that enzymatically destroys collagen in the nucleus. However, it is no longer used in the U.S.
Ozone therapy is another chemonucleolysis technique that injects the combination of air and ozone into the disc and around the nerve root. There are reports of up tp 60-80% success rates in significant reduction of pain from disc herniations. Currently the technique is not used in the U.S.
Endoscopic Percutaneous Disc Decompression
Initially labeled “arthroscopic discectomy” by Kambin, endoscopic techniques have since evolved through several generations technology. LASE was invented in the 1990s which uses a hand held wand with a flexible scope through which a laser fiber can pass. Since there is no significant mechanical decompression, the technique is thought to be safe once the laser is within the disc. Due to high cost there are only few in the US still performing LASE.
Tony Ywung invented a technique called selective endoscopic discectomy that involves placement of a cannula into the disc, use of mechanical manual and automated disc removal, use of an endoscope through which operating Again, there are only a few pain management physicians around the country performing these techniques. The results from endoscopic discectomy challenge efficacy of open discectomy with studies showing a success rate of above 80%. These skills are typically unavailable for pain physicians. However, SPPM, a pain management interventional training group, is beginning to train physicians in this technique in July 2005. The results from endoscopic discectomy rival that of open discectomy with several studies demonstrating a success rate of above 80%.
Conclusion
Percutaneous discectomy has been performed over the past 25 years. Innovative arthroscopic/percutaneous techniques utilizing devices for both manual and automated removal of nucleus pulposus have been developed. Percutaneous Discectomy using both mechanical and laser based instrumentation has opened up many options and warranted more study in the clinical setting. The chief benefits of such minimally invasive techniques include good success rates, reduced trauma, lower costs, and less time lost from work.
References
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