The role of provocative discography in minimally invasive selective endoscopic discectomy

Transforaminal Endoscopic Discectomy Combined With an Interspinous Process Distraction System for Spinal Stenosis

BACKGROUND

The combination of the percutaneous transforaminal endoscopic decompression (PTED) with an interspinous process distraction system (IPS) may offer additional benefit in the treatment of spinal stenosis in patients who have failed nonsurgical treatment.

METHODS

We retrospectively reviewed the medical records of 33 patients diagnosed with lumbar stenosis and radiculopathy and treated them with transforaminal endoscopic lumbar decompression between 2013 and 2017. Primary outcome measures were modified Macnab as well as preoperative and postoperative visual analog scale (VAS) criteria and the Oswestry Disability Index (ODI). Only patients with a minimum follow-up of 2 years were included.

RESULTS

A total of 28 patients were treated with a combination of PTED and percutaneous IPS (group A), and 5 patients were treated with PTED and mini-open IPS (group B). In group A patients, there was a 4.48 reduction in the VAS score. The ODI changed from 50.25 preoperatively to 18.2 postoperatively, and excellent and good Macnab outcomes were obtained in 78% of patients. In group B patients, the mean VAS reduction was 5.2 points. The ODI changed from 44.34 preoperatively to 14.62 postoperatively, and 80% of group B patients achieved excellent and good Macnab outcomes. No complications related to PTED or IPS were observed throughout the 2-year follow-up.

CONCLUSIONS

The addition of IPS to the PTED procedure in select patients may offer additional benefits to patients being treated for lumbar lateral stenosis and foraminal stenosis with low-grade spondylolisthesis.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Feasibility study.

Lumbar Endoscopic Bony and Soft Tissue Decompression With the Hybridized Inside-Out Approach: A Review And Technical Note

This study aimed to showcase the authors' preferred technique of a hybrid of modern "inside-out" and "outside-in" endoscopic decompression. A case series of 411 patients consisting of 192 females (46.7%) and 219 males (53.3%) with an average age of 54.84 ± 16.32 years and an average of 43.2 ± 26.53 months are presented. Patients underwent surgery for low-grade spondylolisthesis (13 of 411, 3.2%), herniated disc (135 of 411, 32.8%), foraminal spinal stenosis (101 of 411, 24.6%), or a combination of the latter 2 conditions (162 of 411, 39.4%). The preoperative Oswestry Disability Index (ODI) and visual analogue scale (VAS) for leg pain were 49.8 ± 17.65 and 7.9 ± 1.55, respectively. Postoperative ODI and VAS leg were 12.2 ± 9.34 and 2.41 ± 5 1.55 at final follow-up (p < 0.0001). MacNab outcomes were excellent in 134 (32.6%), good in 228 (55.5%), fair in 40 (9.7%), and poor in 9 patients (2.2%), respectively. There was end-stage degenerative vacuum disc disease in 304 of the 411 patients (74%) of which had 37.5% had excellent and 50% good MacNab outcomes. Patients without vacuum discs had excellent and good 18.7% and 71.0% of the time. Direct visualization of pain generators in the epidural- and intradiscal space is the authors' preferred transforaminal decompression technique and is supported by their reliable clinical outcomes.

Clinical and Radiological Mid-Term Outcomes of Lumbar Single-Level Total Disc Replacement

STUDY DESIGN

Prospective single-center case cohort study.

OBJECTIVE

Evaluation of clinical and radiographic outcomes of a consecutive 122-patient cohort with discogenic back pain, at 2- to 10-year follow-up periods, treated by a single surgeon, with CHARITÉ Artificial Disc (DePuy Spine, Raynham, MA).

SUMMARY OF BACKGROUND DATA

Minimum 2-year clinical and radiographic level 1 data for the first lumbar artificial disc, the CHARITÉ Artificial Disc (DePuy Spine), have recently been published, demonstrating sustained clinical benefit of the device for the treatment of degenerative disc disease.

METHODS

Patients were assessed preoperatively using clinical outcome measures, including visual analog scale (VAS) score back and leg, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), and Roland-Morris Questionnaires (RMDQ), and further assessed postoperatively, 3-, 6-, 12-months, and yearly thereafter.

RESULTS

Average follow-up was 44.9 ± 23.3 months (n = 122). The median age at surgery was 43.0 ± 9.0 years. Preoperative diagnosis included degenerative disc disease in 118 (96.7%) and internal disc disruption in 4 (3.3%). Surgery was performed at L5-S1 in 96 (77.9%) patients and at L4-L5 in 27 (22.1%). Statistically significant clinical improvements from baseline were observed on VAS (back and leg), ODI, SF-36 PCS, SF-36 MCS, and RMDQ 3 months onward. Back VAS scores decreased from 78.2 ± 21.3 preoperatively to 21.9 ± 27.8 by final follow-up. ODI scores decreased from 51.1 ± 17.3 to 16.2 ± 17.9 at last follow-up. The RMDQ scores also decreased from 16.7 ± 4.7 to 4.2 ± 5.8. SF-36 PCS and MCS increased from 25.7 ± 11.0 to 46.4 ± 10.3 for PCS and from 35.5 ± 17.4 to 51.6 ± 10.8 for MCS. Patient satisfaction surveys indicated that 90.56% patients rated their satisfaction with the surgery as "excellent" or "good" at 2 years. Range of motion averaged 8.6 ± 3.5 (median = 8.0°) at the last follow-up time point.

CONCLUSION

Outcomes verify the clinical efficacy of total disc replacement for treatment of discogenic back pain with or without radiculopathy. The outcomes instruments demonstrated statistically significant improvements 3 months onward.

LEVEL OF EVIDENCE

N/A.

Discoscopic findings of high signal intensity zones on magnetic resonance imaging of lumbar intervertebral discs

A 32-year-old man underwent radiofrequency thermal annuloplasty (TA) with percutaneous endoscopic discectomy (PED) under local anesthesia for chronic low back pain. His diagnosis was discogenic pain with a high signal intensity zone (HIZ) in the posterior corner of the L4-5 disc. Flexion pain was sporadic, and steroid injection was given twice for severe pain. After the third episode of strong pain, PED and TA were conducted. The discoscope was inserted into the posterior annulus and revealed a migrated white nucleus pulposus which was stained blue. Then, after moving the discoscope to the site of the HIZ, a migrated slightly red nucleus pulposus was found, suggesting inflammation and/or new vessels penetrating the mass. After removing the fragment, the HIZ site was ablated by TA. To our knowledge, this is the first report of the discoscopic findings of HIZ of the lumbar intervertebral disc.

Percutaneous endoscopic discectomy and thermal annuloplasty for professional athletes

INTRODUCTION

Percutaneous endoscopic discectomy (PED) for herniated nucleus pulposus has become increasingly popular since first reported by Yeung and Tsou. Additionally, radiofrequency thermal annuloplasty (TA) with PED (PED/TA) has been reported to be effective for discogenic low back pain. We used the PED/TA procedure to successfully treat four professional athletes with discogenic low back pain.

METHODS

All patients were men; their age at operation was 35, 35, 34, and 28 years. Daily low back pain was provoked by discography in all four patients, who had been receiving conservative but ineffective treatment for over 1 year. Surgery was conducted with the patients under local anesthesia. A cannula was placed posterior to the disc and ventral to the posterior annulus fibrosus through a 7-mm skin incision. Degenerated nucleus pulposus at the site was removed percutaneously and the posterior annulus was modulated by bipolar radiofrequency TA.

RESULTS

After surgery, low back pain was resolved in all cases. After effective post-surgical rehabilitation with a physical trainer or physical therapist, all patients returned to their original competitive level.

CONCLUSION

PED/TA is a minimally invasive and effective procedure for discogenic low back pain, especially in athletes.

Discography in practice: a clinical and historical review

Chronic low back pain is the most common cause of disability in individuals between the ages of 45 and 65. Given the variety of anatomic and pathophysiologic causes of persistent low back pain, it is a difficult diagnosis for clinicians to treat. Discography is a diagnostic option that may link a patient's subjective complaints of spinal pain to symptomatic disk disease when non-invasive imaging, such as magnetic resonance imaging (MRI), does not find structural abnormalities. A controversial procedure, discography is only necessary to assess painful discs prior to surgical interventions. For accurate discogram interpretation an experienced spine interventionalist must be careful to exclude false positive results and be aware of the patient's underlying psychological state. This literature review will discuss the following: anatomy and function of the spine and intervertebral disc, intervertebral disc degeneration and discogenic pain, history of discography, indications and contraindications, a description of the procedure, complications, and the current debate regarding its outcomes.

Provocative discography: Current status

Low back pain is a common clinical problem that may be due to a variety of causes, including disc disease. Provocative discography is an imaging-guided procedure in which a contrast agent is injected into the nucleus pulposus of the disc. Despite its controversial history, it remains the only imaging technique that provides both anatomical and functional information about a diseased disc. Disc morphology is usually assessed on either radiographs or computed tomography (CT), or both. Functional evaluation of the disc consists of pain provocation and careful assessment of the patient's response to pain. As provocative discography is an invasive procedure, it should not be used as a screening study in patients with back pain. It should instead be reserved for carefully- selected patients whose painful symptoms cannot be explained by findings on non-invasive imaging modalities such as magnetic resonance imaging or CT, and who are not responsive to conservative measures. Discography is helpful in selection of patients and disc levels to be operated upon. Careful application of indications and meticulous technique are however required if a successful outcome is to be expected.

Lumbar discography: an update

Discogenic pain most commonly affects the low back, buttocks, and hips and is thought to be a byproduct of internal disk degeneration. It is postulated that progressive annular breakdown and tearing results in biomechanical and/or biochemical stimulation of the pain fibers that reside in the outer one third of the annulus. Although multiple imaging modalities, most notably MRI, can show morphologic abnormalities of the spine, discography remains the only test that provides physiologic information regarding what role a given intervertebral disk plays in a patient's symptom complex. The controversy surrounding discography is here to stay until more definitive, well-designed studies are performed. In the meantime, there are certain things that can help the discographer maximize the accuracy of the test: 1. Always try to inject one "normal" disk as a "control level." 2. Be alert for factors that are associated with an increased false-positive rate (abnormal non-anatomic pain maps, a history of chronic pain of spinal or nonspinal origin, abnormal psychometric testing, and prior surgery at the injected disk level). In these cases, special attention should be directed to both the patient's verbal and nonverbal cues during disk injection. 3. Do not give any audible clues as to what level is being injected or when the injection is starting or finishing. In this regard, we find it very helpful to have one of our personnel talk with the patient during this portion of the procedure while closely observing the patient for any nonverbal cues regarding their pain response. This distraction is preferable to a silent room where the patient is intensely focused on what is going on with the injections. We also find that music playing during the procedure helps to relax and often distract the patient as well. 4. If the results are equivocal at a level (i.e., you are unable to determine whether or not the patient's pain response was truly concordant), go on to inject another disk level and then come back to reinject more contrast into the disk in question. As radiologists, we tend to focus on the technical aspects of a procedure and the anatomic/morphologic information it provides. However, it cannot be emphasized enough that when performing lumbar discography, the assessment of the patient's pain response during the injection is the most important component of the procedure, and requires not only technical skills, but an understanding of how best to avoid some of the pitfalls that can lead to inaccurate results.