Percutaneous Disc Decompression Research Articles

Percutaneous Mechanical Disc Decompression Using Dekompressor Device: An Appraisal of the Current Literature

The objective of this study was to determine if the available literature answers the following questions: does percutaneous disc decompression using Dekompressor device relieve radicular pain caused by a small disc herniation? Is the duration of response stable and clinically worthwhile? Is relief of pain corroborated by improvements in physical and social function? Does relief of pain result in reduction in the use of other health care? Is there a risk of serious side effects or complications? DESIGN/SETTINGS: The study was designed as a narrative review and description of the available evidence, drawn from the databases of PubMed, EMBASE, and the Cochrane Library. Innovatively, the concept of the "context of the patient" was introduced in the assessment. It required the assessors to consider the alternatives the patients and their treating practitioners faced. The literature search identified three nonrandomized clinical trials, and a single case series. All studies were reasonably rigorous in reporting relief of pain and the use of analgesics. Evidence with respect to physical functioning was scarce. Although investigators reported on the relief of pain, they lacked rigor when reporting associated outcome measures such as use of other health care and physical functioning. Unfortunately, the context of a patient with persistent radicular pain caused by a small disc herniation is the lack of good alternatives to Dekompressor procedure. The moral question is whether Dekompressor is any less valid an option than perpetual opioids or discectomy. This question would be much easier to answer if the literature on Dekompressor was more rigorous and more compelling in its evidence.

S720 PERCUTANEOUS DISC DECOMPRESSION - RETROSPECTIVE ANALYSIS IN A TERTIARY PAIN CENTRE

European Journal of Pain SupplementsVolume 5, Issue S1 p. 291-291 S720 PERCUTANEOUS DISC DECOMPRESSION — RETROSPECTIVE ANALYSIS IN A TERTIARY PAIN CENTRE G. Baranidharan, G. Baranidharan Leeds Pain and Neuromodulation CenterSearch for more papers by this authorM. Gupta, M. Gupta Leeds Teaching Hospitals NHS Trust, Leeds, UKSearch for more papers by this author G. Baranidharan, G. Baranidharan Leeds Pain and Neuromodulation CenterSearch for more papers by this authorM. Gupta, M. Gupta Leeds Teaching Hospitals NHS Trust, Leeds, UKSearch for more papers by this author First published: 30 January 2012 https://doi.org/10.1016/S1754-3207(11)71004-5Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume5, IssueS1September 2011Pages 291-291 RelatedInformation

Comparative Prospective Randomized Study Comparing Conservative Treatment and Percutaneous Disk Decompression for Treatment of Intervertebral Disk Herniation

To compare short-, intermediate-, and long-term functional results concerning pain reduction and mobility improvement between conservative therapy and percutaneous disk decompression (PDD) in patients with intervertebral disk herniations. The study received approval from both the university ethics panel and the institutional review board. Patients provided informed consent for the study. Over the past 4 years, two randomized groups of 31 patients with sciatica due to intervertebral disk herniation were prospectively studied and compared with the t test. The control group underwent conservative therapy (administration of analgesics, antiinflammatory drugs, muscle relaxants, and physiotherapy) for 6 weeks. The decompression group underwent fluoroscopically guided PDD. Pain reduction and mobility improvement were recorded at 3-, 12-, and 24-month follow-up on a numeric visual scale (NVS) (range, 0-10). The control group had a mean pain score of 6.9 NVS units ± 1.9 prior to conservative therapy. This was reduced to 0.9 NVS units ± 2.0 3 months after therapy; however, it increased to 4.0 NVS units ± 3.4 at 12-month follow-up and further increased to 4.0 NVS units ± 3.4 at 24-month follow-up. The decompression group had a mean pain score of 7.4 NVS units ± 1.4 prior to PDD. This was reduced to 3.0 NVS units ± 2.4 at 3-month follow-up and further reduced to 1.7 NVS units ± 2.4 at 12-month follow-up and 1.6 NVS units ± 2.5 at 24-month follow-up. No complications were noted. When compared with conservative therapy, PDD shows improved amelioration of symptoms at 12- and 24-month follow-up.

Percutaneous Techniques for Cervical Pain of Discal Origin

Cervical discogenic pain is an important cause of suffering and disability in the adult population. Pain management in cervical disc herniation relies initially on conservative care (rest, physiotherapy, and oral medications). Once conservative treatment has failed, different percutaneous minimally invasive radiological procedures can be applied to relief pain. This article offers a systematic review on the percutaneous minimally invasive techniques that can be advocated for the treatment of cervical pain of discal origin. Periradicular steroid injection under image guidance (computed tomography or magnetic resonance imaging) is the first technique to be considered. The steroid injection aims at reducing the periradicular inflammation and thus relieves the radicular pain. The steroid injections present satisfying short-term results, but pain can recur in the long term. Whenever the steroid injections fail to relieve pain from a contained cervical disc herniation, the more invasive percutaneous disc decompression techniques should be proposed. Percutaneous radiofrequency nucleoplasty is the most often applied technique on the cervical level with a low risk of thermal damage. When the indications and instructions are respected, radiofrequency nucleoplasty presents accepted safety and efficacy levels.

Efficacy of a New Navigable Percutaneous Disc Decompression Device (L'DISQ) in Patients with Herniated Nucleus Pulposus Related to Radicular Pain

An institutional, prospective clinical data analysis. To evaluate the safety and efficacy of a new navigable percutaneous disc decompression device (L'DISQ) in patients with lumbar disc herniation with radicular pain. We performed disc decompressions using L'DISQ on 27 patients with persistent disabling back and leg pain for 1 month or longer (average 6.48 months) due to a herniated lumbar intervertebral disc. Baseline data were prospectively gathered before the index procedure and at 1, 4, 12, and 24 weeks post-procedure. Data included pain intensity (visual analog scale [VAS]), measure of disability (Oswestry Disability Index [ODI] and Rolando-Morris Questionnaire [RM]), health-related quality of life (Bodily Pain Scale of Short Form-36 version 2 [SF-36 BP]), and passive straight leg raising test (SLR). The VAS fell from 7.08±1.22 to 1.84±0.99 scores at 24 weeks post-procedure. At 24 weeks, the ODI had fallen from 41.88±10.61 to 16.66±8.55% and the RM from 11.52±3.91 to 2.68±1.97 points. The SF-36 BP dropped significant improvement from 32.89±5.83 to 49.57±4.96 scales. In the SLR test, the angular change of 24 weeks showed considerable improvement from 60.20±20.02 to 83.00±14.29 degrees. No major complication occurred, although two cases developed a disc reherniation 1 month post-procedure. The L'DISQ device is specifically designed to remove herniated disc using a wand that can be navigated into a disc protrusion or extrusion. Following decompression, we measured clinically significant pain improvement and decreased disability for patients with both radicular and axial pain caused by protruded and extruded discs.

Minimally invasive percutaneous techniques for the relief of pain in lumbar disc disease.

Dear Editor, Alleviation of back pain and/or any disability due to pain in patients with lumbar disc disease undoubtedly gives a sense of relief and well being. The use of noninvasive or minimally invasive interventional procedures for this condition is basically aimed at limiting pain and disability. A number of such minimally invasive percutaneous techniques for the treatment of lumbar disc disease have been developed over the years, with the common tenet being the ability to act directly on the disc content without violating the spinal channel or increasing subsequent risk of scarring. Electrosurgical technology has been developed for use in the spine and possesses few, if any of the drawbacks of the other percutaneous disc decompression techniques. These are usually plasma-mediated radiofrequency-based excision and allow precise etching of tissue. When used for tissue ablation (excision) in the disc, these procedures excise target material without gross thermal or structural damage to adjacent tissue (1). We have studied patients using the nucleoplasty procedure developed by Arthro Care Corporation (Sunnyvale, CA), which is performed using a plasma-mediated radiofrequency-based device. This procedure uses radiofrequency to excite the electrolytes in a conductive medium, such as saline solution, to create precisely focused plasma. The energized particles in the plasma have sufficient energy to break molecular bonds, excising or dissolving soft tissue at relatively low temperatures (2-4). In our study (5) on 83 patients the majority of patients reported substantial pain relief within one month following the nucleoplasty discectomy, with the majority of them reporting minimal or no pain or disability and satisfaction with results after one year. Our experience revealed that nucleoplasty discectomy is a suitable, minimally invasive technique that could be considered a valid alternative to surgery when evaluating possible treatment options in patients affected by contained lumbar disc herniation. It appears particularly indicated for patients that have exhausted other conservative treatment modalities but have not yet reached clear-cut indications for open surgical treatment and in such patients it could be safe to give it a trial. Two main mechanisms are reported as possibly being the basis of the effect of percutaneous disc decompression. Mechanical decompression of the nucleus pulpous with partial emptying of the disc space with consequent pressure lowering inside the disc space is considered as a mechanical explanation of the procedure (6). The other mechanism that has been hypothesized is a chemical disruption of degenerative metabolic processes inside the disc space which may induce changes in disc metabolism related to inflammation and/or initiate an autoimmune response in surrounding tissue to affect pain symptomatology (7-9). Based on these hypothesis it is postulated that nucleoplasty can be performed on patients with non-contained disc prolapse as well and that too at higher energy levels, unlike that of our study where it was done on selected patients with contained disc prolapse. Farzanegan et al. (10) in a study published in this journal showed that pain relief after laminectomy, which is a major surgical procedure, for lumbar disc protrusion resulted in improvements in the mental depression that was associated with pain. The main difference between their study and ours was our study advocates the use of nucleoplasty, a non-invasive procedure, for pain relief. In summary, our studies, in conjunction to the study reported in this journal lend credence to the fact that pain relief, which is essential to the physical and mental well being of patients, should be acquired at least initially by non-invasive or minimally invasive procedures, and therefore we recommend nucleoplasty as an initial methodology for alleviation of back pain.

CT-guided percutaneous thoracic disc decompression with spinal endoscopy: 19 cases of upper and middle thoracic intervertebral disc

CT-guided percutaneous thoracic disc decompression with spinal endoscopy: 19 cases of upper and middle thoracic intervertebral disc

Does negative plus negative give positive? The value of combining intradiscal treatment strategies

Combining different treatment strategies is common practice in medical therapy by pharmaceutical agents. Why not do the same in spine surgery? Obviously, any combination of treatments requires rigorous analysis of possible synergistic or antagonistic effects on outcome. Ahn and Lee provide a well-designed prospective study on the combination of percutaneous endoscopic lumbar discectomy with thermal annuloplasty for monoor bisegmental discogenic low back pain. Outcome assessment is based on widely accepted scales, and a follow-up rate of 90% after 2 years is generally considered sufficient for evaluation in spine surgery. The success rate of 70% suggests a considerable value of the proposed combination for discogenic low back pain, although it has dropped from 90% reported in a preceding series of 30 patients presented by the same group in 2009 [4]. Does the combination of two minimally invasive techniques finally offer a surgical solution for discogenic low back pain? We doubt it! The concept of combining a “thermal annuloplasty effect” and a “decompression effect” is not new and has been used since the late 1990s [9]. Intradiscal electrothermal therapy (IDET) has been based on the mechanisms of action proposed by the authors and has also started out with a success rate of 70% [8]. Randomised controlled trials, however, demonstrated that IDET is no better than placebo in the treatment of discogenic low back pain [3, 6]. The selective citation of annuloplasty results as provided in the paper is not scientifically sound. There is no evidence for percutaneous mechanical disc decompression in managing axial low back pain [5]. Thus, both intradiscal decompression and annuloplasty have not demonstrated long-term efficacy according to the pertinent literature. Can we expect that the combination of two ineffective or at least questionable treatment strategies will be effective in the treatment of discogenic low back pain? Does negative plus negative give positive? It cannot be stressed enough that the presented data are not based on a randomised and not even a controlled study. An independent observer does not at all eliminate bias if there is no control group, and telephone interviews as part of the postoperative assessment give limited information. Thus, without further data derived from randomised controlled trials, there is no indication that the proposed treatment works better than standardised conservative care. The authors put great emphasis on the technical aspects of their percutaneous technique: elimination of “inflamed” nucleus tissue, preservation of normal nucleus, thermal modulation along the whole length of the posterior annulus, and so on. However, these considerations are based on unproven assumptions and theoretical pathophysiological speculations. One third of treated segments were classified as Pfirrmann grade 4, in which differentiation of nucleus and annulus is lost by definition [7]. These patients obviously do not have a normal nucleus. What we, however, dislike most about the proposed technique is its destructive nature. Discectomy, be it by open C. Thome (*) Department of Neurosurgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria e-mail: claudius.thome@uki.at

A Systematic Review on the Effectiveness of the NucleoplastyTM Procedure for Discogenic Pain

Background: Nucleoplasty is a minimally invasive procedure for treating pain caused by symptomatic disc herniation that is refractory to conservative therapy. Observational studies have reported differing outcomes for this procedure and thus its effectiveness is yet to be determined. Study design: A systematic review of the efficacy of the nucleoplasty procedure. Objectives: To assess the clinical efficacy of the nucleoplasty procedure for treating back pain from symptomatic, contained disc herniation and to evaluate the methodological quality of the included studies. Methods: The relevant literature for nucleoplasty was identified through a search of the following databases: Pubmed, Ovid Medline, and the Cochrane library, and by a review of the bibliographies of the included studies. A review of the literature of the effectiveness of the nucleoplasty procedure for managing discogenic pain was performed according to the criteria for observational studies using a “Quality Index” scale to determine the methodological quality of the literature. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) for therapeutic interventions. Recommendations were based on the criteria developed by Guyatt et al. Outcome measures: The main outcome measures evaluated were the percentage of pain relief based on visual analogue scale (VAS) or numeric rating scale (NRS), percentage of patients with more than 50% reduction in pain, percentage of patients meeting one or more success criteria after nucleoplasty, and improvement in patient function. Secondary measures noted were reports of complications and the Quality Index scores of each study that was evaluated. Results: The quality of evidence for improvement in pain or function after a nucleoplasty procedure is Level II-3. The recommendation is 1C/strong for the nucleoplasty procedure based on the quality of evidence available. The median Quality Index score was 16 (range 12 – 19), indicating adequate methodological quality of the available literature. None of the studies reported major complications related to nucleoplasty. Conclusions: Observational studies suggest that nucleoplasty is a potentially effective minimally invasive treatment for patients with symptomatic disc herniations who are refractory to conservative therapy. The recommendation is a level 1C, strongly supporting the therapeutic efficacy of this procedure. However, prospective randomized controlled trials with higher quality of evidence are necessary to confirm efficacy and risks, and to determine ideal patient selection for this procedure. Key words: Nucleoplasty outcomes, contained disc hernia­tion, percutaneous disc decompression, Quality Index, discogenic pain, systematic review

Abstract No. 252 EE: Percutaneous intervertebral disc decompression and ablative techniques: A pictorial review

Abstract No. 252 EE: Percutaneous intervertebral disc decompression and ablative techniques: A pictorial review

Study Hints at Efficacy of Percutaneous Disc Decompression

Study Hints at Efficacy of Percutaneous Disc Decompression

An Algorithmic Approach for Clinical Management of Chronic Spinal Pain

Interventional pain management, and the interventional techniques which are an integral part of that specialty, are subject to widely varying definitions and practices. How interventional techniques are applied by various specialties is highly variable, even for the most common procedures and conditions. At the same time, many payors, publications, and guidelines are showing increasing interest in the performance and costs of interventional techniques. There is a lack of consensus among interventional pain management specialists with regards to how to diagnose and manage spinal pain and the type and frequency of spinal interventional techniques which should be utilized to treat spinal pain. Therefore, an algorithmic approach is proposed, providing a stepby-step procedure for managing chronic spinal pain patients based upon evidence-based guidelines. The algorithmic approach is developed based on the best available evidence regarding the epidemiology of various identifiable sources of chronic spinal pain. Such an approach to spinal pain includes an appropriate history, examination, and medical decision making in the management of low back pain, neck pain and thoracic pain. This algorithm also provides diagnostic and therapeutic approaches to clinical management utilizing case examples of cervical, lumbar, and thoracic spinal pain. An algorithm for investigating chronic low back pain without disc herniation commences with a clinical question, examination and imaging findings. If there is evidence of radiculitis, spinal stenosis, or other demonstrable causes resulting in radiculitis, one may proceed with diagnostic or therapeutic epidural injections. In the algorithmic approach, facet joints are entertained first in the algorithm because of their commonality as a source of chronic low back pain followed by sacroiliac joint blocks if indicated and provocation discography as the last step. Based on the literature, in the United States, in patients without disc herniation, lumbar facet joints account for 30% of the cases of chronic low back pain, sacroiliac joints account for less than 10% of these cases, and discogenic pain accounts for 25% of the patients. The management algorithm for lumbar spinal pain includes interventions for somatic pain and radicular pain with either facet joint interventions, sacroiliac joint interventions, or intradiscal therapy. For radicular pain, epidural injections, percutaneous adhesiolysis, percutaneous disc decompression, or spinal endoscopic adhesiolysis may be performed. For non-responsive, recalcitrant, neuropathic pain, implantable therapy may be entertained. In managing pain of cervical origin, if there is evidence of radiculitis, spinal stenosis, post-surgery syndrome, or other demonstrable causes resulting in radiculitis, an interventionalist may proceed with therapeutic epidural injections. An algorithmic approach for chronic neck pain without disc herniation or radiculitis commences with clinical question, physical and imaging findings, followed by diagnostic facet joint injections. Cervical provocation discography is rarely performed. Based on the literature available in the United States, cervical facet joints account for 40% to 50% of cases of chronic neck pain without disc herniation, while discogenic pain accounts for approximately 20% of the patients. The management algorithm includes either facet joint interventions or epidural injections with surgical referral for disc-related pain and rarely implantable therapy. In managing thoracic pain, a diagnostic and therapeutic algorithmic approach includes either facet joint interventions or epidural injections. Key words: Algorithmic approach, chronic pain, chronic spinal pain, diagnostic interventional techniques, therapeutic interventional techniques, comprehensive evaluation, documentation, medical decision making.

Percutaneous Lumbar Laser Disc Decompression: A Systematic Review of Current Evidence

Background: Since the descriptions by Mixter and Barr of open surgical treatment for rupture of the intervertebral disc in 1934, open surgical procedures have become a common practice. Disc herniations have been reported as being contained and non-contained. The results of open surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser disc decompression. Study Design: A systematic review of the literature. Objective: The objective of this systematic review is to evaluate the clinical effectiveness of percutaneous laser discectomy in managing radicular pain secondary to contained disc herniation. Methods: A comprehensive evaluation of the literature relating to mechanical disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted by using only the English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. Results: Based on USPSTF criteria the indicated level of evidence for percutaneous lumbar laser discectomy (PLLD) is II-2 for short- and long-term relief. Limitations: Even though laser discectomy has been in utilization for a number of years and numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials. Conclusion: This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression. Key words: Intervertebral disc disease, chronic low back pain, disc herniation, disc protrusion, radiculitis, contained disc herniation, mechanical disc decompression, percutaneous lumbar laser discectomy, laser assisted spinal endoscopy

Percutaneous cervical disc decompression

Cervical disc nucleoplasty is a significant and clinically demonstrated innovation in percutaneous disc decompression in case of non-herniated disc protrusions or prolpase. It allows a percutaneous decompression via a 19-gauge needle under utilization of the Coblation technique and under C-arm control. Until now the patients suffering of a cervicobrachialgia in cause of a disc prolapse had only the therapeutical solution between conservative treatment and monosegmental spondylodesis or disc prosthesis of the mentioned motion segment. We wanted to demonstrate a new and practicable anatomical pathway for reaching the cervical disc prolapse comparable to the technique for discography of the cervical spine. The introducer needle is advanced into the disc under fluoroscopic guidance using a standard anterior-lateral approach. The controller delivers radiofrequency energy to quickly ablate tissue at temperatures between 50 degrees and 60 degrees C. The decompression will be done in ablation mode by rotating the device through 180 degrees for 5 s in the posterior, medial and ventral third of the cervical disc. After failed conservative treatment over an average time period of 3 months we treated 26 patients with a contained herniated prolapse or protrusion with radicular arm pain by percutaneous decompression under utilization of the Coblation technique with a controlled energy plasma-mediated field. A randomized control group of 30 patients was treated alone conservatively with medical and physical therapy in the same period. The average preoperative VAS was 8.8. With a follow-up time of 2-years we found an average pain reduction with the visual pain score (VAS) of 2.3 who had a further check-up. The VAS was checked 24 h, 1 week, 3, 6, 12 and 24 months postoperatively. No complications with this method were seen. Comparable to the surgically treated group the conservative patients have had a VAS of 8.4. Under using conservative treatment with physical therapy, physiotherapy, analgetics and perineural injections we have had a diminution of the VAS to 5.1 after 2 years. The percutaneous decompression of the cervical disc protrusion with the Perc DC-Spine Wand by using the Coblation mode is a quick and safe procedure. Furthermore, one may state a persistent pain relief in the follow-up time up to 2 years after the percutaneous decompression of the disc.

Percutaneous cervical nucleoplasty in the treatment of cervical disc herniation

Percutaneous disc decompression procedures have been performed in the past. Various percutaneous techniques such as percutaneous discectomy, laser discectomy, and nucleoplasty have been successful. Our prospective study was directly to evaluate the results of percutaneous cervical nucleoplasty (PCN) surgery for cervical disc herniation, and illustrate the effectiveness of PCN in symptomatic patients who had cervical herniated discs. From July of 2002 to June of 2005, 126 consecutive patients with contained cervical disc herniations have presented at the authors' clinic and treated by PCN. The patients' gender distribution for PCN was 65 male, 61 female. The age of patients ranged from 34 to 66 years (mean 51.9 +/- 10.2 years). The levels of involvement were 21 cases at C3-4, 30 cases at C4-5, 40 cases at C5-6, and 35 cases at C6-7. The clinical outcomes, pain reduction and the segment stability were all recorded during this study. A clinical outcome was quantified by the Macnab standard and using VAS. The angular displacement (AD) > or =11 degrees or horizontal displacement (HD) > or =3 mm was considered to be radiographically unstable. In the results of this study, puncture of the needle into the disc space was accurately performed under X-ray guidance in all cases. There was one case where the Perc-D Spine Wand had broken in the disc space during the procedure. The partial Perc-D Spine Wand, which had broken in the disc space could not be removed by the percutaneous cervical discectomy and thus remained there. There were no recurrent cases or complications in our series. Macnab standard results were excellent in 62 cases, good in 41 cases and fair in 23 cases. The rate of excellent and good was 83.73%. The VAS scores demonstrated statistically significant improvement in PCN at the 2-week, 1, 3, 6, and 12-month follow-up visits when compared to preoperational values (P < 0.01). There were no cases of instability following the PCN procedure. There was no significant difference in stability either preoperatively or postoperatively (P > 0.05). Our findings confirm that PCN for the treatment of cervical disc herniation results in a good outcome without any tampering of the stability of the cervical spine. Hence, PCN as a procedure is safe, minimally invasive, less traumatic, requiring less time with an excellent clinical outcome. PCN should be performed for those patients who fail conservative medical management including medication, physical therapy, behavioral management, psychotherapy, and who are unwilling to undergo a more invasive technique such as spinal surgery.

Reassessment of Evidence Synthesis of Occupational Medicine Practice Guidelines for Interventional Pain Management

Background: Appropriately developed practice guidelines present statements of best practice based on a thorough evaluation of the evidence from published studies on the outcomes of treatments, which include the application of multiple methods for collecting and evaluating evidence for a wide range of clinical interventions and disciplines. However, the guidelines are neither infallible, nor a substitute for clinical judgment. While the guideline development process is a complex phenomenon, conflict of interest in guideline development and inappropriate methodologies must be avoided. It has been alleged that the guidelines by the American College of Occupational and Environmental Medicine (ACOEM) prevent injured workers from receiving the majority of medically necessary and appropriate interventional pain management services. An independent critical appraisal of both chapters of the ACOEM guidelines showed startling findings with a conclusion that these guidelines may not be applied in patient care as they scored below 30% in the majority of evaluations utilizing multiple standardized criteria. Objective: To reassess the evidence synthesis for the ACOEM guidelines for the low back pain and chronic pain chapters utilizing an expanded methodology, which includes the criteria included in the ACOEM guidelines with the addition of omitted literature and application of appropriate criteria. Methods: For reassessment, randomized trials were utilized as it was in the preparation of the guidelines. In this process, quality of evidence was assessed and recommendations were made based on grading recommendations of Guyatt et al. The level of evidence was determined utilizing the quality of evidence criteria developed by the U.S. Preventive Services Task Force (USPSTF), as well as the outdated quality of evidence criteria utilized by ACOEM in the guideline preparation. Methodologic quality of each individual article was assessed utilizing the Agency for Healthcare Research and Quality (AHRQ) methodologic assessment criteria for diagnostic interventions and Cochrane methodologic quality assessment criteria for therapeutic interventions. Results: The results of reassessment are vastly different from the conclusions derived by the ACOEM guidelines. The differences in strength of rating for the diagnosis of discogenic pain by provocation discography and facet joint pain by diagnostic facet joint nerve blocks is established with strong evidence. Therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis, therapeutic thoracic medial branch blocks, cervical interlaminar epidural steroid injections, caudal epidural steroid injections, lumbar transforaminal epidural injections, percutaneous and endoscopic adhesiolysis, and spinal cord stimulation qualified for moderate to strong evidence. Additional insight is also provided for evidence rating for intradiscal electrothermal therapy (IDET), automated percutaneous disc decompression, and intrathecal implantables. Conclusion: The reassessment and reevaluation of the low back and chronic pain chapters of the ACOEM guidelines present results that are vastly different from the published and proposed guidelines. Contrary to ACOEM’s conclusions of insufficient evidence for most interventional techniques, the results illustrate moderate to strong evidence for most diagnostic and therapeutic interventional techniques. Key words: Guidelines, evidence-based medicine, systematic reviews, ACOEM, interventional pain management, interventional techniques, guideline development, workers’ compensation, chronic pain guidelines, low back pain guidelines

Review of Occupational Medicine Practice Guidelines for Interventional Pain Management and Potential Implications

In the modern day environment, workers’ compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers’ compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. In 2004, workers’ compensation programs in all 50 states, the District of Columbia, and federal programs in the United States combined received an income of $87.4 billion while paying out only $56 billion in medical and cash benefits with $31.4 billion or 37% in administrative expenses and profit. Occupational diseases represented only 8% of the workers’ compensation claims and 29% of the cost. The American College of Occupational and Environmental Medicine (ACOEM) has published several guidelines; though widely adopted by WCPs, these guidelines evaluate the practice of medicine of multiple specialties without adequate expertise and expert input from the concerned specialties, including interventional pain management. An assessment of the ACOEM guidelines utilizing Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, the criteria developed by the American Medical Association (AMA), the Institute of Medicine (IOM), and other significantly accepted criteria, consistently showed very low scores (&lt; 30%) in most aspects of the these guidelines. The ACOEM recommendations do not appear to have been based on a careful review of the literature, overall quality of evidence, standard of care, or expert consensus. Based on the evaluation utilizing appropriate and current evidence-based medicine (EBM) principles, the evidence ratings for diagnostic techniques of lumbar discography; cervical, thoracic, and lumbar facet joint nerve blocks and sacroiliac joint nerve blocks; therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis; cervical interlaminar epidural steroid injections, caudal epidural steroid injections, and lumbar transforaminal epidural injections; caudal percutaneous adhesiolysis; abd spinal cord stimulation were found to be moderate with strong recommendation applying for most patients in most circumstances. The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system. Key words: Guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ, IOM, AMA, AGREE, workers’ compensation, chronic pain guidelines, low back pain guidelines

Epidural Fibrosis Following Percutaneous Disc Decompression with Coblation Technology

Complications reported from percutaneous disc decompression (PDD) include discitis, anaphylaxis (with chemonucleolysis), instability, increased back pain, and reherniation. To the best of our knowledge, there is no report of epidural fibrosis occurring with any of the many types of PDD. To document a case of epidural fibrosis following PDD with coblation technology (Nucleoplasty), a previously unreported complication of this procedure. Case report. Details are presented on a 46-year-old man's history, diagnostic test results, treatments, and progression of his symptoms. Following PDD with coblation technology at L5-S1, the patient noticed improvement in his left lower extremity radicular symptoms and low back pain. He continued to improve over the following week to near complete relief. He resumed his normal activities. Three months post treatment, he experienced a recurrence of his radicular pain with a diminished left Achilles reflex. A subsequent MRI showed improvement of the previous left paracentral protrusion at L5-S1 along with a new contrast enhancing soft tissue mass. This mass, consistent with epidural fibrosis, was located in the left antero-lateral spinal canal and encased the left S1 nerve root. On the patient's next follow-up visit, he reported spontaneous resolution in his symptoms. He had stopped all pain medications and returned to his usual activities. This case is the first reported occurrence of epidural fibrosis following percutaneous lumbar disc decompression.

Poster 112: Changes in Lumbar Intervertebral Disk Morphology Following Percutaneous Disk Decompression Using Coblation Technology

Objective: To evaluate anatomic changes in disks treated with percutaneous disk decompression using coblation technology. Design: Retrospective comparison of pretreatment and post-treatment magnetic resonance imaging (MRI). Setting: University spine clinic. Participants: Records of 60 consecutively treated patients were reviewed. 15 subjects were identified with both pre and post-treatment MRIs. Interventions: 2 physicians independently reviewed all 30 MRI scans on a 20-in monitor using MagicView imaging software.

Imaging for percutaneous lumbar disc decompression procedures

This article analyzes the proper use of imaging in the performance of procedures for disc decompression by minimally invasive techniques. The importance of obtaining and reviewing images before the procedure is discussed. Reviewed are the positioning, preparation, performance, and follow up of patients undergoing these procedures. The proper views on fluoroscopic imaging are highlighted, and examples are given of desirable images for performing these cutting edge techniques. Clinical pearls and pitfalls for those procedures are reviewed, and examples of proper imaging are shown.