Percutaneous nucleoplasty

Dr. Mohamed Mohi Eldin,
Professor Of Neurosurgery,
Cairo University
Percutaneous
Lumbar Nucleoplasty
for the Treatment of
Discogenic Pain

The General Recent Trend in
Spinal Surgery
 Toward reduction and minimalization
 The destructive effect on bony structures is
eliminated
 Scar formation is greatly reduced

Reducing the size of the
intervertebral disc
 Theoretically reduce the intradiscal pressure and
hence the pressure on the torn annulus
 Creating space necessary for disc retraction.
Percutaneous Discectomy

Percutaneous Discectomy for
Spinal Disc Decompression ?!
 By avoiding the spinal canal, avoided
complications
– infection
– Scarring (often responsible for recurrence of
pain)
 Can also be repeated in the same patient
without eliminating the option of traditional
surgery.
 Requiring only a short hospital stay.

Reducing the size of the IV disc
could be achieved by
 Chemical dissolution (chemodiscolysis, 1964)
 Mechanical aspiration of disc fragments
(percutaneous nucleotomy, discectomy, 1975,
1985, 2002),
 Coagulation (intradiscal electrothermal
annuloplasty -IDET)
 Drying (ozone)
 Evaporation (laser discectomy, 1987)
 Evaporation (Nucleoplasty, 2000)

Percutaneous Disc Therapy Products
> Intradiscal RF Annuloplasty
• Oratec - IDET
• Radionics - discTrode
> Percutaneous Disc Decompression
• Clarus - LASE
• Arthrocare - SpineWand
• Pain Concepts - Dekompressor

Intradiscal coblation therapy
Nucleoplasty®
 Emerged as
– an effective,
– minimally invasive,
– percutaneous technique
– for the treatment of LBP due to contained
herniated discs

Percutaneous
Coblation Disc Decompression
Nucleoplasty
 Is said to be
– safe
– mostly painless procedure,
– with rapid recovery
– on an out patient bases
 Utilizes Coblation technology
 Using radiofrequency energy
– in a less damaging,
– low-temperature environment

Percutaneous Nucleoplasty
 FDA clearance in December
1999
 Introduced in 2000
 Designed to vaporize the disc
nucleus
 RF Generator required
 Over 100,000 patients treated
world wide.
 With 60 - 80% success rate in
most publications..

Coblation Plasma Technology
(small radiofrequency energy)
 Create energised particles that have sufficient
energy to dissolve tissues inside the disc,
 Allows controlled tissue removal,

Coblation Nucleoplasty
 As the wand is going into NP,
vaporization at its end
occurs,
 As the wand is retracted, the
sides of the channel will have
collagen modulation and
shrinkage of the channel size

Coblation
Nucleoplasty
 Lower disc pressure
 Efficient disc
decompression,
 In an outpatient setting
 However, it takes some
time for the therapy to
show its effects

Nucleoplasty
Invokes
decompression,
collagen thermo-modulation
cytokine reduction
Does reduce intradiscal
pressure

Relative Advantages
 Minimal invasion and
trauma (17 G needle)
 No loss of disc height
 No heat injury to the
annulus or surrounding
end plates.

Indications:
Radicular/Axial Symptoms:
Contained lateral focal disc protrusion
Failed conservative therapy
Mild or no Neurological deficit.

Contra-Indications
 Disc height < 50%
 Severe disc degeneration
 Spinal stenosis
 Progressive or severe Neurological Deficit
 Contained herniated disc occupying one-third
or more of spinal canal
 Non-contained disc.
 Evidence of Infection or Coagulopathy
 Age < 18 and > 65

The Procedure
 Procedure is done under mild endovenous
sedation and lasts 20-30 minutes
 Local anaesthesia
 17 Gauge needle
 Ablation with the SpineWand (wire) through
the needle

Needle placement
in the L4–L5 interspace

Checking Nucleoplasty Spine-Wand placement prior to activating

Post Procedure Care
 Procedure-related symptoms. Resolve in 7-10 days
 7 days of pain medication and muscle relaxant
 No lifting, bending or rotating for 1 week.
 Possibly more serious problems
* Stiff neck
* Increasing pain
* Motor dysfunction
 Follow up at 1 week, 1 month, 3 & 6 month, 1 year.
 MRI at 6 months

Nucleoplasty
(Our Experience)
- Introduced Oct. 2005
- Lumbar discs (1-3 levels)

Follow up:
- Clinical follow up at 1 week, 1 month, 3 month, 6
month and 1 y.
- Comparing VAS score and Patient Satisfaction.
- Complications rate.
- MRI at 3 and 6 months

Results
Total patients = 100
Age Range = 20 yrs to 66 yrs
Mean Age = 39.68 yrs
Male : Female = 63 : 35
Average Reduction Score (1 month) = 5.428
Average Reduction Score (3 months) = 5.552
Average Reduction Score (6 months) = 5.451

Results
Difference in
Total VAS Score => 3
Patients No.
Improved Percentage
Post procedure 98 80 81.6 %
1 month
3 months
6 months
Post procedure Improvement
(Total cases = 98)

Results
Complications:
– 1 Patient with discitis
– 2 Patients had increased level of pain
– 2 Patient had numbness both legs for 3 months but
pain resolved
– 30 % Patients had minor symptoms like :
Localised pain, pain at site of injection, muscle spasm
and burning sensation. For up to 2 weeks
So only 1 % significant side effect
Over all satisfaction rate is 71 %

28 y M
back & left leg pain- 17m (VAS 7)
MRI showed L4/L5 central disc protrusion
Post Nucleoplasty, no pain after 3 months (VAS 0)
MRI showed significant reduction at 3 months
Pre
Post

45 y F.
Acute pain (VAS 10) on top of chronic back pain – 3m
MRI showed L5/S1 left para-central protrusion.
Nucleoplasty was done for L5-S1 disc
Significant improvement (VAS 0).
Pre Post

46 y M
back pain radiating to left leg - 10m (VAS 7)
MRI showed left paracentral protrusion at L5/S1 disc
Post Nucleoplasty, pain decreased to (VAS 3)
Pre Post

34 y M
LBP- 13 years (VAS 10)
MRI showed L4/L5 right paracenrtal protrusion.
No improvement after 6 month (VAS 8).
However his MRI showed minimal decrease of disc bulge
Pre Post

Failure of The Outcome
is not failure of the idea,
but it is either
1. Failure of the selection
2. Contiuation of active degeneration
3. Part of the 30% accepted outcome

To Conclude:
Which patient to consider ?
 Discogenic pain (axial/radicular) with no
significant neurological deficit
 Failed (8-12 weeks) conservative therapy.
 Contained disc (protrusion), no migration
or extrusion
 Disc height > 50 %
 Age < 60 y

Nucleoplasty is just
 A new weapon in our hand
 That will add to the treatment options
 In a properly selected case it can
decrease the chance of open
intervention by at least 50%, if not 70%

mmohi63@yahoo.com
mohamedmohieldin.com
mohamedmohieldin2.com

Percutaneous nucleoplasty

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Percutaneous nucleoplasty