Percutaneous Coblation Disc Nucleoplasty

Babak Ashrafnejad MDFellowship in Pain MedicineAnesthesiologistCoblation NucleoplastyA Minimal Invasive Technique for Lumbar Disc DecompressionChymopapain Injections1964 Smith reported enzymatic dissolution of nucleus pulposus in humans.Percutaneous Nucleotomyl975 Hijikata first described in with good to excellent results in 68% of patients.Percutaneous Lumbar Discectomy 1985 Onik et al. introduced a nucleotome for percutaneous discectomy.Laser Disckectomy 1987 Choy and Ascher first used lasers to evaporate the nucleus pulposus. Nucleoplasty 2000 Arthrocare introduces an RF ablation device to vaporize the nucleus pulposus.Percutaneous Lumbar Discectomy 2002 Pain Concepts introduces a 1.5 mm probe for percutaneous discectomy.Percutaneous Disc Decompression HistoryLow Back Pain

approximately 80% of the population will experience at least one episode of low back pain in their lifetime

and

55% will suffer from low back pain associated with radicular syndromes

Conventional open discectomy, is considered the standard treatment for disc herniation induced LBP. In recent years there has been a general trend in spinal surgery toward reductionism and minimalization have been developedFor this purposeMinimally invasive intradiscal techniques that provide percutaneous approach to the disc

Percutaneous procedures premiumMinimally invasiveShort hospital stay Eliminate the risks of postoperative scarringCan be repeated in the same patient without precluding recourse to traditional surgery if they should fail

Plasma Disc Decompression/Nucleoplasty (PDD)Coblation NucleoplastyWhat Is The Nucleoplasty ?Nucleoplasty is a minimally invasive procedure that uses radiofrequency energy to ablate nucleus pulposus tissue in a controlled manner decreased intradiscal pressure

Reduction of pressure on compressed nerve roots TargetThrough the wand, one alternates power and voltage for two modes of actions:

Ablation at 125 VCoagulation at 65 V Coblation

AblationCoagulation

Coblation is a non-heat driven process in which

radiofrequency energy is applied to a conductive medium to generate a highly focused plasma field around the electrode at the tip of the Perc-D Spine WandRadiofrequency energy excites the electrolytes in a conductive medium, creating a precisely focused plasma.

The plasma's energized particles have sufficient energy to break molecular bond within tissue, causing tissue to dissolve at relatively low temperatures (typically 40C to 70C). The result is volumetric removal of target tissue with minimal damage surrounding tissue.

Many Coblation devices also are designed to stop blood (hemostasis) and coagulate or seal bleeding vessels.

This plasma field contains :Sufficient energy to cleave molecular bonds at low temperatures (40 - 70C) into various :

These gases escape through the introducer needleElementary molecules and low molecular weight gases, e.g. oxygen, nitrogen, hydrogen, and carbon dioxide.

Because radiofrequency current does not pass directly through tissue during the Coblation process, tissue heating is minimal. Most of the heat is consumed in the plasma layer, or in other words, by the ionization process.

These ions then bombard tissue in their path, causing molecular bonds to simply break apart and tissue to dissolve. Cooler TemperaturesThe effect of tissue removal from within the disc is hydraulic decompression of the disc.

Nucleous Material RemovalEmpty SpaceVacuum EffectHistologic Findings

Axial SagitalEquipmentA radiofrequency generator system

Wands

DLR / DLG Spine WandDc Spine WandThe Perc-D Spine Wand with 1 mm diameter and bipolar tip 17-gauge introducer needle

Active ElectrodeInsulatorReturn ElectrodetechniquePatient teaching what to expect :1- post-procedure2- Activity limitation

Intra venous Antibiotic30 -60 minutes before the procedure

positionProneSemi - Prone

Kambins Safe Triangle

A series of six channels is created within the disc, removing a portion of the nucleus pulposus.Coagulation mode is then applied to thermally seal the channels. This further decompresses the intervertebral disc.Approximately 1 cc of nuclear tissue (or 10% of the nucleus pulposus) is removed

Each channel is made in about 10 seconds duration for ablation and 10 second for coagolation

Patient SelectionPatient with unilateral sciatica with or without LBP for more than 6 months duration not responsive to conservative treatment. One symptomatic Contained disc herniation shown on MRI.Age : 18-50 y/oVAS > 50 (0-100)Disc Herniation no greater than 1/3 the saggital diameter of spinal canal & Axial symptomsDisc height > 50%Why The middle ages ?

40-60 y/o15-40 y/o60-75 y/o> 75 y/oNo DJd-Fibrous in AF-Pigment in NP-Mod DJd

-AF bulging to NP-Severe Djd-endplate disrup.-Brown pigment-reduct of Height-

Protruded Disc(Contained)Extruded Disc(Non-Contained)Sequestered Disc

Contained Protrusion : Sagittal diagram shows dome-shape of protrusion not exceeding levels of end-plates. Axial diagram shows dome-shaped protrusion limited to disc level, not visible in adjacent axial sections.a contained disc herniation, the disc material herniated through the inner annulus but not the outer annulus; the material is therefore contained, but still can distort the path of the nerve;

Extruded Non contained disc: Sagittal diagram shows caudal migration past end-plate indicating annular rupture.Axial images show domeshaped extrusion at disc level (a) extruded material visible below disc level in sectionthrough bony lateral recess (b).

a non contained herniation, the disc material penetrates both the inner and out layers of the annulus; the material may reside beneath the posterior longitudinal ligament or may penetrate through it, or can be sequestered as a free fragmen Contraindications/Exclusion CriteriaUncontrolled psychological disorders Evidence of instability of the segment (spondylolisthesis)Evidence of infectionSevere and progressive neurological deficit Previous spinal surgery(At/Adjacent)Evidence of spinal stenosisCoagulation disordersPregnancyContraindications/Exclusion CriteriaSpinal fracture or tumorExtruded discBone deformitiesDisc space narrowing more than 50%Morbid obesity (BMI>40)

Contraindications/Exclusion CriteriaEvidence of Cauda Equina SyndromeRadicular pain originated from more than 1 levelAxial pain > Radicular painNerve root injuryDiscitisInfection Bleeding Exacerbation of painFailure to relieve the pain (short/long term)Allergic reactions to injectates

Complications and risk factorsRest for 2 days with limited sitting and walking per day

No driving for at least 3 days.

for first 1 week : limit lifting of no more than 5 kgs, no bending and no twisting of the lower back.

Weeks number 2 and 3: physical activity is allowed, walking, swimming and driving for short distances, and return to work without severe exertion.

Follow-up visits : at 1 week, 1 month, 3 months, 6 months and 1 year intervals.Post procedure Follow upA brace is not required, since the annulus has not been compromised by the procedure. However, a number of Nucleoplasty centers are using a soft brace for two reasons:

1-The brace reminds the patient that they have had a minimally invasive procedure

2-they should allow their back to heal (as they progressively return to normal activities).

studiesPatients and methods: This study was performed on 29 patients (23 males and 6 females) with lumbar disc prolapse causing unilateral sciatica with or without lower back pain for duration more than 3 months with no response to conservative treatment (in the form of medications, bed rest, and physiotherapy) in the period from November 2006 to November 2008. The Perc-D Spine Wand with 1 mm diameter and bipolar tip was used for coblation and the coagulation on the disc utilizing both radiofrequency coblation technology and thermal technology using a radiofrequency Arthrocare generator system 2000 (Arthrocare Corporation, Sunnyvale, CA) to generate coblation and coagulation energy.Conclusion: Percutaneous image guided lumbar disc decompression using nucleoplasty technique seems to be an effective, safe, simple and minimal invasive procedure for relief of sciatica due to lumbar disc prolapse in well selected cases. Nonetheless a longer follow-up period and a larger number of patients is needed to assess the long-term efficacy of this procedure.Percutaneous image guided lumbar disc nucleoplasty:A minimal invasive technique for lumbar disc decompression Khaled Saeed Ebrahim, Amr AlShehaby, Mohamed A AlWardany, Ahmed Darwish, Mohamed Awad Department of Neurosurgery Ain Shams Faculty of Medicine Cairo Egypt PAN ARAB JOURNAL OF NEUROSURGERY , VOLUME 14, NO. 2, OCTOBER 2010From February 2001 to May 2003 we treated 1390 patients, males 43.5% and females 56.5%. They presented with lumbalgia and/or lumbosciatalgia due to disc bulging or partially contained disc herniation (989 cases in L4-L5 and 234 in L3L4, 167 in L5-S1) as shown by TAC and/or NMR investigations.They concluded that a safe volumetric removal of the nucleus is achievedPercutaneous nucleoplasty for discoradicular conflictA. Alexandre, L. Coro` , A. Azuelos, and M. PelloneEU.N.I. European Neurosurgical Institute, Treviso, Italy Acta Neurochir (2005) [Suppl] 92: 8386Methods Forty-two cases of protruded lumbar intervertebral disc treated by coblation nucleoplasty followed-up for two years were analysed. Relief of low back pain, leg pain and numbness after the operation were assessed by visual analogue pain scale (VAS). Function of lower limb and daily living of patients were evaluated by the Oswestry Disability Index.Conclusion Coblation nucleoplasty may have satisfactory clinical outcomes for treatment of protruded lumbar intervertebral disc for as long as two-year follow-up, but longer-term benefit still needs verification.

The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-upHui Zhu,Xiao-Zhong Zhou,Mao-Hua Cheng,Yi-Xin Shen,andQi-Rong Dong Int Orthop. Nov 2011; 35(11): 16771682.

13 pt with LBP

Conclusion: The improvement rates of VAS were 64.6% and 58.7% in 6 and 12 months respectively. Follow up MRI post procedurally revealed radiologic findings in correlation to the symptomatic improvement in all patientsPercutaneous disc decompression using nucleoplasty inpatients with low back pain P. Nikolopoulos, P. Maniatis, A. P. Giannila, A. D. Kelekis, J.Papailiou, C. Triantopoulou; Athens/GR 10.1594/ecr2012/C-2358Methods : Forty-six patients were enrolled in this study from April 2006 to June 2010. All patients had one-level HLD. Disc degeneration was graded on routine T2-weighted magnetic resonance Image (MRI) using the Pfirrmanns grading system and all index levels were grade 3 and grade 4. Indications for surgery were radiculopathy caused by disc protrusion with soft consistency. MRI was done at one month after the procedure in all patients to check post-PDCT change. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNabs criteria.

Results : The mean period of clinical follow-up was 21 months. The average preoperative VAS score for radiculopathy was 7.41.4, while the final follow-up VAS score was 1.40.7 (p