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Percutaneous Discectomy
Fluoroscopic technique The SI joint should be approached from a slight superior and medial position The spinal needle is advanced into the inferior joint space under fluoroscopic visualization When two joint planes are encountered, aim for the medial component (inferior joint space)
CT Technique Patient prone
tomy, laser discectomy and IDET, Nucleoplasty and Stryker instruments. These procedures have a reported with varying success rate. They are associated with various limitations of their own. The Nucleoplasty procedure utilizes Coblation technology and Coagulation mode to decompress the intervertebral disc. As minimally invasive procedures become more widely used, it is important to understand the safety of these devices with respect to temperature measurements at the vital structures in and around the intervertebral disc tissue.
3 or 5 mm axial sections through SI joints Mark level of skin entry site at the same level as the inferior joint space Advance spinal needle into joint space
Selective Nerve Root Injection Indication - Relieve irritative radicular pain Contraindication - Spine infection - Uncorrected coagulopathy
Technique: Lumbar Nerve Root Injection Patient prone - Posterolateral approach Angle image intensifier to demonstrate pedicle with superior articular process below at midpoint of vertebra Direct needle 2-3rrun and slightly anterior to pedicle - Needle follows path of image intensifier Injection - 1-2 cc 1:1 mixture of steroid and preseivative free mixture of 0.25% bupivacaine
Technique: cervical Nerve Root Injection Patient supine - Can turn head slightly away from side of injection Anterolateral approach - Posterior to carotid space Oblique fluoroscopic projection Needle is directed toward posterior margin of neural foramen
Case Report A 55 year old male recently has begun to experience left-sided radiculopathy in an L3 distribution. He has a large far lateral disc herniation at L3 affecting the left exiting L3 nerve root. The patient had failed conservative medical management and presented for possible pain relief via percutaneous nucleoplasty. In the angio SUite, the patient was laid prone on the table and the back prepped and draped in the usual sterile fashion. Standard pre-medication was administered. Under fluoroscopic guidance, initially 25 gauge tuberculin needle followed by a 6 inch 22 gauge spinal needle followed ultimately by a 17 gauge 6 inch Crawford needle is used to access the disc. When the Crawford needle was placed inside the nucleus pulposus, at the junction of the nucleus and the annulus, intravenous contrast is administered. This discogram demonstrates the far lateral and posterior left-sided disc herniation. Contrast fills from side-to-side and throughout the disc. It is a normal appearing disc other than this large far as lateral disc herniation. Percutaneous discectomy is performed with the aid of the Arthrocare wand. A total of six passes are performed as is suggested by the manufacturer. Following percutaneous discectomy, the trocar is pulled back into the Crawford needle, selective nerve root block is performed using 2 cc of 0.25% preservative free Bupivacaine. The needle was removed and Syvek patch placed over the wound site. There is no hematoma. The patient tolerated the procedure well. Two weeks follow up after the procedure: The patient's pain significantly improved and was back to his active normal lifestyle.
References 10:30 a.m.
Percutaneous Discectomy Arra Steve Reddy, MD Beth Israel Deaconess Medical Center Boston, MA The Percutaneous decompression of herniated discs is a well-established clinical approach over the past twenty years. Several Percutaneous techniques are in practice including Chemonucleolysis, Percutaneous lumbar discec-
P318
1. Intervertebral Disc Temparature Measurements During Nucleoplasty and IDET Procedures. Duran N Yetkinler, MD PhD, Lori Brandt RN. Arthrocare corporation, Sunnyvale, CA. 2. Sherk HH et al: Laser diskectomy. Lasers in Orthopedic Surgery, Medical college of Pennsylvania. 16:5, 19932. 3. Choy DS: Percutaneous laser disc decompression (PLDD): Twelve years experience with 752 proce-
a.
b.
c.
d.
Figure (a,b). AP and lateral spot views of the spine at the level of L3/4 demonstrates the 17 gauge Crawford needle at the level of junction of arumlus and nucleus pulposus of the disc. (c,d) AP and lateral spot views of the spine at the level of L3/4 demonstrates the Arthrocare wand within the annulus.
P319
dures in 518 patients. J Clin Laser Med Surg 16(6):325331, 1988. 4. Choy DS et al.: Percutaneous laser disc decompression. Spine17:949, 1992. 5. Saal and Saal: Management of chronic discogenic low back pain with a thermal intradiscal catheter. SOAR, Physiatry Medical Group 382-389,1999 6. Onik G: Percutaneous lumbar diskectomy using a new aspiration probe. Am J Neuroradiology 6:290296,1985. 7. Brown D: Update on chemonucleolysis. Spine 21: 625-585, 1996 10:55 a.m. Management of Vertebral Body Compression Fractures Joshua A. Hirsch, MD Massachusetts General Hospital Boston, .MIl. Percutaneous vertebroplasty (PVP) is the injection of polymethylmethacrylate (PMMA), into a painful, structurally unstable vertebra, with the intention of stabilizing it and consequently relieving pain and restoring mobility. The first PVP was performed in France in 1984 by Deramond and coworkers (1), who reported success in treating an aggressive vertebral hemangioma. Soon thereafter, it was also being successfully performed by them for vertebral compression fracture due to osteoporosis, and tumor invasion.(2,3) In the early 1990's, physicians in the United States became interested in the use of PVP principally for osteoporotic vertebral compression fracture, which occurs annually in about 700,000 Americans, including 25% of postmenopausal women (4,5), and often produces psychologically and physically devastating pain, and an increased risk of death.(6-8) Although the pain of an acute fracture is usually relieved within several weeks by bedrest, anti-inflammatory and analgesic medications, calcitonin injections, or external bracing, it can occasionally remain so severe that some quality of life can be maintained only with a narcotic analgesic medication.(9-11) Moreover, prolonged immobilization by a fracture can have harmful effects, such as acceleration of bone resorption with increased risk for a new fracture, pneumonia, and decubitus problems. 0,12) PVP for the treatment of vertebral compression fracture caused by osteoporosis or tumor invasion, or by a primary infiltrative process with or without collapse (e.g., vertebral hemangioma) has grown rapidly. This appears to be due to a combination of factors, including the fact that the procedure has been developed and popularized by interventional neuroradiologists who already posses the substantial training and experience needed to master this technology.(13-17) This assessment reviews the biomechanical and clinical studies of PVP that have been published in English in
P320
the scientific literature, for the purpose of determining whether this procedure and state-of the-art devices are safe and effective. The biomechanical properties of uncollapsed and collapsed, normal and osteoporotic vertebral bodies from adult human cadavers have been determined before and after the injection of PMMA into them. Dean and coworkers (18) found that the injection of PMMA into 1 or 2 bodies of 4 adjacent, intact, essentially normal lumbar vertebrae from 9 cadavers strengthened the injected vertebrae against initial fracture (p < 0.01) and subsequent collapse (p < 0.05), as compared to noninjected vertebrae. Tohmeh and coworkers (19) found that the injection of PMMA into separated, crushed, osteoporotic vertebral bodies from 10 female cadavers significantly strengthened and stiffened the injected venebrae, as compared to crushed, non-injected venebrae (significance level set at p :S 0.05). Belkoff and coworkers (20) found that the injection of PMMA into separated, crushed, osteoporotic vertebral bodies from 9 human female cadavers Significantly strengthened the injected vertebrae, as compared to crushed, non-injected vertebrae. Certain formulations restored vertebral stiffness while others significantly reduced vertebral stiffness (significance level set at p < 0.05). The findings of 11 clinical studies of PVP are summarized in the follOWing table. Five were prospective studies involving a total of 115 patients - 78 with osteoporotic compression fracture, and 37 with tumor invasion. Six were case series involving a total of 367 patients - 210 with osteoporotic compression fracture, 136 with tumor invasion, 19 with hemangioma, and 2 for postsurgical consolidation. The mean follow-up periods after PVP ranged from 4.2 to 48 months in the five prospective studies (115 patients) and from 5.7 to 30 months in five of the six case series (329 patients); follow-up was limited to the immediate period after PVP in one case series (38 patients). In four prospective studies involVing a total of 78 patients with osteoporotic compression fracture, pain assessment scores were Significantly improved after PVP; in five case series involving a total of 148 patients with osteoporotic compression fracture, 78 to 95% of· the patients described moderate-to-complete pain relief after PVP; and in one case series involving 105 patients with osteoporotic compression fracture, 78% of the patients reportedly had satisfactory results based on reduction of analgesic drug dosage after PVP. In one prospective study involving 37 patients with tumor invasion, 97% of the patients described partial or complete pain relief in the immediate period after PVP, with relief subsequently being maintained in most; in one case series involVing 20 patients with tumor invasion, 65%· of the patients described complete pain relief after PVP; in one case series involVing 8 patients with tumor invasion, 50% of the patients described significant pain relief after PVP; in one case series involving a total of 32 patients with tumor invasion, 72% of the patients reportedly had clear im-
CT Technique Patient prone
tomy, laser discectomy and IDET, Nucleoplasty and Stryker instruments. These procedures have a reported with varying success rate. They are associated with various limitations of their own. The Nucleoplasty procedure utilizes Coblation technology and Coagulation mode to decompress the intervertebral disc. As minimally invasive procedures become more widely used, it is important to understand the safety of these devices with respect to temperature measurements at the vital structures in and around the intervertebral disc tissue.
3 or 5 mm axial sections through SI joints Mark level of skin entry site at the same level as the inferior joint space Advance spinal needle into joint space
Selective Nerve Root Injection Indication - Relieve irritative radicular pain Contraindication - Spine infection - Uncorrected coagulopathy
Technique: Lumbar Nerve Root Injection Patient prone - Posterolateral approach Angle image intensifier to demonstrate pedicle with superior articular process below at midpoint of vertebra Direct needle 2-3rrun and slightly anterior to pedicle - Needle follows path of image intensifier Injection - 1-2 cc 1:1 mixture of steroid and preseivative free mixture of 0.25% bupivacaine
Technique: cervical Nerve Root Injection Patient supine - Can turn head slightly away from side of injection Anterolateral approach - Posterior to carotid space Oblique fluoroscopic projection Needle is directed toward posterior margin of neural foramen
Case Report A 55 year old male recently has begun to experience left-sided radiculopathy in an L3 distribution. He has a large far lateral disc herniation at L3 affecting the left exiting L3 nerve root. The patient had failed conservative medical management and presented for possible pain relief via percutaneous nucleoplasty. In the angio SUite, the patient was laid prone on the table and the back prepped and draped in the usual sterile fashion. Standard pre-medication was administered. Under fluoroscopic guidance, initially 25 gauge tuberculin needle followed by a 6 inch 22 gauge spinal needle followed ultimately by a 17 gauge 6 inch Crawford needle is used to access the disc. When the Crawford needle was placed inside the nucleus pulposus, at the junction of the nucleus and the annulus, intravenous contrast is administered. This discogram demonstrates the far lateral and posterior left-sided disc herniation. Contrast fills from side-to-side and throughout the disc. It is a normal appearing disc other than this large far as lateral disc herniation. Percutaneous discectomy is performed with the aid of the Arthrocare wand. A total of six passes are performed as is suggested by the manufacturer. Following percutaneous discectomy, the trocar is pulled back into the Crawford needle, selective nerve root block is performed using 2 cc of 0.25% preservative free Bupivacaine. The needle was removed and Syvek patch placed over the wound site. There is no hematoma. The patient tolerated the procedure well. Two weeks follow up after the procedure: The patient's pain significantly improved and was back to his active normal lifestyle.
References 10:30 a.m.
Percutaneous Discectomy Arra Steve Reddy, MD Beth Israel Deaconess Medical Center Boston, MA The Percutaneous decompression of herniated discs is a well-established clinical approach over the past twenty years. Several Percutaneous techniques are in practice including Chemonucleolysis, Percutaneous lumbar discec-
P318
1. Intervertebral Disc Temparature Measurements During Nucleoplasty and IDET Procedures. Duran N Yetkinler, MD PhD, Lori Brandt RN. Arthrocare corporation, Sunnyvale, CA. 2. Sherk HH et al: Laser diskectomy. Lasers in Orthopedic Surgery, Medical college of Pennsylvania. 16:5, 19932. 3. Choy DS: Percutaneous laser disc decompression (PLDD): Twelve years experience with 752 proce-
a.
b.
c.
d.
Figure (a,b). AP and lateral spot views of the spine at the level of L3/4 demonstrates the 17 gauge Crawford needle at the level of junction of arumlus and nucleus pulposus of the disc. (c,d) AP and lateral spot views of the spine at the level of L3/4 demonstrates the Arthrocare wand within the annulus.
P319
dures in 518 patients. J Clin Laser Med Surg 16(6):325331, 1988. 4. Choy DS et al.: Percutaneous laser disc decompression. Spine17:949, 1992. 5. Saal and Saal: Management of chronic discogenic low back pain with a thermal intradiscal catheter. SOAR, Physiatry Medical Group 382-389,1999 6. Onik G: Percutaneous lumbar diskectomy using a new aspiration probe. Am J Neuroradiology 6:290296,1985. 7. Brown D: Update on chemonucleolysis. Spine 21: 625-585, 1996 10:55 a.m. Management of Vertebral Body Compression Fractures Joshua A. Hirsch, MD Massachusetts General Hospital Boston, .MIl. Percutaneous vertebroplasty (PVP) is the injection of polymethylmethacrylate (PMMA), into a painful, structurally unstable vertebra, with the intention of stabilizing it and consequently relieving pain and restoring mobility. The first PVP was performed in France in 1984 by Deramond and coworkers (1), who reported success in treating an aggressive vertebral hemangioma. Soon thereafter, it was also being successfully performed by them for vertebral compression fracture due to osteoporosis, and tumor invasion.(2,3) In the early 1990's, physicians in the United States became interested in the use of PVP principally for osteoporotic vertebral compression fracture, which occurs annually in about 700,000 Americans, including 25% of postmenopausal women (4,5), and often produces psychologically and physically devastating pain, and an increased risk of death.(6-8) Although the pain of an acute fracture is usually relieved within several weeks by bedrest, anti-inflammatory and analgesic medications, calcitonin injections, or external bracing, it can occasionally remain so severe that some quality of life can be maintained only with a narcotic analgesic medication.(9-11) Moreover, prolonged immobilization by a fracture can have harmful effects, such as acceleration of bone resorption with increased risk for a new fracture, pneumonia, and decubitus problems. 0,12) PVP for the treatment of vertebral compression fracture caused by osteoporosis or tumor invasion, or by a primary infiltrative process with or without collapse (e.g., vertebral hemangioma) has grown rapidly. This appears to be due to a combination of factors, including the fact that the procedure has been developed and popularized by interventional neuroradiologists who already posses the substantial training and experience needed to master this technology.(13-17) This assessment reviews the biomechanical and clinical studies of PVP that have been published in English in
P320
the scientific literature, for the purpose of determining whether this procedure and state-of the-art devices are safe and effective. The biomechanical properties of uncollapsed and collapsed, normal and osteoporotic vertebral bodies from adult human cadavers have been determined before and after the injection of PMMA into them. Dean and coworkers (18) found that the injection of PMMA into 1 or 2 bodies of 4 adjacent, intact, essentially normal lumbar vertebrae from 9 cadavers strengthened the injected vertebrae against initial fracture (p < 0.01) and subsequent collapse (p < 0.05), as compared to noninjected vertebrae. Tohmeh and coworkers (19) found that the injection of PMMA into separated, crushed, osteoporotic vertebral bodies from 10 female cadavers significantly strengthened and stiffened the injected venebrae, as compared to crushed, non-injected venebrae (significance level set at p :S 0.05). Belkoff and coworkers (20) found that the injection of PMMA into separated, crushed, osteoporotic vertebral bodies from 9 human female cadavers Significantly strengthened the injected vertebrae, as compared to crushed, non-injected vertebrae. Certain formulations restored vertebral stiffness while others significantly reduced vertebral stiffness (significance level set at p < 0.05). The findings of 11 clinical studies of PVP are summarized in the follOWing table. Five were prospective studies involving a total of 115 patients - 78 with osteoporotic compression fracture, and 37 with tumor invasion. Six were case series involving a total of 367 patients - 210 with osteoporotic compression fracture, 136 with tumor invasion, 19 with hemangioma, and 2 for postsurgical consolidation. The mean follow-up periods after PVP ranged from 4.2 to 48 months in the five prospective studies (115 patients) and from 5.7 to 30 months in five of the six case series (329 patients); follow-up was limited to the immediate period after PVP in one case series (38 patients). In four prospective studies involVing a total of 78 patients with osteoporotic compression fracture, pain assessment scores were Significantly improved after PVP; in five case series involving a total of 148 patients with osteoporotic compression fracture, 78 to 95% of· the patients described moderate-to-complete pain relief after PVP; and in one case series involving 105 patients with osteoporotic compression fracture, 78% of the patients reportedly had satisfactory results based on reduction of analgesic drug dosage after PVP. In one prospective study involving 37 patients with tumor invasion, 97% of the patients described partial or complete pain relief in the immediate period after PVP, with relief subsequently being maintained in most; in one case series involVing 20 patients with tumor invasion, 65%· of the patients described complete pain relief after PVP; in one case series involVing 8 patients with tumor invasion, 50% of the patients described significant pain relief after PVP; in one case series involving a total of 32 patients with tumor invasion, 72% of the patients reportedly had clear im-