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Percutaneous nucleotomy: preliminary communication on a decompression probe (Dekompressor1) in percutaneous discectomy. Ten case reports
Journal of Clinical Imaging 29 (2005) 98 – 101
Percutaneous nucleotomy: preliminary communication on a decompression probe (Dekompressor1) in percutaneous discectomy. Ten case reports N. Amorettia,*, F. Huchota, P. Floryb, P. Brunnera, P. Chevalliera, J.N. Brunetona a
Service d’Imagerie Me´dicale, Centre Hospitalier Re´gional et Universitaire de Nice, Hoˆpital Archet, 151 route de Saint-Antoine de Ginestie`re, B.P. 3079, Nice Cedex 3 F-06202, France b Service de Rhumatologie, Centre Hospitalier Re´gional et Universitaire de Nice, Hoˆpital Archet, 151 route de Saint-Antoine de Ginestie`re, B.P. 3079, Nice Cedex 3 F-06202, France Received 20 July 2004; received in revised form 31 August 2004; accepted 13 September 2004
Abstract For the past years, new therapeutic options have been proposed secondary to the progress in the interventional imaging. The purpose of this article is to report a preliminary study on the use of the 1.5 mm ‘‘Dekompressor probe’’ (Stryker, Kalamazoo, MI, USA) in the percutaneous discectomy by decompression. We have conducted, from September 2003 to March 2004, a retrospective review on 10 patients (mean age of 49.8), chosen at random, presenting a nonextruded herniated disc resisting all medical treatments. The procedure is CT guided or performed under fluorosocopy, a discography is performed by introducing the probe at the level of the protruded disc. After local anesthesia, an incision of a few millimeters is performed, allowing the introduction of a coxial trocar to the level of the disc. The decompression probe is then introduced. No technical failure occurred. The results in our series show, in eight patients, a satisfactory result with a decrease of the initial VAS of more than 70% and a complete elimination of the medical therapy. Our preliminary results are encouraging but should also be confirmed by a multicentric based on a large series, and the criteria of inclusion or exclusion must be strictly respected to obtain satisfactory clinical results. D 2005 Elsevier Inc. All rights reserved. Keywords: Percutaneous discectomy; Percutaneous nucleotomy; Dekompressor; Interventional radiology
1. Introduction Lumbar sciatica produced by a herniated disc is the primary cause of infirmity in industrialized nations, with a secondary significant economic impact, to mention, the cost of the various treatments and days lost to work. The initial recommended therapy is based on the medical treatment by antiinflammatory and analgesic agents, rest, and reeducation. In case of the failure of these therapies, the classical alternative is surgical discectomy, which is associated with numerous risks inherent to the invasive procedure, such as infection, unsuccessful results, or recurrence secondary to postoperative fibrosis [1–3]. * Corresponding author. Tel.: +33 4 92 03 63 73. E-mail address: [email protected] (N. Amoretti). 1 Stryker, Kalamazoo, MI, USA. 0899-7071/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2004.10.024
For the past years, new therapeutic options have been proposed secondary to the progress in the interventional imaging [4 –7]. The first communication of the minidiscectomy by decompression is by Kenneth and Robert [8], who report satisfactory results regarding its clinical and functional efficacy. The purpose of our article is to report a preliminary study on the use of the 1.5-mm bDekompressor probeQ (Stryker, Kalamazoo, MI, USA) in the percutaneous discectomy by decompression, a procedure that was performed in 10 patients, with a follow-up of 6 to 12 months. 2. Patients and methods We have conducted, from September 2003 to March 2004, a retrospective review on 10 patients, chosen at
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
99
Table 1 Characteristics of patients with lumbar sciatica by herniated disc, changes in pain score and follow-up No.
Sex
Age
Clinical findings
Disc
Location of hernia
VAS Prenucl.my
Follow-up (months)
1 2 3 4 5 6 7 8 9 10
M M F M M M M F M M
43 39 64 49 38 24 50 54 64 54
Rt. sciatica L5 Lt. sciatica L5 Lt. sciatica L5 Lt. sciatica L5-S1 Lt. sciatica L4 Lt. sciatica S1 Rt. sciatica L5 Lt. sciatica S1 Lt. sciatica L5 Rt. sciatica L5
L4-L5 L5-S1 L4-L5 L5-S1 L4-L5 L5-S1 L4-L5 L5-S1 L5-S1 L5-S1
Preforam. Rt. foram. Lt. preforam. Postmedial Lt. extra-foram. Postmedial Postmedial Paramedial Lt. preforam. Rt. foram.
8 9 9 7 10 8 7 8 7 10
10 10 10 9 9 9 8 8 7 6
random, presenting with a lumbar sciatica from a nonextruded herniated disc resisting all medical treatments. Two women and eight men, with a mean age of 49.8 years and ranging from 24 to 63 years of age, have benefited
from a CT- or fluoroscopy-guided percutaneous discectomy. The criteria of inclusion in this review were the following: the patient was suffering from a lumbar sciatica of a discoradicular origin due to a herniated disc, documented by MRI, which resisted any medical therapy, showed no improvement after 3 weeks following CT-guided infiltration, with preoperative pain score (Visual Analog Scale,
Fig. 1. Preparation of the patient. Fig. 3. Introduction of the trocar.
Fig. 2. Discography.
Fig. 4. Positioning of the probe.
100
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
Fig. 5. Decompression probe.
VAS), satisfactory hydration (hypersignal T2 intradiscal), and maintained height of disc. The criteria of exclusion from the review were an extruded herniated disc, 50% superior discal pinching, progressive neurological deficit, instability of the spine, vertebral fracture, lumbar sciatica without demonstrable disco-radicular antagonism, disagreement between the MRI and clinical findings, abnormal coagulation time, and the presence of an infectious process. Following the procedure, a clinical evaluation of the progress of the radicular pain, measured by VAS, was conducted 24 and 48 h, 7 days, and 3 months, and after every 3 months. Observed is the reduction or the end of the analgesic treatment. The general characteristics of the patients treated by percutaneous nucleotomy are shown in Table 1. The procedure is CT guided or performed under fluoroscopy. The patient is in the prone position under a C-arm (Fig. 1), and a few scans are taken of the location of the disco-radicular problem to properly guide the way of approach. Following the usual cutaneous sterilization, a discography is performed (Fig. 2) by introducing the probe at the level of the protruded disc, in its latero-pedicular aspect or extra-foraminal, in relationship with the location of the hernia. After local anesthesia, an incision of a few millimeters is performed, allowing the introduction of a coaxial 17-g trocar to the level of the disc (Fig. 3). The trocar can be curved manually if the access to the disc is difficult, this, in particular, at the level of the lower lumbar segment. The decompression probe is then introduced through the coaxial trocar (Fig. 4), which, working like a continuous screw, enters the nucleus pulposus (Fig. 5). Once the probe is in place, its correct position is confirmed by CT. The rotational motor is then connected, and rotatory movements are created; at the same time, the radiologist moves the probe to and fro. The tissue of the nucleus pulposus is aspirated along the probe to reach its proximal
chamber (Fig. 6). The procedure ends when no more tissue is coming back, or when the radiologist thinks that the obtained decompression is satisfactory. The procedure lasts between 30 and 40 min. The patient remains hospitalized for 24 h, no postinterventional antibiotic therapy is administered, and any painkiller is progressively suspended in relationship with the VAS of the patient immediately after surgery.
3. Results No technical failure occurred, although some difficulty was found in a patient in whom the disc in L5 was incased between the high portion of the iliac bone; however, a curving of the trocar allowed its satisfactory introduction. No complications were observed immediately after the procedure, nor later. The results in our series show, in eight patients, a satisfactory result with a decrease of the initial VAS of more than 70% and a complete elimination of the medical therapy. The patients returned to their professional activity or their normal employment. A patient presented a definite early improvement with the fall of more than 80% of the VAS, which was, however, followed by a recurrence of the radicular pain, resisting all medical treatments and necessitated a surgical intervention after 2 weeks. A postnucleotomy MRI showed an extrusion of the disc material; retrospectively reviewing the prenucleotomy MRI, a transligament hernia could have been suspected. Another patient showed an initial improvement in the painful symptomatology, followed a month later by a recrudescence of the symptoms, which were alleviated by simple analgesic therapy.
4. Discussion The treatment of lumbar herniated discs has greatly improved in the past few years, thanks to the minimally invasive nucleotomies. The first was the chemical nucleolysis by papain, a procedure that was introduced in 1963 [4]. This treatment, which was very efficient, was discontinued because of secondary anaphylactic shock and fatal outcome.
Fig. 6. Removal of the nuclear tissue through the probe.
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
In 1975, Hijikata [5] introduced the first probe for manual nucleotomy, and in 1985, Onik et al. [6] presented an automatic probe with a suctioning and severing system, once it reached the nucleus pulposus. In 1987, Choy [7] proposed using a laser for obtaining a nucleotomy by vaporization: The probes or needles are positioned at the center of the disc and produce a decrease in the pressure in its periphery by diminishing the volume of the disc, thanks to the aspiration by the nucleotomy probe or by the laser vaporization. While the diameter of the first probe did not allow an approach through the foramina, the technique by laser resulted in a moderate decrease of the pressure. It should be mentioned that the positioning of the laser at the level of the intervertebral foramen can cause a thermal injury on the nerve. The new procedure by decompression that we present seems to us to offer several advantages: [a]
The greatest thickness of the probe is 16 g., or 1.5 mm, and this minimal diameter decreases the risk of injuring the posterior common vertebral ligament and the annulus, permitting a transcanal passage, if necessary. [b] The decompression probe and the trocar can be curved in the event of a more difficult approach. [c] The rotatory system of the probe allows an aspiration of the nucleus, not only in its medial and latero-medial aspects, but also in the foramen and the extra-foramen areas. In this manner, the hernia in the foramen can benefit from an efficient decompression without any risk of injuring the nerve. [d] The removal of a few cubic centimeters of the disc results in a significant decrease in the pressure in
[e]
101
the periphery of the disc and removes the discoradicular antagonism. Our results are comparable to those obtained by Kenneth and Robert [8].
Nonetheless, we recommend a rigorous patient selection: The conservation of a hydrated disc with a satisfactory volume is mandatory because a change in the volume of the nucleus would be followed by a decrease in its peripheral pressure. Our preliminary results are encouraging, but should also be confirmed by a multicentric study based on a large series, and the criteria of inclusion or exclusion must be strictly respected to obtain satisfactory clinical results.
References [1] Stolke D, Sollman WP, Seifert V. Intra- and post-operative complications in lumbar disc surgery. Spine 1989;14:56 – 9. [2] Ramirez LF, Thisted R. Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitals. Neurosurgery 1989;25:226 – 30. [3] Ramirez LF, Thisted R. Using a national health care data base to determine surgical complications in community hospitals: lumbar discectomy as an example. Neurosurgery 1989;25:218 – 25. [4] Smith L, Garvin PJ, Gesler RM, Jennings RB. Enzyme dissolution of the nucleus pulposus. Nature 1963;198:1311 – 2. [5] Hijikata S. Percutaneous nucleotomy A new concept technique and 12 years experience. Clin Orthop 1989;238:9 – 23. [6] Onik G, Helms CA, Ginsburg L, Hoaglund FT, Morris J. Percutaneous lumbar diskectomy using a new aspiration probe. AJR Am J Roentgenol 1985;144:1137 – 40. [7] Choy DS. Percutaneous laser disc decompression [PLDD]: 352 cases with an 8 1/2-year follow-up. J Clin Laser Med Surg 1985;13:17 – 21. [8] Kenneth M, Robert E. Percutaneous lumbar discectomy: clinical response in an initial cohort of fifty consecutive patients with chronic radicular pain. Pain Pract 2004;4:19 – 27.
Percutaneous nucleotomy: preliminary communication on a decompression probe (Dekompressor1) in percutaneous discectomy. Ten case reports N. Amorettia,*, F. Huchota, P. Floryb, P. Brunnera, P. Chevalliera, J.N. Brunetona a
Service d’Imagerie Me´dicale, Centre Hospitalier Re´gional et Universitaire de Nice, Hoˆpital Archet, 151 route de Saint-Antoine de Ginestie`re, B.P. 3079, Nice Cedex 3 F-06202, France b Service de Rhumatologie, Centre Hospitalier Re´gional et Universitaire de Nice, Hoˆpital Archet, 151 route de Saint-Antoine de Ginestie`re, B.P. 3079, Nice Cedex 3 F-06202, France Received 20 July 2004; received in revised form 31 August 2004; accepted 13 September 2004
Abstract For the past years, new therapeutic options have been proposed secondary to the progress in the interventional imaging. The purpose of this article is to report a preliminary study on the use of the 1.5 mm ‘‘Dekompressor probe’’ (Stryker, Kalamazoo, MI, USA) in the percutaneous discectomy by decompression. We have conducted, from September 2003 to March 2004, a retrospective review on 10 patients (mean age of 49.8), chosen at random, presenting a nonextruded herniated disc resisting all medical treatments. The procedure is CT guided or performed under fluorosocopy, a discography is performed by introducing the probe at the level of the protruded disc. After local anesthesia, an incision of a few millimeters is performed, allowing the introduction of a coxial trocar to the level of the disc. The decompression probe is then introduced. No technical failure occurred. The results in our series show, in eight patients, a satisfactory result with a decrease of the initial VAS of more than 70% and a complete elimination of the medical therapy. Our preliminary results are encouraging but should also be confirmed by a multicentric based on a large series, and the criteria of inclusion or exclusion must be strictly respected to obtain satisfactory clinical results. D 2005 Elsevier Inc. All rights reserved. Keywords: Percutaneous discectomy; Percutaneous nucleotomy; Dekompressor; Interventional radiology
1. Introduction Lumbar sciatica produced by a herniated disc is the primary cause of infirmity in industrialized nations, with a secondary significant economic impact, to mention, the cost of the various treatments and days lost to work. The initial recommended therapy is based on the medical treatment by antiinflammatory and analgesic agents, rest, and reeducation. In case of the failure of these therapies, the classical alternative is surgical discectomy, which is associated with numerous risks inherent to the invasive procedure, such as infection, unsuccessful results, or recurrence secondary to postoperative fibrosis [1–3]. * Corresponding author. Tel.: +33 4 92 03 63 73. E-mail address: [email protected] (N. Amoretti). 1 Stryker, Kalamazoo, MI, USA. 0899-7071/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2004.10.024
For the past years, new therapeutic options have been proposed secondary to the progress in the interventional imaging [4 –7]. The first communication of the minidiscectomy by decompression is by Kenneth and Robert [8], who report satisfactory results regarding its clinical and functional efficacy. The purpose of our article is to report a preliminary study on the use of the 1.5-mm bDekompressor probeQ (Stryker, Kalamazoo, MI, USA) in the percutaneous discectomy by decompression, a procedure that was performed in 10 patients, with a follow-up of 6 to 12 months. 2. Patients and methods We have conducted, from September 2003 to March 2004, a retrospective review on 10 patients, chosen at
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
99
Table 1 Characteristics of patients with lumbar sciatica by herniated disc, changes in pain score and follow-up No.
Sex
Age
Clinical findings
Disc
Location of hernia
VAS Prenucl.my
Follow-up (months)
1 2 3 4 5 6 7 8 9 10
M M F M M M M F M M
43 39 64 49 38 24 50 54 64 54
Rt. sciatica L5 Lt. sciatica L5 Lt. sciatica L5 Lt. sciatica L5-S1 Lt. sciatica L4 Lt. sciatica S1 Rt. sciatica L5 Lt. sciatica S1 Lt. sciatica L5 Rt. sciatica L5
L4-L5 L5-S1 L4-L5 L5-S1 L4-L5 L5-S1 L4-L5 L5-S1 L5-S1 L5-S1
Preforam. Rt. foram. Lt. preforam. Postmedial Lt. extra-foram. Postmedial Postmedial Paramedial Lt. preforam. Rt. foram.
8 9 9 7 10 8 7 8 7 10
10 10 10 9 9 9 8 8 7 6
random, presenting with a lumbar sciatica from a nonextruded herniated disc resisting all medical treatments. Two women and eight men, with a mean age of 49.8 years and ranging from 24 to 63 years of age, have benefited
from a CT- or fluoroscopy-guided percutaneous discectomy. The criteria of inclusion in this review were the following: the patient was suffering from a lumbar sciatica of a discoradicular origin due to a herniated disc, documented by MRI, which resisted any medical therapy, showed no improvement after 3 weeks following CT-guided infiltration, with preoperative pain score (Visual Analog Scale,
Fig. 1. Preparation of the patient. Fig. 3. Introduction of the trocar.
Fig. 2. Discography.
Fig. 4. Positioning of the probe.
100
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
Fig. 5. Decompression probe.
VAS), satisfactory hydration (hypersignal T2 intradiscal), and maintained height of disc. The criteria of exclusion from the review were an extruded herniated disc, 50% superior discal pinching, progressive neurological deficit, instability of the spine, vertebral fracture, lumbar sciatica without demonstrable disco-radicular antagonism, disagreement between the MRI and clinical findings, abnormal coagulation time, and the presence of an infectious process. Following the procedure, a clinical evaluation of the progress of the radicular pain, measured by VAS, was conducted 24 and 48 h, 7 days, and 3 months, and after every 3 months. Observed is the reduction or the end of the analgesic treatment. The general characteristics of the patients treated by percutaneous nucleotomy are shown in Table 1. The procedure is CT guided or performed under fluoroscopy. The patient is in the prone position under a C-arm (Fig. 1), and a few scans are taken of the location of the disco-radicular problem to properly guide the way of approach. Following the usual cutaneous sterilization, a discography is performed (Fig. 2) by introducing the probe at the level of the protruded disc, in its latero-pedicular aspect or extra-foraminal, in relationship with the location of the hernia. After local anesthesia, an incision of a few millimeters is performed, allowing the introduction of a coaxial 17-g trocar to the level of the disc (Fig. 3). The trocar can be curved manually if the access to the disc is difficult, this, in particular, at the level of the lower lumbar segment. The decompression probe is then introduced through the coaxial trocar (Fig. 4), which, working like a continuous screw, enters the nucleus pulposus (Fig. 5). Once the probe is in place, its correct position is confirmed by CT. The rotational motor is then connected, and rotatory movements are created; at the same time, the radiologist moves the probe to and fro. The tissue of the nucleus pulposus is aspirated along the probe to reach its proximal
chamber (Fig. 6). The procedure ends when no more tissue is coming back, or when the radiologist thinks that the obtained decompression is satisfactory. The procedure lasts between 30 and 40 min. The patient remains hospitalized for 24 h, no postinterventional antibiotic therapy is administered, and any painkiller is progressively suspended in relationship with the VAS of the patient immediately after surgery.
3. Results No technical failure occurred, although some difficulty was found in a patient in whom the disc in L5 was incased between the high portion of the iliac bone; however, a curving of the trocar allowed its satisfactory introduction. No complications were observed immediately after the procedure, nor later. The results in our series show, in eight patients, a satisfactory result with a decrease of the initial VAS of more than 70% and a complete elimination of the medical therapy. The patients returned to their professional activity or their normal employment. A patient presented a definite early improvement with the fall of more than 80% of the VAS, which was, however, followed by a recurrence of the radicular pain, resisting all medical treatments and necessitated a surgical intervention after 2 weeks. A postnucleotomy MRI showed an extrusion of the disc material; retrospectively reviewing the prenucleotomy MRI, a transligament hernia could have been suspected. Another patient showed an initial improvement in the painful symptomatology, followed a month later by a recrudescence of the symptoms, which were alleviated by simple analgesic therapy.
4. Discussion The treatment of lumbar herniated discs has greatly improved in the past few years, thanks to the minimally invasive nucleotomies. The first was the chemical nucleolysis by papain, a procedure that was introduced in 1963 [4]. This treatment, which was very efficient, was discontinued because of secondary anaphylactic shock and fatal outcome.
Fig. 6. Removal of the nuclear tissue through the probe.
N. Amoretti et al. / Journal of Clinical Imaging 29 (2005) 98–101
In 1975, Hijikata [5] introduced the first probe for manual nucleotomy, and in 1985, Onik et al. [6] presented an automatic probe with a suctioning and severing system, once it reached the nucleus pulposus. In 1987, Choy [7] proposed using a laser for obtaining a nucleotomy by vaporization: The probes or needles are positioned at the center of the disc and produce a decrease in the pressure in its periphery by diminishing the volume of the disc, thanks to the aspiration by the nucleotomy probe or by the laser vaporization. While the diameter of the first probe did not allow an approach through the foramina, the technique by laser resulted in a moderate decrease of the pressure. It should be mentioned that the positioning of the laser at the level of the intervertebral foramen can cause a thermal injury on the nerve. The new procedure by decompression that we present seems to us to offer several advantages: [a]
The greatest thickness of the probe is 16 g., or 1.5 mm, and this minimal diameter decreases the risk of injuring the posterior common vertebral ligament and the annulus, permitting a transcanal passage, if necessary. [b] The decompression probe and the trocar can be curved in the event of a more difficult approach. [c] The rotatory system of the probe allows an aspiration of the nucleus, not only in its medial and latero-medial aspects, but also in the foramen and the extra-foramen areas. In this manner, the hernia in the foramen can benefit from an efficient decompression without any risk of injuring the nerve. [d] The removal of a few cubic centimeters of the disc results in a significant decrease in the pressure in
[e]
101
the periphery of the disc and removes the discoradicular antagonism. Our results are comparable to those obtained by Kenneth and Robert [8].
Nonetheless, we recommend a rigorous patient selection: The conservation of a hydrated disc with a satisfactory volume is mandatory because a change in the volume of the nucleus would be followed by a decrease in its peripheral pressure. Our preliminary results are encouraging, but should also be confirmed by a multicentric study based on a large series, and the criteria of inclusion or exclusion must be strictly respected to obtain satisfactory clinical results.
References [1] Stolke D, Sollman WP, Seifert V. Intra- and post-operative complications in lumbar disc surgery. Spine 1989;14:56 – 9. [2] Ramirez LF, Thisted R. Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitals. Neurosurgery 1989;25:226 – 30. [3] Ramirez LF, Thisted R. Using a national health care data base to determine surgical complications in community hospitals: lumbar discectomy as an example. Neurosurgery 1989;25:218 – 25. [4] Smith L, Garvin PJ, Gesler RM, Jennings RB. Enzyme dissolution of the nucleus pulposus. Nature 1963;198:1311 – 2. [5] Hijikata S. Percutaneous nucleotomy A new concept technique and 12 years experience. Clin Orthop 1989;238:9 – 23. [6] Onik G, Helms CA, Ginsburg L, Hoaglund FT, Morris J. Percutaneous lumbar diskectomy using a new aspiration probe. AJR Am J Roentgenol 1985;144:1137 – 40. [7] Choy DS. Percutaneous laser disc decompression [PLDD]: 352 cases with an 8 1/2-year follow-up. J Clin Laser Med Surg 1985;13:17 – 21. [8] Kenneth M, Robert E. Percutaneous lumbar discectomy: clinical response in an initial cohort of fifty consecutive patients with chronic radicular pain. Pain Pract 2004;4:19 – 27.