Lumbar Disc Precision Treatment: Difference between revisions

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1 x positive concordant provocation discography (pain >7/10 at 1/3 levels)
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Revision as of 16:02, 10 July 2020

Introduction

Leggett et al in 2015 found mixed evidence for radiofrequency procedures for discogenic pain. Helm et al in 2019 concluded that there was level 1 evidence for the use of biacuplasty for the treatment of discogenic pain.[1]

Lumbar Disc Innervation

Disc innervation.jpg

Sinuvertebral nerves, formed by a somatic root from ventral ramus and an autonomic root from grey ramus communicans. An ascending branch passes as far as the above vertebral disc. A descending branch supplies the disc at the level of entry

Fusion

There are no sham controlled studies. There are not even any randomised controlled trials with active controls when disc pain has been proven. RCTs on non specific low back pain were negative.[2] Therefore the benefit of fusion surgery for proven disc pain is unknown.

Radiofrequency Procedures

Intradiscal Electrothermal Annuloplasty

Intradiscal Electrothermal Annuloplasty RCTs
Study N Arms Selection Criteria Results Comments
Freeman 2005[3]

57

  1. IDET
  2. Sham IDET

Provocation CT discography with discrete annular tear or global degeneration

❌Negative study up to 6 months

  • More disabled population than Pauza.
  • Not clear if treating doctor was blinded.
  • Used cefazolin 100mg ?caused irritation.
  • Included patients with positive Waddell’s signs, workers comp, and pain up to 20 years.
  • No response in either group, so questions about metholodology (i.e. no placebo effect)
Pauza 2004[4]

64

  1. IDET
  2. Sham IDET

CT Provocation discography with posterior annular tear only

❓ “Positive” study, but modest improvements only

  • IDET: VAS 6.6 -> 4.2, 40% success for >50% pain relief.
  • Sham: VAS 6.5 -> 5.4. 33% success for >50% pain relief.
  • Statistical benefit but really very modest.
  • Using comparison of mean, many did not benefit at all.
  • Did not control for multilevel disease.
  • Highly selected population.

Lumbar Disc IN, discTRODE, Ramus Communicans RF

Lumbar Disc IN, discTRODE, Ramus Communicans RF RCTs
Study N Arms Selection Criteria Results
Barendse et al, 2001 (RCT)[5]

13

  1. Intranuclear RF
  2. Sham RF

1 x positive analgesic discography (>50% relief)

❌Negative study at 2 months

Kvarstein et al, 2009 (RCT)[6]

10

  1. discTRODE RF
  2. Sham RF

1 x positive concordant provocation discography (pain >7/10 at 1/3 levels)

❌ Negative study up to 12 months

Van Tilburg 2017, (RCT)[7]

60

  1. Ramus communicans RF
  2. Sham RF

1 x positive block at ramus communicans (decrease NRS 2 or more, placement confirmed with sensory and motor stimulation)

❌Negative study at 3 months

Bottom Line

References

  1. ↑ Helm Ii S, Simopoulos TT, Stojanovic M, Abdi S, El Terany MA. Effectiveness of Thermal Annular Procedures in Treating Discogenic Low Back Pain. Pain Physician. 2017;20(6):447-470…. and my opinion for Ramus communicans RF.
  2. ↑ Harris IA, Traeger A, Stanford R, Maher CG, Buchbinder R. Lumbar spine fusion: what is the evidence?. Intern Med J. 2018;48(12):1430-1434. doi:10.1111/imj.14120
  3. ↑ Freeman BJ. IDET: a critical appraisal of the evidence. Eur Spine J. 2006;15 Suppl 3(Suppl 3):S448-S457. doi:10.1007/s00586-006-0156-2
  4. ↑ Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J. 2004;4(1):27-35. doi:10.1016/j.spinee.2003.07.001
  5. ↑ Barendse GA, van Den Berg SG, Kessels AH, et al. Randomized controlled trial of percutaneous intradiscal radiofrequency thermocoagulation for chronic discogenic back pain: Lack of effect from a 90-second 70 C lesion. Spine 2001;26:287-92.
  6. ↑ Kvarstein G, Mawe L, Indahl A, et al. A randomized double-blind controlled trial of intra-annular radiofrequency thermal disc therapy – a 12-month follow-up. Pain 2009;145:279-86
  7. ↑ van Tilburg CW, Stronks DL, Groeneweg JG, Huygen FJ. Randomized sham-controlled, double-blind, multicenter clinical trial on the effect of percutaneous radiofrequency at the ramus communicans for lumbar disc pain. Eur J Pain. 2017;21(3):520-529. doi:10.1002/ejp.945
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