Lumbar Disc Precision Treatment

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A variety of radiofrequency procedures have been developed for the treatment of discogenic pain. An ongoing limitation is the lack of a gold standard for proving discogenic pain, and the term "precision treatment" refers to treatment of a proven pain generator unlike treating "non-specific low back pain." Provocation discography is generally used in research but this procedure has its issues. 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, and level 3 evidence for intradiscal electrothermal annuloplasty for the treatment of discogenic pain. The author is not aware of any Musculoskeletal Medicine specialists in New Zealand using radiofrequency procedures for discogenic pain.

Lumbar Disc Innervation

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 Surgery

There are no sham controlled studies whatsoever for fusion surgery. There are not even any randomised controlled trials with an active control when disc pain has been proven. RCTs on non specific low back pain with an active control were negative. Therefore the benefit of fusion surgery for proven disc pain is unknown, and such surgery has no basis in any high level evidence.

Radiofrequency Procedures

Cooled Radiofrequency Biacuplasty

Two cooled RF electrodes are placed on the posterolateral sides of the annulus to coagulate the nociceptors of the neo-innervated tissue. A dumbbell shape is formed between the two RF probes to cover the posterior annulus. This procedure produces internal disc temperatures in excess of 45° C. Kapural et al used a setting of 50° C for 15 minutes, followed by individual monopolar lesions (RF energy transferred via one probe at a time in sequence) to extend the lateral extent of the central lesion set at 60°C for 2.5 minutes. They used intravenous sedation including midazolam, fentanyl, or propofol. But during the active heating portion of biacuplasty, subjects were awake and indicated whether pain was localized to the lesion area or if they had any other symptoms.

Cooled Radiofrequency Biacuplasty RCTs

Study	N	Arms	Selection Criteria	Results	Comments
Kapural et al 2013	59	Biacuplasty RF Sham RF	Positive provocative discography and negative control.	✅Positive study 6 months: Mean NRS decrease 2.78 vs 1.32, mean SF-36 increase 15. no significant improvement in ODI (except in post hoc <40 yo patients) Success: 29.6% vs 3.3% (15 point increase in SF-36 and 2 reduction in NRS	Extensive exclusion criteria (1894 screened), mainly due to BMI >30 and smoking. The sham procedure was slightly different (probes not placed in disc) Latter 16 had additional monopolar lesions Highest success in younger patients with single level disease Modest benefits only
Desai et al 2016	63	Biacuplasty RF + Medical Mx Medical Mx	Provocation discography	✅Positive study 6 months: Mean NRS decrease -2.4 vs -0.56, Treatment response 50% vs 18% 12 months: Mean NRS decrease -2.2, Treatment response 50% SF36 + 64% ODI	Not placebo controlled

Intradiscal Electrothermal Annuloplasty

in IDET a resistive coil is placed between the annulus and nucleus and along the posterior annulus. It is heated to 90 degrees, Putatively seals the fissure and denatures the annulus.

Intradiscal Electrothermal Annuloplasty RCTs

Study	N	Arms	Selection Criteria	Results	Comments
Freeman 2005	57	IDET 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	64	IDET 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

• DiscTRODE™ (radio-frequency electrode) is positioned within the posterior annulus
• The RF electrode is positioned in the middle of the nucleus. Temperature achieved may not be sufficient to denervate posterior annulus when the heat source is inside the nucleus

Lumbar Disc IN, discTRODE, Ramus Communicans RF RCTs

Study	N	Arms	Selection Criteria	Results
Barendse et al, 2001 (RCT)	13	Intranuclear RF Sham RF	1 x positive analgesic discography (>50% relief)	❌Negative study at 2 months
Kvarstein et al, 2009 (RCT)	10	discTRODE RF 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)	60	Ramus communicans RF 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

Also Ercelen evaluted 120 vs 360 seconds at 80 degrees and found no difference.

Mixed Radiofrequency Studies

Mixed Radiofrequency RCTs

Study	N	Arms	Selection Criteria	Results	Comments
Juch et al 2017	202	Combinations of heterogenous facet RF, SIJ RF, and for disc: Intradiscal Electrothermal Therapy or Biacuplasty Standardised exercise program	Positive provocative discography and negative control.	❌Negative study	This study is too heterogenous to made any sense of. Randomised before blocks because it would otherwise be “unethical”. MINT trials were hugely controversial

Intraosseous Basivertebral Nerve Ablation

This treatment is best thought of as treating endplate pain rather than disc pain, i.e. vertebrogenic pain. It is a more invasive treatment than other ablation procedures as the probe needs to go through bone, and there is a longer burning time. This treatment is very durable as the basivertebral nerve is unmyelinated and does not regenerate. There are no clinicians in New Zealand that offer or have training in this procedure.

Basivertebral Nerve Ablation RCTs

Study	N	Arms	Selection Criteria	Results	Comments
Fischgrund et al 2019	147	Basivertebral nerve thermal ablation Sham ablation	Modic type 1 or 2 changes	✅Positive study Responder rates at 3 months VAS ≥1.5cm in 65.4% At 2 years ODI ≥ 10 points in 76.4% ODI ≥ 20 points in 57.5% VAS ≥1.5cm in 70.2% At 5 years 66% had >50% pain reduction 47% had >75% pain reduction 34% had complete resolution	Follow up for 5 years Blinding maintained for 12 months Optional cross-over at 12 months

Intradiscal Therapies

A small sham controlled trial found intradiscal PRP to be modestly superior to sham for both pain and function. Controlled follow up was only to 8 weeks and at this point the current pain NRS difference was 0.22 vs 1.65 (5% vs 35% relief), and FRI difference was -0.92 vs -13.48. In uncontrolled follow up the benefits were maintained at one year. The only categorical data presented was the number of people "satisfied" which was 56% vs 18%. Selection criteria was flawed due to lack of pressure measurement and lack of excluding those with positive control discs.

Quiz

1 With regards to lumbar disc innervation, which is true?

	Disc innervation is localised to each level and does not cross levels.
	The sinuvertebral nerve has no autonomic supply
	The lateral aspects of the disc have the greatest nerve endings, a smaller number in the posterior aspect, and the least anteriorly.

2 With regards to lumbar disc RF, Which technique has the most evidence to support its use?

	Intranuclear radiofrequency ablation
	Intradiscal electrothermal therapy
	discTRODE
	Biacuplasty

Bottom Line

• Biacuplasty [Level 1]
• IDET [Level 3]
• intradiscal RF[Level 5]
• discTRODE [Level 5]
• Ramus communicans RF [Level 5]
• Fusion Surgery [Level 5]

See Also

• Sacroiliac Joint Precision Treatment
• Lumbar Facet Joint Precision Treatment
• Radiofrequency Neurotomy
• Causes and Sources of Chronic Low Back Pain
• Chronic Low Back Pain

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,