Treating Chronic Back Pain: New Knowledge, More Choices

MBBS, MD (Anesthesiology), FIPP

Director. Interventional Pain and Spine Centre
New Delhi ,India

www.ipscindia.com
 Normal Architecture of the Disc

 Pathophysiology of Disc related pain

 Intradiscal Procedures for

 Discogenic pain
 Herniated disc
 INTERVERTEBRAL
DISC

Nucleous Pulposus

 Irregular network of collagen fibers type II

(viscocity) > type I and elastin fibers

 Proteoglycans( Agrrecan)-Osmotic properties

to resist compression

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ANNULUS FIBROSUS

 Callagen fibers type I (Thickness) > type II

 Runs oblique in alternating direction

---Tensile strength

 Also contains some proteoglycans and

Elastin fibers
 END PLATE

 Approx 1 mm thick
 Considered part of disc rather than body
 Made up of hyaline cartilage mostly (young) and
fibrocartilage (old)
 The collagen fibers of the inner 2/3rds of the
annulus form the fibro cartilaginous component
of the VEP
LUMBAR INTERVERTEBRAL
DISC
- NERVE INNERVATION

 Outer 1/3rds of the annulus circumferentially

 Posterior plexus - Sinuvertebral nerves stems from Rami
Communicans
 Anterior plexus formed by bridging of sympathetic trunks and
the proximal ends of the GRCs
BLOOD SUPPLY AND
NUTRITION

Capillaries arise in
Vertebral body Diffusion

O 2 and glucose
Penetrates Subchondral
Bone
Lactic acid

Terminates at Vertebral End

Plates
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 Pathophysiology

Disc Degeneration –Internal Disc Disruption-

Discogenic pain- Disc Herniation
Pathophysiology-
Disc Degeneration

Decrease in end plate Permiability

Failure of nutrient supply

&
Accumulation of waste

Low p H

Injury
-
DISC
DEGENERATION
 Loss of Proteoglycan &
collagen and degradation

 Fall in osmotic pressure

of disc matrix

No longer behaves


hydrostatically under load

 Loose height and fluid

more rapidly

 Stress concentration along

End plates and Annulus

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INTERNAL DISC DISRUPTION
PATHOPHYSIOLOGY-
INTERNAL DISC
DISRUPTION

 Normal Disc – Pressure evenly distributed along end

plates and annulus

• Degenerated disc – Uneven stress across End

plates and annulus –Fissures and Tear
INTERNAL DISC
DISRUPTION

 Annular tear and fissures

PATHOPHYSIOLOGY-
DISCOGENIC PAIN

Only outer 1/3 is

innervated

Now the whole

disc
can feel

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RISK FACTORS –DISC
DEGENERATION

Age:
Vascular changes e.g. Atherosclerosis
End Plate changes e.g. calcification
Sub cortical sclerosis

Genetic factors :

Aggrecan gene polymorphism

 RISK
FACTORS
Life style:
Prolonged
sitting Lack of Exercise
Obesity

Smoking

Smoking and IVD Degeneration .Spine 1991: Sep; 16(9): 1015-21

Sally Roberts, Jill P.G. Urban
 Aging of Disc Degeneration of Disc
• Affects Nucleous • Annulus & End plates

• Increased proteoglycan • Concentric or radial tear in the

fragmentation and water annulus, Inwards buckling of
content is decreased annulus & radial bulging of outer
annulus
• Nucleus is gradually • Endplate defects & vertical
replaced by collagen bulging of endplates into the
fibers. adjacent vertebral bodies.

• Disc height is
maintained. • Reduced disc height

• Look black on T2 • Look black on T2 weighted

weighted image of MRI image of MRI
Investigations
Plain Radiographs
C T SCAN

•The vacuum disc phenomenon

•Loss of disc height.

•Secondary findings of disc degeneration,

Endplate sclerosis
Osteophyte formation
MRI

 Test of Choice

 Architecture of Disc
 Disruption of endplates

 Secondary changes

 Herniation
MRI
HIZ

Fibrovascular ingrowth into region of Annular tear

The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar

intervertebral disc on MR imaging in the patient with discogenic low back pain.
Eur Spine J. 2005 Jul 27
MRI MODIC CHANGES SECONDARY
TO DISC DEGENERATION

Type- I  Low signal in T1-weighed

sequences and high signal in T2)---edema.

Type II  High signal in T1-weighed sequences

and either high or intermediate signal in T2)
---fatty replacement

Type III  Low signal in T1 and low signal

in T2--sclerotic changes.
 FACET ARTHROPATHY
SECONDARY TO DISC
MRI DEGENERATION
 Disc bears 80% of weight
 Facet joints bears 20 % of weight

A change in the intervertebral disc produces

Change in the whole motion segment
MRI

 Ligamental Buckling Degenerative Changes –

Intraspinal Ligaments
GRADES OF DISC
DEGENERATION

Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration

SPINE Volume 26, Number 17, pp 1873–1878
MODIFIED PFIRRMANN GRADING
SYSTEM-
8 GRADES

Modified Pfirrmann Grading System for Lumbar Intervertebral Disc Degeneration

Spine: 15 November 2007 - Volume 32 - Issue 24 - pp E708-E712
Intradiscal Procedures
DISCOGRAPHY
DISCOGRAPHY -3 COMPONENTS
PROVOCATIVE DISCOGRAPHY-
DERBY’S CLASSIFICATION-
PAIN PROVOCATION AND
DISCOMETRY

 Pain @ <15 psi - chemically

sensitive

 Pain @ 15-50 psi - mechanically

sensitive

 Pain @ 51-90 psi - intermediate

 Pain @ >90 psi - normal disc

 No Pain - normal disc

POST DISCOGRAPHY CT SCAN-(3RD
STEP)
MODIFIED DALLAS GRADES
Site and Extent of Tear

 Grade 0 – Normal disc, cotton ball appearance

 Grade 1 – Radial tear upto inner 1/3 of AF
 Grade 2 – Radial tear upto middle 1/3 of AF
 Grade 3 – Radial tear upto outer 1/3 of AF, but
extends < 30 degrees of disc circumference
 Grade 4 – Radial tear upto outer 1/3 of AF &
extends > 30 degrees of disc circumference
 Grade 5 – Radial tear with extra-annular leakage
into epidural space.

Disc stimulation + Discography = Provocative Discography

Step 1 and 2 Step 3
 Interventions for
Discogenic pain Contained Disc
Herniation
Level of Description Implications
Evidence
1A + RCT’s( good quality) . Benefit >> Risk
1B + RCT’s(methodological weakness). Benefit >> Positive
Risk

Recommendations
2B + RCT’s(methodological weakness). Benefit >
Risk Level of Evidence

2B + RCT’s(methodological weakness). Considered

Contradictory results
2C + Observational Studies. No conclusive
evidence
0 Case reports. Insufficient evidence Only study related
2C - Observational studies- no effectiveness Negative
IDET
 Indication
 Mild to moderate Degeneration
 Absent radicular symptom

 Positive discogram  1week-IDET

 Contraindication
 Large disc herniation
 Canal stenosis

 Disc height loss > 50%

 Mechanism of Action
 strengthen the collagen fibers,
 Seal fissures,
 denature inflammatory exudates, or coagulate
nociceptors
Temperature- 65
degree to 90
degree

16 min

Nerve fiber
damage

Stabilization of
fissures
 Saal JS, Saal JA. Management of chronic discogenic low back pain
with a thermal intradiscal catheter: a preliminary report. Spine.
2000;25:382-8

 Freeman BJ, Fraser RD, Cain CM. et al. A randomized, double-blind,

controlled trial: intradiscal electrothermal therapy versus placebo
for the treatment of chronic discogenic low back pain. Spine.
2005;30:2369-77

 Nunley PD, Jawahar A, Brandao SM. et al. Intradiscal electrothermal therapy

(IDET) for low back pain in worker's compensation patients: can it provide
a potential answer? Long-term results. J Spinal Disord Tech. 2008;21:11-8
POSTERIOR ANNULOPLASTY
 Electrodes (Disctrode) – Placed in Posterior
Annulus
NUCLEOPLASTY
OR
RF COBLATION
 Bipolar radiofrequency probe
 Coblation (molecular

dissociation) technology
to ablate tissue
 Thermal energy for

coagulation
Perc-D Spine Wand

•125 V of Energy
•60-70 degree
(Courtesy of Arthrocare Spine, Sunnyvale, CA.)
NUCLEOPLASTY
OR
RF COBLATION

 Indication
 Discogenic pain
with contained disc
herniation
(No prospective randomized controlled studies for purely
Discogenic pain)

 Contraindication
 Extruded disc

 Disc herniation >33 %

of sagittal diameter of spinal canal
BIACUPLAST
Y

Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for the

treatment of Lumbar Discogenic Pain. PainPractice J. 2007;7:130–135.
Insufficient number of studies about its efficacy and
safety the preliminary findings show that this method
was effective and safe.

Kapural L, Mekhail N. Novel Intradiscal Biacuplasty (IDB) for

the Treatment of Lumbar Discogenic Pain. Pain Practice.
2007;7:130-4

Kapural L, Ng A, Dalton J. et al. Intervertebral disc biacuplasty for the

treatment of lumbar discogenic pain: results of a six-month follow-
up. Pain Med. 2008;9:60-7
Intradiscal Injections

INTRADISCAL
STEROID

• Prevent Inflammatory cascade

• Modic Type – I

•Eur Spine J (2007) 16:925–931

Buttermann GR (2004) The effect of spinal steroid injections for Degenerative
disc disease. Spine J 4:495–505
Intradiscal Injections
METHYLENE
BLUE

• Weak Neurolytic effect

• Inhibition of Guanylate Cyclase

and NO synthesis

PAIN: Volume 149, Issue 1 , Pages 124-129, April

2010
Intradiscal Injections
INTRADISCAL
OZONE

 Anti-inflammatory properties

 Primary Indicaction is Radicular Pain.

Eur J Radiol 2009 Dec; 72(3) :499-504.

INTRADISCAL PROCEDURES FOR DISC
PROLAPSE
INDICATIONS OF PERCUTANEOUS
MECHANICAL DISC DECOMPRESSION

 Unilateral leg pain greater than back pain.

 Radicular symptoms in a specific dermatomal
distribution that correlates with MRI findings.
 Positive straight leg raising test or positive bowstring
sign, or both.
 No improvement after 6 weeks of conservative therapy.
 Imaging studies (CT, MRI, discography) indicating a
subligamentous contained disc herniation.
 Well maintained disc height of 60%.
PERCUTANEOUS DISC DECOMPRESSION

 Rotating probe is inserted through needle

into the disc under X-Ray/ Fluoroscopic
guidance

 Rotating tip removes small portion of disc

material.

 Because only enough of the disc is removed to

reduce pressure inside the disc, the spine
remains stable.
NUCLEOTOMY

 The herniation suctioned

toward the probe where an
integrated knife then cuts it
away from the disk. The
material is then suctioned
away
HYDRODISCECTOMY
 Cutting with water fluidJet technology
 uses the Venturi Effect created by high velocity saline
jets to cut and aspirate targeted tissue
OZONE DISCECTOMY/ OZONUCLEOLYSIS
 It’s action is due to
the active oxygen
atom (singlet
oxygen) liberated
from it.
 It attaches with the
proteo-glycan
bridges in the
nucleus pulposus.
 They are broken
down and they no
longer capable of
holding water.
 As a result disc
shrinks and
mummified and
there is
decompression of
nerve roots.
Regenerative Therapies

 Glucosamine and chondrointin sulphate-

Enhance the Repair response of chondrocytes and retard the

enzymatic degradation of cartilage.

 Cell based Therapies

Stimulate the disc cell to produce matrix

Direct injection of Growth factor/ Cytokine inhibitor- Unsuccessful
Gene of interest is introduced into target cell

 Nucleous Pulposus augmentation

Injectable Nucleous –Solution of Protein polymer and

crosslinking agent
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