The pathophysiology of discogenic pains
is multi-factorial in complex. It includes presence of nerve fibers in the annulus fibrosus, mechanical pressure upon the nerve root, with action of chemical mediators like leukotrienes, phospholipases, prostaglandins and formation of neovascularization.
What we can do for diagnosis is to combine clinical examination with imaging studies. And in the latter case we have non-invasive studies like fluoroscopy, CT, MRI and minimally invasive ones like myelography, discography and percutaneous infiltrations and actually those which are performed selectively
they can provide diagnosis for these patients.
The third (mumbles) for intervertebral disc herniation includes four steps. We can start with conservative therapy course of four to six weeks. We can move on to percutaneous infiltrations
then to percutaneous decompression techniques and finally to endoscopic or surgical techniques. Obviously we can combine infiltrations with conservative therapy or with percutaneous decompression techniques. Starting with injections in the spine, do we actually need the imaging guidance?
According to the literature, imagine guidance increases the technical and clinical efficacy and decreases potential complication rate. It has been written that blind interlaminar epidural infiltrations are inaccurate in more than one third of the cases.
And if we go to clinical cases, these are two examples of injections which were performed blindly. On the upper row you can see it was an attempt for an ozone injection of the facet joint by an orthopedic surgeon. It was a blind attempt and you can see that the oxygen,
ozone transforms to oxygen after three minutes, is everywhere in the retroperitoneal space, but it's not in the facet joint. And the lower row you can see a blind attempt of epidural infiltration by anesthesiologist. The patient after the injection was reporting
severe headache, that is the center scan and you can see air inside the ventricular system of the brain. Percutaneous infiltrations can be performed through a trans-foraminal access to an interlaminar paramedial access through the sacro-coccigial hiatus and in all cases, you can use contrast or air control
before your steroid injection. These injections they go way back to 1950s and in 1970s you have the first trans-foraminal nerve root blocks. What we're actually injecting is long-acting corticosteroid and we do need the imaging for particulate ones because they can cause some complications
as we will see later. We do tend to combine corticosteroids with local anesthetic and we need contrast medium to verify the proper position of the needle. In all cases, when you are using contrast medium, you should be using agents approved for myelography.
Corticosteroids actually provide an anti-inflammatory effect, a direct neural membrane stabilization effect and they do modulate peripheral nociceptor input. On the other hand, local anesthetic interrupts the pain-spasm cycle, interrupts the transmission of the noxious stimuli and resets the nerve itself.
Contraindications include the patient who is unwilling to consent to the procedure, local or systemic infection, hemorrhagic diathesis or anticoagulant therapy and an allergy to any component mixture. As far as I'm concerned, I do prefer to apply three to four sessions of steroid injections
within 12-months period with a maximum of two infiltrations per session. And in all cases, we are using imaging guidance. We can use fluoroscopy, we can use CT or even MRI guidance and here we are using air or contrast medium to verify proper needle position.
And proper needle position does not mean only in the right spot, but you should have the needle outside a vessel. You will cause complication and problems to the patient if you perform intervascular injection of particulate corticosteroids.
And what are the cases you can have a Black Swan Effect. These are the 12 cases of paraplegia reported out of the hundreds of thousands of spinal injections performed. And the most logical pathophysiological explanation was the particles in the steroid where are injected intervascularly and they acted as an emboli
resulting in paraplegia of the patient. The success rate for all these injections ranges between 75 and 87% in the literature in clinical practice. I guess that the magic number is around 70%.
What is worth saying is that trans-foraminal infiltrations they may result in higher pain reduction
when compared to interlaminar epidural infiltrations. Additionally, they seem to be superior to placebo therapies and to blind interlaminar epidural infiltrations for both short- and long-term pain reduction. In one-third of the patients, trans-foraminal infiltrations are surgery-sparing interventions.
And concerning evidence-based medicine, we know that these kind of injections they have a good level of evidence for radiculitis caused by disc herniation, a fair level of evidence for radiculitis caused by spinal stenosis and things are not so good with limited level of evidence to post-surgery syndrome.
And this is a patient, he had a herniation back in 2011. He was treated with a spinal injection, a trans-foraminal infiltration. On May of 2012, you can see that the herniation was gone and what we actually did was give some time to the nature to do its job.
Moving on to percutaneous decompression techniques for the discs, we can have decompression and we can have regeneration techniques for the discs. Specifically for the decompression techniques we can have thermal techniques using laser, continuous or pulsed radiofrequency and plasma energy ablation.
We can have mechanical decompression using a wide variety of devices and we can have chemical decompression by means of Discogel or ozone intradiscal injections. All these techniques, what they are actually based on is that fact that a intervertebral disc is a closed hydro-ablic space and when you are removing a small
part from the nucleus, you are actually causing a significant decrease in the intradiscal disc and this disc pressure actually is what makes the herniation move inwards. And we have these techniques from back in the 1940s. The indications for these kind of treatments
in the intervertebral discs include patients who are capable of providing consent with a symptomatic small to medium-sized herniation and when we are speaking about the size of the herniation, if you have a theoretical line between the facet joints, all herniations which do not cross this line,
they can be percutaneously treated. And when we are speaking about symptomatic cases, symptoms should be consistent with the segmental level where the herniation is located on the MR imaging. For example, if you have a left L4-L5 foraminal herniation, you are expecting the patient
to report a left L4 root neuralgia. Absolute contraindications include sphincter dysfunction, extreme sciatica and progressive neurologic deficit. And actually all these are indications for surgery. Additional absolute contraindications include sequestration or the presence
of asymptomatic herniation, local or systemic infection, spondylosthesis and stenosis of the vertebral canal, anticoagulants, coagulation disorders and the patient refusing to provide informed consent. Most of these techniques are performed under fluoroscopy so we (mumbles) projection with 45-degrees angulation
of the fluoroscopy beam and as far as the lumbar spine is concerned, we perform a direct posterior lateral (mumbles) in the disc. In the final position, we need to have the needle in the anterior third of the disc in the lateral projection towards the midline in the AP projection and you can see
how important the technologist is because we need to have good visualization of what we are doing. Once you are there, you have access to the disc and you can insert any kind of product that you are familiar with, starting from thermal, going to mechanical or chemical decompression.
The magic number for all these techniques concerning success rate is around 80%. The complication rate is very low, between 0.5%. What we do know so far from the literature is that there are no studies of evidence of superiority of one technique over the other.
As we've already said, complications are really rare. Spondylodiscitis is the most fearsome one with a percentage of 0.24% per patient.
If we tried to compare our techniques on a mano a mano basis with surgery, the answer is that first of all, we are minimally invasive
so it's better to start with a percutaneous approach and if it fails within the first year, you can move to a surgical operation. Additionally, even if we compare ourselves with minimal surgical techniques or at least what the surgeons calls minimal, you can see that
what we are doing ends up with a bandage. What they are doing ends up with something like looks like Robocop. So even for spondylodiscitis, because with percutaneous techniques, nothing comes in the air, infection is more common with surgical techniques
rather than a percutaneous one. In the literature, there are certain studies comparing percutaneous techniques with surgical in terms of efficacy and safety and one of them is concluding that at one year, a strategy of laser decompression followed by surgery if needed is resulting
in non-inferior outcomes compared with surgery. And the same results were reported in another study comparing surgical approaches with plasma ablation in the intervertebral disc. And now this are running in Europe a multi-centered trial between ozone and surgical techniques
for herniation of intervertebral discs. If we tried to compare percutaneous techniques with medical therapy we have prospective randomized trials comparing these two therapies and what it has shown is that patients on the conservative arm, they reported that pain came back on the first year
and to stable throughout the follow-up period. So percutaneous techniques, they had a longer lasting and more significant effect than conservative therapy on the pain reduction for these patients.
Nowadays, as you have seen from William, Combimsity actually has really entered our lives
and we are using it in most of the cases. I'm sorry that the video is not playing, but what we actually need is a technologist who is active and is inside in the room with us because after the combimsity, we need somebody to be there for us to provide us with the right angulations
so we can see where the needle are and we can be certain what we are doing.
To conclude, interventional radiology provides percutaneous therapeutic techniques for the treatment of symptomatic disc herniations and these techniques are efficacious with a success rate approximately 80 to 85%,
save with a complication rate below 0.5% and they can be attractive alternatives to endoscopic surgical techniques with a longer lasting effect than conservative therapy. Thank you very much. (applause)
Disclaimer: Content and materials on Medlantis are provided for educational purposes only, and are intended for use by medical professionals, not to be used self-diagnosis or self-treatment. It is not intended as, nor should it be, a substitute for independent professional medical care. Medical practitioners must make their own independent assessment before suggesting a diagnosis or recommending or instituting a course of treatment. The content and materials on Medlantis should not in any way be seen as a replacement for consultation with colleagues or other sources, or as a substitute for conventional training and study.