Lumbar Disc Precision Treatment

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 2019Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain: 2-Year Results From a Prospective Randomized Double-Blind Sham-Controlled Multicenter Study. Int J Spine Surg. 2019;13(2):110-119. Published 2019 Apr 30. doi:10.14444/6015Fischgrund JS, Rhyne A, Macadaeg K, Moore G, Kamrava E, Yeung C, Truumees E, Schaufele M, Yuan P, DePalma M, Anderson DG, Buxton D, Reynolds J, Sikorsky M. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study. Eur Spine J. 2020 Aug;29(8):1925-1934. doi: 10.1007/s00586-020-06448-x. Epub 2020 May 25. PMID: 32451777.	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.Tuakli-Wosornu YA, Terry A, Boachie-Adjei K, Harrison JR, Gribbin CK, LaSalle EE, Nguyen JT, Solomon JL, Lutz GE. Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PM R. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24. PMID: 26314234.
==Quiz==
<quiz display=simple>
{With regards to lumbar disc innervation, which is true?
|type="()"}
-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.
{With regards to lumbar disc RF, Which technique has the most evidence to support its use?
|type="()"}
-Intranuclear radiofrequency ablation
-Intradiscal electrothermal therapy
-discTRODE
+Biacuplasty
</quiz>
==Bottom Line==
*Biacuplasty 
*IDET 
*intradiscal RF
*discTRODE 
*Ramus communicans RF 
*Fusion Surgery 
==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
==References==
Category:Lumbar Spine Procedures
Category:Partially complete articles
Category:Precision Techniques