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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Kotilainen and Valtonen (1994) reported on 2-year follow-up status of 53 patients treated with manual percutaneous discectomy. Both back and leg pain were relieved or markedly diminished in approximately 80% of patients, with the effect seen as largely durable for 2 years. Discitis at the operated disc space was noted in 4% of patients. Mochida et al.

(2001) reported the results after long-term follow-up of a group of 42 patients treated with percutaneous nucleotomy.

Although 71% of the patients reported relief in the immediate postoperative period, this decreased to 55% after 2 years.

A number of studies evaluated percutaneous laser disc decompression (PLDD). Ohnmeiss et al. (1994) retrospectively studied 204 patients with herniated lumbar discs, of whom only 41 met all patient inclusion criteria. These inclusion criteria were leg pain; motor, sensory, or reflex deficit; discographic confirmation of contained disc herniation; no spinal stenosis or spondylolisthesis; and no prior lumbar surgery. Success rates were approximately 70% in patients who met all these criteria, with much lower rates in patients who did not meet the criteria. Casper et al. (1996) studied PLDD prospectively in an uncontrolled study of 100 patients with nonsequestered herniated lumbar discs. These authors reported that 87% of patients had good to excellent outcomes 2 years after surgery; outcomes were measured using the MacNab rating scale. In another prospective uncontrolled study involving 518 patients, Choy (1998) reported that overall success rates ranged from 75% to 89%, although detailed analysis of results was performed only on 350 patients who were treated at a private outpatient facility. Mean follow-up time in this study was 7 years, with a range of 3 months to 12 years.

Gronemeyer et al. (2003) provided long-term follow-up on 200 patients with nonsequestered lumbar disc herniation who underwent PLDD. These patients were followed for 4years, primarily through telephone interviews regarding severity of pain, degree of impairment, use of pain medication, and number of back pain-related sick days, in comparison with presurgical levels. At final follow-up, 73% of patients reported either no pain or a substantial reduction in pain, with 15% reporting no change and 8.5% reporting increased pain. Sensorimotor impairment was also either eliminated or improved in 74% of patients. Approximately half of the patients required some type of pain medication; half of these patients were using levels similar to those required prior to surgery, while half had reduced their consumption. Overall, patient satisfaction was high, 74% of patients were satisfied with the outcome of the therapy, and 81.5% of patients said they would undergo another laser discectomy procedure in the event of another disc herniation.

Results of investigations into the use of a small endoscope or arthroscope to provide access and visualization for surgical treatment of herniated lumbar discs have been reported by several authors. Ditsworth (1998) followed 110 patients for 2 years after endoscopic discectomy. Excellent and good outcomes were seen in approximately 90% of patients. Kambin et al. (1998) reported similarly high rates of success in 175 patients with lumbar disc herniation followed for 28 months after arthroscopic discectomy. Hermantin et al. (1999) performed a randomized prospective study using a group of 60 patients, half of whom were treated arthroscopically and half of whom were treated with open laminotomy/discectomy.

Although both groups reported similar high rates of clinical success, arthroscopic surgery was associated with earlier return to work and less use of narcotic analgesics.

Results from a meta-analysis by Gibson et al. (2006) came to similar findings. These authors analyzed 27 randomized controlled trials of surgery for lumbar disc prolapse that were published up to December 1999 and indexed in the MEDLINE database, including 3 trials that evaluated the effect of APLD for lumbar herniation. Analysis of the pooled data from these trials indicated there is moderate evidence that APLD results in poorer clinical outcomes than standard discectomy or chymopapain treatment.

Discogenic Pain, Treatment - Commercial Medical Management Guideline

Amoretti et al. (2005) reported on the use of DeKompressor probe for the percutaneous discectomy 10 patients chosen at random. Results were satisfactory with a decrease of the initial VAS by more than 70% and a complete elimination of medical therapy in eight patients. The authors state their results should be confirmed by a multicentric large series with the criteria of inclusion or exclusion strictly respected.

Percutaneous laser disc decompression (PLDD) Tassi (2004) described the results of PLDD in 92 patients as evaluated with the MacNab criteria with a follow-up range of 5 to 12 months. Good to excellent improvement was achieved in 76 (82.8%), poor improvement was achieved in 16 (17.2%) patients. No complications were observed.

McMillan et al. (2004) evaluated the short-term efficacy of PLDD in 32 consecutive patients using the standardized symptom score on the American Academy of Orthopedic surgery Outcomes Assessment Questionnaire for neurogenic and back pain. Thirty patients had sciatica at baseline. At 3 months, 24 reported improvement in sciatica symptoms.

Thirty-two patients had discogenic pain at baseline, 24 reported improvement at 3 months.





Ahn et al. (2004) evaluated posterolateral endoscopic laser-assisted disc excisions in 43 patients. Follow-up was 24 to 39 months with a mean of 31 months. According to the MacNab criteria, 81.4% showed excellent or good outcomes. The mean visual analog scale decreased from 8.72 to 2.58.

Toyone et al. (2004) reported on 40 consecutive patients. Twenty underwent standard discectomy, 20 underwent microendoscopic discectomy. The mean duration of follow-up was 40 months. No difference was found in the two groups for resolution of leg pain or low back pain. Method of assessment of pain was not reported in the abstract.

Sacroplasty The literature search identified a nonrandomized controlled study and 3 uncontrolled studies of percutaneous sacroplasty.

Results of these studies provide preliminary evidence that percutaneous sacroplasty improves outcomes for patients who have sacral insufficiency fractures. The best evidence supporting use of this treatment was obtained in the nonrandomized controlled study and the largest available uncontrolled trial. Both of these studies enrolled patients who could not tolerate or failed to respond to conservative nonsurgical therapy. Comparing presurgery with postsurgery, percutaneous sacroplasty provided statistically significant reductions in pain and improvements in mobility and activities of daily living. Two smaller uncontrolled studies of percutaneous sacroplasty do not provide reliable evidence of efficacy since the investigators did not report whether patients underwent nonsurgical treatments for sacral insufficiency fractures before sacroplasty. Further controlled studies with long-term assessment of the results of percutaneous sacroplasty are needed to confirm that it is a safe and effective procedure for sacral insufficiency fractures. (Hayes, Percutaneous Sacroplasty for Treatment of Sacral Insufficiency Fractures, 2009) The only available controlled evaluation of percutaneous sacroplasty for sacral insufficiency fractures was a nonrandomized controlled study7 by Whitlow et al. (2007). For this study, 12 patients (1 man, 11 women; mean age 72 13 years; mean pain score 9 1) who had failure of conservative therapy underwent percutaneous sacroplasty and 21 patients (4 men, 17 women; mean age 74 13 years; mean pain score 9 1) underwent percutaneous vertebroplasty for vertebral fractures. There were no statistically significant differences between the Sacroplasty Group and the Vertebroplasty Group at baseline. At a mean of 21 months after treatment, mean pain scores had decreased to 3 1 for the Sacroplasty Group and 3 for the Vertebroplasty Group. Both procedures were associated with statistically significant decreases in pain compared with baseline (PP Medical Products SpineCATH (TM) Intradiscal Catheter and ElectroThermal® 20S Spine System, ORATEC, Smith & Nephew.

ArthroCare System 2000; ArthroCare 8000S Coblator Surgery System; Perc™ ; SpineWand™ (ArthroCare Corp.) Discogenic Pain, Treatment - Commercial Medical Management Guideline References and Resources Resources Ahn Y, Lee SH, Park WM, et al. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine. 2004 Aug 15;29(16):E326-32.

Alexandre A, Coro L, Azuelos A, Pellone M. Percutaneous nucleoplasty for discoradicular conflict. Acta Neurochir Suppl. 2005;92:83-86.

Amoretti N, Huchot F, Flory P et al. Percutaneous nucleotomy: preliminary communication on a decompression probe (Dekompressor) in percutaneous discectomy. Ten case reports. Clin Imaging. 2005 Mar-Apr;29(2):98-101.

Appleby D, Andersson G, Totta M. Meta-analysis of the efficacy and safety of intradiscal electrothermal therapy (IDET).

Pain Med. 2006 Jul-Aug;7(4):308-16.

Barendse GA, van Den Berg SG, Kessels AH, Weber WE, van Kleef M. 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 Feb 1;26(3):287-92.

Bhagia SM, Slipman W, Nirschl M, et al. Side effects and complications after percutaneous disc decompression using coblation technology. Am J Phys Med Rehabil. 2006;85(1):6-13.

Boswell MV, Shah RV, Everett CR, Sehgal N, Brown AM, Abdi S, Bowman RC 2nd, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS, Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician. 2005 Jan;8(1):1-47.

Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. 2007 Mar;10(2):381.

Casper GD, Hartman VL, Mullins LL. Results of a clinical trial of the Holmium:YAG laser in disc decompression utilizing a side-firing fiber: a two-year follow-up. Lasers Surg Med. 1996;19(1):90-96.

Chatterjee S, Foy PM, Findlay GF. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation. Spine. 1995;20(6):734-738.

Choy DS. Percutaneous laser disc decompression (PLDD): twelve years' experience with 752 procedures in 518 patients.

J Clin Laser Med Surg. 1998;16(6):325-331.

Cohen SP, Shockey SM, Carragee EJ. The efficacy of repeat intradiscal electrothermal therapy. Anesth Analg. 2007 Aug;105(2):495-8.

Cohen S et al. Nucleoplasty in the treatment of lumbar herniated disk: A pilot study. Reg Anesth Pain Med. 2003;28.

Derby, R., Eek., B., and Chen, Y., et al., Intradiscal electrothermal annuloplasty (IDET): a novel approach for treating chronic discogenic back pain. Neuromodulation. 2000:3(2): 82-88. In: ECRI Technology Assessment - Target report #767. Intradiscal electrothermal therapy for discogenic pain. 2000(Nov. 30).

Discogenic Pain, Treatment - Commercial Medical Management Guideline Ditsworth DA. Endoscopic transforaminal lumbar discectomy and reconfiguration: A postero-lateral approach into the spinal canal. Surg Neurol. 1998;49(6):588-598.

Ercelen O, Bulutcu E, Oktenoglu T, Sasani M, Bozkus H, Cetin Saryoglu A, Ozer F. Radiofrequency lesioning using two different time modalities for the treatment of lumbar discogenic pain: a randomized trial. Spine. 2003 Sep 1;28(17):1922Finch PM, Price LM, Drummond PD. Radiofrequency heating of painful annular disruptions: one-year outcomes. J Spinal Disord Tech 2005; 18:6-13.

Freeman BJ, Mehdian R. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep. 2008 Jan;12(1):14-21.

Gibson JNA, Grant IC, Waddell G. Surgery for lumbar disc prolapse. Cochrane Database Syst Rev. 2006;(2):CD001350.

Gibson J, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007;(1):CD001350.

Grevitt MP, McLaren A, Shackleford IM, Mulholland RC. Automated percutaneous lumbar discectomy. An outcome study. J Bone Joint Surg Br. 1995;77(4):626-629.

Gronemeyer DH, Buschkamp H, Braun M, et al. Image-guided percutaneous laser disk decompression for herniated lumbar disks: a 4-year follow-up in 200 patients. J Clin Laser Med Surg. 2003;21(3):131-138.

Haines SJ, Jordan N, Boen JR, et al. Discectomy strategies for lumbar disc herniation: results of the LAPDOG trial. J Clin Neurosci. 2002;9(4):411-417.

Hayes, Inc. Health Technology Brief. Disc Nucleoplasty (ArthroCare-D SpineWand) for Percutaneous Disc Decompression. December 2008.

Hayes Inc. Technology Brief. Percutaneous Sacroplasty for Treatment of Sacral Insufficiency Fractures. May 2009.

Hermantin FU, Peters T, Quartataro L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999;81(7):958-965.

Kambin P, O'Brien E, Zhou L, Schaffer JL. Arthroscopic microdiscectomy and selective fragmentectomy. Clin Orthop.

1998;(347):150-167.

Kapural L, Hayek S. Malak O, et al. Intradiscal thermal annuloplasty versus intradiscal radiofrequency ablation for the treatment of discogenic pain: a prospective matched control trial. Pain Med. 2005;6(6):425-31.

Karasek, M., and Bogduk, N. Twelve-month follow-up of a controlled trial of intradiscal thermal anuloplasty for back pain due to internal disc disruption. Spine. 2000(Nov.) ;25(20): 2601-2607.

Kotilainen E, Valtonen S. Percutaneous nucleotomy in the treatment of lumbar disc herniation results after a mean follow-up of 2 years. Acta Neurochir (Wien). 1994;128(1-4):47-52.

Krugluger J, Knahr K. Chemonucleolysis and automated percutaneous discectomy--a prospective randomized comparison. Int Orthop. 2000;24(3):167-169.



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