Percutaneous Lumbar Disc Decompression

Pain Physician.  2013 Apr;16(2 Suppl):SE151-84.

An updated review of automated percutaneous mechanical lumbar discectomy for the contained herniated lumbar disc.

Manchikanti L, Singh V, Falco FJ, Calodney AK, Onyewu O, Helm Ii S, Benyamin RM, Hirsch JA.

Source

Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY; Spine Pain Diagnostics Associates, Niagara, WI; Mid Atlantic Spine & Pain Physicians of Newark, Newark, DE, and Temple University Hospital, Philadelphia, PA.

Abstract

BACKGROUND:

Lumbar disc prolapse, protrusion, and extrusion are the most common causes of nerve root pain and surgical interventions, and yet they account for less than 5% of all low back problems. The typical rationale for traditional surgery is that it is an effort to provide more rapid relief of pain and disability. It should be noted that the majority of patients do recover with conservative management. The primary rationale for any form of surgery for disc prolapse associated with radicular pain is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, although several alternative techniques, including automated percutaneous mechanical lumbar discectomy, have been described. There is, however, a paucity of evidence for all decompression techniques, specifically alternative techniques including automated and laser discectomy.

STUDY DESIGN:

A systematic review of the literature of automated percutaneous mechanical lumbar discectomy for the contained herniated lumbar disc.

OBJECTIVE:

To evaluate and update the effectiveness of automated percutaneous mechanical lumbar discectomy.

METHODS:

The available literature on automated percutaneous mechanical lumbar discectomy in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria, as utilized for interventional techniques for randomized trials, and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies.The level of evidence was classified as good, fair, and limited or poor, based on the quality of evidence scale developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES:

Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas long-term effectiveness was defined as greater than one year.

RESULTS:

Nineteen studies were included; none of the randomized trials and 19 observational studies met inclusion criteria for methodological quality assessment. Overall, 5,515 patients were studied with 4,412 patients (80%) showing positive results lasting one year or longer. Based on USPSTF criteria, the indicated evidence for automated percutaneous mechanical lumbar discectomy is limited for short- and long-term relief.

LIMITATIONS:

A paucity of randomized controlled trials in the literature describing automated percutaneous mechanical disc decompression.

CONCLUSION:

This systematic review shows limited evidence for automated percutaneous mechanical lumbar discectomy. Automated percutaneous mechanical lumbar discectomy may provide appropriate relief in properly selected patients with contained lumbar disc herniation.

Pain Physician. 2009 May-Jun;12(3):573-88.

Percutaneous lumbar laser disc decompression: a systematic review of current evidence.

Singh V, Manchikanti L, Benyamin RM, Helm S, Hirsch JA.

Pain Diagnostics Associates, Niagara, WI, USA. vj@wmpnet.net

Abstract

BACKGROUND: Since the descriptions by Mixter and Barr of open surgical treatment for rupture of the intervertebral disc in 1934, open surgical procedures have become a common practice. Disc herniations have been reported as being contained and non-contained. The results of open surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser disc decompression.

STUDY DESIGN: A systematic review of the literature.

OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of percutaneous laser discectomy in managing radicular pain secondary to contained disc herniation.

METHODS: A comprehensive evaluation of the literature relating to mechanical disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted by using only the English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF).

OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year.

RESULTS: Based on USPSTF criteria the indicated level of evidence for percutaneous lumbar laser discectomy (PLLD) is II-2 for short- and long-term relief.

LIMITATIONS: Even though laser discectomy has been in utilization for a number of years and numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials.

CONCLUSION: This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression.

Pain Physician. 2009 May-Jun;12(3):601-20.

Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence.

Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti L.

Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA. jahirsch@partners.org

BACKGROUND: Lumbar disc prolapse, protrusion, and extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The typical rationale for traditional surgery is an effort to provide more rapid relief of pain and disability. It should be noted that the majority of patients will recover with conservative management. The primary rationale for any form of surgery for disc prolapse associated with radicular pain is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including automated percutaneous lumbar discectomy (APLD) have been described. However, there is a paucity of evidence for all decompression techniques, specifically alternative techniques including automated and laser discectomy. STUDY DESIGN: A systematic review of the literature. OBECTIVE: To determine the effectiveness of APLD. METHODS: A comprehensive evaluation of the literature relating to automated lumbar disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted of English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria, the indicated evidence for APLD is Level II-2 for short- and long-term relief. LIMITATIONS: Paucity of RCTs in the literature. CONCLUSION: This systematic review indicated Level II-2 evidence for APLD. APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse.

Pain Physician. 2009 May-Jun;12(3):589-99.

Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor.

Singh V, Benyamin RM, Datta S, Falco FJ, Helm S 2nd, Manchikanti L.

Pain Diagnostics Associates, Niagara, WI, USA. vj@wmpnet.net

BACKGROUND: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. STUDY DESIGN: A systematic review of the mechanical disc decompression with Dekompressor literature. OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompressor, a high rotation per minute device utilizing an Archimedes screw, used in mechanical lumbar disc decompression. METHODS: The literature search was conducted utilizing a comprehensive strategy for mechanical disc decompression utilizing the Dekompressor. A literature search was conducted using only English language literature in a comprehensive search of databases including PubMed, EMBASE, the Cochrane Library, along with systematic reviews, and cross-references from reviews, systematic reviews, and individual articles. The quality of the manuscripts included was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and for observational studies with the criteria developed by the Agency for Healthcare Research and Quality (AHRQ). The level of evidence developed by the United States Preventive Services Task Force (USPSTF) was utilized in this review. The evidence was classified as Level I, II, or III with 3 subcategories in Level II for a total of 5 levels of evidence. OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the indicated level of evidence for the mechanical high RPM device or Dekompressor is Level III for short- and long-term relief. LIMITATIONS: Lack of literature, both randomized and observational. CONCLUSION: This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.

Pain Physician. 2009 May-Jun;12(3):573-88.

Percutaneous lumbar laser disc decompression: a systematic review of current evidence.

Singh V, Manchikanti L, Benyamin RM, Helm S, Hirsch JA.

Pain Diagnostics Associates, Niagara, WI, USA. vj@wmpnet.net

BACKGROUND: Since the descriptions by Mixter and Barr of open surgical treatment for rupture of the intervertebral disc in 1934, open surgical procedures have become a common practice. Disc herniations have been reported as being contained and non-contained. The results of open surgical discectomy for contained disc herniation have been poor. Consequently, several alternative techniques have been developed which are minimally invasive including percutaneous laser disc decompression. STUDY DESIGN: A systematic review of the literature. OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of percutaneous laser discectomy in managing radicular pain secondary to contained disc herniation. METHODS: A comprehensive evaluation of the literature relating to mechanical disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted by using only the English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the indicated level of evidence for percutaneous lumbar laser discectomy (PLLD) is II-2 for short- and long-term relief. LIMITATIONS: Even though laser discectomy has been in utilization for a number of years and numerous procedures have been performed there continues to be a paucity of literature of randomized clinical trials. CONCLUSION: This systematic review illustrates Level II-2 evidence for percutaneous laser disc decompression which is equivalent to automated percutaneous lumbar disc decompression.

Pain Physician. 2009 May-Jun;12(3):561-72.

A systematic review of mechanical lumbar disc decompression with nucleoplasty.

Manchikanti L, Derby R, Benyamin RM, Helm S, Hirsch JA.

Pain Management Center of Paducah, Paducah, KY, USA. drlm@thepainmd.com

BACKGROUND: Lumbar disc prolapse, protrusion, or extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The primary rationale for any form of surgery for disc prolapse is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including nucleoplasty, automated percutaneous discectomy, and laser discectomy have been described. There is a paucity of evidence for all decompression techniques, specifically alternative techniques including nucleoplasty. STUDY DESIGN: A systematic review of the literature. OBJECTIVE: To determine the effectiveness of mechanical lumbar disc decompression with nucleoplasty. METHODS: A comprehensive evaluation of the literature relating to mechanical lumbar disc decompression with nucleoplasty was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). A literature search was conducted using only English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross-references from reviews and systematic reviews. OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the level of evidence for nucleoplasty is Level II-3 in managing predominantly lower extremity pain due to contained disc herniation. LIMITATIONS: Paucity of literature, both observational and randomized. CONCLUSION: This systematic review illustrates Level II-3 evidence for mechanical lumbar percutaneous disc decompression with nucleoplasty in treatment of leg pain. However, there is no evidence available in managing axial low back pain.

Photomed Laser Surg. 2007 Feb;25(1):40-4.

Percutaneous laser disc decompression for lumbar disc hernia: indications based on Lasegue’s Sign.

Iwatsuki K, Yoshimine T, Awazu K.

Department of Neurosurgery, Osaka University Medical School, Osaka, Japan. kiwatsuki@nsurg.med.osaka-u.ac.jp

OBJECTIVE: The present study was conducted to establish reasonable indications of patient neurological manifestations for use of percutaneous laser disc decompression (PLDD). BACKGROUND DATA: PLDD is a less invasive surgical procedure for lumbar disc hernia, whose indications have been described on the basis of radiographical findings. METHODS: Sixty-five consecutive patients (45 men and 20 women) with lumbar disc hernia were treated with PLDD by applying a diode laser (wavelength 805 nm). A total of 450-1,205 joules (average, 805.5 joules) were delivered per disc. All patients suffered from radicular pain. They were divided based on the presence of Lasegue’s sign. The post-procedure results at 1 week and 1 year were compared between the groups. RESULTS: PLDD was effective for patients with Lasegue’s sign (80.0%), but ineffective for those without the sign. CONCLUSION: The present study suggests that Lasegue’s sign in patients is an indication of PLDD for lumbar disc hernia.

Pain Physician. 2007 Jan;10(1):7-111.

Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain.

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.

American Society of Interventional Pain Physicians, Paducah, KY 42001, USA. mark.boswell@ttuhsc.edu

Comment in:

  • Pain Physician. 2007 Mar;10(2):381; author reply 381.

BACKGROUND: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. DESIGN: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. METHODS: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). RESULTS: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. CONCLUSION: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.”

Neurol Res. 2005 Apr;27(3):319-23.

The effect of laser irradiation for nucleus pulposus: an experimental study.

Iwatsuki K, Yoshimine T, Sasaki M, Yasuda K, Akiyama C, Nakahira R.

Department of Neurosurgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. kiwatsuki@nsurg.med.osaka-u.ac.jp

BACKGROUND: The radicular pain caused by disc herniation can be explained by two mechanisms: the compression of the nerve root by the herniated disc or the irritation of the nerve root due to chemical factors. Percutaneous laser disc decompression (PLDD) was introduced for the treatment of lumbar disc hernias in the 1980s. Decompression of the nerve root is assumed to be an effective therapeutic mechanism for PLDD. However, laser irradiation might reduce the chemical factors that cause nerve root irritation by altering intra-disc proteins. We used nerve conduction velocities (NCV) and levels of two chemical factors to evaluate the differences between the two groups in this in vivo study. METHODS: All rabbits had the nerve root in contact with the leakage from the nucleus pulposus. One group underwent laser irradiation for the leaking nucleus pulposus including the incision site of the disc and nucleus pulposus itself. The levels of two chemical factors, prostaglandin E2 and phospholipase E2, in the intervertebral disc were measured before and after laser irradiation. RESULTS: NCV in the laser-irradiated group was significantly faster than in the non-laser-irradiated group. The levels of chemical factors were significantly reduced after laser irradiation. CONCLUSIONS: One of the mechanisms thought to be responsible for PLDD’s effectiveness is a decrease in the chemical factors through protein alteration in the intervertebral disc by laser irradiation.

Ortop Traumatol Rehabil. 2004 Jun 30;6(3):314-8.

Percutaneous laser lumbar disc decompression – mechanism of action, indications and contraindications.

Maksymowicz W, Barczewska M, Sobieraj A.

This article describes the development of minimally invasive methods in the treatment of lumbar discopathy, with particular attention to percutaneous laser disc decompression (PLDD). The authors discus the therapeutic operating mechanism of PLDD, emphasizing the importance of the thermal characteristics of laser light, which is responsible for the vaporization and ablation of a small amount of tissue from the nucleus pulposus. This causes a significant reduction in pressure in the closed structure of the disc, and consequently reduced compression exerted by the disk on the dural sac and the nerve roots. Improvement in the flow of cerebro-spinal fluid has also been observed on the level at which the operation is performed. On the basis of our own experience and the reports of other authors, we have specified indications and contra-indications for PLDD. Our conclusion is that PLDD is an effective treatment method for low back pain and ischialgia caused by protrusion or herniation of the nucleus pulposus, with elimination or significant reduction in symptoms in over 75% of those treated; reduction or resolution of neurological deficits that arise in the course of lumbar discopathy has also been observed. This method enables one-stage treatment of multi-level degenerative changes in the intervertebral disc. The only absolute contraindications for PLDD are the presence of sequestration, disturbances in blood coagulation, and bacterial infection.

Aust N Z J Surg. 2000 Jul;70(7):475-9.

Percutaneous endoscopic laser discectomy.

Boult M, Fraser RD, Jones N, Osti O, Dohrmann P, Donnelly P, Liddell J, Maddern GJ.

Australian Safety and Efficacy Register for New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, North Adelaide, SA.

BACKGROUND: The aim of the present paper was to systematically review the literature on percutaneous endoscopic laser discectomy (PELD) with respect to the safety and efficacy of the procedure. Where possible the procedure was compared with open discectomy. METHODS: Studies on PELD were identified using MEDLINE (1984 to December 1999), EMBASE (1974 to December 1999) and Current Contents (1993 to Week 1, 2000). A number of search terms were used: PELD; PLDD (percutaneous laser disc decompression); and laser and (spine or lumbar) and (disc* or disk*). The Cochrane Library was searched from 1966 to issue 4, 1999, using the search terms ‘discectomy’ or ‘discotomy’. Live human studies of patients with lumbar disc prolapses for whom surgery was appropriate were included. Cadaver studies were also included. A surgeon and reviewer independently assessed the retrieved articles for their inclusion in the review. RESULTS: Only 12 papers were identified that related to PELD. The level of evidence for safety and efficacy was low; there were no controlled, blinded or randomized studies. The highest level of evidence came from time series studies. No quantitative analysis could be undertaken for the present review. CONCLUSIONS: Given the extremely low level of evidence available for this procedure it was recommended that the procedure be regarded as experimental until results are available from a controlled clinical trial, ideally with random allocation to an intervention and control group.