Damian Ong1, Nicholas H L Chua2, Kris Vissers1,2,3. 1. Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore City, Singapore. 2. Specialist Pain International Clinic, Singapore City, Singapore. 3. Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.
Abstract
BACKGROUND: Open discectomy remains the standard of treatment for patients with lumbar radicular pain secondary to a prolapsed intervertebral disc. Open discectomy performed in patients with small, contained herniations may result in poor outcomes. The various techniques of percutaneous disc decompression (PDD) have been developed to address this population. METHODS: A literature search was conducted on articles, which address PDD for lumbar radicular pain. Published techniques include chymopapain chemonucleolysis, percutaneous laser disc decompression (PLDD), automated percutaneous lumbar discectomy (APLD), Dekompressor, nucleoplasty, and targeted disc decompression (TDD). In addition, the rationale of provocative discography, selective nerve root injections, and intra-op discograms before performing PDD is discussed in detail. RESULTS: Dekompressor and nucleoplasty have the best level of evidence with a score of 2B+. The chymopapain chemonucleolysis has the most publications, but it is also accompanied by the most significant adverse complications and so it is scored as a 2B+/-. The other techniques are supported mainly by observational studies and thus their scores range between 0 and 2B+/-. There is no supporting evidence for provocative discography in patients with lumbar radicular pain. The evidence for a positive selective nerve root injection as an inclusion criteria or the need for an intra-op discogram shows mixed results. CONCLUSIONS: Nucleoplasty and Dekompressor have a weak positive recommendation for the treatment of patients with lumbar radicular pain. There is no role for provocative discography in this group of patients, although the evidence for a selective nerve root injection or an intra-op discogram is inconclusive.
BACKGROUND: Open discectomy remains the standard of treatment for patients with lumbar radicular pain secondary to a prolapsed intervertebral disc. Open discectomy performed in patients with small, contained herniations may result in poor outcomes. The various techniques of percutaneous disc decompression (PDD) have been developed to address this population. METHODS: A literature search was conducted on articles, which address PDD for lumbar radicular pain. Published techniques include chymopapain chemonucleolysis, percutaneous laser disc decompression (PLDD), automated percutaneous lumbar discectomy (APLD), Dekompressor, nucleoplasty, and targeted disc decompression (TDD). In addition, the rationale of provocative discography, selective nerve root injections, and intra-op discograms before performing PDD is discussed in detail. RESULTS: Dekompressor and nucleoplasty have the best level of evidence with a score of 2B+. The chymopapain chemonucleolysis has the most publications, but it is also accompanied by the most significant adverse complications and so it is scored as a 2B+/-. The other techniques are supported mainly by observational studies and thus their scores range between 0 and 2B+/-. There is no supporting evidence for provocative discography in patients with lumbar radicular pain. The evidence for a positive selective nerve root injection as an inclusion criteria or the need for an intra-op discogram shows mixed results. CONCLUSIONS: Nucleoplasty and Dekompressor have a weak positive recommendation for the treatment of patients with lumbar radicular pain. There is no role for provocative discography in this group of patients, although the evidence for a selective nerve root injection or an intra-op discogram is inconclusive.