Articles

New Technologies for Treating Low Back Pain

Elizabeth F. Yurth M.D.

There are very few people who have not been troubled by low back pain at some point in their life! Low back pain is the second leading cause of lost work time here in the United States-second only to the common cold!  Research suggests that low back pain affects more than ten million Americans annually and costs more than twenty million dollars to try to treat.   Fortunately, we are entering some very exciting times in the treatment of low back pain with more knowledge and more tools available to us than ever before!  Here we will focus on some of the new options available to people with low back pain due to a damaged disc in their back.

Examples of Disc Problems

The spine is basically a long column of stacked bones known as vertebrae.  There are seven vertebrae in the cervical spine, twelve in the thoracic spine and five in the lumbar spine.  Between each of the vertebrae is a fluid filled cushion called a disc.  Discs act as shock absorbers for the spine.  The disc has a tough fibrous outer shell called the annulus.  Inside the annulus is a gel like center termed the nucleus.  The nucleus is made up primarily of water but it also has some chemicals within it that can be quite irritating to nerve tissue if the nucleus is not well contained.  As we age the nucleus does shrink as the water content lessens.

The outer back wall of the disc (the posterior annulus) has many small nerve endings, which are there only to send pain messages. As the disc degenerates, nerve endings grow into the cracks in the disc making the disc more sensitive to pain.  If a disc becomes torn or the annulus weakens enough to allow the disc to bulge out it can irritate or put pressure on the passing nerves creating back and leg pain.

Overhead View of the Intervertebral Disc

Basic treatment options to treat disc injuries have been limited to medications, physical therapy, and spinal corticosteroid injections.  When these treatments failed, patients often face surgery either to remove part of the disc or ultimately a more drastic option to fuse vertebrae together to alleviate the pain. While all of these treatments still remain very useful and have their place in the fight against back pain, there are now more options available to the patient before they consider invasive surgeries.

Intradiscal Electrothermoplasty (IDET)
This novel procedure is an alternative to very invasive surgery for the treatment of chronic low back pain.  It involves the insertion of a needle into the affected disc with the guidance of a real-time x-ray machine (fluoroscope).  A wire is then threaded through the needle and into the disc until it lies just along the inner wall of the annulus (the tough outer portion of the disc).  The wire is then slowly heated to a very high temperature.  The procedure takes about an hour and can be easily performed on an outpatient basis with the patient only mildly sedated.

Intradiscal electrothermal annuloplasty

The exact mechanism by which IDET reduces disc pain is still under investigation. It is likely that the high temperature destroys the small nerve fibers that have grown into cracks and invaded the degenerated disc causing back pain.

The heat also may "melt": the annulus to some degree, which triggers the body to generate new proteins, which reinforce fibers in the annulus.  In the carefully chosen candidate with a torn or degenerated disc the success rate for this procedure is as high as sixty percent.  Done by an experienced physician, the risks of this procedure are very minimal.

Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty)
Nucleoplasty is an even newer treatment for low back pain than IDET.  Again, using live x-ray guidance, a needle is inserted into the disc.  Instead of a thermal heating wire, a radiofrequency probe is inserted into the disc.  This probe creates channels inside the nucleus of the disc.  A very focused plasma field is created which has enough energy to break up molecular bonds in the gel part (nucleus) of the disc.  This essentially vaporizes some of the nucleus.  The result is that 10-20% of the nucleus is actually removed which decompresses the disc and reduces pressure on the outer wall of the disc where the nerve endings are and on the surrounding nerve roots which may be causing leg pain.

Coblation Nucleoplasty

Nucleoplasty takes only thirty to sixty minutes and is also down as an outpatient procedure with only mild sedation.  Again, this procedure is quite effective in the right patient.

Percutaneous Discectomy using the Dekompressor
When a disc bulges enough it begins to put pressure on the passing nerve roots creating leg pain often referred to as sciatica. About 80 –90 percent of patients with a disc injury will improve with conservative measures including time, traction, medications, aerobic exercise and specific strengthening.  For those who fail to get better with conservative treatment,  surgery (discectomy) may be recommended.  The goal of discectomy is to remove a portion of the nucleus, relieving pressure on the annulus and the affected spinal nerve.   In traditional surgery, the patient is put under general anesthesia, an incision is made on the back, and some of the disc nucleus and bone over the spinal canal is removed.

The DEKOMPRESSOR is a newly developed more minimally invasive option for treating small disc bulges.  This procedure is done using only minimal sedation in an outpatient setting. Again using live x-ray guidance, a special probe called the DEKOMPRESSOR, is inserted into the disc.  Once inside a suction mechanism pulls out the bulging portion of the disc.  The patient actually is awake and providing information about pain levels during the procedure.  Patient feedback, which is not available in traditional surgery, significantly reduces the risk of injury to the nerve root.  The procedure takes only 30-60 minutes and the recovery is very fast.

The DEKOMPRESSOR

These new technologies are very exciting!  They offer the opportunity to treat discogenic low back pain and sciatica with much less trauma and risk than surgery.  However, we must remember that they are not for everyone and success depends on selecting the right candidates for the right procedure and finding a physician who is experienced with all the options available to you.

By: Elizabeth F. Yurth M.D.

Dr. Elizabeth Yurth is Board Certified Physiatrist with specialized Fellowship training from Stanford University in Interventional Spine Care and Sports Medicine. She is a partner at Mapleton Hill Orthopaedics, located in Boulder, Colorado.  She is available for consultation regarding these and other treatments for your spine at 303-440-7941.