Percutaneous nucleoplasty for discoradicular conflict. XIX Symposium Neuroradiologicum The World Congress of Neuroradiology Bologna 2010, 4-9 October Percutaneous nucleoplasty for discoradicular conflict. Alexandre A, Alexandre AM*, Corò L European Neurosurgical Institute (EU.N.I.). Treviso *Institute of Radiology - Catholic University of Sacred Heart. Rome

AIM OF INVESTIGATION Evaluating clinical results of nucleoplasty on contained lumbar disc herniations.

NUCLEOPLASTY Sharps LS, Isaac Z. Percutaneous Disc Decompression Using Nuceoplasty. Pain Physician. Volume 5, 2:121-126. 2002. Welch WC, Gerszten PC. Alternative strategies for lumbar discectomy: intradiscal electrothermy and nucleoplasty. Neurosurg Focus 13: 62-68. 2002

MATERIAL AND METHODS 1390 patients with contained disc herniation (consecutive series 2003 to 2006). L3-L4: 234 L4-L5: 989 L5-S1: 167

MATERIAL AND METHODS By posterolateral approach under fluoroscopy through a 17G needle the SpineWand electrode is introduced and radiofrequency is applied, to provoke ablation of the nucleus pulposus.

Kambin's Triangle: firstly described by Kambin in 1972 as a posterolateral approach for a limited nucleotomy, (safe triangular working zone). Base: superior endplate of the inferior vertebra Height: lateral border of the tecal sac Hipotenuse: spinal nerve

MATERIAL AND METHODS Position of the cannula entering the annulus. Lateral and A-P view.

MATERIAL AND METHODS

RESULTS (Roland Morris >70% improvement is considered excellent result; 50 to 70% good result.) 12 months 1319 pt 24 months 678 pt 36 months 201 pt 48 months 80 pt Results Excellent (70% improvement) 679 51,47% 334 49,2% 93 46,2% 34 42,5% Good (50-70% improvement) 416 31,53% 196 28,9% 50 24,87% 22 27,5% Insufficient (>50% improvement) 112 8,49% 88 12,9% - - No result (>20% improvement) 112 8,49% 60 8,9% 58 28,85% 24 30% Roland M, Morris R (1983) A study of the natural history of back pain. Spine 8:141–150

RESULTS (Roland Morris improvement)

RESULTS Nucleoplasty is a safe procedure. There have been no infections, bleeding, nerve root injuries, or worsening of symptoms after the procedure. MRI or CT have been performed 6 months after the procedure, in 498 cases (total 1319 patients). Bulging was eliminated in 128, significantly reduced in 222 and unvaried in 148 cases. This case distribution anyway is not directly correlated to the quality of the clinical outcome.

DISCUSSION It combines coagulation and ablation for partial removal of the nucleus pulposus to decompress the disc, without termal or structural damage to the adjacent tissues*. Pressure reduction through nucleoplasty is highly dependent on the degree of degeneration of the spine. Nucleoplasty markedly reduce intradiscal pressure in nondegenerative discs, but has a negligible effect on highly degenerative discs**. *Chen YC, Lee S, Saenz Y, Lehman NL. Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: an experimental nucleoplasty study. Spine Journal 3:466-470. 2003. **Chen YC, Lee S, Chen D. Indradiscal pressure study of percutaneous disc decompression with nucleoplasty in human cadavers. Spine 28, 7: 661-665. 2003.

DISCUSSION The observed initial decreases in interleukine 1, which has hyperalgesic effects, followed by augmentation in interleukine 8, which may express the reparatory response, might correspond to the two-step clinical amelioration, initially due to the rapid discal loss of volume, and later due to the progressive discal repair.

CONCLUSION Nucleoplasty is a safe procedure. There have been no infections, bleeding, nerve root injuries, or worsening of symptoms after the procedure. Byochemical modification may correspond to the clinical result more than morphological ones. By this minimally invasive procedure patients will not be out of physiotherapy, and out of normal daily activities for more than a few days.