1. HERNIATED DISK: TREATMENT PERCUTANEOUS USING DISCOGEL® T. Sola, Theron J, Diaz C, Vivas E,Cuellar H, Guimaraens L Servicio de Neuroangiografía Hospital General de Cataluña. Barcelona. Spain

2. 80-90% world population: backpain Disc hernia/Developed countries: 20% sick leave 50% early retirement

3. nerve muscles disk articular “percutaneous treatement of hernial disk” Psicological factors Feets

5. Patient objectifs Not more pain Not more drugs Sport

6. Herniated disk: clinical problem Objectif: pain treatment Disc hernia: consequence of dysfonctionement of paraspinal muscles Radiological objectif: disparition of hernia (almost always after clinical amelioration) We dont treat patients with previous surgery

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8. Pre-procedure ¤ Patients selection : - artrhosis+++ - CT : valoration of discal compresion - symptoms+++ - Electromyogram: to determine the degree of urgence ¤ Planification: - clinical symptoms - MRI: determine the levels to treat - correlation pain/radiological findings

9. PROCEDURE Biplanar angyographe Lumbar and dorsal: neuroleptoanalgesia Cervical: general anestesia( patient confort) Medical treatement: systemic antibiotic and antinflamatory

10. PROCEDURE II Lumbar: decubitus left lateral(left post-lat) Dorsal: decubito prono(post-lat approach) Cervical: decubito supino(right Antero- lateral approach) Lumbar and dorsal: 20 G needle Cervical: 21G needle

11. PROCEDURE III Lumbar: 0.8-1.2 cc discogel/level Dorsal: 0.6 cc discogel/level Cervical: 0.4cc discogel/level 1)Needle central 2)Very slowly injection( like Onix) 3)Permanent scopia control of injection

12. PROCEDURE IV Steroid intraarticular infiltration(22G) - Dorsal /lumbar: decubito prono - Cervical: decubito supino * Bilateral. Same treated levels

13. POSTPROCEDURE CT: Discogel distribution 1 night in hospital( control patient) Discharge therapy: tapered anti- inflammatory regimen (10 days)

14. Follow up Consultation all the months 1 year post procedure - paraspinal muscular stimulation seances. If pain still +++:. eventually re-intraarticular infiltration (3 months after treatement).eventually Discogel re-treatment( if MRI confirmed the persistence of hernia) (6 months after treatment). eventually Lumbosacral Liposuction ** Lumbosacral Liposuction.A New Tool for The Treatment of Low Back Pain J.THÉRON1, L. GUIMARAENS2-3,A. CASASCO3, H. CUELLAR3, T. SOLA2Interventional Neuroradiology 13: 153-160, 2007

15. Fev 2008-June 2010 84 patients( 38F and 46M ) Age: 17-81 y ( 40 patients :30-50 years) LOCATION: -Cervical: 12 -Dorsal: 1 -Lumbar: 71

16. Fev 2008-June 2010 84 patiens -TOTAL LEVELS TREATED: 178 - LEVELS/PATIENT: Cervical Dorsal Lumbar 1 2 1 13 2 6 38 3 4 18 4 or + 2

17. Fev 2008-June 2010 84 patiens clinical symptoms Cervical Dorsal Lumbar spine pain(SP) 6 SP+Uni radicul. 8 47 SP+Bi-radicul. 3 1 15 Only radiculalgia 3 others 1

18. COMPLICATIONS No case of infection No anaphylactic reaction 2 lumbar cases: radicular irritation after treatment( for the needle) 1 month antinflammatory therapy

19. PAIN EVALUATION analysis made by patients The numerical rating scales (NRS): - the patients were asked to rate their pain on a 0 to 10 - scale where 0 indicates "No pain" and 10 "The worst possible pain”. Analysis before, 3 months, 6 months and 12 months after treatment Recovery time is proportional to pain time

20. Cervical(12 patients) (fev 08-juin 10) Before treatement 012345678910 3 4 5 6 months 012345678910 33 3 1 1 * 3 Months 012345678910 1 6 31 1 12 months 012345678910 41 1*1*

21. Follow up (CERVICAL:12 patients) - Re-treatment: 0 cases - 1 case cervical to surgery(6 months) arthrosis+++ - 1 patient grade 2 at 12 months TMA arthrosis++

22. Lumbar(71 patients) (fev 08-juin 10) Before treatment 012345678910 2 23 406 6 months 012345678910 112 17 114 2* 3 Months 012345678910 5 11 2517 12 1 12 months 012345678910 2112 11 23*3* 1

23. Follow up (LUMBAR:71 patients) - 3 patients lost - 5 re-steroid infiltration (at 3 months) - 6 Discogel retreatment : - 4 at 6 months - 2 at 12 months - 1 lumbar liposuction : at 12 months * 6 retreatment: good filling of the hernia

24. CT AFTER RE-TREATEMENT

25. ANALYSIS RESULTS CERVICAL versus LUMBAR The evaluation of these results shows that before treatment, the NRS( Pain scale) does not different between cervical and lumbar spine The degree of recovery is much faster at cervical level. Cervical level was not needed any retreatment Hypotese: the difference in weight to bear for the cervical and lumbar spine is directly linked to the fundamental importance of the role of paraspinal muscles in lumbar hernias.

26. Discogel is very effective for the herniated disk((clinical and radiological) Herniated disk is as a locoregional problem and even a global problem (osteoarthosis, feets problems,TMJ and psychological factors in some cases play an important role) Herniated disk : Clinical problem No interference to “eventually posterior” treatments No major complications Follow up: 1 year

27. nerve muscles disk articular “percutaneous treatement of hernial disk” Psicological factors Feets