1. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.2010 1 K. Pardatscher, G. Volpentesta*, C. Bombardieri, A. Giaquinta* Neuroradiology & Neurosurgery* University of Catanzaro, Italy Cattedra di Neuroradiologia Università degli Studi di Catanzaro

2.  Prospective clinical trial on 276 consecutive patients treated with radiopaque gelified ethanol (RGE).  Good results in 91.4% in patients treated only with RGE.  Easy to perform  Efficacious  Harmless 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20102

3.  Enzymatic discectomy with chymopapain (L. Smith 1964)  Manual endoscopic discectomy  Mechanical automatized percutaneous diskectomy (G. Onik 1987)  Radiofrequency nucleoplasty  Laser beam ablation  Ozonotherapy  Acupuncture 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20103

4.  To test the efficacy of the RGE at lumbar level, all our patients had preliminary physical evaluation, CT/MR studies or both.  In case of disc herniation the percutaneous treatment was offered in alternative to surgery, always available by failure of the former.  In case of chronic discogenic pain the treatment was proposed as elective. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20104

5.  Local anesthesia, aseptic conditions, angiographic suite, biplane digital fluoroscopy, lateral decubitus, patient laying on the symptomatic side, RGE injection opposit to the supposed disc structural damage. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.2010 5

6.  RGE DOSE for single disk : 0.4-1.0 ml  Often coaxial technique, specially at L5-S1 level using a 18G x 152mm needle and 22G x 200mm needle (the latter distally bowed like a hockey stick)  No antibiotics intradiscally  Volumetric CT examination with MPR, few hours after the injection  Patients discharged on the next day with anti- inflammatory drugs for one week  Follow-up at 1month, 3months, 6months, 1year 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20106

7.  34 patients included (from 6.11.2008 to 10.6.2010)  Age ranged from 20 to 66 years (mean 45.8)  20 males and 14 females 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20107

8. 40 disks treated in 34 patients A. L2-L3 2 patients B. L3-L4 1 patient C. L4-L5 22 patients D. L5-S1 15 patients  Only one disk in 29 patients  Two disks in 4 patients in the same session  Three disks in separeted sessions in 1 patient 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20108

9. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.20109

10.  Chronic backache, irradiate to the internal side of the right thigh  Reduction of the strength of the right leg  Bilateral pain of the calves 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201010

11. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201011 L2-L3

12. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201012 L2-L3 0.7 ml 3.3.2010

13. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201013 L2-L3 3.3.2010

14. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201014 L4-L5

15. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201015 L4-L5 1.0 ml 13.07.2010

16. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201016 L4-L5 13.7.2010

17. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201017 L5-S1

18. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201018 L5-S1 1.0 ml 20.08.2010

19. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201019 L5-S1 20.8.2010

20. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201020 L5-S1 20.8.2010

21.  Usually RGE migrates promptly, along the fissures of the anulus, to the disc hernia 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201021

22. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201022 L4-L5 23.12.2009

23. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201023 L4-L5 23.12.2009

24. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201024 L4-L5 23.12.2009

25.  For 2 years backache irradiated along the lateral face of the lower left leg to the sole of the foot  Neuroradiological examinations: -CT 19.02.2008 : mild bulging at L4-L5 -MR 12.05.2009: mild bulging at L4-L5 and L5-S1. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201025

26. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201026 L4-L5 19.2.2008

27. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201027 12.5.2009

28. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201028 12.5.2009

29. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201029 L4-L5 0.5 ml 20.11.2009

30. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201030 L4-L5

31.  Interestingly all patients felt some improvement of symptoms on the day of the procedure or on the next one, when they were discharged however  Three patient went to surgery: the first one after four weeks, the others after two weeks (Success rate of 91.2%).  No allergic reactions, nor infections 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201031

32.  One of post-RGE operated patients 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201032

33.  Operated in 1998 for left disk herniation in L5-S1.  Relapse of left sciatica three months before RGE. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201033

34. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201034 L5-S1 3.11.2008

35. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201035 L5-S1 0.7 ml 6.11.2008

36. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201036 L5-S1 6.11.2008

37. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201037 L5-S1 6.11.2008

38.  It was apparent that RGE migrates easily into the symptomatic hernia along the fissures of the anulus, giving to the theory of the”internal disc disruption” proposed by H.V. Crock in 1970, a tremendous actuality.  RGE migrates also to the symptomatic side with an apparently normal anulus on conventional examinations (MR and CT) and therefore seems to correlate strongly with clinical signs. So RGE could be of interest also in the rare cases of side discrepancy. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201038

39.  Back pain and lower limb pain without spinal nerve root compression, that means normal neurologic examination: A)No loss of reflexes B)No loss of muscle strength or atrophy C)No sensory loss - “DISCOGENIC PAIN” - “DISCOGENIC SCIATICA” (referred pain). 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201039

40.  Related to radial anular tears allowing communication between the central nucleus pulposus and the peripheral anulus fibrosus, rich in sinuvertebral nerve-endings  Exposure to degenerated nuclear material (cytokines) induces inflammatory reaction and chemical irritation of nerve-endings 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201040

41.  PREVALENCE of IDD among patients with chronic low back pain between 30% and 50%, with a 95% confidence limit.  Neither pain patterns nor conventional clinical tests are discriminatory  DIAGNOSIS is based on: (International Association for the Study of Pain taxonomy) a) Normal or near normal contour of the disc; b) Provocative discography: concordant back and/or leg pain ; c) CT-DISCOGRAPHY: a full thickness radial anular fissure. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201041

42. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201042 Courtesy of Dr. Douglas M. Gillard Normal lumbar disc anatomy Pathological lumbar disc (IDD)

43.  Three our patients operated upon after a relative time-interval must be considered a failure of the technique. It doesn’t automatically mean that the RGE doesn’t work, but it may be the expression of the fact that the speed of the clinical gain does not match up with the patient’s expectations. Surprisingly enough in the first case operated upon, shown before, the neurosurgeons found only a small residual lump of granulation tissue. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201043

44.  EASY TO PERFORM  ALSO AT MULTIPLE LEVELS  NO COMPLICATIONS  EFFICACY ALONE  MAY BE ASSOCIATED TO OTHER PERCUTANEOUS TECHNIQUES (intrarticular steroids injection, APD, RFN)  Elective indication in the frequent cases of INTERNAL DISC DISRUPTIONS 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201044

45. 07/03/2016 XIX Symposium Neuroradiologicum Bologna 4-9.10.201045