Abirritation of Discogenic Pain Model in SD Rats by Paravertebral Ozone Injection / 中山大学学报(医学科学版)

@#【Objective】To investigate the analgesic and degenerated regularity of paravertebral ozone injection in the discogenic pain model of SD rats ，and to reveal the mechanism of analgesic effect of ozone preliminarily.【Methods】 Male SD rats（n = 65）were randomly divided into control group（n = 15），model group（n = 25）and ozone group（n = 25）. The L5- 6 intervertebral discs of SD rats in model group and ozone group were punctured to establish discogenic pain models. Ozone was injected paravertebrally in ozone group rats on the 22nd day after modeling. The rats in control group were normal. A quantitative allodynia assessment technique and MRI were used to detect the 50% mechanical withdrawal threshold（50%MWT）and Pfirrmann grade of L5-6 intervertebral discs at different time intervals. The expression of tumor necrosis factor-α（TNF- α）and calcitonin gene-related peptide（CGRP）in left dorsal root ganglion and sciatic nerve were detected by western blot.【Results】The 50% MWT of both hind paws were different from each other in three groups at each time after the 22nd day after modeling（P < 0.05）. In the ozone group，the 50% MWT rose on the 22nd day after modeling（left 7.6±6.8，right 3.6±1.0，P < 0.05 vs pre-ozone injection），and reached the peak on the 24th day after modeling（left 10.6±8.2，right 7.9±6.7，P < 0.05 vs pre-ozone injection），and maintained this level until the 56th day after molding. In the ozone group，the L5-6 intervertebral disc degeneration was apparently visible compared with model group（P < 0.05）. The expression of TNF- α and CGRP in dorsal root ganglion and sciatic nerve were different from each other in three groups（model>ozone>control，P < 0.05）.【conclusions】Paravertebral ozone injection can alleviate the pain of discogenic pain model rats，but aggravates the degeneration of the lumbar disc. Paravertebral ozone injection can reduce the expression of TNF-α and CGRP in the sciatic nerve and dorsal root ganglia of discogenic pain model rats.

Nucleoplasty: Percutaneous Plasma Disc Decompression for the Treatment of Lumbar Disc Herniation

STUDY DESIGN: A review of the literature regarding nucleoplasty. OBJECTIVES: This aim of this article is to provide current information on nucleoplasty as a therapeutic intervention for herniated disc or discogenic back pain in degenerative disc disease. SUMMARY OF LITERATURE REVIEW: Nucleoplasty as a therapeutic intervention for discogenic pain is performed with increasing frequency, and has been reported to involve few complications and to have satisfactory clinical results. MATERIALS AND METHODS: Review of the literature. RESULTS: In nucleoplasty, the intervertebral disc is approached percutaneously. In this paradigm, a bipolar high frequency device in combination with ablation and coagulation is used to create a channel in the intervertebral disc in order to reduce intervertebral disc volume and to decrease intervertebral pressure and inflammatory markers. Standard indications for nucleoplasty have not been established, but it has been reported that the procedure had excellent outcomes regardless of the presence of radiculopathy or the results of discography. Many studies have reported their outcomes using various categories, because the procedure is comparatively new. Concomitantly, long-term follow-up studies remain to be performed, and each study reported a different follow-up period. CONCLUSIONS: Nucleoplasty has been found to show an excellent prognosis for discogenic back pain and a low incidence of complications. Moreover, since it is a minimally invasive procedure, it offers improved possibilities for return to daily life and work. If degenerative changes have not progressed to a great extent or the intervertebral level remains intact, nucleoplasty may be considered prior to surgery. Due to the lack of reports on the subject, prospective analyses in the future are required.

What is the Role of Epidural Injections in the Treatment of Lumbar Discogenic Pain: A Systematic Review of Comparative Analysis with Fusion

BACKGROUND: Lumbar discogenic pain without pain mediated by a disc herniation, facet joints, or the sacroiliac joints, is common and often results in chronic, persistent pain and disability. After conservative treatment failure, injection therapy, such as an epidural injection, is frequently the next step considered in managing discogenic pain. The objective of this systematic review is to determine the efficacy of lumbar epidural injections in managing discogenic pain without radiculopathy, and compare this approach to lumbar fusion or disc arthroplasty surgery. METHODS: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and lumbar fusion or disc arthroplasty in managing lumbar discogenic pain was performed with methodological quality assessment and grading of evidence. The level of evidence was based on the grading of evidence criteria which, was conducted using 5 levels of evidence ranging from levels I to V. RESULTS: Based on a qualitative assessment of the evidence for both approaches, there is Level II evidence for epidural injections, either caudal or lumbar interlaminar. CONCLUSIONS: The available evidence suggests fluoroscopically directed epidural injections provide long-term improvement in back and lower extremity pain for patients with lumbar discogenic pain. There is also limited evidence showing the potential effectiveness of surgical interventions compared to nonsurgical treatments.

Utilidad práctica de la discolisis percutáneas con ozono medicinal en patología degenerativa discal lumbar y hernias discales lumbares contenidas / Practicality of Percutaneous Discolysis with Medicinal Ozone Lumbar Degenerative Disc Pathology and contained Lumbar Herniated Disks

Objetivo: Se trata de una síntesis del tratamiento elegido con Ozono para las afecciones tipo hernias discales contenidas no protruidas del segmento lumbar bajo y de patologías degenerativas de dicho segmento que son causa de dolor discogénico lumbar y cervical. Metodología: Esta técnica se practica en la unidad de Hemodinamia, por el contrario, con un excelente equipo de arco en C y por la facilidad de guardar en CD todo el procedimiento y otorgarle al paciente una copia del mismo. Muestro un resultado basado en la VAS y Test de Oswestry antes y después de varias sesiones de Ozonoterapia paravertebral adicional a aquellos casos que fueros objeto de Disconucleolisis Percutáneas. Conclusiones: Resultados halagadores de mucha satisfacción convirtiéndose esta técnica en una alternativa mas para el tratamiento de estas afecciones de la Columna Vertebral afectada por las referidas entidades(AU)

Objective: This is a summary of the chosen treatment for conditions such Ozone herniated discs contained no low back protruded segment and that segment degenerative diseases that cause Lumbar and Cervical discogenic pain. Methodology: This technique is practical in the Hemodynamics unit for ease of CD store in the whole procedure and gives the patient a copy of it. Show a score based on VAS before and after several sessions of paravertebral Ozone additional cases that Percutanes Disconucleolisis object privileges. Conclusions: Results satisfacion becoming very flattering of this technique in an alternative one for the treatment of these conditions of Spine(AU)

Effect of Intradiscal Monopolar Pulsed Radiofrequency on Chronic Discogenic Back Pain Diagnosed by Pressure-Controlled Provocative Discography: A One Year Prospective Study

OBJECTIVE: To investigate the efficacy and safety of percutaneous intradiscal monopolar pulsed radiofrequency (PRF) in patients with chronic disabling discogenic back pain. METHOD: Twenty-six subjects (7 males; mean age 43.2 years) with chronic back pain refractory to active rehabilitative management were recruited. All subjects underwent MRI for evaluation of Modic changes, and monopolar PRF (20 min at 60 V) at the center of target lumbar intervertebral disc confirmed by pressure-controlled provocative discography. Clinical outcomes were measured by the visual analogue scale (VAS), Oswestry disability index (ODI), and sitting tolerance time (ST) for 12 months after treatment. Successful clinical outcome was described as a minimum of 2 point reduction in VAS compared with the baseline at each follow-up period. RESULTS: The mean VAS for low back pain reduced significantly from 6.4+/-1.1 at pre-treatment to 4.4+/-1.9 at 12 months (p<0.05). The mean ODI score was 47.3+/-15.4 points at pre-treatment and 36.7+/-19.5 at 12 months (p<0.001). The ST was 27.8+/-20.4 minutes at pre-treatment and 71.5+/-42.2 at 12 months (p<0.001). However, successful clinical outcome was achieved at 58%, 50%, and 42%, measured at 3, 6, and 12 months post-treatment. There were no significant relationship between the clinical outcome and Modic changes; no adverse events were recorded. CONCLUSION: The results demonstrated that the application of intradiscal monopolar PRF might be relatively effective but limited; successful intervention for chronic refractory discogenic back pain is needed. To achieve the optimal outcome through intradiscal PRF, we suggested further studies about stimulation duration, mode, and intensity of PRF.

Neural Mechanisms of Discogenic Back Pain: How Does Nerve Growth Factor Play a Key Role?

It was reported that nerve fibers were present in the inner part of lumbar intervertebral discs from patients with discogenic pain. Because there are no nerve fibers in the inner part of annulus fibrosus in normal condition, this finding suggests nerve ingrowth into the disc may be a cause of discogenic pain. Disc degeneration is often asymptomatic, thus, to understand the differences between symptomatic and asymptomatic disc, it is necessary to understand the pathogenesis of discogenic pain. We recently revealed that over 90% of the nociceptive dorsal root ganglion (DRG) neurons innervating the disc are sensitive to nerve growth factor (NGF), which is related to inflammatory pain. This indicates that discogenic pain is closely related to inflammation and NGF may play a key role. The increase of inflammatory mediators in symptomatic discs has been reported; we therefore studied the effects of disc inflammation and found that it induces sensitization of disc-innervating neurons and nerve ingrowth into the disc. More recently, it was shown that annular rupture induces nerve ingrowth, an increase of inflammatory mediators in the disc, and upregulation of calcitonin gene-related peptide, a pain-related molecule in DRGs. These findings led us to believe that annular rupture triggers inflammation and nerve ingrowth, inflammatory mediators then further promote nerve ingrowth into the disc and sensitization of disc-innervating neurons, and discogenic pain finally becomes chronic. NGF, found in symptomatic discs, may act as a key factor in generating chronic discogenic pain by sensitizing disc-innervating neurons and stimulating nerve ingrowth into the disc.

Clinical and Radiological Findings of Discogenic Low Back Pain Confirmed by Automated Pressure-Controlled Discography

OBJECTIVE: Few studies on the clinical spectrum of automated pressure-controlled discography (APCD)-defined positive discs have been reported to date. Thus, the present study was undertaken to analyze clinical parameters critical for diagnosis of discogenic pain and to correlate imaging findings with intradiscal pressures and pain responses in patients with APCD-positive discs. METHODS: Twenty-three patients who showed APCD-positive discs were selected for analysis. CT discogram findings and the degrees of nuclear degeneration seen on MRI were analyzed in comparison to changes of intradiscal pressure that provoked pain responses; and clinical pain patterns and dynamic factors were evaluated in relation to pain provocation. RESULTS: Low back pain (LBP), usually centralized, with diffuse leg pain was the most frequently reported pattern of pain in these patients. Overall, LBP was most commonly induced by sitting posture, however, standing was highly correlated with L5/S1 disc lesions (p < 0.01). MRI abnormalities were statistically correlated with grading of CT discogram results (p < 0.05); with most pain response observed in CT discogram Grades 3 and 4. Pain-provoking pressure was not statistically correlated with MRI grading. However, it was higher in Grade 3 than Grade 4. CONCLUSION: APCD-positive discs were demonstrated in patients reporting centralized low back pain with diffuse leg pain, aggravated by sitting and standing. MRI was helpful to assess the degree of nuclear degeneration, yet it could not guarantee exact localization of the painful discs. APCD was considered to be more useful than conventional discography for diagnosis of discogenic pain.

High-Intensity Zone on L-spine MRI: Clinical Relevance and Association with Trauma History

STUDY DESIGN: This is a retrospective study. PURPOSE: We wanted to investigate the clinical relevance of the lumbar high intensity zone (HIZ) on magnetic resonance imaging (MRI) and the relationship of trauma history to internal disc disruption (IDD). OVERVIEW OF LITERATURE: HIZs on lumbar spine (L-spine) MRI have been suggested as a reliable marker of IDD by some authors. The prevalence and type of spinal trauma in IDD have not yet been carefully analyzed. METHODS: L-spine MRIs of 737 patients with low back pain with or without associated leg pain were reviewed for the presence of HIZs. HIZs on T2-weighted MR images were determined according to the Aprill and Bogduk criteria. A review of medical records and a telephone interview were performed for further analyses of pain. RESULTS: HIZs were found in 117 patients and 153 discs among a total of 737 patients who met the inclusion criteria. Both a medical record review and a telephone interview were possible with 99 patients. Among these, 42 patients had had an episode of trauma. Seventeen of these had a relatively high-energy injury such as a traffic accident or a fall. Regarding back pain, 27 patients complained of typical discogenic back pain. Only 11 patients had both a trauma history and typical discogenic pain and 41 patients (42%) had neither a trauma history nor typical natural pain. CONCLUSIONS: Given the low incidence of discogenic pain, a HIZ on an L-spine MRI appears less meaningful than often assumed as a specific marker of IDD. Trauma, such as a traffic accident, seems unlikely to be the main cause of IDD.

Percutaneous Laser Disc Decompression for Treatment of Lumbar Discogenic Pain / 中国康复理论与实践

@# Objective To investigate the therapeutic effect of percutaneous laser disc decompression on lumbar discogenic pain.Methods56 patients with lumbar discogenic pain were treated with percutaneous laser disc decompression with Nd:YAG laser(wavelength 1064 nm).They were followed up for more than 3 months with Macnab criteria.ResultsAll the patients were followed up.At the end point of postoperative 3 months,32 patients had an excellent outcome,20 were good,3 patients were fair,1 patient were poor.No complication(infection and nerve injury)had been observed.ConclusionPercutaneous laser disc decompression is a safe,little invasive and effective treatment modality for lumbar discogenic pain.

Histological Changes after Intradiscal Steroid Injection to the Intervertebral Disc in Disc Injury Rabbit Model

OBJECTIVE: To evaluate the degeneration changes of disc injury rabbit model produced by needle puncture to intervertebral disc and to observe the histological changes of the degenerated disc treated with intradiscal steroid. METHOD: The subjects were composed of 10 L4-5 intervertebral discs (study group) and 10 L3-4 intervertebral discs (control group) of Newzealand white rabbits. The rabbits' discs were exposed by anterior approach and degeneration was elicited by 21 G needle puncture. After 4 weeks, the study group was injected with 0.2 ml triamcinolone acetonide (Tamcetone 40 mg/ml) and the control group was injected with 0.2 ml normal saline, intradiscally. The discs were extracted on 4 weeks after degeneration and stained with Hematoxylin-Eosin and investigated by light microscopy. RESULTS: Degenerative changes, including fissuring and focal fibrosis, were elicited in the all groups, but there were no significant histological differences between the two groups. CONCLUSION: We concluded that the degenerative changes are well observed in disc injury rabbit model. The mollification of discogenic pain following intradiscal steroid injection in practice may not be explained from light microscopic histological changes of the disc. Further biochemical or electromicroscopic study will be necessary to clarify the mechanism of alleviation of discogenic pain by intradiscal steroid.

Percutaneous Laser Hypothermia in the Treatment of Lumbar Discogenic Pain / 中国微创外科杂志

Objective To evaluate the efficacy of percutaneous laser hypothermia in the treatment of lumbar discogenic pain. Methods From June 2006 to March 2008,35 patients with lumbar discogenic pain were treated by low-frequency laser hypothermia in our hospital with 1 second impulse time,1 second interval time,3.5 w power,and 30 minutes duration. The effectiveness of the therapy was evaluated afterwards. Results Among the cases,15 patients were treated by one operation,20 patients received a second therapy,and 6 underwent the therapy for totally 3 time; the treatment was effective in 32 cases (excellent in 7,good in 24,and fair in 1). The therapy is ineffective in 2 cases. One case was converted to open surgery for unsatisfying outcomes of the laser hypothermia. The total effective rate was 91.4%(32/35),and fineness rate was 88.6%(31/35). Conclusions Percutaneous laser hypothermia is an effective treatment for lumbar discogenic pain. The indications for the procedure should be selected strictly.

Percutaneous laser disc decompression in the treatment of discogenic back pain / 中国微创外科杂志

Objective To evaluate curative effects of percutaneous laser disc decompression(PLDD) in the treatment of discogenic low back pain.Methods A total of 36 patients with discogenic low back pain was included in the study.The PLDD was performed by using the DIOMED semiconductor laser treatment,with a power of 15 W,1 s-pulse duration,1 s-interval,and an energy of radiation of 800~1 200 J.Curative outcomes were evaluated based on the Visual Analog Scale(VAS) criteria. Results The operation time was 15~60 min(mean,30 min).The pain provocation was observed in 32 patients.Follow-up examinations were conducted in the 36 patients for 6~36 months(mean,11 months).The postoperative VAS scores were improved by ≥ 3 points in 18 patients and ≥ 2 points in 14 patients.Results revealed that 32 patients(88.9%) reported a good response and 4(11.1%) reported no response. Conclusions Percutaneous laser disc decompression is a safe,effective,and minimally invasive procedure that can be used for patients with discogenic low back pain.

The Efficacy of Radiofrequency Neurotomy of the Ramus Communicans Nerve for Intractable Chronic Discogenic Pain / 대한마취과학회지

BACKGROUND: Chronic discogenic pain is commonly intractable to various conservative treatments and anatomic correction through operation. Nowadays, a radiofrequency thermocoagualation technique applying the pathophysiologic mechanism that cause discogenic pain and the pathways of transmission of discogenic pain have been successfully tried. This study was performed to evaluate the efficacy of radiofrequecy thermocoagulation of the ramus communicans nerve in patients who suffered from intractable discogenic pain even after intradiscal electrothermal therapy. METHODS: The authors evaluated 13 cases in which radiofrequency thermocoagulation of the ramus communicans nerve was used for patients suffering from chronic discogenic pain even after intradiscal electrothermotherapy. Ten weeks after the procedure, we compared VAS scores of the pre- procedure and post-procedure state. RESULTS: Fifty-four percent of patients had an excellent decrease in the VAS score (VAS < 3). One patient complained of a mild motor weakness of the lower extremity but recovered completely by postoperative day 26. CONCLUSIONS: In the cases of intractable chronic discogenic pain, it is valuable to perform a rhizotomy of the ramus communicans nerve with radiofrequency.

Histological Changes of the Intervertebral Disc with Intradiscal Steroid Injection

OBJECTIVE: To observe histological changes of the intervertebral disc injected with intradiscal steroid and mollification of discogenic pain. METHOD: A study group of 25 Sprague-Dawely rats was divided into five subgroups. A control group of 10 Sprague-Dawely rats was divided into five subgroups. The rats' intervertebral discs were exposed by an anterior surgical approach. For study group, the rats were injected intradiscally methylprednisolone acetate 4 mg (Depomedrol, 40 mg/ml) to the L4-L5 intervertebral disc, methylprednisolone sodium succinate 4 mg (Solumedrol, 40 mg/ml) to the L5-L6 intervertebral disc, and triamcinolone acetonide 4 mg (Triamcinolone, 40 mg/ml) to the L6-S1 intervertebral disc. For control group, the rats were injected intradiscally 0.1 ml of saline to the L5-L6 intervertebral disc and a needle was inserted in the L6-S1 intervertebral disc. The intervertebral discs were extracted after 1 week, 2 weeks, 3 weeks, 4 weeks, and 16 weeks. The extracted intervertebral discs were stained with Hematoxylin-Eosin and examined histomorphometrically. RESULTS: There is no significant histological change in either group until 4 weeks after the different types of steroid were injected. Focal fibrotic change was present in the Solumedrol and Triamcinolone injection subgroups after 16 weeks. CONCLUSION: We concluded that rapid mollification of discogenic pain following intradiscal steroid injection may not result from histological change of the disc. Further biochemical study will be neccessary to clarify mollification mechanism of discogenic pain by intradiscal steroid injection.

Visualization of Disc Degeneration: Comparison between Magnetic Resonance Imaging and Discography

OBJECTIVE: To determine the relationship between magnetic resonance imaging (MRI) and discography in visualization of disc degeneration. METHOD: Forty-eight patients with suspected discogenic pain in lumbar spines and degenerative changes of the lumbar intervertebral discs in T2-weighted magnetic resonance imaging were studied. Five types of discogram (cottonball, lobular, irregular, fissured, and ruptured) were classified by identifiable features in shape and density of radio-opaque shadow. Three types of MRI (bulging, protrusion, and extrusion) were classified by degrees of disc herniation. The correlation between two imaging techniques of lumbar intervertebral discs were analyzed using Spearman's correlation coefficient. RESULTS: Of sixty-three discs, MRI finding of the disc herniation revealed as follows: bulging, 17 discs; protrusion, 20 discs; extrusion, 26 discs. Discography revealed as follows: cottonball, 15 discs; lobular, 2 discs; irregular, 11 discs; fissured, 10 discs; ruptured, 25 discs. 46 discs of 63 discs showed internal structural abnormalities (irregular, fissured, or ruptured). There was no statistically significant correlation between MRI and discography in visualization of the disc degeneration (r=0.081). CONCLUSION: Severity of the lumbar intervertebral disc degeneration in MRI was not correlated with degenerative severity of discographic imaging. Supplementary discography may be useful in evaluation of patients with discogenic pain since discographic imaging when compared to MRI visualizes disc degeneration more accurately.