Percutaneous Disc Decompression Provides Long-Term Relief of Sciatica Pain
By Fran Lowry
Medscape Medical News
December 4, 2009 (Chicago, Illinois) — Minimally invasive percutaneous disc decompression trumped traditional conservative treatment for painful herniated discs in this first-ever randomized controlled trial to compare the 2 therapies, Greek researchers announced at the Radiological Society of North America 95th Scientific Assembly and Annual Meeting.
Alexios Kelekis, MD, PhD, an interventional radiologist from the University of Athens in Greece, told reporters at a press conference that the vast majority of people — 70% to 90% — will experience some form of back pain at some point in their lives; 36% of the time, it will be due to a herniated disc.
The usual treatment for a herniated disc includes a trial of various analgesics, muscle relaxants, physical therapy, and rest.
Most patients will recover in 3 months with such treatment; however, this comes at a cost, including gastrointestinal tract bleeding and other complications from analgesics. Moreover, their symptoms eventually return, Dr. Kelekis said.
Percutaneous disc decompression is performed on an outpatient basis under local anesthetic. With fluoroscopic guidance, a needle is inserted within the intervertebral disc and material is removed, diminishing the pressure from the hernia to produce pain relief. It requires only a very tiny skin puncture in the back and no sutures.
Potential risks include discitis or infection of the disc, epidural abscess, reflex sympathetic dystrophy, nerve root injury, and injury to retroperitoneal structures. None of these occurred in the current study, Dr. Kelekis said.
This prospective study randomized 31 patients to traditional management, which consisted of 6 weeks of "rigorous" treatment with analgesics, anti-inflammatory drugs, muscle relaxants, and physiotherapy, and 31 patients to percutaneous disc decompression.
All patients (34 males, 28 females; mean age, 36 ± 5.8 years) had intervertebral disc herniation confirmed on magnetic resonance imaging (MRI) and had undergone 1 or more unsuccessful trials of medical treatment.
Patients rated their pain severity before and after treatment on a numeric visual scale, with 1 being the least and 10 being the most severe pain.
The patients who were managed traditionally got better faster. Within a month, their pain was gone. But their relief was short-lived and they gradually began to relapse. A year later, their pain scores had risen again, and by 24 months, they were back to square one, Dr. Kelekis said.
Specifically, the mean pain score in the traditional group was 6.8 before the start of conservative management. One month later, it had dropped to 0.9. By month 12, it had risen to 3.9, and was 4.09 at 24 months.
Pain relief took longer to occur in patients who underwent disc decompression, which was effective in 80% of patients. Before the procedure, the mean pain score was 7.4; at 1 month, it was 2.96; at 12 months, it was 1.67; and at 24 months, it was 1.61.
The difference between the 2 treatments was statistically significant at 12 and 24 months (P ? .01).
"Sciatica and back pain due to small herniation do not seem to have the tendency to disappear by themselves after 2 years," Dr. Kelekis told Medscape Radiology. "At least in our study, all conservative-care patients relapsed to their previous status."
The patients treated with the percutaneous approach, however, did not relapse.
"The clinical significance is that patients should not wait as long to have a percutaneous treatment if one sees relapses of back and leg pain that correlates with a small herniated disc on MRI," he said.
Study coauthor Dimitrious K. Filippiadis, MD, PhD, from General University Hospital in Athens, told Medscape Radiology that the time has come to be slightly more aggressive in the management of back pain.
Dr. Filippiadis, who presented the study at a Scientific Session, knows first-hand about percutaneous disc decompression, because he underwent the procedure himself.
"I don't think we should wait for 6 weeks of conservative treatment, because the patient will relapse. This is what happened to me. I went through 2 weeks of conservative therapy and I didn't see any change in my pain," he said in an interview. "I had percutaneous disc decompression at 3:00 in the afternoon and at half past 5 I was having a beer with Prof. Kelekis, discussing the procedure. The morning after, I went on holidays and took it easy for about 10 days. Ever since then, I do not feel any pain. This is very important, because I can work normally and am not impeded by pain."
Moderator Joseph Tashjian, MD, president of St. Paul Radiology in Minnesota, said: "I think one of the nice things about Dr. Kelekis's approach here is that he is actually doing a mechanical procedure to somehow reduce the disc pressure on the nerve, which is a permanent effect, rather than the temporary effect that you get with drugs and physical therapy, which really doesn't remove the original cause of the back pain."
Doing the procedure gives interventional radiologists a chance to become truly involved — much as a primary care physician would — in the care of these patients, Dr. Tashjian told Medscape Radiology.
"Clinicians must make sure that this procedure is applicable to the type of pain patients have and that the imaging findings correlate with the symptoms they are having, so that if we do go ahead and place a needle into the disc space, it works," he said.
"If we are able to correlate the imaging findings, correlate the symptoms, and do a very good job of selecting the patient, we really will get excellent results with this technique. I think his study shows that. And it's a long-term result, not a short-term result."
Dr. Kelekis reports being a teaching consultant for ArthroCare and DePuy-Spine/Johnson Johnson. Dr. Filippiadis and Dr. Tashjian have disclosed no relevant financial relationships.
Radiological Society of North America (RSNA) 95th Scientific Assembly and Annual Meeting: Abstract SSK13-05. Presented December 2, 2009.
