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作者：Fran Lowry  
出處：WebMD醫學新聞

　　December 4, 2009 (芝加哥) — 希臘研究者於北美放射協會第95屆科學會議暨年會中報告指出，在首次比較椎間盤脫出(Herniated Disc)疼痛處置之兩種治療方法的隨機控制試驗中，經皮椎間盤減壓術(percutaneous disc decompression)這項微創手術戰勝了傳統保守治療方法。
　　
　　希臘雅典大學介入放射科醫師Alexios Kelekis博士在記者會中表示，多數人(70%- 90%)在一生中，某個時間點會發生某種程度的背痛；其中有36%是因為椎間盤脫出。
　　
　　椎間盤脫出的一般治療包括試用各種止痛藥、肌肉鬆弛劑、物理治療與休息。
　　
　　Kelekis博士表示，多數病患在這類治療的3個月內會恢復；不過，可能會有胃腸道出血和其他止痛藥併發症的代價，再者，他們的症狀最後可能復發。
　　
　　經皮椎間盤減壓術可以在門診時於局部麻醉下進行。藉由透視造影導引，將一根針插入椎間盤、移除突出物，消除造成疼痛的壓力源，此方法僅需在背部皮膚穿刺一個很小的洞，無須縫合。
　　
　　Kelekis博士表示，可能的風險包括，椎間盤炎或感染、硬膜外膿瘍、反射性交感神經性萎縮、神經根損傷、後腹膜構造損傷。目前的研究中，這些情況並未發生。
　　
　　這篇前瞻性研究將31名病患隨機分派到傳統處置，包括6週的止痛藥物、抗發炎藥物、肌肉鬆弛劑、物理治療等仔細治療，31名病患分派到經皮椎間盤減壓術。
　　
　　全部病患(34名男性、28名女性；平均年紀36± 5.8歲)都經磁振造影(MRI)確認有椎間盤突出，以及曾有1種以上的藥物治療失敗經驗。
　　
　　病患根據數字視覺量表(1分最不痛、10分最痛)，在治療前後對自己的疼痛嚴重度進行評分。
　　
　　Kelekis博士表示，使用傳統方式處置的病患比較快達到效果，1個月內，他們的疼痛消失，但是，他們的緩解只是短暫的，之後漸漸開始復發，1年後，他們的疼痛分數再度上升，24個月時，他們回到原點。
　　
　　特別的是，傳統方式組的平均疼痛分數在開始保守處置前為6.8分，1個月後，降低至0.9分，12個月時，上升到3.9分，24個月時為4.09分。
　　
　　接受減壓術的病患達到疼痛緩解的時間比較久，其中80%病患有效。手術前，平均疼痛分數為7.4分；1個月時，為2.96分；12個月時，為1.67分；24個月時為1.61分。
　　
　　兩種治療方式在12個月和24個月時的差異達統計上的顯著意義(P≦.01)。
　　
　　Kelekis博士向Medscape Radiology表示，因為小突出引起的坐骨神經痛和背痛，在2年後似乎不會自行消失，至少，在我們的研究中，所有保守照護的病患都復發到原本的狀態。
　　
　　不過，使用經皮椎間盤減壓術的病患沒有人復發。
　　
　　他表示，臨床意義是，如果病患的MRI顯示為小椎間盤突出相關的背痛和腳痛復發，可考慮立即進行經皮治療方式。
　　
　　共同研究者、雅典大學綜合醫院的Dimitrious K. Filippiadis博士向Medscape Radiology表示，這對於背痛處置的時間上會比較積極一些。
　　
　　Filippiadis博士在科學小組會議中發表此研究，瞭解經皮椎間盤減壓術的第一手資訊，因為他自己也接受這項手術。
　　
　　他在受訪時表示，我不認為我們需等待6週的保守治療，因為病患終將復發，這也是我親身經驗，我接受了2週的保守治療，但是疼痛狀況沒有改善，後來我在下午3點接受經皮椎間盤減壓術，然後，在5點半時，我就和Kelekis教授喝啤酒討論該手術。隔天早上，我前往度假，並輕鬆地度過10天。之後，我未再感覺任何疼痛，這相當重要，因為我可以正常工作而不受疼痛的阻礙。
　　
　　會議主持人、明尼蘇達聖保祿放射科理事長Joseph Tashjian醫師表示，我認為，Kelekis博士的方法的好處之一是，他的確進行了一種可以減少椎間盤神經壓力的機械性手術，且有持續的效果，而非藥物和物理治療的暫時性效果，是真正的將背痛的痛源移除。
　　
　　Tashjian醫師向Medscape Radiology表示，進行此一手術可讓介入放射科醫師有機會真正參與這些病患的照護，而不是只有一線照護醫師。
　　
　　他表示，醫師們必須確定此一手術可運用的疼痛類型患者，以及相關的影像檢查結果，那麼，當我們將針插入椎間盤時，就會發揮效果。
　　
　　如果我們可以將影像檢查和症狀產生關聯，並且慎選病患，我們可以發揮此技術的最佳結果，我認為此研究就是如此，達到長期而非短期的結果。
　　
　　Kelekis博士報告擔任ArthroCare和 DePuy-Spine/Johnson Johnson的教學顧問。Filippiadis博士和 Tashjian醫師皆宣告沒有相關財務關係。
　　
　　北美放射協會(RSNA)第95屆科學會議暨年會：摘要SSK13-05。發表於2009年12月2日。


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.