1. Disc Annuloplasty
Andrea Trescot, MD, FIPP

2. DISCLOSURE
Andrea Trescot, MD
Director of Education, WIP
Medical director: Pinnacle Lab Services (not relevant to this
program)

3. Disc as a Source of Pain?
• Although reports of nerve fibers
in the annulus fibrosis were seen
as early as 1940, consideration
of the discs as a source of pain
(as apposed to HNP) did not
come until 1970
Roofe PG. Innervation of the annulus fibrosus and posterior longitudinal
ligament: fourth and fifth lumbar level. Arch Neurol Psychiat.
Chicago, 1940;44;100.
Crock HV. A reappraisal of the intervertebral disc lesion. Med J Aust
1970;1:983-989

5. • Clues for painful, degenerative
disc:
– “dark” appearance on T2 weighted
image
– loss of height
– reactive changes of the end-plates
and high intensity zone (HIZ)
Imaging Correlation

6. Large Disc Herniation

10. Disc Annuloplasty
• The term intervertebral disc
annuloplasty indicates any procedure
aimed at repairing the annulus of a
bulging intervertebral disc before it
herniates.
• Potentially addresses a problem that is
difficult to treat with standard surgical
techniques

11. Abtruse Acronyms
TIPs - Thermal intradiscal procedures
IDET - Intradiscal electrothermal therapy
IDEA - Intradiscal electrothermal annuloplasty
IDTA - Intradiscal thermal annuloplasty
IRFT - Intradiscal radiofrequency thermocoagulation
PIRFT- Percutaneous intradiscal radiofrequency thermocoagulation
… and Confusing Semantics
PIRFT is commonly used to designate two procedures where RF is
directly aplied to the disc,The Intranuclear RF and the RF
annuloplasty with the DiscTRODE
IDET is commonly used to designate the RF annuloplasty done with
the SpineCath

12. discTRODE™

13. Percutaneous Intradiscal Radiofrequency
Thermocoagulation (PIRFT)
• discTrode™ placed a heating element
across the posterior annulus (within
the lamelli) form one side, with a
thermister from the other side
• Technically difficult and rarely
performed any more

15. Intradiscal Electrotherapy

16. Intradiscal Electrothermal Annuloplasty
(IDET)
• Also known as Intradiscal Thermal
Annuloplasty (IDTA)
– Placement of a thermal catheter within
the disc
• between the annulus and the nucleus

18. L4
SAP
L3
L3-4
= puncture
target

19. ANESTHETIC
NEEDLE

20. PROCEDURE
NEEDLE

26. STYLETTE REMOVED

35. Complications
• catheter breakage
• nerve root injuries
• post-IDET disc herniation
• cauda equina syndrome
• infection
• epidural abscess
• spinal cord damage

37. Nerve root
Dura
Before IDET

38. Operating
wire probe
Adhesions
After IDET

39. IDET Conclusion
• Safe
• Minimally invasive
• Outpatient procedure
• Effective for well-selected patients
• May prevent or delay the need for fusion
• May need follow-up adhesiolysis

40. Bipolar “Conventional” RF
• Attempts were made
to place an RF needle
at each side of the
disc, using a bipolar
energy to create a
“heat strip”

41. The cannulae should be placed between 4
and 6 mm apart to maximize the surface
area of the resultant lesion. Treatment
duration of 120 to 150 seconds at 90°C is
required to maximize the size of the strip
lesion
Pino et al. Reg Anesth Pain Med 2005
Why Bipolar “Conventional” RF
Can’t be Effective

42. Why Bipolar “Conventional” RF Can’t
be Effective

43. “Cooled” Radio Frequency Lesioning

44. Probe
• Without cooling, the size of lesion is limited by the heat generated in the tissue
adjacent to the electrode
• It is not desirable to raise tissue temperature above 95° C
• Cooling the tissue adjacent to the electrode allows effective heating at a greater
distance
Non-cooled
Cooled
Temperature
Distance
80° C
45° C
r
Ionic Heating Using Cooled RF

45. Internal cooling
doubles the lesion
radius and increases
the lesion volume by
a factor of 8
Standard RF
Internally-
Cooled RF
Cooled vs. Non-Cooled RF Lesions

46. (a) Single lesions
(b) Strip lesion
Tissue
Tissue
Two electrodes of similar size are used. A grounding pad is not
required.
If electrodes are not close together, separate lesions are made
If electrodes are close enough, a “strip lesion” is made
TransDiscal Biacuplasty
Physics

47. Cooled RF Probe

48. • Radiofrequency current is concentrated
between electrodes on two straight probes.
•The electrodes are internally cooled, allowing
deep, even heating and eliminating tissue
adherence.
• Temperature sensors allow monitoring at the
electrode tips and disc periphery.
• Heating parameters can be adjusted to
achieve a specific thermal dose.
TransDiscal Biacuplasty
Logics

49. RF Annuloplasty
Physics
Lesion in chicken breast

50. TransDiscal RF Annuloplasty
Physics
Lesion in egg white

51. TransDiscal Biacuplasty
Procedure

56. Conclusion
• Radiofrequency lesioning provides the
potential for denervation as well as
disc sealing, theoretically providing
pain relief as well as pathology
reversal
• RF techniques for the disc continue to
evolve.
• Advances in imaging technology may
speed up that evolutionary process

57. Obrigada
Andrea Trescot, MD, FIPP
DrTrescot@gmail.com