2. Chymopapain Injections
◦ 1964 Smith reported enzymatic dissolution of nucleus pulposus in
◦ l975 Hijikata first described in with good to excellent results in 68% of
Percutaneous Lumbar Discectomy
◦ 1985 Onik et al. introduced a nucleotome for percutaneous discectomy.
◦ 1987 Choy and Ascher first used lasers to evaporate the nucleus
◦ 2000 Arthrocare introduces an RF ablation device to vaporize the
Percutaneous Lumbar Discectomy
◦ 2002 Pain Concepts introduces a 1.5 mm probe for percutaneous
3. approximately 80% of the population
will experience at least one episode of
low back pain in their lifetime
55% will suffer from
low back pain associated with radicular
4. Conventional open discectomy, is
considered the standard treatment for
disc herniation induced LBP.
In recent years there has been a
general trend in spinal surgery toward
reductionism and minimalization
10. Through the wand, one alternates power and
voltage for two modes of actions:
Ablation at 125 V
Coagulation at 65 V
14. Radiofrequency energy excites the electrolytes in
a conductive medium, creating a precisely
The plasma's energized particles have sufficient
energy to break molecular bond within tissue,
causing tissue to dissolve at relatively low
temperatures (typically 40°C to 70°C).
The result is volumetric removal of target tissue
with minimal damage surrounding tissue.
Many Coblation devices also are designed to stop
blood (hemostasis) and coagulate or seal
15. This plasma field contains :
Sufficient energy to cleave molecular bonds
at low temperatures (40 - 70°C) into various
These gases escape through the introducer
Elementary molecules and low molecular weight
gases, e.g. oxygen, nitrogen, hydrogen, and carbon
16. • Because radiofrequency current does not pass
directly through tissue during the Coblation
process, tissue heating is minimal.
• Most of the heat is consumed in the plasma
layer, or in other words, by the ionization
• These ions then bombard tissue in their path,
causing molecular bonds to simply break
apart and tissue to dissolve.
17. The effect of tissue removal from within the
disc is hydraulic decompression of the disc.
37. Each channel is made in about 10
seconds duration for ablation and 10
second for coagolation
40. Patient with unilateral sciatica with or without LBP for
more than 6 months duration not responsive to
One symptomatic Contained disc
herniation shown on MRI.
Age : 18-50 y/o
VAS > 50 (0-
41. Disc Herniation no greater than 1/3 the saggital
diameter of spinal canal & <6mm in axial view
Radicular symptoms > Axial
Disc height > 50%
45. a contained disc herniation, the disc
material herniated through the inner
annulus but not the outer annulus; the
material is therefore contained, but
still can distort the path of the nerve;
46. a non contained herniation, the disc
material penetrates both the inner and
out layers of the annulus; the material
may reside beneath the posterior
longitudinal ligament or may penetrate
through it, or can be sequestered as a
47. •Uncontrolled psychological disorders
•Evidence of instability of the segment
•Evidence of infection
•Severe and progressive neurological
•Previous spinal surgery(At/Adjacent)
•Evidence of spinal stenosis
48. •Spinal fracture or tumor
•Disc space narrowing more than
•Morbid obesity (BMI>40)
49. •Evidence of Cauda Equina Syndrome
•Radicular pain originated from more than
•Axial pain > Radicular pain
50. • Nerve root injury
• Exacerbation of pain
• Failure to relieve the pain (short/long
• Allergic reactions to injectates
51. Rest for 2 days with limited sitting and walking per day
No driving for at least 3 days.
for first 1 week : limit lifting of no more than 5 kgs, no
bending and no twisting of the lower back.
Weeks number 2 and 3: physical activity is allowed,
walking, swimming and driving for short distances, and
return to work without severe exertion.
Follow-up visits : at 1 week, 1 month, 3 months, 6
months and 1 year intervals.
52. • A brace is not required, since the annulus has
not been compromised by the procedure.
However, a number of Nucleoplasty centers
are using a soft brace for two reasons:
• 1-The brace reminds the patient that they
have had a minimally invasive procedure
• 2-they should allow their back to heal (as
they progressively return to normal activities).
54. Patients and methods: This study was performed on 29 patients (23 males and 6
females) with lumbar disc prolapse causing unilateral sciatica with or without lower back
pain for duration more than 3 months with no response to conservative treatment (in
the form of medications, bed rest, and physiotherapy) in the period from November
2006 to November 2008. The Perc-D Spine Wand with 1 mm diameter and bipolar tip
was used for coblation and the coagulation on the disc utilizing both radiofrequency
coblation technology and thermal technology using a radiofrequency Arthrocare®
generator system 2000 (Arthrocare Corporation®, Sunnyvale, CA) to generate coblation
and coagulation energy.
Conclusion: Percutaneous image guided lumbar disc decompression using nucleoplasty
technique seems to be an effective, safe, simple and minimal invasive procedure for
relief of sciatica due to lumbar disc prolapse in well selected cases. Nonetheless a longer
follow-up period and a larger number of patients is needed to assess the long-term
efficacy of this procedure.
55. From February 2001 to May 2003 we treated 1390 patients, males 43.5% and females
56.5%. They presented with lumbalgia and/or lumbosciatalgia due to disc bulging or
partially contained disc herniation (989 cases in L4-L5 and 234 in L3L4, 167 in L5-S1)
as shown by TAC and/or NMR investigations.
They concluded that a safe volumetric removal of the nucleus is achieved
Forty-two cases of protruded lumbar intervertebral disc treated by coblation nucleoplasty followed-up
for two years were analysed. Relief of low back pain, leg pain and numbness after the operation were
assessed by visual analogue pain scale (VAS). Function of lower limb and daily living of patients were
evaluated by the Oswestry Disability Index .
Coblation nucleoplasty may have satisfactory clinical outcomes for treatment of protruded lumbar
intervertebral disc for as long as two-year follow-up, but longer-term benefit still needs verification.
57. 13 pt with LBP
The improvement rates of VAS were 64.6% and 58.7% in 6 and 12 months respectively.
Follow up MRI post procedurally revealed radiologic findings in correlation to the
symptomatic improvement in all patients
58. • Methods : Forty-six patients were enrolled in this study from April 2006 to June 2010. All patients had
one-level HLD. Disc degeneration was graded on routine T2-weighted magnetic resonance Image (MRI)
using the Pfirrmann’s grading system and all index levels were grade 3 and grade 4. Indications for
surgery were radiculopathy caused by disc protrusion with soft consistency. MRI was done at one
month after the procedure in all patients to check post-PDCT change. The clinical outcomes were
evaluated using Visual Analog Scales (VAS) score and MacNab’s criteria.
• Results : The mean period of clinical follow-up was 21 months. The average preoperative VAS score
for radiculopathy was 7.4±1.4, while the final follow-up VAS score was 1.4±0.7 (p<0.001). In
MacNab’s criteria, 41 patients (89.1%) had achieved favorable improvement (excellent and good) until
• Conclusion : PDCT is a safe and efficient treatment modality in a selective patient with HLD.
Nucleoplasty reduces pain in the long term and increases patients’
functional mobility. Compared to other treatments, it is an effective,
low-complication, minimally invasive procedure used to treat
cervical and lumbar disc herniations. Under the given catalog of
indications, it appears to be superior to conservative therapy.
Patients experience greater pain relief after cervical nucleoplasty
than after lumbar nucleoplasty. Studies published to date show a
heterogeneous picture of inclusion and exclusion criteria. Therefore,
a bias of the data presented here cannot be ruled out with certainty.
Initial results suggest the possibility of extending the indication to
include disc extrusions.
60. Level of Evidence
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence obtained from well-designed controlled trials without randomization
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than
one center or research group
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also
be regarded as this type of evidence
III: Opinions of respected authorities, based on clinical experience descriptive studies and case reports or
reports of expert committees
2B/weak recommendation, moderate- quality evidence