Disc Got You Down?

Less-invasive spinal decompression therapies may help you avoid risky surgery and significant downtime.

By Erica Krystek
From Lava Magazine, August/September 2011

Herniation, protrusion, bulge or tear. Hearing any of these words in reference to a lumbar back injury can be devastating to any athlete, but in particular to the avid multisport devotee who may equate those words to surgery, rest and a temporary change of lifestyle. Treatment options for disc injuries have been mostly limited to medications, physical therapy, spinal corticosteroid injections and decompression tables. But when these treatments do not provide longterm benefits, patients often face the grim prospect of surgery.

Surgery for such injuries, whether it’s a discectomy (the removal of herniated disc material that presses on the nerve root or the spinal cord) or a laminectomy (the removal of thickened tissue or lamina that narrows the spinal canal), are not always without complication. As with any general anesthesia procedure involving the spine, there are the obvious risks— though they are extremely small—of death and paralysis. Additionally, with discectomy or laminectomy, there are the dangers of damage to the dura or lining of the spinal canal, scarring of the spinal nerves and damage to the main blood vessels, all of which can lead to spinal instability and deformity. Though these side effects are uncommon, the risk may compel you to explore other therapies that aim to replace the artistry of a surgeon’s blade with less-invasive weaponry. Thermoelectric heat, radiofrequency energy, and yes, Star Wars fans, even laser beams, are among your current options in the alternative decompression therapy arsenal. These methods seek to get you back to your rigorous training schedule faster with fewer post-treatment hurdles.

ELECTROTHERMAL HEAT THERAPY.

Of the less-invasive procedures investigated throughout the years to treat lumbar disc disease, procedures can be divided into two general categories: those that are designed to remove or ablate disc material, and thus decompress the disc, and those that are designed to alter the biomechanics of the disc to achieve pain relief. Intradiscal electrothermal therapy (or IDET) is defined by the latter and, as its name implies, uses heat as its primary weapon.

During this procedure, which requires only local anesthesia, X-ray imaging is used to place a tiny catheter in the outer layer of the affected disc. An electrical current then passes through the catheter, heating a small outer portion of the disc to a temperature of about 185 degrees Fahrenheit for roughly five minutes, at which point the tissue shrinks and hardens, sealing any tears. It also cauterizes the small nerve fibers in the periphery of the disc, essentially destroying pain receptors in the area without actually retracting the disc herniation itself.

In contrast with traditional surgery, patients can typically return home within one to two hours. There is often an increase in symptoms the few days following an IDET procedure, but after that the disc pain should continue to decrease— with significant improvement and a noticeable increase in range of motion about six weeks after the procedure1.

Michael Wolff, M.D., medical director of Southwest Spine and Sports in Scottsdale, Ariz., who specializes in IDET and other lessinvasive disc decompression therapies, cautions that patients should limit activity immediately after the procedure, as the disc fibers are initially weakened.

“After an essential four weeks of rest, I’d advise the patient to begin a physical therapy regimen that targets predominantly core strength and limits any rotational-type exercises until at least six to eight weeks after the procedure,” he notes. “Though each patient is different, IDET recipients should be fully functional and back to their normal routines three months after the procedure—even triathletes.”

IDET is thought to be most effective for disc injury patients who have significant lumbar pain without the presence of sciatica or additional leg pain. As with any alternative therapy, success can depend on whether the right patient with the right symptoms is selected for treatment1.

“Patient selection is everything and technique is the difference between success and failure,” says Wolff. “Not only does the doctor need to have patient selection knowledge, but the patient also needs to have doctor selection knowledge. Having a well-trained professional who performs these specialized therapies regularly is key.”

A few early studies show encouraging results for IDET patients, with a 60- to 80-percent improvement rate reported in the months following the procedure. Unfortunately, because IDET is relatively new, there are still no longterm studies to evaluate how these patients are doing years down the road.

LASER THERAPY.

Percutaneous laser disc decompression (or PLDD) is similar to IDET in that the procedure is performed on an outpatient basis and requires only local anesthesia. And much like the preparation for IDET, during PLDD, a tiny catheter is inserted into the outer layer of the diseased disc under X-ray guidance to transmit the therapy’s energy. But the similarities end there. PLDD therapy aims to heal the injury by removing part of the diseased disc with a laser, rather than changing its composition. It is also considered an effective treatment for a herniated disc with or without additional sciatica in the lumbar region.

During PLDD, once the catheter is positioned, an optical fi ber is inserted and laser energy is sent through the fi ber, vaporizing a tiny portion of the disc nucleus. This creates a partial vacuum, which draws the herniation away from the nerve root, thereby relieving the pain. And unlike discectomy, there is no cutting, scarring or potential for spinal instability to develop since only a tiny portion of the disc is vaporized.

The effect of the laser on lumbar pain is usually immediate and the patient can be discharged within 30 minutes. The entire healing process, however, will last a few weeks, during which time swelling at the injury site should gradually dissipate. It is recommended that you not partake in strenuous exercise or heavy lifting during this time or until released by the physician to do so.

Dr. Wolff, who does not perform PLDD, cautions that there may be a bit more risk involved with this procedure versus newer techniques.

“With laser treatment it’s more diffi cult to see how far you have gone and how much [tissue] you have taken,” he says. “Whereas with IDET or nucleoplasty you have certain depth markers that help make it more accurate.”

Though varied among studies, the success rate of PLDD is relatively high—reported at anywhere from 70 to 100 percent.

RADIOFREQUENCY THERAPY.

The newest and most signifi cant breakthrough in the fi ght against disc disease is radiofrequency discal nucleoplasty, which, like PLDD, falls into the tissue ablation category. This therapy uses radiofrequency energy, delivered by a probe with small electrodes inserted into the disc, to disintegrate portions of the injured tissue. Distinct from IDET and PLDD, which both use forms of heat, discal nucleoplasty uses radiofrequency to create a low-temperature plasma fi eld of particles that contain the necessary energy to scramble and break the molecular bonds of the tissue, thus dissolving it. This creates small channels in the disc, which aid in decompression.

The advantages of this method (in comparison to IDET and PLDD) are that it supposedly provides for more precise and localized tissue removal, while danger to surrounding healthy disc material is minimized because of the low temperature. Discal nucleoplasty is thought to be most appropriate for discs that have bulged, but not ruptured, and can be used for both patients with and without sciatica symptoms2.

“All of these therapies, but specifi cally nucleoplasty, work better when the disc is tall and not collapsed,” Dr. Wolff says. “Imagine your disc as an oreo. If it’s a double-stuffed oreo you will have better results.”

Because only a tiny incision is required for nucleoplasty, just like the other therapies mentioned, there are no stitches and the insertion point is simply covered with a bandage. The patient can be sent home immediately. Though individualized, recovery is fairly quick, with recipients able to return to some form of activity within two weeks.

Dr. Wolff has had much success treating patients— specifically triathletes—with this radiofrequency method, having them back to their normal training regimen in as little as 12 weeks.

“Though each patient’s results will vary, most can begin physical therapy at two weeks,” he says. “At four weeks swimming can be added back into the routine, and at six weeks patients can typically return to the bike. By eight to 10 weeks running can be added—but slowly—with mileage gradually increasing over time. By 12 weeks, [a triathlete] can be back to business as usual.”

Radiofrequency therapy seems promising, indeed, but because is still in its infancy, there are no long-term studies available to evaluate the condition of patients many years later.

FUTURE THERAPIES.

While all forms of spinal decompression treatment—everything from oral medication to traditional surgery— still remain useful and have their place in the fight against disc disease, there are now more options available to the patient than ever before thanks to budding technology. And these less-invasive, therapies continue to evolve and improve as new research becomes available.

Leading the next generation of outpatient treatments are Platelet Rich Plasma (PRP) and stem cell therapies, though it may be quite some time before these methods are FDA approved become mainstream.

“Biological treatments have the most potential and are the next step that needs to be explored,” Dr. Wolff says. “With PRP therapy, protein poor plasma—the sticky stuff that stops you from bleeding out—can potentially plug and seal tears in the disc wall, and protein rich plasma—super concentrated platelets filled are growth factors may have regenerative properties. Stem cells have the ability to turn into and mimic and turn into other cells that are in the area of injection whether it be cartilage or disc material. However, we don’t know what a stem cell will do when it is introduced to a cancer or sick cell, for example. Much more research and still needs to be done.”

Before seeking any treatment for disc injury, it is imperative to speak with your doctor and receive a proper diagnosis. Orthopedic specialists working at traditional hospitals may offer IDET, PLDD or radiofrequency discal nuceloplasty treatments as part of their regular practice if they have the necessary equipment available to them and have undergone proper training. It really depends on the hospital. Otherwise, you will likely find these innovative therapies offered at specialty, spine and sports therapy clinics in your area.

References:
1. Lester, Jonathon, M.D. (2004). IDET: an Alternative
to Invasive Surgery for Chronic Low Back Pain. Retrieved from
http://www.spine-health.com.
2. Yurth, Elizabeth F. M.D. (2004), New Technologies for Treating Low Back Pain. Retrieved from
http://www.mapletonhill.com/