Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 832-840
World Neurosurgery

Original Article
Clinical Efficacy and Its Prognostic Factor of Percutaneous Endoscopic Lumbar Annuloplasty and Nucleoplasty for the Treatment of Patients with Discogenic Low Back Pain

https://doi.org/10.1016/j.wneu.2017.06.112Get rights and content

Objective

The choice of appropriate treatment of discogenic low back pain (DLBP) frequently is difficult. This study sought to identify the clinical efficacy of percutaneous endoscopic lumbar annuloplasty and nucleoplasty (PELAN) to treat patients with DLBP and to investigate prognostic clinical or radiologic variables.

Methods

Eighty-nine patients with a diagnosis of DLBP who underwent PELAN were included. Numeric Rating Scale (NRS) for back pain, Oswestry Disability Index % (ODI%), and modified Macnab criteria were measured at short-term (3–4 weeks) and long-term follow-up period (at least 12 months) to investigate clinical efficacy of PELAN. The subjects were defined as successful group in case of 50% or more reduction of NRS, 40% or more reduction of ODI%, and good or excellent response of Macnab criteria. Clinical and radiologic variables were compared between successful and unsuccessful outcomes group to determine prognostic variables.

Results

NRS and ODI% were significantly reduced at short- and long-term follow-up after PELAN. Sixty-two (69.7%) and 68 (76.4%) obtained successful NRS reduction and 59 (66.3%) and 68 (76.4%) accomplished successful ODI% reduction at short-term and long-term follow-up, respectively. Successful Mcnab response was found in 61% at short term and 65.2% at long term. Pain during waist flexion among clinical variables was significantly related to good clinical outcomes and Modic change among radiologic variables was significantly related to poor clinical outcomes.

Conclusions

PELAN provided favorable outcomes in patients with DLBP who were refractory to conservative treatments. Flexion pain was good prognostic, and Modic change was a poor prognostic variable.

Introduction

It is estimated that discogenic low back pain (DLBP) resulting from internal disc disruption accounts for approximately 40% of chronic low back pain cases.1 DLBP is axial low back pain caused by the degeneration of the nucleus pulposus, tearing of the posterior annulus fibrosus, and subsequent intradiscal changes.2 Posterior annular damage facilitates the migration of the nucleus pulposus into the outer annulus, which is followed by physiologic responses, such as nerve ingrowth into the herniated nucleus pulposus and the formation of vascularized granulation tissue.3 The bulging disc irritates the nociceptors that are present in the posterior annulus, posterior longitudinal ligament, or dural sac. Inflammatory mediators produced by ingrowing nerve endings also stimulate nociceptors. Furthermore, because of the poor blood supply and the high tensile stress, the healing process is insufficient or defective. These chemical and mechanical processes produce DLBP.4, 5

The treatment of DLBP remains controversial. There are no established treatments for DLBP, although this appears to be a common problem among patients with chronic low back pain.6 Various conservative treatments, including the use of medication, exercise, and physical therapy, currently are used; however, their effects frequently are limited. For patients with DLBP who have not responded to conservative treatment, surgical treatment, including spinal fusion or disc replacement, may be considered.7, 8, 9 However, these surgical techniques are invasive and sometimes are associated with severe complications.10, 11

Therefore, a variety of alternative minimally invasive percutaneous intradiscal procedures have been attempted to obtain successful pain relief while maintaining as much normal disc tissue as possible.12, 13, 14 Percutaneous endoscopic lumbar annuloplasty and nucleoplasty (PELAN) is a minimally invasive treatment performed to decompress the posterior portion of the nucleus or granulation tissues in the torn annulus without touching the central and anterior regions of the disc. PELAN is a distinctive procedure that enables physicians to mechanically remove the lesion site with laser energy or forceps under direct visualization by endoscopy and via intraoperative fluoroscopy. This property allows for the effective removal of targeted tissue and the preservation of as much healthy tissues as possible.15

Previously, we demonstrated that PELAN with direct endoscopic view procured favorable clinical results in patients with DLBP. Approximately 70% of patients diagnosed as DLBP obtained significant pain reduction and functional improvements.16 Although clinical and radiologic evaluations as well as diagnostic tests are used to identify patients who are candidates for PELAN, selecting patients is sometimes challenging. Furthermore, diagnostic tests frequently have been criticized because of their invasiveness and limits to diagnostic accuracy. Indeed, provocative discography frequently has been criticized because it can result in disc tissue damage and further aggravate disc degeneration.17

Thus, it is important to identify, via the use of clinical and radiologic assessments, patients who can experience good clinical results. However, to the best of our knowledge, there has been no study regarding clinical or radiologic findings that predict clinical outcomes after endoscopic minimal procedure including PELAN in patients with DLBP. Therefore, the purpose of this study was to identify the clinical efficacy of PELAN in treating patients with DLBP and to investigate the clinical or radiologic variables that can predict its outcomes.

Section snippets

Subject and Clinical Evaluation

This retrospective study was approved by the institutional review board of our hospital. Patients who had undergone PELAN from August 2012 to December 2015 to treat DLBP in the Department of Physical Medicine and Rehabilitation were included in this study. PELAN was conducted in patients who satisfied the following criteria: 1) chronic low back pain and 2 or more of the clinical manifestations that suggest discogenic pain (e.g., sitting pain, flexion pain, lifting difficulty, or pain on

Results

The mean age of patients was 37.1 ± 11.4 (95% confidence interval [CI] 34.7–39.5) years and the mean duration of pain was 17.4 ± 14.1 (95% CI 14.5–20.4) months. The mean long-term follow-up period was 14.9 ± 5.11 (95% CI 13.8–16.0) months. Of the 89 patients, 30 had 2 or more disc lesions. All exhibited a positive response of provocative discography in 1 or 2 lesions, which were treated by PELAN. Of the remaining 59 patients who exhibited single-disc lesions, 51 patients (86.4%) showed a

Clinical Efficacy of PELAN

Selecting the appropriate treatment of DLBP can be challenging. Although several clinicians pursue conservative management, it often is disappointing. Conversely, surgical options are extensive and can produce severe complications. PELAN, a minimally invasive technique, allows for physicians to remove target tissues and to preserve healthy anterior disc tissues under direct endoscopic view. This technique can be used to mechanically remove a pinched nucleus, granulation tissues, or damaged

Conclusions

PELAN provided favorable outcomes in patients with DLBP who were refractory to conservative treatments and contributed to a reduction in the requirement for extensive surgical treatment. Among the clinical variables assessed in this study, pain during waist flexion was significantly associated with good clinical outcomes. Furthermore, among radiologic variables assessed in this study, Modic change, as indicated by MRI, was significantly associated with poor clinical outcomes.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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