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