- Department of Neurosurgery, Taichung Veterans General Hospital, 160 Sec3 Chung-Kang Road, Taichung - 407 05, Taiwan, R.O.C
- Center for General Education, Jen-Teh Junior College of Medicine, Nursing and Management, 79-9 Sha-Luen Hu, Houloung Town, Miaoli County 356, Taiwan, R.O.C
- Department of Materials Science and Engineering, Feng Chia University, 100 Wen-Hwa Road, Taichung - 407 24, Taiwan, R.O.C
- Department of Orthopaedic Surgery, China Medical University Hospital, 2 Yue-Der Road, Taichung - 404 47, Taiwan, R.O.C
Hsi-Kai Tsou, Chiung-Chyi Shen, Hsien-Te Chen
Department of Orthopaedic Surgery, China Medical University Hospital, 2 Yue-Der Road, Taichung - 404 47, Taiwan, R.O.C
DOI:10.4103/2152-7806.67107© 2010 Tsou HK This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Tsou H, Chao S, Kao T, Yiin J, Hsu H, Shen C, Chen H. Intradiscal electrothermal therapy in the treatment of chronic low back pain: Experience with 93 patients. Surg Neurol Int 04-Aug-2010;1:37
How to cite this URL: Tsou H, Chao S, Kao T, Yiin J, Hsu H, Shen C, Chen H. Intradiscal electrothermal therapy in the treatment of chronic low back pain: Experience with 93 patients. Surg Neurol Int 04-Aug-2010;1:37. Available from: http://sni.wpengine.com/surgicalint_articles/intradiscal-electrothermal-therapy-in-the-treatment-of-chronic-low-back-pain-experience-with-93-patients/
Background:Low back pain (LBP) has become a main cause of absenteeism and disability in industrialized societies. Chronic LBP is an important health issue in modern countries. Discogenic LBP is one of the causes of chronic low back pain. The management of chronic discogenic LBP has been limited to either conservative treatment or operative treatment. Intradiscal electrothermal therapy (IDET) is now being performed as an alternative treatment.
Methods:Ninety-three consecutive patients undergoing IDET at 134 disc levels from October 2004 to January 2007 were prospectively evaluated. All patients had discogenic disease with chronic LBP, as determined by clinical features, physical examination and image studies, and had failed to improve with conservative treatment for at least 6 months. Follow-up period was from 1 week to 3 or more years postoperatively.
Results:There were 50 male and 43 female patients, with a mean age of 46.07 years (range, 21-65 years). The results were classified as symptom free (100% improvement), better (≥50% improvement), slightly better (
Conclusions:In conclusion, IDET offers a safe, minimally invasive therapy option for carefully selected patients with chronic discogenic LBP who have not responded to conservative treatment. Although IDET appears to provide intermediate-term relief of pain, further studies with long-term follow-up are necessary.
Keywords: Chronic low back pain, intradiscal electrothermal therapy, discogenic pain
Chronic low back pain (CLBP) affects 60% to 85% of the population at least once in their life, and those whose problems become chronic account for 10% to 20%.[
In the past 3 years, we preferred the diagnostic criteria for lumbar discogenic pain according to the clinical features, physical examinations and image studies. The purpose of this study was to evaluate IDET's role as a definitive treatment for chronic discogenic low back pain in strictly selected patients. We hypothesized that IDET would be a beneficial additional treatment option for chronic discogenic low back pain. Here we present a single-arm, prospective analysis on 93 patients who had severe low back pain with or without radicular pain. They all were treated with application of IDET, and we evaluated the efficacy of IDET and the ability of patients to manage day-to-day tasks of life after IDET treatment.
The IDET was performed as an outpatient procedure from October 2004 to January 2007 according to the inclusion and exclusion criteria listed in
negative control disc annular penetration of the dye single painful discs only positive pain behavioral signs during injection (Assessment of pain-related behavior was made on the basis of observations through a window from the start of the injection until its completion. Five types of pain-related behavior were recorded: guard/brace/withdraw, rubbing, grimacing, sighing, or verbalizing. The participant was considered to have demonstrated pain-related behavior if he or she exhibited two or more of these types of behavior.).[
negative control disc
annular penetration of the dye
single painful discs only
positive pain behavioral signs during injection (Assessment of pain-related behavior was made on the basis of observations through a window from the start of the injection until its completion. Five types of pain-related behavior were recorded: guard/brace/withdraw, rubbing, grimacing, sighing, or verbalizing. The participant was considered to have demonstrated pain-related behavior if he or she exhibited two or more of these types of behavior.).[
The degree of pain was recorded by visual analog pain scale. Oswestry low back pain disability questionnaire has been designed to give information as to how back pain has affected ability to manage everyday tasks of life. So we used Oswestry low back pain disability questionnaire to evaluate the ability to manage everyday tasks of life.
The IDET procedure
The IDET procedure uses a navigable intradiscal catheter with a thermal resistive coil. The procedure was performed under local anesthesia with lidocaine. Using fluorography, a 30-cm spineCATH catheter (Oratec Interventions, Inc., Menlo Park, CA) with a 5-cm active electrothermal tip was inserted anteriorly into the annulus or nucleus via a 17-gauge introducer. The active tip was advanced anterior-laterally inside the nuclear tissue and directed circuitously to return posteriorly, providing an ideal position to heat the entire posterior annulus. Once a satisfactory position was obtained in the anteroposterior, lateral views, the catheter was connected to a lead and passed to an independent technician. In all cases, the catheter tips were within 5 mm of the posterior vertebral margin upon review of saved fluoroscopic films. We used a standard protocol in which heating began at 65°C and was increased incrementally by 1°C every 30 seconds to achieve a final temperature of 90°C. The final temperature was maintained for 4 minutes, giving a total treatment time of 16.5 minutes.
The demographic and clinical features of the patients are listed in
The results were classified as symptom free (100% improvement), better (≥50% improvement), slightly better (<50% improvement), unchanged and aggravated. The results of low back pain after IDET are listed in
The results with regard to post-IDET lower limb pain are listed in
A significant improvement in physical functioning was demonstrated by the IDET-treated group as measured by the physical functioning scale of the Oswestry low back pain disability questionnaire. A significant improvement was detected at 6 months post-treatment. The average of Oswestry scale scores of the 89 patients pre-IDET was 31.72, which decreased to 16.66 after 1 year of IDET treatment. There was 47.48% improvement from pre-IDET to 1 year post-IDET [
The data were analyzed by using paired t tests to evaluate the therapeutic effects of IDET treatments. We constructed a 99% (α= 0.01) confidence interval, and we found it would reject null hypotheses H0. Thus, IDET treatments showed significant beneficial effects.
Intradiscal electrothermal heating treatment is a minimally invasive procedure used to treat patients with low back and referred leg pain, but how or why heating decreases discogenic pain is unclear.[
Derby et al. recently published a review paper about evidence-informed management of chronic low back pain with intradiscal electrothermal therapy.[
In our paper, we have described treatment of 93 cases with 134 degenerated disc levels by applications of IDET procedure and tried to analyze the results. The single-arm, prospective analysis showed that the application of IDET is a safe and useful intervention for chronic low back pain. The satisfactory pain relief obtained in the majority (more than 50%) of our patients only with chronic low back pain and lower limb pain justifies a study of at least 2 years. Approximately more than half of the patients were satisfied with their outcomes, and nearly all continued to follow up approximately 2 years post-IDET in this study cohort. These results are a great contrast to those of the previous studies evaluating outcomes of the IDET procedure.
Although the initial research appeared promising, IDET should be scrutinized more closely using controlled studies. On more long-term follow-up of this patient population, we find that this procedure may be less effective than previously reported. Only through the use of a blinded, treatment-uncontrolled study with long-term follow-up can questions regarding the efficacy of IDET be fully answered.
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