THE EVOLUTION IN THE TREATMENT
OF SPINAL DEGENERATIVE
PATHOLOGIES: FROM DEMOLITIVE TO
CONSERVATIVE OR REGENERATIVE
PROCEDURES
Alexandre A*, Caloprisco G*, Corò L.*, Borean A.M.*, Alexandre A.M.**
*EU.N.I. , Treviso
**Istituto di Radiologia, Policlinico Gemelli , Roma
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Surgery for disc herniation
1902: The Italian physician Bonomo, suggested laminectomy
via the transdural approach to remove the disc
1909: first surgery was performed by Oppenheim and Kruse...
1937: Mixter and Barr performed laminectomy via the
transdural approach, to remove the disc
1939: Love introduced the intralaminal–extradural
approach for discectomy
1977: microsurgery was introduced by Caspar and Yasargil
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SURGERY IS INDICATED FOR PATIENTS
WHO PRESENT ONE OF THE
FOLLOWING:
1) Severe or progressive motor palsy
2) Acute pain lasting for more than 3 months
and resistant to conservative treatment
AHCPR, 1994, No. 95-0642
CLINICAL PRACTICE GUIDELINE
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Evidence based Medicine ?
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CT/MR have shown peridural scarring,
epidural space endoscopy has confirmed
the hypothesis of epidural adhesions
in herniations and stenosis
Revel and Co ,Lancet 27:1223, 1988
Alexandre A,and Co, WFNS, Sidney, 2001
Raffaeli W. Acta Neurochir. 92, 2005
Reverberi C.Acta Neurochir.92, 2005
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discal
tissue degeneration
Increase of : PLA 2, MMPs, PGE2, IL6
inducing infiammatory processes
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secondary reaction is the epidural
hyper-vascularization > stasis > edema
(macrofags)
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activation of fibrinogenous
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ORGANIZATION
Substitution of necrotic infiammatory
tissue
(fibrine)
GRANULATION TISSUTE
(fibroblast rich tissue)
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epidural space adhesion
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spontaneous h. regression
• Bozzao (Radiology, 24,1992)
“Lumbar Disc herniation may be primarily a
non-surgical disease…”
• Delauche-Cavallier - Spine 1992
• Ellenberg –Archives of PM&R 1993
– 43% of patients with HNP and radiculopathy
completely resolve with conservative care within 6
– 18 months
– 36% improved
– 21% unchanged
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Circulation and Sciatica
• Local radicular hyschemia
• Arachnoideal fibrosis imparing CBF
circulation and nourrishment
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Circulation and Sciatica
Karunlahti, MD – ISSLS 2003
• Direct correlation between radicular
haematic perfusion and clinic
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byochemical alterations
induced by hypoxia
Biochemical parameters of discal entrapment
25
20
SOD
15
ONOO
10
CAT
NO
5
0
16h
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24h
48h
56h
14gg
venousTimestasis and edema
At present
Degenerative Disc Disease
is considered one of the most
common spinal disorders.
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the relevant existing research literature on
the problem of
Degenerative Disc Disease
has been reviewed specifically in order to
understand disc degeneration process,
distinguished from physiological aging.
An HS ;
Adams M.A. and P.J. Roughley
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What is Intervertebral Disc Degeneration
The process of disc degeneration is an
aberrant, cell-mediated response to
progressive structural failure.
A degenerate disc is one with
structural failure
combined with accelerated or advanced
signs of aging
Michael A. Adams, PhD; Peter J. Roughley, PhD, Spine
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The problem of intervertebral disc degeneration
has been approached from many sides,
from orthopedic surgery to molecular biology,
the scientific literature is particularly diverse.
There is no consensus
on what disc degeneration actually is,
or how it should be distinguished from
the physiologic processes of growth, aging,
healing, and adaptive remodeling
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Metabolite transport is by diffusion
Deficiencies in metabolite transport
appear to limit both the density
and metabolic activity of disc cells.
Discs have only a limited ability
to recover from any metabolic
or mechanical injury.
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The effect
of disc degeneration and of
epidural fibrotic modifications >
> mild nerve hypoxic disfunction.
Its clinical manifestation is
chronic pain
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CONSERVATIVE TREATMENT
FOR PATIENTS RESISTANT
TO PHYSIOTHERAPY AND DRUGS
?
A treatment aimed to correct the
biochemical mechanism of
degeneration – dysfunction- pain provocation:
Ozone discolysis
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External stimuli > transitory stress
activate in the nucleus
the cell reaction
silent gene > mRNA
shock proteins
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shock proteins
heat shock p. (HSP)
glucose-regulated p. (GRP)
oxidative shock p. (OSP)
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oxidative shock proteins (OSP)
will allow
better resistence
to oxydative stress.
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Ozone
inhibits production of prostaglandines
inhibits macrophagic production of
proteinase
favours local production of antioxidant
enzymes which will neutralyze endogenous
ROS
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Favours
production of enzymes
able to neutralyze
proinflammatory cytochines
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Increases
the release of
immunosoppressive citochines
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the disc is composed by
type 2 and 3 collagen,
Elastine
proteo- glicanes
glicosammino-glicanes
carboidrate chains
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Disc tissue:
macromolecolar structure
including relevant wather content
allowing amortization
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Intradiscal
oxidation
of glucose, galattose ,
N-acetilglucosamine, glicuronic acid,
glycine,
4-hydrossiproline,
Hawkins e Davies, 1996
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Entails disruption
of intra/inter-molecular valencies
and collapse of the
three-dimensional structure
Hawkins e Davies, 1996
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EXERIMENTAL STUDIES
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Normal disk
findings
Micro and macrovacuolar
degeneration
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Normal condrocyte islands
Hyperhydrated amorphous matrix
hyperhydrated because of inflammation
amorphous matrix
serrounding
condrocyte islands is
rich of water
Dehydrated amorphous matrix
after 0203treatment
Alexandre A. WFNS, Sidney 2001
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Anyway the target
is not
the morphological modification
to be seen in NRM
But biochemical modification
relieving pain
A. Alexandre
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PAIN
TREATMENT IS STRONGLY
CONSERVATIVE
OR MINI-INVASIVE
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Experimental Observational study
cod 119
Milan University
Pharmacology Institute
2005 - 2008
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1920 patients
in 3 groups
A - deg.disc arthropathy 509: 26.5%
B - FBSS
1027: 53.49%
C - herniated lumbar disc 384:
20%
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Treatment group A
deg.disc arthropathy
paravertebral periganglionar 0203
15 micrograms Ozone concentration
two cycles of 6 sessions
+ discolysis
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Treatment group B
FBSS
• paravertebral 0203 periganglionar injection
15 micrograms Ozone concentration
two cycles of 6 sessions
+ endoscopic discolysis
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Treatment group C
herniated lumbar disc
paravertebral 0203 periganglionar injection
15 micrograms Ozone concentration
two cycles of 6 sessions
+ discolysis
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Patient Group A
degenerative disc arthropathy
•
•
•
•
9 p. (1.76 %)
225 p. (44.2 %)
122 p. (23.9%)
153p. (30.05%)
no clinical result
moderate result *
good clinical result *
excellent result
* On to discolysis
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discolysis in the 225 patients with
moderate result
•
•
•
•
43 out of 225 (19.11%)
57
(25.33%)
121
(53.77%)
4
( 1.77 %)
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go to excellent
go to good
remained moderate
passed to poor
discolysis in the 122 patients
with good result
• 65 out of 122 (53.27 %) excellent result
• 55
(45.08 %) good result
• 2
( 1.63%) moderate result
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Patient Group A
degenerative disc arthropathy
•
•
•
•
Excellent 261 cases out of 509 (51.27 %)
Good
112
(22
%)
Moderate 123
(24.16 %)
Poor
4
( 0.78 %)
• It was impossible to treat 9 cases out of 509 (1.76 %)
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Patient Group A
degenerative disc arthropathy
excellent + good gives
373 cases out of 509 = 73.28 %
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Patient Group B: FBSS
•
•
•
•
•
•
2 p. (0.194%)
30 p. (2.92%)
256 p. (24.9%)
441 p. (42.94%)
298 p. (29.01%)
--------total 1027
treatment not tolerated
no useful clinical result *
moderate result *
good result *
excellent result
* On to discolysis
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discolysis of the 30 with no result
•
10 poor result, insufficient
•
15 moderate improvement
•
5 good improvement
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Discolysis in the 256
“moderate outcome “
• 20 out of 256 ( 7.8 %) excellent result
• 64 out of 256 (25 %)
good result
• 172 out of 256 (67.18 %) moderate result
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Discolysis in the 441
“ good outcome”
• 105 out of 441 (23.8 %) excellent result
• 314 out of 441 (71.2 %) good result
• 22 out of 441 ( 4.9 %) moderate result
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Discolysis in the 298
“ excellent outcome “
• - 35 p. were satisfacted and decided to
suspend treatments (11.74% out of 298 p.)
• - 263 underwent discolysis:
258 out of 263 (98 %)
remained excellent
5 out of 263 (1.9 %) moderate loss
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Global for FBSS
•
•
•
•
Excellent
Good
Moderate
Poor
418 / 1027 (40.7 %)
383 / 1027 (37.29 %)
214 / 1027 (20.83 %)
10 / 1027 ( 0.97 %)
• treatment not tolerated: 2 cases out of 1027
(0.19 %)
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Global for FBSS
Adding together
excellent + good gives 801
cases out of 1027 = 77.99 %
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Treatment Group C:
herniated lumbar disc
• Out of 384 patients, 78 (20.3 %) benefited
greatly from the outpatient treatment :
• Good
in 49 (12.76 %)
• Excellent in 29 ( 7. 55 %)
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Treatment Group C:
herniated lumbar disc
anti-coagulant therapy (4 p.)
existing cardiologic problems (2)
just paravertebral therapy with a result
considered
• Good
in 4 (1.0 %)
• Excellent in 2 (0.52%)
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Treatment group C
herniated lumbar disc
The remaining 300 patients were treated
with an intradiscal injection
compared with a similar series of 300 patients
treated by microdiscectomy
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Treatment group C
herniated lumbar disc
• Type of lumbar hernia
•
•
•
•
Microdiscectomy
Contained 197 (65.6%)
Extruded
93 (31 %)
Migrated
10 ( 3.3%)
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discolysis
200 (66.6%)
82 (27.3%)
18 ( 6 %)
Treatment group C
herniated lumbar disc
• Regression of pain (VAS Regression > 4 )
•
•
•
•
Microdiscectomy
4-6 months 292 (97.3%)
1 year
275 (91.6%)
18 months 250 (83.3%)
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discolysis
280 (93.3%)
276 (92 %)
262 (87.3%)
Treatment group C
herniated lumbar disc
• regression of pain / type of hernia
•
Microdiscectomy
Discolysis
• Contained 163/197 (82.74%) 172/200 (86 %)
• Extruded 85 / 93 (91.39%) 76 / 82 (92.6 %)
• Migrated
9 / 10 (90%)
15 / 18 (83.33%)
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Treatment group C
herniated lumbar disc
• regression of pain / intraforaminal hernia
•
•
microdiscectomy
22 (91.6%)
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discolysis
22 (84.6%)
Treatment group C
herniated lumbar disc
•
•
•
•
•
regression of sensorial dysfunction at 18 m.
Microdiscectomy
Discolysis
complete
82.5 %
83.2 %
partial
12.4 %
9.4 %
insignificant
5.1%
2.4 %
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Treatment group C
herniated lumbar disc
•
•
•
•
•
regression of motor deficit at 18 months
Microdiscectomy
Discolysis
complete
86.6%
85.7%
partial
9.8%
8.3%
insignificant
3.6%
6 %
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Treatment group C
herniated lumbar disc
•
•
•
•
•
Regression of initial severe motor deficit
Microdiscectomy
Discolysis
complete
44.4%
40%
partial
22.2%
20%
insignificant 33.3%
40%
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Treatment group C
herniated lumbar disc
• complications observed in the two series
of case records related to the procedure:
• Microdiscectomy: 4 csf fistulas
1 bacterial discitis
• Discolysis:
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2 chemical discitis
Treatment group C
herniated lumbar disc
• There were no statistically significant
differences in the outcome for the two
techniques at 18 months after treatment.
There is, however, the absolute difference
in invasiveness of approach
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Treatment group C
herniated lumbar disc
A failure from microdiscectomy is a FBSS
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LINEE GUIDA MINISTERIALI
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