Streams of water, balloons offer back pain relief

New techniques offer minimally invasive option

What do a stream of water, a balloon, and a titanium implant have in common? They are all components of new techniques to treat different conditions that cause back pain, and they all can be performed in an outpatient surgery setting.

After conservative treatments such as epidurals, massage, physical therapy, and acupuncture have not relieved back and leg pain caused by a herniated disc, the next step does not have to be major back surgery, says Didier Demesmin, MD, a pain management specialist in Milltown, NJ. Hydrodiscectomy is an outpatient procedure that s performed under local anesthesia. "When you remove some of the nuclear material from the disc, you can reduce the amount of pressure that is causing the disc to herniate," he explains.

Using the Hydrocision SpineJet Hydrodiscectomy System (Hydrocision; Billerica, MA), Demesmin removes the nuclear material with a high-pressure stream of water. "It takes about three minutes to remove 20% of the nuclear material to reduce the herniation," he says.

Hydrodiscectomy takes about 30 minutes to perform, and discharge is usually one to 1½ hours after the procedure is complete. "There is some soreness where the tool went through muscle in the back, but the patient is usually free of any pain or soreness associated with the herniated disc and the procedure in one to two weeks," says Demesmin.

With proper patient selection, the success rate for hydrodiscectomy is between 70% and 80% for total relief, says Demesmin. "Even patients who experience a 50% reduction in pain appreciate the procedure because it does enable them to reduce narcotic medication they may be taking, and it is an improvement," he says.

Patients like reducing the use of narcotics to control pain for many reasons, including the cost-savings, says Demesmin. Reimbursement is not a problem for the procedure, so it is a win-win for the patient, he adds.

The benefit of hydrodiscectomy over other procedures to reduce nuclear material in the disc is the use of water, which does not conduct heat and does not exclude older patients from the procedure, says Demesmin. "As people age, their discs degenerate and lose moisture content," he says. "Other discectomy procedures rely upon a certain amount of moisture in the disc to properly and safely work, but hydrodiscectomy can be performed on patients of all ages."

While hydrodiscectomy cannot be used for patients whose back pain is caused by lumbar spinal stenosis (LSS), the X Stop Interspinous Process Decompression System is the first technique available for treatment of the condition that is caused by a narrowing in the lumbar spinal canal that carries nerves to the legs. As the space shrinks, the nerves that go through it are squeezed, causing pain in the back, legs, and buttocks.

"X Stop is the closest thing to a no-risk procedure for these patients as possible with any type of surgery," says James F. Zucherman, MD, an orthopedic surgeon in San Francisco and inventor of the procedure. Typically, LSS patients are treated with nonoperative treatments such as steroid injections, which has a success rate of less than 13%, he says. The next step to treat LSS has been fusion of the spine to stabilize it and prevent further narrowing. "The benefit of the X Stop procedure is that we can stabilize the spine without removing tissue or eliminating any other treatment in the future," he says.

In the X Stop procedure, a titanium metal implant is placed between the spinous processes of the vertebrae in the patient's lower back, says Zucherman. "It is designed to be a permanent implant without attaching to the bones or ligaments," he explains. The implant positions the spine so that the spinal canal is not squeezing the nerves, he adds.

Balloons and cement treat fractures

While a herniated disc can cause severe pain, spinal fractures in an osteoporosis patient not only mean persistent pain, but few realistic treatment options as well. Treatment for spinal fractures related to osteoporosis typically have been treated by bed rest, medication, and bracing, but this approach does not offer relief from continuing pain and deformity of the spine caused by the fracture.

B. Christoph Meyer, MD, an orthopedic surgeon in Houston, says vertebroplasty is a procedure that has been around for a while, and it does relieve pain when cement is placed in the bone to stabilize it. The disadvantage of vertebroplasty is that the deformity caused by the fracture is not addressed, and the cement freezes the deformity so that it cannot be corrected, he explains.

"Balloon kyphoplasty allows me to use a minimally invasive procedure to insert a balloon into the space where the fracture occurred, inflate the balloon to partially correct the deformity, and then cement the bone to stabilize it," says Meyer. "Ninety-eight percent of my patients have total or near total pain relief following balloon kyphoplasty."

His patients are very satisfied with the results of the procedure, and one way that Meyer knows about this satisfaction is the patient's reaction if they suffer a fracture in another part of their spine. "About 15% of my patients will have additional fractures because osteoporosis puts them at risk," he says. "While they are hesitant or anxious the first time I suggest balloon kyphoplasty, when they come to me with another fracture, they are the ones who suggest the procedure."