Motion-Sparing Innovations for Treatment of Back Pain
March / April 2005
Minimally invasive, motion-sparing techniques are increasingly
becoming the standard for the diagnosis and treatment of
back pain at the University of Pennsylvania Health System.
Degenerative disc disease is often the culprit, but other
conditions in the joints, muscles and nerve fibers can mimic
pain, making diagnosis more challenging.
One diagnostic study,
called discography, can be performed to isolate as well as
compare normal anatomy to abnormal anatomy by way of digital,
computer X-ray with contrast (fluoroscopy). This minimally
invasive technique uses needles placed in several discs of
the neck or back to simulate normal pressure on the discs
to determine if that pressure produces the pain.
An X-ray or MRI will often show a disc to be diminished
in stature or dehydrated. “The troublesome thing is
not all discs that look badly — hurt,” says Philip
Maurer, MD, pain medicine specialist at Pennsylvania
Hospital. “We
need to determine which segments that look badly on X-ray
or MRI are actually responsible for symptoms, versus those
that are not.”
If disc disease is found to be responsible for the pain,
treatment can begin with the least invasive approach and
move on to more invasive options as necessary for better
results.
Dr. Maurer was a pioneer in the study of intradiscal electrothermal
therapy (IDET) or annuloplasty in the late 1990s. IDET is
a very minimally invasive, motion-enhancing procedure that
uses heat to heal damaged annulus fibrosis (nucleus) and
coagulate little nerve fibers in the disc. This technique
was proven in controlled clinical studies to reduce pain
by at least 50 percent in 60 percent of patients. “Because
it is minimally invasive, some patients are willing to accept
less of an outcome,” Dr. Maurer says.
When the annulus fibrosis is moderately intact, a partial
disc replacement can be performed by injecting the center
core with a synthetic material that would mimic the normal
nucleus in the cervical and lumbar spine. This can be performed
as open surgery or, more progressively, as a very minimal
procedure similar to discography.
Richard
Balderston, MD, chief of spine services at Pennsylvania
Hospital and clinical professor of orthopedic surgery, is
the only physician in the region performing lumbar disc replacement.
His partner, Scott
Rushton, MD, orthopedic surgeon at Pennsylvania
Hospital, recently completed the first cervical disc replacement
in the region. Both surgeons are participants in an FDA study
to determine whether an artificial disc replacement in an
appropriate patient is comparable to a spinal fusion operation. “Disc
replacement currently is the only technology that has the
capacity to increase the range of motion at a disc space,” Dr.
Balderston says.
Disc replacement surgery is performed through
the belly or the front of the neck, so the back muscles
are not opened.
The damaged disc is replaced with a movable part and normal
disc height and alignment are restored.
Currently, two and a half years into the study, Dr. Balderston
concludes that disc replacement is a viable alternative to
spinal fusion, with less morbidity, considerably less time
in the hospital, less pain medication and an earlier return
to work and to normal function. “It is rare to age
without developing back problems,” Dr.
Maurer points out. “We are the only mammals that stay
on our feet as we age — the obligatory biped — putting
a lot of load on the spine. When baboons get old, they walk
on all fours.”
Researchers aim to keep us upright as they continue to develop
improved injectable disc material. In the future, biologic
solutions will enable us to alter genes in the disc so that
more disc material can be generated. “It is exciting
to think of the future of regenerative technology,” says
Dr. Maurer. “Ultimately, that's where we are going
with the treatment of disc related back pain.”
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