Background
Neck and radicular arm pain is a common and debilitating condition. Currently a significant number of patients fail last-line conservative palliative therapy and are faced with surgery as a final resort. The Cervical DISC Nucleoplasty procedure, a percutaneous disc decompression approach designed to treat contained disc protrusion, provides a safe and effective minimally-invasive option for many of these patients.

Cervical DISC Nucleoplasty percutaneous disc decompression is used to treat symptomatic patients with contained herniated discs. Contained herniated discs may present axial (i.e. felt in the neck) or radicular (i.e. felt in the limbs) symptoms which may include weakness, pain, numbness, tingling or loss of functional ability.

Objective
To discuss the relatively new technique of Cervical DISC Nucleoplasty from a European clinical perspective and facilitate a white paper document in order to standardise patient diagnosis, treatment and follow up protocol.

Attendees
Host: Dr Alessandro Cesaroni - Rome, Italy

Guests: Dr Alberto Alexandre - Treviso, Italy; Dr. Diego Beltrutti - Bra, Italy, Mrs Giovanna Catanea - Rome, Italy, Dr Giuseppe Ciliberto - Chieti, Italy, Professor Giorgio D’Este - Rome, Italy, Dr Rainer Dünnebeil - Mühlacker, Germany, Dr Achim Lüth - Freiburg, Germany, Dr Salgado - Siviglia, Spain, Dr Raffaele Sanita - Rome, Italy, Dr Bernd Ferkmann - Recklinghausen, Germany, Prof. Vizzioli - Napoli, Italy, Ass Prof. Kemal - Yucesoy Izmir,Turkey, Dr Marin Zarza - Madrid, Spain

Discussions
Effectiveness of the Cervical DISC Nucleoplasty procedure based on European experience

Discussions regarding the effectiveness of the Cervical DISC Nucleoplasty procedure concluded in strong agreement from all members present that the procedure is a safe effective method of treating contained herniations of the cervical disc. Members of the floor reported complete resolution of symptoms in over 80 percent of patients and satisfactory results in over 90 percent of patients¹.

Questions were raised regarding the duration of conservative care required prior to performing the procedure. It was agreed that 3-4 weeks was an adequate time frame for the administration of conservative care, yet under appropriate circumstances this period could be shortened in order to slow or limit further degradation of the cervical disc.

Members of the floor presented clinical outcome data based on individual experience. An example of this is presented in Table 1².

Table 1. Preliminary Clinical Results of Cervical DISC Nucleoplasty (taken with permission from Associate Professor Kemal Yucesoy).
No.	Age	Sex	Level	VAS Pre/post op	Pre Op Northwich Park Neck pain Questionnaire	Pre Op Neck Disability Index (max 50)
1	39	F	C 5-6	8-1	80.5	38
2	45	F	C 5-6	6-1	94.4	34
3	61	M	C 4-5	5-1	38.8	13
4	33	F	C 4-5 C5-6	6-0	50	19
5	46	F	C 4-5	8-1	75.2	37
6	46	F	C 4-5 C5-6	9-0	83.3	38
7	46	F	C 4-5 C5-6	9-1	58.3	30
8	44	F	C 5-6 C6-7	8-1	72.2	37
9	35	M	C 5-6	8-2	50	26
10	42	F	C 4-5 C5-6	8-2	75	31
11	50	F	C 5-6 C6-7	5-2	33.3	18
12	30	F	C 5-6	9-4	77.8	32
13	55	F	C 5-6	8-0	50	30
14	42	F	C 5-6 C6-7	9-0	61	25

Patient Selection Criteria and diagnosis based on European experience
The floor discussed appropriate patient selection criteria based on individual experience and discussed the benefits of the technique for both radicular and axial/occipital nerve pain. It was agreed that whilst treatment of axial pain has met with considerable success, the best results are achieved from patients with predominant radicular pain. Agreed upon inclusion and exclusion criteria were as follows:

Inclusion criteria

• Arm/ radicular pain with or without neck pain.
• MRI evidence of contained disc protrusion.
• Failure of appropriate conservative therapy.

	Case Example 1. 39 year old Female, VAS 8 - 1, Pre Op NDI 38

Exclusion criteria

• Greater than 50 percent loss of disc height
• Herniation greater than 1/3 the sagittal diameter of the spinal canal
• Disc Extrusion
• Spinal stenosis
• Infection (general and local)
• Tumour
• Central cord lesion
• Radicular pain in more than two cervical disc levels
• Progressive neurological deficit

There was discussion over spinal instability as an exclusion criterion. The floor generally was not in agreement; with some members pointing out that treatment to stabilise the spine could follow DISC Nucleoplasty.

Discography as a diagnostic tool was also debated with discussions concluding that discography should not necessarily be used as a prerequisite for Cervical DISC Nucleoplasty and MRI evidence is normally sufficient as a diagnostic tool in most cases. However discography could be used as an additional tool in difficult cases where more diagnostic information is required. No member of the forum had performed the technique at the C2-C3 level and all members agreed that the technique works well for the C3 to C7 levels.

Case Example 2. 46 year old Female, VAS 9 - 0, Pre Op NDI 38

Clinical Outcome Tools
The members of the floor each used a variety of outcome tools to measure the effectiveness and follow up of the Cervical DISC Nucleoplasty procedure. These include (in decreasing numerical order): Visual Analogue Scale (n=9), Return to Work (n=3), SF 36 (n=2), Roland Morris (n=2), Neck Disability Index (n=2), Norwich Park Neck Pain questionnaire (n=1), Symptom Check list (n=1) and JOA (n=1). Many of the members present also used quality of life and patient satisfaction as outcome tools.

There was a general consensus amongst members of the floor that there exists a need for a standardised outcome measure for minimally invasive procedures which incorporates pain, function, quality of life and patient satisfaction. Follow up protocols were also discussed. Whilst many members of the floor already used similar patient follow up times, it was suggested that this should also be standardised in order to pool data for publication and for easier comparison of results.

Post Operative Protocol
Differences were noted in post-operative procedures, i.e. some members of the forum used post operative neck braces post operatively for up to five day whilst others did not feel there was a need for any form of brace. There was a general agreement that the use of post operative braces was mainly for psychological reasons.

There was also significant discussion regarding the use of post-operative physiotherapy and a detailed review of physiotherapy procedures was presented. The time from surgery to the commencement of physiotherapy varied from directly afterwards to approximately 10 to 14 days post-op. The majority of members were in agreement that physiotherapy is an important part of the rehabilitation process and that physiotherapy specific to minimally invasive therapies such as DISC Nucleoplasty should be developed.

	Case Example 3. 42 year old Female, VAS 9 - 0, Pre Op NDI 25

Practical Tips
General anesthesia as opposed to local anesthesia is seemingly preferred for the Cervical DISC Nucleoplasty procedure by many members of the forum. Reasons include patient comfort, complete head and neck immobilization and muscle relaxation. Many attendees also used preventative antibiotics prior to the procedure, i.e. Cephalosporin or 3rd generation cycle based.

Conclusions
In general all members were in agreement that the meeting was a success and that the knowledge shared was of value. All members strongly endorsed the method of cervical DISC Nucleoplasty as a safe and effective method of treating patients with contained herniated discs.

Editor’s note: Further information about both lumbar and cervical disc nucleoplasty can be obtained from the disc nucleoplasty website, www.discnucleoplasty.com.

Alternatively please contact your local ArthroCare representative.

The Perc-DC™ SpineWand™ used for Cervical DISC Nucleoplasty	Perc™-DC SpineWand™ looped tip inside the disc

1. These figures are supported by the following publications: C Slipman et al., Proceedings of the NASS 20th Annual Meeting /The Spine Journal 5 (2005) 1S-189S, P. V. Nardi, D. Cabezas and A. Cesaroni., Acta Neurochir (2005) [Suppl] 92: 73-78.
2. Unpublished data

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