Spinal Balloon Nucleoplasty: Hypothetical Treatment for Herniated Nucleus Pulposus, pp. 703-711
Authors: Sena Topatan and Ahmet Basaran
Abstract: Low back pain is the most common cause of disability and absence from work under the age of 45. The annual incidence of back pain is estimated to be 5% and the lifetime prevalence is 80%. Majority of the patients with persistent symptoms are suffering from radiculopathy that is mainly caused by a herniated nucleus pulposus (HNP). Degenerated discs with internal disruptions may cause axial back pain whereas protrusion or herniation of a disc may result in radicular pain. Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a HNP or herniated disc. HNP can heal spontaneously due to spontaneous resorption. Besides pressure nucleus pulposus, without any compression, may induce similar changes when applied epidurally to the nerve roots. Nevertheless, combination of chronic mechanical compression and application of nucleus pulposus causes a more pronounced nerve injury. Most patients with a lumbar herniated disc do not need surgery. For the initial management bed rest, physical therapy and medications are usually recommended. Physiatrist can provide noninvasive therapies, such as ultrasound or diathermy to project heat deep into the tissues of the back or administer manual therapy, if mobility of the spine is impaired. They may help improve posture and develop an exercise program for recovery and long-term protection. Open surgical procedures targeting the intervertebral discs are carried out frequently for years. But especially because of its lack of superiority over the conventional therapies in the long-term and the risk of development of failed back surgery syndrome, the investigators are forced to develop minimally invasive techniques of disc decompression. In the last two decades, better understanding of the spinal anatomy, function and pain generating mechanisms along with the technological achievements, has accelerated the development of many modalities for the treatment of low back pain. Chemonucleolysis, automated percutaneous lumbar discectomy (APLD), intradiscal laser discectomy, intradiscal electrothermal therapy (IDET) and most recently percutaneous nucleoplasty are the minimally invasive techniques developed for this aim.When dual pathophysiology (pressure and inflammatory reaction), spontaneous resorption, and natural course of HNP are taken into account, any treatment modality that eliminates both the pressure and contact of the nucleus pulposus with the nerve root via creating extra time for healing to take place might prove beneficial. These requirements can be provided by spinal balloon nucleoplasty (SBN), which can be used in combination with other treatment modalities such as chymopapain injection. In this hypothetical method, epidural access to the subarachnoid space is established via epidural needles, thereafter a specially designed balloon tipped catheter is advanced. When the catheter is ideally placed with the help of CT or MRI, the balloon at the tip is inflated to relieve pressure and to prevent contact of the nerve root with HNP. The answer to the question, will SBN find a place in clinical practice? is obscure. But a homology can be established with uterine fibroid embolization, which has found clinical use in a period of 30 years approximately.