CHEMONUCLEOLYSIS OF LUMBAR DISC HERNIATION WITH ETHANOL

 

 

C. RIQUELME,  M. MUSACCHIO, F. MONT’ALVERNE, V. LENZ, A. TOURNADE COLMAR – France

 

INTRODUCTION

 

Herniated intervertebral discs and degenerative joints disease are the major causes of low back pain and sciatica.

Conservative or surgical therapies are the treatments of  choice in most cases. However, in selected patients with well defined clinical and radiological criteria, percutaneous treatment can be proposed.

The efficiency of percutaneous treatment in lumbar disc herniation (LDH) with chymopapain has been well demonstrated. However, patients with allergic background, refusing surgical treatment or already treated with chymopapain nucleolysis, can not have the benefit of this procedure.

Regarding lytic and necrotizing actions of ethanol on biological tissues, it has been used as an effective therapeutic agent in many interventional procedures (sympaticolysis, hepatiques tumors and others), and these actions can be used on nucleus pulposus to treat LDH.

We reported our personal experiences with this new technical procedure in 118 patients during the annual meeting of the French Society of Radiology in Paris, France and the 86^th annual meeting of the radiological Society of North-America in Chicago, USA, and our results showed that this percutaneous procedure had some advantages compared to chymopapain nucleolysis like non allergic or local or aseptic inflammatory complications, non important post-treatment pain, non disc shrinkage or “chemical discite” and very short clinical recovery time.

Since then, we decided to extend this treatment to all our patients.

To our knowledge, threre are no other studies in international litterature concerning LDH treated with absolute alcohol.

 

MATERIALS ET METHODS

 

Between june 1991 and november 2002, 480 patients were treated with absolute alcohol nucleolyse in our departament, 280 males et 200 females aged from19 to 77 years. Crural radiculopathy or sciatica were the most frequent clinical presentations, confirmed with lumbar CT scan or MRI. Extruded hernia, neurological deficit or cauda equina syndrome were considered contraindication for absolute alcohol nucleolysis. The localisations were: 200 parasagittals, 120 medians, 90 foraminals and 70 extraforaminals herniations.

All the patients underwent general anesthesia, the procedures were performed under digital radioscopy, placed and fixed in lateral rigth position. The puncture was made on the left lateral side, about 5 cm from the medial line, with a tip curved 18G needle, in the jonction of  the midle and posterior third of the disc. The nucleus pulposus was opacified using a non-ionic contrast media. Injection dose was 2 mesures of 1 cc. Realization time, about 10 minutes.

 

 

 

 

 

 

RESULTS

 

The results of absolute alcohol nucleolysis were evaluated clinically according to the persistance, the degree of reduction or complete relief of the clinical signes over 12 months of follow-up.

We had 2,45 % of bad results and a success was obtained in 97,55 %. Non clinical manifestations or complications related to the procedure occurred. In addition, long-term preservation of the intervertebral space was seen on follow-up and no discal inflamatory reactions developed after the procedure.

 

DISCUSSION

 

Several percutaneous therapeutic strategies have been developped for discal herniation treatment over the years: percutaneous discectomy, laser nucleolysis, oxygen-ozone disc injection and chymopapain discal nucleolysis. They have different percentages of successes an failures. Ethanol can cause necrosis and sclerosis of the biological tissues and we thought that if it can be used carefully and accuralely inside the disc, it can be a powerful therapeutic weapon and benefit in disc herniation treatment.

Absolute alcohol can reduce the discal herniation by spliting of proteoglycans and glycosaminoglycans of the nucleus pulposus. Nevertheless, ethanol action can affect dura and nerve roots and for this reason  the amount of ethanol and the discal injection site should be carefully chosen and respected. We estimate that a minimal dose of 2 mesures of 1 cc in the central part of the disc is safe. Using these parameters, our experience has shown that absolute alcohol nucleolysis is an excellent an safe therapeutic alternative in the treatment of LDH.

 

CONCLUSION

 

Absolute alcohol nucleolysis is a very simple procedure performed rapidly, made percutaneously under digital radioscopy, it can be proposed in patients with history of allergy or previously treated with chymopapain, in ambulatory conditions.

Pain relief is obtained rapidly after treatment and the patient can rapidly get normal daily activities, including professional work.

No infectious, allergic, inflammatory complications or important post-nucleolysis pain was noted.

Finally, absolute alcohol nucleolysis has an exellent cost-efficiency rate.