Before Resorting to Surgery, Consider Nucleoplasty for Disc Herniation

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TweetNucleoplasty can relieve pain and improve quality of life for many patients with herniated discs as well as or better than conservative management, a new review has found.

Herniation resolves within weeks to months with no treatment in at least 90% of cases. But when anti-inflammatories and steroids—both oral and injected—fail, surgery often follows, raising the specter of potentially serious complications for patients.
“There are a variety of interventions that have their place between conventional conservative measures and surgical treatment,” said Dmitri Souzdalnitski, MD, PhD, a pain medicine fellow at the Cleveland Clinic in Ohio. “Nucleoplasty is one of them.” Nucleoplasty also might help keep patients with chronic pain from becoming part of the “epidemic of opioid prescriptions,” he added.
Dr. Souzdalnitski and his colleagues analyzed three previously published studies of nucleoplasty, or plasma disc decompression, for herniation. Dr. Souzdalnitski presented the results at the 2010 annual fall meeting of the American Society of Regional Anesthesia and Pain Medicine, in Phoenix (abstract 50).
The studies, totaling 275 patients, showed that pain scores were lower after nucleoplasty compared with conventional management for a period of two to six months. Based on the two most recent studies, both of them randomized trials, the researchers found the approach improved pain scores in three months by about 22% more than traditional treatments (P<0.01). Patients receiving nucleoplasty reported reductions in pain of an average of five points on a 10-point scale.
“Nucleoplasty might be less invasivethan surgery, and it may provide more long-lasting effects than steroid injections, which don’t seem to last very long,” said Roger Chou, MD, associate professor of medicine at Oregon Health & Science University, in Portland, and director of clinical guidelines development for the American Pain Society.
But Dr. Chou expressed some concerns. One of the studies was not randomized, while the other two were randomized but not blinded, which could exaggerate the estimated benefit. He also pointed out that the trials addressed different conditions: cervical and lumbar disc herniations. “These conditions are really not the same, and in my opinion, it’s not appropriate to combine the results,” he said.
Furthermore, none of the studies compared nucleoplasty with surgery, and the study that compared nucleoplasty with an epidural steroid injection included people who already had failed that treatment. These patients might have been unlikely to respond to another injection, Dr. Chou said.
Although the poster did not address safety, Dr. Chou found no significant differences in his earlier review of back pain interventions (Spine 2009;34:1078-1093).
The investigators agreed that additional research is needed to determine long-term benefits and risks. “We have to be more proactive in exploring and applying new targeted treatments for pain as opposed to unjustified prescription of opioids for chronic back pain,” Dr. Souzdalnitski said.

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TweetFor people who have tried every alternative, this could be a good way to go.