I. Overview
The patient’s dural sac is generally not compressed, also known as intradiscal disorder. It was first proposed by Crock in 1970. As an important cause of low back pain, it has attracted increasing attention from scholars.
II. Pathogenesis
With the wide application of immunohistochemical techniques, the pathogenesis of discogenic lower back pain has been further understood. There has been increasing evidence that the underlying pathogenesis is an inflammatory response. Inflammation and abnormal mechanical motion cause painful nerve endings in the anterior aspect of the annulus fibrosus to be stimulated, even when abdominal palpation is performed.
However, different types of intervertebral disc disease differ in terms of nerve conduction pathways and mechanisms of inflammatory transmitter production, and these differences are extremely important for the choice of treatment and prognosis. The sinuvertebral nerve (SVN) is mostly considered as its afferent pathway.
Clinical presentation
1, age and medical history The age of onset is mostly around 40 years old, with/without history of trauma.
The pain is often sore and swollen, mainly located in L4~5, L5~S1 interspinous, posterior iliac, posterior gluteal, inguinal, anterior femoral, posterior femoral, and greater trochanter; the symptoms are aggravated after activity, especially after the vertical stress of the spine is increased, and cannot sit or stand for a long time; the symptoms are heavier in sitting position than in standing position, and the pain can be aggravated by coughing and sneezing, with recurrent episodes lasting for a long time (up to several months or more). Crock believes that agitating chemicals in the nucleus can flow around the nerve root through the fissure of the fiber ring and produce radicular radiating pain without numbness, weakness and other nerve damage.
3. Physical examination Objective signs are minimal. There is no obvious lumbar tenderness, with or without lumbar muscle spasm. However, extension, lateral flexion and rotation are limited. Femoral nerve pull test is often negative, and lumbar pain or lumbar pain is greater than leg pain during straight leg raise test. There are usually no signs of nerve damage. Abdominal palpation can sometimes induce low back pain.
IV. Diagnostic criteria
There is no gold standard for the diagnosis of discogenic lower back pain, and it is generally believed that the following conditions must be met.
1. With or without history of trauma, recurrent episodes of low back pain lasting for more than 6 months.
2. Typical symptoms and signs are present.
3. Positive CT discography or MRI with typical single-segment signal reduction and high signal area in the posterior part of the annulus fibrosus.
V. Treatment
1. Conservative treatment
For patients whose pain is not particularly severe and whose onset time is relatively short, conservative treatment can be adopted. These include bed rest, traction, massage, medication, lumbar circumference, physical therapy, and sympathetic nerve block around S2 nerve root.
2. Intradiscal hormone therapy
For patients whose symptoms cannot be relieved by long-term conservative treatment, intra-disc hormone therapy can be tried before surgery, and the dose and timing of application of hormone must be mastered. However, no long-term effective reports on intra-disc hormone therapy have been seen.
3. Intradiscal thermotherapy and nucleoplasty.
IDET is an emerging invasive treatment method with less damage in recent years, which works on the fibrous annulus, i.e., heating the diseased fibrous annulus through heat-producing cords, shrinking collagen fibers, burning granulation tissue, coagulating invading nerve endings, thus stabilizing the fibrous annulus and relieving the patient’s pain; IDET is characterized by controllable temperature and proximity heating, which is less harmful to the surrounding normal tissues. IDET is characterized by controlled temperature and proximity heating, less damage to surrounding normal tissues, etc.
Saal JA et al. found that IDET provided comparable or greater relief of low back pain and better functional recovery than vertebral body fusion. They also demonstrated for the first time that IDET can completely relieve discogenic pain.
Myeloplasty is a much more recent technique that uses radiofrequency energy to remove a small amount of nucleus pulposus tissue and create a pore inside the nucleus pulposus, ultimately resulting in a reduction in pressure within the disc. The tissue of action is the nucleus pulposus, which has the following advantages compared to IDET.
(1) The working temperature is lower and the thermal damage to the surrounding structures is less.
(2) The ablation tip is limited to the nucleus pulposus, which is safer.
(3) The operation technique is easier to master and the operation time is shorter.
4. Surgical treatment
(1) Surgical indications The treatment of discogenic lower back pain has undergone decades of development, and there is still no consensus on the surgical indications and methods.
It is generally considered that surgery should be considered in the following cases.
① Recurrent symptoms lasting for more than 1 year;
②Conservative treatment is ineffective;
(3) Positive discography.
(2) Simple discectomy The relief rate of low back pain is low and the recurrence rate is high. The important reason is that the pain-causing substances in the intervertebral disc cannot be completely removed and the residual inflammatory media can still cause irritation to the nerve endings under the condition of intervertebral micromovement or instability, so most scholars do not support the above method for the treatment of discogenic lower back pain.
(3) Posterior posterolateral fusion Because the intervertebral micromovement after posterior posterolateral fusion is sufficient to stimulate nerve endings and produce pain. Therefore, many scholars believe that postero-lateral fusion should be abandoned in favor of interbody fusion.
(4) Interbody fusion Interbody fusion eliminates intervertebral micromovements to the greatest extent possible, and theoretically, the clinical satisfaction rate should be positively correlated with the fusion rate. The reason for the controversy is the lack of uniform criteria for the evaluation of both. For example, the fusion success rate is difficult to determine by imaging diagnosis alone, and the clinical satisfaction rate is also related to smoking, psychological quality, etc.
(5) Discectomy intervertebral Cage fusion The efficacy of fusion is more certain, as it removes the pain-causing disc and inflammatory material while reestablishing the stability of the spine, and the clinical outcome is usually satisfactory as long as the preoperative localization of the diseased disc is accurate. However, fusion is, after all, performed at the expense of the physiological structure and function of the disc; increased motion compensation occurs in the functional units of the spine adjacent to the surgery after traditional intervertebral or laminar implant fusion, resulting in increased stress in the area.
Various pathological conditions such as proliferative degenerative arthritis of the synovial joint, spinal stenosis and disc degeneration occur in the surgically adjacent segment. In addition, the large surgical trauma and the high cost of treatment are also disadvantages of fusion surgery.
(6) Artificial disc replacement and nucleus pulposus replacement
5.Minimally invasive treatment – radiofrequency thermal coagulation target therapy
Radiofrequency thermal coagulation target treatment is accurately positioned under the C-type X-ray machine, monitored under digital subtraction, and directly denatured and coagulated the herniated nucleus pulposus under the precise guidance of the navigation system; contraction reduces the volume and relieves the compression. It does not hurt the normal nucleus pulposus tissue, while repairing the rupture of the fibrous ring, inactivating the nerve endings of the nascent lesions in the disc, directly blocking the release of glycoproteins and beta proteins in the nucleus pulposus fluid, and the warming effect plays a good therapeutic role on the injured fibrous ring, edematous nerve roots and inflammatory reactions in the spinal canal, and the symptoms disappear or are reduced immediately after treatment.
This method is which place has the disease to remove which place, there is no disease place is not hurt in the slightest. The treatment electrode of neurological special RF is only 0.7mm, just like an acupuncture needle, the whole treatment without anesthetic, analgesic, antibiotics, hormones, just a physical change process, no side effects to the human body, making the treatment more green, more humane. These safety measures are not available in any minimally invasive devices and methods.
The safety and treatment issues that doctors and patients are most concerned about have been brought to the forefront, making it easy and natural for doctors to do spinal surgery to cure herniated discs like taking a walk or chattering. At the same time, the history of treating intervertebral discs has changed from a treatment method whose main purpose is to accelerate degeneration to one whose main purpose is to repair. It has pushed the treatment of herniated disc, cervical spondylosis and spinal cord type cervical spondylosis to the pinnacle of the medical world.
There are many spinal cord cervical spine patients who have been paraplegic for more than half a year and cannot be cured by open surgery, and after using radiofrequency thermal coagulation target treatment, the patients have returned to work and become the biggest miracle and highlight of spinal surgery in the 21st century, which is the most minimally invasive, safest, least painful, fastest and least risky treatment method internationally.
Six, safety guarantee
1, efficient and safe The treatment electrode of the neurological RF instrument is only 0.7mm, just like an acupuncture needle, the whole treatment without anesthetics, analgesics, antibiotics, hormones, just a physical change process, no side effects on the human body, it removes the diseased nucleus pulposus tissue directly without hurting any normal tissue, making the treatment greener and more humane.
2.Precise positioning Radiofrequency thermal coagulation target treatment is accurately positioned in the C-arm X-ray machine, detected at the time under digital subtraction, and directly acting on the diseased nucleus pulposus under the precise guidance of the navigation system, with data accurate to less than 1mm and angular error less than 1 degree, making the treatment more accurate and effective.
3.Identification of nerves The precise identification and stimulation function of the nerve system, which is unique to the neurological system of the RF instrument, can measure the nerves within 1cm of the treatment range and distinguish motor nerves or sensory nerves precisely, which means that it is impossible to damage the patient’s nerves when you want to treat. Even if you are not a doctor, there is no accident.
4.Precise identification of tissues The impedance display function unique to this device can accurately distinguish the nucleus pulposus fiber ring, calcification points, bone and blood vessels, and accurately display them with tones and numbers, making the treatment more accurate and safe.
5.Temperature controllable The RF instrument can adjust the temperature arbitrarily with the error below 2℃ to ensure the safety of the treatment and no infection and thermal damage after the treatment.
6.Precise calculation The volume of lesion to be removed is precisely calculated before treatment and preplanned, that is to say, how much of the nucleus pulposus of the lesion is removed, making the treatment more efficient.
These six safety measures are not available in any minimally invasive devices and methods. At present, radiofrequency thermal coagulation target technology is a treatment method with the main purpose of repair, gradually replacing the previous treatment method with the main purpose of accelerating disc degeneration, which is epoch-making in the history of minimally invasive spinal treatment.