The treatment method for chronic lower back pain has gone beyond the traditional nerve block and drug treatment methods, and the application of minimally invasive interventional therapy in discogenic lower back pain is becoming more and more popular, and has now become the basic means of treating chronic discogenic lower back pain in pain departments.
I. Diagnosis of discogenic lower back pain
Discogenic lower back pain is an extremely common clinical condition, which is chronic lower back pain caused by intra-disc disorders (IDD) such as degeneration, intra-fibular ring fracture, discitis, etc. stimulating pain receptors in the intervertebral disc without radicular symptoms, without radiological evidence of nerve root compression or excessive displacement of vertebral segments, and can be described as chemically mediated discogenic pain.
(I) Clinical features
The most important clinical feature of discogenic lower back pain is decreased tolerance to sitting, with pain often increasing in the sitting position, and the patient can usually only sit for about 20 minutes. The pain is mainly located in the lower back, but sometimes it can also spread to the lower extremities. 65% of the patients have pain below the knee in the lower extremities, but there are no specific signs for diagnosis.
(B) Imaging features
1, MRI: T2-weighted images show low-signal changes (disc darkening) in the diseased disc, and the presence of a high-signal area behind the annulus fibrosus is a sensitive manifestation of IDD, but it cannot be used as the gold standard for specific diagnosis. This is because MRI can be normal in 10% to 20% of patients with disc tears.
2. Intervertebral discography.
Discography is currently the most reliable means of diagnosing discogenic pain. Discography can only be considered positive if pain is induced and replicated during discography and if discography shows a tear in the annulus fibrosus. If there is only a tear of the annulus fibrosus or leakage of the contrast agent and the patient has no induced or replicated pain, it means that the disc may not be related to the patient’s pain.
(iii) Diagnostic criteria
1, or no history of trauma, with recurrent symptoms lasting >6 months.
2, typical clinical manifestations as described above.
3, positive discography or MR manifestation of typical single-segment intervertebral disc with low signal and high signal area in the posterior part of the fibrous ring.
Minimally invasive interventional treatment of discogenic lower back pain
Non-surgical treatment of discogenic lower back pain should last at least 6-8 weeks, and minimally invasive interventional treatment can be used for poor results.
(A) Radiofrequency nucleus pulposus and fibrous annuloplasty
Including radiofrequency myeloplasty (Coblation); Intradiscal electrothermal annuloplasty/nucleoplasty (IDET). It has been reported that the total effective rate is close to 70% to 80% with the application of IDET at one-year follow-up.
1, Treatment methods include.
① localized puncture.
② Testing; 50 Hz sensory function measurement is given first, followed by motor function measurement at 2 Hz, with special attention paid to whether the patient has abnormal sensation in the lower extremities during testing.
③ Radiofrequency thermocoagulation: pay attention to the timing in warming up when the temperature reaches the predetermined temperature, and pay attention to the patient’s complaints: pain, soreness, heaviness and heat sensation in the lower back, with special attention to the presence of radiating pain in the lower limbs. Time each thermal coagulation cycle for 3 minutes, two cycles in total. Determining the thermocoagulation temperature based on sensory and motor stimulation localization is very important intraoperatively.
2. Observation of resistance during puncture: the resistance of the puncture needle in the fibrous ring is 143-224W, which is of high value for intraoperative localization.
(II) Ozone myelolysis
Foreign statistics show that the efficiency of ozone treatment for lumbar disc lesions is 66-86%. Previous reports have shown that medical ozone treatment of lumbar disc lesions has no recent or long-term comorbidities.
Indications and contraindications.
Muto et al. suggested that indications for medical ozone treatment of lumbar disc lesions should be.
① lower back pain or/and sciatica without severe neurological deficits.
② mild degree of inclusive herniation.
③ Those who have been ineffective with conservative treatment for at least 8-12 weeks.