Oct. 19, 2000 -- For people suffering from chronic low back pain that is not easily diagnosed, there may be hope on the very near horizon.
A relatively new procedure known as intradiscal thermal annuloplasty (IDTA) seems to be effective in treating some forms of back pain and may offer a new treatment option.
Back pain has so many possible causes, sorting out the specific cause of one person's pain can be a real challenge. That's why most of the time physicians try conservative treatment first. Patients receive non-steroidal anti-inflammatory medicines (NSAIDs) like ibuprofen or aspirin, muscle relaxants, physical therapy and home-based stretching routines.
However, if the pain is still present after giving those methods a good try, more tests are needed. One likely source of pain is the fibrous discs separating the spinal vertebrae. The physician will probably use magnetic resonance imaging (MRI) to check for a disc pressing on a nerve, or a possible tumor. He will also try discography, in which dye is injected within the disk.
One possible cause of persistent back pain is degeneration of the disk's central pulp. If that is the problem, then IDTA may be helpful, according to research published in the Oct. 15 issue of the journal Spine.
In this procedure an electrode is threaded through a needle around the central part of the disc and then heated to coagulate the damaged part of the disc and destroy the nerve endings that transmit pain signals. "If someone has intrusive chronic back pain that interferes with work, family life and play, if they've tried physical therapy and medications without relief, they need to know there is now a needle-based intervention that may help them," says study author Michael Karasek, MD. "Before this, the only other available option would have been major surgery." Karasek is medical director of the Northwest Spine Group in Eugene, Ore.
IDTA was approved for general use by the FDA in the spring of 1998. At present, only some insurers cover it, while others say it is still too experimental. "Insurers today are quite strict in adopting new technologies. They want to see years of data with multiple studies proving efficacy and safety," Karasek says. "We feel this study goes a long way toward satisfying those requirements. My understanding is [that] all the major carriers are closely examining this issue, because they understand this marks the advent of a new era in spine treatment."
In this study, more than 50 patients with back pain due to internal disc disruption were offered the treatment; in 17 cases their insurance companies refused to pay, so this group received physical rehabilitation and pain-relief medications instead.
Researchers compared the 35 who received IDTA treatment with the others who didn't. They found that 23 of the patients who received the procedure experienced a significant decrease in pain, compared with only one in the other group. Twelve months later, these patients still felt significantly better. About two-thirds of those who had the procedure experienced some benefit, and nearly one-quarter obtained complete relief of pain.
This procedure is only suitable for certain patients, the authors emphasize. It is not suitable if there is an extruded, or displaced, disk pressing on a nerve, or when disk heights have decreased. To get such good results, you need doctors with lots of experience in discography. "The two physicians who did these procedures were highly skilled 'needle jockeys,'" says Karasek. "They were very good at placing the needle in the disc and understanding the images they saw."
"This is valuable research, particularly since lower back pain is one of the most common causes of time lost from work," Miles Day, MD, tells WebMD. "Neurosurgery is expensive and time consuming, and cannot guarantee successful results. This new procedure is not a panacea or silver bullet, but it is a valuable tool." Day is a pain specialist at Texas Tech Medical Center's International Pain Institute and an assistant professor of pain medicine and anesthesiology at Texas Tech University Health Sciences Center in Lubbock.
The procedure itself takes only about an hour, under local anesthesia, Day says. Patients should not expect immediate improvement. For the first two weeks after the procedure, the pain may even be worse, because the disk needs time to heal. But over the next several months, the pain should gradually lessen. "I would never say to a patient, 'this will fix all your pain'. I would tell them they may see 25% or 50% improvement," Day says.
Dennis Doherty, DO, agrees. "If it were my back or my wife's back or my mother's back, I would try this procedure, particularly if the only alternative is [major surgery]." Doherty is medical director of the Shepard Pain Center and associate clinical professor of anesthesia and pain management at Emory University School of Medicine, both in Atlanta.