DESCRIPTION
A variety of minimally invasive techniques have been investigated over the years as a treatment of low back pain related to disc disease. Techniques can be broadly divided into those that are designed to remove or ablate disc material and thus decompress the disc, or those that are designed to alter the biomechanics of the disc annulus. The former category includes chymopapain injection, automated percutaneous lumbar discectomy, laser discectomy, and most recently disc decompression using radiofrequency energy technology (e.g., DISC nucleoplasty™). Techniques that alter the biomechanics of the disc include intradiscal electrothermal annuloplasty (i.e., the IDET procedure) or percutaneous intradiscal radiofrequency thermocoagulation (PIRT). It should be noted that three of these procedures use radiofrequency energy - disc nucleoplasty, IDET and PIRT - but apply the energy in distinctly different ways such that the three procedures are unique and should be considered separately.
One form of disc decompression using radiofrequency energy is known as coblation (e.g., DISC nucleoplasty™). This technology involves the percutaneous removal of disc material by using a low-temperature resister probe to disintegrate and evacuate disc material, followed by thermal treatment of adjacent residual disc material. The technique consists of small, multiple electrodes that emit a fraction of the energy required by traditional radiofrequency energy systems. The result is that a portion of nucleus tissue is ablated not with heat, but with a low-temperature plasma field of ionized particles. These particles have sufficient energy to break organic molecular bonds within tissue, creating small channels in the disc. The proposed advantage of this technology is that the procedure provides for a controlled and highly localized ablation, resulting in minimal therapy damage to surrounding tissue. Individuals considered candidates for this technology include those with bulging discs and sciatica. In contrast, the presence of a herniated disc is typically considered a contraindication for the IDET or PIRT procedure.
POLICY
Percutaneous disc decompression and treatment of associated low back pain using low-temperature, localized, radiofrequency energy is considered investigational.
See also:
Percutaneous Intradiscal Radiofrequency Thermocoagulation for the Treatment of Discogenic Pain (i.e., IDET or PIRT)
Percutaneous Discectomy
ADDITIONAL INFORMATION
Percutaneous disc decompression and treatment of associated low back pain using low-temperature, localized, radiofrequency is relatively new technology, with minimal published literature and no controlled trials.
A February 2005 article written by Cohen, S. P., et al in the Journal of Spinal Disorders and Techniques stated an evaluation study was conducted by the Pain Management Center, Department of Anesthesiology and Critical Care Medicine at Johns Hopkins Medical Institution in Baltimore, Maryland and concluded that nucleoplasty was not an effective long-term treatment for lumbar radiculopathy.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2009). Decompression of intervertebral discs using laser (laser discectomy) or radiofrequency energy (DISC nucleoplasty™) (7.01.93). Retrieved April 21, 2009 from BlueWeb.
Boswell, M. V., Shah, R. V., Everett, C. R., Sehgal, N., McKenzie-Brown, A. M., Abdil, S., et al. (2005). Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician, 8 (1), 1-47.
Boswell, M.V., Trescot, A.M., Datta, S., Schultz, D.M., Hansen, H.C., Abdi, S., et al. (2007). Interventional techniques: evidence-based practice guidelines in the management of spinal pain. Pain Physician, 10 (1), 7-111.
National Institute for Health and Clinical Excellence. (2006, May). Percutaneous disc decompression using coblation for lower back pain. Retrieved April 21, 2009 from http://www.nice.org.uk/nicemedia/pdf/ip/IPG083guidance.pdf.
Singh, V. & Derby, R. (2006). Percutaneous lumbar disc decompression. Pain Physician, 9 (2), 139-146.
Singh, V., Piryani, C., Liao, K., & Nieschulr, S. (2002). Percutaneous disc decompression using coblation (nucleoplasty™) in the treatment of chronic discogenic pain. Pain Physician, 5 (3), 250-259.
Welch, W. C., & Gerszten, P. C. (2002). Alternative strategies for lumbar discectomy: Intradiscal electrothermy and nucleoplasty. Neurosurgical Focus, 13 (2), 1-6.
ORIGINAL EFFECTIVE DATE: 6/1/2004
MOST RECENT REVIEW DATE: 7/9/2009
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