Thermal

Various radiofrequency procedures have been designed for the treatment of discogenic low back pain. The goal is to accurately place a radiofrequency device in the posterior annulus of the intervertebral disc where the painful nerve endings are located. Electrical energy is then used to ‘turn off’ the nerve endings, thus decreasing the sensation of pain from the disc.

Three technologies have undergone study and received attention over the last 15 years:

  • Intradiscal Thermal Annuloplasty (IDTA); better known as Intradiscal Electrothermal Therapy (IDET)
  • Posterior Radiofrequency Ablation (PRFA)
  • Biacuplasty (Transdiscal)

Unfortunately, when closely studied, the efficacy of these radiofrequency procedures has failed to fully meet expectations. Therefore, scientists have begun to search for an improved approach to radiofrequency lesioning of the posterior disc annulus. Recent attempts to fine-tune the biacuplasty procedure have been encouraging.

Biacuplasty (Transdiscal)

  • Biacuplasty (Transdiscal) is the most recently developed thermal technology in interventional spine pain management. Simply put, biacuplasty claims to be an easier, more reliable, minimally invasive approach for burning the nerve fibres in your painful disc.
  • Intradiscal Biacuplasty utilizes a bipolar system that includes two cooled, radiofrequency electrodes placed on the posterolateral sides of the outer ring of the disc (annulus fibrosus). Cooled radiofrequency may increase the lesion size and facilitate ablation (neurotomy of the nerve fibres in the back of the disc) compared to standard RF electrodes.
  • Biacuplasty is still in its early stages of clinical research. Early results are very encouraging. This procedure offers the advantage of being a much simpler operative technique than its predecessor, IDET.
Intradiscal Modulation
Fig 1. Illustration demonstrating a band of radiofrequency current between 2 Transdiscal probes.
Fig. 2 Intra-operative x-ray of the final placement of two Transdiscal probes.

 

  • Inclusion Criteria:
    • Age ≥ 21
    • History of chronic low back pain (>6 months) unresponsive to non-operative care (including physical therapy, anti-inflammatory medication, epidurals, diagnostic facet joint/medial branch blocks, and sacroiliac joint interventions as performed or deemed appropappropriate by the Investigator)
    • Stabilized on pain medication regimen for >2 months as defined by a <10% change in dosage
    • Leg pain, if present, is not due to nerve compression.
    • Leg pain, if present, does not extend below the knee and is no greater than 50% of overall pain experience.
    • Single level concordant pain reproduction present on lumbar discography in desiccated disc. Magnetic resonance Imaging (MRI) image also supports discography findings. Changes in other disc spaces in the lumbar region do not demonstrate neural compressive lesion.
    • Minimal disc height loss -Disc height at least 50% of adjacent control disc.

Intradiscal Modulation in BC

Minimally invasive thermal ablation spinal procedures for discogenic low back pain have been around for decades. As already discussed above, thermal ablation for discogenic low back pain traditionally targets the collection of small nerve endings in the posterior margin of a painful intervertebral disc (E.g. biacuplasty). Newer procedures might target the small sensory endings that reside in the vertebral body (bone) immediately adjacent to the disc (E.g. BVN ablation). A number of procedures have shown great potential, only to fall short of expectations, showing modest results in long-term clinical trials. The scientific literature supports BVN ablation and biacuplasty as the thermal ablation procedures with the best clinical data

Both biacuplasty and basivertebral nerve ablation require very careful selection of ideal candidates (patients) to achieve the results displayed in positive clinical trials. Currently, in British Columbia, the procedure that has received the most enthusiasm and support has been basivertebral nerve ablation (BVN Ablation). This is currently being offered through the Radiology Department at St. Paul’s Hospital in Vancouver, British Columbia. In order to qualify for referral for BVN ablation, a specialist assessment is necessary. You need to be deemed a good candidate based upon your provided clinical history, displayed physical examination, and the appearance of your lumbar spine MRI study.

Not all patients with “discogenic” or “vertebrogenic” lower back pain are appropriate. Patients must have a strongly supported leading diagnosis of discogenic/vertebrogenic lower back pain at one or two intervertebral levels (The symptoms for each condition are similar). The referring physician must ensure that alternate diagnoses have been ruled out, and appropriate rehabilitation has been pursued, prior to referral for the ablation procedure. Because BVN ablation is new to British Columbia, patients need to be aware that wait times at SPH may be, unfortunately, prolonged (months).

Currently, biacuplasty is not offered in British Columbia. This partially relates to strict inclusion criteria associated with this procedure. Also, the growing enthusiasm behind BVN ablation has diminished some of the attention placed on biacuplasty. Biacuplasty is available in some pain centres in Eastern Canada (Ontario, Quebec). If you are considered a high-quality candidate, a referral can be made by Dr. Helper for evaluation with one of his colleagues out east.”

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