Last Updated on October 18, 2023
Nucleoplasty is a percutaneous procedure where a probe is percutaneously inserted into the intervertebral disc under fluoroscopy to carry percutaneous disc decompression using bipolar radiofrequency energy to dissolve the tissue of nucleus pulposus and decrease the intradiscal pressure.
Bipolar radiofrequency liquifies nucleus pulposus contents which are removed at the target site that results in decompression.
Lumbar disc herniation can cause spinal nerve root compression. This often results in lower back pain and radicular pain in the lower limb with or without neurological deficit.
Most of the herniated discs are amenable to conservative treatment. Discectomy is the gold standard procedure for those requiring surgical intervention and has a very high success rate.
The nucleoplasty is one of the minimally invasive procedures that can be done under local anesthesia and on a patient basis.
Relevant Anatomy
The disc is a soft cushion-like structure present between vertebral bodies that helps to cushion the load when the spine is loaded. The disc is connected to the superior and inferior vertebra by vertebral end plates forming a fibrocartilaginous joint.
The discs contribute to one-fourth to one-third of the length of the vertebral column.
The intervertebral disc consists of a thick outer ring of fibrous cartilage called the annulus. Annulus fibrosis surrounds an inner gel-like core called nucleus pulposus.
Thus nucleus pulposus is surrounded by annulus and end plates.
With age or loading the cracks might appear in annulus fibrosis resulting in disc herniation. This causes inflammatory changes and compression of the neural structures to cause back pain and/or radicular pain in the lower limb.
Indications for Nucleoplasty
It is most useful in patients with nerve root irritation due to smaller disc bulges or contained ruptures.
The indications include
- Pain back and/or radiculopathy for more than 6 months
- Failure to respond to conservative measures like physical therapy, drugs, epidural injections, or selective nerve root blocks.
- Small single-level disc causing compression
- Preferably confirmed by discography
- At least 50% of disc height is preserved
Contraindications
- History of the previous procedure at the intended level
- Image-confirmed annular tear
- Sequestered disc
- Multilevel disc involvement
- Spinal stenosis or other spinal pathologies at the level
- Infection in the region where entry is made
- Spinal instability
Procedure of Nucleoplasty
Nucleoplasty is usually performed on an outpatient basis. Local anesthesia and mild sedation may be used to reduce discomfort and anxiety.
Some authors recommend discography before doing the procedure to rule out annulus tear which is confirmed if the contrast injected in the disc does not pass to the epidural space.
1 g of cefazolin was administered intravenously prior to the procedure for prophylaxis.
With the patient in the lateral position, using a posterolateral approach, a 17 gauge needle is introduced via a posterolateral approach toward the identified disc level maintaining aseptic conditions.
Under fluoroscopic guidance, the needle is advanced to the central portion of the disc.
A coblation bipolar device catheter is then introduced through the needle into the disc and positioned where the ablation is desired. The catheter has a low-temperature resister at its tip which generates a plasma field.
This plasma field disintegrates disc material into its hydrogen and oxygen constituents which escape through the needle. The tissue ablation and thermal treatment create a series of channels within the disc, reducing the pressure from the contained disc herniation or the nerve root and other pain-generating structures.
The catheter is advanced ablation mode slowly and withdrawn in coagulation mode. About 4-6 channels are made.
After the procedure, the patient is kept under observation for 2–4 hours.
Complications of Nucleoplasty
- Infectious discitis
- Sore skin puncture site
- Increased back pain intensity
- Numbness in the lower limb
Results and Conclusion
The reported success rate with nucleoplasty is 60-80% in different series. However, the results are not equivalent to the discectomy procedure. It is a minimally invasive procedure and that is an advantage over discectomy. Though mostly performed in the lumbar disc, nucleoplasty has been reported in cervical disc herniation too.
The patient selection is of great importance in this procedure. To obtain good clinical results, an appropriate selection of patients according to the indications of nucleoplasty must be done.
Several studies have found favorable results with nucleoplasty in the treatment of leg pain without axial symptoms.
In recent years many studies on nucleoplasty have been published. However, it requires further research to evaluate long-term results and indications.
References
- Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician. 2006;9:139–146. [Link]
- Sharps LS, Isaac Z. Percutaneous disc decompression using nucleoplasty. Pain Physician. 2002;5:121–126. [Link]
- Gerges FJ, Lipsitz SR, Nedeljkovic SS. A systematic review on the effectiveness of the nucleoplasty procedure for discogenic pain. Pain Physician. 2010;13(2):117–132. [Link]
- Kumar NS, Shah SM, Tan BW, Juned S, Yao K. Discogenic axial back pain: is there a role for nucleoplasty? Asian Spine J. 2013;7(4):314–321. [Link]
