IDET - IntraDiscal ElectroThermal AnnuloplastyTherapy

What is IDET (IntraDiscal ElectroThermal AnnuloplastyTherapy)?
IntraDiscal ElectroThermal Annuloplasty Therapy is a recently developed technique for the treatment of pain coming from a spinal disc. A special probe is inserted into the disc and heated. This causes the collagen in the disc wall to contract, thicken, and may numb the nerves in the wall of the disc. IDET is a minimally invasive outpatient surgical procedure developed over the last few years to treat patients with chronic low back pain that is caused by tears or small herniations of their lumbar discs.

The IDET process takes about an hour to complete and is done as follows:

… The procedure is performed with a local anesthetic and mild intravenous sedation

… A hollow introducer needle is inserted into the painful lumbar disc space using a portable x-ray machine for proper placement

… An electrothermal catheter (heating wire) is then passed through the needle and positioned along the back inner wall of the disc (the annulus), the site believed to be responsible for the chronic pain.

… The catheter tip is then slowly heated up to 90 degrees Celsius for 15-17 minutes

… The heat contracts and thickens the collagen fibers making up the disc wall, thereby promoting closure of the tears and cracks. Tiny nerve endings within these tears are cauterized (burned), making them less sensitive.

… The catheter is removed along with the needle and, after a short period of observation, the patient goes home

… A lumbar support is worn for 6 to 8 weeks, followed by an appropriate course of physical therapy. Lifting and bending precautions are necessary during this time to allow for adequate healing of the disc.

HOW DOES THE IDET PROCEDURE WORK?

As part of the aging process, cracks or fissures may develop in the wall of the disc. Infiltrated by small nerve endings and vessels, these fissures are a chronic source of pain in many patients. Additionally, the inner disc tissue (nucleus) will frequently bulge into these fissures in the outer region of the disc, likewise stimulating pain sensors within the disc. When performing the IDET procedure, the physician applies controlled levels of thermal energy (heat) to a broad section of the affected disc wall. The thermal energy contracts and thickens the collagen of the disc wall. Results of this may include contraction or closure of the disc wall fissures and a reduction in the bulge of the inner disc material.

Am I a candidate for IDET?
If you have back pain from a damaged disc (discogenic pain) that does not respond to less invasive therapies, you may benefit from an IDET procedure. Most back pain gets better on its own in the first month or two, so physicians do not consider IDET until at least three months after the onset of back pain. Also, if your back pain is not severe enough to limit your activities, you probably should not have IDET. IDET is currently indicated for patients with chronic back pain that does not respond to at least 3 months of conservative treatment.

Conservative treatment typically includes a combination of:

… Medication

… Rest

… Activity modification

… Physical therapy and/or appropriate exercise program

It is important to note that up to 90% of patients get better with the above therapies and do not require additional treatment.

For those who fail to respond and have significant limitations in their daily function, additional testing such as MRI Imaging and Lumbar Discography may be useful in determining which discs, if any, may be responsible for the chronic pain.

Candidates for IDET include patients with back pain caused by:

… Small herniations

… Internal disc tears

… Mild disc degeneration limited to one or two levels

The presence of multiple abnormal, painful discs does not bode well for a good, predictable surgical outcome, regardless of the surgical procedure performed.

Relative contraindications for IDET include:

… Severe disc degeneration

… Spinal stenosis

… Neurological symptoms (such as leg weakness)

… Large disc herniations

… Pacemakers

… Spinal Cord Stimulators and Peripheral Nerve Stimulators

… Disc or Spinal infections

Is there anything else I should try before thinking about IDET?
Before considering IDET, you should try less invasive treatments such as anti-inflammatory medications, physical therapy and epidural steroid injections.

How do I know if my pain is from a damaged disc?
With age or from an injury, the wall of the spinal discs can get cracks (fissures). This condition is call Internal Disc Disruption or Degenerative Disc Disease. Also, the wall can weaken and bulge out (a herniated disc). When the disc causes pain, the pain is usually felt as a deep ache in the back and sometimes in the buttocks and into the thigh. However, pain from facet joints in the back and from the sacroiliac joints (SI joints) can be in the same location and feel the same. The best way to tell if the pain is from a damaged disc is with discography.

Is this the same pain as sciatica?
Sciatica is pain that shoots down the leg from an irritated nerve. Often a herniated disc causes the nerve irritation. IDET would not directly treat the sciatica and is not currently recommended for patients with sciatica. Nevertheless, if you have both, low back pain and leg pain, it may help the back pain component.

Can all painful discs be treated with IDET?
IDET may not be appropriate if the disc is very narrowed, if the spinal canal is narrowed, if the spine is unstable, or if you have various general health conditions. Painful discs in the neck cannot be treated with IDET, only in the low back. For disk pain in the neck, there is a different technique that is used.

How long does the IDET take?
It takes about 60 to 90minutes for IDET on one disc, about 2 hours for two discs.

How is it actually performed?
IDET is usually performed as an outpatient procedure. The procedure is performed in an aseptic environment, to maintain sterility. You lie face down on an x-ray table. Local anesthesia and mild sedation will be used to make you more comfortable during the procedure. Using fluoroscopy (x-ray), a needle is inserted into the disc and through the needle a flexible catheter to positioned in the disc. Once in proper position, this catheter is heated for about 17minutes. When done, the catheter and needle are removed and you are ready to go home about an hour later with a Band-Aid over the needle insertion site.

Will the procedure hurt?
Local anesthesia and mild sedation will be used to make you more comfortable during the procedure. During the heating, you may feel a reproduction of your usual lower back pain. This is an excellent sign that the heating is being done in the correct area.

Will I be "put out" for this procedure?
IDET is usually performed as an outpatient procedure. Local anesthesia and mild sedation will be used to make you more comfortable during the procedure. You will need to be awake enough to tell your physician what you are experiencing during the procedure. It is actually contraindicated to use general anesthesia for this procedure.

What should I expect after the procedure?
You will probably have a flare-up of your back pain for a few daysósometimes up to a week. You will be advised to use ice packs initially and you may need extra medication during this period. Almost everyone is back to, at least, their usual level of pain within a week.

When will my pain get better?
Your pain should gradually improve over the weeks and months following the IDET. Improvement can occur as long as 6 to 12 months after the procedure.

What should I do after the procedure?
This procedure is normally a day-procedure. Some patients may be kept overnight for observation. You will need to have a ride home. You will need to wear a special corset that will support your back and limit your motion. It is very important to limit your activities after the IDET to allow the disc wall to stiffen and heal. You will be given detailed instructions after the procedure.

How successful is IDET?
The national success rate for improvement in pain and function is about 70%. Success is considered at least a 50% improvement in pain. Long-term outcome studies are not yet available but are in progress. Some studies suggests that approximately70% to 80% of patients are satisfied with the procedure.

General areas of improvement include:

… Most of these patients report an increased activity level and improved sitting tolerance

… The usage of pain medication seems to be diminished

… Improvement is frequently noted within a few days of the procedure but may take up to 6 to8 weeks to be noticed. Improvement may continue for 4 to 6 months

… Results, so far suggest that most people who feel significant improvement after one year continue to do well at two years of follow-up

Several factors seem to help predict a successful outcome, including:

… Single level disc disease

… Good catheter placement at the time of the procedure

… Absence of secondary gain issues (such as financial gain from pending litigation or workers compensation).

This last factor ñ secondary gain ñ clearly impacts the outcome of all spinal procedures.

Studies are underway to determine the long-term effect of IDET on the appearance of the disc on MRI imaging.

What are the risks of IDET?
No serious complications have yet been reported. But there are always risks. Infection in the disc is a possibility and is a terrible condition, so very careful sterility is used along with antibiotics. Bleeding requiring emergency surgery and nerve damage are also possible risks. There is also the risk that it may not help your pain or may make it worse. There are always possibilities of unknown risks or reactions. Please discuss your concerns with your physician. IDET is a very safe procedure with a very low risk for complications. Disc space infection and nerve injury are seen less than 1% of the time

What are the alternatives to IDET?
If you have disc pain, the alternatives are to treat the pain conservatively with medication, physical therapy and epidural steroid injections or to have a surgical spinal fusion.

WHO SHOULD NOT HAVE THIS PROCEDURE?
If you are on a blood thinning medication (e.g. CoumadinÆ), or if you have an active infection going on, you should not have the procedure.

WILL MY INSURANCE COVER THE PROCEDURE?

As with any new medical procedure, some insurance companies are slower to begin reimbursement than others. We have a staff specifically trained to work with doctors to help procure reimbursement for patients.

HOW MUCH DOES IT COST?

The cost for the IDET procedure varies based upon physicians, states, facilities and procedure complexity. It is estimated that the average cost of the entire procedure is approximately $8800.