Nucleoplasty

Questions and Answers

What is Nucleoplasty?
Nucleoplasty is a minimally invasive procedure developed to treat patients with contained, or mildly herniated discs. Nucleoplasty literally means removal of the nucleus (nucleus pulposus is the center gel-like substance of the disc.) The outer band-like substance of the disc is the annulus fibrosis. Typically when a disc herniates, the annulus fibrosis opens and allows the nucleus pulposus to protrude and compress structures such as nerves. This nuclear material has been shown to irritate neural structures, causing swelling and if untreated, it may cause a compartment syndrome that may result in permanent nerve damage. Nucleoplasty does not involve an incision. A special access needle is placed into the disc under x-ray guidance. A wand-like device is then inserted through the needle and into the disc. The device uses heat to remove disc material and seal the channel made by the needle. Several channels are made depending on how much disc material needs to be removed.Ý Nucleoplasty is a minimally invasive procedure for treating patients symptomatic with low back and leg pain caused by a herniated disc.

What is a herniated disc?
The disc functions as a shock absorber between the vertebras of the spine. A herniated disc has a defect or weakness in the wall, similar to a "blister" in the sidewall of a tire, which can lead to pressure on sensitive nerve roots and pain receptors in the back.

What does minimally invasive mean?
It means that there is not an incision as in a surgical operation, but is a procedure that is performed through a thin needle percutaneously.

Nucleoplastyô

The nucleoplasty device is a catheter that creates a small, highly localized plasma field. This catheter is percutaneously inserted into the intervertebral disc through a stylet. The location is confirmed using fluoroscopy. The catheter is activated and gentle movements are made to the catheter as it lies within the disc space. In this way, small amounts of disc material may be ablated within the disc space and disc decompression may be effected.

This technique is percutaneous and does not require any incision. It is most useful in patients with nerve root irritation due to smaller disc bulges or contained ruptures.

Nucleoplasty is usually performed on an outpatient basis. Local anesthesia and mild sedation may be used to reduce discomfort during the procedure. You will be awake to provide important feedback to the physician.

With the guidance of x-ray images, your physician will first advance a needle into the disc. A specialized device known as a SpineWandô, will then be introduced through the needle into the disc. Therapy consists of creating a series of channels in your disc and then thermally treating the tissue immediately adjacent to the wand. The process usually takes approximately one hour.

What is percutaneously?
This means through the skin, again as opposed to making a surgical incision.

Who is a candidate for this procedure?
Indications include back pain or combined back and leg pain, that have not improved after approximately three months of conservative therapy, such as rest, pain medication, physical therapy. Also:

… Positive MRI for contained disc herniation or bulge

… Positive discogram reproducing patient's symptomatic pain

… Contained disc herniation which measures less than 30% of the diameter of spinal canal)

Who may benefit from nucleoplasty therapy?
Patients with contained disc herniations may benefit from this therapy. Nucleoplasty is a minimally invasive procedure developed for these patients, combining disc decompression with thermal treatment.

How is Nucleoplasty performed?
The procedure is performed in a surgical center with fluoroscopic (x-ray) guidance. Nucleoplasty is done with the patient lying on the stomach. Intravenous sedation is given to help with comfort and relaxation. The skin is cleaned with an antiseptic solution and the back is numbed with a local anesthetic before the procedure is performed. The patient is monitored with an electrocardiogram, blood pressure cuff and blood oxygen-monitoring device.

What will I feel during the procedure?
You will feel a sense of pressure, or mild discomfort when the needle is inserted into the disc. When an abnormal disc is injected, you will feel pain. Your physician will closely monitor your comfort level during the entire procedure and provide sedation as needed.

Will the injections hurt?
The procedure involves inserting a needle through skin and deeper tissues, so there is some discomfort involved. However, your doctor will numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the disc. Most of the patients receive intravenous sedation and pain medication, which makes the procedure easy to tolerate. You may have a flare-up of your back pain after the injection, but this gets better in a day or two and can usually be managed with ice packs and oral pain medication.

Is the nucleoplasty procedure painful?
No. Nucleoplasty is performed under local anesthesia, with mild intravenous sedation. The procedure itself is virtually painless, and has little to no post-procedure pain.

Will I be "put out" for this procedure?
No. This procedure is done under local anesthesia (ìNovocaine.î) Most of the patients also receive intravenous sedation and analgesia, to help them relax and make the procedure easier to tolerate. The amount of sedation given depends upon the patient. You need to be awake enough to tell the doctor what you are feeling.Ý This is one of the main advantages of this procedure, the fact that the patients do not have to be exposed to the risks of general anesthesia.

How many discs are treated?
Based on your symptoms and your MRI, your doctor will determine which disc(s) may be causing your pain. Typically, only one to two disc are treated at a time.

How long does Nucleoplasty take?
Nucleoplasty takes about 30 to 45 minutes, depending on the amount of disc material that needs to be removed.

What should I do after the procedure?
We advise patients to take it easy the day of the procedure. You may need to apply ice to the affected area for 20-30 minutes at a time for the next 48 hours. Your doctor will provide specific activity restrictions, if indicated. Typically driving, lifting, bending/twisting at the waist are restricted in the first few weeks. Formal physical therapy, if indicated, may begin at 2-3 weeks post-procedure.

What are the risks and side effects of nucleoplasty?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is discomfort, which is temporary. Sometimes, the access needle brushes past a nerve root and the nerve root is irritated. This pain gets better quickly, although, in the worse case scenario, it may last up to eight months. Other risks include infection, bleeding, permanent nerve damage, and worsening of symptoms. Fortunately, because the procedure is performed with x-ray in a controlled environment, serious side effects and complications are rare.

Who should not have this injection?
If you are on a blood thinning medication (e.g. CoumadinÆ, PlavixÆ), or if you have an active infection anywhere in your body, you should not have the procedure. If you are on any blood thinners, you will need to come off of them, prior to your procedure. Make sure to notify your physician and/or nurse about it.

Who is not a candidate for this procedure?
Severe degenerative disc disease, or disc arthritis, with narrowing >25% of disc space. Disc herniation greater than 25 to 30% into the spinal canal. Back pain from other sources, such as bony arthritis, spinal fracture, or tumor.

How does nucleoplasty work?
Nucleoplasty works by utilizing a multifunctional device called a SpineWandô. The wand is passed through a thin introducer needle into the center of the disc, called the nucleus. When the proper position is confirmed by x-ray techniques, the SpineWand is used to perform two separate tasks. First, it creates a channel, removing tissue and then it heats and shrinks the tissue through coagulation. This decompresses the disc, reducing the pressure both inside the disc and on nerve roots.

Is there a long period of disability after the procedure?
No. We recommend a standard post-procedure exercise rehabilitation, but it is not mandatory.

Does one need to wear a back support or brace after nucleoplasty?
No. There is no requirement for post procedure bracing.