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66
Korean J Pain 2020;33(1):66-72
https://doi.org/10.3344/kjp.2020.33.1.66
pISSN 2005-9159 eISSN 2093-0569
INTRODUCTION
Low back pain (LBP) and radiculopathy secondary to in-
tervertebral disc pathology is one of the most common
medical problems of all spinal, and even chronic pain
disorders. Based on recent concepts, it is believed that the
mechanisms of pain generation in radicular pain are si-
multaneous mechanical deformation of an intervertebral
disc and irritation of the nerve root by chemical mediators
originating from an injured disc, provoking inflammatory
Original Article
This is an open-access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License (http://cre-
ativecommons.org/licenses/by-nc/4.0/), which permits unrestricted
non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
© The Korean Pain Society, 2020
Author contributions: Masoud Hashemi: Study conception; Payman
Dadkhah: Methodology; Mehrdad Taheri: Investigation; Pegah Katibeh:
Resources; Saman Asadi: Project administration.
Effectiveness of intradiscal injection of radiopaque gelified
ethanol (DiscoGel®)
versus
percutaneous laser disc decompression
in patients with chronic radicular low back pain
Masoud Hashemi1, Payman Dadkhah1, Mehrdad Taheri1, Pegah Katibeh2, and Saman Asadi1
1Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Department of Pediatric Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
Received May 28, 2019
Revised September 7, 2019
Accepted September 26, 2019
Correspondence
Saman Asadi
Pain Clinic, Akhtar Hospital, Shahid
Beheshti University of Medical Sciences,
Sharifi Manesh St., Poule Roomi Ave,
Shariati St., Tehran 11111, Iran
Tel: +98-9177113169
Fax: +98-2122007340
E-mail: asadisa@sums.ac.ir
Background: Low back pain secondary to discopathy is a common pain disorder.
Multiple minimally invasive therapeutic modalities have been proposed; however, to
date no study has compared percutaneous laser disc decompression (PLDD) with
intradiscal injection of radiopaque gelified ethanol (DiscoGel®). We are introducing
the first study on patient-reported outcomes of DiscoGel®
vs.
PLDD for radiculopa-
thy.
Methods: Seventy-two patients were randomly selected from either a previous strat-
egy of PLDD or DiscoGel®, which had been performed in our center during 2016-
2017. Participants were asked about their numeric rating scale (NRS) scores, Os-
westry disability index (ODI) scores, and progression to secondary treatment.
Results: The mean NRS scores in the total cohort before intervention was 8.0, and
was reduced to 4.3 in the DiscoGel® group and 4.2 in the PLDD group after 12
months, which was statistically significant. The mean ODI score before intervention
was 81.25% which was reduced to 41.14% in the DiscoGel® group and 52.86% in
the PLDD group after 12 months, which was statistically significant. Between-group
comparison of NRS scores after two follow-ups were not statistically different (
P
=
0.62) but the ODI score in DiscoGel® was statistically lower (
P
= 0.001). Six cases
(16.67%) from each group reported undergoing surgery after the follow-up period
which was not statistically different.
Conclusions: Both techniques were equivalent in pain reduction but DiscoGel®
had a greater effect on decreasing disability after 12 months, although the rate of
progression to secondary treatments and/or surgery was almost equal in the two
groups.
Key Words: Chronic Pain; Disability Evaluation; Discectomy; Intervertebral Disc; Low
Back Pain; Pain Management; Radiculopathy; Visual Analog Scale
DiscoGel®
vs.
PLDD in radiculopathy
Korean J Pain 2020;33(1):66-72www.epain.org
67
responses and increase the sensory neuron susceptibility,
resulting in radicular pain [1-3].
Multiple therapeutic modalities, such as minimally
invasive procedures and percutaneous techniques, have
been recently proposed for the removal of herniated disc
fragments (which have caused nerve root compression)
and for developing the treatment of LBP and radiculopathy
while minimizing procedure-related muscle and ligament
injury [4-7].
Percutaneous laser disc decompression (PLDD) is anoth-
er acceptable choice in the management of herniated lum-
bar disc disease and radiculopathy. PLDD is an indirect
way of decompressing the compromised nerve root by us-
ing laser energy to vaporize a small volume of the nucleus
pulposus and reducing the pressure in the intervertebral
disc. Decreasing the intradiscal pressure would retract the
herniation away from the compromised nerve root, thus
reduce the amount of nerve root injury [8,9]. PLDD does
not require hospitalization or anesthesia, and is therefore
associated with lower healthcare costs than conventional
surgery [10].
Another minimally invasive percutaneous treatment
that has recently been made available by exploiting the
chemical properties of pure ethanol is radiopaque gelified
ethanol (DiscoGel
®
). DiscoGel
®
is a newly proposed sterile
viscous intradiscal solution in the form of gelified ethanol
associated with tungsten in suspension, which is more
viscous than absolute alcohol and was introduced in 2007
for treatment of pain from lumbar discs that failed con-
servative treatment with an absence of neurological defi-
cit. This class III intradiscal medical material is injected
into the nucleus pulposus to decompress the intradiscal
space. The presence of cellulose, which is a gelling agent,
would decrease the possibility of epidural leakage from
the administered agent that may occur with pure (not geli-
fied) ethanol. The tungsten particles are used to control
progression of the gel in the disc and through any annular
fissures using fluoroscopic images [11-13].
Both treatments are performed in an outpatient setting
with the patient in prone position, under local anesthesia
and sterile conditions. In PLDD technique, an 18-G needle
is placed centrally in the nucleus pulposus and parallel to
the endplates in a posterolateral approach, guided by fluo-
roscopy. A glass fibre of 600 microns is advanced through
the needle, and laser energy (Biolitec, Jena, Germany;
980 nm, 7 W, 0.6 sec pulses, interval 1 sec) is applied to a
total energy delivery of 1,500 J (2,000 J for level L4-5) [8,9].
In the intradiscal injection of DiscoGel
®
, an 18-G needle
is inserted into the median and posterior part of the disc
and DiscoGel
®
is injected slowly (0.1 mL during a 30 sec
period). The amount of DiscoGel
®
injected into the disc
depends on the amplitude of the disc space and the rela-
tive capacity of the disc to accommodate the gel, usually
between 0.5-0.8 mL. The needle is left in place for 2 min-
utes after the application to prevent late leakage [11,13].
Due to a paucity of evidence for prospective studies re-
garding the effectiveness of these techniques and patients’
long-term outcome in terms of radicular pain manage-
ment and functional ability score improvement, this pres-
ent study was designed to compare the effectiveness of
intradiscal injection of DiscoGel
®
and PLDD in 72 patients
with LBP and radiculopathy due to lumbar intervertebral
disc herniation. Since the 1-year follow-up improvement
would be the most important clinical landmark after
these procedures, this report consists of patients’ reported
results from a period of 12 months. Outcome measures
included pain intensity and functional disability, assessed
at baseline, 6 months, and 12 months following the treat-
ment. Additional lumbar spine injections and/or progres-
sion to surgery were secondary outcome measures.
MATERIALS AND METHODS
The present prospective cohort study was designed and
conducted in the Anesthesiology Research Center (Teh-
ran, Iran), during December 2018, aiming to compare the
results from a one-year follow-up of two previously per-
formed interventions of PLDD and intradiscal injection of
DiscoGel
®
in patients with unilateral or bilateral radicular
LBP due to lumbar intervertebral disc herniation.
The study protocol was approved by the Local Ethics
Committee of the Shahid Beheshti University of Medical
Sciences (IRB number: IR.SBMU.RETECH.REC.1397.1285)
and the study was performed in accordance with the
ethical standards of the 1964 Declaration of Helsinki. All
data were kept confidential, patients’ anonymity was pre-
served, and the patients were not charged for the purposes
of the study. The consent was previously taken from all pa-
tients, in this study we compared the results after one year.
The study population was made up of patients who had
undergone either PLDD or intradiscal injection of Disco-
Gel
®
in the Anesthesiology Research Center during 2016-
2017. Inclusion criteria were being aged 20-70 years, a
history of unilateral or bilateral radicular pain to the lower
extremities due to lumbar intervertebral disc herniation
without neurologic deficits, whose diagnosis were proved
by physical examination and medical imaging (radiologic
imaging and magnetic resonance imaging), and were not
responsive to conservative treatments during at least past
3 months. Exclusion criteria were a history of vertebral
fracture, spinal canal stenosis, a history of any lumbar
surgery or malignancy, peripheral nerve neuropathies,
uncontrolled diabetes mellitus, and an inability to com-
68
https://doi.org/10.3344/kjp.2020.33.1.66Korean J Pain 2020;33(1):66-72
Hashemi, et al
municate in Persian language.
Sample size calculation was performed using the re-
sults from a previous pilot study on 20 cases (10 random
cases from each procedure), assuming an α-error of 0.05,
a power of 80%, an estimated difference between the two
groups as 0.487, and standard error defined as 1.350. As a
result, 60 cases were considered to be included. However,
due to our prediction of cases with no follow-up, a 20% in-
crease in sample size was certified and a total of 72 cases,
who had undergone previous interventions and met the
criteria, were included in the present study. Patients were
randomly selected using the sort range randomly utility
in Excel (Microsoft, Redmond, WA), according to whether
they had received a previous PLDD or DiscoGel
®
.
Baseline and demographic data for all patients were re-
corded in the patients’ profiles and all of the participants
were called by one independent researcher. If any patient
was unreachable after 3 calls at different times of a day and
different days of a week, the patient was excluded from the
st udy.
During the phone call interview, the study aim and ob-
jective were described to each patient and participants
were instructed to respond to the questions or rate each
scale independently.
Pain intensity was evaluated based on a verbal numeric
rating scale (NRS). The NRS is one of the most commonly
used self-reporting scales for measuring pain, likely due to
its ease of use (it requires no specialized equipment) and
also because its 0 to 10 metric is preferred by health care
professionals. The validity and reliability of this scale has
been previously established [14]. Patients typically were
asked, “How strong is your pain during the past 14 days,
where 0 is no pain and 10 is the strongest or worst pain you
can imagine?”.
Functional ability was evaluated based on the Oswes-
try disability index (ODI). The ODI is a self-administered
questionnaire measuring “back-specific function” on
a 10-item scale with six response categories each. Each
item scores from 0 to 5, higher scores being worse, which
is transformed into a 0% to 100% scale. The ten items in-
clude pain intensity, personal care, lifting, walking, sit-
ting, standing, sleeping, work, social life, and traveling.
Patients with scores between 0% to 20% have minimal
disability, between 21% to 40% have moderate disability,
between 41% to 60% have severe disability, 61% to 80% are
crippled and 81% to 100% are bed-bound or exaggerating
their symptoms. The validity and reliability of this scale
has been previously established [15].
Additional lumbar spine injections and/or a progression
to lumbar decompression surgery, diskectomy, or any oth-
er treatments after 1-year post-intervention were assessed
and the answers were documented in their profile.
Due to the duration of follow-up and for reasons such as
death, migration, or changes in the status of sample cases
over time, the presence of cases with no follow-up (loss-
to-follow-up) and therefore non-response (or response re-
fusal) bias was predictable. To minimize this bias, besides
considering a 20% increase in sample size (as mentioned
before), inclusion and exclusion criteria were limited, and
therefore, the samples were condition-specific and homo-
geneous. As a result, the sample population would repre-
sent the community studied.
In order to avoid recall bias, the primary outcome mea-
sured concentrated on the current condition of the pa-
tients (specifically the previous 2 wk). In order to avoid re-
sponse bias, patients were provided with adequate details
and necessary clarifications about the questions and the
correct way of responding to the questionnaires.
Statistical analysis was performed using SPSS ver. 18
(IBM Corp., Armonk, NY).
Demographic factors were presented by frequencies
and related percentages; continuous data were displayed
by means and standard deviation. The statistical analy-
sis is based on the assessment of differences in outcome
measurements between both groups and comparison of
averages at single time points. An independent-samples
t
-test, chi-square, or student
t
-test, as appropriate, and
repeated measurements using analysis of variance were
used to compare the variables at baseline, 6 months and
12 months after follow-up.
P
values < 0.05 were considered
to be statistically significant.
RESULTS
During the recruitment period (2016-2017), a total of 72
subjects with unilateral or bilateral radicular pain, sec-
ondary to lumbar intervertebral disc herniation, had
undergone either an intradiscal injection of DiscoGel
®
or PLDD in the Anesthesiology Research Center. Twelve
months after the procedures, all 72 subjects (100%) were
available for follow-up.
Baseline and demographic characteristics of the entire
cohort were analyzed. The average age of the participants
was 48.2 years old, ranged between 21 and 70 years old,
with 43 subjects being male (59.72%). Twenty-six cases
(36.11%) were smokers. The mean duration of pain and
radiculopathy prior to the intervention was 12.19 months,
ranged between 3 and 60 months. Mean pain intensity
(NRS scores) was 8.0 (before the procedures). The mean
functional disability index (ODI score) was 81.25% before
the procedures. Twelve cases (16.67%) reported undergo-
ing surgery at least 6 months after the 1-year follow-up.
Upon analyzing baseline data from PLDD group, the av-
DiscoGel®
vs.
PLDD in radiculopathy
Korean J Pain 2020;33(1):66-72www.epain.org
69
erage age of participants was 44.6 years, ranged between
21 and 70 years, with 21 subjects being male (58.33%).
Fourteen cases (38.89%) were smokers. Mean duration
of pain and radiculopathy was 13.30 months, ranged
between 3 and 60 months. Mean pain intensity at base-
line was 8.00. Mean functional disability at baseline was
83.84%. Six cases (16.67%) reported undergoing surgery at
least 8 months after the 1-year follow-up.
Upon analyzing baseline data from DiscoGel
®
group,
the average age of participants was 47.3 years, ranged
between 26 and 70 years, with 22 subjects being male
(61.11%). Twelve cases (33.33%) were smokers. Mean dura-
tion of pain and radiculopathy was 10.88 months, ranged
between 3 and 36 months. Mean pain intensity at base-
line was 8.02. Mean functional disability at baseline was
78.35%. Six cases (16.67%) reported undergoing surgery at
least 6 months after the 1-year follow-up. Data are demon-
strated in Tab le 1.
Upon comparing and analyzing the outcome results
between PLDD & DiscoGel
®
group, NRS scores in the to-
tal cohort before intervention was 8.0 (ranged from 5-10).
After receiving the intervention and during the 12 months
follow-up, the mean NRS score in the DiscoGel
®
group had
decreased to 4.3. This difference in NRS scores before and
after intervention was statistically significant (
P
= 0.005).
After receiving the intervention and during the 12 months
follow-up, the mean NRS score in the PLDD group had
decreased to 4.2. This difference in NRS scores before and
after intervention was statistically significant (
P
= 0.006).
However, between-group comparison of NRS scores in the
two groups after two follow-up visits showed no statisti-
cally significant difference between the two groups (
P
=
0.62). Data are demonstrated in Fig. 1. ODI score before
intervention was 81.25% (ranged from 48%-100%).
After receiving the intervention and during the 12
months of follow-up, the mean ODI score in the DiscoGel
®
group had decreased to 41.14%. This difference in ODI
scores before and after the intervention was statistically
significant (
P
= 0.012).
After receiving the intervention and during the 12
months of follow-up, the mean ODI score in the PLDD
group had decreased to 52.86%. This difference in ODI
scores before and after the intervention was statistically
significant (
P
= 0.019).
Between-group comparison of ODI score in the two
groups after two follow-up visits showed a statistically
significant difference between the two groups at
P
= 0.001
and the mean ODI score in the DiscoGel
®
group was statis-
tically lower than the PLDD group. Data are demonstrated
in Fig. 2.
Six cases from each group (16.66%, n = 36 per group) re-
ported undergoing surgery after the follow-up period. This
difference between the two groups was not statistically
different.
90
80
70
60
50
40
30
20
10
ODI
6moBefore treatment 12 mo
0
PLDD
DiscoGel
Time points
Fig. 2. Comparison of Oswestry disability index (ODI) between two
groups in different time points (
P
= 0.001). PLDD: percutaneous laser
disc decompression, DiscoGel
®
: radiopaque gelified ethanol.
9
8
7
6
5
4
3
2
1
NRS
6moBefore treatment 12 mo
0
PLDD
DiscoGel
Time points
Fig. 1. Comparison of numeric rating scale (NRS) scores between two
groups in different time points (
P
= 0.62). PLDD: percutaneous laser disc
decompression, DiscoGel
®
: radiopaque gelified ethanol.
Table 1. Baseline Characterization of Total Cohort
Variable PLDD group (n = 36) DiscoGel
®
group (n = 36)
Age (yr) 44.6 ± 14.3 47.3 ± 2.0
Sex (M/F) 21/15 22/14
Smoking (yes/no) 14/22 12/24
Pain duration (mo) 13.3 ± 14.2 10.9 ± 6.9
NRS score 8.0 ± 1.5 8.0 ± 1.8
ODI score (%) 83.8 ± 12.3 78.4 ± 14.7
Values are presented as mean ± standard deviation or number only.
PLDD: percutaneous laser disc decompression, DiscoGel
®
: radiopaque
gelified ethanol, M: male, F: female, NRS: numeric rating scale, ODI: Os-
westry disability index.
70
https://doi.org/10.3344/kjp.2020.33.1.66Korean J Pain 2020;33(1):66-72
Hashemi, et al
DISCUSSION
A wide range of pain management modalities including
minimally invasive percutaneous treatments have been
suggested in recent years for discogenic pain secondary
to lumbar disc herniation. In the present cohort study, we
compared the effectiveness of two different modalities by
evaluating the improvements in patients’ pain and func-
tional scores.
PLDD is an attractive Food and Drug Administration-
approved treatment modality for lumbar radiculopathy
that reduces intradiscal pressure by vaporization of a
small volume of water within the nucleus pulposus.
The result would be a decline in intradiscal pressure and
also a more even distribution of weight across the disc,
with a subsequent relief of discogenic pain; this is per-
formed most commonly for lumbar disc pathologies [16,17].
Due to its minimally-invasive nature, the decrease in the
risk of damage to the muscles, bone, ligaments, and nerves
along with less back pain, a shorter hospital stay and
shorter recovery period in comparison with conventional
surgical methods are anticipated, and several cohort stud-
ies have previously showed the safety and potential ben-
efits of PLDD [7,8,16,18-23]. On the other hand, multiple
prospective randomized trials do exist that have revealed
the lack of efficacy of PLDD alone or compared with con-
ventional surgeries such as microdiscectomy [9,10,24].
After the introduction of a substance based on Disco-
Gel
®
and its success in partial debulking of the nucleus
pulposus with percutaneous intradiscal administration
and consequent reduction of intradiscal pressure, this
treatment has been tested in several controlled random-
ized studies. DiscoGel
®
is a newly proposed sterile viscous
solution of DiscoGel
®
which is more viscous than absolute
alcohol and has been recently used in minimally invasive
procedures for treatment of discogenic lumbosciatia. After
intradiscal injection of DiscoGel
®
no morpho-structural
changes in the nuclear tissue or annulus were found [11],
spurring hope that it could serve as an alternative for in-
vasive conventional surgery or microdiscectomy in cases
where there was no response to the other treatment mo-
dalities [25]. DiscoGel
®
induces its useful effects by some
hypothetic mechanisms. Three significant hypotheses
are:
- a diminishing of the intradiscal pressure as a result of
induced dehydration of the nucleus
- a neurolytic effect on the growing neurons
- alcohol-induced necrosis of small piece of nucleus
pu lpos us [1 2]
Initial and preliminary studies in 2007 and 2010 by
Theron et al. [26,27] have defined satisfactory results along
with the safety and efficacy of gelified ethanol in the per-
cutaneous treatment of cervical and lumbar disc hernias.
With no of adverse effects either during the procedure or
after it, the authors showed promising results that suggest
a feasible and safe alternative in the treatment of spinal
disc hernias. Since 2014, many other investigations have
shown that intradiscal DiscoGel
®
injection is a minimally
invasive, low cost, safe, and effective intervention that may
be a valuable choice in proper selected discopathies before
making plans for surgery [12,13,28].
Compared with the findings obtained in the present
study, using either PLDD or intradiscal injection of Dis-
coGel
®
, our results were satisfactory, as the overall thera-
peutic success rates were almost the same, although the
decrease in functional disability was much greater in the
DiscoGel
®
group. However, regarding the frequency of the
need for secondary treatment options like conventional
surgery after PLDD or intradiscal injection of DiscoGel
®
, a
paucity of evidence exists.
In a newly designed retrospective, observational study
by Klessinger [29] in 2018, the frequency of additional open
surgery after PLDD in a long time period (10 yr) was exam-
ined retrospectively. The authors concluded that PLDD is
not a replacement for open discectomy. Since it is broadly
believed that conventional surgery is the gold standard
treatment for patients with lumbar disc herniation and
radiculopathies, PLDD and intradiscal injections of Disco-
Gel
®
need to be compared with conventional surgery, and
the cost-effectiveness needs to be studied in multiple pain
management centers along with larger sample sizes.
Along with documented benefits of DiscoGel
®
, an inter-
esting finding was multiple reports concerning the role of
disc microbial infection in disc degeneration. Pilot stud-
ies have shown infection rates when disc-only cultures
are performed, and
Propionibacterium acnes
has been
the predominant organism followed by
Streptococcus
sp.
Therefore, the association of bacterial disc infection with
the
P. acnes
strain in the induction of the same degen-
erative process as observed in patients with chronic LBP
and Modic changes, have been recently proposed [30,31].
Many studies have claimed a strong connection between
Modic changes and non-specific LBP and that is why so
much attention is given to this pathologic change [32]. The
prolonged antiseptic effect of gelified ethanol within a de-
generative and potentially infected nucleus appears to be
appropriate to fight infection, at least in theory, which can
serve as an interesting issue for further studies on Disco-
Gel
®
.
The present analysis was performed in a Persian con-
text, which limits the generalizability of findings since it
may not be representative for other settings. Also, the lack
of a comparison population for conservative therapies in
the course of symptoms is another limitation for which
DiscoGel®
vs.
PLDD in radiculopathy
Korean J Pain 2020;33(1):66-72www.epain.org
71
future multi-central extensive studies with comparison
groups are recommended to further document the safety,
efficacy, and effectiveness of PLDD and intradiscal injec-
tion of DiscoGel
®
in discopathies. Although several cohort
studies have been published, to date no study had been
performed comparing PLDD with intradiscal injection of
DiscoGel
®
.
In the present research, we introduced the first prospec-
tive cohort study on patient-reported outcomes of PLDD
vs.
intradiscal injection of DiscoGel
®
for radiculopathy in
lumbar disc herniation from the points of pain and func-
tional disability. Findings from our clinical investigations
showed that both treatment modalities are equivalent in
their clinical effects on pain, but DiscoGel
®
had a greater
effect on decreasing the level of functional disability after
12 months of follow-up, although the rate of progression to
secondary treatments and/or surgery were almost equal in
the two groups.
ACKNOWLEDGMENTS
The authors would like to thank Atefe Alaee (aalaei@alum-
nus.tums.ac.ir) for her critical reading of the manuscript
and helpful comments.
CONFLICT OF INTESTEST
No potential conflict of interest relevant to this article was
reported.
FUNDING
No funding to declare.
ORCID
Masoud Hashemi, https://orcid.org/0000-0002-8526-3074
Payman Dadkhah, https://orcid.org/0000-0003-4183-4581
Mehrdad Taheri, https://orcid.org/0000-0002-8482-5434
Pegah Katibeh, https://orcid.org/0000-0002-1380-314X
Saman Asadi, https://orcid.org/0000-0002-9531-8382
REFERENCES
1. Govind J. Lumbar radicular pain. Aust Fam Physician 2004;
33 : 40 9-12 .
2. Rhee JM, Schaufele M, Abdu WA. Radiculopathy and the
herniated lumbar disc. Controversies regarding pathophysi-
ology and management. J Bone Joint Surg Am 2006; 88: 2070-
80.
3. Wheeler AH, Murrey DB. Chronic lumbar spine and radicu-
lar pain: pathophysiolog y and treatment. Curr Pain Head-
ache Rep 2002; 6: 97-105.
4. Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic re-
view of therapeutic lumbar transforaminal epidural steroid
inject ions. Pain Physician 2009; 12: 233-51.
5. Hahne AJ, Ford JJ, McMeeken JM. Conservative management
of lumbar disc herniation with associated radiculopathy: a
systematic review. Spine (Phila Pa 1976) 2010; 35: E488-504.
6. Menchetti PPM, Bini W. Percutaneous treatment in lumbar
disc herniation. In: Minimally invasive surgery of the lum-
bar spine. Edited by Menchetti PPM. London, Springer. 2014,
pp 83-105.
7. Skovrlj B, Gilligan J, Cutler HS, Qureshi SA. Minimally in-
vasive procedures on the lumbar spine. World J Clin Cases
2015; 3: 1-9.
8. Ren L, Guo H, Zhang T, Han Z, Zhang L, Zeng Y. Efficacy
evaluation of percutaneous laser disc decompression in the
treatment of lumbar disc herniation. Photomed Laser Surg
2013; 31: 174-8 .
9. Singh V, Manchikanti L, Calodney AK, Staats PS, Falco FJ,
Caraway DL, et al. Percutaneous lumbar laser disc decom-
pression: an update of cu rrent evidence. Pa in Physician 2013;
16(2 Suppl): SE229-60.
10. Sobieraj A, Maksymowicz W, Barczewska M, Konopielko M,
Mazur D. Early results of percutaneous laser disc decom-
pression (PLDD) as a treatment of discopathic lumbar pain.
Ortop Traumatol Rehabil 2004; 6: 264-9.
11. Guarnieri G, De Dominicis G, Muto M. Intradiscal and intra-
muscular injection of Discogel
®
—radiopaque gelified etha-
nol: pathological evaluation. Neuroradiol J 2010; 23: 249-52.
12. Léglise A, Lombard J, Moufid A. DiscoGel
®
in patients with
discal lumbosciatica. Retrospective results in 25 consecutive
patients. Orthop Traumatol Surg Res 2015; 101: 623-6.
13. Volpentesta G, De Rose M, Bosco D, Stroscio C, Guzzi G,
Bombardieri C, et al. Lumbar percutaneous intradiscal
injection of radiopaque gelified ethanol (“Discogel”) in pa-
tients with low back and radicular pain. J Pain Relief 2014; 3:
145.
14. Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006; 15
(Suppl 1): S17-24.
15. Fairbank JC, Pynsent PB. The Oswestry disability index.
Spine (Phila Pa 1976) 2000; 25: 2940-52.
16. Zhao XL, Fu ZJ, Xu YG, Zhao XJ, Song WG, Zheng H. Treat-
ment of lumbar intervertebral disc herniation using C-arm
fluoroscopy guided target percutaneous laser disc decom-
pression. Photomed Laser Surg 2012; 30: 92-5.
17. Knezevic NN, Mandalia S, Raasch J, Knezevic I, Candido KD.
Treatment of chronic low back pain - new approaches on the
72
https://doi.org/10.3344/kjp.2020.33.1.66Korean J Pain 2020;33(1):66-72
Hashemi, et al
horizon. J Pain Res 2017; 10: 1111-23.
18. Epstein NE. Should anyone perform percutaneous endo-
scopic laser diskectomy and percutaneous lumbar disc de-
compressions? Surg Neurol Int 2016; 7(Suppl 42): S1080-4.
19. Ishiwata Y, Takada H, Gondo G, Osano S, Hashimoto T, Ya-
mamoto I. Magnetic resonance-guided percutaneous laser
disk decompression for lumbar disk herniation--relationship
between clinical results and location of needle t ip. Surg Neu-
rol 2007; 68: 159-63.
20. Haufe SM, Mork AR, Pyne M, Baker RA. Percutaneous laser
disc decompression for thoracic disc disease: report of 10
cases. Int J Med Sci 2010; 7: 155-9.
21. Lee DY, Lee SH. Carbon dioxide (CO2) laser-assisted micro-
discectomy for extraforaminal lumbar disc herniation at the
L5-S1 level. Photomed Laser Surg 2011; 29: 531-5.
22. Ren L, Guo B, Zhang T, Bai Q, Wang XH, Zhang L, et al. Medi-
um-term follow-up findings in imaging manifestation after
percutaneous laser disc decompression. Photomed Laser
Surg 2013; 31: 247-51.
23. Hashemi SM, Dadkhah P, Taheri M, Abootorabi SMHS. Ef-
fects of percutaneous laser disc decompression (PLDD) on
clinical outcome of teared vs intact protruded intervertebral
discs: a prospective cohort study. 2018; 2: 279-85.
24. Brouwer PA, Brand R, van den Ak ker-van Marle ME, Jacobs
WC, Schenk B, van den Berg-Huijsmans AA, et al. Percutane-
ous laser disc decompression versus conventional microd-
iscectomy in sciatica: a randomized controlled trial. Spine J
2015; 15: 857-65.
25. Asgharzadeh A, Khoshnood N. Evaluating the safet y and ef-
ficacy of discogel in the treatment of herniated lumbar disc:
a systematic review. Healt h Tech Asmnt Act 2017; 1: e62329.
26. Theron J, Cuellar H, Sola T, Guimaraens L, Casasco A, Cour-
theoux P. Percutaneous treatment of cervical disk hernias
using gelified ethanol. AJNR Am J Neuroradiol 2010; 31: 1454-6.
27. Theron J, Guimaraens L, Casasco A, Sola T, Cuellar H, Cour-
theoux P. Percutaneous treatment of lumbar intervertebral
disk hernias with radiopaque gelified ethanol: a preliminary
study. J Spinal Disord Tech 2007; 20: 526-32.
28. Bellini M, Romano DG, Leonini S, Grazzini I, Tabano C, Fer-
rara M, et al. Percutaneous injection of radiopaque gelified
ethanol for the treatment of lumbar and cervical interverte-
bral disk herniations: experience and clinical outcome in 80
patients. AJNR Am J Neuroradiol 2015; 36: 600-5.
29. Klessinger S. The frequency of resurgery after percutaneous
lumbar surgery using dekompressor in a ten-year period.
Minim Invasive Surg 2018; 2018: 5286760.
30. Zamora T, Palma J, Andia M, Garcia P, Wozniak A, Solar A,
et al. Effect of propionibacterium acnes (PA) injection on in-
tervertebral disc degeneration in a rat model: does it mimic
modic changes? Ort hop Traumatol Surg Res 2017; 103: 795-9.
31. Rao PJ, Phan K, Reddy R, Scherman DB, Taylor P, Mobbs RJ.
DISC (degenerate-disc infection study with contaminant
control): pilot study of Australian cohort of patients without
the contaminant control. Spine (Phila Pa 1976) 2016; 41: 935-
9.
32. Chen Z, Zheng Y, Yuan Y, Jiao Y, Xiao J, Zhou Z, et al. Modic
changes and disc degeneration caused by inoculation of pro-
pionibacterium acnes inside intervertebral discs of rabbits: a
pilot study. Biomed Res Int 2016; 2016: 9612437.
