Scientific basis for nucleoplasty

Effective treatment of low back pain has been a challenge for physicians and patients alike. After the description of herniations by Mixter and Barr, attempts were made to account for back pain in the absence of a frank herniation. Painful discs with a normal external morphology and not causing nerve root compression were first described by Dandy as a “concealed ruptured intervertebral disc.” Crock later introduced the term “internal disc disruption” for a damaged intervertebral disc which included annular tears, nuclear displacement and contained herniations. The inflammatory response to an internally disrupted intervertebral disc can be acute or progress to chronic inflammation with pain and permanent damage. Pain from activation of this inflammatory process may be severe enough for patients to consider surgical intervention. Open surgery, however, may not be applicable for pain from contained herniations nor does it always yield a successful result. Many patients are not good candidates for surgery or choose not to undergo spinal operations for pain. In the past, few options existed for these patients. Disc decompression by partial removal of the nucleus was shown to decrease pressure in the disc and relieve pain. Nucleoplasty is a newer minimally invasive procedure used to treat lumbar discogenic pain by percutaneous disc decompression. The scientific rationale, patient treatment evidence and indications for nucleoplasty are presented, along with a discussion of antibiotic prophylaxis in minimally invasive procedures.