Re-evaluation of percutaneous volume reduction of the intervertebral disk for inclusion into health benefit catalogue in Austria

Different minimally invasive surgical procedures are used to reduce the intervertebral disk volume in the treatment of back pain and provide a treatment alternative to surgery:

• Intradiscal electrothermal therapy (IDET) involves the percutaneous threading of a catheter composed of thermal resistive coil into the disk. Thereby, the posterior annulus of the disk is heated, causing contraction of collagen fibers and destruction of afferent nociceptors;
• For chemonucleolysis, a medium is injected into the vertebral disc with the goal to dissolve the nucleus pulposus. In 2009, an enzyme called chymopapain was common as a medium; today, ozone-oxygen mixture is used instead;
• Percutaneous nucleotomy involves puncturing the intervertebral disc and inserting a canula through which the nucleus and anulus tissue is cut and removed, using either alligator forceps or cutter blades;
• Percutaneous laser disk decompression, by contrast, uses electromagnetic laser energy in order to decrease the intra-discal pressure.

This report is the first update of two systematic reviews compiled by Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) in 2009:

• The first report had evaluated literature on Chemonucleolysis and intradiscal electrothermal therapy (IDET). Chemonucleolysis was recommended for inclusion into health benefit catalogue with restrictions due to missing placebo controlled trials. For IDET, no benefit was shown by the evidence available at that time and it was therefore not recommended for inclusion.
• The second report from 2009 that the re-evaluation is based on assessed percutaneous nucleotomy and percutaneous laser disc decompression. The conclusion in 2009 was that both procedures are not more effective than standard interventions, such as open discectomy, microdiscectomy or chemonucleolysis.

A significant amount of literature has been published since 2009. LBI-HTA identified following systematic reviews (SRs) and randomized controlled trials (RCTs) as relevant for the four procedures evaluated in this review:

• Chemonucleolysis: 2 SRs, 4 RCTs
• Percutaneous nucleotomy: 2 SRs
• Percutaneous laser disc decompression: 1 SR, 1 RCT
• Intradiscal electrothermal therapy: 3 SRs

For percutaneous nucleotomy, percutaneouslaser disc decompression and intradiscal electrothermal therapy an overview of reviews was done for the current update, including SRs and meta-analyses relevant on these topics. Concerning chemonucleolysis, the main topic of this update-report, systematic reviews and meta-analyses as well as most recent RCTs and controlled studies were included.

Based on this evidence, chemonucleolysis is equally safe and tends to be more effective compared to comparative interventions. However, since placebo-controlled trials to provide high-grade evidence are still missing, LBI-HTA repeatedly only recommends chemonucleolysis with restrictions for inclusion into health benefit catalogue.

Evidence about the other three percutaneous procedures published since 2009 was still not sufficient to prove the efficiency and safety of these methods. They are therefore not recommended for inclusion into health benefit catalogue in Austria.

See English abstract and the full report in German here.

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