Annular Tear

Unfortunately, not all of the published IDET studies have reported complication rates, perhaps because tran-

Annular Tear MriAnnular Tear Mri

Fig. 12. (A) Starting in the lateral projection, the IDET catheter is advanced through the introducer needle; as it reaches the anterior nuclear-annular interface it usually makes a turn (arrowhead). (B) The catheter is advanced further until it makes a turn posteriorly. The image intensifier (II) is then rotated into the frontal projection. (The arrow on distal radiopaque marker still in the introducer needle.) (C) In the frontal projection, the IDET catheter is advanced across the disc. Notice how the proximal marker is superimposed on the introducer needle. Care must be taken to ensure that the catheter is not touching the needle. (D) By slightly rotating the II either cranially or caudally one can see that the catheter and needle tip are not touching. (E) The final catheter position must be verified in the lateral projection to ensure that the catheter is not in the spinal canal. It also appears that the catheter and needle are touching. (Arrow, proximal marker; arrowhead, distal marker. The heating element lies between the markers.) (F) By slightly rotating the II the catheter tip and introducer needle are separated. Now it is safe to proceed with the heating protocol.

Fig. 12. (A) Starting in the lateral projection, the IDET catheter is advanced through the introducer needle; as it reaches the anterior nuclear-annular interface it usually makes a turn (arrowhead). (B) The catheter is advanced further until it makes a turn posteriorly. The image intensifier (II) is then rotated into the frontal projection. (The arrow on distal radiopaque marker still in the introducer needle.) (C) In the frontal projection, the IDET catheter is advanced across the disc. Notice how the proximal marker is superimposed on the introducer needle. Care must be taken to ensure that the catheter is not touching the needle. (D) By slightly rotating the II either cranially or caudally one can see that the catheter and needle tip are not touching. (E) The final catheter position must be verified in the lateral projection to ensure that the catheter is not in the spinal canal. It also appears that the catheter and needle are touching. (Arrow, proximal marker; arrowhead, distal marker. The heating element lies between the markers.) (F) By slightly rotating the II the catheter tip and introducer needle are separated. Now it is safe to proceed with the heating protocol.

Annular Tear Mri
Fig. 13. Diagram showing the correct needle position and catheter within the disc. (The arrowhead illustrates an annular tear. AF, Annulus fibrosis; NP, nucleus pulposus.) (Courtesy of Smith and Nephew, Menlo Park, CA.)

sient lower extremity pain is an accepted side effect for a short period of time following the procedure and is not a complication. Saal et al. reported no adverse events or complications in their study of 62 patients followed over 24 mo (29). McGraw et al. reported one minor complication of radicular pain that improved after 6 wk in their study of 30 patients with 41 treatment levels (30,31). In the prospective study reported by Saal et al., they reported no complications in 58 patients followed over a 2-yr duration following treatment with IDET (32). There has been one report of a major complication of cauda equina syndrome, which likely resulted from poor catheter positioning beyond the expected posterior location of the annulus as well as the application of persistent thermal energy despite the patient's complaints of severe lower extremity pain and pelvic pain (33). There has also been one case report of vertebral osteonecrosis following IDET (34). This developed in a 28-yr-old man treated for axial back pain radiating to the buttocks. L4-5 and L5-S1 were treated uneventfully with IDET. The patient returned 5 mo with worsening symptoms. An MRI showed edema in the L5 and S1 vertebral bodies with disc space collapse. Osteomyelitis was considered and the patient underwent a biopsy of L5 and the L5-S1 disc space. The biopsy revealed necrotic bone and disc material with cultures remaining negative (34).

Approximately 25,000 IDET procedures have been performed in the United States at this point, and there have been no reports of discitis. Obviously, given the similarity of this procedure to discography, discitis remains a potential complication. One plausible explanation for the absent discitis rate might be the coaxial nature of the catheter system, such that the catheter within the disc applying the heat to the posterior annulus does not contact the skin, which would be the primary source for infection.

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Back Pain Revealed

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