Viadisc/Disc Injections

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masterPain

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I saw a patient last week who had the viadisc a little over a month previous with severe pain which began immediately after the procedure.

Given our limitations for discogenic pain I was hopeful this might be an option in the future. We have a handful of physicians performing regular disc injections therapeutically and diagnostically for intracept. I think repeatedly sticking 22g needles into the disc space is a horrible idea for the patient long term. Anyone have any thoughts?
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masterPain said:
I saw a patient last week who had the viadisc a little over a month previous with severe pain which began immediately after the procedure.

Given our limitations for discogenic pain I was hopeful this might be an option in the future. We have a handful of physicians performing regular disc injections therapeutically and diagnostically for intracept. I think repeatedly sticking 22g needles into the disc space is a horrible idea for the patient long term. Anyone have any thoughts?
Click to expand...

Idiotic for intracept.

Unproven for anything else. Hopefully this changes because these are the worst patients to see - young, healthy people who aren’t on narcotics who have a real problem with nothing to do for it.
 
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masterPain said:
I saw a patient last week who had the viadisc a little over a month previous with severe pain which began immediately after the procedure.

Given our limitations for discogenic pain I was hopeful this might be an option in the future. We have a handful of physicians performing regular disc injections therapeutically and diagnostically for intracept. I think repeatedly sticking 22g needles into the disc space is a horrible idea for the patient long term. Anyone have any thoughts?
Click to expand...

Agree with you. We have a new surgeon who has been requesting discograms this year and I’ve refused all of them.

Was never a great idea in the past, but now that intracept is here, there is no good reason to ever put a needle into a disc again.

Intracept doesn’t require a diagnostic intradiscal injection. If radicular pain, then epidural. If axial only pain, I could understand ruling out the facet joints with MBB. For likely intracept patients, I frequently do diagnostic MBB because it helps auth after the MBB fail.

But if no radicular pain, they fail MBB, and don’t have SIJ symptoms, then it’s the disc 98% of the time. No reason to risk discitis or further disc damage.
 
There was a prospective study in the spine journal years back showing huge increase incidents in spinal fusions after provocative discography. Can someone find it?

The Spine Journal 16 (2016) 273-280
 
bedrock said:
Agree with you. We have a new surgeon who has been requesting discograms this year and I’ve refused all of them.

Was never a great idea in the past, but now that intracept is here, there is no good reason to ever put a needle into a disc again.

Intracept doesn’t require a diagnostic intradiscal injection. If radicular pain, then epidural. If axial only pain, I could understand ruling out the facet joints with MBB. For likely intracept patients, I frequently do diagnostic MBB because it helps auth after the MBB fail.

But if no radicular pain, they fail MBB, and don’t have SIJ symptoms, then it’s the disc 98% of the time. No reason to risk discitis or further disc damage.
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The thing is, intracept doesn’t treat discogenic pain nor is it FDA approved for such. It’s for endplate inflammation/Modic changes. Some papers have indicated there’s some overlap in innervation of disc and endplates but as it stands now:

Vertebral endplates —> BVN
Discs —> sinovertebral nerves from DRG of exiting spinal nerve

I’ve had a handful of patients fail intracept for isolated discogenic pain as a Hail Mary which only solidifies my option of the innervation of the two entities.
 
masterPain said:
The thing is, intracept doesn’t treat discogenic pain nor is it FDA approved for such. It’s for endplate inflammation/Modic changes. Some papers have indicated there’s some overlap in innervation of disc and endplates but as it stands now:

Vertebral endplates —> BVN
Discs —> sinovertebral nerves from DRG of exiting spinal nerve

I’ve had a handful of patients fail intracept for isolated discogenic pain as a Hail Mary which only solidifies my option of the innervation of the two entities.
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this. i see too many people confused between the two.
discogenic pain/degeneration can and often move to the vertebrogenic pain
 
seems like every few years we revisit disc injections. someone shows a marginal study of a new technique or a new device or a new substance to stick in the disk. but more data then comes out rejecting the premise that there is benefit...

the data doesnt change. disc injections, discograms, IDET, steroid, antibiotic, ozone, biologic etc havent shown any benefit and shouldnt be considered.
 
It’s an avascular structure with little to no ability to repair itself. Needle puncture further weakens the annulus and accelerates degenerative disc disease.

Does anyone have promising results from Viadisc?

Spine surgeons often discuss the detrimental effect of disc puncture on ACDFs.

I will perform discograms at the request of surgeons for surgery staging, that’s it.

If someone can track down the study from above it will be eye opening for the board.
 
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bedrock said:
Agree with you. We have a new surgeon who has been requesting discograms this year and I’ve refused all of them.

Was never a great idea in the past, but now that intracept is here, there is no good reason to ever put a needle into a disc again.

Intracept doesn’t require a diagnostic intradiscal injection. If radicular pain, then epidural. If axial only pain, I could understand ruling out the facet joints with MBB. For likely intracept patients, I frequently do diagnostic MBB because it helps auth after the MBB fail.

But if no radicular pain, they fail MBB, and don’t have SIJ symptoms, then it’s the disc 98% of the time. No reason to risk discitis or further disc damage.
Click to expand...
How do you treat the discogenic pain not from disc bulging or pain from degenerated flattened discs? Refer to surgery for fusion? DRG?
 
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Status Sciaticus said:
How do you treat the discogenic pain not from disc bulging or pain from degenerated flattened discs? Refer to surgery for fusion? DRG?
Click to expand...

Degenerative discs completely change the biomechanics of the spine. It goes form around 80/20% ventral to posterior distribution to 60/40. Meaning, all the load is distributed posteriorly to the facets. (Ie facet hypertrophy)

IMO MBBs should be the first go to. If this fails then we are stuck with ISPs to try and fuse the segment (ie minuteman). I do not follow this treatment algorithm but it’s the only tool we have to treat discogenic pain.

Otherwise NSGY —> fusion (horrible option)
 
masterPain said:
we are stuck with ISPs to try and fuse the segment (ie minuteman). I do not follow this treatment algorithm but it’s the only tool we have to treat discogenic pain.
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I don't think there's any evidence for ISP for discogenic pain. If anything, you're going to make it worse by causing segmental kyphosis and increasing anterior loading. I don't like poking the disc but I'd inject a number of things before doing this.
 
RoloTomassi said:
I don't think there's any evidence for ISP for discogenic pain. If anything, you're going to make it worse by causing segmental kyphosis and increasing anterior loading. I don't like poking the disc but I'd inject a number of things before doing this.
Click to expand...

masterPain said:
Degenerative discs completely change the biomechanics of the spine. It goes form around 80/20% ventral to posterior distribution to 60/40. Meaning, all the load is distributed posteriorly to the facets. (Ie facet hypertrophy)

IMO MBBs should be the first go to. If this fails then we are stuck with ISPs to try and fuse the segment (ie minuteman). I do not follow this treatment algorithm but it’s the only tool we have to treat discogenic pain.

Otherwise NSGY —> fusion (horrible option)
Click to expand...


ISP for discogenic pain is a bad idea. Not really much better than a surgical fusion.
 
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Taus said:
Too bad they never did papaya allergy testing with chymopapain…
Click to expand...

Can someone who was around at the time these were done explain to me…

Did Patients have anaphylaxis immediately postop? Was it and anaphylaxis that was resistant to standard treatments?

Did they have delayed anaphylaxis or allergic reactions that resulted in progressive disc degeneration an accelerated rate?

Was the procedure considered to be successful in those who did not develop allergic reactions?

Was there ever consideration of using immunosuppressants (if the answer to number three was yes)

This is a chapter in interventional spinal pain management that I feel I don’t know nearly enough about



All links broken and deleted. Tapatalk error with IOS.
 
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masterPain said:
It’s an avascular structure with little to no ability to repair itself. Needle puncture further weakens the annulus and accelerates degenerative disc disease.

Does anyone have promising results from Viadisc?

Spine surgeons often discuss the detrimental effect of disc puncture on ACDFs.

I will perform discograms at the request of surgeons for surgery staging, that’s it.

If someone can track down the study from above it will be eye opening for the board.
Click to expand...
you know, if you highlight the study then right click, a tab will show "Search the web for... "

click that and you get a link to this article:

pubmed.ncbi.nlm.nih.gov

Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study - PubMed

The disc puncture and pressurized injection performed during provocative discography can increase the risk of clinical disc problems in exposed patients.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

masterPain said:
Degenerative discs completely change the biomechanics of the spine. It goes form around 80/20% ventral to posterior distribution to 60/40. Meaning, all the load is distributed posteriorly to the facets. (Ie facet hypertrophy)

IMO MBBs should be the first go to. If this fails then we are stuck with ISPs to try and fuse the segment (ie minuteman). I do not follow this treatment algorithm but it’s the only tool we have to treat discogenic pain.

Otherwise NSGY —> fusion (horrible option)
Click to expand...
other than the outside chance that MBB will help, this is not a disease we should be treating with injections.

unfortunately, that paradigm seems not to be in the wheelhouse of spine physicians.
 
bedrock said:
ISP for discogenic pain is a bad idea. Not really much better than a surgical fusion.
Click to expand...
I’d say ISP is way better in the long run vs traditional fusion. Worst case scenario take it out ISP, not a ton of anatomical damage.

I am not advocating for ISPs for discogenic pain I’m just saying it’s the only questionable option we have. I’ve done 3 minuteman’s in my career and none of them for discogenic pain. All unable to have traditional spine surgery due to age or health status. And to be honest I’m not a huge fan of it.

If I were a patient I’d elect for ISP >>>>>> lumbar fusion all day everyday twice on Sunday.

Not sure about Viadisc vs ISP
 
masterPain said:
I’d say ISP is way better in the long run vs traditional fusion. Worst case scenario take it out ISP, not a ton of anatomical damage.

I am not advocating for ISPs for discogenic pain I’m just saying it’s the only questionable option we have. I’ve done 3 minuteman’s in my career and none of them for discogenic pain. All unable to have traditional spine surgery due to age or health status. And to be honest I’m not a huge fan of it.

If I were a patient I’d elect for ISP >>>>>> lumbar fusion all day everyday twice on Sunday.

Not sure about Viadisc vs ISP
Click to expand...
I’m missing something here…. if traditional fusion doesn’t work well for axial discogenic lbp….then why would isp work for same diagnosis?
 
Taus said:
I’m missing something here…. if traditional fusion doesn’t work well for axial discogenic lbp….then why would isp work for same diagnosis?
Click to expand...
Who said it does not work well for discogenic pain? I think fusions work to treat discogenic pain but the surgery itself causes pain in addition to long term sequelae like adjacent segment disease.

You guys are taking what I said out of context. I was not advocating for ISPs for discogenic pain. I was saying the only procedure available to us for possible treatment are ISPs. The only surgical treatment for surgeons is lumbar fusion or arthroplasty. (Disc replacement)
 
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masterPain said:
Who said it do not work well for discogenic pain? I think fusions work to treat doscogenic pain but the surgery itself causes pain in addition to long term sequelae like adjacent segment disease.

You guys are taking what I said out of context. I was not advocate for ISPs for discogenic pain. I was saying the only procedure available to us for possible treatment are ISPs. The only surgical treatment for surgeons is lumbar fusion or arthroplasty. (Disc replacement)
Click to expand...

Sometimes the most appropriate medical recommendation is NOT a procedure
 
Taus said:
I am very confused by this statement. I would say the literature and most ethical spine surgeons would disagree.
Click to expand...

I would say most spine surgeons agree fusing the segment with the painful disc works but causes a cascade of future problems. Fusions for disc pain is also a more old school approach imo
 
masterPain said:
I would say most spine surgeons agree fusing the segment with the painful disc works but causes a cascade of future problems. Fusions for disc pain is also a more old school approach imo
Click to expand...
I guess we will have to agree to disagree on that.
 
Viadisk has worked well in my patients. Use mostly in those who don’t want/cant have surgery, have had rfa etc. it’s not a miracle cure but is a good tool to have with those with severely degenerative discs.

Disc pain is hard to diagnose, and frankly the procedure shouldn’t be super high up on the treatment algorithm, but I’m happy with the results
 
masterPain said:
I would say most spine surgeons agree fusing the segment with the painful disc works but causes a cascade of future problems. Fusions for disc pain is also a more old school approach imo
Click to expand...

The literature states that it works 50-70% in the setting of a positive discogram. 30-50% fail rate after a huge anterior/posterior surgery with known potential long-term complications is quite bad. Any surgeon saying it consistently works well is not being honest.

I believe Steve once said the only thing you can do for these people if you treat them is give them a diagnosis of Failed Back. Unfortunately, he is probably correct.
 
MD87 said:
The literature states that it works 50-70% in the setting of a positive discogram. 30-50% fail rate after a huge anterior/posterior surgery with known potential long-term complications is quite bad. Any surgeon saying it consistently works well is not being honest.

I believe Steve once said the only thing you can do for these people if you treat them is give them a diagnosis of Failed Back. Unfortunately, he is probably correct.
Click to expand...

I said we are severely lacking in discogenic pain treatment and only real options are fusions. Fusions are horrible due to long term sequelae of the treatment itself.

I am not advocating for fusions. Do they work? Yes. Do they cause a whole host of new issues? YES!

Let’s review:

Do fusions treat the discogenic pain? Yes (up to 70% according to you)

Are fusions good option for discogenic pain? NOOOOOOOO

For the record I am NOT advocation for fusions of any variety for discogenic pain.

Hence, why they’ve fallen out of favor by spine surgeons

I’m highly suspicious of Viadisc at this point. Would also like to see non biased/industry based study
 
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Taus said:
I guess we will have to agree to disagree on that.
Click to expand...
I actually brought this subject up to a prominent local neurosurgeon last week. He hypothesized if you completely remove the painful disc/and or fused segment how could it not treat discogenic pain? (if it’s indeed single level appropriately diagnosed discogenic pain). Clearly you might not need to do full disc replacement/ALIF but a standard fusion would stop movement at that level.

But the pain from surgery/hardware could be a new source of chronic pain so what are you actually accomplishing? Especially when you are predisposing patient to risk of future surgeries.
 
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A local pain doc wanted to charge one of my patients 15k for discseel procedure
 
Dr. Ice said:
A local pain doc wanted to charge one of my patients 15k for discseel procedure
Click to expand...
Lol same. Prob same guy w my patients. I told the patient nobody else does the procedure after the larger trials came out it showed it doesn’t work better than placebo.

I had a another patient get an EMG by the same guy, looks like he contracts with another local group for emg, Stone cold normal study, and normal lumbar mri but the conclusion said consistent with chemical radiculitis from a occult annular fissure.
 
Taus said:
Lol same. Prob same guy w my patients. I told the patient nobody else does the procedure after the larger trials came out it showed it doesn’t work better than placebo.

I had a another patient get an EMG by the same guy, looks like he contracts with another local group for emg, Stone cold normal study, and normal lumbar mri but the conclusion said consistent with chemical radiculitis from a occult annular fissure.
Click to expand...

Wow. I’d hate to be that guy if a lawyer questioned on the stand about his scientific justification for that diagnosis.
 
oh its fine to start with these "studies" that arent.

1. it is premature to initiate treatment in actual patients based on these preliminary "studies".

2. there are ways around other than relying on the company. that does include involving Medicare or at an academic center that pays for the devices, instead of getting them from the company.

3. at the very least, when it comes to studies with controls, one should not allow the company to influence study design or do the actual data collection and calculations.
 
You mean nobody is doing white rami communicans ablations at L2 for discogenic pain anymore … get with the times people . 😆
 
Taus said:
Lol same. Prob same guy w my patients. I told the patient nobody else does the procedure after the larger trials came out it showed it doesn’t work better than placebo.

I had a another patient get an EMG by the same guy, looks like he contracts with another local group for emg, Stone cold normal study, and normal lumbar mri but the conclusion said consistent with chemical radiculitis from a occult annular fissure.
Click to expand...
I wouldn't even know what to say to a patient when they pay 15k for a procedure that doesn't even work.
 
I had a patient who had discseel recently. "I think it helped". Didn't sound too convincing.
 
lobelsteve said:
It is gray rami. And yes.
Click to expand...

Gray, white, potato, pitato… you smell me .

"Discogenic pain" refers to pain originating from a damaged intervertebral disc, and "white rami" are the nerve fibers that carry sympathetic signals from the spinal cord to the sympathetic chain ganglia, and research indicates that these white rami, specifically at the L1 and L2 levels, play a key role in transmitting pain signals from a degenerated disc, contributing to the sensation of discogenic pain in the lower back.
 
SpineandWine said:
I agree with @masterPain
No need to violate disc

What were results with IDET when people were doing that back in the day?
Click to expand...
I recall interviewing for a job, and the guy was talking about IDET. He said, “They are great. If you get one approved with work comp, they pay so well you can shut down clinic for the rest of the day.” Didn’t want to get into the weeds about efficacy in other domains.

“Pain was the dream of the ‘90s.”-Dr. Usso
 
cowboydoc said:
I recall interviewing for a job, and the guy was talking about IDET. He said, “They are great. If you get one approved with work comp, they pay so well you can shut down clinic for the rest of the day.” Didn’t want to get into the weeds about efficacy in other domains.

“Pain was the dream of the ‘90s.”-Dr. Usso
Click to expand...
 
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