Sharman, great post.
IDET: I think that the great acceptance it received years ago is pretty much gone. It is good in theory and there are some happy patients running around out there - as well as some unhappy ones too. I've been in the OR for IDET procedures. The thing that bothers me about it is that it's blind. The surgeon can see where the wire is with flouroscopy, but has no way of knowing what is happening as the energy is being applied. I like the idea of thermal annuloplasty for some cases of discogenic pain with good remaining disc height, but IDET would not be my first choice.
SED: I've attended the surgeons' training for Dr. Yeung's SED with thermal annuloplasty and have seen many SED surgeries. I really like the targeted approach. He can see the tissues that he's removing. I love the way he stains the nucleus with indigocarmine and can identify degenerated tissue from healthy tissue. When he's applying energy with the laser or RF probes for the thermal annuloplasty part of the procedure, he's looking at the tissue he's working on. He can see how it responds. If the annular tear is shrinking as he's heating the annulus, he keeps going. If it's going in the wrong direction he stops. I know many SED patients including many failures. Remember that these types of minimally invasive procedures are done in the hopes of salvaging a degenerated disc and avoiding more invasive surgeries. I would have been a perfect candidate for SED before my ADR procedures and I wonder if I'd have metal in my back now if I knew about Dr. Yeung years ago.
Nucleus Replacements: I've seen many different nucleus replacement technologies brought to the market in the last few years. I've been in the OR for some implantations. It is all interesting technology... especially the new flowable procedures where they inject a flowable polymer that fills the disc space and provides cushioning in addition to maintaining the disc space. It will be interesting to see how this all plays out. So far, nucleus replacements don't seem to have lived up to the hype about them, but as the problems are solved and the technology improves, I think they'll get it right.
Many of the less invasive procedures do depend on being applied before the DDD is too great. However, when they can perfect annulus repair, in conjunction with nucleus replacement or regeneration, that will eliminate or reduce the need for total disc replacements. I've seen several different versions of annulus repair and they look promising. It's still early, but again... they'll get it right eventually.
Endplate Abrasion. I posted about this last month (
here). I got to spend some time in the OR with Dr. Hoogland and question him about this procedure. It makes sense that improving the flow of water and nutrition between the vertebral body and the disc will help slow the degeneration of the disc, or potentially even rehydrate the disc. I believe that there is evidence to show that it can happen. However, I'd like to learn what percentage of the cases it will happen in. Is it most of the time, some of the time, rarely? I believe that Dr. Hoogland is a world-leading endoscopic surgeon and if I need endoscopic spine surgery, he's one of the very few people in the world that I'd consider.
With most of the minimally invasive procedures, I believe that if what you need is a discectomy, then going to someone who does a superior MISS discectomy, you stand an excellent chance of success. As always, the diagnosis is key... determining what you need and then going with the least invasive procedure that stands a good chance of resolving your problems is the best way to go. This is said knowing that a substantial number of people will still graduate to more invasive procedures... that doesn't mean the less invasive procedure was the wrong decision, even though in their case they will wish that they skipped that procedure and got out the big guns. But without the motivation to try less invasive procedures, there would be no success for them, and many more problems associated with more invasive procedures.
I have little experience with prolo, intradiscal prolo, many other types of intradiscal injections, etc.... except for the failed patients I've seen who have graduated on to ADR surgery. I've scrubbed in on lumbar disc replacements with patients with a many different types of past treatments. For the most part, these treatments seem to have seriously disrupted the disc nucleus tissue. As I mentioned above, it has a different consistency, texture, color, density... Note that people with successful treatments are not seeking me out and are not having further spine surgery. The population of people I deal with is a self-selecting negative population who have failed prior treatments. I cannot draw conclusions about the efficacy of treatments that I see in the failed patients.
I started seeing Bertagnoli's presentations on autologous chondrocyte implantation several years ago. It looks very promising, but in this treatment, it requires an intact annulus. When the disc herniation is removed, they go into the disc and harvest more healthy nucleus tissue. That is sent to the lab where they culture more of 'your own tissue'. 3 months later, they pressure test your disc and it must hold 200 psi for 15 minutes. (I'm typing this from memory... I may have the numbers wrong. 200 psi sounds high to me as I never see pressures that high in discography.) If your disc will hold pressure, they inject 20 times the number of cells that they harvested. I've seen films of post-op patients who's formerly black discs are white at 2 years out. Is this the norm? I don't know. Is there a huge buzz about this at the conferences? No. I'm headed back to Straubing in a week... I'll talk to Bertagnoli and see if there is a relevant update.
Mark