Sciatica due to a lumbar disc herniation and nerve root irritation is a huge public health problem not yet benefiting from an unequivocal treatment approach. Even cervical hernias with brachialgia afflict a substantial range of the population.
Medical and physical therapies represent the first therapeutic steps. When these fail, minimally invasive treatments may play an important role; percutaneous techniques can be applied as intermediate measures between conservative treatment and surgery, avoiding the adverse events of surgical discectomy.
In the last 2 decades, we have witnessed a consistent development of percutaneous materials and techniques for the treatment of symptomatic herniations. Chemonucleolysis is a minimally invasive percutaneous technique allowing the intradiscal injection of materials that dehydrate or “digest” discal portions. Evidence regarding the safety and efficacy of various materials, such as oxygen-ozone and radiopaque gelified ethanol (RGE), has increased. Notably, RGE is a viscous solution containing ethyl alcohol and cellulose derivative products associated with the contrast agent tungsten, recently introduced into clinical practice. Theron et al,1,2 Stagni et al,3 and Volpentesta et al4 reported encouraging outcomes of using RGE in disc herniations. Thus, we decided to apply percutaneous RGE discal injection in patients with radicular pain caused by both lumbar and cervical disc herniations.
Our diagnostic neuroradiologic team in Siena, Tuscany, Italy, led by our colleague Dr. Alfonso Cerase, has immense expertise and experience in neuroradiology of the spine. In daily clinical practice, we interpret many spinal CTs and MRIs of patients accessing the emergency department because of radiculopathy and, unfortunately, failed back surgery syndrome. I have always thought that there should be alternative and more conservative methods for the treatment of symptomatic hernias other than those that temporarily relieve pain. Thus, my work was inspired by the goal to give a valid alternative for the treatment of disc herniation and reduce leg or brachial pain as soon as possible. This was then possible after observing the preliminary, amazing results obtained by my mentors and instructors Dr. Stefano Marcia (Cagliari, Sardinia, Italy) and Dr. Mario Muto (Napoli, Campania, Italy). Thus, we decided to use RGE which, different from other similar products, can dehydrate only the herniated part of the disc while preserving the disc space.
In our study published in AJNR in 2015, a reduction of at least 4 points on the Visual Analog Scale (VAS) and at least 40% on the Oswestry Disability Index (ODI) score (P < 0.001) occurred in the first 3 months after treatment in 85% of patients, who were then able to resume their normal activity without intraperiprocedural complications. In our experience, percutaneous RGE for cervical and lumbar disc herniations was safe and had good clinical outcomes. We received quite a lot of positive feedback about this paper and subsequent studies on this topic that we have presented at a variety of international meetings.
These results have changed our practice. Currently, neurologists, neurosurgeons, and orthopedic surgeons refer to our unit patients with back pain and recurrent drug-resistant symptoms, with no benefit of rest and medical therapy and minimal pain reduction after 4 to 6 weeks of physical therapy.