48 Medical Imaging and Radiotherapy Journal (MIRTJ) 41 (Suppl. 1) Medical Imaging and Radiotherapy Journal (MIRTJ) 41 (Suppl. 1) PERKUTANO MINIMALNO INVAZIVNO ZDRAVLJENJE HERNIJE DISKA PERCUTANEOUS MINIMALLY INVASIVE TREATMENT OF DISC HERNIATION Kristian Valec, Iva Mertük, Denis Števanec Splošna bolnišnica Murska Sobota, Oddelek za radiologijo, Ulica Dr. Vrbnjaka 6, 9000 Murska Sobota / General Hospital Murska Sobota, Department of Radiology, Dr. Vrbnjaka 6, 9000 Murska Sobota Korespondenca / Corresponding author: iva.mertuk@gmail.com Prejeto/Recived: 15. 1. 2024 Sprejeto/Accepted: 7. 5. 2024 IZVLEČEK Uvod in namen: Število odraslih obremenjenih z akutno in kronično bolečino v hrbtenici je v svetu vse pogostejše. Ocenjuje se, da ima približno 80 % odraslih v zahodnem svetu bolečine v hrbtenici. Eden najpogostejših vzrokov za bolečine v hrbtenici je hernija diska, ki sproži bolečino preko mehanske kompresije z imunološkimi in vnetnimi spremembami. Z leti se je pojavilo več različnih terapij za zdravljenje hernije diska, od konzervativnega zdravljenja, do minimalno invazivnega in perkutanega zdravljenja, vse do odprtih kirurških posegov. Konzervativno zdravljenje je glavni steber zdravljenja za večino bolnikov, obstaja pa vse večja zaskrbljenost glede uporabe opioidne terapije. Poleg tega vztrajna bolečina (več kot 6 mesecev) pogosto vodi v razmislek o minimalno invazivnih tehnikah ali odprti operaciji. Odprta operacija je lahko učinkovita 49–95%, vendar prinaša tveganje splošne anestezije, visokih stroškov in pooperativnih zapletov. Alternativa kirurški terapiji so številni minimalno invazivni postopki, uporaba katerih se je drastično povečala skozi leta. Namen teh postopkov je zmanjšanje pritiska na medvretenčno ploščico in razbremenitev hernije diska brez poškodbe hrbteničnega kanala. Pogosto ponavljajoč se minimalno invaziven postopek je uporaba preparata DiscoGel (radiopačen želatinast etanol). DiscoGel je sterilna viskozna raztopina, ki vsebuje: etilni alkohol, celulozno derivatni produkt in volfram (radioneprepustni element). 96-odstotni čisti etilni alkohol povzroči lokalno nekrozo jedra medvretenčne ploščice, deluje mehansko prek dehidracije diska ter ima dvojni mehanizem delovanja na znotraj vretenčni disk: - hidrofi lno moč (ki vodi migracijo vode z obrobja/periferije diska do dekompresije diska in zmanjšuje znotrajdiskalni pritisk), - sočasno odlaganje dela gela na mestu injiciranja. Glavni pomanjkljivosti etanola pa sta prekomerna difuznost in pomanjkanje radiološke preglednosti. Metode: Literatura, opis primera iz naše bolnišnice ter protokol slikanja, ki ga uporabljamo pri perkutanem minimalno invazivnem zdravljenju hernije diska. Rezultati in razprava: Zaradi bolečin v križu (lumbago) s pridruženim išiasom, bolečinami v ledveni hrbtenici in desni spodnji okončini, šepanja pri hoji in močnega drevenenja v desno nogo, je bil pacient napoten na MR preiskavo ledvene hrbtenice (junij 2022). Na podlagi MR izvida in diagnoze je bil pacient predlagan za perkutano minimalno invazivno zdravljenje (januar 2023). Pred začetkom posega inštrumentarka pripravi material ter pacienta namesti na preiskovalno mizo. Bolniki z bolečinami v ledvenem delu hrbtenice so nameščeni v bočni položaj. Noge so rahlo pokrčene. V tem položaju bolnik nato izboči hrbet (mačji hrbet). Inštrumentarka sterilno umije vbodno mesto in pacienta sterilno pokrije. Ker je poseg potekal v lokalni anesteziji, je na začetku posega zdravnik perkutano z leve strani pod kontrolo diaskopije v podkožje do nivoja levega fasetnega sklepa apliciral lokalni anestetik 1% Xylocain. Poseg je potekal brez zapletov. Po posegu je bilo odrejeno 2-urno mirovanje na oddelku. Pacient je bil nato odpuščen v domačo oskrbo. Dobil je pisna navodila za mirovanje in postopno obremenjevanje po posegu. V primeru poslabšanja naj bi kontaktiral operaterja, na kontrolni pregled pa je bil naročen čez 3 mesece. Vloga radiološkega inženirja pri perkutanem minimalno invazivnem zdravljenju je natančno spremljati zdravnika in področje kjer izvaja poseg. Z diaskopijo moramo cev RTG aparata postaviti v položaj, pri katerem je hrbtenica pozicionirana povsem stransko, kar uravnavamo s kotoma RAO IN LAO. Prav tako moramo poravnati terminalne plošče obeh vretenc (zgornjo in spodnjo terminalno ploščo obeh vretenc v področju posega) s kotoma kranialno in kavdalno. Ves čas preiskave spremljamo zdravnika z diaskopijo na področju posega ter po njegovih navodilih premikamo cev iz položaja AP v stranski položaj in nazaj (večkrat). S tem omogočimo zdravniku, da spremlja pot igle s katero zbada ter vbrizgava DiscoGel. Zaključek: S perkutanim minimalno invazivnim zdravljenjem zmanjšamo pritisk na disk in razbremenimo hernijo diska brez poškodb hrbteničnega kanala. Pogosto ponavljajoč se minimalno invaziven postopek je uporaba preparata DiscoGel. Obravnavali smo pacienta zaradi bolečin v križu (lumbago) s pridruženim išiasom, bolečinami v ledveni hrbtenici in desni spodnji okončini, šepanja pri hoji in močnega drevenenja v desno nogo. Opravili smo perkutano invazivno zdravljenje z aplikacijo DiscoGela. Ključne besede: diskus hernija, perkutano minimalno invazivno zdravljenje, DiscoGel Medical Imaging and Radiotherapy Journal (MIRTJ) 41 (Suppl. 1) 49 Medical Imaging and Radiotherapy Journal (MIRTJ) 41 (Suppl. 1) ABSTRACT Introduction and Purpose: The number of adults burdened by acute and chronic low back pain is increasing worldwide. It is estimated that approximately 80 % of adults in the Western world have back pain. One of the most common causes of back pain is a herniated disc, which triggers pain through mechanical compression with immunological and infl ammatory changes. Over the years, several diff erent therapies have emerged for the treatment of herniated discs, ranging from conservative treatment to minimally invasive and percutaneous treatment, to open surgery. Conservative treatment is the mainstay of treatment for most patients, but there is growing concern about the use of opioid therapy. In addition, persistent pain (more than 6 months) often leads to consideration of minimally invasive techniques or open surgery. Open surgery can be 49-95 % eff ective but carries the risk of general anaesthesia, high costs and post- operative complications. Alternatives to surgery include several minimally invasive procedures, the use of which has increased dramatically over the years. The aim of these procedures is to reduce the pressure on the intervertebral disc and relieve the disc herniation without damaging the spinal canal. A frequently repeated minimally invasive procedure is the use of DiscoGel (radio-opaque gelatinous ethanol). DiscoGel is a sterile viscous solution containing ethyl alcohol, a cellulose- derivative product and tungsten (a radio-opaque element). The 96 % pure ethyl alcohol causes local necrosis of the nucleus of the intervertebral disc, acts mechanically through disc dehydration, and has a dual mechanism of action on the intra-vertebral disc: - hydrophilic power (which guides the migration of water from the periphery of the disc to the decompression of the disc and reduces intradiscal pressure), - simultaneous deposition of part of the gel at the injection site. The main disadvantages of ethanol are excessive diff usivity and lack of radiological transparency. Methods: Literature, a case report from our hospital and the imaging protocol used for percutaneous minimally invasive treatment of herniated disc. Results and Discussion: Due to low back pain (lumbago) with associated sciatica, pain in the lumbar spine and right lower limb, claudication when walking, and severe right leg pain, the patient was referred for MRI of the lumbar spine (June 2022). Based on the MRI fi ndings and diagnosis, the patient was proposed for percutaneous minimally invasive treatment (January 2023). Before the procedure, the instrumentation nurse prepares the material and places the patient on the examining table. Patients with lumbar spine pain are placed in the lateral position. The legs are slightly fl exed. In this position, the patient then arches his back (cat-back). The instrumentation nurse washes the puncture site sterilely and covers the patient sterilely. As the procedure was performed under local anaesthesia, at the start of the procedure the doctor injected the local anaesthetic 1 % Xylocaine percutaneously from the left side under diascopy control into the subcutaneous tissue to the level of the left facet joint. The procedure was uneventful. After the procedure, a 2-hour ward stay was ordered. The patient was then discharged to home care. They were given written instructions for bed rest and gradual weight bearing after the procedure. In case of deterioration, they were to contact the operator, and were scheduled for a follow-up examination in 3 months. The role of the radiographer in percutaneous minimally invasive treatment is to closely monitor the doctor and the area where the procedure is being performed. The diascopy must be performed with the tube of the X-ray machine in a position where the spine is positioned fully lateral, which is controlled by the RAO AND LAO angles. The terminal plates of both vertebrae (the upper and lower terminal plates of both vertebrae in the area of the procedure) must also be aligned with the cranial and caudal angles. Throughout the examination, we accompany the physician with diascopy in the intervention area and move the tube from the AP position to the lateral position and back (several times) according to his instructions. This allows the physician to monitor the path of the needle used to prick and inject the DiscoGel. Conclusion: Percutaneous minimally invasive treatment reduces pressure on the disc and relieves disc herniation without damage to the spinal canal. A frequently repeated minimally invasive procedure is the use of DiscoGel. We treated a patient for low back pain (lumbago) with associated sciatica, pain in the lumbar spine and right lower limb, claudication when walking and severe right leg stubbing. Percutaneous invasive treatment with DiscoGel was performed. Keywords: disc herniation, percutaneous minimally invasive treatment, DiscoGel LITERATURA / REFERENCES Kuhelj D, Dobrovolec A, & Kocijancic IJ (2019). Effi cacy and durability of radiopaque gelifi ed ethanol in management of herniated discs. Radiology and Oncology, 53(2), 187–193. https://doi.org/10.2478/raon-2019-0026 Marcia S, Bellini M, Hirsch JA, Chandra RV, Piras E, Marras M, Sanna AM & Saba L (2018). Effi cacy of an ethyl alcohol gel in symptomatic disc herniation. European Journal of Radiology, 109, 101–107. https://doi.org/10.1016/j.ejrad.2018.10.029