Worldwide experience with sequential phase-shift sound cancellation treatment of predominant tone tinnitus.

OBJECTIVE: To report clinical data from six centres in the US, Western Europe and Asia which have used phase-shift sound wave cancellation for treatment of predominant tone tinnitus, from the first treatment in 2000 to 2009. METHOD: Clinical data were obtained from New York City, London, Erie (Pennsylvania, USA), Antwerp, Grottamare (Italy) and Kuala Lumpur, and summarised. RESULTS: A total of 493 patients were treated. A reduction in tinnitus volume (defined as > or =6 dB) was seen in 49-72 per cent of patients.

Response of extruded intervertebral herniated discs to percutaneous laser disc decompression.

OBJECTIVE: To describe the clinical features of 21 patients with extruded (but nonsequestered) herniated intervertebral discs before and after treatment with percutaneous laser disc decompression (PLDD). BACKGROUND DATA: PLDD was introduced in February, 1986, by Choy and Ascher. This relatively noninvasive technique for the treatment of herniated intervertebral discs has been extensively described elsewhere. Previously, only uncomplicated disc herniations were treated with PLDD, with a success rate according to the MacNab criteria of 89% and a complication rate of 0.4 to 1.0%. Until 1998, the author and others adhered to strict criteria of patient selection to produce "clean" data that could be analyzed without complications. However, after 12 years of accumulating clinical data, it became feasible and desirable to "expand the envelope" and attempt treatment of more complicated cases. METHODS: Twenty-one patients with magnetic resonance imaging (MRI)-documented extruded, but nonsequestered, herniated discs with appropriate pain syndromes were treated with PLDD. RESULTS: Eighteen of the 21 patients treated achieved the top category of the MacNab criteria, with good pain relief, and in some instances, reversal of neurologic deficits. CONCLUSIONS: Patients with extruded but nonsequestered disc herniations may now be included in the group selected for PLDD.

Familial incidence of intervertebral disc herniation: an hypothesis suggesting that laminectomy and discectomy may be counterproductive.

OBJECTIVE: To determine (1) if familial and genetic factors play a role in the genesis of disc herniation, (2) the incidence of multiple disc herniations, (3) the incidence of disc reherniation in patients treated with standard laminectomy and discectomy, and (4) to construct a hypothesis that best explains all three. SUMMARY BACKGROUND DATA: It is known that there is a substantial incidence of disc herniation in first order relatives of patients with herniated nucleus pulposa (HNP), that multiple disc herniations are not uncommon, and that disc reherniations and repeat operations after laminectomy and discectomy range from 5 to 37%. Also, there is a recent report of a genetic defect leading to defective cross-linkage of collagen strands in patients with HNP. METHODS: Using the questionnaire method, a group of the author's patients with documented HNP treated with percutaneous laser disc decompression (PLDD) was surveyed as to the existence of known disc herniations among first order relatives. Analysis of the author's series of 621 patients with HNP disclosed the incidence of multiple disc herniations. A comprehensive literature search provided data on reherniations and reoperations following laminectomy and discectomy. RESULTS: In 174 respondents, the number with first order relatives who had HNP was 74 (or 43%). This compares with the national incidence of HNP of 1.7%. The statistical significance yields a P = 0.0001. In the 621 patients with known HNP, the number who had more than one herniated disc was 236 (or 38%). In multiple reports in the literature, the incidence of reherniation after laminectomy and discectomy ranged from 5 to 37%. CONCLUSIONS: The simplest hypothesis explaining all of the above is that intervertebral disc herniation is due to an acute or subacute increase of intradiscal pressure acting against a congenitally weak anulus fibrosus and posterior longitudinal ligament, and therefore laminectomy and discectomy, by further weakening these structures, may be counterproductive.

Early relief of erectile dysfunction after laser decompression of herniated lumbar disc.

OBJECTIVE: The use of percutaneous laser disc decompression (PLDD) for the treatment of erectile dysfunction caused by herniated disc disease is described. SUMMARY BACKGROUND DATA: Disc herniation is often overlooked as a cause of erectile dysfunction, with few cases reported in the literature. METHODS: Two patients with erectile dysfunction were treated with PLDD as outpatients. RESULTS: In addition to the early return of erectile function in both cases, immediate pain relief was achieved in the second case. Follow-up visits confirmed continued normal sexual function and lack of pain. CONCLUSIONS: The literature now includes 23 cases well-documented cases of erectile dysfunction caused by spinal cord disc herniation. PLDD is a minimally invasive procedure that that can be used to treat herniation of intervertebral discs, which has been found to cause erectile dysfunction.

Percutaneous laser disc decompression in spinal stenosis.

OBJECTIVE: The authors determined whether percutaneous laser disc decompression (PLDD) is an effective treatment for spinal stenosis where bulging or protruding discs are a contributing factor. SUMMARY BACKGROUND DATA: Spinal stenosis is associated primarily with the middle-aged and elderly patients, its chief symptom being low back and/or radicular pain worsened by walking. The condition is particularly resistant to conservative measures and to open surgery. PLDD is a minimally invasive treatment for intervertebral disc protrusions with low morbidity and a high success rate. METHODS: This unblinded study was undertaken to determine whether PLDD would alleviate the pain of spinal stenosis in patients who also had protruding lumbar discs. Thirty-five patients of both sexes and all ages with MRI-documented lumbar spinal stenosis associated with bulging or protruding discs were treated with PLDD on an outpatient basis. Pain relief was the only parameter followed. Patients were asked to rate their pain immediately after treatment, one day later, four weeks later, and at a follow-up ranging from five to forty-nine months later. Pain was quantified on a scale of 0-10, with 0 being a total absence of pain and 10 being severe pain. A score of 0-2 was considered excellent, 3-5 good, and 6-10 poor. RESULTS: Excellent results were seen in 69% of cases, good in 9%, and poor in 22%. Pain relief immediately after treatment always continued through the four weeks and five to forty-nine-month follow-ups. CONCLUSIONS: It was our conclusion that PLDD compares favorably with open surgery in the treatment of lumbar spinal stenosis that is partially or completely due to bulging or protruding discs.

Effect of tragus clips on gastric peristalsis: a pilot study.

In the past 22 years we have used the "hunger point" on the tragus of the ear to induce aversion to cigarette smoking and inhibit appetite for weight reduction with varying degrees of success. This has generally been accomplished by inserting press needles into the tragus of both ears. Because these needles gradually lose effect over a 5- to 7-day period, they have had to be changed every 5 to 7 days. To obviate this need, ear-clips (Aculite; I-Openers, Cranston, RI) were devised to be worn on the tragus. Previous work using press needles on the tragus induced slowing of gastric peristalsis, thought to be mediated by inhibition of a branch of the vagus nerve that innervates the tragus. The present study measured the duration of single gastric peristaltic waves before and after wearing the ear-clips for two cycles. There was a marked prolongation of gastric peristalsis time (GPT) when the ear-clips were applied, a return to baseline times when the clips were off, and a second, but less dramatic prolongation when the clips were on, p = 0.01. We conclude that the ear-clips were effective in delaying gastric peristalsis, and may have value in reducing appetite in association with weight loss programs.

Percutaneous laser disc decompression (PLDD): twelve years' experience with 752 procedures in 518 patients.

BACKGROUND AND OBJECTIVE: Percutaneous laser disc decompression (PLDD) is a procedure in which herniated intervertebral discs are treated by reduction of intradiscal pressure through laser energy. This is introduced by a needle inserted into the nucleus pulposus under local anesthesia and fluoroscopic monitoring. The small volume of nucleus vaporized results in a sharp fall of intradiscal pressure, with consequent migration of the herniation away from the nerve root. First proposed by the author in 1984, this concept was validated by 2 years of in vitro experiments. Our aim was to apply this concept to a large series of patients with herniated disc disease. STUDY DESIGN/MATERIALS AND METHODS: A nonrandomized, nonblinded study was conducted in male and female patients with symptomatic, image-documented intervertebral herniated discs in a 12-year period using PLDD as the only treatment modality. RESULTS: The author's own series consists of 752 intervertebral discs in 518 patients over a period of 12 years. The overall success rate ranged from 75% to 89% with a complication rate of less than 1%. CONCLUSION: PLDD has proven to be safe and effective. It is minimally invasive, is performed in an outpatient setting, requires no general anesthesia, results in no scarring or spinal instability, reduces rehabilitation time, is repeatable, and does not preclude open surgery should that become necessary.

Magnetic resonance imaging of the lumbosacral spine under compression.

OBJECT: This study was undertaken to duplicate the more physiological imaging of lumbar disk herniation possible with the "sitting magnetic resonance imaging (MRI)" that exists at Harvard and Zurich. METHOD: A compression frame was constructed of plywood that would fit into a standard MRI machine. A patient lying in the frame, on extending the bent knees, would experience a compressive force on his lumbar and thoracic spine, thus duplicating the higher intradiscal pressures found in the sitting position. RESULTS: It was found that in 50% of patients so studied there was reproduction of their pain syndromes as well as augmentation of disk herniation by MRI. CONCLUSION: The compression frame used during MRI of the spine results in a more physiological representation of herniated disks seen in the erect position.

Rapid correction of neurologic deficits by percutaneous laser disc decompression (PLDD).

Immediate correction of neurologic deficits due to herniated disc disease following percutaneous laser disc decompression (PLDD) has not previously been reported. In a review of 182 cases of herniated intervertebral disc disease with radicular pain syndromes, the author observed a high percentage of return of absent ankle and knee jerk reflexes, return of straight leg raising to normal, and a change of the characteristic rolling to one side, bending the knees, and propping up with the hands as the usual maneuver to change from a supine to a sitting position ("Choy sign") to an ability to sit up directly by trunk flexion, immediately, and at 1 day after PLDD. The neurophysiologic implications are discussed.

Percutaneous laser disc decompression.

Herniated disc disease has an incidence of 1.7% in the U.S. Heretofore, open operative procedures were the rule for this condition when conservative measures were ineffective. Choy and Ascher introduced this new technique in February 1986 using a Nd:YAG laser introduced into the disc through an optical fiber in a needle. Percutaneous laser disc decompression is based on the principle that in an enclosed hydraulic space, such as an intact disc, a small reduction in volume is associated with a disproportionate fall in pressure. In the disc, this partial vacuum causes the herniated portion to move away from the nerve root back toward the center of the disc. This technique has been taught worldwide and is being performed in most of Europe, Japan, the United States, and Korea. In this special issue devoted to percutaneous laser disc decompression (PLDD), we will set forth the basic science of PLDD, patient selection, use of the holmium:YAG, and the Nd:YAG lasers, operative technique, and results.

Change of intradisc pressure versus volume change.

To gain further insight into the biomechanics of the intervertebral disc and determine a potential mechanism for causation and relief of symptoms related to a herniated disc, the pressure-volume relationship was determined within the nucleus pulposus (NP). In 17 intact human cadaver lumbar discs, pressure was measured continuously within the NP by means of a miniature strain gauge at the tip of a size 4 French (1.3 mm) catheter inserted into the NP. The volume of the NP was increased at the slow, continuous rate of 0.034 ml/min by the pump-regulated infusion of saline colored with methylene blue. In 12 unloaded discs, NP pressure rose in a linear fashion (linear r2 = 0.96) from an initial mean pressure of 174 +/- 81 kPa. The mean rate of pressure rise was 327 +/- 109 kPa/ml of volume increase. The peak pressure reached was limited to 550 kPa by the capacity of the strain gauge. Similar linear relationships were obtained during saline infusion into 5 vertically loaded discs. The data define the pressure-volume relationship within the disc and show that the NP, surrounded by the relatively inelastic annulus and the solid vertebral end-plates, has the properties of a tight hydraulic space in which a large pressure rise will regularly result from a small increase in volume. Presumably, the opposite is also true. The data may provide a biomechanical basis for variation in symptoms related to physiological changes in disc volume, and for any benefit obtained from interventions designed to remove disc tissue.

Fall of intradiscal pressure with laser ablation.

In an experimental system where intradiscal pressure could be measured before and after laser ablation, we found that there was a significant fall of intradiscal pressure after 1000 J of Nd:YAG laser energy was delivered to fresh cadaver discs. That this was not due to fenestration was demonstrated by control experiments using an identical system, but without turning on the laser. Here, there was no significant fall of intradiscal pressure.

Efficiency of disc ablation with lasers of various wavelengths.

In testing the CO2 lasers in CW and pulse mode, the erbium:YAG, the Nd:YAG 1318 microns and 1064 microns, the argon, the holmium:YAG, and the excimer, we found the greatest efficiency in the CO2 CW and pulse mode, and the lowest efficiency in the argon. Data with the holmium:YAG were unreliable because of the early generation laser tested. The Nd:YAG was second only to the CO2 laser, and because the latter has no waveguide, we deemed the Nd:YAG the laser of choice for PLDD.

Patient selection: indications and contraindications.

Patient selection is critical to the success of PLDD. In general, the herniation must have continuity with the parent disc; rupture of the annulus is not a contraindication. Several other orthopedic conditions constitute absolute or relative contraindications. All patients must be individualized. Our criteria for inclusion is undergoing continuing change. What is unacceptable now may, with modifications, become acceptable in the future. It is important not to adopt a fixed position at this early stage of PLDD.

Techniques of percutaneous laser disc decompression with the Nd:YAG laser.

The great importance of correct needle placement with appropriate radiologic monitoring is emphasized. The needle tip must be just past the annulus, and the needle itself must be parallel to the disc axis, and preferably halfway between the superior and inferior end-plates. Dosimetry is described. A novel (extrathecal) approach to the L5-S1 disc when this cannot be entered from a dorsolateral angle is described. Our technique for cervical disc PLDD is briefly described.