Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose. Miller MR, Mathews RS, Reeves KD. Pain Physician. 2006 Apr;9(2):115-21.
Dr. Reeves’ Notes: Note that the great majority of the time the pain source is not the disc, and treatment of the paraspinal /paradiscal ligaments/tendons eliminates pain. However some pain is from the disc as well in a portion of the patients. 25% dextrose injected in severely degenerative lumbar discs (too severe for IDET) with multiple tears reduced pain in a durable manner. Effects were quick enough to suggest a neurolytic mechanism via hypertonicity or other (IE neovessel) mechanisms.
Note that this study, although involving high concentration (Hypertonic) dextrose, was not intended in its conception as a study of prolotherapy, but primarily because a prolonged nerve blocking effect (neurolysis) of markedly hypertonic solutions was proposed. Improvement in these patients was too quick (hours to days) to be explained on the basis of regeneration effects on the disc. The durability of improvement was potentially related however to regenerative effects of the intradiscal dextrose.
Note also that this study was only for severe degenerative discs (discs with severe tears) and is a pilot study, meaning much more work needs to be done to determine what solutions are best for direct disc injection. The great majority of the time disc treatment is not necessary because prolotherapy for supportive structure will eliminate or improve pain sufficiently. This study examined only patients with particularly severe discs in patients not responsive to prolotherapy of supportive structures. Therefore results in unscreened patients without prolotherapy on other spinal structures first, may not be comparable.
To view this study on degenerative discs in PDF format, click here.
A copy of the abstract of the degenerative disc study is available here, with a copy of the content below.
BACKGROUND:
Degenerative discs are thought to produce nerve root pain either mechanically or chemically. Particularly in the case of advanced degenerative disc disease, this clinical entity has often proven to be symptomatically resistant to peridural steroids, Intra-discalElectrothermoplasty (IDET) and direct surgical intervention. Exposure of irritated nerves to hypertonic dextrose is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a pilot study involving injection of a combination of dextrose, glucosamine, chondroitin and dimethylsulfoxide into degenerative discs of patients with chronic low back pain of discogenic origin.
OBJECTIVE:
To assess the effects of disc space injections of hypertonic dextrose in patients experiencing chronic advanced degenerative discogenic leg pain, with or without low back pain.
STUDY DESIGN:
Prospective consecutive patient series. Methods: Patients with moderate to severe degenerative disc disease without herniation and with concordant pain reproduction with CT discography were included. All had failure of a physical therapy trial and substantial but temporary relief with two fluoroscopically guided epidural steroid injections. Patients underwent bi-weekly disc space injection of a solution consisting of 50% dextrose and 0.25% Bupivacaine in the disc(s) found positive on discography. The study was performed in an out-patient surgery center in the United States. Outcome measures included an 11-scale numeric pain score (0-10).
RESULTS:
Each patient was injected an average of 3.5 times. Overall, 43.4% of patients fell into the sustained improvement group with an average improvement in numeric pain scores of 71%, comparing pretreatment and 18 month measurements.
CONCLUSION:
The results suggest that intradiscal injection of hypertonic dextrose may have a place in the management of pain arising from advanced lumbar degenerative disc disease.
Derby R, Eek B, Lee S, Seo KS, Kim B. Comparison of Intradiscal Restorative Injections and Intradiscal Electrothermal Treatment (IDET) in the Treatment of Low Back Pain. Pain Physician. 2004;7:63-66.
Dr. Reeves’ Notes: In this study a treatment approach was used as a comparison that has fallen out of favor (IDET) It is important to note that prolotherapy (intradiscal restorative injection therapy) with a combination of solutions (glucosamine, chondroiting, dextrose and dimethylsulfoxide) did not lead to flare that IDET did and had an apparently equivalent benefit. The complicating factor is several components of the injection solution and the comparison to a non-current treatment option. Nevertheless a fascinating study pointing to the need for more research on disc health and correction of disease.
To view a copy of the complete study of Degenerative Disc Disease (Combination Solution) in PDF format, click here.
A copy of the abstract of the study on Degenerative Disc Disease (Combination Solution) is available here, with a copy of the content below.
This was a pilot study to test the potential effectiveness of intradiscal restorative injection therapy and compare with intradiscal electrothermal therapy (IDET). Thirty-five patients for intradiscal injection and seventy-four for IDET took part in the study. All patients had intractable chronic discogenic low back pain, confirmed by discogram study. Injection solution consisted of glucosamine and chondroitin sulfate combined with hypertonic dextrose and dimethylsulfoxide. Outcome was rated as 0-10 on visual analog scale (VAS), satisfaction rate, and flare up before and after the procedures. Post-procedure, patients were followed from 6 months to 18 months. Painrelief was statistically significant for both procedures, but slightly better for injections (2.2 VAS) than for IDET (1.27 VAS). 47.8% of IDET patients reported that they felt better,whereas 65.6% of injection patients reported this outcome. Among IDET patients, 35.8% reported they were worse, while no restorative injection patient reported worsening of pain. Post-procedure flare-up occurred more frequently after restorative injection (81%) than after IDET (68.9%) and was more severe (7.9 versus 6.1 VAS, respectively). However, the duration of pain flareup was notably shorter for restorative injections (8.6 days) than for IDET (33.1 days). Biochemical intradiscal restorative injections may be useful to reduce pain and disability in patients with chronic discogenic low back pain, and have clinically similar efficacy to IDET, but with improved cost-benefit ratio. The results of this study indicate that controlled random prospective comparative studies need to be performed to establish the efficacy of this treatment.
