Placebo-controlled Trial of Transdiscal Radiofrequency Annuloplasty

A Randomized, Placebo-controlled Trial of Transdiscal Radiofrequency Annuloplasty for Treatment of Discogenic Lower Back Pain

Each patient was assigned to one of the two groups: IDB or Sham. On the day of the procedure, an IV was inserted in pre-procedural area and patient transported to the procedure room. The procedure will be completed under fluoroscopy in prone position. Patients were given 1-4 mg of midazolam for relaxation before the procedure and, if needed, 50-100 mcg of fentanyl IV during the procedure. The patients was randomly assigned to treatment or placebo using computer-generated codes maintained in sequentially numbered opaque envelopes. The physician performing procedure was informed of the assignment. In IDB group, guided by the fluoroscopic imaging, two transdiscal probes was positioned in the posterior annulus using a posterolateral, oblique approach. First, two electrically insulated 17G transdiscal introducers was used to gain an access to the disc space. Than, two radiofrequency probes will be positioned through each of the introducers bilaterally to create a bipolar configuration. Placement of the transdiscal probes within the disc annulus will be confirmed using oblique, lateral, and anterior-posterior fluoroscopic images. Sham group had their introducers and electrodes positioned just outside of the disc. This was also be documented using fluoroscopy. Investigator attached the electrodes to inactive heater control device that provide a similar auditory and visual experience for the patient. Patients were therefore remain blinded to actual treatment and physician performing procedure was not involved in patient's follow-up. Patients were awake and communicating with the physician conducting the procedure and if pain in legs were present and increased during the procedure, the heating protocol would be stopped. Following completion of procedure the patient was transferred to recovery and monitored for 45 minutes, then discharged home with instructions. The patients were followed over a period of 12 months.

Study Overview

• Status: Completed
• Conditions: Lower Back Pain
• Intervention / Treatment: Device: The Transdiscal Radiofrequency Annuloplasty; Device: The Transdiscal Radiofrequency Annuloplasty

Detailed Description

Back Pain

• Study Type: Interventional
• Enrollment (Actual): 64
• Phase: Phase 1

Contacts and Locations

Study Locations

• United States
  • North Carolina
    • Winston-Salem, North Carolina, United States, 27103
      • The Center for Clinical Research
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic Pain Management

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• The inclusion criteria will be as follows:

  • Age 18 + years
  • History of chronic low back pain unresponsive to nonoperative care (including physical therapy and anti-inflammatory medication) for longer than 6 months of at least 5 on VAS
  • No surgical interventions within the last 3 months
  • Back pain more than leg pain which is commonly exacerbated by sitting
  • Pain reproduction present on provocative discography in degenerated disc but not in control discs
  • Disc height at least 50% of adjacent control disc
  • Evidence of single level degenerative disc disease or two level disease without evidence of additional degenerative changes in other disc spaces on MRI

Exclusion Criteria:

• The exclusion criteria are :

  • Evidence of compressive radiculopathy with predominant leg pain
  • Nucleus pulposus herniation on the MRI
  • Disc bulges > 5 mm
  • Prior lumbar surgery of any kind
  • Presence of concordant cervical or thoracic pain
  • Symptoms or signs of the lumbar canal stenosis
  • Evidence of structural abnormality at the symptomatic level like spondylolisthesis
  • Chronic severe conditions such as rheumatoid arthritis and fibromyalgia
  • Patients with pending workers compensation claim, litigation or disability income remuneration
  • Psychological issues by exam or history
  • Beck Depression Inventory (BDI) >20
  • Pregnancy
  • Systemic infection or localized infection at the anticipated entry needle site
  • Allergies to contrast media or to any medication to be used in the procedure
  • Traumatic spinal fracture
  • History of coagulopathy, unexplained bleeding
  • Progressive neurological deficits
  • History of opioid abuse
  • Presence of free disc fragments on MRI
  • More than 2 discs degenerated on MRI
  • Immunosuppression (eg. AIDS, cancer, diabetes, other surgery within last 3 months)
  • Smoking
  • BMI (body mass index) >30 kg/m2
  • Subject unwilling to consent to the study
  • Participation in another investigation within 30 days of signing informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Intradiscal Biacuplasty; On the day of the procedure, patients were given midazolam for relaxation and, if needed, fentanyl IV during the procedure. For treatment subjects, two TransDiscal probes were positioned under fluoroscopic guidance in the posterior annulus of the intervertebral disc. The probes were attached to the Radiofrequency generator and Radiofrequency energy was delivered. Placement of the probes within the disc annulus was confirmed using oblique, lateral, and anterior-posterior fluoroscopic images. Following completion of procedure the patient was transferred to recovery and monitored for 45 minutes then discharged home with instructions. It was expected that the patient limit their activities during the first week after the procedure.	Device: The Transdiscal Radiofrequency Annuloplasty; Adjustment in dosage form, frequency and or duration.; Other Names: Intradiscal Biacuplasty Active Comparator; Device: The Transdiscal Radiofrequency Annuloplasty; interventions include adjustment to dosage form,frequency,duration or switching to treatment arm A; Other Names: Sham: Placebo Comparator
Placebo Comparator: Sham; Sham procedures mimicked active treatment procedures, except that the probes were positioned just outside of the disc and no radiofrequency energy was delivered through the electrodes. Thus, sham patients were provided similar tactile, auditory and visual experiences as treatment patients, without receiving the active RF treatment. Following completion of procedure the patient was transferred to recovery and monitored for 45 minutes then discharged home with instructions. It was expected that the patient limit their activities during the first week after the procedure. The study will be unblinded at 6 months. If the patients in the IDB group show significant improvement compared to placebo they will be offered IDB.	Device: The Transdiscal Radiofrequency Annuloplasty; Adjustment in dosage form, frequency and or duration.; Other Names: Intradiscal Biacuplasty Active Comparator; Device: The Transdiscal Radiofrequency Annuloplasty; interventions include adjustment to dosage form,frequency,duration or switching to treatment arm A; Other Names: Sham: Placebo Comparator

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Physical Function	Physical function as measured by the Short Form (36) Health Survey questionnaire physical function component. Scale range for physical function component: 0 (minimum: worse outcome) to 100 (maximum: best outcome).	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain	Pain level as measured by the Numerical Rating Scale. Scale range: 0 (minimum: best outcome) to 10 (maximum: worse outcome)	6 months
Disability	Disability as measured by the Oswestry Disability Index. Scale range: 0 (minimum: best outcome) to 100 (maximum: worst outcome)	6 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid Usage	Patient reported Opioid usage (converted to morphine equivalents)	6 months

Collaborators and Investigators

• Sponsor: Baylis Medical Company
• Investigators: Principal Investigator: Leonardo Kapural, MD, Center for Clinical Research; Principal Investigator: Bruce Vrooman, M.D., The Cleveland Clinic

Publications and helpful links

General Publications

• Kapural L, Vrooman B, Sarwar S, Krizanac-Bengez L, Rauck R, Gilmore C, North J, Girgis G, Mekhail N. A randomized, placebo-controlled trial of transdiscal radiofrequency, biacuplasty for treatment of discogenic lower back pain. Pain Med. 2013 Mar;14(3):362-73. doi: 10.1111/pme.12023. Epub 2012 Dec 28.

Study record dates

Study Major Dates

• Study Start: September 1, 2007
• Primary Completion (Actual): September 1, 2012
• Study Completion (Actual): September 1, 2012

Study Registration Dates

• First Submitted: September 9, 2008
• First Submitted That Met QC Criteria: September 9, 2008
• First Posted (Estimate): September 10, 2008

Study Record Updates

• Last Update Posted (Estimate): January 8, 2014
• Last Update Submitted That Met QC Criteria: November 20, 2013
• Last Verified: November 1, 2013

More Information

Terms related to this study

• Keywords: Lower Back Pain
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Back Pain; Low Back Pain
• Other Study ID Numbers: IRB 07-594

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No