When To Consider Disc Annuloplasty For Intractable Back Pain
General Surgery
Chronic low back pain caused by disc problems, also known as discogenic pain, can significantly affect daily function and quality of life. This condition occurs when the nucleus pulposus, the soft inner core of an intervertebral disc, pushes through a tear in the annulus fibrosus, the disc’s tough outer layer, leading to persistent and localised pain.
While many patients find relief through conservative treatments such as physiotherapy or medication, some continue to experience discomfort. For these individuals, a specialised minimally invasive procedure called annuloplasty may offer effective pain relief and improved mobility.
The Challenge of Discogenic Pain and Initial Management
Managing discogenic pain usually begins with conservative, non-surgical treatments aimed at reducing inflammation, strengthening core muscles and restoring movement. This initial phase often includes physiotherapy, anti-inflammatory medication and sometimes epidural steroid injections. For many patients, these methods provide enough relief to resume normal activities.
However, when an annular tear is the main cause of ongoing lower back pain and symptoms persist for more than six months despite consistent conservative care, doctors may consider interventional options. In these cases, the pain comes from a tear in the outer layer of the disc (annulus fibrosus), a condition that can be treated with a minimally invasive procedure called annuloplasty.
Understanding Annuloplasty
Annuloplasty, also called intradiscal electrothermal therapy (IDET) or radiofrequency annuloplasty, is a minimally invasive procedure that targets the source of disc-related back pain. A thin catheter is inserted into the damaged disc under X-ray guidance, where controlled heat or radiofrequency energy is applied.
This process seals the annular tear to prevent leakage of inflammatory material and desensitises pain-sensing nerves in the disc wall. Annuloplasty can provide lasting relief for chronic discogenic pain that does not respond to conservative treatments, though a thorough evaluation by a specialist is necessary to determine suitability.
Who is an Ideal Candidate?
The decision to perform annuloplasty depends on meeting certain criteria. Ideal candidates usually meet the following criteria:
- Chronic Symptoms: Persistent low back pain for at least six months that does not radiate significantly into the leg (i.e., minimal or no true sciatica)
- Failure of Conservative Care: Documented failure to respond to comprehensive conservative treatments
- Diagnostic Confirmation: MRI evidence showing disc degeneration and a high-intensity zone (HIZ), which indicates an active annular tear, usually at one or two lumbar levels
- Confirmatory Test: A positive response to a diagnostic injection, such as a provocative discography, which precisely confirms the symptomatic disc
If a patient meets these standards, the intervention can be considered as the next logical step before exploring major surgical fusion procedures.
When Annuloplasty Is Not Recommended
While annuloplasty can be effective for selected patients, it is not suitable in certain situations. These contraindications help ensure safety and guide appropriate treatment:
- Severe Disc Collapse: When more than half of the disc height is lost, the disc is too unstable for the procedure.
- Major Structural Deformity: Large disc protrusions, sequestered fragments or spinal instability (such as advanced spondylolisthesis) require alternative surgery like decompression or fusion.
- Active Infection: Local or systemic infections, including discitis or osteomyelitis, increase the risk of serious complications.
- Coagulopathy: Patients with bleeding disorders or those unable to pause anticoagulant use cannot safely undergo the procedure.
- Neurological Deficit: Annuloplasty is not indicated for progressive motor weakness or cauda equina syndrome, which require urgent surgical decompression.
How Dr Thor Timothy Can Help
Dr Thor Timothy is a consultant pain specialist and anaesthesiologist in Singapore with nearly 20 years of medical experience, including over a decade in pain medicine. With multiple international qualifications and expertise in minimally invasive procedures such as radiofrequency ablation, spinal cord stimulation and disc annuloplasty, he provides precise and patient-centred care.
Before recommending annuloplasty, Dr Thor conducts a thorough evaluation to ensure suitability. This includes:
- Medical history review to assess symptoms, treatment history and pain duration
- Physical examination to identify possible nerve or disc involvement
- Imaging studies, such as MRI or CT scans, to confirm the presence of an annular tear
This careful assessment helps identify patients who will benefit most from the procedure while avoiding unnecessary intervention. Drawing from his experience as the former director of Acute Pain Services at Singapore General Hospital, Dr Thor offers tailored care focused on long-term pain relief, functional recovery and improved quality of life. You may visit https://www.thepainspecialist.sg/ to learn more.
