Intradiscal Methylene Blue

Intradiscal Methylene Blue

 

This is a very new, and despite a few positive studies, unproven treatment for pain coming from the discs in the spine.

If you are suffering from disc pain, however, and thinking of fusion or disc replacement, both major surgeries, the uncertainty surrounding and experimental nature of this treatment may be an acceptable risk, especially when compared to the long term outcome risk of fusion.

How is it done?

 

1) intravenous antibiotics, and or sedation.

2) Fluoroscopically, video X-ray guided placement of a small needle inside the suspected painful disc.

3) Disc is injected with contrast to confirm that it is a “bad” disc.

4) If confirmed by the patient as “yes indeed that’s my pain!” then…

5) Inject methylene blue with local anesthetic.

6) Remove needle and over course of the following week pain hopefully diminishes.

 

How does it theoretically work?

 

1) Methylene blue, in addition to being a powerful anti-oxidant, is mildly neurotoxic at 0.5 to 1% concentration.

2) With a painful disc, the nerves pathologically grow deep into the disc and feel the disc injuries there, and report the pain up to you, the owner.

3) Injection of the methylene blue stuns/kills the terminal (end of the nerve) nerve fibers inside the disc, rendering the disc painless.

4) It is gradually metabolized inertly.

5) To date, we have had some patients with good success, some with no improvement.  No one has gotten worse.

 

 

Tell me the bad stuff, the risks, what could happen?

 

First, its unproven. It is an EXPERIMENTAL procedure. However…

There IS internationally peer-reviewed, well performed, double blinded, placebo controlled, prospective evidence of efficacy– in China.

A few papers have been published.  It appears to be safe. It has been injected in the body for decades without consequence.

There has been a 0% complication rate.  We have had no complications.

However, as methylene blue is a bright blue color it was injected into the spinal CANAL early on to track cerebral spinal fluid flow, and putting the neurotoxin inside the sac containing the spinal nerves was a bad idea.  It killed the nerves there and there werecatastrophic outcomes.  That should give you pause.

 

It underscores that ALL MEDICAL PRACTICE, and ALL LIFE has RISK.

 

That’s why we use video x-ray guidance, to virtually guarantee intradiscal injection.

Putting the needle in the thecal sac, while intending to put it in the disc, is possible, but with xray confirmation, it would be VERY DIFFICULT to do without intending to do.

So. Its possible, but highly unlikely, and the photos prove the location.

You can’t take a picture of you in Boston when you’re in San Diego.

 

Methylene blue has not been studied in long term outcomes.

You can develop infection with any injection, but infection in the disc is serious.

The exiting nerve may be pierced or injured.

Discuss this with me, know the full compliment of risks.

The first and bedrock tenet of medicine: “First do no harm…” is key to our philosophy and practice!

 

Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

Eur Spine J. 2007 January; 16(1): 33–38.

Baogan Peng,corresponding author Intradiscal Methylene BlueIntradiscal Methylene Bluecorrauth1 Yingmin Zhang,2 Shuxun Hou,1 Wenwen Wu,1 and Xiaobing Fu3

 

This article was a preliminary report of prospective clinical trial of a group of patients with chronic discogenic low back pain who met the criteria for lumbar interbody fusion surgery but were treated instead with an intradiscal injection of methylene blue (MB) for the pain relief. Twenty-four patients with chronic discogenic low back pain underwent diagnostic discography with intradiscal injection of MB. The principal criteria to judge the effectiveness included alleviation of pain, assessed by visual analog scale (VAS), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. The mean follow-up period was 18.2 months (range 12–23 months). Of the 24 patients, 21 (87%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement in the changes in the ODI and the VAS scores were obtained in the patients with chronic discogenic low back pain (P=0.0001) after the treatment. The study suggests that the injection of MB into the painful disc may be a very effective alternative for the surgical treatment of chronic discogenic low back pain.
Keywords: Discogenic low back pain, Discography, Methylene blue, Injection

 

Low back pain is one of the most common causes of disability. It is estimated that 80% of the population will experience back pain to a significant extent at some time during their lives [1]. The pain is generally thought to be the result of nerve root compression, but several clinical studies have showed that merely less than 30% of low back pain can be ascribed to nerve root compression [11]. Mooney [17] has placed this figure as low as 1%. Recent studies have found that the discogenic pain which is caused by annular disruption is the most common cause of chronic low back pain [11].
The treatment of discogenic low back pain is one of the most challenging clinical problems to the spinal surgeon. Undoubtedly, nonoperative treatment, including bed rest, exercise, traction, drug therapy, transcutaneous electrical nerve stimulation, manipulation, etc. may be effective for some patients. However, a substantial number of patients experience no improvement with these therapeutic attempts [25]. For these patients, surgical management may be necessary because of their poor response and functional limitations. A novel, valid, and minimally invasive method of management for discogenic low back pain is therefore desirable.
The pathogenesis of discogenic low back pain is extremely complicated and poorly understood. Our previous study discovered that the distinct pathological characteristic of the painful discs was the formation of a zone of vascularized granulation tissue with extensive innervation extending from the outer layer of the annulus fibrosus into the nucleus pulposus along a torn fissure as shown on CT discography [21]. Our findings suggested that the zone of granulation tissue may be the culprit responsible for causing the discogenic low back pain. With this assumption in mind, it is presumed that if the nerve fibers and nerve endings growing into the disc along the tear could be devitalized, discogenic pain would be alleviated or abated.
Ever since methylene blue (MB) was first synthesized in 1876, it has been used in many different areas of clinical medicine [31]. Its neurotropic effect enables it to block nerve conduction or destroy nerve endings; therefore, the local injection of it has been used for the treatment of various painful ailments and idiopathic pruritus ani [3, 5, 15, 24]. Having recognizance of its neurotropic action, we attempt to use intradiscal MB injection for the treatment of discogenic low back pain. This article is a summary of prospective clinical trial of a group of patients with discogenic low back pain, who met the criteria for interbody fusion surgery, but were treated instead with an intradiscal MB injection.

 

International Association for the Study of Pain (IASP):

Journal of Pain. 2010 Apr;149(1):124-9. Epub 2010 Feb 18.

A randomized placebo-controlled trial of intradiscalmethylene blue injection for the treatment of chronic discogenic low back pain.

Source

Department of Spinal Surgery, General Hospital of Armed Police Force, Beijing 100039, China. pengbaogan@163.com

Abstract

A preliminary report of clinical study revealed that chronic discogenic low back pain could be treated by intradiscal methylene blue (MB) injection. We investigated the effect of intradiscal MB injection for the treatment of chronic discogenic low back pain in a randomized placebo-controlled trial. We recruited 136 patients who were found potentially eligible after clinical examination and 72 became eligible after discography. All the patients had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-six were allocated to intradiscal MB injection and 36 to placebo treatment. The principal criteria to judge the effectiveness included alleviation of pain, assessed by a 101-point numerical rating scale (NRS-101), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. At the 24-month follow-up, both the groups differed substantially with respect to the primary outcomes. The patients in MB injection group showed a mean reduction in pain measured by NRS of 52.50, a mean reduction in Oswestry disability scores of 35.58, and satisfaction rates of 91.6%, compared with 0.70%, 1.68%, and 14.3%, respectively, in placebo treatment group (p<0.001, p<0.001, and p<0.001, respectively). No adverse effects or complications were found in the group of patients treated with intradiscal MB injection. The current clinical trial indicates that the injection of methylene blue into the painful disc is a safe, effective and minimally invasive method for the treatment of intractable and incapacitating discogenic low back pain.

Copyright 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

 

J Chemother. 2002 Oct;14(5):431-43.

Abstract

Since it was first synthesised in 1876, Methylene Blue (MB) has found uses in many different areas of clinical medicine, ranging from dementia to cancer chemotherapy. In addition, MB formed the basis of antimicrobial chemotherapy–particularly in the area of antimalarials–and eventually led to the discovery of the neuroleptic drug families. More recently, the photosensitising potential of MB and its congeners has been recognised, and these are being applied in various antimicrobial fields, especially that of blood disinfection. The range of activities of MB is due to the combination of its simple chemical structure and facility for oxidation-reduction reactions in situ.

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