Minimally Invasive Solutions for Lumbar Disc Herniation

In this interview, Ferdinand Formoso, DO, discusses the role of condoliase as a minimally invasive treatment for lumbar disc herniation, its safety profile, potential areas for further research, and its ability to address unmet needs in spine care by bridging the gap between conservative treatments and surgical interventions.

Feridinand Formoso, DO: My name is Ferdinand Formoso, DO. I'm a doctor of osteopathic medicine with residency training and subspecialty training. I'm a physical medicine rehab primary specialist. And then I did interventional pain management and interventional spine fellowship training. Both of those were done at Temple University. I'm the owner and medical director of a private practice here in Jacksonville, Florida. It's called Formoso Pain Specialists. I've been in practice with my patients for almost 20 years at this point, doing interventional physiatry.

How do you see condoliase fitting into the current treatment paradigm for lumbar disc herniation alongside conservative care and surgical options?

Dr Formoso: I think it's a great addition because currently, we basically have very conservative treatments: anti-inflammatories, maybe oral steroids, and other various medications that are available for neuropathic pain, and then epidural steroid injections, which tend to generally be short-lived and, for most patients, don't seem to provide lasting results. Leaping from that into a surgical intervention, there are many patients out there—and I can tell you because I see them every day—that really try to avoid surgery, if at all possible. So this is kind of a perfect procedure that bridges that gap between a typical epidural steroid style of procedure and a much more invasive surgical procedure. It fits in that sweet spot there that I think most patients feel pretty comfortable about.

What are your thoughts on the safety profile of condoliase, particularly the higher incidence of treatment emergent adverse events in the study?

Dr Formoso: Overall, I think from a safety perspective, it was very safe. There was a slightly higher incidence of treatment adverse events. If you looked at the delta between the actual treatment arm and the sham arm, there was about an 18% delta there. Also, to note, none of the serious adverse events were tied to the treatment itself, which I think was very important. Overall, it proved to be a very safe treatment.

What further research or data would you like to see to better evaluate condoliase's role in pain medicine?

Dr Formoso: My thought was that we would want to start thinking about looking at other parts of the spine, [such as the] cervical spine. But also, what would be interesting is to see how this works for patients with thoracic herniations, which are rare but also of note. Thoracic herniations are very difficult to access and treat surgically. Again, although rare, for patients that have thoracic herniations, which are traditionally very difficult to access surgically because of the anatomy, maybe this could offer them an option.

The other thing is this study was really focused on lateral herniations that were causing unilateral limb symptoms. There are a number of patients that have central disc herniations that are relatively small. It would be interesting to see how those patients would respond and maybe create a study specifically looking at central disc herniations.

How do these findings align with unmet needs observed in the landscape of medications related to lumbar disc herniation?

Dr Formoso: Like I said earlier, I think there is a need for a minimally invasive treatment to deal with smaller disc herniations. We've had, over the years, different devices that were invented and tried, and other chemicals that we've injected into the disc in an effort to try to reduce disc protrusions. Those seem to not really work very well over time and have evaporated from the treatment landscape. I think this is a really great treatment option, offering a percutaneous—which is the key here—a needle-based treatment for patients with disc herniations. This has been around in Japan and has a great safety record in Japan, and I'm excited that now we may have it available here for use in America.

What is the primary message or takeaways you would like the audience to take away from this?

Dr Formoso: I think our field, in general, is a very exciting field. There are new innovations coming out all the time. What I'm hopeful for is as we evolve in spine care, we will continue to be able to offer minimally invasive treatment options for patients. My goal as an interventional spine specialist is to be able to offer patients a way to treat issues like this without cutting.

In my experience, I've seen that in patients who have spine surgery, it changes the anatomy—the natural anatomy—forever. As much as we can avoid changing that anatomy, the better off patients will be in the long-term. The other key here is if you don't respond to this treatment, it doesn't stop you from then exploring the traditional surgical options, which I think have their weaknesses, but some patients do need to progress to that. This will not preclude those patients from being able to explore those options if necessary. Our hope is that most patients will not have to do that.