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11 May 2010
Percutaneous Discectomy is a class of minimally invasive surgical procedures designed to treat symptomatic herniated discs. Lumbar disc herniation or protrusion is the most common cause of nerve root pain and accounts for nearly 5% of all low back pain (1). Herniated discs are initially treated with conservative treatment, which includes rest, avoiding any aggravating activity, physical therapy, chiropractic care, and medical treatment (anti-inflammatory medications, oral steroids, muscle relaxers, and opiates). In some cases, the disc may heal effectively without further intervention. Epidural steroid injections may be performed for diagnosis and treatment of the nerve root inflammation (radiculitis) after conservative treatment fails.
Traditionally, the definitive treatment for a herniated disc has been open discectomy. Because of surgical risks, more minimally invasive measures have been researched for contained disc herniation, like percutaneous discectomy. Percutaneous discectomy can be beneficial for many, but surgery is absolutely indicated when new bowel/bladder problems or progressive weakness are involved.
The first percutaneous approach targeting the disc was documented in the 1950s for biopsying the disc (2), and the first manual percutaneous discectomy for disc decompression was introduced in the 1970s (3). In the 1980s and ‘90s safer, smaller needles were used to develop Nucleoplasty, Percutaneous Laser Discectomy, Automated Percutaneous Lumbar Discectomy, and the Mechanical High RPM Device by Stryker known as the Disc DeKompressor. We will further discuss these different technologies below.
Anatomy
The human backbone or spinal column consists of 33 individual vertebrae that surround and protect the spinal cord.
Each vertebrae is separated by an intervertebral disc, which is a soft cushion that provides support and absorbs the stress that the vertebrae receive during daily activities. The disc consists of an inner, gel-like substance called the nucleus pulposus, and an outer fibrous membrane called the annulus fibrosus. A herniated intervertebral disc results from the weakening and bulging outwards of the annulus, and protrusion of the nucleus, which most commonly occurs posteriorly or backwards. The spinal disc is in close vicinity to the nerve roots as they branch from the spinal cord and exit between the vertebrae. Therefore, a disc protrusion in the lumbar spine may compress one or more nerve roots causing pain to radiate into the back or legs (4). Disc herniation is classified into a few different conditions depending on the severity of injury. A protrusion, or contained herniation, occurs when the inner disc material bulges, but does not rupture the annulus. An extrusion occurs when the annulus is ruptured but any expelled nucleus is not completely severed from the disc. An extreme condition is a sequestered disc, in which the pulposus is expelled from the disc and is no longer attached to the disc. An extrusion or sequestration is considered a non-contained herniation. Counter intuitively, the severity of symptoms does not always correlate with the extent of the herniation (5). Discs have the propensity of herniating either acutely as the result of traumatic injury (i.e. fall or accident), or secondary to chronic strain and degeneration. The nucleus pulposus becomes dehydrated over time, which decreases its effectiveness as a shock absorber, and the annulus fibrosus loses its elasticity which increases the incidence of tearing. Thus, the spinal discs become more prone to injury with age.
Procedure
Percutaneous Discectomy is typically done with IV sedation instead of general anesthesia, thus allowing the patient to provide feedback to the physician and avoid the risks involved with general anesthesia. Patients are positioned comfortably face down for the procedure. After a sterile cleaning of the area, a local anesthetic is injected to numb the area. During the procedure the patient is likely to feel some pressure, but should otherwise have minimal pain. A cannula is then carefully placed into the disc with x-ray guidance. A probe is then introduced through the cannula and the pressure placed on the nerve roots is decompressed by various methods. Nucleoplasty combines coagulation and tissue ablation to form channels in the nucleus and decompress the herniated disc (6, 7). Percutaneous Laser Discectomy utilizes nuclear vaporization through heat generated by a laser. Its hypothesized mechanism is changing the pressure between the nucleus pulposus and the peridiscal tissue causing a retraction of the herniation away from the nerve root (8, 9, 10). In Automated Percutaneous Lumbar Discectomy, a pneumatically driven, suction-cutting probe results in a reduction of intradiscal pressure and decompression of the nerve root compression. (11). Lastly, the DeKompressor probe is a “mechanical high rotation-per-minute device designed to extract the nuclear material through an introducer cannula using an auger-like device that rotates at high speeds” (12).
Benefits
Percutaneous Discectomy has been proven to be a safe and effective treatment for select patients with lumbar disc herniation who have failed conservative treatment. Two studies have precisely replicated results showing that Manual Lumbar Percutaneous Discectomy is 88% effective in relieving sciatica in the setting of disc protrusion (13, 14). Another large study of over 1,000 patients found Automated Percutaneous Lumbar Discectomy had excellent results and extremely low complication rates in 79% of patients with discogenic low back pain (15). Multiple studies have also indicated that patients experience much improved functional status after Percutaneous Discectomy. In a study of 1,525 patients with lumbar disc herniation or back pain that failed conservative therapy, 84% of participants were symptom free with no restriction in daily activities , or greatly improved symptoms while they returned to work after Percutaneous Discectomy (17). A study of radicular pain radiating down one’s leg(s) found that 88.1% of patients were very satisfied with the results of Percutaneous Discectomy while achieving a dramatic improvement in their functional status (90.5%), and reported no procedure related complications (16).
A 1998 study found that nucleotomy is an “effective and safe alternative to open disc surgery in the treatment of patients with a small prolapse or a small protrusion who have not responded to conservative treatment” (18). Subsequently, in 2005, a study concluded that “significant pain relief, functional improvement, and a decrease in medication use were achieved following nucleoplasty” (19). Multiple other studies have found that nucleoplasty produced good outcomes in patients with Lower Back Pain and/or leg pain that already failed conservative treatment (80%, and 88% respectively) (20, 21).
A 1996 study concluded that Percutaneous Laser Discectomy is a “safe and successful alternative for the treatment of patients with a small to moderately sized herniated nucleus pulposus” (9). Later, in 2003, another publication reported that 74% of 200 patients were satisfied with outcomes, suggesting laser is a safe and effective method to treat symptomatic contained intervertebral disc herniations (22).
A recent study found that 72% of patients presenting with lumbar discogenic disease and treated by percutaneous discectomy using the DeKompressor system experienced a decrease in pain of more than 70%. The same study noted the location of the hernia affected the outcome, as disc protrusions in the posterolateral foraminal or extraforaminal location had better outcomes as opposed to posteromedian disc protrusion. (23)
Overall, advantages of Percutaneous Discectomy vs. open discectomy may include a shorter recovery, decreased epidural scar formation, avoidance of general anesthesia, preservation of spinal stability, and decreased cost (11). "Less pertinent scarring and less postoperative fibrosis may be expected" with the DeKompressor (25). When compared to microdiscectomy, Percutaneous Discectomy patients had a higher satisfaction and comparable clinical results (24).
Risks
With lower risks than traditional back surgery, Percutaneous Discectomy is considered an appropriate treatment for many patients who suffer from back pain (12). The most common complaint is mild back pain at the injection site shortly after the procedure. Extremely rare but more serious complications may include spinal cord compression, bleeding/hematoma, or infection, which are decreased by the use of x-ray guidance and sterile technique.
General contraindications for Percutaneous Discectomy are bone spur impingement on the nerve root, previous surgery with scar tissue, nerve entrapment, spondylolisthesis, bony spinal stenosis (8, 10,) non-contained disc herniation, disc sequestration or extrusion, infection, Cauda Equina syndrome, newly developed neurological deficit, and uncontrolled coagulopathy or bleeding disorders (26).
Live Procedures
Dr. Paul Lynch demonstrates a Percutaneous Discectomy procedure to remove excessive disc material from bulging or contained herniated discs, thus reducing pressure in the disc and providing pain relief.
Pain Doctor Tory McJunkin at Arizona Pain Specialists gives a detailed explanation and example of what and a Percutaneous Discectomy procedure is and how someone suffering from chronic pain can benefit from such a procedure.
References:
1. Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev 2009; 2. Bressler HB, Keyes WJ, Rochon PA, Badley E. The prevalence of low back pain in the elderly. A systemic review of the literature. Spine 1999; 24:1813-1819. 3. Hijikata S. An experimental study on the reactive changes after disc injuries. Nippon Seikeigeka Gakkai Zasshi 1970; 44: 135-152. 4. Boult, M, et al. Systematic review of percutaneous endoscopic laser discectomy: Update & Re-appraisal ASERNIP-S Report No. 5. Adelaide, South Australia: ASERNIP-S, February 2000. 5. Ohnmess DD, Vanharanta H, Ekholm J. Degree of disc disruption and lower extremity pain. Spine 1997;22:1600-1605. 6. Sharps, LS, et al. "Percutaneous Disc Decompression Using Nucleoplasty." Pain Physician. 2002; 5(2): 121-126. 7. Chen, YC, et al. “Intradiscal Pressure Study of Percutaneous Disc Decompression with Nucleoplasty in Human Cadavers.” Spine. 2003; 28(7): 661-665. 8. Caspar, GD, et al. "Percutaneous Laser Disc Decompression with Holmium:YAG laser." Journal of Clinical Laser Medicine & Surgery. 1995; 13(3): 195-203. 9. Bosacco, SJ, et al. "Functional Results of Percutaneous Laser Discectomy." American Journal of Orthopedics. 1996; 825-828. 10. Choy, DSJ. "Percutaneous Laser Disc Decompression (PLDD): Twelve Years' Experience with 752 Procedures in 518 Patients." Journal of Clinical Laser Medicine and Surgery. 1998; 16(6): 325-331. 11. Delamarter, RB, et al. "Percutaneous Lumbar Discectomy." Journal of Bone and Joint Surgery. 1995; 578-584. 12. Boswell MV, et al. American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111. 13. Hoppenfeld S. Percutaneous removal of herniated lumbar discs. 50 cases with ten-year follow-up periods. Clin Orthop Relat Res. 1989 Jan;(238):92-7. 14. Shapiro, S. "Long-term follow up of 57 patients undergoing automated percutaneous discectomy." J Neurosurg. 1995; 83: 31-33. 15. Bonaldi G. Automated percutaneous lumbar discectomy: technique, indications and clinical follow-up in over 1000 patients. Neuroradiology. 2003 Oct;45(10):735-43. 16. Alò KM, Wright RE, Sutcliffe J, Brandt SA. Percutaneous lumbar discectomy: one-year follow-up in an initial cohort of fifty consecutive patients with chronic radicular pain. Pain Pract. 2005 Jun;5(2):116-24. 17. Teng, GJ, et al. "Automated Percutaneous Lumbar Discectomy: a Prospective Multi- institutional Study." Journal of Vascular and Interventional Radiology. 1997; 8(3): 457-463. 18. Kotilainen, E, et al. “Long-Term Outcome of Patients who Underwent Percutaneous Nucleotomy for Lumbar Disc Herniation: Results after a Mean Follow-up of 5 Years.” Acta Neurochir (Wien). 1998; 140:108-113. 19. Reddy AS, Loh S, Cutts J, Rachlin J, Hirsch JA. New approach to the management of acute disc herniation. Pain Physician. 2005 Oct;8(4):385-90. 20. Bonaldi G, Baruzzi F, Facchinetti A, Fachinetti P, Lunghi S. Plasma radio-frequency-based diskectomy for treatment of cervical herniated nucleus pulposus: feasibility, safety, and preliminary clinical results. AJNR Am J Neuroradiol. 2006 Nov-Dec;27(10):2104-11. 21. Mirzai H, Tekin I, Yaman O, Bursali A. The results of nucleoplasty in patients with lumbar herniated disc: a prospective clinical study of 52 consecutive patients. Spine J. 2007 Jan-Feb;7(1):88-92. 22. Gronemeyer, DHW, et al. "Image-Guided Percutaneous Laser Disk Decompression for Herniated Lumbar Disks: a 4-Year Follow-up in 200 Patients." Journal of Clinical Laser Medicine & Surgery. 2003; 21(3): 131 138. 23. Amoretti N, David P, Grimaud A, Flory P, Hovorka I, Roux C, Chevallier P, Bruneton JN. Clinical follow-up of 50 patients treated by percutaneous lumbar discectomy. Clin Imaging. 2006 Jul-Aug;30(4):242-4. 24. Mayer, HM, et al. “Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy.” J Neurosurg. 1993; 78: 216-225. 25. Lierz P, Alo KM, Felleiter P. Percutaneous lumbar discectomy using the Dekompressor System under CT-control. Pain Pract 2009; 9:216-220. 26. Singh V, Derby R. Percutaneous lumbar disc decompression. Pain Physician. 2006 Apr;9(2):139-46.
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