Percutaneous Discectomy least traumatic of therapies for disc disease
Now there’s new innovative treatment options for patients suffering from low back and leg pain due to contained disc herniations, especially for those who have failed conservative treatments and are interested in trying minimally invasive options prior to considering traditional back surgery.
What is Percutaneous Discectomy?
The procedure is called Percutaneous Discectomy (PD), and is one of the most promising and least traumatic of all the available therapies for degenerative disc disease. It is performed under x-ray using local anesthetic (sometimes with light sedation), and is much less invasive than traditional surgical treatments.
Percutaneous means “through the skin” or using a very small incision. Discectomy is the surgical removal of herniated spine disc material that presses on a nerve root or the spinal cord.
There are several percutaneous procedures. All of them involve inserting small instruments between the vertebrae and into the middle of the disc. Fluoroscope monitoring is used during surgery to guide the movement of the surgical instruments. The surgeon can remove disc tissue by cutting it out, sucking out the center of the disc, or by using lasers to burn or evaporate the disc. Each of these techniques removes part of the disc nucleus, creating space for the herniated disc wall and relieving pressure on the nerve.
Who performs PD?
A physician with special training would ideally perform the procedure. One current and hopefully temporary drawback with this method is that there are relatively few competently trained and experienced physicians who are capable of meeting the demand for the procedure. Physicians who are certified in a specialty such as interventional pain management, orthopedic surgery, neurosurgery or interventional radiology, and experienced in discography are qualified to do PD.
Some patients who might be good candidates for PD are sometimes referred to a back specialist who may not have specific training in this less invasive procedure. Consequently, some patients are told that a conventional, more invasive open procedure is necessary. Not being totally aware of the alternatives, they can be easily convinced that the open procedure is the only alternative.
Understandably, a surgeon who has become familiar and competent with laminectomies and fusions may be unlikely to favor an alternative. On the other hand, the “consumer” in pain has little opportunity or ability to truly evaluate the merits of a medical procedure and is primarily interested in pain relief. Pain and disability tend to make people dependent and trusting. It is important for patients to ensure that they understand any medical procedure. In this particular case, if your physician does not offer an alternative, ask if the percutaneous discectomy procedure is “contraindicated.” Your physician should then give you a reasonable answer. If not, find out why with further exploration before agreeing to an open procedure.
PD is a widely accepted treatment for patients with small contained herniations for which open surgical discectomy offers a poor chance of success.
When is PD contraindicated?
A percutaneous discectomy may not be appropriate when the disc material has pushed completely through the capsule of the annulus fibrosus (fibrous ring of the intervertebral disk) and/or the posterior longitudinal ligament and entered the spinal canal. In that case, it would be contraindicated to put a microtome into potential contact with the spinal cord or nerve roots.
As long as the displaced disc material is shown (by an imaging study such as NMRI, CT, Discogram, or Myelogram) to be definitely within the capsule and well away from the spinal nerve elements, this technique can be used, particularly if a procedure called the O’Connor Technique (employs a unique method in which back pain sufferers, themselves, can easily identify the nature of their problem, relocate the displaced disc material, and prevent it from dislocating again by performing simple, specific, sequential, non-painful, postural, movements of the body that may instantly relieve spinal pain) has failed.
It is my opinion that the most lateral and anterior approach serves patients best. Any procedure that compromises the integrity of the disc capsule should be performed such that it minimizes the future probability of disc material ultimately migrating through the surgically weakened capsule. During surgical manipulation, a pathway should not be created in the disc’s capsule that may allow pieces of disc material to travel outside the disc space when future weight-bearing flexion resumes.
A device that has shown great success is STRYKER Corporation’s DEKOMPRESSOR. It is an auger (microtome) introduced through a needle-like device that “corkscrews” out material located within the disc nucleus or center to relieve pressure and decompress the bulging disc. With appropriate patient selection and in the hands of a trained specialist, PD using the DECOMPRESSOR is safe and highly effective at preserving or restoring neurological function, stabilizing spinal segments, improving functional status, and relieving pain.
DEKOMPRESSOR PD is very straightforward. A patient receives a local anesthetic and possibly mild sedation – no general anesthetic is required. The needle insertion is simple, with little pain, and it requires only a tiny puncture in the skin, similar to a simple injection. Once the needle is inserted into the disc, the disc decompression itself takes only a few minutes. The entire procedure lasts about 30-45 minutes, and the patient is able to leave shortly afterwards, with only a small bandage over the needle insertion site.
Laser-based technology utilizes the same approach as in the microtome-facilitated discectomy, but a laser removes the material by vaporization and suctioning. The post-PD recovery is undemanding. Patients typically feel little pain after the procedure. Patients are required to avoid lifting and strenuous exercise for a period of time, and may go back to sedentary work after only a week or two. Patients with more physically demanding occupations may need to wait longer to recommence work. Some physical therapy may be prescribed.
Discuss All Treatment Options
Although PD has been performed over the past 25 years, it is recent innovative techniques utilizing both mechanical, as in the DEKOMPRESSOR, and laser based instrumentation that has opened up more effective treatment options for people suffering from herniated discs. If you suffer from back problems related to disc disease be sure to discuss all treatment options with your physician, including PD which affords good clinical success rates, reduced trauma, lower costs, and less time lost from work.
Stanley Golovac, MD is the co-director of Space Coast Pain Institutue. Dr. Golovac completed his education at UTESA University in 1985, where he received his Doctor of Medicine. Upon graduation, Dr. Golovac completed his postgraduate training in Family Practice Residency Program at St. Mary Hospital in New Jersey and in the Department of Anesthesiology at Jackson Memorial Hospital in Miami. Dr. Golovac gained extensive clinical experience in anesthesiology, emergency room medicine, and alternative services. He served as Assistant Clinical Professor of Anesthesia at the University of Miami Jackson Memorial Center for several years, and then as a practicing Pain Consultant in the Miami area. He currently utilizes his expertise at Cape Canaveral Hospital/Health First Pain Management and the Space Coast Surgery Center of Pain Management. For more information log on to YourPainInstitute.com