Selective Endoscopic Discectomy: Extremely Minimally Invasive Surgery

spinal stenosis

TRANSFORAMINAL SELECTIVE ENDOSCOPIC DISCECTOMY: extremely minimally invasive surgical treatment for lower back and leg pain.

While 95% of people who sustain an injury to their lower back will recover with a combination of conservative treatment and preventative measures there is a small group of patients who fail to respond to these measures.

This article is meant for those patients who remain unhappy with their symptoms and have been advised by their treating physicians that they would have to live with their present symptomatology or undergo extensive spinal surgery. The following information is about SELECTIVE ENDOSCOPIC DISCECTOMY an alternative procedure for those patients who do not want to live with chronic pain, undergo extensive spinal surgery and do not want to have general anesthesia.

The typical patient frequently presents several months or more after having sustained an injury to the lower back with no previous history of any back problems. Initial treatment from the general practitioner, chiropractor or emergency room physician might include that the patient take anti-inflammatory medication, analgesics, muscle relaxants, limit activities and receive physiotherapy. When the patient's problem did not resolve the patient may have been sent to an orthopedic or neurosurgical specialist who scheduled the patient for an MRI scan that may have revealed one or multiple disc bulges, disc protrusions or disc herniations. The patient may have been provided with additional treatment in the form of a lower back brace and a series of epidural cortisone injections along with specific trunk/abdominal/lower back stabilization exercises or Pilates exercises. While the patient may have noticed some partial improvement with any or all of the above measures he or she may have significant residual lower back pain and radicular pain into one or both of the legs. At that point the patient may have been told that surgical intervention would be necessary in the form of either a micro lumbar laminectomy or a Metrx discectomy under general anesthesia or if the problem was more extensive that a spinal fusion or disc replacement surgery might be indicated.

At that point after thorough review of the patient's history and performing a complete physical examination and discussing the patient's MRI scan I might find that the patient could be a candidate for the SELECTIVE ENDOSCOPIC DISCECTOMY procedure if the patient was found to have either a contained lumbar disc protrusion or lumbar disc herniation unassociated with elements of severe arthritic changes. At that point we would recommend to the patient that additional confirmatory testing be performed in the form of a provocative discogram to determine the exact disc that is causing the residual pain and then follow the discogram with a SELECTIVE ENDOSCOPIC DISCECTOMY procedure.

A discogram is an X-ray study performed under flouroscopic control in an outpatient surgical center using local anesthesia. A needle is placed in the center of the abnormal disk and in an adjoining normal disc and a solution consisting of X-ray contrast dye mixed with indigo Carmine blue dye is injected into these discs. Since the patient is awake as the dye causes increasing pressure in the center of the disc most likely this will reproduce the patient symptoms in the back and/or leg pain and also define the abnormal anatomy of the damage disc on the floroscope. If the patient's symptoms are reproduced by this discogram it is considered a positive concordant discogram and the patient can then be treated with the SELECTIVE ENDOSCOPIC DISCECTOMY either immediately or at a later time if insurance authorization is required.

The SELECTIVE ENDOSCOPIC DISCECTOMY procedure is then performed under local anesthesia with the patient awake and in the prone position on special pillows. A small needle is inserted into the disc space after local anesthesia has been administered. A 7mm (1/4inch) skin incision is made and a spine arthroscope is slipped into the abnormal disc. Under fluoroscopic control, the micro-instruments (mini forceps, mini curettes, and mini cutters-shavers) and the laser probe are used for removal of only the damaged disc material. The laser is used for further removal and shrinkage of the disc for the purpose of disc decompression and tightening up of the annulus. The procedure takes about 30 minutes to an hour per disc, on the average. The amount of disc removed and shrinkage by the laser varies, but includes only the herniated and damaged portion. The supporting structure of the disc is not affected. Upon completion, the probe is removed and a small Band-Aid is applied over the needle incision. Since the patient is awake during the procedure frequently they are interested in watching the monitor as we remove the damage disc material.

After surgery the patient is sent home and advised to use ice packs on the lower back and take mild oral analgesics and rest for few days. Many patients are able to resume work within a few days. The patient are advised prior to the procedure that if the preoperative pain was primarily lower back that in excess of 86% good and excellent results should be expected. If the patient's pain was back and leg pain good and excellent results should approach 92%.

Most of the time the patient's return to the office one week later feeling much improved and wanting to know why this procedure was not performed on them earlier and why the procedure works. We believe that this technique is successful because the abnormal portion of the disc that is creating internal pressure against the annulus and nerve root is removed, the fissures in the annulus that allow leakage of disc fluid and material are sealed and tighten up and the constant flow of irrigating saline through the endoscope washes out the irritating damaged metabolites( prostaglandins, histamines,and substance P & X). No deep tissue is cut and generally no bone has to be removed.

The following patients are not candidates for selective endoscopic discectomy:

1. The rare patient than has a disk that has become a fully extruded and migrated up into the spinal canal.

2. The patient has extensive spinal stenosis will need an extensive amount of bone removed which is better done with open surgery.

3. The patient has extensive spinal instability and requires a spinal fusion that must be done with an open procedure.

For those patients who are afraid of having extensive spinal surgery and have been told that they will have to live with their lower back pain, SELECTIVE ENDOSCOPIC DISCECTOMY is an exciting successful minimally invasive surgical alternative procedure that it is performed under local anesthesia and has a very high rate of patient satisfaction. For further information see www.back-surgery-online.com.