Minimally Invasive Surgery for Lumbar Disc Herniation

We currently have many choices for minimally invasive partial disc removal procedures. If we look at the hemilaminectomy and posterior discectomy as the standard procedure we have the following minimally invasive approaches:

Posterior Approach

• Microdiscectomy
• Endoscopic Posterior discectomy

Posterior Lateral Approach

• Arthroscopic Posterolateral discectomy
• Automated Percutaneous Lumbar discectomy
• Percutaneous Laser discectomy Arthroscopic
• Percutaneous Laser discectomy
• Chemonucleolysis
• Thermocoagulation

Anterior Approach

• Endoscopic Anterior Subtotal discectomy
• Retroperitoneal
• Laparascopic
• Wide Abdominal Rectus Plication
• What procedure is appropriate?

Each of these procedures works in some situations. The key to success is understanding the capacity of each to deal with the array of problems that present themselves as herniated disks. The following issues should be considered:

• What exactly is causing the symptoms?
  • Neural compression
  • Incompetent posterior annulus
• Is it from one or multiple segments?
• Is the anatomic derangement more or less easily dealt with by any particular approach?
• Which approach carries the least morbidity?
• Which procedure is most likely to be successful?
• Which procedure is associated with the shortest recovery period?
• Does the procedure burn any bridges for future treatment methods?
• Has my experience prepared me to execute this procedure safely and efficiently?
• What are cost considerations?

Herniated Discs With Neural Compression
These are the classic surgically treated cases that everyone agrees tend to do well as a group if surgery is performed in a timely fashion. The fact that there is neural compression also means that the disc protrusion is "on" the nerve and visualizing the nerve so as not to damage it would seem advantageous and efficacious, as indirect approaches may not always decompress the nerve. Techniques involving direct visualization such as Microdiscectomy per Williams, arthroscopic per Kambin and transforaminal such as Mathews would be most fitting for the pathology assuming appropriate surgeon experience.

Posterior Annulus Syndromes
Not infrequently patients may have lower extremity pain without neural compression. Broad based disc bulges with lower extremity pain, internally disrupted discs, herniations that can be seen to not contact neural elements. In most of these cases the pain is from the posterior annulus nociceptors and is associated with attenuation and deterioration of the posterior annulus. Sitting intolerance relative to ambulating is typical, as stretching of the posterior annular wall from the "creeping" posteriorly migrating nuclear material is not tolerated. Frequently these patients have predominant low back pain but those that do not respond to posterior disk decompression which seems to reduce the pressure that is resulting in posterior disc wall tensile force. This can be readily accomplished by anterior subtotal discectomy most effectively. This exposure makes it technically easy to extensively evacuate the posterior inner third of the disc leaving the posterior most annular wall with its nociceptors free of further damage and exposed to lower tensile forces from the "deflated" disk. Endoscopic retroperitoneal or transperitoneal approaches allow this to be accomplished with minimal morbidity and hospitalization. No neural fibrosis is created by the approach. The same evacuation can be accomplished by posterior open and endoscopic and/or flouroscopic posterior lateral approaches. However the former creates some neural fibrosis and necessitates further damage to the posterior annulus which may be problematic in these patients who tend to have more facilitated pain sensitivity. The latter requires great technical demands to fully evacuate the posterior inner disc with inflammation and mechanical trauma around the dorsal root ganglion. A series of 27 consecutive patients treated with anterior endoscopic subtotal discectomy is presented.

In patients with predominantly back pain, fusion has been the traditional treatment of choice. We are all familiar with the morbidity and typically long recovery times associated with fusions. And what is appropriate with greater than two-segment painful degenerative disc disease with or without herniation?

Several injection specialists in our area have begun early clinical trials utilizing intradiscal thermocoagulation and sclerotherapy for treatment of annular disruption pain syndromes. We will be hearing about the results of these shortly if successful.

The wide abdominal rectus plication for treatment of back pain was reported by Toronto in 1991. We present a series of multilevel painful degenerative disk disease treated by this "minimally invasive approach".

Spine 1994 Mar 1;19(5):526530

Ambulatory surgery is safe and effective in radicular disc disease.

Bookwalter JW 3rd, Busch MD, Nicely D
Oakland Neurosurgical Associates, Pittsburgh, Pennsylvania.

Advances in medicine, including diagnostic techniques and therapeutic procedures, have resulted in the ambulatory management of many diseases. A number of surgical procedures previously considered to require hospitalization now are offered on a routine basis as an outpatient or shortstay admission. Although the use of microdiscectomy for the treatment of virgin herniated disc in ambulatory patients has been reported in very limited numbers, it has not been applied to other problems, such as recurrent herniated disc, far lateral disc, or foraminal stenosis. In addition, it only has been used in optimal patients. The authors analyzed a diverse group of patients who underwent outpatient microdiscectomy and found, for most patients studied, hospitalization was not necessary. Seventyfour patients were prospectively studied to determine whether unilateral root decompression for disc or stenosis could be accomplished on an ambulatory basis. Ninety percent of the patients were able to be discharged on the day of surgery. There was no significant morbidity related to the ambulatory approach. The authors also found a significant cost saving for third party reimbursers.

Comments

* Comment in: Spine 1995 Apr 1;20(7):8612

Spine 1995 Mar 1;20(5):599607

Development of degenerative spondylosis of the lumbar spine after partial discectomy. Comparison of laminotomy, discectomy, and posterolateral discectomy.

Kambin P, Cohen LF, Brooks M, Schaffer JL
Graduate Hospital Disc Treatment and Research Center, Department of Orthopaedic Surgery, Pennsylvania, USA.

Study Design
The development of degenerative spondylosis after successful operative decompression of the affected nerve root was prospectively evaluated in a comparative case series of 100 patients with a herniated lumbar nucleus pulposus.

Objectives
The objective of this study was to compare the relative incidence of degenerative spondyloarthrosis after successful posterior laminotomy and discectomy and posterolateral extradural discectomy for decompression of a compromised lumbar nerve root.

Summary Of Background Data
The relationship between the radiographic appearance of degenerative spondylosis and prior operative procedures has been controversial and at times contradictory. The posterior operative approach with a partial discectomy has been associated with a significant incidence of postoperative degenerative spondylosis and intraneural and perineural fibrosis, complications that may be minimized, or perhaps even eliminated, with the posterolateral evacuation of the offending intervertebral disc fragment.

Methods
Each patient had: 1) not responded favorably to nonoperative treatment, 2) a persistent radiculopathy, 3) correlative imaging studies with no preoperative spondyloarthrosis and 4) minimum 2year followup. Fifty patients were treated by posterior laminotomy and discectomy and fifty were treated by a posterolateral extradural discectomy. Postoperative spondylosis was graded based on the radiographic presence or absence of osteophytes, the intervertebral disc height, the vertebral body alignment and the facet joint changes.

Results
At an average postoperative followup of 65 months, the incidence of a one-grade increase in degenerative spondylosis was 80% of the laminotomy and discectomy patients as compared to 39% of the posterolateral discectomy patients.

Conclusions
The increased incidence of spondyloarthrosis with the posterior approach suggests that minimally invasive posterolateral extradural procedures should be considered for the decompression of a compromised lumbar nerve root.

J Neurosurg 1996 Mar;84(3):462467

Transforaminal arthroscopic decompression of lateral recess stenosis.

Kambin P, Casey K, O'Brien E, Zhou L
Department of Orthopaedic Surgery and Division of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, USA.

The purpose of this study was to evaluate the feasibility and efficacy of arthroscopic decompression of lateral recess stenosis, determine potential associated complications, and present an alternative method to access the lateral recess of the lumbar spine. Forty patients were selected in whom the authors found clinical and computerized tomography evidence of lateral recess stenosis and sequestered foraminal herniations. All 40 were treated with a posterolateral arthroscopic technique, and 38 were available for this followup evaluation. A satisfactory result was obtained in 31 patients (82%). No neurovascular complications were encountered; however, other complications included an infection of the disc space in one patient and a causalgictype pain in the involved extremity in four patients. The associated postoperative morbidity in this group of patients was minimal and resulted in rapid rehabilitation and return of patients to preoperative functioning level.

Neurosurg Clin N Am 1996 Jan;7(l):5963

Transforaminal endoscopic microdiscectomy.

Mathews HH
Department of Orthopaedic Surgery, Medical College of Virginia, Richmond 23294, USA.

Foraminal epidural endoscopic surgery (FEES) is a minimally invasive spine surgery technique that allows maximum exposure for visualization, identification, and exploration of anatomy, pathology, and structures at risk; therefore, it provides for dissection of neuropathologic anatomy and documentation of surgical correction. Minimal intervention with maximum surgical capability supports consideration of FEES as "microdiscectomy through a cannula."

Neurosurg Clin N Am 1996 Jan;7(l):7785

Laparoscopic lumbar discectomy: description of transperitoneal and retroperitoneal techniques.

Obenchain TG, Cloyd D
Department of Neurological Surgery (TGO), Palomar Medical Center, Escondido, California, USA.

Dissatisfaction with minimally invasive lumbar discectomy via the posterolateral route led the authors to develop the laparoscopic lumbar discectomy technique. The technique has evolved to a retroperitoneal route that is easier and safer than the tranperitoneal one. The ideal treatment for lumbar disc herniation is accessing the epidural space directly for selective removal of the disc herniation rather than indirectly treating it via a transdiscal route. The authors describe a method of accessing the epidural space directly through the foramen using a combined discographic and retroperitoneal approach.

ROSS JS, Robertson JT, Frederickson RC, Petrie JL, Obuchowski N, Modic MT, deTribolet N
Div. of Radiology, Cleveland Clinic Foundation, Ohio, USA.

The purpose of this study was to investigate the presence of any correlation between recurrent radicular pain during the first six months following first surgery for herniated lumbar intervertebral disc and the amount of lumbar peridural fibrosis as defined by MR imaging. 197 patients who underwent firsttime singlelevel unilateral discectomy for lumbar disc herniation were evaluated in a randomized, doubleblind, controlled multicenter clinical trial. Clinical assessments, performed by physicians blinded to patient treatment status, were conducted preoperatively and at one and six months postoperatively. The enhanced MR images of the operative site utilized in the analysis were obtained at six months postoperatively. Radicular pain was recorded by the patient using a validated visual analog pain scale in which 0 no pain and 10 = excruciating pain. The data obtained at the 6 month time point were analyzed for an association between amount of peridural scars as measured by MR imaging and clinical failure as defined by the recurrence of radicular pain. The results showed that the probability of recurrent pain increases when scar score increases. Patients having extensive peridural scar were 3.2 times more likely to experience recurrent radicular pain than those patients with less extensive peridural scarring. In conclusion, this prospective, controlled, randomized, blinded, multicenter study has demonstrated that there is a significant association between the presence of extensive peridural scar and the occurrence of recurrent radicular pain.

Surg Endosc 1995 Jul;9(7):826829

Laparoscopic laser lumbar discectomy. Operative technique and case report.

Slotman GJ, Stein SC
Department of Surgery, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden 08103, USA.

Approximately 300,000 patients each year in the United States undergo laminectomy for disabling lumbar disc herniation. Postlaminectomy hospitalization is 37 days and convalescence may be prolonged. As an alternative to laminectomy, we have developed a technique for performing L5Sl lumbar discectomy laparoscopically. Using an anterior approach, the intervertebral disc space is opened and the discectomy is performed under direct videolaparoscopic imaging. After pneumoperitoneum is established, the patient is placed in a steep Trendelenburg position. The small bowel is retracted cephalad and the colon is moved to the left. The iliac vessels are identified visually and by Doppler probe, and the presacral space is dissected in the midline to expose the L5Sl disc. In the case presented, the disc annulus was opened with the Nd:YAG contact laser, and discectomy was performed under direct videolaparoscopic vision using standard neurosurgical instruments modified for laparoscopy. The posterior longitudinal ligament can be visualized directly to define the posterior limits of the completed discectomy. In the case described, pain relief was confirmed immediately after the procedure. The patient was discharged after 2 hospital days, and returned to normal activity in 8 days.

Am Surg 1996 Jan;62(l):6468

Laparoscopic L5Sl discectomy: a costeffective, minimally invasive general surgeryneurosurgery team alternative to laminectomy.

Slotman GJ, Stein SC
Division of General Surgery, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden, USA.

Laparoscopic LSS1 discectomy (LLD) is a promising new technique for managing disabling pain from herniated lumbar disks. It is unknown, however, whether the clinical results of LLD are superior to those of traditional laminectomy (LAM). This study was undertaken, therefore, in order to compare LLD and LAM in the management of L5S1 disk herniation unresponsive to conservative treatment measures. Clinical records of 22 patients who underwent 23 LLD procedures and of 23 LAM patients were reviewed with respect to demographics and median age, operative blood loss, operative time, hospital stay, and time of rehabilitation to work/normal activity, as well as postoperative morbidity, recurrent symptoms, longterm functional status, and in-hospital patient charges. Two LLD patients had undergone LAM previously, and one had a percutaneous microdiscectomy. All LLD patients had relief of disk pain immediately after surgery. Morbidity after LLD included transient brachial plexus neuropraxia (1), urinary retention (1), and rectus hematoma (1). No LAM complications were reported. Among LLD patients, compared with LAM, median age (34.5 years versus 40 years), estimated blood loss (12 mL versus 68 mL), hospital length of stay (1 day versus 3 days), time to normal activity (17 days versus 79 days) and mean in-hospital patient charges ($5,737 +/ 283 versus $7,762 +/ 662) were reduced significantly (P < 0.05). LLD operating time was significantly longer than LAM (210 versus 160 minutes median, P < 0.01). With a median followup time of 11.0 months (range, 2 to 23 months) all LLD patients had returned to normal activity, whereas 7 of the LAM group (30%) remained disabled (P < 0.01). Sixtyeight per cent of LLD patients were painfree during followup, compared with 39 per cent of the LAM group (P < 0.05). Sixtyfour per cent of LLD patients and 57 per cent of the LAM group needed postoperatively physical therapy. One LLD and 4 LAM patients required reoperation, by LLD and LAM, respectively, for recurrent disk herniation. LLD is a safe, costeffective, minimally invasive operation for managing disabling L5Sl disk herniation. Compared with LAM, LLD reduces blood loss, length of stay, rehabilitation time, and patient charges, and improves longterm functional and painfree status. LLD should be considered as an alternative to LAM for patients with herniated L5Sl intervertebral disks unresponsive to conservative management.

Spine 1988 Mar;13(3):360362

Treatment of the isolated lumbar intervertebral disc herniation: microdiscectomy versus chemonucleolysis.

Watters WC 3d, Mirkovic S, Boss J
Baylor College of Medicine, Houston, Texas.

A longterm goal of spine surgeons has been to reduce the morbidity, cost, and recuperative period of primary lumbar disc surgery. In this paper, microdiscectomy and chemonucleolysis are evaluated and compared with respect to achieving these goals. Two groups of successive, noncompensation patients numbering 50 each were studied. All patients met standard clinical and imaging criteria for an isolated lumbar vertebral disk herniation. One group was treated with chemonucleolysis and the second with microdiscectomy. Average followup exceeded 3 years. While both treatment groups achieved the stated goal when compared with traditional laminectomy, the microdiscectomy groups demonstrated statistically superior treatment results, with reduced time to return to work, and fewer required subsequent surgical procedures.

Am J Surg 1995 May; 169(5) :496498
Laparoscopic lumbar discectomy.

Zelko JR, Misko J, Swanstrom L, Pennings J, Kenyon T
Department of Minimally Invasive Surgery, Legacy Portland Hospital, Oregon, USA.

Background
Minimally invasive spine surgery is gaining popularity. Results of currently used percutaneous posterior techniques fall short of standard open microdiscectomy. Using a posterior percutaneous technology with an anterior laparoscopic approach may improve results and still maintain the advantages of a minimally invasive procedure.

Methods
Patients with symptomatic lumbar protruded discs confirmed by computed tomography or magnetic resonance imaging were offered the procedure. Transperitoneal visualization of the retroperitoneum was supplemented with fluoroscopic guidance. A small window made to the disc allowed the percutaneous nucleotome to be inserted through the anterior annulus. The automated nucleotome aspirated the nucleus, leaving the ligaments intact.

Results
All patients underwent successful dissection and placement of the nucleotome. of the 23 patients, 21 left the hospital in less than 24 hours. The initial neurologic outcome is that 20 out of 23 patients had improved symptoms or were asymptomatic. Complications were minimal.

Conclusion
Laparoscopic lumbar discectomy is safe, and for carefully selected patients, can be an alternative to posterior microdiscectomy.

WIDE ABDOMINAL RECTUS PLICATION (WARP) AS A TREATMENT FOR LOW BACK PAIN Mark R. Drzala, MD, James F. Zucherman, MD, Ken Y. Hsu, MD, Randall B. Weil, MD, David Chang, MD.
St. Mary's Spine Center, San Francisco, CA 94117.

Introduction
Patients with end stage multilevel lumbosacral degenerative disk disease with chronic low back pain were treated favorably with wide abdominal rectus plication (WARP) abdominoplasty at our institution from 1995 to 1997. Similarly, in 1990, Toranto reported that in 25 patients who previously had chronic persistent low back pain, 24 experienced alleviation of back pain following a WARP procedure. Contraction of the abdominal muscles (internal and external obliques, and transverse abdominis) adds dynamic ligamentous support to the fixed spine via their attachments to the lumbodorsal fascia. Farfan postulated that by means of a laterally directed force from the oblique musculature, the lumbodorsal fascia shortens the dorsal ligament of the spine, thereby creating an extension moment about the spine. This serves to assist the spinal column in compressive load bearing. Intraabdominal pressure is also thought to participate in lumbosacral spine biomechanics by unloading die spinal musculature.

Method
From April of 1995 to September of 1997, ten patients of mean age 46.4 years (range 36 to 57) with chronic, disabling low back pain, refractory to all conservative measures for a minimum of one year, and who were considered poor candidates for multilevel fusion, underwent a WARP abdominoplasty. Provocative discography was performed on all patients preoperatively to assist in localizing symptomatic lumbosacral disk levels. Additional criteria for patient selection included relief of back pain with an abdominal brace and a positive abdominal compression test. Oswestry function test scores were obtained preoperatively and at followup for all patients.

Results
Four patients had one previous lumbar spine operation. Preoperative discography confirmed two painful lumbosacral levels in four patients, three levels in four patients, four levels in one patient, and five levels in one patient. Patient followup ranged from 6.0 to 30.9 months (average 16.2 months). All patients had an average improvement of 14.9 11119.5 points in their Oswestry scores. Our single complication included a superficial wound infection in one patient. One patient required reoperation for a recurrent herniated disk, which lie sustained in an MVA six months after his WARP procedure. Another patient initially improved, but subsequently reinjured her back after sustaining a fall. All patients were satisfied with the outcome of this procedure and would recommend it to similarly indicated patients.

Conclusion
Some patients with painful multilevel degenerative disk disease are unable to fully participate in physical therapy, most likely due to segmental loading sensitivity of the lumbar spine. For those patients who subsequently become deconditioned, have failed other measures of nonoperative treatment, and are not candidates for fusion, a WARP procedure may be of benefit. WARP appears to assist the spinal column with compressive load bearing by providing dynamic ligamentous support and increasing intraabdominal pressure. Longterm followup of a larger series of patients may confirm the efficacy of this procedure.