80% of people suffer from low-back, back and neck pain that requires impatient treatment at least once in a lifetime irrespective of race, age and sex. Although the spinal pains are so common, only 27% of such pains are disc-related. The intervertebral discs not only transmit the weight but also can change shape flexibly as we are standing and move around. The nucleus of the disc and the surrounding annulus create this dynamic effect. Like the horizontal car tyres, discs receive the loads in tilting and loading, diffuse, reduce and transmit the force of gravity, and then go back to their initial positions. This suspension action is repeated thousands of times in a day. The aim is to receive the loads and also preserve the intervertebral relation and stability. Discs keep the intervertebral space at a fixed height while the muscular, connective and nervous tissues are stretched to a certain degree to achieve dynamic stability.
The water retention capabilities of the matrix proteins in the disc decline due to the morphological changes that aging brings. Diminished disc elasticity decreases the water retention capability. Decreased nourishment by diffusion increases the matrix cracks. Plastic deformations occur as the morphological changes become permanent in the disc that has become fragile and lost its elasticity in time. Disc height is decreased, the joints are worn out due to excessive mobility and the disc surface is ruptured in a way that the nucleus moves and compresses the nerves. As a result, SPINAL PAIN occurs.
Disc-related pains require medical treatment by maximum 8.3%, while 2.7% of such pains require inpatient treatment. 9 million people all around the world undergo inpatient treatment (0.45%) while only 1 million people in the world undergo surgery in a year. This figure also includes all open fusion surgeries and discectomies.
Treatment of low-back pain requires a multi-disciplinary approach, which includes the following specialties:
– Physical therapy specialist
– Spinal surgeon
Algorithmic treatment principles require anti-inflammatory therapy and bed rest for maximum 3 days at primary level. Algologists apply block-pain therapies and the physical therapy specialists apply physical therapies for resistant and chronic cases. All therapies are supported through muscle strength- posture discipline and ergonomic measures with the help of the physiotherapists. Surgery is the last resort in case of recurrent resistant cases due to compression in the neural elements, osteoarthritis, and pronounced loss of disc height. The indications for open surgery are presented below:
– Cauda equina syndrome
– Progressive neurologic deficit
– Conservative treatment failure
– Insensible paresthesis effecting life
– Pains characterized by attacks and requiring bed rest for more than three times a year
Indications for minimally invasive (percutaneous endoscopic) surgeries vary at this point. Pronounced neurologic, cauda equina might be contraindicated. Endoscopic surgery is also indicated for cases that require bed rest for more than three times a year but that are not indicated absolutely for surgery. PAIN that reduces the quality of life and does not respond to the conservative treatment IS NOT A DESTINY FOR THIS POPULATION: Endoscopic surgery is a treatment option that only aims at improving the quality of life.
Open Surgery Modalities:
– Lumbar Microdiscectomy
– Hemilaminotomy / discectomy
– Laminectomy / discectomy
– Total Disc Replacement
– Nucleus Replacement
Surgery has been evolving into less invasive methods that aim at fast return to daily routine postoperatively. In its evolution, surgery has tended to replace the nucleus and increase the disc height. Less invasive methods have been groundbreaking with the fusion surgeries performed with percutaneous screws while the semi-open methods renew the disc nucleus and increase the disc height while also aiming to relieve pain through external support used to open the disc space.
Hippocrate’s “First, Do No Harm” (Primum Nil Nocere) approach is the basis of the present day’s medicine. The ideal therapy regarding the surgery that are evolving into less harming treatment modalities should
– respect the anatomic structures
– be harmless
– target the cause
– improve the quality of life
– enables returning to normal routine in the shortest time possible.
History of Minimally Invasive- Percutaneous Endoscopic Surgery
1857: Virchow first described disc protrusion. In 1901, Horsley applied the first decompression; Goldthwait described annular tear and extruded nucleus pulposus as a cause of pain in 1911.
1913: Elsberg treated pain through laminectomy that was used for many years in open surgery.
1922: Siccard and Forestier applied the first provocative discography technique by using lipiodol and sowed the seeds of minimally invasive techniques. This examination method made it possible to reveal the disc pathology on X-ray films. The pathologic level had pain during the procedure.
1934: Peet and Echols distinguished between the disc herniation and root compression
1937: Pool described the first endoscopic intervention modified from the otoscope, enabling the first endoscopy to be performed.
1939: Love used the interlaminar microdiscectomy without bone resection through mini incision.
1955: It was unusual to apply medical treatments to improve the quality of life until the Binocular Microscopic Discectomy technique was developed.
1960: Risotomies were introduced, pain transmission from the painful segments was blocked.
1973 Kambin introduced the endoscopic procedure.
1974: Shealy performed risotomy by applying percutaneous radiofrequency. İntradiscal therapies became popular while Choy introduced chymopapain and laser discectomies.
1977: Hijikata performed Percutaneous Endoscopic Discectomy, while in 1978 Williams used microscope in classic discectomy
1980: Anthony Yeung introduced the endoscope dedicated for spinal endoscopy (Wolf:YESS) for today’s surgery. Since 1980, Miss pedigree has been branching out thanks to more than one hundred thousand successful operations.
– A. Yeung (Wolf-Yess)
– MT. Knight (EKL-Kiss)
– H. Leu (Storz-Leu)
– T. Hoogland (Joimax-Thessys)
– Martin Sawitz, John Chiu, Sang-Ho Lee, Akira Dezava
Advantages of MISS: It is patient-centered.
Length of stay at hospital hardly exceeds one day following the minimally invasive surgery. Patients can return to work only in a few days. Recovery is fast as this procedure does not harm the healthy tissues. Therefore, specific hospitals with low bed capacity can heal many patients in a short time. Short hospital stay reduces the costs. Patient-centered triangle of Hospital-Insurance- Employer yields a perfect result.
Concepts of Minimally Invasive Surgery:
1. Central Decompression:
a. Chemonucleosis: Chymopapain is injected into the disc to reduce pressure. Its indications were restricted and it is almost abandoned.
b. Nucleotomy: It is one of the intradiscal standard treatments. Intradiscal space is discharged by using mechanical instruments.
- Automatic Nucleotomy: It refers to the vacuum discharge of the disc by means of a motor.
d. Radiofrequency nucleoplasty: It refers to the denaturation of nucleus by means of radiofrequency.
- Laser ablation: Laser power is used to evaporate the nucleus.
f. LASE: Laser-assisted endoscopy: It enables camera-guided laser application into the disc with a very special probe. It is a groundbreaking procedure of treatment.2. Subannular decompression and Annuloplasty
a. Subannular decompression: It marks the beginning of the endoscopic surgery. The disc is excised from the torn annulus at a safe subannular distance.
Annuloplasty: Laser or radiofrequency is used to repair annulus. (Figure-3-4)3. Selective Discectomy: This is the final stage. Only the fragment that causes compression is excised to repair the disc and annulus. It is also possible to insert nucleus prosthesis.
Lumbar disc herniation is approached laterally under local anesthesia in prone or supine position, thoracic disc herniation is approached laterally in slightly lateral position and the cervical disc herniation is approached anteriorly.
Skin is incised 0.5-1 cm (percutaneous), special cameras with a diameter of 5-7 mm are used and the protrusion is accessed without harming the healthy anatomic structures. Only the element that compresses the nerve is excised. Disc structure is preserved and healed.
Percutaneous Spinal Endoscopy helps avoid cutting the healthy anatomic structures without bleeding.
– Percutaneous endoscopic lumbar discectomy (PELD) (Lumbar disc herniation) [Lumbar foraminoscopic, Extraforaminal distant lateral, Interlaminar]
– Percutaneous endoscopic thoracic discectomy (for thoracic herniation)
– Percutaneous endoscopic cervical discectomy (for cervical herniation)
Advantages of Percutaneous Endoscopic Surgical Treatment
– It is performed under local anaesthesia, there is no need for general anaesthesia.
– The procedure is performed through normal anatomical holes, healthy tissues are not harmed to access the disc. Therefore, there is little bleeding.
– Selective fragmentectomy (on the compressing fragment is excised- disc is preserved)
– Disc is preserved, recovery of annulus is stimulated, healing capacity is increased
– Intradiscal or extradiscal decompression can be performed.
– Provocative examination is used to find the precise location of the level in case of multi-level lumbar disc herniation.
– Root examination (probing)
– Foraminoplasty (expansion of intervertebral foramen) is possible.
– Epiduroscopy (examination of the spinal cord) is possible.
– Extraforaminal and distant lateral investigation is possible. Nerve compression outside the canal can be diagnosed easily.
– Safe percutaneous intradiscal treatment portal
– Morbid Obesity
– Cauda Equina
– Complicated herniation (with adhesions-sequestrated)
– Open surgery recurrence
– Non-compliant patients
– Bleeding Diathesis
Future Treatment Options
Percutaneous treatments, advantages of epidural region to access the disc, the advanced devices, genetic developments and robotic surgery can help us protect the normal tissues and promote better health. The treatments that are under development include but not limited to:
– Annulus repair
– Percutaneous nucleoplasty (Injection)
– Percutaneous intradiscal stem cell infusion.