A total of 100 consecutive cases aged 19-65 years operated by the MED procedure for L4-5 or L5-S1 PIVD from August 2002 to December 2005 were retrospectively evaluated for the result. All the cases were operated on by a single surgeon. The inclusion criteria were patients having lumbar disc prolapse with unilateral radiculopathy, on clinical evaluation, positive straight leg raising test and identification of a single nerve root lesion. Any patients with bilateral symptoms, double root involvement and cauda equina syndrome were excluded. On imaging, types of disc operated were all posterolateral discs including sequestrated (n=18) or migrated and selected central discs (n=8) with unilateral symptoms. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases (n=7) to isolate the single root lesion when MRI was inconclusive. All patients were operated only after proper conservative management for minimum 6 weeks which consisted of rest, modification of activities, physiotherapy and analgesics and anti-inflammatory drugs. The duration of symptoms ranged from 6 weeks to 8 years. The surgery was done by the Metrx system of Medtronic.
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All the procedures were done under general anesthesia. The patient was placed in prone position on either bolsters or a spinal frame, with the abdomen free and the spine flexed to open the interlaminar space. The surgeon stood on the side of the disc prolapse, the TV monitor was at the head end and IITV on the opposite side. A flexible arm assembly was attached to the operating table rail to hold the tubular retractor with an endoscope in a stable position, freeing the surgeon's hands.
The incision was marked in AP and lateral projection in IITV. The guide wire entry point is the key for the port and we checked the wire in IITV. In AP projection it should be at the inferior edge of the superior lamina and in lateral projection, it should be parallel to the disc space [ ]. Once the entry point was marked about 1-1.5 cm lateral to the midline, an 18-mm skin incision was made. The subcutaneous tissue and fascia were incised. The first dilator was introduced over the guide wire and the guide wire was then removed. The dilator was docked over the lamina and medial, lateral, superior, and inferior edges of the lamina were felt and the muscles were separated subperiosteally. The other dilators were sequentially introduced over the first dilator. This sequentially dilated the paraspinal muscles. The 18-mm tubular retractor was introduced over the last dilator and the final position was checked under IITV [ ].
The endoscope was connected to the coupler, camera, and light source. The whole assembly was introduced through the tubular retractor and the coupler was fixed to the outer margin of the tubular retractor.
Once the endoscope was inserted the first step was the orientation of the image. A proper image orientation occurs when the underlying anatomy show the medial part on the top of the screen (12 o'clock) and the lateral one on the bottom (6 o'clock). One could accomplish this by placing a surgical instrument in a lateral position and then rotating the orientation ring on the camera/coupler until the instrument appears to be on the bottom of the video screen. The inferior edge of the lamina [ ] was identified after removing the soft tissues by coagulation and rongeur. The ligamentum flavum below the inferior edge of the lamina was identified and with the help of penfield the space was created between the flavum and the lamina. The overhang lamina was removed with the help of Kerrison rongeur till the edge of the flavum is reached. The flavectomy is done by punches after protecting it from the underneath dura. If required for this maneuver the flexible arm could be loosened to move the tubular retractor up and down. This was called “wanding” of the retractor. Once the flavectomy was done, the dural margin and nerve root were identified [ ]; the nerve root was then gently retracted. If there was large disc, tight root, sequestrated disc or lateral recess stenosis, the laminoforaminotomy could be widened for adequate root decompression. After retraction of the root, epidural dissection was carried out. The veins could be coagulated with bipolar coagulation. Once the disc space was reached, the sequestrated pieces could be removed or if annulotomy was required then it could be carried out with a micro-knife [ ]. Any loose pieces inside the disc space were removed with disc forceps. After discectomy, the final check of the root mobility was done. Entry port needs to be planned accordingly. Sometimes wanding of the scope was required to reach the site of sequestration or angulation required for reaching the central disc area.
Closure was done after a thorough wash and the dura was covered with a gelfoam. The scope was removed and the lumbodorsal fascia was sutured. Subcuticlar skin sutures were taken and dressing was applied.
All the patients except three were operated by an 18-mm tubular retractor. After enough experience with an 18-mm port, the last three patients were operated by a 16-mm tubular retractor. The patients were allowed to walk as soon as the patient was comfortable and surgical pain decreased. The patients were discharged between 24-48 h. Patients were encouraged walking till pain tolerance for 3 weeks. They were allowed all activities except bending forward, lifting weight and sitting for more than 30 min. Bending forward and lifting weight were restricted till 3 months postoperative. They were allowed to return to work after 3 weeks. The patients were followed up after 2, 6 and 12 weeks. The mean follow up was 12 months, (range 3 months-4 years). They were evaluated for symptoms of back pain, leg pain, and neurological deficit. Any new symptoms, complications of surgery, or the need for conversion to open surgery were also evaluated. The results were graded as excellent, good, fair, or poor depending on relief of back and leg pain, use of analgesics, and any complications. We have used modified Macnab criteria for grading the results. Excellent - no pain/restriction of activity and being able to do all activities; good - occasional pain with relief of presenting symptoms and returning to work with some modification; fair - some improved functional capacity but still handicapped or unemployed and poor results-having objective symptoms of root involvement or repeat surgery at the index level. The results were reviewed by the authors and not by an independent reviewer.
Ortho Sport & Spine Physicians is a leading provider of minimally invasive spine surgery and endoscopic discectomy surgery. We are an orthopedic and spine practice featuring a dedicated team of interventional spine physicians and orthopedic specialists who specialize in finding solutions to chronic and acute pain conditions and injuries. Our double board-certified physicians are highly skilled and experienced in performing minimally invasive spine surgery procedures, including endoscopic discectomy. By combining state-of-the-art technology and equipment with our surgical expertise, we are able to help our patients with herniated discs find long-term relief from their pain and other symptoms and return to an active and healthy lifestyle.
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Ortho Sport & Spine Physicians is pleased to offer expert minimally invasive herniated disc treatment to patients nationwide. If you suffer from pain and other symptoms due to a herniated disc and non-surgical treatments have failed, you may be a good candidate for this outpatient procedure. Endoscopic discectomy offers many advantages over traditional open back surgery, including fewer chances of complications, less post-operative pain and a shorter recovery time. With endoscopic discectomy, the spine remains intact and there is little chance of scar tissue development. This has important implications for the long-term success of the procedure.
What is an endoscopic discectomy? An endoscopic discectomy is a highly effective and minimally invasive treatment that can be used to relieve the pain caused by a herniated, protruded or extruded disc. The procedure involves inserting an endoscope into a small incision in the back under the guidance of a fluoroscope to remove a small portion of the affected disc or to push it back into place. Endoscopic discectomy is an outpatient procedure and takes an average of an hour to complete. After the surgery, patients can return home with a small band-aid placed over the incision.
If you would like to get more information or find out if you are a candidate for this minimally invasive surgical procedure, please contact the Endoscopic Discectomy Specialists at Ortho Sport & Spine Physicians today and schedule a consultation with one of our interventional spine physicians. For your convenience, we accept most insurance plans as well as several other forms of payment. We look forward to helping you stay active and live your best life!
Please note how small the incisions are compared to my index finger. Remember: a traditional, open 2 level discectomy had a 5 to 7 inch long incision.
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