frequent procedures
PERCUTANEOUS DISK
DECOMPRESSION
The
history of disk surgery dates back to 1934, when open surgical
procedures were used to remove disk material in order to relieve
radicular pain due to disk herniation. The pioneers of this
technique include William J. Mixter, M.D, and J.S. Barr, M.D. At
that time, they published an article in The New England Journal of
Medicine, in 1934 that dealt with the procedures that they were
doing. The principle was based on the suggestion that relieving a
biomechanical compression of a nerve root, which is next to a disk
herniation, can achieve pain relief for the patient regarding low
back pain and leg pain. However, in the past several years, and with
the advent of the CT scan, the MRI and the previous availability of
the myelogram, it has been noted that a disk herniation site and
surgical excision had a correlation with eventual surgical outcome.
In other words, in one situation it was found that disk
Anesthesia Machine
herniation measuring less than 6 mm had a
success rate of only 24 percent after discectomy, compared to a
success rate of 98 percent for patients with a 9 mm or larger disk
herniation. This has been, for many years, one of the guiding
principles on which modern neurosurgeons made a decision as to
whether or not to operate when a patient presents to them with
radiologic evidence of disk herniation or bulge as documented in the
MRI, myelogram or CT scan study. Clinical experience has shown many
surgeons that an open surgical excision of a small herniated disk or
protrusion does not typically result in a significantly beneficial
outcome.
In 1944, the first
steps in percutaneous disk decompression, or minimally invasive
decompression of a herniated disk started with E.F. Jansen and A.K.
Balls, who published their experience using the enzyme chymopapain
from crude papain, a proteolythic enzyme from papaya latex. Further
studies showed that chymopapain had a selective affinity for
chondromucoprotein, which is found abundantly in the middle of the
disk within the jelly component called the nucleus pulposus.
Injection of chymopapain into the middle of a herniated disk was
able to chemically result in hydrolysis of the chondromucoprotein
portion of the nucleus while the surrounding tissue was not
affected. This finding led to use of that same agent for treating
herniated nucleus pulposus with significant success rates ranging
from 66 percent to 88 percent success. Another agent, other than
chymopapain, that was useful includes collagenase. Chymopapain was
abandoned as a technique because numerous reported incidents of
transverse myelitis and anaphylactic shock.
Following this initial foray, surgical techniques were evolved and
used to achieve disk decompression.
Percutaneous disc decompression a minimally-invasive surgery
approach to pain management is accomplished by four different
techniques today namely:
-
Nucleoplasty:
Nucleoplasty is used synonymously with percutaneous disk
decompression method using
coblation
technology, the most notable of which is the Perc-DLE
SpineWand decompression catheter. In this procedure, low-grade
radiofrequency
energy is used to dissolve nuclear material through molecular
disassociation, changing the internal environment of affected
nucleus pulposus, or the jelly portion of the middle of the
disk. The procedure is usually done under monitored anesthesia
care or light general anesthesia in a hospital setting and
results in a small reduction of volume of the nucleus pulposus
through altering the long chain of the proteoglycan content of
the nucleus pulposus. This results in a loss of water-binding
capacity and eventually reduction in the volume or content of
the nucleus pulposus (middle of the disk). This reduction
results in a disproportionately large drop in the pressure
within the disk itself and results in clinically significant
retraction of the herniation from the nerve root concerned with
symptomatic relief being achieved. This procedure has very low
incidence of side effects or complications. Potential
complications, however, may include discitis and nerve root
irritation during an attempt to gain access to the nucleus
pulposus, especially as the patient may be under general
anesthesia. The success rate is high and the pressure gradient
between the nucleus pulposus and the peri-discal tissue tends to
result in both clinical and structural improvement in the
herniation, protrusion or bulge in the level affected. This kind
of procedure is best being done in patients with small or medium
herniation size without any disk fragment or extruded disk being
present or contributing to the pain experience. This
nucleoplasty technique can also be used to treat patients with
positive provocative discography in association with some disk
protrusion, bulge or herniation who are not good candidates for
open surgery techniques. Dr Ogoke has extensive experience using
this technique.
-
Percutaneous
discectomy, the best known of which is
the
dekompressor. The percutaneous decompression technique is
achieved through a cannula inserted through the annulus fibrosis
from a posterolateral approach under light and general
anesthesia, or monitored anesthesia care, followed by mechanical
decompression technique and approval of the material of the
nucleus pulposus from the disk itself to achieve a reduction in
volume of the nuclear material in the nucleus pulposus as well
as the decompression of the disk's pressure in the disk that is
herniated. This frequently achieves significant pain reduction
in patients. Dr Ogoke uses this technique.
-
Laser-assisted
disk decompression. Laser-assisted
disk decompression is usually done using the Ho:YAG laser. The
best known is the
Lase. The laser technique can be effective but has been
shown to have increased morbidity in the surrounding tissue at
which the procedure is done to achieve decompression of the
disk. The exact extent and frequency by which this microscopic
morbidity will clinically affect the patient has not been
extensively studied.
-
Radiofrequency
(electro-thermal) discoplasty. The
latest technique of decompression of the disk internally using a
percutaneous approach is the radiofrequency discoplasty, in
which the patient's nucleus pulposus is entered
via
a posterolateral approach under fluoroscopic guidance and an
IDET-type electrothermal catheter, with a smaller length of
exposed electro-thermal units, is advanced to a position to lie
next to the area of herniation in the posterior portion of the
disk on the posterolateral or central portion of the disk. The
area is then heated with radiofrequency waves to achieve
denaturation of the affected area and achieve pain resolution.
In selected cases, this technique can also be highly beneficial.
The procedure is also done under light general anesthesia or
monitored anesthesia care in a hospital unit. The product
manufacturer is the
Smith &
Nephew Company. Dr Ogoke has experience with this technique
as well.
SUMMARY:
In summary, the various techniques available for percutaneous disk
decompression are modern, minimally-invasive techniques that allow
the patient to receive good quality care in a short procedure done
in an outpatient basis with minimal blood loss and minimal
postoperative pain as well as minimal scar formation and rapid
recovery. Long-term sequelae of open lumbar laminectomy, as well as
the problems associated with loss of architectural stability when
extensive laminectomies are done, is thereby avoided. The patient,
therefore, tends to do better both short-term and long-term with
minimal morbidity and rapid return to normal function. The most
commonly used techniques in Pioneer Valley Pain Management include
the coablation or nucleoplasty, the dekompressor and the RF
(radiofrequency) discoplasty techniques. These procedures carry an
acceptable low morbidity and low complication rates.
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