What is a Percutaneous Discectomy?

Percutaneous Discectomy is a class of minimally invasive surgical procedures designed to treat symptomatic herniated discs. Lumbar disc herniation or protrusion is the most common cause of nerve root pain and accounts for nearly 5% of all low back pain (1). Herniated discs are initially treated with conservative treatment, which includes rest, avoiding any aggravating activity, physical therapy, chiropractic care, and medical treatment (anti-inflammatory medications, oral steroids, muscle relaxers, and opiates). In some cases, the disc may heal effectively without further intervention. Epidural steroid injections may be performed for diagnosis and treatment of the nerve root inflammation (radiculitis) after conservative treatment fails.

Traditionally, the definitive treatment for a herniated disc has been open discectomy. Because of surgical risks, more minimally invasive measures have been researched for contained disc herniation, like percutaneous discectomy. Percutaneous discectomy can be beneficial for many, but surgery is absolutely indicated when new bowel/bladder problems or progressive weakness are involved.
The first percutaneous approach targeting the disc was documented in the 1950s for biopsying the disc (2), and the first manual percutaneous discectomy for disc decompression was introduced in the 1970s (3). In the 1980s and ‘90s safer, smaller needles were used to develop Nucleoplasty, Percutaneous Laser Discectomy, Automated Percutaneous Lumbar Discectomy, and the Mechanical High RPM Device by Stryker known as the Disc DeKompressor. We will further discuss these different technologies below.

Percutaneous Discectomy is also known as Dekompressor (Stryker) is a non-surgical, effective treatment for back and neck pain associated with herniated disc disease. The pain relief associated with this therapy is due to decompression of the spinal discs and facet joints, thus reducing the pressure exerted onto the spinal cord and nerve roots causing pain (Boswell 2007). Separating each individual spinal vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. Since the discs are designed to be soft and provide support, they have a tendency to herniate posteriorly (bulge backwards) through the outer disc segment and ligaments. These bulging discs can cause irritation to the adjacent nerves. Disc disease is one of the most common causes of chronic neck and back pain and accounts for approximately 10% of all lower back pain complaints. Disc disease may be acute, herniation resulting from trauma, or more commonly from chronic disease. Degenerative disc disease is a process, which is due to a thinning and degeneration of the discs over time. Commonly seen, neck and back pain may go into painless remission with periods of decreased or absent symptoms, however, the pain often returns causing a chronic pain syndrome. If your pain has lasted longer than four weeks or is severe in nature you should see a pain specialist about treatment options. Ongoing research has hinted that early intervention decreases the incidence of developing chronic pain. Decompression therapy is often considered when the pain has not improved after a month and is radicular, resulting from irritation of the nerve roots.

Anatomy

The human backbone or spinal column consists of 33 individual vertebrae that surround and protect the spinal cord.

Each vertebrae is separated by an intervertebral disc, which is a soft cushion that provides support and absorbs the stress that the vertebrae receive during daily activities. The disc consists of an inner, gel-like substance called the nucleus pulposus, and an outer fibrous membrane called the annulus fibrosus. A herniated intervertebral disc results from the weakening and bulging outwards of the annulus, and protrusion of the nucleus, which most commonly occurs posteriorly or backwards. The spinal disc is in close vicinity to the nerve roots as they branch from the spinal cord and exit between the vertebrae. Therefore, a disc protrusion in the lumbar spine may compress one or more nerve roots causing pain to radiate into the back or legs (4). Disc herniation is classified into a few different conditions depending on the severity of injury. A protrusion, or contained herniation, occurs when the inner disc material bulges, but does not rupture the annulus. An extrusion occurs when the annulus is ruptured but any expelled nucleus is not completely severed from the disc. An extreme condition is a sequestered disc, in which the pulposus is expelled from the disc and is no longer attached to the disc. An extrusion or sequestration is considered a non-contained herniation. Counter intuitively, the severity of symptoms does not always correlate with the extent of the herniation (5). Discs have the propensity of herniating either acutely as the result of traumatic injury (i.e. fall or accident), or secondary to chronic strain and degeneration. The nucleus pulposus becomes dehydrated over time, which decreases its effectiveness as a shock absorber, and the annulus fibrosus loses its elasticity which increases the incidence of tearing. Thus, the spinal discs become more prone to injury with age.

Procedure

Percutaneous Discectomy uses a single-use probe called the “Stryker Dekompressor” which is placed under x-ray guidance. You will be pre-treated with a sedative that will help you to relax, but you will remain awake for the procedure. Before the treatment begins, you will be comfortably positioned on your stomach, with your knees supported on the table. Your physician will inject a local anesthetic with a small needle to numb the area. Once the area is numb, a larger needle is placed into the affected disc with x-ray guidance. The probe is placed through this needle and the procedure is initiated. You may feel pressure during this part of the procedure, but should not experience pain. The Dekompressor uses a pump method to remove excessive disc material from bulging or contained herniated discs, thus reducing pressure in the disc and providing pain relief.

Percutaneous Discectomy is typically done with IV sedation instead of general anesthesia, thus allowing the patient to provide feedback to the physician and avoid the risks involved with general anesthesia. Patients are positioned comfortably face down for the procedure. After a sterile cleaning of the area, a local anesthetic is injected to numb the area. During the procedure the patient is likely to feel some pressure, but should otherwise have minimal pain. A cannula is then carefully placed into the disc with x-ray guidance. A probe is then introduced through the cannula and the pressure placed on the nerve roots is decompressed by various methods. Nucleoplasty combines coagulation and tissue ablation to form channels in the nucleus and decompress the herniated disc (6, 7). Percutaneous Laser Discectomy utilizes nuclear vaporization through heat generated by a laser. Its hypothesized mechanism is changing the pressure between the nucleus pulposus and the peridiscal tissue causing a retraction of the herniation away from the nerve root (8, 9, 10). In Automated Percutaneous Lumbar Discectomy, a pneumatically driven, suction-cutting probe results in a reduction of intradiscal pressure and decompression of the nerve root compression. (11). Lastly, the DeKompressor probe is a “mechanical high rotation-per-minute device designed to extract the nuclear material through an introducer cannula using an auger-like device that rotates at high speeds” (12).

Benefits

Percutaneous Discectomy has been proven to be a safe and effective treatment for select patients with lumbar disc herniation who have failed conservative treatment. Two studies have precisely replicated results showing that Manual Lumbar Percutaneous Discectomy is 88% effective in relieving sciatica in the setting of disc protrusion (13, 14). Another large study of over 1,000 patients found Automated Percutaneous Lumbar Discectomy had excellent results and extremely low complication rates in 79% of patients with discogenic low back pain (15). Multiple studies have also indicated that patients experience much improved functional status after Percutaneous Discectomy. In a study of 1,525 patients with lumbar disc herniation or back pain that failed conservative therapy, 84% of participants were symptom free with no restriction in daily activities, or greatly improved symptoms while they returned to work after Percutaneous Discectomy. A study of radicular pain radiating down one’s leg(s) found that 88.1% of patients were very satisfied with the results of Percutaneous Discectomy while achieving a dramatic improvement in their functional status (90.5%), and reported no procedure related complications (16).

A discectomy using the Dekompressor is a lower-risk treatment option for neck and back pain. The procedure may decrease pain, increase mobility, and eliminate the need for traditional surgical interventions. This treatment is designed to correct the underlying problem, not just relieve the symptoms. The procedure is a minimally invasive procedure that causes much less scarring and fibrosis that is commonly associated with other interventions. A study reported in 2007 “discectomy is minimally invasive, safe and effective for treating disc herniations and that 89% of patients treated by this method stated they achieved successful outcomes from the therapy“ (Tzaan 2007).

A 1998 study found that nucleotomy is an “effective and safe alternative to open disc surgery in the treatment of patients with a small prolapse or a small protrusion who have not responded to conservative treatment” (18). Subsequently, in 2005, a study concluded that “significant pain relief, functional improvement, and a decrease in medication use were achieved following nucleoplasty” (19). Multiple other studies have found that nucleoplasty produced good outcomes in patients with Lower Back Pain and/or leg pain that already failed conservative treatment (80%, and 88% respectively) (20, 21). A 1996 study concluded that Percutaneous Laser Discectomy is a “safe and successful alternative for the treatment of patients with a small to moderately sized herniated nucleus pulposus” (9). Later, in 2003, another publication reported that 74% of 200 patients were satisfied with outcomes, suggesting laser is a safe and effective method to treat symptomatic contained intervertebral disc herniations (22).

A recent study found that 72% of patients presenting with lumbar discogenic disease and treated by percutaneous discectomy using the DeKompressor system experienced a decrease in pain of more than 70%. The same study noted the location of the hernia affected the outcome, as disc protrusions in the posterolateral foraminal or extraforaminal location had better outcomes as opposed to posteromedian disc protrusion. (23)

Overall, advantages of Percutaneous Discectomy vs. open discectomy may include a shorter recovery, decreased epidural scar formation, avoidance of general anesthesia, preservation of spinal stability, and decreased cost (11). “Less pertinent scarring and less postoperative fibrosis may be expected” with the DeKompressor (25). When compared to microdiscectomy, Percutaneous Discectomy patients had a higher satisfaction and comparable clinical results (24).

Risks

With lower risks than traditional back surgery, Percutaneous Discectomy is considered an appropriate treatment for many patients who suffer from back pain (12). The most common complaint is mild back pain at the injection site shortly after the procedure. Extremely rare but more serious complications may include spinal cord compression, bleeding/hematoma, or infection, which are decreased by the use of x-ray guidance and sterile technique.

General contraindications for Percutaneous Discectomy are bone spur impingement on the nerve root, previous surgery with scar tissue, nerve entrapment, spondylolisthesis, bony spinal stenosis (8, 10,) non-contained disc herniation, disc sequestration or extrusion, infection, Cauda Equina syndrome, newly developed neurological deficit, and uncontrolled coagulopathy or bleeding disorders (26).

As with all medications and surgical procedures, there is always a risk of complications. With lower risks than traditional back surgery, discectomy is considered an appropriate treatment for many patients who suffer from back pain (Boswell 2007). The most common complaint is mild back pain at the injection site shortly after the procedure. Other more serious and far less common complications include spinal cord compression, excessive intracranial pressure, bleeding, hematoma, or infection. These particular risks are decreased by the use of x-ray and sterile technique.

The American Society of Interventional Pain Physicians developed a large evidence-based practice guideline for the management of chronic spinal pain with interventional techniques. The 2007 article stated that for percutaneous discectomy using the Dekompressor resulted in greater than 70% improvement in pain in 79% of patients undergoing the treatment for postero-lateral disc herniations. (Boswell 2007). The reduction in pain allows patients to experience enough relief to become active again. Often patients regain the ability to resume their normal daily activities.

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