Transcutaneous Lumbar Diskectomy for Internal Disk Derangement: A New Indication

Richard A. Marks, MD, Baylor/Richardson Medical Center, Richardson, Tex

South Med J. 2000;93(9) 

In This Article

Abstract and Introduction

Background. Percutaneous diskectomy has been used effectively to treat lumbar disk herniation. The purpose of this review was to determine whether transcutaneous diskectomy is an effective surgical option for treating lumbar internal disk derangement.
Methods. Comprehensive retrospective review via personal interview included 103 consecutive patients available for long-term follow-up. For determining results as excellent, good, fair, or poor, the criteria included subjective relief of back and/or leg pain, ability to perform preinjury job functions, residual physical restrictions, use of medications, and need for subsequent surgery. Factors affecting results were statistically analyzed.
Results. The overall success rate was 83%, with no statistically significant differences in results based on sex, workers' compensation status, or levels of diskectomy.
Conclusions. The favorable results from this series illustrate the high success rate of transcutaneous lumbar diskectomy in a heterogeneous patient population. Coupling the rate of success with a low rate of complications, transcutaneous lumbar diskectomy appears to be an effective, minimally invasive treatment for internal disk derangement.

Low back pain with or without sciatica is a major cause of morbidity throughout the world. Up to 80% of the population may complain of at least one episode of acute low back pain during their active lives.[1] The annual incidence is estimated at 5%, with associated costs thought to exceed $16 billion annually.[2] In many cases, these symptoms are attributed to disk alterations such as herniations through the annulus fibrosus. Much more frequently, when a diagnosis is pursued radiographically, no such herniations are seen. The evaluations in such cases would tend to indicate either soft tissue involvement alone, or an injury to the inner structure of one or more disks.

Physician care for patients who have low back pain with or without sciatica dictates reduction or elimination of pain while incurring the least risk and morbidity.[3] Noninvasive approaches are becoming increasingly popular with the associated diminished potential for blood loss or soft tissue destruction,[4] as well as shorter hospital stays and lower subsequent total costs. Sherk et al[5] reported pain reduction with use of Holmium laser disk decompression. Numerous authors have investigated the lower costs and morbidity with relatively high success rates of outpatient procedures, ranging from chemonucleolysis to arthroscopic microdiskectomy.[6,7,8] Hijikata[9] was the first to describe percutaneous nucleotomy for a lumbar disk herniation. His technique involved manual removal of the nucleus pulposus with forceps introduced into the disk through cannulas up to 5.5 mm in diameter. In 1985, Onik et al[10] introduced a more refined approach to removing the nucleus from herniated lumbar disks. With a small (2 mm) diameter automatic probe, Onik's technique permitted a procedure involving greater convenience and less morbidity than the manual resection technique of Hijikata. It was proposed to be safely and effectively used after failure of conservative therapy when treating herniated lumbar disks and to be used as a treatment option before more invasive techniques, such as lumbar laminotomy, laminectomy, microdiskectomy, or lumbar fusion.

Literature supports this basic approach as a reasonable alternative to traditional open surgery for a herniated nucleus pulposus[11] but does not support its efficacy for internal disk derangement.[12] The purpose of this study was to determine the results of transcutaneous diskectomy for patients who had a diagnosis of internal disk derangement.

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