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

Discussion

The results of this retrospective review indicate that transcutaneous lumbar diskectomy is an effective treatment for internal disk derangement, with 63% of patients achieving an excellent or good subjective outcome. The current accepted treatment method after failure of conservative treatment of internal disk derangement has been spinal fusion. Although many studies have reported results after spinal fusion, only a few studies report the results specific to patients with a diagnosis of internal disk derangement.[13,14,15,16,17,18] Two of the studies included outcome ratings similar to those used in the present study, which evaluated pain, return to work and daily activities, and use of narcotic medication. Parker et al[18] reported their results of posterolateral fusion in patients with diskogenic low back pain and found 39% good or excellent results and 48% poor results. Blumenthal et al[13] analyzed their results of anterior lumbar fusion for patients with internal disk disruption and found that 73% of patients had a successful result, which was defined as the ability to return to work and normal activities and no use of narcotic pain medication. Other studies evaluating clinical outcome of spinal fusion for patients with internal disk derangement report 86% to 89% satisfactory subjective results, but the studies do not give sufficient information regarding the rating system; therefore, their results cannot be compared with those in the present study.

The spinal fusion studies do report a pseudarthrosis rate of 6% to 27%.[13,16,17,18] Other reported complications of spinal fusion include graft extrusion, retrograde ejaculation, hematoma, pulmonary embolism, persistent pain at the graft site, and peroneal nerve palsy.[13,15,16,17,18] Many investigators have attempted disk decompression through percutaneous means with the hope of decreasing morbidity and complications. Multiple studies[1,3,19] report less than 1% diskitis, successfully treated by antibiotic care, as the only significant complication observed thus far. Thus, there seems to be a consensus that procedures of this sort involve less morbidity than standard open operative treatment of certain disk injuries. Techniques similar to that used in this study involve mechanical removal of disk material via modified pituitary rongeurs inserted through percutaneously placed tubes. Such techniques achieved a success rate of 70% to 85%, an overall statistic with which I concur; however, those results were found when investigating treatment for lumbar disk herniations,[11] and the procedure has not been previously considered effective for internal disk derangement.

In the present study, patients had low back pain with or without leg pain, but the classic physical findings of sciatic nerve irritation were only incidental considerations. Several reports[3,4,11] emphasize that the indications for percutaneous lumbar diskectomy include the following: (1) unilateral leg pain greater than or equal to back pain; (2) paresthesia in a specific dermatomal distribution; (3) positive straight leg raising test and/or positive bowstring sign; (4) neurologic findings of muscle wasting, weakness, sensory change, or reflex abnormality; (5) lack of improvement after conservative care; and (6) positive MRI and/or computed tomography showing subligamentous nuclear herniation at a location consistent with clinical findings. In the current study, lumbar diskectomy indications number 5 and 6 were strictly observed while numbers 1 through 6, if present in any given patient, were incidental findings only.

Usual contraindications for transcutaneous lumbar diskectomy include spinal stenosis, calcified disk herniation, severe degenerative facet disease without disk disease, radiographic evidence of free or extruded disk fragments, clinical evidence of significant progressive neurologic deficits and/or cauda equina syndrome, or existence of other conditions, such as fracture, tumor, pregnancy, or active infection that would place the patient at risk.[9,11] I was constrained by these same contraindications. Other suggested contraindications include advanced age, workers' compensation cases, multilevel disk surgery, and litigation.[3,9] The use of transcutaneous lumbar diskectomy has been discouraged for patients with internal disk derangement.[3,4,12]

Although the patient population used for this study stands clearly isolated from what had been previously accepted as candidates for transcutaneous disk resection, I believe the results justify the use of the technique for patients with internal disk derangement. The selection criteria, though clinically less stringent than previously recommended for this procedure, included a longer than usual trial of conservative care. The time from onset of symptoms to surgery was from 4 to 82 months, with the mean time being 15 months.

The results in this study also showed no statistically significant difference with regard to sex, workers' compensation status, and multilevel surgery. There was a statistically significant difference with regard to age. Clinically, among patients ≤60 years old, only 16 of 98 patients had a poor subjective outcome. I believe the transcutaneous lumbar diskectomy procedure is still an efficacious option for carefully selected patients more than 60 years old.

The limitation of this study was that patients were interviewed retrospectively and treatment was not randomized. This report is of 103 consecutive patients who had a diagnosis of internal disk derangement treated by one method -- transcutaneous lumbar diskectomy. I believe the results of this study can be compared with similar studies of spinal fusion for the treatment of internal disk derangement.

Strict guidelines were followed during the course of conservative treatment before operative treatment was considered. The results of this study lead me to recommend the following indications for using the transcutaneous lumbar diskectomy procedure:

  1. Significant subjective pain affecting quality of life.

  2. No improvement after at least 4 months of conservative treatment.

  3. MRI and/or diskogram studies showing respectively dessication and/or radial tears or fissuring (constituting evidence of internal disk derangement) at locations consistent with clinical findings and subjective complaints.

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