NUANCES IN PERCUTANEOUS DISCECTOMY - 09/09/11
Résumé |
It has been more than 12 years since we published the initial article introducing automated percutaneous lumbar discectomy (APLD).7 At that time, there was tremendous resistance to the concept of a minimally invasive treatment for herniated lumbar discs. Chemonucleolysis had been rushed onto the scene with great fanfare, only to be destroyed by the occurrence of devastating complications, such as transverse myelitis. In effect, at that time there essentially was no field of minimally invasive lumbar spine surgery.
Thomas Paine, in his essay Common Sense, wrote “time makes more converts than reason.” It can now be said that the concept of minimally invasive lumbar spine surgery, personified by APLD, has stood the test of time. Percutaneous discectomy, with the lead of APLD, gained its own CPT code and with it left behind the “twilight zone” of experimental procedures, paving the way for payment by third party payers. Those most adamantly opposed to the concept of minimally invasive spine surgery, the neurosurgical community, recently sponsored the January 1996 issue of Neurosurgical Clinics of North America on the subject giving it further legitimacy.
APLD, although perhaps not reaching its full potential in volume of cases performed, has had a significant impact on the evolution of this field, being extremely successful in achieving its major goal, that of safety. The original goal of APLD was to have a highly safe, minimally invasive treatment for lumbar disc herniations with an associated reasonable success rate. At this time, there have been over 140,000 APLD cases performed (this number is probably underestimated due to the fact that the disposable instrument has been routinely resterilized outside of the United States) with a mortality rate of zero, there never having been a reported death associated with the procedure. In over 50 published series, there has been no instance of permanent nerve injury or great vessel damage, the only reported complication being a discitis rate of 0.2%, equivalent to that of discography.10 It can now be said unequivocally that APLD is the safest treatment for herniated lumbar discs. Contrast this with open discectomy, or even microdiscectomy as outlined in a study by Ramirez and Thisted,15 in which the complication rate associated with 28,000 open discectomies was examined. In this study, there was a major complication in 1 in 64 patients, with major neurologic complication associated in 1 in 334 patients; 1 in 1700 patients died from the procedure. In another prospective study by Stolke et al,17 the intraoperative complication rate associated with lumbar discectomies carried out by experienced neurosurgeons was examined. In 481 procedures a complication rate of 14% was reported, including one death, three nerve injuries, and a discitis rate of approximately 1%.
The use of the operating microscope and the decreased size of the resultant incision, constituting the so-called microdiscectomy, has not appreciably decreased the complication rate associated with lumbar spine surgery as indicated by the article published by Pappas et al.13 In 654 microdiscectomies, there were two major vascular injuries, one of which resulted in death. A major bowel injury was also reported. It was basically in response to this situation of high morbidity lumbar disc surgery that APLD was successfully developed.
Theoretically, APLD works by centrally decompressing the nucleus pulposis, with that decreased pressure transmitted through the rent in the annulus to the herniation. This results in decreased pressure on the affected nerve. The success rate of any percutaneous procedure based on the concept of central disc decompression is, therefore, highly dependent on selecting patients with pathology that is amenable to such an approach. The success rate of APLD has been reported anywhere from 43% to 85% depending on the patient's selection criteria.2, 16 It is the balancing of the very low morbidity associated with APLD that makes it competitive, in certain patient populations, with open discectomy, which reports higher success rates of over 90%. It is of interest, however, that when microdiscectomy is examined in a prospective fashion with the criterion of patient satisfaction being included, the success rate falls to approximately 75%, very similar to the percutaneous methods.14
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| Address reprint requests to Clyde Helms, MD, Department of Radiology, Duke University Medical Center, Durham, NC 27710 |
Vol 36 - N° 3
P. 523-532 - mai 1998 Retour au numéro
Article précédent
- PERCUTANEOUS EPIDURAL AND NERVE ROOT BLOCK AND PERCUTANEOUS LUMBAR SYMPATHOLYSIS
- Steven C. Link, Georges Y. El-Khoury, W. Bonner Guilford
- PERCUTANEOUS VERTEBROPLASTY WITH POLYMETHYLMETHACRYLATE : Technique, Indications, and Results
- Hervé Deramond, Claude Depriester, Pierre Galibert, Daniel Le Gars
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