Is The Scalpel More Potent Than The Needle, Catheter or Endoscope?
The use of a scalpel for the purpose of discectomy has been the surgical standard since discectomy first started. With the advent of newer and more advanced technologies there has been a continuing effort to improve patient safety and efficacy as well as decrease procedure cost. How well these varying approaches have been in accomplishing these goals is the subject of this section of the Burton Report®.
The Percutaneous Approach To The Intervertebral Disc
The percutaneous approach to the intervertebral disc has been attractive to many because it seems to be “easy.” Being a circus high wire acrobat also appears to be “easy”, but it isn’t. In other words, for the skilled and experienced spine professional, this methodology can be highly successful in selected cases.
As demonstrated by the many patient disasters which led to the withdrawal of chymopapain for nucleolysis the ability of a carpenter is more important than the nail. This dictum is universally applicable and needs to be carefully considered by any patient considering any form of minimally invasive discectomy. In the following discussions the efficacy of chymopapain (chymo) will be used as a point of reference for the other described procedures.
Automated Percutaneous Lumbar Discectomy (APLD)
Automated percutaneous lumbar discectomy (also referred to as Percutaneous Nuclectomy) was introduced by Gary Onik in 1985 as a means of providing a more safe mechanical means of physically debulking the interior of a disc.
His work was influenced by S. Hitikata of Japan who first developed the percutaneous method. APLD was recognized as being helpful in contained disc herniations and contra-indicated in non-contained disc herniations. The good news regarding APLD was its greater overall safety than chymopapain injection. The bad news was that it’s efficacy was not, in the Burton Experience, as high as some of the standard invasive therapies and that APLD’s cost was high. By year 2000 APLD was rarely performed.
In the early 1970s Parviz Kambin began to perform percutaneous nuclectomy at the Graduate Hospital in Philadelphia using his version of the Craig biopsy instrumentation popularized by Hijikata in 1975, . By the 1980s, however, Kambin had developed endoscopic instrumentation which allowed the operator to directly visualize the disc annulus and disc fragments in real time. The illustration on the left shows a mono-polar arthroscopic microdiscectomy (AMD) approach. The surgeon has the opportunity to visualize the end of the inserted tube (middle image in blue) and the annulus of the disc (middle image in red) as well as the depths of the interspace. With continued development bi-polar approaches were developed (image right) as well as the beginning of microsurgical discectomy. The good news about AMD is that in the hands of a skilled operator a true minimally invasive procedure was possible. This has been particularly for lateral free-fragment disc herniations which could often be well treated by this technique. The bad news about AMD, according to the Burton Experience, is the fact that many surgeons attempting it simply did not have the skills to do so effectively and safely for the patient and many patients, after AMD, still required a second, open, spinal surgery.
It is important to note that for the selected patient being treated by a skilled procedurist AMD can be a highly effective therapy.
Few procedures in spine care have ever matched the media & marketing hype which was associated with the introduction of chymopapain injection in the 1970s. In the area of “minimally-invasive” lumbar operative procedures” however, few have matched the M2H exploitation of the term “laser” being used in spine therapy.
The four images below are direct intradiscal endoscopic photographs. In the the last image to the right a green dye has been used to identify granulation tissue. These images shown are from the Editor’s collection.
While there are a few skilled practitioners experienced in using laser safely and effectively in spine care the Burton Experience has yet to identify many such individuals. Through the use of terms such as “thermodiscoplasty, thermoannuloplasty” and “band-aide surgery” laser discectomy has raised to new heights fraud and abuse of modern technology and has, in the process, created procedure mills designed primarily for the benefit the procedurists and not the patients.
Nucleoplasty is one of a number of minimally invasive disc procedures also developed to “debulk” a herniated disc. Nucleoplasty uses a thermal probe (Perc-D Coblation Probe) to “ablate and coagulate” discal tissue by producing a zone of coagulation which is then absorbed by the body. How much of this procedure is M2H and how much is reality is difficult to determine.
Anterior Approach Microscopic Discectomy (AAMD)
The anterior approach to the lumbar spine for the purpose of discectomy represents legitimate application of technology whose zenith has not arrived because of the long learning curve required of those who practice it and the fact that this approach goes through a “lion country” fraught with danger due to potential injury to important nerves, great vessels, ureters, lymphatics, etc.
The Burton Experience has been that these risk factors are such that AAMD has not been a commonly performed procedure.
Quite frankly the great majority of minimally invasive procedures are “investigative” in the hands of most practitioners. There does, however, exist a small group of uniquely gifted spine practitioners, usually a small group of spine specialist invasive radiologists, for whom these are “standard” procedures. Some of the most experienced procedurists belong to the InternationalSpinal Injection Society. For the patient smart enough to look beyond the media & marketing hype (i.e. the “band-aid” surgery bit) and locate a spine care specialist who understands the process of patient selection, and is actually able to make a specific diagnosis, minimally invasive might be a reasonable step forward (but only IF they are utilized when less invasive therapies fail). The Burton Experience suggests, however, that this might be a quest worthy of Diogenes of Sinope‘s search for an “honest man.”
In addition to the above it has been the Burton Experience that about 50% of those having a minimally invasive procedure require additional conventional surgery to fully address the problem. In addition, concurrent pathology, such as lateral spinal stenosis is typically not addressed in a minimally invasive procedure. The patient with a minimally invasive procedure is at significantly higher risk of developing recurrent or other problems. When all is said and done surgical discectomy (microdiscectomy or microsurgical discectomy) remains the “gold standard” of care when performed by a qualified individual (i.e. Board Certified in Spinal Surgery) on a patient who meets the criteria for such. In addition the prudent patient should always perform some “due diligence” in selecting their surgeon.