ENDOSCOPIC LUMBAR DISCECTOMY

Full endoscopic lumbar discectomy is a minimally invasive surgical procedure. In other words, it is a surgical procedure performed with a very small skin incision. Patients suffering from herniations that cause back-leg or neck-arm pain, stenosis that causes nerve compression of the spine, or spinal canal stenosis can be treated with endoscopic spine surgery. This method was first applied in the lumbar region and is most commonly applied in the lower back. Spine endoscopy in the lumbar region is most commonly known as ”Percutaneous Endoscopic Lumbar Discectomy” (PELD). In endoscopic lumbar discectomy, the endoscope (camera) allows the surgeon to reach the targeted area through a skin incision that is the size of a keyhole. For this reason, this procedure is also called “keyhole surgery”. When reaching the targeted tissue, the surrounding soft tissue and muscles are expanded with tissue expanders instead of being cut. This allows the surgery to be performed without damaging surrounding tissues. As a result, there is less postoperative pain and a faster recovery period and return to daily life. This surgery eliminates the need for general anesthesia and can be performed under local anesthesia. Because of the clear image obtained with the endoscope, the surgeon can correct the specific pathology that is causing the patient pain without damaging the healthy parts of the spine.

ABOUT THE PROCEDURE

The general principles of endoscopic lumbar discectomy are similar to arthroscopy procedures performed in other joints. The surgical field is inflated with water by continuously providing physiological serum to the field and bipolar radiofrequency (RF) is used to stop small bleedings, shrink the disc tissue and burn inflammatory and granulation tissues.

With advancements in technology and surgeon experience, endoscopic lumbar disc herniation surgery can be performed using two different techniques: monoportal and biportal. In both techniques, the procedure time varies according to the procedure performed, but the average surgery time is approximately 30-60 minutes on average. A 0.5-1 cm skin incision is made as the entry point. This entry point from the skin varies according to the area of the procedure and approach being used.

There are two main surgical approaches used in the lumbar (lower back) region in the monoportal technique. The first is the “posterolateral-transforaminal” approach, where the surgeon enters the spine through the foramen (the holes where the nerve roots come out of the spine). This procedure is performed with a certain inclination, approximately 10-13 cm from the spine. The second approach is called the “interlaminar” approach, which is entered from just behind the spine.

Deciding on which of these two approaches will be used in a patient’s surgery depends on the surgeon’s experience and the level on the spine that the procedure will be performed. This decision is made using an X-ray device called a fluoroscopy in the operating room. The transforaminal approach can be performed under local anesthesia and sedation, and does not require general anesthesia. This is a great advantage, especially in elderly patients who have health problems that prevent them from using general anesthesia. Sedation provides the patient with sufficient comfort during the operation and allows the patient to be able to move their legs, allowing the doctor to communicate with the patient during the procedure. As the patient is awake, the risk of nerve injury during the procedure is minimized because of the communication between the surgeon and the patient. In addition, when the pressure on the nerve is removed, the patient can immediately express this as their leg pain decreases.

As endoscopic lumbar disc herniation surgery is performed without cutting surrounding tissues, the cannula is placed over tissue expanders using then operating room fluoroscopy. The endoscope and the hand tools used for the procedure are passed through the cannula. The skin incision is only 0.5-1 cm. Since the nerve roots in the area can be seen directly, they can be protected while only the necessary disc tissue is removed. Under the direct view of the endoscope, the damaged nucleus pulposus (the jelly-like part inside the disc that has herniated) can be selected and removed from the disc.

In the biportal technique (UBE surgery), a camera is used to enter through a small 5 mm long hole created from a suitable point, similar to that in the monoportal technique. Surgical instruments are then advanced through a second 5 mm hole to reach the patient’s herniated disc and to remove the herniated tissue.

Herniations in the foraminal and extraforaminal regions that are difficult to reach with traditional methods can easily be removed with endoscopic lumbar disc herniation surgery. Additionally, the narrowings in the nerve exit holes (foraminal stenosis) that can occur with aging of the spine that can cause compression of the nerve roots can easily be enlarged with the help of today’s high-speed endoscopic cutters and other hand tools, therefore eliminating nerve compressions.

Endoscopic lumbar disc herniation surgery can also be performed for annulus tears. The annulus fibrosis is the outermost and hardest part of the disc. Annulus tears are a condition that can also cause back and leg pain without there being a complete herniation of the disc. When performing endoscopic lumbar disc herniation surgery on annulus tears, the surgeon removes the jelly-like nucleus pulposus material that is stuck in the tear that prevents healing. In such cases, thermal annuloplasty is performed. Thermal annuloplasty is an additional procedure performed with bipolar radiofrequency (RF) and used in endoscopic spine surgery. In this procedure, radiofrequency (RF) energy is used to burn the pain receptors located in the annulus, the outer and tough layer of the disc, which is the root cause of the patient’s back pain. In addition, the inflammatory/granulation tissues accumulated inside the annulus are cleaned and the elongated or torn fibers of the annulus are reduced in size, shrinking the annulus and therefore the disc, sealing it from the inside of the disc, hence alleviating back pain.

WHAT ARE THE ADVANTAGES OF ENDOSCOPIC DISCECTOMY?

• It does not cause epidural bleeding or adhesion around the nerves.
• Since most of the disc tissue is preserved, a metallic cage plate or prosthesis is not required.
• Instability in the spine is very rare.
• Recurrence of herniation is extremely rare since this procedure is performed by opening a small chanel in the disc.
• There is rapid recovery as the procedure time and the hospital stay are both very short.
• Patients can be discharged from the hospital usually on the same day and return to their daily lives within a short period of time.

No. Endoscopic discectomy is not only performed on the lumbar region. It can also be used in symptomatic disc herniations in the neck (cervical) and back (thoracic) regions. These procedures are explained in further detail in the related sections.

WHAT ARE THE POTENTIAL COMPLICATIONS?

Although very rare, there are potential complications that could arise. With an experienced surgeon, complication rates are much lower in endoscopic surgeries compared to traditional open surgery. Nerve injury, burning sensation and numbness in the leg and arm, complex regional pain syndrome, dural tears, internal organ injury, bleeding and instability in the spine are potential complications and may require additional treatment.

No matter which surgical method is performed, there can be some scar tissue formed in the surgical area. Although scar tissue formation is much less prominent in endoscopic spine surgery than in other surgical techniques, it is possible. This scar tissue formation may be responsible for leg pain that may occur after the procedure. The risk of permanent leg pain in endoscopic surgery is less than 1-2%.

Although this cannot be considered as a complication, the most common patient complaint is slight numbness or a burning sensation in the leg after surgery. This can be seen immediately after surgery, or days or weeks later. According to some theories, the main reason for this condition is the sudden removal of pressure on a nerve that has been under pressure and numb for a long time as well as the increase in blood flow in the region. The burning sensation in the leg can also be caused by the radiofrequency (RF) burning of the nerves on the disc, which is a routine part of the procedure. However, the exact cause is still not known. This condition is almost always temporary. Nerve blocks or drug therapy may be required, although rare.

It is very important to fully and accurately inform the patient about this procedure and its risks before an endoscopic lumbar discectomy as patients may consult many doctors who may or may not know this technique prior to consulting an experienced endoscopic spine surgeon. Because patients may get many different opinions depending on the doctors’ abilities and experiences, it is important to discuss the purpose of endoscopic surgery, the patient’s expectations and why experienced surgeons prefer this technique in great detail prior to endoscopic spine surgery.

Another possible complication is that there may be a feeling of discomfort in the lower back post-surgery. Activity is restricted to some extent in the evening prior to the day of the surgery, and activity at home is increased gradually post-surgery the next day. While the patient’s leg pain before the operation may decrease immediately, it may also decrease over the next few months. The pain may increase temporarily and its pattern may also change temporarily. The patient should be closely monitored by the surgeon for 1-2 weeks after the operation. Although it varies according to the patient’s profession, the patient can usually return to work 1-4 weeks after surgery.

WHAT SHOULD BE CONSIDERED AFTER SURGERY?

In order to prevent the recurrence of a herniated disc, it is necessary to avoid positions deemed “risky” for post-surgery patients. These include sitting for long periods of time and leaning forward while sitting in the first 1 week to 10 days after surgery.

We do not recommend long walks in the first week or 10 days post-surgery. Meals can be eaten at the table with family members, but we recommend you lie on your back, side or even face down in bed afterwards. It would be beneficial to move often while laying down, changing your current position, not in a twisting manner, but like a page in a book.

The hospital staff will have dressed the surgical site at the end of the procedure. Since the patient will not have a very large wound post-surgery, redressing the surgical site can be done on the 3rd and 5th days after being discharged. Since the wound is closed with absorbable stitches removal of the stitches will not be necessary.

For patients working in offices or have sitting jobs, returning to work on the 5th to 7th day after surgery is possible. For those working in jobs requiring manual labor, such as lifting heavy objects, it is advisable to rest for up to 4 weeks after surgery.