Lumbar Endoscopic Discectomy

What are Lumbar Discs?
Lumbar discs are the structures which serve as shock absorbers between the vertebrae of the spinal column. The center of the disc, called the nucleus, is soft and springy and accepts the shock of standing, walking, running, etc. The outer ring of the disc, called the annulus, provides structure and strength to the disc. The annulus is comprised of a complex series of interwoven layers of fibrous tissues which hold the nucleus in place.

What is a Herniated Disc?

Herniated discs are often called a "slipped disk". This term was derived from the action of the nuclear tissue when it is forced from the center of the disc. The disc itself does not slip. However, the nuclear tissue located in the center of the disc can be placed under so much pressure that it can cause the annulus to herniate or rupture. When the disc has herniated or ruptured, it may create pressure against one or more of the spinal nerves which can cause pain, weakness or numbness in the lower back, leg or foot (sciatica). Other common names for a herniated disc are "protruded disk" and " ruptured disk". Herniated disc surgeons can treat slipped disks with the procedures below.

Treatments for Herniated Lumbar Discs
Depending upon the results of the physical and radiologic examinations and the severity of your condition, your doctor may offer you two forms of treatment. The first common treatment prescribed for lower back pain caused by the herniated lumbar disc is conservative therapy. Conservative therapy may consist of a period of bed rest, analgesics, chiropractic, physical therapy and/or muscle relaxants.

However, if after therapy the pain has not been relieved, a surgical procedure may be considered. My philosophy is to do the least invasive surgical procedure which combines the least surgical risk with the greatest opportunity for success. Outpatient procedures are also less costly.

What is LED (Lumbar Endoscopic Discectomy)?

LED is an outpatient surgical procedure to remove herniated disc material. An anesthesiologist provides intravenous sedation. The surgeon also uses local anesthesia. With the help of x-ray guidance and a video endoscope, a 3mm probe is inserted through the skin into the herniated portion of the disk. The herniated nucleus is then removed with a unique hydrodiscectomy tool, suction and disc grasping instruments, thereby relieving the pressure on the nerve root.  Only the herniated portion of the nucleus is removed (approximately 10 – 15 %), leaving the rest of the disc intact.  The hydrodiscectomy equipment provides a very powerful suction which draws the disc material in to the tip of the probe.  The disc material is then pulverized by a powerful jet of salt water which allows it to be suctioned away.  The disc protrusion is decompressed in a matter of minutes. The puncture in the skin is very small (4 mm) in comparison to larger incisions required for open surgery.

LED is different from open lumbar disc surgery because there is no large skin incision or damage to the back muscles. Most of the complications that may occur with open surgery are eliminated with the LED procedure.

Indications: Who Should Consider This Procedure?
This procedure is specifically designed for patients with the disc problems accompanied by the following:

1. Low back pain.
2. Severe leg pain, sciatica.
3. Pain that has not responded to conservative treatments, i.e., bed rest, analgesics, chiropractic, physical therapy and/or muscle relaxants
4. Multiple disc protrusions may be treated at the same surgery.
5. Herniated lumbar discs (prolapsed, protruded, ruptured and extruded) confirmed by radiologic studies that may include one or more of the following:
   • Cat Scanning
   • Magnetic Resonance Imaging
   • Enhanced CAT scan
   • Myelography
   • Discography

Contraindications: Who Should Not Consider This Procedure?

Patients who have lower back pain not caused by a herniated disc. Patients who have severe spinal stenosis (build-up of bone in the spinal canal). Mild cases of spinal stenosis associated with disc protrusions are still considered good candidates.

Only patients with clinical symptoms confirmed by physical examination and radiologic studies are considered for the LED procedure.

The Surgery
The procedure is performed in a hospital or an outpatient surgery center under conscious sedation by an anesthesiologist as well as local anesthesia administered by Dr. Schiffer. Using x-ray guidance, a 3mm tube is advanced into the disc under x-ray control and then multiple instruments are used to remove the disc. Along with suction and a special instrument which pulverizes the disc with a safe strong jet of water, the nucleus is liquefied and easily removed. Dr. Schiffer is able to decompress the disc protrusion in a matter of less than 5 minutes. He also has special flexible ?grabbing? instruments to remove large fragments. If the patient?s main complaint is leg pain alone or leg pain with minimal back pain, then the procedure is usually concluded at this point. Upon completion, a Band-aid is applied over the puncture site. Many patients comment that the entire procedure causes less discomfort than an epidural steroid injection. For those patients who have multiple disc problems, Dr.Schiffer is unique in that he operates up to four disc levels in one surgery.

Postoperative Course
Most patients feel immediate relief from pain following the procedure. Walking is permitted the same day and patients are discharged from the surgical center in one hour. Some patients experience lower back muscle spasms that may last a few days following the procedure. This pain can be relieved with muscle relaxants and analgesics, heat and light massage, if needed.

Advantages
The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerve roots in your low back. Since the insertion of the probe does not invade the spinal canal, there is no risk of postoperative scarring of the nerves which often occurs with “open” surgery.  Additionally, because the procedure is performed under intravenous sedation by an anesthesiologist as well as local anesthesia, it is much safer for the patient than that performed under a general anesthetic. Finally, because the surgery is performed on an outpatient basis, you will be discharged one hour after the surgery.

Even though many people think that laser is the most modern technique, we specifically do not use a laser to remove disc tissue. Although some lasers are presumed to be “cold”, all lasers produce heat, and we have found that in some instances the nerve root or nerve root ganglion can be injured by the heat creating a serious sympathetic pain syndrome that sometimes can be worse than the original complaint. Therefore, Lumbar Endoscopic Discectomy which is basically a water technique is much safer than the laser procedure.

Sometimes, if the patient has a significant amount of back pain, Dr. Schiffer usually encourages the patient to have a thermal annuloplasty, which takes an additional 15 minutes. The reason for this is that patients with significant low back pain have thinning of the annulus(covering of the disc). In an attempt to heal the annulus, the body responds by growing new microscopic blood vessels and nerve rootlets in the area. These tiny C fiber nerve rootlets carry the back pain impulses to the nervous system (the nerve rootlets play no part in normal sensation or movement). In this procedure, a metal catheter is placed in the disc under x-ray guidance and when it is properly localized, it is heated.  By heating the annular fibers with a catheter, the tiny C fibers are made nonfunctional. In addition, the heat stimulates a remodeling of the annulus during the recovery phase. The heating portion of the procedure is painless. The original back painless.

Typical Stay
Patients are normally seen in our clinic Day One, surgery is performed Day Two and on Day Three patients are once again evaluated in the clinic after which they can return home.

Summary
Clinical results with Lumbar Endoscopic Discectomy, over the past 4 years have demonstrated:

• Excellent success rates
• The structure of the disk is still maintained
• Serious complications are very rare
• No hospitalization
• Faster return to work and normal activity; and because there is no hospitalization, significant cost savings

For more information about Lumbar Endoscopic Discectomy, please contact Dr. Schiffer.