Percutaneous Lumbar Spine Surgery, 5 year experience in the Orthopaedic Department of Mexico

Braulio Hernández  Carbajal; Felipe Camarillo  Juárez; Jorge  Hernández Ynurreta

Percutaneous Lumbar Spine Surgery, 5 year experience in the Orthopaedic Department of Mexico's General Hospital

B Carbajal, F Juárez, J Hernández Ynurreta

Citation

B Carbajal, F Juárez, J Hernández Ynurreta. Percutaneous Lumbar Spine Surgery, 5 year experience in the Orthopaedic Department of Mexico's General Hospital. The Internet Journal of Minimally Invasive Spinal Technology. 2006 Volume 1 Number 1.

Abstract

Introduction: Lumbar and radicular pain due to disk herniation is the most common cause of surgery, and the hemilaminectomy and diskectomy is the most common surgical procedure to treat this pathology. The reports of postop complication of this technique are frequent (20%), including fibrosis, sand, neurological and vascular lesions; so other surgical alternatives have been tried. In 1975, Hijikata presented his work on decompression and nucleotomy using a percutaneous manual technique under local anesthesia with good satisfactory results. In 1989, Monteiro published his experience and his instruments in 225 patients and reports 75% good results.

Objective: To describe the Monteiro's percutaneous manual nucleotomy technique of the lumbar spine segment, and to present our experience in 5 years of work.

Methods and Materials: 450 patients were found to be operated with different minimally invasive techniques; 234 patients were operated with percutaneous manual nucleotomy and had at least one year follow-up. Inclusion criteria were: failure of the medical and rehab treatment, at least 3 months; disk herniations of less than 50% of the spinal canal; age less than 60 years old; Lassegue's sign greater that 45º; non progressive motor and sensory deficit; positive discography; positive IRM or CAT scan for disk herniation; one or two level disease.
Exclusion criteria: foraminal herniations, cauda equine, multilevel disease.

Technique: Under local anesthesia, 0.5% lidocaine, conscious sedation, ambulatory surgery basis, C arm fluoroscopy, patient in prone position with 70º hip flexion to correct lordosis and tense the posterior longitudinal ligament and reduce the herniation. With a positive discography, a 10 mm posterolateral approach is performed and a guide wire is placed in the posterior third of the disk and the consecutive dilators are placed until 6 mm and then a working sheath is inserted; a trephine is used to cut the annulus fibrosus, the nucleus is loosen using a small curette, the it is extracted using forceps and graspers. Approximately 1 cc of disk material is extracted until symptoms are diminished; the interior of the disk is washed with sterile solution to extract small disk fragments. Sterile strips are used to close the wound, suture is not required but it can be used.

Assessment: MacNab's criteria are used. Good results: absence of pain with no disability. Regular results: intermittent episodes of pain and disability in some activities that require a great effort. Bad results: no modification in pain patterns. Lassague's sign and Visual analogue scale of pain (0 to 10 scale) were also used.

Results: 234 patients: 150 females, 84 males. Average age: 37.5. 428 disks were operated. Results at 3 months: 72% good, 23% regular, 5% bad. At six months, 82% good, 13% regular, 5% bad. At twelve months, 84% good, 11% regular, 5% bad. More than two years, 79% good, 16% regular, 5% bad.

Complications: Aseptic discitis in 4 cases, psoitis in 20 cases, postop radiculitis in 46 cases, paresia in 3 cases which resolved within 3 months.

Clinical Case: 36 year old female with lumbar and right ciatic pain due to a posterolateral discal herniation at L5/S1; a percutaneous manual nucleotomy was performed with good results at 2 years follow up; the postop discography shows no herniation and an empty space can be seen at the operated level.

Conclusions: It is a cheap surgical procedure, 3 times cheaper than the open surgery procedure. The local anesthesia is a warranty for the patient, because it allows the clinical aware state monitoring, to avoid damage to the nerve root. It has proven to be an effective method with good clinical results of 75%.

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Percutaneous Lumbar Spine Surgery, 5 year experience in the Orthopaedic Department of Mexico's General Hospital

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