Through the analysis of papers by Lofrese et al. it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation.
The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions. 1).
see Lumbar microdiscectomy
In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material.
In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation 6).
Discectomy surgery has evolved from wide open to microscopic and now endoscopic.
The frequency of herniotomy is gradually increasing in LDH treatment. Herniotomy used to be synonymous with fragmentectomy or sequestrectomy. The term ‘herniotomy’ is defined as removal of the herniated disc fragment only, and the ‘conventional discectomy’ as removal of the herniated disc and degenerative nucleus from the intervertebral disc space.
Minimally invasive discectomy
In the U.S., it has been estimated that the Medicare system spends over $300 million annually on lumbar discectomies.
In conjunction with the traditional discectomy, a laminotomy is often involved to permit access to the intervertebral disc. In this procedure, a small piece of bone (the lamina) is removed from the affected vertebra, allowing the surgeon to better see and access the area of disc herniation.
Automated percutaneous lumbar discectomy
Percutaneous Endoscopic Lumbar Discectomy
Quality of Life (QOL), pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy 8).
From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being.
Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support 9).
see Lumbar discectomy in obesity
Of 50 patients, 33 (66%) had conducted a search for the surgery on the Internet. All university graduates, 88.2% of high school graduates, and 18.7% of primary-secondary school graduates had conducted an Internet search. The quality and reliability of the information was high (4.5 points) for 2 (7.1%) websites, moderate (2.3 points) for 6 websites (21.4%) and poor (1 point) for 20 websites (71.4%) as scored with the DISCERN® instrument. The mean DISCERN® score of was 1.1 for websites of health-related institutions or healthcare news, 2.75 for personal websites of physicians and 2.5 for personal websites of non-physicians. The mean DISCERN® score of all websites was 1.5.
Most of the patients undergoing lumbar disc surgery at our clinic had searched information about the surgical procedure on the Internet. We found that 92.9% of the websites evaluated with the DISCERN® instrument had inadequate information, suggesting low-level reliability 12).
An incidental durotomy rate of 4.9% was observed. Higher rates of wound infection (2.4 vs 1.3%; OR 1.88; 95% CI: 1.31 – 2.70; p < 0.001), wound dehiscence (0.9 vs 0.4%; OR 2.39; 95% CI: 1.31 – 4.37; p = 0.004), and serious adverse events related to incidental durotomy (0.9 vs 0.2%; OR 4.10; 95% CI: 2.05 – 8.19; p < 0.0001) were observed in incidental durotomy patients. In-hospital costs were increased by over $4,000 in patients with incidental durotomy (p < 0.0001).
Incidental durotomies occur in almost one in every twenty elderly patients treated with primary lumbar discectomy. Given the increased hospital costs and complication rates, this complication must be viewed as anything but benign 13).
127 patients (of 148 total) with data collected 3 months postoperatively. The patients’ average age at the time of surgery was 46 ± 1 years, and 66.9% of patients were working 3 months postoperatively. Statistical analyses demonstrated that the patients more likely to return to work were those of younger age (44.5 years vs 50.5 years, p = 0.008), males (55.3% vs 28.6%, p = 0.005), those with higher preoperative SF-36 physical function scores (44.0 vs 30.3, p = 0.002), those with lower preoperative ODI scores (43.8 vs 52.6, p = 0.01), nonsmokers (83.5% vs 66.7%, p = 0.03), and those who were working preoperatively (91.8% vs 26.2%, p < 0.0001). When controlling for patients who were working preoperatively (105 patients), only age was a statistically significant predictor of postoperative return to work (44.1 years vs 51.1 years, p = 0.049).
In this cohort of lumbar discectomy patients, preoperative working status was the strongest predictor of postoperative working status 3 months after surgery. Younger age was also a predictor. Factors not influencing return to work in the logistic regression analysis included sex, BMI, SF-36 physical function score, ODI score, presence of diabetes, smoking status, and systemic illness. Clinical trial registration no.: 01220921 ( clinicaltrials.gov ) 14).