Regardless of race, age and gender, it was determined that 80% of each individual suffered from back and neck pain that requires bed treatment at least once in their life. Neck hernia.
Although spinal pain is so common, disc-based pain is 27%. The disc structures between the vertebrae have elastic deformations during the transfer of weight, standing upright and during movement. It provides this dynamic effect with the nucleus (nucleus) in its structure and the annulus structure surrounding it.
Like a horizontal automobile tire, the disc absorbs the load during bending and loading, reduces and transfers the weight by spreading, then returns to its original state. This suspension effect continues thousands of times during the day. The aim is to maintain the relationship and stability between the vertebrae, apart from meeting the load. While the discs keep the distance between the vertebrae constant at a certain height, the muscle-ligament and nerve structures remain at a certain tension and provide dynamic stability. As a result of the structural changes of the matrix proteins in the disc structure with aging, their water retention properties decrease.
With decreasing disc elasticity, water retention ability decreases. Decrease in diffusion feeding increases the matrix cracks, and plastic deformations occur in the fragile disc with reduced elasticity over time, with the permanent structural changes. The height of the disc decreases, the joint structures are eroded by excessive movement, even the disc wall is torn and the nucleus moves and presses on the nerve structures.
And as a result, spinal pain occurs.
Medical Treatment Requirement does not exceed 8.3% among disc-related pain, while those with outpatient treatment are 2.7%. The number of inpatients in the world is 9 million (0.45%), the group that receives surgical treatment is only 1 million per year in the world. This number includes all open surgical fusion and discectomies. Low back pain treatment is multidisciplinary.
Multidisciplinary Approach
»Physical therapist
" Neurology expert
" Physiotherapist
»Algologist
»Spinal surgeon
It is possible with the cooperation of physicians working in their branches. Progressive (algorithmic) treatment principles require anti-inflammatory therapy in primary care and bed rest not exceeding 3 days. In resistant and chronic cases, algologists apply block-pain treatments, physical therapists apply physical therapies. All treatments are supported by muscle strength-posture discipline-ergonomic measures with the support of physiotherapists. Surgical compression of the neural structures is the last step of choice in recurrent resistant cases due to osteoarthritis, significant loss of disc height.
Open surgery indications:
» Cauda equina syndrome
»Progressive neurological deficit
»Failure of conservative treatment
»Paresthesias that are not obvious but affect life
»Pains that progress with attacks and require more than three rest times a year can be counted.
The indication for minimally invasive (closed endoscopic) surgeries differs at this stage. Prominent neurological deficit, cauda equina may be a contraindication. Endoscopic surgery has a place in cases requiring bed rest more than three times a year, but without an absolute surgical indication.
PAIN, which does not respond to conservative treatment that reduces the quality of life, is NOT THE FATE OF THIS POPULATION: it is a treatment that is purely aimed at improving the quality of life.
Open Surgical Treatments
»Lumbar Microdiskectomy
»Hemilaminotomy / discectomy
»Laminectomy / discectomy
»Fusion
»Nonfusion
»Total Disk Replacement
» Nucleus Replacement
While surgery is moving towards less invasive methods, it is the fastest return to daily life after treatment. Surgical evolution has tended to increase disc height by regenerating the nucleus. While less invasive methods (LESS Invasive) surgeries broke new ground with percutaneous (piercing the skin) fusion (freezing) surgeries with screws, they also tried to increase the height by renewing the disc core with semi-open methods, on the other hand, they tried to reduce pain with external supports that open the disc space. Table-1
Open Surgery Fusion Nonfusion Disc prosthesis Nucleus Replacement Less Invasive Surgery Fusion PLIF-TLIF Nonfusion Xstop vs Nucleus Replacement PDN MISS Surgery Minimal Invasive Intradiscal Discectomy Selective Discectomy Anulus Repair Nucleus Replacement Hippocrates “First, Harmful” (Primum Nil Nocbbere) approach is the current approach. Ideal treatment for surgery progressing towards more and more harmless treatments
»Respectful to anatomical structures
»Harmless
»For the cause
»Increasing the quality of life
»There should be a treatment that can return to normal life in a short time.
Minimally Invasive - Closed Endoscopic Surgery History:
» 1857 Virchow begins with his description of disk protrusion. 1901 Horsley applied the first decompression, 1911 Goldthwait cited annulus rupture and nucleus pulposus extrusion as the cause of pain.
»1913: Elsberg treated pain with laminectomy treatment used for years in open surgery.
»1922 Siccard and Forestier sprinkled the first seeds of minimally invasive techniques that applied the first provocative discography technique using lipiodol. With this examination method, disc pathology could be revealed on x-ray. The pathological level gave pain during the procedure.
» 1934: Peet and Echols differentiated between disc herniation and root compression
»1937: Defining it as the first endoscopic intervention (MYELOSCOPY) modified from the pool otoscope, the first endoscopy was performed.
»1939. Love applied the interlaminar microdiscectomy technique without resecting the bone with a mini incision.
»Until 1955 Male Binocular Microscopic Discectomy technique was developed, wars were unorthodox to use medical treatment to improve the quality of life.
»1960 Rhizotomies were activated, pain transmission from painful segments was interrupted.
» 1974 Shealy performed Rhizotomy by applying Percutaneous (piercing the skin) Radio Frequency procedure. While intra-discal treatments are becoming popular, chymopapapin and Choy laser powered discectomies
»1973 Kambin launches endoscopy application
» 1977 Hijikata performed Percutaneous Endoscopic Discectomy, 1978 Williams Microscope used in classical discectomy
»1980 Anthony Yeung introduced the endoscope specially prepared for spinal endoscopy (Wolf: YESS) to today's surgery. After more than one hundred thousand successful procedures since 1980, Miss Family Tree is gradually branching out.
Family tree
»Hijikata-Kambin
»A. Yeung (Wolf-Yess)
»MT. Knight (EKL-Kiss)
»H. Leu (Storz-Leu)
»T. Hoogland (Joimax-Thessys)
»Martin Sawitz, John Chiu, Sang-Ho Lee, Akira Dezava
CISS advantages: Patient-centered
After minimally invasive surgery, the hospital stay rarely exceeds one day. Returning to work after the procedure is limited to a few days. Recovery is very fast as it does not damage normal tissues. Therefore, specific hospitals with a low number of beds will restore a large number of patients to their health. Short hospital time lowers the cost. The result is excellent for the patient-centered Hospital-Insurance-Employer triangle.
Minimally Invasive Surgery Concepts
1. Central Decompression:
a. Chemonucleosis: It aims to liquefy and reduce the pressure by injecting chymopapain into the disc. Its indication is limited and it is almost abandoned.
b. Nucleotomy: It is one of the standard treatments in the disc. It is the emptying of the disc using mechanical tools. (Figure-1) Figure-1: Nucleoplasty Figure-2: Taken from the Clarus Medical catalog.
c. Automatic Nucleotomy: It is the vacuum evacuation of the disc with the help of a motor. (Figure-2)
D. Radiofrequency nucleoplasty: It is the denaturation and wrinkling of the nucleus using radiofrequency. (Figure-3)
to. Laser ablation: It is the evaporation of the nucleus with laser energy. (Figure-4)
f. LASE: Laser assisted endoscope: It provides camera-assisted laser application into the disc with a special very thin probe. It has made a breakthrough in treatment. (Figure-4)
2. Subanular decompression and Annuloplasty
a. Subanular decompression: This is the beginning of endoscopic surgery. The disc is removed from the torn annulus from a subanular safe distance. (Figure-5)
b. Annuloplasty: The annulus is repaired using laser or radiofrequency energy. (Figure-3-4)
3. Selective Discectomy: It is the last stage. Only the compressing fragment is removed, the disc and annulus are repaired. It will be possible to apply a nucleus portal.
a. Foraminoscopy (Figure-6) b. Epiduroscopy (Figure-6)
Surgical Technique For lumbar hernia;
Under local anesthesia, it is worked from the side in the prone or lateral lying position, the back hernia from the side in the slightly lateral lying position, and the neck hernia from the front.
The hernia is reached without damaging the normal anatomical structures by using 5-7 mm special working channel cameras by perforating the skin 0.5-1 cm (Percutaneous). Only the part pressing on the nerve is removed. Disc structure is preserved and its recovery is provided. By Percutaneous Spinal Endoscopy, without cutting normal anatomical structures or bleeding,
»Percutaneous endoscopic lumbar discectomy (PELD) (Lumbar Hernia) - Lumbar foraminoscopic - Extraforaminal far lateral - Interlaminar
» Percutaneous endoscopic thoracic discectomy (Back Hernia)
»Percutaneous endoscopic cervical discectomy (Neck Hernia) Advantages of Percutaneous Endoscopic Surgical Treatment
»Local anesthesia is used, the patient does not receive general anesthesia.
»The procedure is applied through normal anatomical holes, normal structures are not damaged in order to reach the disc. Therefore, the bleeding is very less.
»Selective fragmenttectomy (only the pressing fragment is removed-the disc is preserved)
»The disc is protected, the healing of the periphery (Annulus) is stimulated, increasing the healing capacity
»In-disc decompression can be made.
»With a provocative examination, the level can be determined precisely in multi-level lumbar hernia.
»Root inspection (probing)
» Foraminoplasty (enlargement of the nerve exit hole) is possible.
» Epiduroscopy (examination of the spinal canal) is possible.
»Extraforaminal and far lateral examination is possible. Extra-canal compression of the nerve can be easily diagnosed.
»Safe percutaneous intradiscal treatment portal Contraindication
»Morbid Obesity
»Cauda Equina
»Complicated hernias (adherent-sequestered)
»Open Surgery recurrence
» Non-compliant patient
»Bleeding Diathesis Future Treatments Percutaneous treatments provide advantages in reaching the disc in the epidural region, the addition of advanced new instruments, genetic advances and robotic surgery, preserving normal tissues and a healthy life will be possible. From emerging treatments;
»Anulus repair
» Percutaneous nucleoplasty (Injection)
»Percutaneous intradiscal stem cell infusion are just a few of them.