Surgery is often appropriate for conditions that do not improve with the usual treatment. In this event, a strong, flexible spine is important for a quick recovery after surgery. There are several surgical approaches to treating a herniated disk, including the classic discectomy, microdiscectomy, or percutanteous discectomy. The basic differences among these procedures are the size of the incision, how the disk is reached surgically, and how much of the disk is removed.
Discectomy is the surgical removal of the portion of the disk that is putting pressure on a nerve causing the back pain. In the classic disectomy, the surgeon first enters through the skin and then removes a bony portion of the vertebra called the lamina, hence the term laminectomy. The surgeon removes the disk material that is pressing on a nerve. Rarely is the entire lamina or disk entirely removed. Often, only one side is removed and the surgical procedure is termed hemi-laminectomy.
In microdiscectomy, through the use of an operating microscope, the surgeon removes the offending bone or disk tissue until the nerve is free from compression or stretch. This procedure is possible using local anesthesia. Microsurgery techniques vary and have several advantages over the standard discectomy, such as a smaller incision, less trauma to the musculature and nerves, and easier identification of structures by viewing into the disk space through microscope magnification.
Percutaneous disk excision is performed on an outpatient basis, is less expensive than other surgical procedures, and does not require a general anesthesia. The purpose of percutaneous disk excision is to reduce the volume of the affected disk indirectly by partial removal of the nucleus pulpous, leaving all the structures important to stability practically unaffected. In this procedure, large incisions are avoided by inserting devices that have cutting and suction capability. Suction is applied and the disk is sliced and aspirated.
Arthroscopic microdiscectomy is similar to percutaneous discectomy, however it incorporates modified arthroscopic instruments, including scopes and suction devices. A suction irrigation of saline solution is established through two entry sites. A video discoscope is introduced from one site and the deflecting instruments from the opposite side. In this way, the surgeon is able to search and extract the nuclear fragments under direct visualization.
Laser disk decompression is performed using similar means as percutaneous excision and arthroscopic microdiscectomy, however laser energy is used to remove the disk tissue. Here, laser energy is percutanteously introduced through a needle to vaporize a small volume of nucleus pulpous, thereby dropping the pressure of the disk and decompressing the involved neural tissues. One disadvantage of this procedure is the high initial cost of the laser equipment. It is important to realize that only a very small percentage of people with herniated lumbar disks go on to require surgery. Further, surgery should be followed by appropriate rehabilitation to decrease the chance of re-injury.
Chemonucleolysis is an alternative to surgical excision. Chymopapain, a purified enzyme derived from the papaya plant, is injected percutaneously into the disk space to reduce the size of the herniated disks. It hydrolyses proteins, thereby decreasing water-binding capacity, when injected into the nucleus pulpous inner disk material. The reduction in size of the disk relieves pressure on the nerve root.
Spinal fusion Surgery
Spinal fusion is the process by which bone grafts harvested from the iliac crest (thick border of the ilium located on the pelvis) are placed between the intervertebral bodies after the disk material is removed. This approach is used when there is a need to reestablish the normal bony relationship between the vertebrae. A total discectomy may be needed in some cases because lumbar spinal fusion can help prevent recurrent lumbar disk herniation at a particular level.
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