Lumbar Microdiskectomy

The pathophysiology and natural course of degeneration of intervertebral disks are still not fully understood, and optimal surgical treatment of herniated lumbar disk (HLD) is constantly evolving, with a trend toward less invasive procedures.[1] [2] [3] Therefore, the results of the article entitled “Epidural catheter-assisted percutaneous transforaminal endoscopic diskectomy: a technical note” by Kim et al,[4] published in J Neurol Surg A in September, 2020, are of importance. However, the gold standard method of microdiskectomy, which is widely performed on patients with HLD, has not been mentioned and discussed in the article. Although the authors successfully treated HLDs in two patients using a procedure unlike traditional methods, these patients could have been effectively treated using well-established microsurgical techniques. For example, a similar patient with downward-migrated disk fragment compressing the nerve root in the foramen was treated with the conventional microdiskectomy in our clinic. The patient's pre- and postoperative magnetic resonance (MR) images and the image during surgery are shown in [Fig. 1].

Fig. 1 (a) Preoperative T2-weighted magnetic resonance imaging (MRI) reveals a massive disk herniation at L5–S1 (arrow). (b) Intraoperative image showing the herniated disk surrounded by abundant vascular structures. (c) Intraoperative picture showing the removal of the herniated disk. (d) Postoperative T2-weighted MRI shows the removal of the disk fragment and decompression of the nerve root.

Lumbar microdiskectomy has been the most commonly used, effective, and safe method in the surgical treatment of HLD since the 1970s.[5] [6] [7] Comparison of lumbar microdiskectomy and endoscopic tubular methods has been performed in many studies, and there is no high-quality evidence showing any superiority of endoscopic methods to microdiskectomy in many parameters including efficacy, incision length, operative time, blood loss, and hospital stay.[2] In percutaneous endoscopic methods, it has been shown that patients are exposed to significant radiation due to intraoperative fluoroscopy.[8] In the method of Kim et al,[4] blindly advanced epidural catheter can cause unnecessary epidural bleeding, dural tears, and cerebrospinal fluid fistulas.

Health care systems are rapidly changing globally and the evolution of surgical techniques are at risk of being driven by the development of high technology and medical devices.[9] [10] [11] [12] [13] A framework termed IDEAL has been proposed for initiating surgical innovations.[14] A new method ideally goes along the following introductory stages: simulator or animal studies, a proof-of-concept study in the first human patient, a prospective study involving up to 30 patients in an early stage, the inclusion of surgeons with no previous experience in a larger prospective study, a randomized controlled trial comparing the results of the innovative procedure to the gold standard, and ultimately evaluation of long-term results.[12] [14] Overall, Kim et al provide a clear description of a promising technique of epidural catheter-assisted percutaneous endoscopic diskectomy in a proof-of-concept study.

Publication History

Received: 05 October 2020

Accepted: 28 October 2020

Article published online:
22 February 2021

• References

• 1 Aras AB, Guven M, Balak N, Ayan E, Uyar SB, Elmaci I. Evaluation of the association between matrix metalloproteinase 11 and intervertebral disc disease. Turk Neurosurg 2016; 26 (02) 274-279
• 2 Pinheiro-Franco J, Vaccaro A, Benzel E. et al. Advanced Concepts in Lumbar Degenerative Disk Disease. Berlin: Springer-Verlag; 2016
• 3 Jarebi M, Awaf A, Lefranc M, Peltier J. A matched comparison of outcomes between percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for the treatment of lumbar disc herniation: a 2-year retrospective cohort study. Spine J 2020; 21 (01) 114-121
• 4 Kim KJ, Jang J, Jang IT. Epidural catheter-assisted percutaneous transforaminal endoscopic diskectomy: a technical note. J Neurol Surg A Cent Eur Neurosurg 2020; 81 (05) 472-474
• 5 Yaşargil M. Microsurgical operation of the herniated lumbar disc. Adv Tech Stand Neurosurg 1977; 4: 81-82
• 6 Balak N, Demirkesen O, Efendioglu M. et al. Diagnostic approach to reveal retroperitoneal injury during lumbar discectomy. J Neurosurg Sci 2010; 54 (03) 129-133
• 7 Denli Yalvac ES, Balak N. The probability of iatrogenic major vascular injury in lumbar discectomy. Br J Neurosurg 2020; 34 (03) 290-298
• 8 Aydın AL, Sasani M, Sasani H. et al. Comparison of two minimally invasive techniques with endoscopy and microscopy for extraforaminal disc herniations. World Neurosurg 2020; (e-pub ahead of print) DOI: 10.1016/j.wneu.2020.09.022.
• 9 Balak N, Broekman MLD, Mathiesen T. Ethics in contemporary health care management and medical education. J Eval Clin Pract 2020; 26 (03) 699-706
• 10 Cote DJ, Balak N, Brennum J. et al. Ethical difficulties in the innovative surgical treatment of patients with recurrent glioblastoma multiforme. J Neurosurg 2017; 126 (06) 2045-2050
• 11 Cote DJ, Bredenoord AL, Smith TR. et al. Ethical clinical translation of stem cell interventions for neurologic disease. Neurology 2017; 88 (03) 322-328
• 12 Muskens IS, Diederen SJH, Senders JT. et al. Innovation in neurosurgery: less than IDEAL? A systematic review. Acta Neurochir (Wien) 2017; 159 (10) 1957-1966
• 13 Zaki MM, Cote DJ, Muskens IS, Smith TR, Broekman ML. defining innovation in neurosurgery: results from an international survey. World Neurosurg 2018; 114: e1038-e1048
• 14 McCulloch P, Altman DG, Campbell WB. et al; Balliol Collaboration. No surgical innovation without evaluation: the IDEAL recommendations. Lancet 2009; 374 (9695): 1105-1112