Spinal Cord

Backache is the main cause of absence from work in working population. It is also the main presenting complaint of almost 60% of patients in any busy orthopedic surgeon's practice. Commonest cause of backache is "prolapsed inter-vertebral disc" which is commonly known as slipped disc.

Between two vertebras there is fibro-cartilagenous structure known as disc. Inter-vertebral disc is composed of outer tough fibrous structure called annulus fibrosus, which encloses jelly like structure called nucleus pulposus. Tear of annulus forces nucleus out side, this nucleus material which has come out presses on the neural structures lying behind disc and causes backache, leg pain(sciatica).

Conventional treatment of slipped disc involves rest, physiotherapy and analgesics for adequate period of time. However, failure of conservative treatment, all progressive neurological deficit, and intractable pain, surgery is required.

Conventional Spine surgery involves taking long incisions, forceful muscle retraction for prolonged time, removal of normal tissues like ligaments and bone to approach area of pathology. Most of the times these surgeries are done under prolonged general anesthesia.

This long incisions and injury to normal structures results in

• Increased blood loss
• Increased scar tissue formation
• Increased chance of neural injury
• Epidural scarring
• Denervation of paraspinal muscles

All these cause increased morbidity and failed surgery syndrome. Since many times patients require to stay in bed for long duration of time, and there is also loss of work, earning , patients tend to avoid surgery and prefer to suffer pain and disability. Now there is hope for all these suffering population, in the form of minimal invasive spine surgery.

Minimal Invasive spine surgery involves

• Use of very small incisions,
• Minimal muscle retraction,
• Less normal tissue damage
• Targeted treatment of pathology.

Advantages:-

• Many surgeries are done under local anesthesia, hence surgeries can be done even in patients with high risk of anesthesia.
• There is less blood loss.
• Minimal morbidity.
• Patient can be mobilized very early and he can be back to work faster.
• It prevents complications associated with prolonged bed rest.

Since normal tissues are not removed or damaged, post operative pain is less and also there is less chance of failed back syndrome.

Percutaneous endoscopic lumbar discectomy is the ultimate form of minimal invasive spine surgery. In this form of surgery, an instrument called endoscope is used. Whole surgery is done under local anesthesia and patient is fully awake during surgery. In fact for successful surgery patients active participation is necessary.

Patient is made to lie prone on operation table and exact entry point is mapped on patients body using image intensifier x-ray system. A long spinal needle is passed from side of back which goes into disc directly by-passing other bone and ligaments. Through this needle guide wire is passed and after taking 5mm incision, dilator and working cannula are passed under local anesthesia., through which endoscope is passed. Camera and monitor is attached to endoscope and prolapsed part of disc is removed under vision. Wound is closed with single stitch. Patient gets immediate pain relief and he can go home in 24 hrs and can resume his work soon.

Advantages:-

• Surgery done under local anesthesia with conscious sedation
• 5 mm skin incision
• Endoscope used for surgery
• No muscle, ligament or normal tissue damage
• Targeted fragmentectomy. (directly prolapsed disc tissue removed.)
• Minimal blood loss
• Patient can be discharged in 24 Hrs.
• No prolonged bed rest required after surgery. Can resume work sooner.
• Even prolapsed, migrated, extra-foraminal, recurrent discs can be removed. Very good technique for old and medically compromised patients.