The Use of Minimal Invasive Techniques for Lumbar Herniated Disc in Comparison to More Classical Approaches

Abstract

Sciatica due to lumbar disc herniation refractory to conservative treatment is effectively treated by surgery. The primary goal of surgery is retrieval of herniated disc fragments and decompression of the nerve root. After the historical publication of Mixter and Barr [1], who performed extensive laminectomy with transdural excision of the herniated disc, lumbar disc surgery became one of the most frequently performed surgical procedures worldwide. With the introduction of the microscope in the late 1960s, Yasargil and Caspar launched the unilateral microdiscectomy [2]. Presently, unilateral transflaval microdiscectomy by using the microscope or headlight with loupe magnification, is regarded as the golden standard. However, a shift towards minimally invasive approaches to the spine has started. The rationale behind minimally invasive spine surgery is less tissue damage, shorter hospitalisation, and faster recovery while achieving a good clinical outcome comparable with that of open conventional surgery. Minimally invasive spine surgery has adopted several techniques from other fields and has been influenced by endoscopy, biochemical advances, lasers, and image guidance systems. Intradiscal chymopapaine has been used more than 30 years but has been abandoned since it is less effective than surgical nerve root decompression [3]. Hijikata and Kambin are credited for their first report of percutaneous nucleotomy by inserting a 7 mm diameter tube under local anaesthesia with partial resection of disc material [4]. Choi and Ascher reviewed the first results of percutaneous laser disc decompression aiming at decreasing intradiscal pressure and subsequent nerve root relief [5]. The concept of posterolateral endoscopic discectomy changed from central nucleotomy to transforaminal nerve root decompression, which was launched by Hoogland [6] A few years later, Foley and Smith introduced the transmuscular approach of microendoscopic tubular discectomy with advanced optics and instruments applicated in laparoscopic surgery [7], which was later modified with the operative microscope.