Each patient’s treatment plan should be individualized based on the source of the pain, the severity of pain and the specific symptoms that the patient exhibits.
Patients who are not relieved with conservative treatment, or have severe nerve compression or have neural deficit require surgery. A few conditions like cauda equina syndrome, marked by progressive weakness in the lower limbs and/or sudden bowel or bladder dysfunction, requires immediate surgery.
Aim of surgery for herniated disc is to relieve compression on the nerve by removing the offending structure i.e. herniated disc. At one time, surgical removal [discectomy] was the sole method. With advent of new technologies, new options have been added. Currently, a surgeon may choose a surgery from following options, depending upon the type of disc herniation and his expertise. Many a methods have just recently been introduced and we would know more about them as the results are evaluated in the long term.
- Discectomy/Microdiscectomy [with or without fusion, as indicated]
- Intradiscal Electrothermal Annuloplasty
- Transforaminal endoscopic surgical system [Tessys]method
- Spinal Fusion
- Disc arthroplasty
Discectomy or open discectomy removal of disc after surgical incision. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.
The traditional open discectomy, or Love’s technique used bigger incisions for exposure of the disc but now a days asmalle r incision is used and the procedure is called microdiscetomy. It uses loupe or microscope for the procedure.
Intradiscal Electrothermal Annuloplasty
Intradiscal electrothermal annuloplasty is a relatively newer treatment,a less invasive and outpatient procedure. The procedure is performed under local anesthesia. Under fluoroscopy, a hollow needle is inserted into the painful disc and a thin electrothermal catheter [heating wire] is passed through the needle into the disc, and maneuvered into place around the outer edge of the central nucleus. The wire is heated slowly to a temperature of 90 degrees Celsius for about 15 minutes. Heat can potentially contract and shrink the fibers that make up the disc wall, closing any tears.
IDET is not for severe disc degeneration, nerve compression, spinal instability and/or narrowing of the spinal column (spinal stenosis). The long-term results of this procedure are still unknown.
Transforaminal Endoscopic Surgical System
Also popularly abbreviated to e TESS, in this method, the surgeon removes the herniated portions of the disc using endoscope. This surgery is done under local anesthesia and general anesthesia is rarely needed. The herniated disc is approached through intervertebral foramen and removed. This method is quite recent and few centers perform it.
It is a minimally invasive procedure and the risks of bleeding, infection and nerve injury are reduced. This also leads to less post-operative pain and faster recovery.
Laminectomy means removal of lamina, a posterior arch of the vertebral bone lying between the spinous process pedicles and the transverse processes of each vertebra. Laminectomy, conventionally also removed posterior spinal ligament and the spinous process. It is a procedure for decompressing the spine or gaining more access to the deeper regions and is now rarely done for herniated disc unless it has resulted in secondary canal canal stenosis.
Intervertebral Disc arthroplasty
It is also called artificial disc replacement, or total disc replacement and is a type of arthroplasty. In intervertebral disc arthroplasty degenerated intervertebral disc are replaced with artificial discs. It is done both for lumbar and cervical disc herniations to treat chronic, severe low back and cervical pain resulting from degenerative disc disease.
It is an alternative to spinal fusion which aims at eliminating pain while preserving motion.
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