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Abstract
Over the years, interest in Minimal Invasive Spine Surgery has increased dramatically. The potential benefits of small incisions, limited tissue disruption, enhanced visualization and illumination, shorter hospital stays, and faster recovery times have been the incentive to pursue these minimally invasive procedures. In the case of lumbar discectomy, the primary objective is to decompress the affected nerve root. The compressed nerve must be left fully decompressed and freely mobile. This may require bony decompression, nerve root manipulation, and removal of herniated nucleus pulposus. In the past several years techniques have been developed to excise or ablate portions of lumbar discs without performing an open procedure. These include chemonucleolysis by injection of chemopapin into the nucleus pulposus. Mechanical percutaneous discectomy first described in 1975, has increased greatly in popularity since the introduction of an automated nucleotome probe in 1985. Laser and arthroscopic microdiscectomy ( AMD) represent more recent innovations, as dose laparoscopic lumbar discectomy via an anterior surgical approach. All of the previously mentioned percutaneous procedures attempt to decrease the volume of disc herniation indirectly by reducing the amount of nuclear material contained within the anulus . Large clinical series have failed to prove the relationship between the reduction of the size of the core of the nucleus pulposus and the decompression of the neural elements by the extruded nuclear material. Moreover, none of these percutaneous intradiscal procedures directly removes nuclear material that has extruded through an anular defect such as occurs in extruded and sequestrated disc herniations, the lesion most closely linked to lumbar radiculopathy.[Thongtrangan et al.,2004] In our study we used microendoscopic discectomy ( MED) for surgical treatment of 50 lumbar disc herniation in 50 patients, 35 men and 15 women, their age ranged from 17- 62 years (average 39.5 years), all of the patients had the following inclusion crieteria; single level of disc herniation, in a virgin back, and with typical radiculopathy that is more dominant-in almost all of the cases- on one of the lower limbs. None of the patients had the one of the following exlusion crieteria; 1-Cases treated successfully with non-operative measures, including ( rest, medication, and physiotherapy ) and the patient is satisfied with the results of the non-operative measures, and is not motivated for surgical solution for his\her pain syndrome.2-Cases with lumbar canal stenosis.3-Cases with previous operative procedures on the spine involving the level and the side of the newly developed disc herniation.4- Patients with known psychological disturbance, or those patients having abnormal psychometrics (i.e. more than 2 points on the pain drawing score).5- Clinical and radiographic evidence of congenital anomalies, marked instability, or infection. All the patients have been conducted to a thorough general and local clinical examination to exclude the other possible causes of back pain associated with sciatica, and only those who met the inclusion crieteria were involved in this study. Since pain and disability are the two most important items to be investigated from the patient through clinical history taking (for their strong predictive value over the outcome of the patient postoperatively); all of the patients are submitted to: Numerical Rating Scale ( NRS ) for pain. Oswestry Disability Index ( ODI ) for disability. Pain drawing (for psychological evaluation). None of the patients included in this study showed poor psychometrics and the score ranged from 1-2 points which indicates good psychometry. Moreover, all of the drawings correlated well with the complaint and the results of the physical examination of the patients. The preoperative MRI revealed the following: 28 patients (56%) had lumbar disc herniation at L4,5 level , 18 patients (39%) at L5 S1 level, and 4 patients (8%) at L3,4 level. •14 discs (28%) were found herniated 9-12 mm or more in the posterior direction inside the spinal canal, and was considered to be sequestrated. •26 discs (52%) were found herniated between 6-9 mm, and was considered to be extruded or subligamentous sequestration. N.B. 20 disc herniations of the previous two categories were found to be distally migrated ( on the sagittal cuts ). •10 discs (20%) were found herniated less than 6 mm, and was considered to be protruded. The patients were treated on an out-patient basis by hemilaminotomy, medial facetectomy and discectomy using the latest procedure in minimally invasive spine surgery (MISS ) concerned in treating disc herniations ; that is microendoscopic discectomy (MED) procedure, utilizing microendoscopic tubular retractor system ;(METRx ) system, with a mean surgical time of 112.8 minutes, with the average length hospital stay (LOS) of 9 hours, 44 patients (88%) did not require postoperative analgesic medication and the remaining 6 patients (12%) used it until stiches removal. All the patients were followed prospectively , the follow-up period ranged from 6-18 months (average12 months). For Postoperative Clinical Evaluation all the patients were asked to fullfil the following: •Numerical Rating Scale ( NRS ) for pain. •Patient Satisfaction Index ( PSI ) for patient satisfaction. •Modified MacNab crieteria, for postoperative outcome evaluation. •Oswestry Disability Index (ODI). The NRS decreased from mean score of 2.16 preoperative to mean score of 1.36 postoperative for back pain after 3 months, and from mean score of 7.82 preoperative to mean score of 1.32 after one month decreasing to 0.4 after 3 months postoperative for leg pain. The ODI dropped from mean score of 31.82 preoperative to a mean score of 2.98 postoperative at 3 months’ follow-up visit. The SLR test returned to normal (70-90 degrees) in 46 patients out of 47 patients who had +ve SLR preoperative, within one month postoperative. Sensory deficit has completely resolved in 34 patients out of 41 patients who had sensory disturbances preoperative . As regard radicular manifestations: Sensory deficit has completely resolved in 34 patients out of 41 patients who had sensory disturbances preoperative. All of the 22 patients (44%) who had grade 4 motor power preoperatively, improved to grade 5 (normal) within 3 months postoperatively. All of the 4 patients (8%) who had absent knee jerk regained their full reflex strength ( compared to the healthy side ) within 3 months postoperative. 16 patients out of 20 (40%) patients who had absent ankle reflex regained their full reflex strength within 3 months postoperative. All the patients returned to their presymptomatic work and daily activity within the first month postoperative with a mean of 17.1 days Patients’ satisfaction scores reflected a 98 % complete satisfaction with MED procedure and the outcome, and willingness to undergo the surgery again for the same condition (according to satisfaction score in the follow-up sheet). According to Mcnab crieteria ; 46 patients (92%) were in the excellent category, three patient (6%) were in the good category, one patient (2%) were in the fair category, and non of patients were in the poor category.