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Microscopic Discectomy: A minimally invasive surgery to treat lumbar disc herniation (herniated disc)

Healthy spinal disk has a soft, jellylike center (nucleus) encased in a rubbery exterior (annulus). Disc herniation, also called herniated disc or slipped disc develops when some of the nucleus pushes out through a tear in the annulus. This condition is often the result of an aging-related wear and tear, known as disc degeneration.

As we age, these disks become less flexible and are at greater risk of tearing or rupturing with even a minor strain. Although herniated disc can occur in any part of the spine, it is more common in the lower back (lumbar spine) than in the neck (cervical spine). If it is left untreated, herniated disc can irritate a nearby nerve, resulting in pain and weakness in an arm or leg. Pain and tingling sensation often radiate from the back to the buttock and leg.

To diagnose for herniated disc in most cases, medical history, comprehensive physical examination and neurological examination are required. In some cases, imaging tests might be further required, including X-ray, CT scan and MRI scan. MRI scan usually provides the most accurate assessment of the lumbar spine area, demonstrating where a herniation has occurred. Additional tests, such as electromyograms and nerve conduction studies might be considered.

In patients who have mild-to moderate symptoms, non-surgical approaches are primary treatment options. These include modifying activities to avoid movement that aggravates pain, taking a full rest, taking oral pain medications and physical therapy. Alternative approaches, such as acupuncture and chiropractic might help to subside symptoms. However, if pain does not improve with oral medicines, corticosteroid injections with spinal imaging guidance might be administered into the area around the spinal nerves. During the non-surgical treatments, disease severity needs to be continually monitored by using pain score evaluation and disability index in order to determine patient’s level of function in activities of daily living, allowing for treatment outcome measurement.

To identify source of pain caused by herniated disc, fluoroscopic guided epidural steroid injections are intended to identify the exact location of slipped disc and provide pain relief, allowing the patients to improve their low back pain and radiating pain to the legs.  With the assistance of a special x-ray, known as a fluoroscope, the spine surgeon directs a needle through the skin, between the bony vertebrae and into the epidural space. A fluoroscope monitor enables the spine surgeon to look at the needle in real time to ensure that the steroid is injected as close to the inflamed nerve root as possible. After injection, if the pain is eliminated instantly, the suspected nerve root clearly appears to be the source of back pain. Besides identification of source of pain, epidural steroid injections also help to reduce inflammation in the nerve root. If conservative treatments fail to improve symptoms, a minimally invasive spine surgery might be considered, if appropriate.

Standard open spine surgery usually involves large incisions, more pain and more postoperative complications as well as longer recovery periods. Due to surgical advances, a minimally invasive surgical procedure, known as microscopic discectomy has been considered “gold standard” and widely conducted to overcome those surgical limitations. During a minimally invasive microscopic discectomy procedure, small incisions will be made over the affected part of the spine. A lighted surgical microscope is used to assist spine surgeon in visualizing the affected disc and surrounding tissues, enabling the herniated portion of the disc under the nerve root to be precisely removed. By giving the nerve root more space, pressure is relieved and the nerve root can begin to heal. Since microscopic discectomy is performed through small incisions, patients often experience less pain, lower postoperative complications, less traumatic injuries to surrounding nerves and tissues which can lead to substantially faster recovery and quick return to daily life and activity. In addition, microscopic discectomy poses less chance of disc herniation recurrence.

At Spine Center, Bangkok International Hospital, all minimally invasive spine surgeries including microscopic discectomy have been performed by highly experienced and well-certified spine surgeons supported by multidisciplinary team consisting of neuro-spine surgeons, orthopedic-spine surgeons, anesthesiologists, physiatrists (physical medicine and rehabilitation), nurses and pharmacists specialized in spine care. To ensure the highest degree of safety, cutting-edge technologies have been deployed, including advanced surgical microscope, O-armTM system and IOM (Intraoperative Neurophysiological Monitoring). The O-armTM system is an intraoperative 2D/3D imaging system used during the surgery. It allows the spine surgeon to perform spine surgery with more accuracy in placement of spinal instruments for improved surgical outcomes. In combination with navigation system, it shortens operative time and reduces the risk of reoperation with less radiation exposure from imaging system. Moreover, Intraoperative Neurophysiological Monitoring or IOM has been used to monitor the possible damages to the nerves while operating, leading to reduced postoperative neurological complications.

Advantages of microscopic discectomy

  • Reduced damages to surrounding nerves and muscles
  • Smaller incision with a better cosmetic outcome
  • Less pain
  • Less operative time consumption
  • Faster recovery and quick return to daily life.

Before being discharged from the hospital, patients need to be physically independent and able to conduct their daily activities, such as sitting and getting out of the car, getting out of bed, sitting on a chair and taking a shower. To relieve pain, pain medications can be taken as prescribed. During the first 2 weeks after returning home, patients are not advised to sit longer than 60 minutes each time. Lifting heavy objects, performing vigorous tasks or sitting in vibrating vehicles should be also avoided. After 2 weeks, patients can start appropriate exercise to regain their muscle strength in the abdomen and the back. It is important to maintain a healthy weight in order to prevent recurring herniated disc. Moreover, to help prevent a herniated disc, it is highly recommended to exercise regularly to strengthen the muscles and stabilize the spine, maintain good posture by keeping the back straight and aligned, particularly when sitting for long periods, avoid lifting heavy objects and quit smoking.