New Approaches to Slipped Disc
Endoscopic Removal of Prolapsed Disc
Prolapsed intervertebral disc in the low back, also called slipped disc or herniated disc is a fairly common problem affecting active individuals between the ages of 25 to 55. It usually occurs between the 4th and 5th lumbar vertebral and the firth lumbar and first sacral vertebra.
This may or may not be related to an acute injury. The pain is usually in the low back and associated with pain and numbness and /or weakness going down one or the other leg.
The diagnosis is confirmed on clinical examination. Initial treatment should be conservative with rest, pain control and physical therapy. A large proportion responds well and should be followed up with a rehabilitative programme to prevent future recurrence. A small group does not respond. If the symptoms remain disabling then surgical intervention would need to be considered. Conventional surgery would be microdiscectomy or laminectomy. These procedure involve an incision in the back of the spine to open up the relevent level of the spine. A membrane which covers the nerve between the vertebrae (the ligamentum flavum) is excised. The nerve is then retracted (pulled to one side) and the disc space opened and the disc removed. The procedure is done under general anesthesia. The patient is admitted for one to three days.
However, recently, a new approach has been used: endoscopic disc removal. This is a form of keyhole surgery (minimal access surgery). It is done under local anesthesia and as a day stay patient, that is, the patient is admitted in the morning and discharged in the afternoon. A puncture wound is made at the back away from the spine. Under xray control, the scope which contains a camera is introduced. Under direct vision, the nerve is protected and the disc removed. The patient is allowed to get up when he feels comfortable and confident and is then discharged in the afternoon.
However, the procedure is not suitable for cases where the pain in the leg is caused by compression from boney spurs and not from the disc. It may also not be suitable for a disc prolapsed between the firth lumbar and first sacral level if the patient’s built is such that the pelvis bone prevent access to the disc space.
Position of patient for endoscopic disc removal under local anaesthesia with radiological control
Size of keyhole incision: 1cm
Endoscopic view of disc material: stained blue with methylene blue
Instruments used for removal of the disc: forceps and endoscopic laser
Triple layers demonstrated epidural space (red), annulus (white) disc remnants (blue)