Donnerstag, 3. Dezember 2015

History in Disk Treatment - The posterolateral access and Intradiscal Decompression

Percutaneous Nucleotomy 


1975 Chemonucleolysis was banned within US against the protest of many surgeons due to a study by the Walter Reed Hospital at 104 Veterans by the FDA. Never the less Chemonucleolysis has been continued in Kanada, Germany and some more countries. In the same year Hijikata published a surgical method with the aim of intradiscal decompression via the posterolateral approach. He called this intervention "Percutaneous Nucleotomy". 

Source: Hijikata S, Yamagishi M, Nakayama T, Oomori K: Percutaneous nucleotomy: a new treatment method for lumbar disk herniation. J Toden Hosp; 1975; 5:5-13.

Material and Methode: The Operation technique had the same access as Chemonucleolysis. The posterolateral acces was performed by blunt dilation. But insteadt of chemical substance mechanical instruements were used. Hijikata used injection needle, guide wire, dilators, Operation tubes and graspers and rongeurs to remove gelatinous mass inside of the disc. It was also expected that by reduction of the nucleous volume  the bulging will colapse and release the affected nerve. 
For Guidewire placement and controll of the entire operation process the C-arm x-ray machine was used.

Progress: Even the entrance whole into the anulus fibrosus became larger than that one of chemonucleolysis the method was accepted by some pioneer surgeons and inspired them till today  to create advanced operation methods by minimally invasive spinal operation techniques. 
The operation technique was spreaded by Schreiber, Suezawa and Leu (Swiss located) at an early stage and pbulished.

Within US Parviz Kambin also used Percutaneous Nucleotomy. He described the "Safe Zone" which is also called "Kambine Zone". The Kambine Zone describes the area were instruments could be manupulated by minmized risk to demage neural structures and vessels, Thus helped many surgeons to become experienced in anatomical orientation and reduced lurning curve.

Source:  Leu Hj., Schreiber A.: 10 Jahre Perkutne Diskuschirurgie: Bilanz und Perspektiven. DGOT, Mitteilungsblatt 19 (1989) 3/52
Kambin P, Gellman H: Percutaneouslateral discectomy of the lumbar spine: a preliminary report. Clin Orthop; 1983; 174:127-132.
Kambin P, Brager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res; 1987: Oct;(223):145-54

Alternate Method: Created at nearly the same time Percutaneous Nucleotomy is in competition to Microdiscetomy of Caspar/Yasargil.  The difference is that in microdiscectomy the prolapsed disc material is removed directly under a three-dimensional view, while it is assumed that in percutaneous discectomy  with partial resection of nucleus pulosus the bulging will collapse  and thus will lead to decompress the affected nerv. Both treatments have advantages and disadvantages, but Microdiscectomy became the "Gold Standard".

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