Abstract
The clinical effectiveness of percutaneous and transforaminal endoscopic discectomy procedures has been evaluated by the system used or compared to open laminectomy or micro-discectomy but are not evaluated based on the location and characteristics of the abnormal disc. This review proposes that outcomes are primarily related to disc size, biomechanics, location, and associated segmental fibrotic and bone changes as well as the surgeon's skill in using various systems rather than the specific system used. In these cases, the surgeon needs to decide if the goal of the procedure is simply internal decompression of an abnormal but contained herniated disc or release of the entrapped nerve root by a large contained disc, extruded and migrated disc fragment, or coexistent foraminal stenosis. Percutaneous and tubular transforaminal procedures are quite different, technically ranging from simple discectomy aspirating probes to larger endoscopic systems, providing the capability to remove large extruded free disc fragments, with or without foraminotomy. Recently, the ability to perform interbody fusion has been added to the range of procedures able to be performed endoscopically. At the same time, biologic solutions to disc degeneration are rapidly evolving and may have a place in combination with these procedures. This article reviews the interrelationship between clinical signs and symptoms, radiologic findings, and the biochemistry and biomechanics of the affected disc segment. Understanding the role played by all these factors enables the surgeon to evaluate both the disc and surrounding bone structures pre-operatively to determine if the clinical signs and symptoms are related to enlargement and displacement of a contained disc or compression or impingement of the nerve root. Based on this, the surgeon can choose different surgical systems, allowing simple decompression of a contained disc, possibly adding biologics, with a 'small' system, while a large herniated disc, or extruded fragment, causing root impingement, would require a ‘larger’ system that provides direct endoscopic visualization within the epidural space, foraminal decompression with drills, and direct surgical manipulation and freeing of the nerve root. By choosing the surgical system based on characteristics such as disc size, location, and associated inflammatory and fibrotic changes, the effectiveness of minimally invasive procedures will be more consistent and improve as the surgeon's diagnostic and operative skills improve.
Highlights
BackgroundThe literature regarding percutaneous and transforaminal endoscopic discectomy hasHow to cite this article Palea O, Granville M, Jacobson R E (January 20, 2018) Selection of Tubular and Endoscopic Transforaminal Disc Procedures Based on Disc Size, Location, and Characteristics
Disc pathology is a continuum of disease where one form of disc pathology evolves into another, often with long asymptomatic periods, and where there can be a mixture of secondary facet and bone changes evolving along with the original disc pathology
Before examining the reasons for adopting different surgical systems based on the underlying radiologic segmental spinal pathology, it is critical to understand the interrelationship between clinical symptomatology, radiologic findings, spinal biomechanics, and what is known regarding the physiologic, biochemical, and inflammatory response within the abnormal disc and surrounding tissues
Summary
The literature regarding percutaneous and transforaminal endoscopic discectomy has. How to cite this article Palea O, Granville M, Jacobson R E (January 20, 2018) Selection of Tubular and Endoscopic Transforaminal Disc Procedures Based on Disc Size, Location, and Characteristics. Pathologic studies show these fissures and tears occur more in the posterior part of the disc, indicating that herniations do not develop in all directions but are associated with some shifting of disc nucleus posteriorly [10, 24,25] This is associated with disc space narrowing, facet joint fluid and eventually Modic endplate changes indicating more chronic inflammation and degeneration [8,9]. The development of angiogenic and neural proliferative reactions in response to tissue inflammation from the breakdown of nuclear disc substances may be where biologics will be effective in treating the abnormal disc at its earliest stages to treat 'pain' but to have an effect on the degenerative process {3, 25-27] It is possible biologics will be combined with these minimally invasive approaches to arrest or reverse both disc degeneration as well as the localized changes that result from the inflammatory process around the disc capsule, annulus, and nerve root
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