A prerequisite for surgical intervention is the presence of appropriate local clinical symptoms or radiculopathy (irritation or damage to the nerve roots) with corresponding imaging findings (CT, MRI). In principle, a meticulous clarification of the surgical indication is necessary! A second opinion may be useful.
Indications
Absolute indication for emergency surgical intervention
- Progressive (increasing) and acute severe motor deficits with a degree of strength ≤ 3/5 according to Janda.
- Signs of spinal cord damage, such as rectal or urinary bladder dysfunction
- Kauda syndrome with acute paraparesis (bilateral incomplete paralysis (paresis) of a pair of extremities, e.g., paralysis of both legs)
Relative indications
- Sensory deficits and refractory pain with matching clinic and imaging.
- Severe pain leading to immobility that did not improve within four weeks despite conservative therapy
- Recurrent pain that leads to incapacity for work
Note: In all other cases without emergency indication, the primary conservative therapy is the means of choice. Furthermore, it should be noted that after more than 6 months of symptoms, the postoperative outcome in the case of surgical intervention worsens with the passage of time. Waiting too long will thus increase the risk of chronicity….
Classical procedures
- Microsurgical sequestrectomy (removal of the detached disc fragment) for transligamentous or sequestral herniation (treatment of choice).
- Partial hemilaminectomy (ablation of part of the vertebral arch) and discectomy (surgical removal of the intervertebral disc) (obsolete)
- Arthrodesis (stiffening of the joint) of the vertebral bodies (only in exceptional cases).
The following is a description of the procedures for surgical treatment of disc-related radiculopathy (irritation or damage to the nerve roots). See also under CT-guided periradicular therapy (PRT) wg pain management for radicular symptoms.
Percutaneous Interventional Procedures
Indications for the decompensated procedures listed below:
- Radiculopathy ≥ 6 months and resistance to conservative therapy.
- Correlating findings in computed tomography (CT)/magnetic resonance imaging (MRI)/discography (X-ray-based procedure to visualize the intervertebral disc by injection of a contrast agent) (disc prolapse ≤ dislocation grade 3 according to Krämer).
- Positive nerve strain signs (e.g., Lasègue), ≥ 60% residual disc height.
Decompressive procedures in the treatment of lumbar disc prolapse (herniated disc in the lumbar spine) (elective indication alternative to microsurgical sequestrectomy):
- Chemonucleolysis (chymopapain, ozone, ethanol) – enzymatic dissolution of portions of the nucleus pulposus (biliary nucleus).
- Nucleoplasty (coblation, “cooler controlled ablation”) – removal of disc tissue by cobalation (short for controlled ablation) using bipolar radiofrequency technology (RAF technology) by means of which plasma-induced tissue disruption is produced.
- Percutaneous laser disc decompression (PLDD) – vaporization (evaporation) of nucleus tissue and shrinkage of the annulus using introduction of a laser (diode, holmium, Nd:YAG laser) via a hollow needle.
- Percutaneous manual and automated disc decompression – automated percutaneous lumbar discectomy (disc removal; APLD) by a combined cutting and suction procedure using a so-called nucleotome.
Indications for the procedures listed below for discogenic local back pain:
- Duration ≥ 6 months and therapy resistance to conservative therapy.
- Discography positive
- ≥ 60% residual disc height
- Inconspicuous neurology, nerve extension signs negative.
- No nerve root compression on CT/MRI.
Procedure for discogenic localized back pain:
- Intradiscal electrotherapy (IDET) – “shrinking”, ie denaturation of collagen and thus contracting the same, and thermal ablation (Latin ablatio “ablation, detachment”) of nociceptors (pain receptors) by means of a termoprobe inserted into the intervertebral disc and heated to 90 ° C starting at 65 ° C.
- Intradiscal biacuplasty (IDB) – thermal procedure on the annulus using RF technology.
Further notes
- A systematic review (21,180 patients) and a prospective study examined the incidence of recurrent back pain and hernia recurrence after surgical treatment for lumbar disc hernia: In the systematic review, patients had back pain recurrence two years postoperatively in 3-34%, and 5-36% in the longer term. Hernia recurrence developed within 2 years in between 0 to 23% of patients.The prospective study showed a one-year rate of 22% of patients or two-year rate of 26% of patients with worsening low back pain or increase in a loss of function compared to three months earlier.
