Percutaneous Discectomy – Integrative Pain Center of Arizona
(This procedure goes by many, many names including: laser discectomy, laser decompression, PLEDD, PLD, LASE™, posterior lateral extra foraminal disc decompression, Nucleoplasty™, chemonucleolysis)
This is a minimally invasive surgical procedure for buttock and leg pain from a small herniated disc (slipped disk, disc protrusion). Although pain radiating from the back and buttock down one leg can have many causes, sometimes the problem is a “contained herniated disc” pushing against the nerve root enough to cause leg pain. The majority of people with this problem recover with conservative treatment that includes analgesics and physical therapy, occasionally accompanied by oral or epidurally injected steroid medication. When this treatment is inadequate and pain persists, surgical removal of the disk may be necessary. The time tested method involves an open surgical procedure to remove bulging disc and disc fragments. This is generally quite successful for relieving leg pain. Removal of disk material through a large needle or endoscope placed within the disk is an alternative to open surgical diskectomy that may have advantages for a minority of carefully selected patients who need discectomy. Several techniques have been developed for percutaneous discectomy, but the idea behind each technique is the same, to indirectly decompress the disk.
What is the purpose of percutaneous discectomy?
To decrease leg pain from disk herniation (sciatica, radiculitis, radiculopathy). Percutaneous diskectomy is a pain relief procedure, intended to reduce buttock and leg pain quickly.
Who might benefit?
A carefully selected group of patients with a diagnosis of herniated disc (disc protrusion) who have buttock and leg pain that does not get better with conservative treatment and which is causing moderate interference with daily activities. This is a procedure for patients with relatively small disc herniations who are not good candidates for open surgical diskectomy, or who do not wish to try percutaneous diskectomy first before considering open surgical diskectomy.It is best to be evaluated by a spine surgeon before having percutaneous diskectomy, because the medical literature suggests that when a patient is a good candidate for open surgical diskectomy, the results are somewhat better than percutaneous diskectomy. Many doctors who perform percutaneous diskectomy are spine surgeons or work with a spine surgeon to make sure that patients are given access to all the reasonable options for their care and are given good information on the benefits and drawbacks of the all the different treatment options. When the disk herniation is too small and the consultant spine surgeon does not suggest surgery, percutaneous diskectomy may help.
Who should not have percutaneous diskectomy?
- Patients with pressure on nerves that is causing severe weakness, numbness, or changes in bowel or bladder control. Patients with these symptoms need urgent medical evaluation for possible surgery.
- Patients with certain types of disk herniations as seen on MRI:
- Large herniated disks.
- Patients with “extruded” herniated disks
- Patients with “free disk fragments” that have broken off their disk herniation.
- Patients with moderate or severe disk degeneration or severe spinal stenosis. The procedure does not work well when the entire disk is degenerating.
- Patients with evidence of spinal instability at the level of disk herniation.
- Patients who are pregnant.
- Patients with active infections.
- Patients on blood thinning medications who cannot stop the medications for at least one week.
How is it actually performed? The following are som of the technologies that have been or are used to accomplish the goal: decompression of nerve root:
1. Injection of an enzyme to dissolve some of the nucleus pulposus (chemonucleolysis). This is not performed frequently in the United States.
2. Removal of disk material using a mechanical device with or without an endoscope.
3. Removal of disk material using a laser to vaporize a small cavity within the disk (device manufacturers and marketers have called this: laser discectomy, laser decompression,PLD, LASE™)
4. Removal of disk material using a device that vaporizes a small cavity within the disk by creating a plasma field (Nucleoplasty™)
There is not enough research to conclusively say that one technique is better than another.
How long does the procedure take?
About 30 minutes for each disk.
Will I be “put out” for this procedure?
No – an anesthesiologist or nurse will be with you to give you sedation and pain relievers, but you are awake enough so you can give the physician valuable input during the procedure.
Will the procedure hurt?
The procedure involves inserting a needle through the skin and underlying tissue into the disc, so some discomfort is involved. However, the doctor will numb the skin around the needle to reduce discomfort and you’ll receive a mild sedative before the needle is placed. Actual removal of the disc is usually not painful. Post procedure pain is usually mild to moderate and can last from one to two days to two weeks. Post procedure pain is a bit more severe with the laser discectomy technique. You will be given pain medication by your doctor to help with postoperative discomfort and pain.
What are the risks and side effects?
This procedure is safe compared to other back surgery procedures. However, as with any procedure, there are risks, side effects and the possibility of complications. The most common side effect is pain at the site of the needle insertion, which is temporary. The other risk factors involve bleeding, infection, damage to nerves and injection into blood vessels and surrounding nerves. Fortunately, serious side effects and complications are uncommon. A rare complication of this procedure is an infection in the disc, which is referred to as discitis. The procedure has not been in use long enough to know if there are delayed problems that might occur 15 or more years after, but there is no sound reason to suspect that there will be problems late after the procedure.
Will my insurance cover percutaneous diskectomy?
Most insurers do.
Do I have any special limitations after the procedure?
Patients need to rest for the first 2 days and then can resume light activities including desk work, as long as these are not very painful. Pain should be the guide to activity. Between two days and two weeks after the procedure, patients may lift up to 20 pounds and perform light chores around the house, go for walks, start swimming. Of course, patients need to use common sense and avoid any activity that provokes pain during this period. Lifting of more than 20 pounds, bending, climbing, crawling should be postponed until two weeks and should be postponed further if they’ve provoke pain.