Discectomies are performed when a herniated intervertebral disc (“slipped disc”) puts enough pressure on the nerve root to cause pain and sometimes symptoms of numbness, weakness, and difficulty controlling bowel or bladder.
Surgery may be recommended after 6 weeks if nonsurgical, conservative care has failed, or prior to completing a full 6 weeks of nonsurgical care if: There is severe pain and the patient is having difficulty maintaining a reasonable level of functioning, or if the patient is experiencing progressive neurological symptoms, such as worsening leg weakness and/or numbness.
There are a number of surgical procedures for treating sciatica from a disc herniation putting pressure on a nerve root. Collectively, these procedures are sometimes referred to as “lumbar disc decompression” or similar phrases.
Techniques for removing a disc from the “outside in” approach, cutting away herniated disc material and then going into the disc to remove some of the center of the disc, include:
- The first procedure is typically surgical discectomy, and this still remains commonly used technique.
- Traditional discectomy performed under a microscope to improve visualization is called a “microdiscectomy”.
- Discectomies can be done through a tube – or “endoscope”. Combining endoscopic discectomy with a microscope has been called “micro-endoscopic discectomy”.
Techniques that involve only removing material from the center of the disc are also available and the simplest, fastest and least costly of these is called “nucleoplasty” percutaneous discectomy. This is an outpatient procedure that can be done in the office, which takes about 10 minutes under local anesthesia, which is done through a needle the size of a large IV cannula.
Percutaneous discectomies are not for patients who have large disc herniations or pieces of disc that had broken loose, they are for patients with sciatica (pain from the back radiating to the buttock and down the leg usually) that has failed conservative treatment or is causing too much pain during conservative treatment and that have disc herniations 6 mm or smaller. They work by decompressing the center of the disc to reduce pressure in the disc and allow the moderate small disc herniation to shrink in size, thus decompressing the nerve root.
The reader will see that with nucleoplasty percutaneous discectomy results on decreasing pain are about as good as other surgical options available for patients with small to moderate sized disc herniation, risk is low, cost is very low compared to other procedures, and recovery is fast.
So why is it that a percutaneous discectomy is rarely recommended? Why are more complex and risky procedures, such as a lumbar microdiscectomy, more commonly used?
Comparing Risk & Reward
It’s not because the complex procedures are more effective. In fact, those who opt for a percutaneous discectomy have seen very positive outcomes. “Analgesic consumption was stopped or reduced in 42 patients (85%) at 6 months and in 46 patients (94%) 1 year after the procedure. Overall patient satisfaction was 81% at 2 weeks, 85% at 6 months, and 88% at the latest follow-up.”
The patients going in for a lumbar microdiscectomy must undergo full anesthesia, can only have the procedure done in the hospital and the patient may remain there overnight. The doctors will generally remove not just the tissue of the herniated disk, but also a piece of the vertebrae bone in order to have more visibility.
In a surgery of this caliber, there is also more room for mistakes. Incidental durotomies are a common complication that occurs during invasive spinal surgeries. This complication occurs when an accidental tear of the dural sac is resulted from the sharp utensils used during the lumbar spine surgery. The Journal of Neurosurgery reports that these incidental durotomies occur in 3.5% of microdiscectomies.
With any procedure, there is also risk of infection. However, there is a higher risk with some procedures than in others. With a lumbar microdiscectomy, the Journal of Spinal Cord Medicine reports that infections are “quoted to be 3% or even lower, but the incidence increases to as high as 12% with the addition of instrumentation”.
In comparison, the occurrence of infection after a percutaneous discectomy is far lower. A finding of 0.016% per examination chance of infection was found.
A microdiscectomy can be a pricey endeavor. The baseline price for a microdiscectomy ranges from $15,000 to $75,000, and that does not include the upwards of $15,000 for hospital bills and anesthesia. A percutaneous discectomy, if undertaken at IPCAZ, will cost a patient between $2,000 and $3,000.
The problem is, insurance companies are not noble and trustworthy businesses, in fact, they don’t really seem to be worried about what procedures will be the best choice for a patient at all. Insurance companies are generally solely worried about making money. For this reason, the much cheaper percutaneous discectomy is often not covered by insurance.
Choosing the best procedure for YOU
Ultimately, it’s up to the patient to decide what procedure is the best for their particular situation. If a patient is experiencing persistent leg pain/sciatica from a small, moderate disk herniation with no serious symptoms indicating the need for immediate disc decompression surgery such as loss of bladder control, severe leg pain and numbness, etc., then it is reasonable to ask about the less invasive, less expensive, less risky, and just as effective nucleoplasty percutaneous discectomy.