Advantages of PELD(Percutaneous Endoscopic Lumbar Discectomy) - Advanced Minimal Invasive Technique

Percutaneous Endoscopic Lumbar Discectomy (PELD)

Percutaneous Endoscopic Lumbar Discectomy (PELD) is a unique approach which is quickly getting popular amongst patients and surgeons in the treatment of nonsequestrated disc herniation (disc prolapse) as it reduces the post operative hospitalization and recovery time.

An advanced minimal invasive technique, Percutaneous endoscopic lumbar discectomy (PELD) is performed for the decompression of the lumbar disc space and removal of nucleus pulposus via a posterolateral approach. In addition to decompression surgery, the technique has been found effective in management of spinal tumors and structural deformities. This surgery is recommended in patients who fail to respond effectively to conservative treatment with pain killers like NSAIDs (Non Steroidal Anti inflammatory Drugs) or when the pain threshold is low. In this form of surgery, an instrument called endoscope is used and the whole surgery is done under local anesthesia with the patient fully awake during surgery.

Who may require PELD?

Individuals suffering from chronic low back pain and disability may benefit from a PELD procedure. It is often used to treat patients suffering from degenerated discs, bulging discs or herniated discs that compress upon the surrounding structures within the spinal canal causing nerve compression, sciatica and low back pain. It can also be used if the patient fails to respond to conventional management therapies including direct injection therapies for three months or more. The surgery is also found to be successful in resection of spinal tumors, fusion and structural deformities of the spinal cord.

Relevant Anatomy

The human spine is made up of 33 bony segments called vertebrae which are stacked one above the other. These vertebrae are separated by small, soft, cushion like structures called the intervertebral discs that act as shock absorbers. These discs undergo degeneration due to age related wear and tear, resulting in disc herniation or prolapse. They compress the surrounding soft tissues or nerves giving rise to severe pain. If the vertebral discs in the lower back or the Lumbar region are compressed, they result in pain and tingling in the legs and spasms in the back.

Procedure and types of PELD

Percutaneous endoscopic lumbar discectomy is the ultimate form of minimal invasive spine surgery. It is an endoscopic daycare surgical procedure which is conducted in about 60 minutes, under local anesthesia with mild sedation. Patient is made to lie on his front on the operation table and exact entry point is mapped on patient’s body using image intensifier x-ray system. A small incision is made about 8-10 centimeters from the midline on the posterior part of the body. Now there are two different ways in which the inter-vertebral disc material can be removed (i.e. manually or using laser).

• Manual procedure also known as automated percutaneous discectomy involves insertion of a long spinal needle from side of back, directly into the disc, by-passing other bone and ligaments. Through this needle, guide wire is passed and after taking 5mm incision, dilator and working cannula are passed, through which endoscope is inserted. Camera and monitor is attached to endoscope and prolapsed part of disc is removed under vision.
• The laser surgery is referred to as percutaneous laser discectomy (PLD), which uses an external imager called the fluoroscope to direct the probe. The probe delivers laser energy which vaporizes a part of the inter-vertebral disc material and decompresses the nerve root. The most frequently used laser for treatment is Holmium yttrium- aluminum-garnet (Ho:YAG) laser.

In either procedure, the wound is closed with single stitch. Patient gets immediate pain relief and he can go home in 24 hrs and can resume his work soon.

Advantages of PELD

• Surgery is done under local anesthesia with conscious sedation.
• No muscle, ligament or normal tissue damage and minimal blood loss.
• Patient can be discharged in 24 hrs. No prolonged bed rest required after surgery.
• Early return to work.
• Even prolapsed, migrated, extra-foraminal, recurrent discs can be removed.
• Very good technique for old and medically compromised patients.
  
  
  
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Why do so many people suffer from low back pain?

Have you ever asked, "Why do so many people suffer from low back pain?" The answer involves a brief overview of the lumbar spine. Although the entire spine is involved in everyday activities of rest and movement, the low back can be vulnerable to many pain-provoking disorders. Simple sprains and strains from overexertion, a herniated disc from a slip and fall, degenerative disc disease or spinal stenosis from normal aging, and other disorders can cause low back pain.

To help you understand back pain, the following brief and illustrated anatomy lesson is provided.

What Is the Lumbar Spine?

The lumbar spine (low back) is the third major region of the spine; it is below the cervical spine and thoracic spine. Most people have five bones (vertebrae) in the lumbar spine, although it is not unusual to have six. Each vertebra is stacked on top of the other and between each vertebra is a gel-like cushion called an intervertebral disc. The discs help to absorb pressure, distribute stress, and keep the vertebrae from grinding against each other.

Ligaments and Tendons: Connective Lumbar Spine Soft Tissues

The vertebrae and discs are held together by groups of ligaments . Ligaments connect bone to bone, whereas tendons connect muscle to bone. In the spine, tendons connect muscles to the vertebrae. The ligaments and tendons help to stabilize the spine and guard against excessive movement in any one direction.

Lumbar Spine Joints

The spine also has joints that are similar to knees, elbows, and other joints. The spinal joints are called facet joints 

The facet joints have been described as finger-like, and they link the vertebrae together. The facet joints are located at the posterior area of the spinal column (on the back side of the spinal column).

In addition, the facet joints help to make the spine flexible and enable you to bend forward, backward, and side to side.

The lumbar spine has several distinguishing characteristics:

·         The lower the vertebra is in the spinal column, the more weight it must bear. The five vertebrae of the lumbar spine (L1-L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso.

·         The lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury.

·         The lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when walking and running.

·         The spinal cord travels from the base of the skull through the spinal column and ends at about T12-L1 - where the thoracic spine meets the lumbar spine. At that point numerous nerve roots from the spinal cord continue down and branch out, forming the "cauda equina," named for its resemblance to a horse's tail. These nerves extend to the lower extremities (buttocks, legs and feet). Because the spinal cord does not run through the lumbar spine, it is quite rare that a lower back problem would result in spinal cord damage or paralysis.

Lumbar Intervertebral Segment

Physicians usually explain a patient's pathology by focusing on one intervertebral segment, or spinal segment. The lumbar spine has 5 intervertebral segments, termed lumbar segment 1 through 5 (e.g. L1, L2, L3, L4, and L5).

Each lumbar spine segment is comprised of:

·         Two vertebrae, such as L4-L5, stacked vertically with an intervertebral disc between them. A healthy disc is cushiony, with a lot of water, and has a sponge-like substance. It acts like a shock absorber in the spine, allowing flexibility and providing protection from jarring movements.

·         The two adjacent vertebrae are connected in the back of the spine by two small joints called facet joints. The facet joints of the lumbar spine allow movement to bend and twist the low back in all directions.

·         There are nerves that branch off from the spinal column at each level of the spine. They pass through small holes in the back of the lower spine. They then connect together to form the sciatic nerve, which travels into the legs down the back of each thigh and into the calves and feet.

Doctors usually talk about a patient's lumbar disc problem, or nerve or other lower back problem, as the level that includes two vertebrae and the disc between them, such as L3-L4 or L4-L5. If the disc at the very bottom of the spine is affected, that segment is called the lumbosacral joint L5-S1

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