Description of the operation of percutaneous nucleotomy with laser vaporization for hernia or protrusion of intervertebral discs
Percutaneous nucleotomy with laser vaporization for herniated or protruded intervertebral discs consists of two main steps: creating optimal access and destroying or removing material of the intervertebral disc. In addition to chemonucleolysis, the following possibilities exist for the destruction or removal of the material of the intervertebral disc:
- laser vaporization of disc tissue
- automated discectomy
- mechanical removal of disc tissue using grasping forceps
Differences in methods confront the surgeon with the need to distinguish between a hidden herniated disc (contained herniated disc) and an open (non contained herniated disc). With a hidden herniated disc, treatment consists of reducing intradiscal pressure by reducing the mass of the nucleus pulposus.
All of the above possibilities are available for this. Access is from the back (posterolateral approach) in the direction of the caudal and ventral direction, past the nerve root, clearly visible on computed tomography of the spine.
In an open hernia with a torn annulus fibrosus, the material of the intervertebral disc either protrudes under the posterior longitudinal ligament (subligamentary disc herniation), or it is loosely located in the epidural space when the longitudinal ligament is also torn (sequestered disc herniation).
In contrast to the nonselective intradiscal reduction of material in latent disc herniation, subligamentary and sequestered disc herniation require selective removal of protruding disc material, and access planning is of great importance. Operations of percutaneous (percutaneous) nucleotomy with laser vaporization of intervertebral discs are performed for protrusions or hernias of the disc of the cervical, thoracic or lumbar spine.
Percutaneous nucleotomy procedure with laser vaporization for herniated or protruded intervertebral discs
1. Open herniated disc
- A puncture is performed using a puncture needle in a pre-designated and designated access site under CT control (control using a computer tomography). The needle is inserted under CT control up to the yellow ligament (ligamentum flavum). With the simultaneous injection of saline sodium chloride solution, the puncture needle is inserted further up to the protruding material of the intervertebral disc. After inserting a 0.8 mm string and removing the puncture needle, an expanding sleeve is first carefully inserted (with the aim of strengthening) up to the hernia, and then the access is expanded with a dilator. An operating cannula with an outer diameter of 5.5 can now be placed over it. In addition to CT monitoring, the correct position of the operating cannula can be verified endoscopically. For this, HOPKINS® 30 ° and 0 ° optics are available. After insertion of the endoscope into the sheath, the flow of the rinsing solution through the connection with the LUER lock is adjusted on the rinsing sheath so that a clear image is displayed on the monitor. After checking the correct position of the cannula, both on the CT image and with the help of an endoscope, you can begin to remove the exposed material of the intervertebral disc. Open sequestered discs can now be removed with grasping forceps. In the case of subligamentary open herniated disc herniation, the posterior longitudinal ligament should first be opened with a trephine. After the ligament is opened, the open herniated disc is then removed using grasping forceps. If, in addition to the herniated intervertebral disc, there is a noticeable buckling of the annulus fibrosus, then we additionally carry out, as a rule, intradiscal laser vaporization using a laser tube under optical control.
2. Hidden herniated disc
- In this case, treatment consists only in reducing intradiscal pressure by reducing the mass of the nucleus pulposus. Access to the intervertebral disc is carried out in the same way as in the case of the open hernia described above. Due to the simplicity of the method and the minimal risk of complications, we carry out this tissue reduction by the method of laser vaporization using a laser tube under optical control.