Spine Surgery

Stitch less Spine Surgery

Information

For many years medical science has tried dealing with the issues of lumbar disc herniation in the least invasive manner. PELD and PELF are the techniques which have not only made these interventions minimally invasive, but have added a new dimension to the philosophy of treating Sciatica and Neurogenic claudication.
To briefly recapitulate the procedure, under local (or general) anesthesia, a long needle is introduced 10 to 12 cm lateral to midline aiming towards entering the desired disc at the intervertebral foramen level. This is done under continuous biplanar fluoroscopic control. After passing a guide wire, a dilator and working sheath are serially introduced using the Seldinger technique. A spinal endoscope of 20 to 30 degrees angulation is then passed with continuous irrigation. The nerve roots (exiting and transiting) are directly visualized. The offending disc fragment is then shrunk using radio-frequency waves and then removed mechanically with microscopic shaver. Laser can also be used to vaporize the herniated disc under direct vision. Endoscopic drills are used to remove the under-surface of the facet joint and clear the osteophytes. The lateral and foraminal part of the ligamentum flavum is removed with endoscopic punches and roungers. The disc fragment which is central or centro-lateral can also be removed by placing the endoscope at the perfect angle. The undersurface of the decompressed and pulsating thecal sac can be visualized to confirm the decompression. Bleeding is controlled by trigger-flex radiofrequency apparatus.

After the procedure is over, the small opening in the skin is closed simply by taping it. So this virtually becomes stitchless surgery. If the disc prolapse is causing bilateral root compression, this procedure can also be done bilaterally (simultaneously)                                                

     

The obvious advantages of PELD & PELF are:
  • Stitchless Surgery
  • Completely new approach. Does not disturb the important paraspinal muscles, spinal bones & ligamentum flavum. No retraction of thecal sac and nerve roots is required.
  • Preservation of ligamentum flavum, maintaining the sanctity of the sac & epidural space. Prevents post operative epidural scarring.
  • Foraminal Stenosis due to disc, osteophytes and the ligamentum can only be addressed directly by this procedure. (this is impossible by routine posterior approach unless the facet joint is removed partly or completely.
  • Early (immediate) mobilization and resumption of duties is possible.
One has to Remember
  1. PELD & PELF procedures are extremely useful if the patient selection is perfect.
  2. Conventional (Posterior) Endoscopic Spine Surgery does not have all the advantages of PELD & PELF (One should remember to differentiate the two)
  3. PELD & PELF are conceptually not very new, but due to the advancement in instrumentation, they have become super effective and are proven so by experience in the last four to five years.
  4. They have to be viewed as one of the many modalities useful for treatment of Spinal Problems.

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