Through advancements in modern surgical technology surgeons worldwide have started performing a surgical procedure called a micro endoscopic discectomy (MED). The operating surgeon uses special instrumentation combined with a real-time camera display to remove a herniated disc or fragments of one through a very small incision.
A microscopic discectomy is performed for the same reasons as a traditional discectomy to accomplish the same results. An endoscopic microdiscectomy is performed to remove a herniated disc by using much smaller incisions. In a traditional discectomy your surgeon makes a large enough incision which he can visually see and remove herniated disc fragments. In a micro discectomy your surgeon will use small incisions combined with a small camera to locate the problematic fragment(s) and remove them with special surgical instruments. The procedure may or may not require general anesthesia and because it is done with a smaller incision there is usually less tissue damage.
There are only specific situations where an endoscopic microdiscectomy is viable. Many patients seeking surgical procedure are better suited to a traditional discectomy, or other minimally invasive surgery. Although the thought of a faster and easier recovery may sound enticing, the important thing to remember is the surgery must be performed properly.
MED (Micro Endoscopic Discectomy) Procedure
In most cases the patient will be "put under" with general anesthesia, but some surgeons prefer to perform a MED using either local or spinal anesthesia alleviating some patient uneasiness and concerns about general anesthesia. With the patient sedated he/she is turned onto their abdomen and secured into position with pads. A fluoroscope is used during the procedure to show live X-ray pictures on a monitor, helping the surgeon see what fragments need to be removed.
Using the fluoroscope the team confirms the disc space and injects an extended duration local anesthetic through the muscle and around the bone that protects the disc. With the use of a wire and varying sizes of dilators the incision is progressively enlarged without the need to cut any muscle. It will usually take four to five dilators for the incision to enlarge to roughly the size of a nickel, which will be used as the entry point for the procedure. When the final dilator is in place, a circular retractor is placed into position to create a working channel. Once the working channel is in place all the dilators are removed.
The endoscope is then attached and positioned to the edge of the channel that was just created allowing the surgeon to operate via images projected to a TV screen. The rest of the procedure is performed through the working channel.
Once the procedure is completed the wound is flushed with antibiotics. As the fluoroscope is removed your surgeon will be able to see how the tissue is coming together and place stitches to help hold the tissues together at various levels, promoting better healing.
Typically a few stitches are used on the exterior of the wound and a loose bandage is secured. After a few hours of monitoring in the recovery room, if everything goes well, the patient is allowed to leave the hospital. All that is left is for the patient to continue follow up appointments and start recovering from the procedure.
Endoscopic discectomy is an alternative technique to Microscopic discectomy.
Endoscopic discectomy
In this technique an endoscope is used to visualize the nerve root and the prolapsed disc material. Through a small incision a working insert, containing the endoscope is introduced at the affected disc level.
HOPKINS II telescope 0 degree
The surgical field (ie. bone, nerve root and the disc material) is visualized on television screen
The working insert also contains a nerve root retractor and a channel for the micro instruments to enter and reach the disc material. The prolapsed disc materials are removed through a 8mm small channel
Disc materials removal
The whole surgical procedure is performed by the surgeon looking at the television screen. Endoscopic micro discectomy claims to have produced less muscle dissection. Both these procedures (MLD and MED) are minimally invasive spine surgeries
The advantages of these procedures are : -
Early ambulation - patients getup and walk on the same day of the surgery.
Less hospital stay
Cosmetically acceptable - ideal for young patients
Less morbidity, ie. less post operative back muscle pain.
Handling of the neural tissues are gentle and precise due to excellent illumination and magnification.
Double hook retractor system
Innovation & advancement in lumbar discectomy technique
To improve the surgical results Dr. Parthiban has introduced a new concept in retractor system in the surgical armamentarium. Minimally invasive spine surgery is recommended for its low morbidity rate. The double hook retractor, retract lumbar paraspinal muscles against spinous process, thus obviates the limitations of single hook systems.
In Micro lumbar discectomy, an incision less than 3 cm is made between two adjacent lumbar spinous processes. Subperiosteal separation of paraspinal muscles from the spinous processes and laminae is performed. A suitable Dr.Parthiban's double hook retractor is selected and the hooks are placed over the lateral aspect of the adjacent spinous processes. The hooks avoid the interspinous ligament. A suitable flat blade is now introduced on the sides of the paraspinal muscles. The parallel bars of the retractor system is now introduced in the slots available on the blades, and are distracted over a serrated bar. This maneuver now efficiently retracts the paraspinal muscle away from the spinous processes and thus providing a rectangular surgical field exposing the adjacent laminae, interlaminar space and the medial edge of the facet joint. The interspinous ligament is not disturbed.
Dr. Parthiban's Double hook retracts Muscle against bone
Hooks on adjacent spine
In lumbar foraminotomy for excision of extreme lateral disc prolapse, a 20mm incision over the selected spinous process is made and the paraspinal muscles are separated to expose the lateral edge of pars and facets.
A 55mm long / 15mm Dr.Parthiban's double hook retractor is selected and the hooks are applied over the sides of the adjacent spinous process. The paraspinal muscles is now retracted against the spinous process using the flat blade, until the lateral edge of the pars is visualized. In both these procedures the paraspinal muscles are retracted effectively against the bone (spinous process) by the Dr.Parthiban's double hooks. The blades are always even and need no replacement during the procedure. All conventional micro discectomy instruments can be used without technical difficulties.
The Dr.Parthiban's double hook retractor designed by Dr. Parthiban obviates all those problems observed with single hook systems. Since the two hooks rest on adjacent spinous process, the inter laminar space is always stable. No restriction of instruments at any stage of the surgery was observed. Soft tissue insult is very limited. The Dr.Parthiban's double hook concept can be applied to all micro lumbar retractor system.
The Dr.Parthiban's double hook retractor is a simple innovative modification that uses the bones for efficient retraction of paraspinal muscles in micro lumbar discectomy and foraminotomy, thus preserving the interspinous ligament. It obviates the limitations experienced in single hook systems.
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