Low back pain with sciatica are among the most common complains in the population. With improvement of diagnostic facilities, such as MRI, it became clear that two third of population over the age of 15 years has prolapsed disks. Most of them have minor complains and others has a major clinical manifestations. It is very rare to see a patient coming to the clinic complaining of LBP with sciatica, without the presence of PLD. One case per thousand, require surgical intervention.
With the evolution of new technologies and innovations in technical standards, a trend for minimally invasive and minisurgical approaches became regaining popularity. Some of these standards are meaningless and the others even causing harm. There is misuse of some the new standards. Mild bulging of disc for example, which can be resolved over several weeks of rest, is not in need for percutaneous discectomy, which got popularity 15 years ago.
Understanding the relative amount of extrusion, the relation with neural structures, the functional loss, the disability of the patient due to the PLD, the type of occupation, the psychological state of the patient and many other factors play very important role in selection of patients, who are in need for surgical intervention.
Excluding the major neurosurgical centers, where subspecialties are divided among certain neurosurgeons, 80% of neurosurgical activities of general neurosurgeons are in the spine pathologies. With experience and thousands of operations for PLD, it is becoming clear, where to concentrate in improving the surgical standards to achieve better outcome.
Taking into account, that the neurological manifestations are due to direct compression by the extruded disc material and in some cases accompanied by elements of instability and the presence of hypertrophic changes of the bony and ligamentous structures on the nerve roots, the recovery of the compressed nerves, after their decompression, must reflect the recovery of the neurological deficit. Here come, the role of the neurosurgeon to minimize the degree of surgical trauma during that.
Using for years, the established technical standards of laminectomy, laminotomy, flavotomy, hemiflavotomy , fenestrations and etc. procedures with the Smith-Kerrison rongeurs can harm the nerve roots before reaching them, causing postoperative complications and deterioration of the neurological status of the patient, with the confirmation that the neurosurgeon did not performed any mistake during the operation.
The recovery rate of the nerve roots, after their decompression, is dependent upon several parameters; among them is the severity of compression, the length of time of the presence of such compression, the age of the patient, the presence of other pathologies, such as diabetes mellitus and psychological status of the patient.
Meticulous intradiscal cleaning has its merits and odds. Knowing that cervical disc can be totally removed with the posterior longitudinal ligament, the recurrence rate is zero. But due to anatomical structure of the lumbar disc, total removal of the disc with the annulus fibrosis is not logical, because it will cause disaster; the neurosurgeon must leave intentionally several outer layers of the annulus to keep the vertebral column stable. This fact has its drawbacks with the presence of postoperative intradiscal mass displacement in 40% of operated patients and the presence of 7-10% clinically confirmed recurrence of disc, mandating reoperation for second and in rare cases third time.
The presence of preoperative primary discitis with subsequent extrusion in patient, undergoing surgery, especially in diabetics must be dealt with cautions, considering the possibility of osteomylitic complications.
With introduction of new digitally assigned video recording for all surgeries, using the microscope, or the parallax coaxial magnifying and recording loupes with retrospective analysis of the operation, some facts came to arise, explaining why some of the complications took place, despite the fact that the neurosurgeon took all precautions during surgery.
Implantation of artificial disci still far from introduction, as a routine surgical standard, for lumbar disc surgery, due to its possible complications and the lack of general acceptance among neurosurgeons.
The use of endoscopic facilities, percutaneous procedures and chemonucliolysis must be considered as complementary procedures during the major surgical resolution of the patientís disc problem.
Postoperative fibrosis, at least in my opinion, is not a cause of genuine pain and other causes must be considered as postoperative pain. Using foreign materials to minimize the postoperative adhesions is not convincing and preservation of the epidural fat, and transferring it to the roots, where due to maximum compression, the fat is absent, aided with the patientís own fat in pedicle minimize the postoperative fibrosis.
Because the lumbar disc prolapse is a very wide field, concentration, here will be directed upon some aspect of neurosurgical standards, which the author gained through experience with more than three thousands of operations during the last twenty years.
New&Old surgical standard
One of the general principles, tailored for the last 15 years, is using drill before performing flavotomy. Over the time with perfect knowledge of the anatomical relationships of the flavum to the facets and laminae, it is easy to perform drilling, using different diameters of burrs to achieve decompression of the flaval elements over the already compressed neural structures to avoid the surgical trauma of flavotomy by using the Smith-Kerrison rongeurs, the jaw of the most smaller size is more than 1 mm, insertion of which to perform flavotomy is crucial in causing trauma to the compressed nerves. More than thousand operations were performed in such way and it is a routine practise.