The endoscopic minimally invasive method has decisively revolutionized the treatment of disc-hernias and other spinal problems. This sparing and comfortable procedure can be applied in removing all types of hernias as well as treating chronic back-pain. Recently it has become more common to treat complicated spinal conditions, such as spinal stenosis, by means of the endoscopic method. Thanks to modern diagnostic methods, like MRI and discography, the exact source of pain can now be located and removed by means of endoscopy.

  HEALING AND A NEW LIFE FOR THE DISC

This minimally invasive technique not only enables a gentle removal of a hernia, but also encourages a fast regeneration of the affected disc.
In order to expedite the regeneration and revitalization of the disc, the fossil cover plate of the adjacent vertebral body is abraded by means of fine instruments, thus improving a better blood-circulation of the disc and endorsing the growth of a buoyant, stable protective annulus. The water-balance of the disc increases. MRI images substantiate the healing of the intervertebral disc within 3 months after the operation.

 Endoscopic removal – Endoscopic Nucleotomy

What is the cause of a hernia? Is it always necessary to operated?Herniated discs are very common. Their four main causes are:

•  Natural, inherent weakness of the disc-tissue.
•  Sudden rotation of the upper body
•  Heavy lifting/shifting
•  Lack of exercise and permanent sitting may cause a stall of the rear-portion of the disc, resulting in weakness, tears and bulges of the    affected part of the disc.

A poor muscle-condition can furthermore add to the potentiality of a slipped disc. We speak of a slipped disc, when the ventral protective-annulus of the disc tears and bulges. This causes the soft tissue to leak out and aggravate or jam the nerve – resulting in severe pain.
This pain can radiate into the buttocks, leg or foot. The pain which goes from back to leg may be accompanied with numbness, tingling, crawling of ants, weakness or heaviness.

In some cases a herniated disc can recede with intake of pain-medication combined with two weeks of rest, during which the patient should avoid bending, lifting and shifting. Subsequently the patient should undergo physiotherapy, including strengthening exercises for the abdominal – and back-muscles. However, if the condition does not improve after two weeks of rest and the patient notices a distinct numbness and weakness of the muscles, a detailed examination and diagnosis would be advisable. In such cases an endoscopic removal of the hernia could be the best solution, which is least invasive and with minimal complication and very cosmetic.

   What does the treatment consist of?

The endoscopic removal of a hernia is a cohesive, percutaneous (under local anesthesia, no general anesthesia required) operative treatment. Ectopic or leaked-out tissue is removed, thus freeing the nerve. The procedure is performed in local anesthesia in a sterile, state of the art operating room with anaesthetic stand-by. It is said to cause less pain than a dental treatment. Small cannulae with increasing diameter up to 6 mm are conducted up to the hernia. The herniated disc is visualized through the endoscope, on a big TV monitor, magnified 20 times, hence no chance of nerve damage (as they are visualized very clearly) and removed by means of small instruments. Leftover tissue is shrunk by means of a laser or radio frequency cautery ( ELLMAN , USA ). In some cases, an enzyme is used to reduce/shrink the nucleus (core of the disc) in order to release pressure off the protective annulus thus fostering the subsequent healing-process.
The adjacent, fossil cover plate of the vertebral body is then sometimes abraded and refreshed with special instrument. This promotes the revitalization of the disc, the growth of a buoyant, stable protective annulus and improves the blood circulation of the disc.

Because the endoscopic nucleotomy is not an open but a minimally invasive closed surgery, there are little or no complications, pain or scarring. In the majority of the cases, patients can leave the clinic one day after the procedure. Younger patients can be treated on an out-patient basis.

   What are advantages of endoscopic spine surgery?

•  Tissue-conserving technique
•  Better healing of the torn disc
•  No noteworthy scarring
•  Sparing, comfortable local anaesthesia
•  The patient can walk without pain just two hours after surgery
•  The patient can return home one day after surgery
•  Faster return to familiar activities
•  Marginal relapse rate
•  Very low-risk
•  Cosmetic

After the removal of the degenerative, protruded portion of the disc the adjacent, fossil cover plate of the vertebral body is abraded and refreshed with special instruments. New disc-material re-grows within 3-5 weeks! MRI images substantiate the healing of the intervertebral disc within 3 months after the operation.

“Endoscopic” does not equal “Endoscopic”

The most fundamental difference and advantage of our method, compared to other, so called endoscopic methods, is the safe lateral (from the side) approach in local anaesthesia that bypasses and conserves the nerves and the Ligamentum flavum.

Most clinics apply the risky dorsal (from behind) endoscopic approach which always sacrifices the crucial nerve-protecting ligament of the spine, the Ligamentum flavum. In order to reach the slipped disc, nerves have to be pulled aside, involving a considerable risk of nerve-injury. Due to the dorsal approach these types of operations are extremely painful, hence have to be performed in general anaesthesia.

  What kind of post-operative care and rehabilitation will be required after the Endoscopic Decompression?

The patient will be examined by a physician one day after the operation. Furthermore, a physiotherapist will advise the patient about a customized post-operative rehabilitation. In most cases, physiotherapy can be initiated one week after the treatment. The patient is advised to wear a protective brace for the first two weeks after the treatment. This brace enables the patient to actively participate in his familiar activities. Six weeks after the operation the patient can return to his normal fitness-routine.

  When can a patient return to work?
Light office work can be taken up after the first or second week following surgery. Physical work should be restrained during the first six    weeks and subsequently slowly increased.

   When can sportive activities be taken up again?
In principle all kinds of exercise can be taken up after the operation. Swimming and cycling are admissible after just 2-3 weeks. Other    exercises can be taken up gradually after 6 weeks.

What is the success-rate?

Since 1989, we have performed more than 8000 minimally invasive spine operations. Over the last couple of years the success rate of endoscopic hernia removals has risen to over 95%. Data of all patients operated is ascertained and analyzed statistically by means of questionnaires.

HERNIATED DISC IN THE NECK AREA

Percutaneous Nucleotomy

When is treatment necessary?

Patients with a cervical hernia reports pain in their neck-area, which often radiates into the shoulder and arm. In the majority of cases this pain is accompanied by a loss of sensation, tingling sensations or loss of mobility in the arm and hand. If these symptoms are persistent after a 2 weeks period of rest, medication and physiotherapy, a percutaneous nucleotomy is a significant alternative to conventional open surgery. The mobility of the vertebrae and the delicate nerve-structures are conserved by means of the percutaneous nucleotomy. This technique is also suitable in severe cases – eminently large herniated disc or spinal stenosis. A cervical hernia can be demonstrated by means of MRI.

  What does the treatment consist of?

The Percutaneous nucleotomy is a new, minimally invasive technique, which in most cases can be performed on an outpatient basis and in a safe, local anaesthesia. A thin 4 mm cervical endoscope (Karlstroz) and holmium-yag laser, is used for the surgery. Treatment is performed in a state of art operating theatre with anaesthetics stand-by. The patient is positioned comfortably on his back and is anaesthesized locally. Small cannulae with increasing diameters are conducted up to the slipped disc. Subsequently the slipped disc is visualized on the TV monitor, magnified 20 times, by the cervical endoscope (Wooridul, Karlstorz) and removed by means of small instruments, thus freeing the nerve. In some cases an enzyme is used to shrink the nucleus (core of the disc) in order to release pressure off the protective annulus, fostering the subsequent healing process. In contrast to conventional operative treatment for cervical hernias, there is no need for a fusion of the vertebral bodies. The treatment lasts only about 45 minutes and patients can singly leave the recovery room just two hours after the Percutaneous nucleotomy and return to their hospital – or hotel room. Because the Percutaneous nucleotomy is a minimally invasive procedure, there are little or no complications, pain or scarring.

In the majority of the cases, patients can leave the clinic one day after the procedure, following a thorough check-up. A post-operative neck collar is not necessary.

  What kind of post-operative care and rehabilitation will be required after the Percutaneous Nucleotomy?

As a rule, the pain usually disappears immediately after the percutaneous nucleotomy and patients can return home one day after the treatment. Very rarely patients turn to light painkillers. On the morning after the operation patients are examined by a physician and are advised about correct post-operative behaviour and therapy by physiotherapist. Physiotherapy can be initiated one week after the treatment. Light office work can be taken up a week after the treatment and a normal physical work-and exercise-routine can be resumed after maximum six weeks.

  What is the success rate?

Data of all patients operated in our facilities are obtained via questionnaires and analysed statistically. Since 2005 we have performed more than 50 cervical spine operations. 90% of our patients report of a good to excellent result. No significant complications occurred to date. The risk of a recurrent cervical hernia is very minor.

What are the advantages of the Percutaneous nucleotomy compared to open surgery?

•  The Percutaneous nucleotomy is a save, low-risk treatment but is at least as effective as open surgery.
•  A fusion-operation can be avoided for more than 90% of patients concerned.
•  Only a very minor amount of tissue has to be removed, thus maintaining a good stability.
•  Fine nerve-structures are spared, as opposed to the open procedure.
•  By avoiding a fusion-operation, the characteristic additional strain on adjacent levels can be averted.
•  Percutaneous nucleotomy is performed in local anaesthesia, excluding all risks of general anaeshtesia.
•  A postoperative neck collar is not necessary.
•  Treatment can be performed on an out-patient basis or patients can be released within one day of the Percutaneous nucleotomy. Long hospitalization can be avoided.
•  Cosmetically no scar.