Clinical outcomes Of Hernia Nucleous Pulposus after

Microendodiscectomy
Ahmad Fauzi1, Luhtfi Gatham2, S. Dohar AL Tobing3, Asrafi Rizky Gatham2
1
Department of Orthopaedic Surgery, Lampung University, Indonesia. 2Department of Orthopaedic Surgery,
Fatmawati Hospital, University of Indonesia. 3Department of Orthopaedic Surgery, Ciptomangunkusumo Hospital,
University of Indonesia.

Background. There are several options of surgical treatment of Hernia Nucleous Pulposus
(HNP) such as discectomy and micro-endodiscectomy (MED). The fundamental differences
from these procedures are the size of the incision, the discectomy procedure and the volume
of the disc taken. To date, however, no class 1 of evidence on the efficacy has been
published and study describing its safety and factors influence the efficacy are scarce
especially in Indonesia. The aim of this study is to evaluate the clinical outcome and safety in
patients undergoing MED for HNP
Method. Patient who underwent MED for HNP between Januari 2015 and December 2016
were prospectively followed. The outcome evaluated were Visual Analog Score (VAS) for leg
and back pain and Oswestry Disability Index (ODI). The pretreatment means were compared
with the means obtained after surgery using paired t-test.
Results. A total of ... patients underwent surgery for HNP. The mean duration of surgery (
SD) was... minutes. The pretreatment means scores on VAS and ODI were.... After surgery,
the scores on the VAS and ODI were significantly reduced to..., respectively (p<0,00). A total
of... complications were observed, such as ...dural tear, ... deficit of ankle dorsiflexion, and ...
cases of paresis in the foot.
Conclusions. MED appears to be a safe and effective intervention for HNP and has similar
clinical outcomes compared to conventional open discectomy. High quality randomized
controlled trials are required to study the efficacy and cost effectiveness of MED.

Key words. Hernia nucleous pulposus; microendodiscectomy; clinical outcomes.

Introduction.
Due to the increasing incidence of chronic low back pain, the numerous modalities
available for diagnosis and management, escalating costs and its impact on health care
resources, our understanding of the causes, diagnosis and treatment of lumbar disc
herniation has evolved over the past century1. Symptomatic h e r n i a n u c l e o u s p u l p o s u s
( H N P ) can be managed variably : conservatively, with interventional pain treatment, or
surgically.2 In patients with persistent or progressive symptoms after 6 to 12 weeks of
conservative treatment, surgery is indicated. Disc herniation is seen in 1 in 10,000 in general
population and 10% patients may require surgical intervention. Historically, Laminectomy
was performed to remove the offending disc material. This was associated with significant
morbidity and delayed rehabilitation.3
Less invasive techniques were introduced over last 2 decades.4 With the development of
modern microspinal surgical techniques, Minimally invasive techniques have revolutionized
the management of pathologic conditions of the spine such as lumbar disc herniation. 5 Open
microdiscectomy is still the gold standard procedure for treating HNP,6 albeit without Class I
evidence. Improvements in the use and design of optics and surgical instruments have led to
the utilization of full endoscopic surgical procedures, such as the micro-endodiscectomy
(MED). The surgical efficacy of these endoscopic techniques is expected to be at least
comparable to that of the conventional, more invasive open procedures, but with reduced
hospitalization and a shorter time to recover. Micro-endodiscectomy (MED) is a minimally
invasive treatment in which the incision size is further reduced, to approximately 1 inch.
Furthermore, no paraspinal muscle is cut or detached from the insertion. Consequently,
MED is thought to have a further reduced invasiveness as well as result in reduced muscle
and epidural scarring. Since its establish ment, MED has been shown to be a promising
minimally invasive technique.7 The minimal tissue damage during MED could make a
difference in effectiveness, and this could potentially lead to a lower intensity of both leg
and back pain, faster rehabilitation and integration, and thus lower costs for society.
However, study describing the safety and factors influence the efficacy are scarce especially
in Indonesia. In this study we describe the clinical outcome of patients who underwent MED
for HNP.

Methods.
We performed prospective analysis of data of all patients who underwent MED for HNP
between January 2015 and December 2016. One hundred seventy-two patients who had
undergone a first-time, single-level micro-endodiscectomy at L2-3, L34, L45, or L5S1
were identified. These records were then reviewed for patient demographics (age, sex,
height, weight, and body mass index), type of radiculopathy (level and side), VAS and ODI
score before and after surgery, comorbid factors (diabetes, hypertension, smoking),
operative time (in minutes), estimated blood loss (in milliliters), percentage of patients with
intraoperative CSF leakage and neurological deficits, percentage who required conversion to
an open procedure and repeated surgery, length of stay and days of mobilization (in days).
Occupational activities were divided into the following 2 categories: light work (i.e., office
jobs, household tasks), and heavy work (e.g., construction workers, farming, etc).8

Surgical Procedure.
The patient is brought into the operating room and is put under general anesthesia. The
patient is turned onto his abdomen and padded into position. A fluoroscope is brought in for
use during the remainder of the operation. The patient's back is scrubbed with sterile soap,
and a sterile field is created. Drapes are placed accordingly, and the surgery begins. The
disc space is confirmed using the fluoroscope, and a long acting, local anesthetic is injected
through the muscle and around the bone protecting the disc. A half to one-inch incision is
made. A thin wire is placed through the incision and lowered until it touches the bone.
Progressively larger dilators are brought down on top of one another following the wire. In
this manner, the muscle is split rather than separated from the bone.
By the time the fourth or fifth dilator is placed, the muscles are stretched to an opening
roughly the size of a nickel. It is through this opening that the procedure is performed. Over
the last dilator, a working channel is positioned; this circular retractor holds back the muscles
and now the dilators can be removed. The retractor is held in place by a mechanical arm
attached to the table.
During the procedure, the surgeon use an endoscope (a camera) to help with the surgery.
The endoscope, which is about as thick as the ink in a ballpoint pen, is attached to the edge
of the working channel. It projects an image of the base of the working channel blown up to
the size of the TV screen. This allows for microscopic manipulation and removal of the
tissues. One disadvantage of an endoscope is that it only provides monocular vision. That
means its like looking through only one eye. Depth perception is diminished in this
technique.
When a small amount of muscle is left over the lamina, or exposed bone, this is cleaned
off. In order to access the nerve, this roof of bone must be removed; this can be done with a
small, high-speed drill or a Kerrison rongeur. The bone just below the endoscope covers the
nerve, as it is about to exit the spine. By removing the bony cover, the nerve can be exposed
and then safely moved away. After the bone is removed, the yellow ligament can be seen
which protects the underlying nerves. All the nerves, except the exiting nerve, are grouped
together in the thecal sac where they float loosely in spinal fluid. Care is taken as the yellow
ligament is separated and removed, exposing the thecal sac and the exiting nerve root. A
very small retractor is placed just on the outside of the root, and the nerve and thecal sac are
moved together. Directly below the retractor lies the herniated disc.
The disc material has a consistency similar to uncooked shrimp. When a small puncture
is made into the tissue covering the disc, the disc will often times begin to ooze out.
Sometimes the covering of the disc is already torn or even ruptured. Various tools are used
to remove the ruptured disc and other loose fragments of disc in the surrounding area. No
attempt is made to remove the entire disc at that level; that is what is supporting those
vertebrae. When completed, the small hole will fill in on its own. The case at this point is
essentially finished.
The wound is irrigated with antibiotics. As the scope is withdrawn, we can see the tissues
coming back together. A stitch or two is placed at various levels to hold the tissues together
to help healing. Typically, buried stitches are used to close the skin, and none need to be
removed at a later date. Commonly, Steri-Strips and a loose bandage are applied to the
wound. The patient is then positioned on a stretcher, woken up, and sent to the recovery
room.9

Outcomes.
The outcomes of this study were the scores on Visual Analog Score (VAS) for leg and back
pain and Oswestry Disability Index (ODI). 10 The VAS for back and leg pain measures the
pain from 0, indicating no pain, to 10 representing the worst pain ever experienced in the
back and leg.The ODI measures the disabilities caused by back pain, ranging from 0 for no
functional impairment to 100 indicating maximum functional impairment. The ODI and the
VAS scores were assessed at baseline and 6 weeks prospectively. Patients were followed
for 6 weeks after surgery at the outpatient clinic and discharged if no signs of radiculopathy
were present. In case of recur rent or persistent radiculopathy, a postoperative MRI was
requested to identify recurrence of HNP. Additionally, operating time, complications, and the
estimated amount of blood loss were evaluated.

Statistical Analyses.
Descriptive statistics were used to analyze demographic data and Likert-type scales. Paired
t-tests were performed to compare pre- and postoperative scores on the ODI and VAS.
Results are presented as means with standard deviations. A p value less than 0.05 was
considered statistically significant. All statistical analyses were performed with SPSS
(version 21.0, IBM Corp.).

Result.

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