Dr.Salim Daher R.
(Doctor in Neurosurgery at University of Paris-France)

Percutaneous disectomy is a minimal invasive technique that allows to eliminate discal hernia without the need for major surgery, anesthesia nor hospitalization. Click on any of the following items to get more information:  What is Percutaneous Disectomy? Background: A little history Technique description Advantages of this method Types of Percutaneous Disectomy

What it is?

Percutaneous disectomy or nucleotomy is a new method used to eliminate hernias of the spine at lumbar as at cervical level, without the needings of major surgery unlike the classical method used to treat these hernias until now. The method consists in the making -with the patient awake and under local anesthesia with sedation-, of a lateral opening of the intervertebral disc with special instruments that are no more that 4-millimeter thick, and the later extraction of the hernia, decreasing the pressure inside of the damaged disc with the consequent dissapearing of pain.

It's important to point out that this method doesn't replace classical surgery; it's just another method that could avoid the major surgery, and could be used when a well-driven medical treatment, and/or rehabilitation have failed. Moreover, not all the discal hernias can be eliminated by this method: the broken discs or the patient's who present neurological deficits must not be treated by this method.

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Background: A little history.

This new method appears because a deficit on assuring good results for the classical surgery (laminectomy), in which 40% of the patient's present some kind of post-operatory fibrosis (defective internal scar that compresses even more the nerves previously affected by the discal hernia) whose consequences are very lamentable and must be avoided.

Percutaneous disectomy or nucleotomy dates from the 80's when a japanese doctor named Hijikata publishes the first intend of percutaneous aboarding of an intervertebral disc. In 1987 Monteiro, from Belgium, presented at Philadelphia a serie of 6 nucleotomies made by himself with some instruments made by him own; then in Switzerland, Professor Screiber begins experimenting with this method, perfecting the instruments and manufacturing another ones, able to get inside the spine and watch all the contents of the disc in a TV set. Dr. Schreiber was elected president of the "Association of Percutaneous Nucleotomy" aka "Gieda Inter-rachis" (International group for the studying of rachis surgical aboardings) in December 1994 in a congress made in Paris, France.

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Technique description:

It must be said that though there are few physicians in the world that practice this technique future shows an significant extension of this method and many other endoscopic methods of spinal aboarding, which represent minimal agression to the patient. There are 3 ways of making the disectomy and all of them are made with the patient awake and only under local anesthesia with sedation (first contraindication is general anesthesia because the patient itself will be telling the doctor about his pain, and how it disappears through the course of the operation).

An initial point is opened a few inches away from the spine. Through a hole that will be closed with only 1 suture point, and using a specialized technique the doctor reaches the affected disc and removes the hernia, whether automaticly (Automatic Percutaneous Disectomy) using a device that aspires the contents of the center of the disc, or manual using several special instruments that allow extracting the material of the degenerated disc.

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Advantages of this method:

The Percutaneous Disectomy have a lot of advantages over the classic surgery. Here are some:

• The spine is not injured.
• There are no side effects like fibrosis nor spinal instability, unlike they many times happen after classic surgery.
• Patient doesn't need hospitalization, that's the technique is ambulatory: patient ingress in the morning and leaves the clinic at afternoon.
• Doesn't need general anesthesia (but there is allways an anesthesiologist during the sedation procedure).
• Surgeon's effort is less and shorter.
• Resting time after the operation never exceeds 1 week, that's why lost of labour time is dramatically less than with classic surgery.
• Even is better for Insurance Companies, because the amount of money they will have to pay for percutaneous disectomy is 60% less than for classic surgery.

With this new method, patient gets a date for a specific day, ingresses in the morning and it's home at night, beeing able to reintegrate to work in a few days. All this makes percutaneous disectomy (that means eliminating hernias through the skin) a truly revolutionary method with lots of advantages.

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Types of Percutaneous Disectomy

There are two types of percutaneous disectomy: automatic and manual.

• Automatic Percutaneous Disectomy:
  Consists of a console connected to several tubes and devices that are introduced into the intervertebral space and produce an aspiring effect in the center of disc lowering interdiscal pressure. This method is relatively complex and expensive, because every kit used to perform an automatic percutaneous disectomy costs about $1.500. This type of technique can't be used on all hernias because if the disc is rough and fibrous or it's calcified it wouldn't make any improvement.
• Manual or semi-automatic Percutaneous Disectomy:
  Represents a less traumatic option, because instruments used are much thinner, not beeing above 3 or 4 milimeter thick at lumbar level and sometimes 2 or 3 milimeters at cervical level. In this technique, surgeron inserts very thin and delicate instruments through a small hole made on the skin, and treats the hernia that produces the lumbo-sciatica or the cervical-brachial neuralgia. A interdiscal verification with a micro-videoendoscopy device is made to see into the disc in a monitor that the patient itself watches during the operation. That is, the patient watches it's own intervention as it's made because he/she's totally awake. The little hole on the skin is so small, that sometimes it doesn't need suture but a band-aid after the procedure.
• Laser Percutaneous Disectomy:

This procedure it's carried out under local anesthesia, with a light sedation. It consists on passing a needle through the skin (percutaneous), from behind and lightly lateral, to the center of the herniated disk. The position of the needle is constantly controlled with X-ray.
Once the needle has been placed, a optical fiber endoscopy is passed through it to the center of the disk. This instrument allows the neurosurgeon to see the pulpous nucleus and at the same time it has another optical fiber that drives the laser ray, with which the disk evaporates. Once the surgeon is sure that the space that has taken place in the center of the disk it is enough, he retires the endoscopy and the needle.
As the procedure it's made under local anesthesia, the patient passes directly from the operation room to her room. She/he generally leaves walking of the hospital the same day, some hours after of their entrance. The patient can return to work, depending on his/her job, in 2 to 6 weeks.
Unfortunately not all the patients they can benefit of this surgery type, it depends on the characteristics of the disk hernia. For example, if the disk has a broken anulus (external ring) and the external ligaments, or there is a fragment of loose disk, you must make a clasic diskectomy.


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Chemonucleolisys, or the inyection of a liquid that destroyed the pulpuous nucleus has been declined world wide.

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Conclussions Useful in protuded disc Outpatient procedure Local anesthesia Minimal incision No peridural fibrosis Minimal complications Reduced cost vs. standard surgery

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Disease: Discal Hernia

Surgical Alternatives

Centro Médico Guerra Mendez, Torre "D" nivel Mezzanina Consultorio 003 - Calle Rondón, Valencia 2001 - Edo. Carabobo - Venezuela. Telefonos: (+58 241) 859-6454 - Directo: (+58 241) 856-1154 - Celular: (+58 414) 340-2116 Fax: (+58 241) 859-7083 Email: salim@daher.com.ve

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