Spine 1997 April;22(7):828-830. Copyright © 1997 Lippincott Williams... http://ipsapp002.lwwonline.com/content/search/1140/54/25/fulltext.htm...

Minimally Invasive Disc Surgery

Nucleotomy Versus Fragmentectomy
Gary M. Onik, MD; Parviz Kambin, MD; Mark K. Chang, MD

SPINE 1997;22:828-830

There is continued debate as to the optimum surgical management of a

herniated disc with sciatica. There are proponents of conventional microdiscectomy as well as those who
advocate minimally invasive approaches, including central disc decompression or nucleotomy as well as
arthroscopic lumbar microdiscectomy and fragmentectomy. In this controversy (I), Dr. Gary Onik takes the
position that central disc decompression is both safe and efficacious and may be the procedure of choice for
recurrent disc herniations (II). Dr. Parvis Kambin takes the opposing position and advocates
arthroscopically assisted fragmentectomy as the procedure of choice.

II Percutaneous Discectomy (Fragmentectomy)

Position

Minimally invasive procedures for herniated discs are not all the same. The key distinction among them is
theability to extract disc fragments that are compressing the nerve root directly. Arthroscopic
microdiscectomy provides the capability for such targeted fragmentectomy. In contrast, procedures in which
only nucleotomy is performed may reduce intradiscal pressure but do not approach the posterior anular or
subligamentous pathology and, thus, offer inferior outcome.

Rationale

The concept of nuclear debulking for the treatment of patients with a herniated disc was introduced by
Lyman Smith in 1964 when he experimented with chymopapain. In the early and mid-1970s, Kambin and
Hijikata independently developed percutaneous techniques for the resection and evacuation of nuclear tissue
via a posterolateral approach. In the 1980s, automated nucleotomy and laser nuclear ablation were
introduced, and there was a spectacular rise and fall in the popularity of chemonucleolysis.

The basis behind each of these procedures rested on the notion that central nucleotomy could diminish
intradiscal pressure enough to decompress an impinged nerve root. Early reports, usually published by
inventors and manufacturers of these procedures, touted very promising results.2 Later, as more objective
and careful studies emerged, the success rate for these techniques fell to disappointing levels.

Such outcomes were not surprising because there has been no evidence in the literature that a cavity created
in the center of a disc has reduced collagenized posterior or posterolateral herniated fragments. Moreover,
imaging studies conducted after nucleotomy failed to show alteration in the size or shape of the herniation.1

Realizing central nuclear debulking was inadequate, Kambin4 worked in the mid- to late 1990s to develop
an arthroscopic technique to access posterior herniated fragments. Like the others, this procedure could be
performed with the patient under local anesthesia, but, in sharp contrast to previous procedures, arthroscopic

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microdiscectomy offered the ability to extract specific herniated fragments and decompress the nerve root
directly. These capabilities have resulted in a higher success rate, one approaching that of open procedures
with no accelerated spondylosis.5

Of course, interpreting results for various procedures remains controversial. Chemonucleolysis has received
the most scrutiny and has been subjected to double-blinded prospective studies. Of these, only one
concluded chemonucleolysis was superior to a placebo.3 Even that study has been criticized for its limited
patient sample, short follow-up period, and failure to take into account the vast anatomic and pathologic
conditions that may affect the outcomes of procedures. These shortcomings highlight the difficulty of
undertaking a double-blinded prospective study on minimally invasive procedures for herniated disc. The
data from another double-blinded prospective study suggested that neither chemonucleolysis nor automated
nucleotomy provided an acceptable rate of satisfactory outcome.6

Method

The size and location of the disc herniation determine the method of surgical management to be used.
Sequestered and migrated fragments or bony lateral recess stenosis cannot be decompressed via an
arthroscopic technique, so an open procedure is recommended. Extraforaminal, foraminal, and small
paramedial herniations can be accessed through a single portal approach. However, for central,
subligamentous, or nonmigrated sequestered herniation, a biportal technique facilitates extraction of the
fragments with uninterrupted arthroscopic visualization (Figure 1). The latest development is an oval
cannula, 5 mm × 8 mm in inner diameter, that allows simultaneous insertion of an arthroscope and forceps;
thus, decompression through a single portal also can be performed with direct visualization. To insure
adequate decompression, the arthroscope may be passed under the pars interarticularis for final inspection of
the dural and intracanicular structures (Figure 2).

Figure 1. Intraoperative intradiscal view of the ventral dural after removal of a

nonmigrated sequestered fragment.

Figure 2. Arthroscopic inspection of the spinal canal, demonstrating adequate

decompression of the traversing nerve root.

As mentioned previously, arthroscopic microdiscectomy may be performed with the patient under local
anesthesia as long as analgesics and sedatives are also used systemically. Administration of Fentanyl
(Abbott Laboratories, Chicago, IL) around the dorsal root ganglion has eliminated the occurrence of
transient postoperative hyperthesia, which was noted to occur in patients before this practice began. In
addition, 1% lidocaine is injected into the anulus before resection.

Conclusion

Among percutaneous procedures, arthroscopic microdiscectomy stands alone in the ability to perform
targeted fragmentectomy. Removing just the herniated disc material and preserving the other structures
have longterm prognostic implications. Although results reported in the literature show that this procedure

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is not perfect, the advantages of arthroscopic microdiscectomy even now are obviously clear.

Parviz Kambin, MD
Mark K. Chang, MD
Medical Institute of Orthopaedic and Spine Surgery; Berwyn, Pennsylvania

References

1. Delamarter RB, Howard MW, Goldstein TB, et al. Percutaneous lumbar discectomy: Pre and postoperative
magnetic resonance imaging. J Bone Joint Surg [Am] 1995;77:578-84.

2. Surgical Indications and Techniques. In: Hanley EN, Delmarter RB, eds. The Lumbar Spine. Philadelphia: W.B.
Saunders Co., 1996:516.

3. Javid MJ, Nordby EJ, Ford LT, et al. Safety and efficacy of chymopapain in herniated nucleus pulposus with
sciatica. JAMA 1983;249:2489-94.

4. Kambin P. Arthroscopic microdiscectomy. Arthroscopy 1992;8:287-96.

5. Kambin P, Cohen LF, Brooks M, Schaffer JL. Development of degenerative spondylosis of the lumbar spine after
partial discectomy: Comparison of laminotomy, discectomy, and posterolateral discectomy. Spine
1995;20:599-607.

6. Revel M, Payan C, Valle C, et al. Automated percutaneous lumbar discectomy versus chemonucleolysis in the
treatment of sciatica: A randomized multicenter trial. Spine 1993;18:1-7.

Scott D. Boden, MD
Robert McClain, MD
Associate Editors; Controversy

If you would like to submit a controversy article, please call the Spine Journal Office at (603) 650-1122 or
send the article to the Spine Journal office at 7254 Strasenburgh Hall, Dartmouth College, Hanover, NH
03755.

Acknowledgement date: November 21, 1996.

Acceptance date: November 20, 1996.

Device status category: 4.

Address correspondence to: Robert McClain, MD; University of California-Davis; Dept. of Orthopaedic Surgery; 2230
Stockton Blvd. Sacramento, CA 95817

Spine 1997 April;22(7):828-830

Copyright © 1997 Lippincott Williams & Wilkins
All rights reserved

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