2009 Volume 18 Issue 12 Pages 875-881
"Primum nil nocere" (minimally invasive procedure) has been the perennial pursuit for surgeons since the time of Hippocrates. However, due to recent advances in optical technology and the development of related devices, remarkable progress has been made in lumbar discectomy using minimally invasive surgery. By minimizing not only the skin incision but also approach related morbidity, nerve root damage can be reduced to a minimum. And one day surgery (outpatient surgery, same day surgery, ambulatory surgery) hastens the patients' return to normal life. In the U.S., outpatient surgery has grown in popularity since Medicare's introduction of the prospective payment system for in-hospital treatment in 1983. As for lumbar disc surgery, a surgical technique which is equally applicable to disc herniation at a high location or a traverse section has been developed. This procedure is conducted under either local or general anaesthesia and is designed to take pressure off of the nerve root by directly excising the disc that is pushing against the nerve root. The surgery can be done on an outpatient basis or with one overnight stay in the hospital, and most patients can be released from the hospital within 24 hours. This technique is called Percutaneous Endoscopic Lumbar Discectomy (PELD) and the disc can be dissected from the lateral intervertebral foramen or between the interlaminar window of the vertebrae. PELD originated from the Percutaneous Nucleotomy procedure devised by Hijikata et al. in 1975 and the introduction of endoscopic techniques has enabled a direct approach for lumbar disc herniation, located further posteriorly than the nucleus pulposus. It is not an exaggeration to say that this technique was created in Japan. Minimal damage to the posterior longitudinal ligament and bones reduces postsurgical instability. The procedure is also advantageous in preventing lumbar facet syndrome and vertebral canal stenosis. The patients' satisfaction rate is high in terms of postoperative recovery and reducing the usage of NSAIDs, and compared to microscopic discectomy and the MED technique, PELD can be considered as a less invasive surgical technique for lumbar disc herniation. This technique makes the most of the space within the intervertebral foramen where, as Kambin claimed, a safe approach to the lesion is possible. And, as we make the skin incision more medially than reported before in order to approach the intervertebral foramen at a steep angle, the occurrence of an exiting nerve lesion at a superior location has also decreased. This surgical method would be a promising alternative to the MED technique as well as to microscope-assisted technique.
