The Bright and Dark Faces of Percutaneous Endoscopic Lumber Discectomy under Local Anesthesia

Background: Lumbar disc herniation is one of the most common problems in orthopedics and neurosurgery and can be presented as low back pain, leg pain (radicular pain) or both. Intervertebral discs consist of an outer fibrous ring, the anulus fibrosus disci intervertebralis, which surrounds an inner gel - like center, the nucleus pulposus. The fibrous ring of an intervertebral disk can be damaged and allows the soft central portion, the nucleus pulposus, to bulge out beyond the affected fibrous rings. [1] Minimal invasive techniques for lumbar disc herniation should give the same gools of standard techniques but with minimal soft tissue damage, less blood loss and early recovery of the patient. These minimal invasive techniques for surgical treatment of lumbar disc herniation involved using microscope or endoscopy with many modifications aiming to minimize soft tissue damage and improve the early patient recovery with optimum results [2, 3, 4]. Patients and method: During the period between January 2019 to December 2020, 45 patients were included in this study according to inclusion and exclusion criteria, where it involves patients presented with single level disc prolapse or herniation, not responding to conservative treatment. The procedure takes an average of 110 min, under local anaesthesia, the proper procedure is done while communication with the patient is still throughout the operation, the wounds are small and the patient is allowed postoperatively to walk and use the bathroom 2 hours later. Results: The ages of the patients was between 19 - 69 years old (average 41.16), including 11 females and 34 males. The levels operated upon was vary from 3 cases in L3 - 4, 22 cases at L4 - 5 level and 20 cases in L5 - S1 levels. This includes 16 discs with left radiculopathy and 30 discs with Right one. Discussion: The benefits of this approach include less damage to the paraspinal musculature and less bruises. To decompress the exiting nerve root, bone removal is not necessary and this prevents the possibility of causing spinal instability. [12, 13, 14] There is still no breach of the spinal canal, meaning there is less epidural bleeding and epidural scarring. Percutaneous endoscopic discectomy allows removal of not only fragments located in the center of the nucleus, but also fragments that have migrated posteriorly and posteroaterally. Since percutaneous endoscopic discectomy, several studies have demonstrated good to excellent clinical outcomes based on change of illness - related conditions and physical signs. [12, 13, 15, 16] In our study the average operative time was 110 minutes which is comparable with other studies (15 min. - 3 hours) [17, 18] Using local anesthesia which is safe, simple, effective and fast way of anaesthesia. Surgeons can maintain effective communication with patients. This surgical procedure also lessens chances of nerve root injury. Also, the patient is allowed to walk after 2 hours from the operation and go to the bathroom (allowance to walk). The complications are more or less than that mentioned in other studies and it seems similar to that in conventional surgery however there is less chance of instability and early degrative changes that is usual after the open procedure, the complications are started to be less with the upgrading surgical skill?s curve. Recommendations: We recommend the percutaneous lumbar discectomy procedure since it is characterized by small incisions, less soft tissue distraction, and maintenance of spinal structural stability, good operative field visualization, continuous communication with the patient during the operation, less blood loss, early recovery, short hospital stay in comparison to the traditional open procedure.