Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence.

Pain Physician. 2009 May-Jun; 12(3): 601-20Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti LBACKGROUND: Lumbar disc prolapse, protrusion, and extrusion account for less than 5% of all low back problems, but are the most common causes of nerve root pain and surgical interventions. The typical rationale for traditional surgery is an effort to provide more rapid relief of pain and disability. It should be noted that the majority of patients will recover with conservative management. The primary rationale for any form of surgery for disc prolapse associated with radicular pain is to relieve nerve root irritation or compression due to herniated disc material. The primary modality of treatment continues to be either open or microdiscectomy, but several alternative techniques including automated percutaneous lumbar discectomy (APLD) have been described. However, there is a paucity of evidence for all decompression techniques, specifically alternative techniques including automated and laser discectomy. STUDY DESIGN: A systematic review of the literature. OBECTIVE: To determine the effectiveness of APLD. METHODS: A comprehensive evaluation of the literature relating to automated lumbar disc decompression was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and Agency for Healthcare Research and Quality (AHRQ) criteria was utilized for observational studies. A literature search was conducted of English language literature through PubMed, EMBASE, the Cochrane library, systematic reviews, and cross references from reviews and systematic reviews. The level of evidence was classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria, the indicated evidence for APLD is Level II-2 for short- and long-term relief. LIMITATIONS: Paucity of RCTs in the literature. CONCLUSION: This systematic review indicated Level II-2 evidence for APLD. APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse.

Systematic Review of Percutaneous Lumbar Mechanical Disc Decompression Utilizing Dekompressor(R).

Pain Physician. 2009 May-June; 12(3): 589-599Singh V, Benyamin RM, Datta S, Falco FJ, Helm S, Manchikanti LBACKGROUND: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor(R) a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. STUDY DESIGN: A systematic review of the mechanical disc decompression with Dekompressor literature. OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompressor, a high rotation per minute device utilizing an Archimedes screw, used in mechanical lumbar disc decompression. METHODS: The literature search was conducted utilizing a comprehensive strategy for mechanical disc decompression utilizing the Dekompressor. A literature search was conducted using only English language literature in a comprehensive search of databases including PubMed, EMBASE, the Cochrane Library, along with systematic reviews, and cross-references from reviews, systematic reviews, and individual articles. The quality of the manuscripts included was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and for observational studies with the criteria developed by the Agency for Healthcare Research and Quality (AHRQ). The level of evidence developed by the United States Preventive Services Task Force (USPSTF) was utilized in this review. The evidence was classified as Level I, II, or III with 3 subcategories in Level II for a total of 5 levels of evidence. OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the indicated level of evidence for the mechanical high RPM device or Dekompressor is Level III for short- and long-term relief. LIMITATIONS: Lack of literature, both randomized and observational. CONCLUSION: This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.

Percutaneous endoscopic lumbar discectomy by transiliac approach: a case report.

Spine. 2009 May 20; 34(12): E443-6Choi G, Kim JS, Lokhande P, Lee SHSTUDY DESIGN: Case report. OBJECTIVE: The authors report a new percutaneous endoscopic lumbar discectomy (PELD) technique for the treatment of lumbar disc herniation with a high iliac crest via a transiliac approach. SUMMARY OF BACKGROUND DATA: When the iliac crest is high, the L4-L5 and L5-S1 disc spaces are located deep in the pelvis, so they are not easily accessible via a suprailiac route. METHODS: A 51-year-old man manifested left gluteal and leg pain due to an up-migrated soft disc herniation at the L4-L5 level. Transforaminal PELD via a transiliac approach was performed to remove the herniated fragment, achieving complete decompression of the nerve root. RESULTS: The symptom was relieved and the patient was discharged the next day. CONCLUSION: When a conventional transforaminal PELD is impossible due to the presence of a high iliac crest, PELD via a transiliac route could be a alternative option in selected cases.