Same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy

Abstract

The 2-year experience of one neurosurgeon with Kambin's orthopedic instruments and frame for arthroscopic microdiscectomy is reported. Arthroscopy using a unilateral approach and monoportal technique is a valuable adjunct to fluoroscopic monitoring. One hundred patients underwent same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy. In addition, suspected spinal tumors in three patients were treated by biopsy and infection of the disc space was drained in one. A prototype operating discoscope was employed for delivery of the neodymium:yttrium-aluminum-garnet laser beam to assist with hemostasis. Seventy-five "ideal" cases were identified that exhibited the following features: 1) up to a 6-month history of unilateral sciatica symptoms, which responded to bed rest; 2) mechanical signs of nerve root irritation when the patient was erect; 3) computerized tomography or magnetic resonance imaging studies interpreted as showing one protruding or prolapsed disc without extrusion; 4) no segmental spondylosis at the level of a herniated nucleus pulposus; 5) no motor weakness; 6) no prior disc surgery; 7) no obesity; and 8) no diabetes mellitus. Twenty-five "nonideal" cases failed to meet one or more of the above criteria. Good outcome rates were not substantially different in the two groups, success being judged in part by patient satisfaction. Complete success was evidenced in two-thirds of cases by early return to work, but improvement was also determined by increased mobility and a reduction in pain medication from narcotic to analgesic agents. Three patients underwent repeat surgery (laminotomy), but only one improved. Two years has provided sufficient clinical experience to determine that a percutaneous endoscopic procedure under neuroleptanalgesia may become a significant surgical alternative.