1

UNIVERSAL ENDOSCOPICDISCECTOMY (UED)

By: S.M. Rezaian, M.D., Ph.D. From:California Orthopaedic Medical Clinic, Inc.Beverly Hills, Ca

Contents:1. UED2. Introduction3. Dedication4. Materials5. Technique6. Level of Surgery7. Complications8. Scores9. 9-12 The Results13. Conclusion

2

INTRODUCTION

Because post surgical specimens Because post surgical specimens of patients, who had posterior of patients, who had posterior lumbar surgery showed, extensive lumbar surgery showed, extensive scar formation of dorsal column scar formation of dorsal column muscles and epidural adhesion muscles and epidural adhesion ( (Rezaian et al,1986,W.Rezaian et al,1986,W. Rauschning, 2001).Rauschning, 2001). Minimal invasive discectomy is Minimal invasive discectomy is advance, preferred technique to advance, preferred technique to convention open discectomy convention open discectomy (Kambin (Kambin 1975, Hijakata 1979, Rezaian 1986 & Chiu Savitz 1975, Hijakata 1979, Rezaian 1986 & Chiu Savitz

Young 2003).Young 2003). Nevertheless a universal Nevertheless a universal safe technique applicable to all safe technique applicable to all levels and in all ages yet to levels and in all ages yet to develop. This technique is here develop. This technique is here presented in this direction.presented in this direction.

For the last 70 years (1934-2004), Laminectomy, discectomy considered as classic surgical treatment of herniated disc.In this technique general anesthesia and 3-7 days hospitalization are required.The results are good in 69% 80% of cases, However, with numerous complications (K. Gill and J.W. frymoyer, 1997, Frank M. Phillips and Benjamin Cunningham, 2002).

3

DEDICATION

He said; we must find another technique to remove a few grams innocent tissue of herniated disc which gives so pain relieve to the patient with a fewer IATROGENIC complications (Jonathon Cohen, 1986).We dedicate this technique (UED) TO The memory of Joseph Barr.

Joseph Barr in 1964In a special TALK to the Orthopaedic club of San Diego said: “He is sorry to see so many failure back surgery".

4

OUTPATIENT PROCEDURE

But since we have perfected our technique since January 1992-December 2002, altogether 1096 discs were operated in 613 patients. 109 cervical discs in 98 patients, and 990 discs of Lumbar spine in 515 patients as out patient procedure. The patients were `13 to 91 years old. 282 were female and 331 were male. The patients have been followed 2-10- years.

MATERIAL:

Since January 1985-January 2004, all together 2219 discs have been operated with minimal invasive surgery,

5

TECHNIQUE

A tiny point site of surgery

SURGERY IS CARRIED OUT UNDER LOCAL ANESTHESIA WITH FLUOROSCOPICCONTROL AND ENDOSCOPIC VISUALIZATION OF HERNIATED DISC.10-15-ML. Normal SALIN WITH EPINEPHRINE IS INJECTED IN THE DIRECTION OF SURGERY, PRTICU-LARLY INTO THE FORAMENA AND IN THE POSTERIOR PART OF DISC, IN LUMBAR SPINE. AND BETWEEN THE CAROTID SHEET AND THE TRACHEAL MASS IN FRONT OF THE ANTERIOR LONGITU-DINAL LIGEMENT, POSTERIOR TO THE OSEPHIGUS, IN CERVICAL DISC SURGERY ;TO MINIMIZE THE RISK OF NEURO-VASCULAR INJURY, AND PROVIDE BLOODLESS FIELD. Figures 1,2,3

4

8

Material of disc removed

Artist drawing

Endoscopic inside disc of a patient

Micro-instrument at surgery

4

Micro-instrument

The use of laser at surgery

THE SOFT DISC IS CUT SHARP AND REMOVED WITH MICRO-SURGICAL BASKET & FORCEPS, ETC. Figures 4,5,6,8. HARD DISC, SCARS AND OSTEOPHYTES ARE EVAPORATED WITH HOLMUN LASER. Figures 7.

6

LEVEL OF SURGERY

The surgery was performed at the level of;C5 - C6 in 52 cases,C6 – C7 in 18 cases,both levels in 36 cases. Level L4 – L5 in 65 cases,L5 – S1 in 25 cases, and both levels in 375 cases,more than 2 levels 50 cases.

7

COMPLICATIONS

Infection Nile

Permanent neurovascular damage.Nile

Temporary Para paresis fully. Recovered incases.

Acute laryngitis in 1 case.

Reflex Sympathetic dystrophy (RSD) in 1 case.

Instrumental breakage (did not change their excellent result in 1 case).

8

SCORES

Excellent means return to the same job, no need for medication.

Good means return to the same job but occasionally had pain and needs NSAI drugs.

Fair means changed the job and needs medication.

Poor means could not go to ANY job or needs further surgery.

Unknown means lost in a follow-up or died UNRELATED CAUSE

9

THE RESULTS

Independent reviews were carried out by a non surgeon physician and questioner responded by the patients; The patient and physician were considered the following results:

Excellent = 60% (368 cases)Good = 30% (184 cases)Fair = 3% (20 cases)Poor = 2% (13 cases)Unknown = 5% (30 cases)

10

RESULTS

Pain sheet before & after surgery

11

KA a 13 years old girl well developed and nourished injured her back in a sport at school, she was suffering from low back pain and left sciatica. Extensive conservative treatment did not relieved her pain for 18 months. Her SLR test was limited to 10-150. she could not sit therefore could not go to school Fig. 1. A discogram showed shattered disc L5-S1. Fig 2. Only 3 hour after UED she was pain free. Her SLR improved to 900 Fig. 3.Two weeks later she was back to swimming. 10 years later she is symptom free Fig. 4.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Patient’s pain sheet before & after surgery

Fig. 5

RESULTS

12

RESULTS

13

CONCLUSION

We believe Minimal Invasive Universal Endoscopic Discectomy, is worth it to be considered as standard surgical technique, instead of the Smith-Robinson or the Claward procedures (in cervical herniated disc) or Laminectomy and Discectomy ( in herniated lumbar disc). It is safer, less risky with a fast return to normal activities, and more economic.