J Neurol Surg A Cent Eur Neurosurg 2021; 82(03): 294-296
DOI: 10.1055/s-0040-1722749
Letter to the Editor

Lumbar Microdiskectomy

Naci Balak
1   Department of Neurosurgery, Istanbul Medeniyet University, Göztepe Hospital, Istanbul, Turkey
› Author Affiliations

The pathophysiology and natural course of degeneration of intervertebral disks are still not fully understood, and optimal surgical treatment of herniated lumbar disk (HLD) is constantly evolving, with a trend toward less invasive procedures.[1] [2] [3] Therefore, the results of the article entitled “Epidural catheter-assisted percutaneous transforaminal endoscopic diskectomy: a technical note” by Kim et al,[4] published in J Neurol Surg A in September, 2020, are of importance. However, the gold standard method of microdiskectomy, which is widely performed on patients with HLD, has not been mentioned and discussed in the article. Although the authors successfully treated HLDs in two patients using a procedure unlike traditional methods, these patients could have been effectively treated using well-established microsurgical techniques. For example, a similar patient with downward-migrated disk fragment compressing the nerve root in the foramen was treated with the conventional microdiskectomy in our clinic. The patient's pre- and postoperative magnetic resonance (MR) images and the image during surgery are shown in [Fig. 1].

Zoom Image
Fig. 1 (a) Preoperative T2-weighted magnetic resonance imaging (MRI) reveals a massive disk herniation at L5–S1 (arrow). (b) Intraoperative image showing the herniated disk surrounded by abundant vascular structures. (c) Intraoperative picture showing the removal of the herniated disk. (d) Postoperative T2-weighted MRI shows the removal of the disk fragment and decompression of the nerve root.

Lumbar microdiskectomy has been the most commonly used, effective, and safe method in the surgical treatment of HLD since the 1970s.[5] [6] [7] Comparison of lumbar microdiskectomy and endoscopic tubular methods has been performed in many studies, and there is no high-quality evidence showing any superiority of endoscopic methods to microdiskectomy in many parameters including efficacy, incision length, operative time, blood loss, and hospital stay.[2] In percutaneous endoscopic methods, it has been shown that patients are exposed to significant radiation due to intraoperative fluoroscopy.[8] In the method of Kim et al,[4] blindly advanced epidural catheter can cause unnecessary epidural bleeding, dural tears, and cerebrospinal fluid fistulas.

Health care systems are rapidly changing globally and the evolution of surgical techniques are at risk of being driven by the development of high technology and medical devices.[9] [10] [11] [12] [13] A framework termed IDEAL has been proposed for initiating surgical innovations.[14] A new method ideally goes along the following introductory stages: simulator or animal studies, a proof-of-concept study in the first human patient, a prospective study involving up to 30 patients in an early stage, the inclusion of surgeons with no previous experience in a larger prospective study, a randomized controlled trial comparing the results of the innovative procedure to the gold standard, and ultimately evaluation of long-term results.[12] [14] Overall, Kim et al provide a clear description of a promising technique of epidural catheter-assisted percutaneous endoscopic diskectomy in a proof-of-concept study.

Publication History

Received: 05 October 2020

Accepted: 28 October 2020

Article published online:
22 February 2021

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