Since the development of operating microscopes in the 1980s and modern MRI scanners in the early 1990s, two inventions that revolutionised spinal surgery, little has changed in what we have to offer most patients needing surgery for sciatica. However, for a lucky group of sufferers it has just undergone a second revolution.
The endoscope has long since put an end to most open abdominal and pelvic surgery. Wards and weeks full of patients with foot-long incisions, pain beyond words, vomiting and long periods of time off work have now largely been replaced by day-case surgery, fingernail-width nicks and rapid recoveries.
An endoscope is an instrument used to examine the interior of a hollow organ or body cavity. Unlike most other medical imaging devices, endoscopes are inserted directly into the body or organ. Since their inception, surgeons have tried to use endoscopes within the spine. Partly because of the prodigious challenges navigating nerve tissue throws up and partly because of parallel advancements in microscopic surgery, the endoscope gained little traction in spinal work.
In the spine standard endoscopic techniques placed the probe directly into the main body of the disc. It was hoped, rather naively in retrospect, that by sucking out the healthy intact central part of the disc, the prolapsed (‘slipped’) part would pop back in. Some added laser technology but the basic flaw remained, as did the prolapse!
This all changed with the development of the transforaminal nerve root block – side entry into the spinal canal – which means we can now enter the spine right over the prolapsed part of the disc. It even allows for the nerves to be clearly seen and protected, just as with a microscope.
The advantages of this procedure are that the incision is less than a centimetre, no muscle is cut, no general anaesthesia is required and patients may go home the same or the next day.
The limitations are that only soft disc prolapses can be removed this way. Commonly there is also bony narrowing and that cannot readily be dealt with at the same time.
The spine is a very challenging surgical arena. Using the endoscope in this way however, certainly creates substantial opportunities. Correctly applied, the treatment offers a substantial benefit to those patients whose prolapse lends itself to the technique.
This article is based on a presentation given by ISEH consultant Peter Hamlyn at the Sports Injuries and Sports Orthopaedics Conference held in January 2015, chaired by ISEH Clinical Director Professor Fares Haddad.