My entire career has been devoted to treating patients with the least number and simplest modalities of the spine. Performing minimally invasive interventional treatment for disc herniations means less postoperative discomfort, a shorter recuperative time, and less risk of complications (most importantly resulting in an unexpected and unintended exacerbation of pain). The treatment continuum for discogenic pain or a disc herniation would first be a percutaneous disc decompression procedure, then a endoscopic discectomy, followed by some type of open surgery. This could be a micro-discectomy; the most aggressive surgery being a lumbar fusion operation.
The main cause of the back pain maybe vertebrogenic or discogenic. Vertebrogenic pain is due to the various joints in the spine, which are the facet and sacroiliac joints. Discogenic conditions are abnormal and painful cervical and lumbar intravertebral discs. Such abnormal conditions may involve disc bulges, herniations, annular tears, and degenerative changes among others.
As I am a pain specialist, I will limit the remainder of this discussion to minimally invasive treatments of disc herniations. The two main procedures which I perform are percutaneous disc decompression, and endoscopic discectomies. Percutaneous decompression procedures involve reducing intradiscal volume and subsequent pressure by placing a large bore needle called a trocar into the intervertebral disc. The endoscopic discectomy procedure involves making a small incision to place an endoscope at the area of the disc herniation.
There are several different types of procedures which fall under the category of percutaneous disc decompression. These include devices which can vaporize some of the nucleus proposes material, and others which extract a small amount of the nucleus. The trocar is usually about 1/8 inch in diameter.
These treatments reduce the disc by a very small fraction, only about 1/20th of the volume of the nucleus pulposus. However, studies have shown that this results in a dramatic reduction of intradiscal pressure to normal levels. I have performed these procedures in all areas of the spine including cervical (neck), thoracic (mid back), and lumbar (lower back). These treatments can take only about 15 minutes to perform, and can produce a permanent improvement in pain. Patients walk out of the center about an hour later, and some report an immediate relief of pressure in their back. This treatment is an excellent option for patients with small contained disc herniations and discogenic pain of other causes. I have effectively and permanently treated hundreds of patients with these modalities thus avoiding open surgery. A video which depicts the procedure can be seen here: https://youtu.be/16TknhL-yGs
Endoscopic discectomies involve placement of an endo scope at the area of the disc herniation. This is connected to a fiberoptic cable and a large television screen. Therefore, the abnormal area can be examined under direct visualization. I can see if the disc herniation is pressing on the nerve root, or if there is any compromise of the neuroforamen or spinal canal. Various tools can be used to treat the condition. A grasper is used to remove a small amount of the disc herniation, a rhizotomy device to seal any annular tears which exist, and additionally a drill is available to remove excess bone to open up the nerve canal, and reduce impingement. The ultimate result is to reduce the disc herniation and any nerve impingement which exist. The benefits of this are a small incision, less chance of scar formation, less postoperative discomfort, and a lower recuperative time.
In conclusion, many different conditions of the spine involving disc herniations and nerve impingement can be treated with either percutaneous disc decompression or an endoscopic discectomy. There are a great deal of benefits of these minimally invasive therapies over open surgery. These are permanent treatments that have less risk of complications versus open surgery, as well as less postoperative discomfort and less recovery time.