Health : New Alternative to Back Surgery
A quick, outpatient operation for one of the most troublesome back problems--slipped or herniated disks--is emerging as a tantalizing alternative to major surgery.
In the procedure--called percutaneous diskectomy--surgeons insert a needle-like instrument into the middle of the affected spinal disk and cut out excess disk material under vacuum pressure, without using even a general anesthetic. The removal of the thick, sticky nucleus allows the enlarged disk to soften and contract, which relieves the pressure on the spinal nerve that creates the maddening discomfort of the low-back and leg pain commonly called sciatica.
Not a Cure-All
If successful, the procedure allows patients to return to work in an average of two weeks--as opposed to a minimum of six weeks for conventional surgery--at half the cost of traditional operations. If the procedure fails, there is no barrier to then undergoing the full operation, doctors say.
But mindful of the furor caused by chymopapain, the highly touted but unsuccessful drug substitute for back surgery introduced a decade ago, doctors who have begun to introduce the operation to their patients quickly caution that the procedure should not be considered a cure-all for everyone with a backache.
Percutaneous diskectomy can be used in patients who have recurring back problems after conventional major surgery, called laminectomy, in which most or all of a slipped or misshapen disk is scraped away and removed. Patients whose sole complaint is low-back pain are usually not candidates.
The principal use of the procedure is as a treatment for sciatica--in which leg pain may be the most troublesome symptom and pain actually in the back itself may be minimal or even nonexistent.
The new procedure is attracting significant attention now because medical journals are starting to publish the first reports of several independent studies evaluating its success rates.
However, percutaneous diskectomy is hardly new. It was first described by Japanese surgeons in 1975 and was used sparingly in the United States until three years ago. Its popularity was limited because it was time-consuming and unreliable. But in 1984, new automated equipment and better imaging to guide the needle-like device into the spine were introduced, and the popularity and potential of percutaneous diskectomy began to change radically. Today, according to surgeons who have used the device extensively, between 17,000 and 25,000 people have already had the new surgery; it is estimated that at least 50,000 people a year might be candidates.
In the journal Orthopedics, Dr. James Morris, a UC San Francisco orthopedic surgeon, published the results of a study that finds a 73.5% success rate for the operation in 479 patients.
To be classified as a “success,” Morris said, a patient had to require no additional treatment for back problems, have moderate to total relief from pain, not need pain-killing drugs and regain normal back function. In addition, Morris’ criteria require that both patient and surgeon be satisfied with the results.
Like other back experts, Morris, one of the first to use the technique, said any back-pain patient should first be treated by conservative means, including possible bed rest, other relaxation methods and painkillers.
Variety of Causes
Back pain can have a variety of causes, ranging from simple muscle strain to severe damage to the vertebrae. Among the most common, however, is the slipped disk, in which a spinal disk--actually a thick, rubbery growth that fits between the vertebrae and functions as a lubricant and shock absorber for the mechanical action of the spine--expands and pushes against the sciatic nerve, which runs down the spinal column.
In many disk cases, part of the disk actually separates and the fragment moves into the spinal canal. Percutaneous diskectomy, Morris and other experts said, is appropriate only for patients whose slipped disks have remained intact. If a fragment has separated, the procedure is useless. Diskectomy is also useless if a bony spur has formed on the spine itself and the disk has pushed against it.
About 200,000 Americans who now have back symptoms need surgery every year, according to Dr. Gary Onik, a Pittsburgh radiologist who helped develop the technique.
Onik estimated that, given the procedure’s limitations, about 25% of the people who do have full-scale surgery could probably use the technique instead.
That proportion, however, is open to some debate. Morris said some studies have indicated that 30% to 60% of patients who have surgery could benefit from the technique. Dr. G. William Davis, a Nashville surgeon who has worked with Morris, said that as many as 80% of people with troublesome cases of sciatica can be cured by the new operation.
Greatest Promise
Davis said the new procedure has shown its greatest promise in younger patients. In a study published last year in the American Journal of Sports Medicine, researchers at the University of Florida in Gainesville reported on the differences in operations on six football players with severe back problems. Two had diskectomy. Four had conventional surgery. The diskectomy patients reported full recoveries in four to six weeks and returned to the game. The four who underwent laminectomy reported less successful treatment and could not play again.
“I think when you look at the Olympic skier back skiing in three weeks or the football player back practicing in 2 1/2 weeks, that, for them, it’s a breakthrough,” said Onik. “But its applicability is not universal since it works only in a well-defined group of people.
“Overall, it’s hard to call it a (wide-ranging) breakthrough for back pain. But for the patients it works for, it’s a wonderful thing.”
A half dozen experts questioned by The Times agreed that fees for diskectomy are slightly less than half the cost of laminectomy. Onik said an average price for laminectomy is about $4,200 and that diskectomy costs about $2,000. He and other physicians said that while health insurance plans originally balked at paying for it, many have begun to cover it.
