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The better option

Tuesday, November 06, 2018

Microendoscopic decompression offers many advantages in treating spinal problems, says Dr. Arvind Kulkarni

Lumbar canal stenosis is the most common diagnosis in elderly people above 65 years of age. Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots.

Although all cadavers above the age of 65 years have some degree of canal stenosis, about five in 1000 are symptomatic. The diagnosis is as common as osteoarthritis of the knees. In this condition, the lumbar spinal canal becomes narrow as a result of degenerative changes like wear and tear, as a result of which the nerves supplying the lower limbs as well as the ones supplying the urinary bladder and bowel will get affected. These patients get pain on walking and standing because the spinal canal becomes the narrowest in these positions and gets better on sitting and forward bending (because the spinal canal widens in these positions).

This phenomenon is called neurogenic claudication. In severe cases, patients may even get a neurological deficit in the forms of altered sensations, weakness, loss of balance on walking and even urinary and bowel incontinence.

The treatment for this condition is called decompression.This involves opening up the canal and making the nerves free. Open surgeries and Microlumbar decompression are the commonly done surgeries for this condition. Open surgery, which is popularly known as laminectomy, is associated with long incisions, unnecessary removal of the supporting bone, scarring, formation of 'post-laminectomy membrane' due to adhesions, increased hospital stay and in some cases leading to instability becoming a part of 'failed back surgery', needing a second surgery to stabilise the spine.

We have been treating this condition using a technique called 'Microendoscopic decompression' in which a specialised tubular retractor is used to perform the decompression. The diameter of the tube is 18mm and this is a key-hole surgery. Decompression of both the right as well as the left nerve roots as well as the entire dural sac is performed through a single key-hole without causing any significant soft tissue or bony collateral damage.

The advantages are many. First of all the technique is elegant in expert hands. It has a cosmetic appeal. The scar is hardly 1.5-2cm long and appears like an ordinary scratch, unlike a long ugly scar after laminectomy. Since there is no muscle or bony trauma, the contours of the back are well preserved.

The dependence of the patient on pain-killers for the wound site pain is absolutely minimal compared to an open surgery. In fact, patients do not express any experience of wound site pain after a few hours of surgery. Since the tissue trauma is so minimal, there is no stress on the patient's metabolic functions, unlike after a bigger surgery with significant tissue trauma.

Most of these patients are elderly with an accompanying baggage of associated conditions such as diabetes, hypertension and heart issues. A swift and painless procedure such as this makes a big difference with regards to their recovery.

In obese patients, the surgery makes a big difference. Obese patients have wound healing problems and the spine is quite deep. A long incision is otherwise needed to reach depths of six to seven cm. The entire procedure can be done using a keyhole in these patients (lots of patients with this condition are obese because they do not walk as a result of claudication pain and hence accumulate weight).

The blood loss with this procedure is minimal. Only those structures that cause stenosis are excised and removed leaving the bony support as well as the muscles and ligamentous supporting structures intact. The patients are made to walk within a few hours after surgery and can go home the very next day. A waterproof dressing is applied such that the patient can take a bath as early as he/she wishes to.

The technique is also used to perform 'Microendoscopic discectomies' for disc herniations (slipped disc). The benefits are the same as mentioned above as compared to the open technique.

Dr Arvind G Kulkarni is Head of Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital

Short takes

As the body ages, the spinal canal can become narrower, leading to pain and difficulty in walking and standing.

Decompression involves opening up the canal and freeing the nerves.

While open surgeries have been used to treat the problem, it is also possible to use a keyhole surgery.

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