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Percutaneous Discectomy
(Nucleoplasty)
The first percutaneous therapy for
lumbar disk herniation was
chemonucleolysis with chymopapain, a
procedure initially reported in
1964.7 Chemonucleolysis was followed
by automated percutaneous diskectomy8
and later by laser-assisted
percutaneous diskectomy. These
procedures have the same goal: to
relieve nerve root compression by
removing a portion of the central
nucleus pulposus. Chemonucleolysis
accomplishes this goal by use of a
chemical reaction, automated
percutaneous discectomy by use of
mechanical removal, and
laser-assisted discectomy by use of
laser energy.
These techniques permit only a
central nucleectomy; they cannot be
targeted at localized areas of disk
pathology, and they are limited to
patients with contained disk
herniations and an intact annulus.
Unlike microdiscectomy, these
procedures cannot be used for
patients with extruded disk fragments
that have broken through the annulus
and posterior longitudinal ligament.
Chemonucleolysis clearly has some
clinical benefit; however, randomized
controlled trials have found it to be
less effective than surgery.
Chemonucleolysis is rarely used in
the United States because of
anaphylactic reactions and neurologic
complications associated with
inadvertent injection of chymopapain
into the subarachnoid space.
Automated percutaneous discectomy was
developed by Onik and Maroon as an
alternative to microdiskectomy. This
procedure was briefly popular in the
1980s, but interest waned after it
was found to be less effective than
microdiscectomy.
Laser-assisted discectomy also dates
to the 1980s. Despite encouraging
clinical reports about this
procedure, critical assessment of
laser-assisted discectomy has been
hampered because the procedure has
never been compared directly with
microdiscectomy.
Both automated percutaneous
discectomy and laser-assisted
discectomy appear to be safe
techniques in experienced hands but
generally are regarded as being less
effective than microdiscectomy.
Neither has gained widespread
acceptance.
Endoscopic discectomy techniques have
been described by several
investigators.12-16 The term
endoscopic discectomy encompasses
several different but related
procedures. This lack of procedural
uniformity has made assessing the
usefulness of the technique
difficult. No single endoscopic
technique has emerged as superior to
the others or as superior to
microdiscectomy.
Electrothermal disk decompression is
a novel procedure that involves
targeted disk ablation by application
of heat energy via thermal catheters
placed within the disk. This
procedure, a variant of intradiscal
electrothermal therapy, is discussed
in the next section. No clinical data
are available about the effectiveness
of electrothermal disk decompression.
Numerous minimally invasive
procedures have been proposed for
lumbar disk herniation during the
past 40 years. Some have shown
clinical benefit, but none have been
proved superior to lumbar
microdiscectomy, still the gold
standard for surgical treatment of
lumbar radiculopathy secondary to
disk herniation.
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