| Chronic low back pain is one of the most common problems of all age groups worldwide. If conservative treatment fails, the following surgical options -- depending on the underlying cause - currently apply: lumbar discectomy, disc arthroplasty or fusion surgery as the ultimate procedure. An emerging technique, nucleoplasty, aims at targeting early stages of disc degeneration. There are various mechanical, polymeric or tissue engineered devices for nucleus pulposus replacement, some of which have been subjects of studies and clinical trials. We are already looking back at a history of failed devices; as well, complications have been reported such as migration, extrusion and subsidence. On most devices, no long-term data are available yet. Our theory is that for any successful nucleus pulposus replacement in order to stabilize, delay or even improve lumbar disc degeneration, an appropriate cavity has to be created prior to injection or implantation of a new device. The current gold standard procedure to get nucleus pulposus material out of the intervertebral disc is the classic open microdiscectomy which is performed with pituitary rongeurs. Another surgical procedure of a percutaneous nuclectomy via arthroscopic shavers was investigated and the outcome -- size and location of the created cavity - compared with the established rongeur-method, using three different approaches: anteriolateral, posteriolateral and posterior access to the intervertebral disc. The cavities were larger when created with the rongeurs, however, after some modification of instruments, for example curved shavers, nuclectomy via automated shavers might be a good and less invasive surgical alternative. |
