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ABSTRACT
In its first decade of use, percutaneous nucleotomy has proven its value in decompressive indications for lumbar disc disease. Indications include contained disc herniations as isolated pathology, or in combination with other lumbar pathology at risk for decompensation after open hemüaininotomy, eg, spondylolysis/olisthesis or former open operative procedures. The precise indications underline the need for conclusive preoperative screening, such as disco-scan and contrastdiscomanometry. Overall results are 85% favorable. Percutaneous intervertebral fusion is also presented.
Since the first description and clinical introduction of open hemilaminotomy with discotomy by Mixter and Barr in 1934, postoperative problems of local epidural cicatrization and segmental instability had to be managed to obtain primary neurologic decompression - the so-called posthemilaminotomy syndrome. Functional compensation of these structural inconveniences is generally limited by reduced muscular stabilization: the open surgical approach interferes directly witìi the main dorsal stabilizing muscles and ligament structures. The need for another therapeutic approach was recognized early. In die purely diagnostic field, the dorsolateral function of die intervertebral space described by Craig4 in 1956 was the first step in this direction.2 The difficulties with adapted tools and restricted quality of available fluoroscopic control prevented the breakthrough of this advantageous approach.
In tiie early 1970s, Kambin3 applied a modified Craig instrumentarium for minimum possible fenestration of the annulus fibrosis, in combination with the dorsolateral open hemilaminotomy. One of the aims of this procedure was to prevent epidural cicatrization by sparing epidural and durai structures. In die same period, Hijikata4 introduced new instruments for closed percutaneous removal of herniated disc tissue by dorsolateral intervertebral unction (Fig 1).
At the Balgrist Clinic, we adopted this operative technique in 1979 using Hijikata's original instruments. After a first series, these instruments, conceived for the small Asiatic build, could not completely fit die taller European statures. In cooperation with our biomechanical department, we had to change the design in 1980, which resulted in a pluri-cannular instrument for btiateral percutaneous approach, which is still used (Fig 2).
But even entering from both sides, we encountered some difficulties in obtaining satisfactory removal in cases with considerable amounts of subligamental protruded disc tissue. It was still not possible to locate dislodged disc material, especially in the posterior subligamental area, and extract it precisely. There was even...