CERVICAL PERCUTANEOUS THERMAL DISCECTOMY GOALS

CERVICAL PERCUTANEOUS THERMAL DISCECTOMY GOALS
Cervical Percutaneous Thermal Discectomy Goal medical negligence animations

The goal of a percutaneous discectomy is to cause the disc herniation to retract, which in turn can lead to a decrease in neck and arm pain.
   
INTRODUCTION
Sudden trauma or gradual degeneration can weaken the annulus fibrosis or wall of the intervertebral disc. This can then bulge outwards, forming a disc protrusion or a contained disc herniation. The pressure of the bulge against the surrounding structures causes neck pain and the pressure against the nerve root causes arm pain.

Percutaneous discectomy is a minimally invasive disc decompression technique which is performed through a needle. The discectomy removes some nucleus material from the intervertebral disc whilst minimizing damage to the adjacent tissues. The removal of nucleus material decreases the pressure within the disc, which can result in the contained disc herniation retracting. This in turn can lead to a decrease in neck and arm pain. The percutaneous approach decreases the pain, complications and recovery time, and maximizes the spine's strength and stability after the procedure.

INDICATIONS
The indications for a percutaneous discectomy are
- neck or arm pain, caused by
- a contained disc herniation seen on radiological imaging
- that has not responded to at least three months of conservative treatment including pain relief medication, bed rest, physical therapy and pain relieving injections. Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

ALTERNATIVES
The non-surgical alternatives to percutaneous discectomy may be
– activity modification
– weight loss
– aerobic exercise, such as walking, cycling, and swimming
– strength and flexibility exercises
– physical therapy
– hydrotherapy
– heat and cold pads
– acupuncture
– pain-relieving medications such as acetaminophen or paracetamol, non-steroidal anti-inflammatory drugs, glucosamine, chondroitin

The surgical alternatives to percutaneous discectomy may be
– steroid and local anesthetic injections
– open or minimally-invasive microdiscectomy
– surgical fusion
– disc replacement. Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

INFORMED REFUSAL
It is your right to delay or refuse the recommended treatment for your condition. However, this delay or refusal may lead to the worsening of your symptoms, such as increased arm pain, pins and needles, weakness or numbness. You should ask your doctor what might happen should you choose not to undertake the recommended treatment.

BEFORE
Before the percutaneous discectomy
- a doctor will perform a medical examination and any necessary tests to ensure that your general health will permit an anesthetic to be given and the procedure to be performed
- you will be advised when to stop any medications that will increase your bleeding risk ie aspirin, non-steroidal anti-inflammatories, anti-coagulants, vitamin E, glucosamine and any herbal medicines (chamomile, danshen, garlic, gingko, devil’s claw, ginseng, fish oil, willow bark, feverfew, and goji berries)
- you may be admitted into the hospital on the day before or on the morning of the procedure
- don't eat or drink anything  for six hours before the procedure
- wear loose-fitting clothes that are easy to take off and put on. Do not wear any jewelry.
- before the procedure, the skin on your neck will be cleaned and you will be given a general health check. The skin on your neck may be shaved.
- an intra-venous line will be placed into a vein in your arm to administer fluid and medications
- you may be given a sedating medication to make you drowsy before being given your anesthetic
- you will be given a general anesthetic that will put you to sleep
- let your doctor know if you develop a fever, cold or flu symptoms before your scheduled procedure.

GOALS
The goal of a percutaneous discectomy is to cause the disc herniation to retract, which in turn can lead to a decrease in neck and arm pain.

TECHNIQUE
You will be lying on your back. Your skin will be cleaned. A small needle will be used to inject some local anesthetic to numb the skin. This may sting for a couple of seconds. A cannula will be introduced into the inter-vertebral disc. Fluoroscopy, an x-ray television, is often used to help guide the cannula to the correct position. The device will be advanced from the cannula and will destroy some nucleus pulposus to decrease the pressure within the disc. Then the cannula will be removed. A small bandage will be placed on the skin. Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

NO SMOKING
Smoking damages every part of your body and decreases the chance of a successful procedure. If you smoke, you should stop now.

EXPECTATIONS
The expectations of a percutaneous discectomy are
- the entire procedure will take about half an hour
- you will experience some minor discomfort after the procedure. Neck pain can be relieved by placing wrapped ice packs on the injection site for ten to twenty minutes every one to two hours, as needed. Take care not to freeze the skin.
- numbness and tingling usually settles over a couple of weeks
- most  people return to sedentary work in one to two weeks
- heavy work should wait up to six weeks
- there may be some remaining neck pain after the procedure from pre-existing disease else where in the neck.

REHABILITATION
Rehabilitation from a percutaneous discectomy -
-  you will be observed at the clinic for half an hour
– you should have someone else drive you home
– you may need a day of bed rest after the procedure
– take your pain relief medication as required
– check your wound twice a day. If you notice any redness, swelling, green or yellow discharge, or opening of the wound, see your family doctor immediately and call your surgeon
– you may have small bandages called steri-strips on your incision. Keep these dry. These can be removed when they begin to peel off by themselves or after one week. Otherwise external sutures will be removed in one to two weeks.
– you should keep the wound dry. Otherwise showering is permitted, but avoid baths, swimming and creams for one week. The incision may then be cleaned gently using regular soap and water. Only rub gently and don’t use perfumed soaps.
– you should avoid lifting and strenuous exercise for awhile
– you will need a course of supervised physical therapy.

ON-GOING CARE
You have a weak spot in your neck, and surgery can never return it to full strength. You will need to engage in lifelong neck care to reduce the risk of further neck problems. You should always maintain correct posture, lose any excess body fat, continue your daily exercise program and avoid unnecessary stresses on your neck.
Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

POTENTIAL COMPLICATIONS OF A CERVICAL PERCUTANEOUS DISCECTOMY
ACCIDENTAL SPINAL CANAL INJECTION
Accidental injection of medication into the spinal canal can cause an unexpected decrease in nerve function. The effect varies, depending on the type and amount of medication, and its location in the spinal canal. The effect will eventually wear off. If the effect is in the upper neck, it can interfere with breathing and may require breathing assistance.

ADHESIVE ARACHNOIDITIS
Adhesive arachnoiditis is a rare complication of cervical surgery. It starts as an inflammation of the arachnoid membrane surrounding the spinal cord and nerve roots. It can be triggered by surgery, trauma such as a dural tear (membrane around spinal cord), chemical irritants such as radiographic contrast dye (mainly older ones), infection or hemorrhage. The inflammation can lead to scar tissue and adhesions that stick the nerve roots together. This tension on the nerve roots interferes with local blood flow and nerve function, leading to back or leg pain, numbness, cramps and stiffness. Arachnoiditis often develops gradually, over one to six or more months. There is no cure. The treatment is physical therapy and pain management medications and techniques.

ALLERGIC REACTION TO MEDICATION
An allergic reaction to the medications used can occur. This can cause a rash, swelling of the eyelids, hands, joints and throat, difficulty breathing, low blood pressure and death. These reactions are easily controlled with the right equipment and medications.

ANESTHESIA
Anesthesia is used so you will feel no pain during the procedure. Anaesthesia can be
Local – where the medication is injected into the skin around the site of the surgery to numb only surrounding tissues
Regional – where the body part is anesthetized by numbing a major nerve or part of the spinal cord.
Conscious sedation – where a full anesthetic is not given, rather, medications are used to create a near-sleep relaxed state.
General – where you are rendered unconscious and temporarily paralyzed. In this instance, medication is given to you through an IV line, and machines breath for you and monitor you, along with your Anesthesiologist. Most percutaneous discectomies use local anesthesia, so that you won’t feel pain during the operation.

ARTERY INJURY - VERTEBRAL
The vertebral artery passes close to the vertebral bodies in the neck. Injury during surgery is uncommon. Puncture causes bleeding that can usually be controlled by topical agents, repair or blockage of the artery. If the blood supply to the brain from the other vertebral artery is functioning, then full recovery is likely if the bleeding is quickly treated. Injury may however lead to paralysis or death.

ARTERY PERFORATION
Arteries are large blood vessels that can carry blood under pressure throughout the body. Your doctor will be very careful to avoid injuring arteries near your operation site. An artery perforation can result in significant bleeding and blood loss. This is very uncommon. If an artery is perforated, the artery can usually be repaired and the lost blood can be replaced by a blood transfusion. A specialist vascular surgeon is often asked to repair arteries. Late consequences of artery injury include fistula, hemorrhage, pseudo-aneurysm, thrombosis and emboli.

CEREBROSPINAL FISTULA
A tear in the dura, which contains the spinal cord and the cerebrospinal fluid, can allow cerebrospinal fluid to leak out through the wound, and onto the skin. This is called a cerebrospinal fistula. It may cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. There is a risk of infection and meningitis. The dural tear may reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or surgery to repair.

DEATH
No physician can guarantee a risk-free procedure. All operations and procedure have some risks. Some risks are minor inconveniences, while some are major disabilities. The risks increase with repeat operations on the same area of your body. Your entire medical staff will do their best to eliminate all risks to you, before, during and after your surgery. However sometimes, even after the surgery goes well, serious problems can arise that can result in death. These include pneumonia, pulmonary emboli, heart attack and stroke. You should discuss these risks with your Physician and your Anesthesiologist.

DISC ANNULUS INJURY
Penetrating the disc annulus during surgery can leave a weak spot in the disc wall. This can make the disc more susceptible to further disease. However the disc requiring surgery is already abnormal, and is at increased risk of further herniations or accelerated degenerative disc disease. Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

DISC DEGENERATION
Surgical procedures on a disc, such as needle or catheter insertion, are usually done on a diseased disc, but may be performed on a normal disc while looking for the abnormal disc. The procedure will puncture the disc, and can weaken the disc's ability to handle normal stresses. This can lead to accelerated degeneration or herniation of the disc, which can lead to pain and decreased mobility. However, degeneration and herniation is part of the normal aging process, and it can be difficult to identify the cause. Pain can be treated by exercises, medications and pain management or surgical procedures.

DISC DESTABILIZATION
When some nucleus is removed from a damaged intervertebral disc, it can weaken the disc's ability to move and to absorb stress. This can accelerate the pre-existing disc degeneration process. The unstable disc also places increased stress on the adjacent tissues. These two processes can cause additional symptoms, and may need an operation to correct.

DISC HERNIATION - RECURRENT
The recurrence of a disc herniation after repair occurs in five to fifteen percent of people. One third of cases are due to an isolated traumatic event, such as falling or twisting. Sometimes it occurs without any obvious trauma or external force. The herniation can be removed with a revision discectomy operation. Repeat recurrences usually mean the hole in the disc can not heal properly, and the disc may eventually need to be replaced or removed. This revision surgery is more difficult to perform and has a higher risk of complications.

DISCITIS
Discitis is an infection of the intervertebral disc. It can occur spontaneously, without any surgical procedure. Post-operative discitis can occur up to six weeks after a disc operation or injection, and most commonly causes worsening pain after an initial period of relief. Risk factors include age, smoking, obesity, diabetes, malignancy, chemotherapy, immune suppression, malnutrition, indwelling venous catheters, concurrent infections and extended hospitalization. Discitis is treated with antibiotics. Often a prolonged (months) course of antibiotics is required. Discitis with infection of the adjacent bone, or osteomyelitis, can be very difficult to cure, even with antibiotics. Discitis can lead to an epidural abscess that can cause spinal cord compression or cauda equina syndrome, and may require an operation to cure.

DUROTOMY
The dura is a thin layer of tissue that forms a sac containing the brain, spinal cord and nerve roots. The sac is filled with cerebrospinal fluid or CSF. The dura can be torn during spinal surgery leading to a leak of the fluid from the sac. This complication is more difficult to avoid during repeat surgery at the same location, or when operating on severe spinal narrowing or a large disc herniation. A dural tear with the leakage of cerebrospinal fluid, can cause a headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. A continuing leak can lead to a cerebrospinal fluid cyst under the skin, or a leakage of fluid from the wound. Dural tears can reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or an additional operation to repair.

EPIDURAL ABSCESS
Epidural abscess is a collection of pus that has formed in the epidural space of the spinal canal due to a bacterial infection. It can occur spontaneously, or occur one to two days after a spine procedure. As well as the usual signs of infection, the abscess can place pressure on the spinal cord and block its blood supply. Antibiotics may resolve the infection. If not, aspiration with a needle or a surgical drainage procedure may be required.

EPIDURAL HEMATOMA
If bleeding occurs into the epidural space around the spinal cord, it may form a collection of blood, called an epidural hematoma. If the hematoma is large, it can compress the spinal cord and nerve roots leading to pain, weakness, numbness and bowel and bladder problems. A surgical procedure may be required to stop the bleeding and remove the hematoma. Cervical Percutaneous Thermal Discectomy Goal medical negligence animations.

FLUOROSCOPY
Fluoroscopy uses X-rays to obtain instant pictures of the inside of a patient during a surgical procedure. This is very useful when devices need to be accurately positioned. X-rays are a form of ionising radiation. They can potentially cause cancer, reproductive abnormalities, cataracts and radiation dermatitis. Any effect depends on the amount and duration of exposure to the X-rays. During surgical procedures, the exposure is usually not significant. Your doctors will minimize the radiation dose to yourself and themselves by minimising the intensity and duration of exposure and by using lead shields. Pregnant women can wear extra shielding. By way of comparison, a pelvic (AP) x-ray gives a radiation dose of 0.7 mSv, and a pelvic CT gives 10.0 mSv. The world average background radiation level is 2.4 mSv per year.

HEMATOMA
During any surgery, some blood vessels will be cut. Your surgeon will stop all significant bleeding before suturing the wound shut. Sometimes bleeding recommences after the operation, forming a collection of blood in the tissues, called a hematoma. The hematoma can cause pain, pressure on adjacent tissues or become infected. It may need to be removed by inserting a drainage tube or performing a surgical operation.

HEMORRHAGE    
During surgery, blood vessels must be cut to access the desired location in your spine. Your surgeon will plan the surgical route to avoid large blood vessels, and will ensure bleeding has stopped before finishing the operation. Sometimes, one of these cut blood vessels begins re-bleeding after the operation. If the amount or location of the bleeding is causing you a problem, your surgeon may need to perform a further procedure to stop the bleeding and remove the accumulated blood.

INFECTION
Infections occur in less than one percent of spinal operations. If the wound becomes more painful or tender, red, hot or swollen, oozes a clear or yellow fluid and doesn’t heal, or if you have fever or chills, the wound may be infected. Your Surgical Team will use sterile instruments, aseptic techniques, antibiotics and regular wound care to minimize this risk. Infections can be :
superficial, involving the skin. These infections usually respond to oral antibiotics and washing the site. Sometimes the wound needs cleaning and re-suturing in the operating theatre.
deep, involving the vertebrae or spinal cord. This is more serious and may require intravenous antibiotics, and further operations to drain the infection. Rarely, infected bone graft or hardware may need to be removed.
Wound infections are more likely if you smoke, have diabetes, are overweight, or if the wound took a while to heal or there was a hematoma.
If you have any concerns, you should contact your doctor immediately.

INJECTION SITE PAIN
Pain at the injection site usually settles quickly.

LOCAL ANESTHETIC TOXICITY
If the medication is accidentally injected into one of the blood vessels around the spine, it can enter the general circulation. Depending on your sensitivity, low levels of local anesthetic in the blood can cause dizziness, ringing in the ears, headache, anxiety, nausea and increased heart rate, blood pressure and breathing rate. More severe reactions include muscle twitching, seizures, loss of consciousness, and low heart rate, breathing rate and blood pressure. This is a very rare complication.

PERFORATION
There are a number of important structures next to your operation site. These include the spinal cord and nerves and their cover – the dura, and arteries and veins. Depending upon the site of your surgery, they also include the intestine in the abdomen, the lungs in the chest, and the esophagus and trachea in the neck. Your doctor will take every care to protect these structures, but they can be accidentally perforated during the procedure. If they are injured, they will be repaired as best as possible.

PSEUDOMENINGOCELE
Sometimes a persistent leak of cerebrospinal fluid from the spinal canal can occur after the operation, through a tear in the dura. This fluid can collect under the skin and form a pseudomeningocele. Most pseudomeningoceles do not cause any symptoms. Some cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. They may also compress adjacent structures causing further symptoms. The pseudomeningocele may take days to years to appear, then may resolve spontaneously, or require bed rest, a blood patch procedure, drainage, or a surgical repair.

RESIDUAL PAIN
Some pain remaining after the procedure is very common. Surgery can not restore the spine back to a pre-diseased state. Some pain should be expected to come from the area of the operation. In addition, pain from adjacent areas already damaged by the disease, or by their own degenerative problems will most likely continue. Usually any residual pain is mild, but it may be severe or even worse than the original problem.

THERMAL INJURY
When using heat to remove some nucleus pulposus, it is possible that the heat may be transferred to adjacent nerves or blood vessels. These structures could be injured, leading to new symptoms. This is more likely when severe scarring has brought the adjacent structures closer to the heat source, such as in previous surgery, inflammation or arachnoiditis.

VASOVAGAL REACTION
Sometimes, during or after the procedure, patients can experience a temporary nervous fluctuation called a vaso-vagal reaction. This produces lightheadedness, a ringing in your ears, sweating, increased heart rate, lower blood pressure and fainting. This is easily treated and usually improves rapidly.

CERVICAL PERCUTANEOUS THERMAL DISCECTOMY GOALS
Cervical Percutaneous Thermal Discectomy Goal medical negligence animations
This article was written with the assistance of the following surgeons.

Dr Paul Licina. Dr Licina is spinal orthopedic surgeon, and co-founder of Brisbane Orthopaedic Specialist Services in Brisbane, Queensland, Australia. www.brisbaneorthopaedics.com.au/paul_licina.html

Dr Matthew McDonald. Dr McDonald is a spinal neurosurgeon based at Wakefield Hospital, Adelaide, South Australia, Australia. www.wakefieldneurosurgery.com.au

Dr Richard Parkinson. Dr Parkinson is a spinal neurosurgeon based at St Vincent's Clinic, Sydney, New South Wales, Australia. www.svph.com.au/index.php?option=com_content&task=view&id=145&Itemid=178

Dr Lali Sekhon. Dr Sekhon is a spinal neurosurgeon, and founder of Nevada Neurosurgery in Reno / Carson City, Nevada, USA. www.nevadaneurosurgery.com