Back Surgery Without Stitches

By John Langone

Lower back pain, as prevalent as the common cold, is the price human beings pay for walking upright. In most cases, simple treatments like bed rest, exercise and pain-killers bring relief. But many sufferers are not so lucky. If one or more of their spinal disks -- pulpy masses that cushion pairs of vertebrae -- rupture and press on nerve roots, the pain that radiates from the back and down the legs can be excruciating and disabling. For many the only treatment is surgical removal of part of the blown disk, a major operation called a laminectomy that requires general anesthesia, the dissection of muscle and removal of bone.

Now there is a new and far less traumatic option for some disk patients. Known as percutaneous automated diskectomy, it is an outpatient procedure performed under local anesthesia through a tiny (2 mm long) incision in the back. Developed by Radiologist Gary Onik and Neurosurgeon Joseph Maroon of Allegheny General Hospital in Pittsburgh, the operation breezed through its clinical trials, and has been performed on some 15,000 patients around the country -- at approximately one-third the cost of conventional surgery.

The relatively simple operation is similar to arthroscopic surgery, in which damaged tissue is removed, typically from knee joints, through a hollow tube. In the diskectomy technique, a stainless-steel tube, guided by X ray, is slipped into the incision until the tip of the instrument rests against the disk. Next the surgeon threads a combination cutting-suction device the diameter of a pencil lead down the cannula, pushes it gently into the center of the disk and steps on a floor pedal. Suction draws disk material, which has the texture of crab meat, into a porthole near the probe's tip. There it is neatly sliced off with a tiny pneumatically driven guillotine-like blade that slides back and forth. After each cut, the probe is flushed of disk tissue, which is sucked out and collected in a bottle.

The procedure usually takes less than an hour and requires no stitches. Patients walk out of the hospital with only a Band-Aid over the incision. Recalls Sheila Aronoff, who had the surgery at Allegheny General last year: "I could feel the pain start to leave while I was in the recovery room. Except for those whose jobs require physical labor, the vast majority of patients are back at work in a week or two. Discomfort is rare: most patients need only a non-narcotic analgesic, if anything. Says Onik: "The biggest problem is keeping them from doing too much too soon because they feel so much better." Another important advantage is that the operation can be repeated or followed by a laminectomy if necessary. But when the more drastic operation is performed first, reoperation is much more difficult because of the scar tissue and adhesions that often form around the nerve roots, causing chronic pain and loss of flexibility.

Despite its high marks, the new operation can be less successful than a laminectomy and is not for everyone. Onik says it works only for a "contained" rupture -- a disk that has become distended but has not yet broken through the fibers that hold its contents in place. Moreover, 12% to 15% of Onik's patients require a second operation, usually a laminectomy, because X rays failed to reveal that the tissue had already burst out of the disk and lodged against a nerve. An additional 10% experience only partial relief but are not in enough pain to want another operation.

Still, Onik and others who perform the minisurgery are enthusiastic about its proven success in nearly four out of five cases. "It's made it possible for me to reduce the number of laminectomies I do by 70%," observes Nashville Back Specialist G. William Davis, who claims that he has done more of the new operations than any other surgeon. "The savings in pain and money are enormous."

With reporting by Suzanne Wymelenberg/Boston