Percutaneous Endoscopic Cervical Discectomy (PECD)

Percutaneous Cervical Micro-decompression Endoscopic Cervical/Lumbar Discectomy with Laser Thermodiscoplasty, is a new procedure to shrink and remove a herniated disc. Using brief general (cervical) or local (lumbar) anesthesia and the help of x-rays for guidance, specially designed micro-instruments, the discectome and a laser probe are inserted into the herniated disk space, and a portion of the offending disk is removed with suction and then vaporization with a laser to shrink the disc further, instead of open surgery.
Percutaneous cervical/lumbar discectomy is different from standard disk surgery because there is no muscle dissection, bone removal, bone fusion, or incision, except for a puncture wound to accommodate the micro-instruments that are inserted into the herniated disk. Most complications that occur with conventional surgery, therefore, are eliminated with this procedure.
The procedure is performed under brief general (cervical) or local (lumbar) anesthesia with the patient awake and in a supine (cervical) or lateral (lumbar) position. A small needle is inserted into the disc.
Over this probe, a slightly larger sleeve is inserted to permit a 2mm incision to be made in the disk itself. Using x-ray fluoroscopy control, the micro-instruments (forceps, currets, cutters), the discectome (which is a hollow probe with a cutting knife inside), and the laser probe are inserted into the disk space through a sleeve. Very small pieces of the disk material are removed and suctioned. The laser shrinks the disk bulge further. The procedure takes about 20 minutes, on average. X-ray exposure is minimal.
The amount of disk removed varies. The supporting structure of the disk is not affected. Upon completion, the needle is removed and a small Band-Aid is applied over the probe incision.
The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerves in the neck or back areas. Since insertion of the probe through the muscle is the only wound, there is no scarring in or around the nerves postoperatively. Additionally, it is an outpatient procedure. Unfortunately, patients who have large free fragments of disk in the spinal canal, as determined by the x-ray, cannot benefit from this procedure. However, the laser can shrink the bulging disc further for disc decompression.
It is essential to understand that all patients are not relieved of their pain with this procedure. Approximately 90 percent of patients will experience pain relief. Patients who do not obtain relief within three to six weeks may be considered for micro-cervical disc removal and fusion, depending on the circumstances. There does not appear to be any detrimental effect from performing percutaneous cervical discectomy before micro-cervical procedure to remove bony discs and bony fusion.

Under local or general
anesthesia, the patient was placed in a supine position with the neck extended by placing a rolled towel under the shoulders. A soft strap was placed over the forehead for stabilization. The shoulders were gently distracted downward with tape. C-arm fluoroscopy was used in anteroposterior and lateral planes to direct the placement of a spinal needle onto the disc surface. Initially, at the point of entry adjacent to the medial border of the right sternocleidomastoid muscle, firm pressure was applied digitally in the space between the muscle and the trachea and pointed toward the vertebral surface. The larynx and trachea were displaced medially and the carotid artery laterally. The esophagus was made more prominent with the insertion of an endotracheal tube. The pulse of the carotid artery was augmented with sympathomimetics. The anterior cervical spine was palpated with the fingertips, and a #18-gauge spinal needle was passed into the disc space. The position was confirmed fluoroscopically. A 2 to 3 mm skin incision was made, and a narrow guide wire was passed through the needle. The needle was then removed. A blunt trocar was introduced over the guide wire down to the interspace, followed by a cannula. A trephine inserted through the cannula cut the annulus in a circular fashion. Minicurettes loosened and removed disc material prior to introduction of a suction-irrigation system and the discetome with a guillotinecutting blade (Fig. 1). The instruments included a probe, grasper forceps, and laser fiber (Fig. 2). Movement in a critical fan sweep maneuver, a 25° rocking excursion of the cannula hub from side to side, increased the removal up to a 50° coneshaped area within the disc space (Fig. 3). The procedure was closely monitored with the fluoroscope (Fig. 4) and an endoscope (Figs. 5A, B). The holmium: yttrium-aluminum-garnet laser with right angle or side-fire probe facilitated the discectomy. In addition, nonablative levels of holmium laser energy (500 joules) or thermodiscoplasty added shrinking of collagen and fibrocartilage; the tightening effect further decompressed and hardened the herniated cervical disc.