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How get an Advantage from Minimally
Invasive Nucleoplasty Surgery

Minimally invasive spinal surgery of
traditional open surgery to relieve
chronic back pain is ideal for
outpatient facilities. These disc
decompression cases are usually
short procedures, with handpicked,
low-risk patients, strong success
ratios and fewer post-op
complications than open surgery.
And the demand for these
procedures continues to surge. But
how do you make disk
decompression surgery profitable?
I've been performing outpatient spinal surgery for 15 years.

Not all herniated disk patients are eligible for minimally invasive spinal
surgery. The ideal candidate has:
No severe spinal stenosis (build-up of bone in the spinal cavity).
Well-maintained disc height, preferably with 30 percent or less disc
collapse.

If such conservative treatments as bed rest, analgesics and physical therapy
fail to relieve the problem, I do tests such as discography, MRI and CAT
scans. If these tests confirm that the problem is a herniated disc and the
patient meets the aforementioned criteria, he is a good candidate for
outpatient surgery such as nucleoplasty.

If you want to make a case with your payers to reimburse for spinal
procedures, you can draw on the significant volume of clinical data proving
the efficacy of outpatient disc surgery, which strongly suggests that these
procedures can prevent the need for more expensive open procedures.
Open disc surgery results in epidural scarring and also requires a much
lengthier recovery period than minimally invasive spinal surgery, where the
patient can be ambulatory the same day and post-op pain is minimal.


Nucleoplasty is not
appropriate for large
herniations or those with
extruded fragments;
when surgery is required
lumbar microdiscectomy
or discectomy remain the
preferred treatment in these cases. The majority of herniations, however,
are small and contained. In over 50% of cases, clinical symptoms disappear
with time, and the herniation shrinks over 8-9 months. Nucleoplasty can
provide pain relief during this period.
If the disc prolapse is mainly central (that is, directed backwards rather
than to one or other side, the presenting complaint is likely to be back pain
rather than leg pain. Clinical features that indicate a greater likelihood of
nucleoplasty working in such instances include severe restriction of lumbar
flexion (bending forwards) and reduced straight leg raising test. These tests
indicate the possibility of dural irritation. The disc prolapse should be more
than minor.
If the disc prolapse directed backwards but more to one side (i.e.
posterolateral) it is more likely that leg pain will be a feature. This pain may
be referred in nature rather than radicular. That is, the leg pain may be
diffuse rather than shooting.
Nucleoplasty may be an appropriate treatment for patients with:
Radicular pain greater than back pain
Poor response to previous medical treatment and physiotherapy
MRI demonstrating disc herniation less than 6mm in size.
The procedure may not be appropriate for patients with:
Spondylolisthesis
Segmental instability
Herniation 6mm in size, or with extruded fragments
Severe disc degeneration
MRI finding of complete annular disruption
Age >60 years
A painful disc which has height less than 50% of that of the
adjacent disc.

Some practitioners also perform discography prior to treatment. In some
cases, this is intended to confirm concordant pain at each level, and rule out
the involvement of other levels. In other cases, the procedure is conducted
to confirm that the outer annulus has retained its integrity, and to identify
patients with true internal disc disruption.
Efficacy
A systematic review of the efficacy of the nucleoplasty procedure for
treating LBP from symptomatic, contained disc herniation found Level II-3
(reasonably strong) evidence for improvement in pain or function after a
nucleoplasty procedure.
No randomised control trials investigating nucleoplasty have been
published. A range of lower quality studies have assessed the efficacy of the
treatment, with a majority reporting positive or promising results.
Recently published practice guidelines for the evidence-based treatment of
chronic spinal pain have concluded that there is limited evidence for the
effectiveness of nucleoplasty.
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