Becker's Spine Review

15 Optimization of Herniated Disc Repair in Minutes O ne of the most common diagnoses that Scott Blumenthal, MD, sees in his practice at Plano-based Texas Back Institute is disc herniation accompanied by sciatica. e typical procedural solution is a discectomy, which involves the removal of the torn, ruptured or herniated part of the disc. e purpose is to reduce pressure on the nerve and relieve the sciatica. In some cases, surgeons may prescribe rest or nonsteroidal anti- inflammatory medication for disc herniation with mild to moderate pain, and epidural steroid injections or physical therapy in other cases. When conservative treatment fails, surgeons may then recommend surgical procedures including lumbar laminotomy, artificial disc replacement or discectomy procedures. Among the surgical treatment options, discectomy procedures are the most common. 1 Dr. Blumenthal recommends discectomy for patients with disc herniation that have undergone the appropriate trial of nonoperative treatment and continue to report persistent or disabling leg or back pain. For appropriately indicated patients, discectomy is a proven procedure associated with positive outcomes. "When surgeons perform a discectomy, one of the decisions they have to make is how much of the disc material to remove," he said. "You can simply remove that broken off piece of disc and leave the majority of the disc behind, which could increase the chance of re-rupturing or re-herniation. Some surgeons elect to be more aggressive and remove as much disc as possible and that could possibly cause disc collapse or accelerate the degeneration that has already begun, which caused the disc to herniate in the first place." When performing traditional discectomy, an open defect remains, which is not ideal, however most surgical systems do not currently include tissue closure. One of the new technologies available is Anchor Orthopedics' AnchorKnot® Tissue Approximation Kit used in herniated disc repair, designed with input from surgeons in the field. Aer surgeons perform a successful discectomy, they can use the system to address the challenges associated with an open defect. e procedure allows surgeons to use sutures on both sides of the defect and then tighten them down. Aer triggering the device on each side, a pre-tied knot deploys and is secured in place before cutting the suture. e result is a complete circumferential closure of the defect. "It works very much like a meniscal repair," Dr. Blumenthal said. "It's a very well-engineered sophisticated suture deployment system. e beauty of this procedure is that it's an adjunct to a minimally invasive discectomy, adding only minutes to the procedure." On average, the closure takes five minutes. "I have been using the device for around two years and the learning curve is short," Dr. Blumenthal said. "Aer two to three procedures it becomes second nature, and it can be done through the standard microdiscectomy incision." A 2011 study published in Spine compared 108 patients undergoing lumbar discectomy for single-level herniated discs at five institutions. Around one-fourth of the patients demonstrated recurrent disc herniation at the same level as prior to the initial surgery, and the study authors concluded that "clinically silent" recurrent disc herniations are common postoperatively. 2 However, the literature also showed that tissue-sparing approaches and smaller residual defects are associated with reduced risk of recurrent herniation. 3 "For young, active patients with small discs, there is a benefit to performing minimal discectomy," said Dr. Blumenthal. "You can remove the herniated part of the disc and close the tissue within minutes. If it makes sense to you, then it's worth trying at your facility." Anchor Orthopedics offers an initial tutorial for the surgical team to ensure everyone understands the technology and is prepared to deliver the best outcome possible. For the appropriately selected patient, the benefits of tissue closure are abundant and demonstrate clear value to healthcare delivery.n Anchor Orthopedics XT Inc., the developer of the AnchorKnot® Tissue Approximation Kit, aims to provide surgeons with novel solutions that optimize procedures in disc repair in an effort to preserve the biomechanics of the patient and improve surgical outcomes. 1 American Association of Neurological Surgeons. "Herniated Disc" accessed 3/26: https://www.aans.org/Patients/Neurosurgical-Conditions-and- Treatments/Herniated-Disc 2 Lebow, Richard., et al. "Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging." Spine 36.25 (2011): 2147-2151. 3 Carragee, E. J., Spinnickie, A. O., Alamin, T. F., & Paragioudakis, S. (2006). A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine, 31(6), 653-657. Sponsored by:

• Cover