A 32 year old software professional was suffering with severe low back pain and radiating pain in both the legs. He was unable to stand straight and could not walk more than a few metres due to the pain.
His MRI revealed a large disc prolapse at L3-L4 level causing significant nerve root compression causing his symptoms and there was a significant risk of further worsening, affecting the nerve function causing paralysis in lower limbs as well as his bladder and bowel control. It was clear that he needed a surgery to release the compression on the nerves.
But he was pronounced to be a high risk candidate for anesthesia due to his morbid obesity and impaired lung function. It meant that he had a high risk of needing ventilatory support if he was put under general anesthesia as his morbid obesity might hamper his recovery while reversing the anesthesia.
An Endoscopic disc surgery under local anesthesia through a transforaminal approach was considered the most suitable option for him as it avoids the need for general anesthesia. Although a transforaminal endoscopic disc surgery is a routinely done procedure, morbid obesity in this particular patient presented certain unique challenges.
- The procedure is always done under X-Ray guidance (Image Intensifier) and visualizing the spine in obese patients, to identify the correct level and position of the endoscope, can be difficult or sometimes not possible.
- As the procedure is usually done in a prone position, the tolerance of this patient to lie prone without respiratory difficulty needed to be assessed. A pre-operative trial was done to see whether the patient would be able to tolerate prone position for at least an hour.
- He had a skin to disc distance of over 21 centimetres for endoscopic approach. But the length of the spine endoscope sleeve is only 18.5 centimetres and it may make it difficult to reach the target area and the procedure might have to be abandoned.
- His deep fat layer would mean a high incidence of wound healing problems with conventional midline open disc surgery.
Despite the above mentioned challenges, the procedure was successfully carried out as the patient could tolerate the prone position long enough to complete the surgery. The length of the scope was just enough to reach the target area and there was enough visualization of the spine with the image intensifier. The patient was awake throughout the procedure and was comfortable and communicating with the surgeon during the entire duration of the surgical procedure.
The patient had immediate pain relief and was able to walk without the leg pain and with straight posture within a few hours after the procedure. He was discharged from the hospital the next day. He recovered rapidly and was back to work within four weeks.
This case beautifully emphasizes the advantages of an endoscopic disc surgery in terms of avoiding general anesthesia and attaining the desired results safely while enabling a fast recovery and return to work in patients at high risk of complications with conventional open disc surgery.
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