Diagnostic and therapeutic technology assessment. Reassessment of automated percutaneous lumbar diskectomy for herniated disks.
Although the safety of the APLD procedure is clearly established both by reports in the published literature and by a consensus of the DATTA panelists, there was no consensus among the DATTA panelists on the effectiveness of the procedure. The average 75% success rate reported in the larger studies contrasts with the 95% success rate reported for laminectomy and diskectomy. For APLD, careful patient selection is essential. Candidates must have failed an adequate trial of conservative therapy (bed rest and limitation of activity) and have disk herniation documented by appropriate imaging studies. These studies are important because they can demonstrate not only the degree of herniation, but also whether it is contained within the annulus and if any free fragments are present. For herniated lumbar disks with nuclear material outside and contiguous with the annulus, a statistically significant consensus of DATTA panelists believed that APLD is an inappropriate procedure. Another study has shown that the procedure can be taught to other surgeons without compromising patient safety, and, as reported, this holds with large numbers of cases. In appropriately selected patients, the clinical trade-off of APLD appears to be between a procedure with a 75% success rate with low risk and rapid recovery vs one with a 95% success rate and a more prolonged recovery. A research question is whether APLD could be extended to patients who have undergone previous surgery whose disks reherniate after a successful laminectomy. Conversely, does an APLD procedure that fails to relieve symptoms complicate subsequent laminectomy? It is recognized that there is a need for prospective, controlled, randomized clinical trials comparing APLD with laminectomy to resolve these and other issues.
D000574:American Medical Association; D006801:Humans; D007403:Intervertebral Disc / Q000601:surgery*; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D011677:Punctures; D013673:Technology Assessment, Biomedical; D014481:United States