Microdiscectomy is a method that helps us clear hernias in our cervical, lumbar, or rarely, back by causing the least harm on tissues. Surgical microscope is superior to the naked eye in that it lights up a narrow tunnel and enhances the view, thus allowing for a safe surgery. Endoscopy offers the same convenience, however, surgical microscope allows surgeons to work under 3D pictures, which makes it superior to endoscopic technique. For instance, in the traditional technique, when we work on a hernia of one segment, we need to make an incision that is big enough to let the light in in order to get an illuminated view of the surgical area. In other words, we will have to make a wound of 5-6 cms in size when a wound of 2 cms would do. Also, if we use a surgical microscope while working around nerves, we can get a better view of tissues in 3D, and it helps us to do our work more safely. Since it is supported by the manufacturer companies, we can work through a small wound in the endoscopic method, too, however the image is in 2D as in the case of televisions. Furthermore, in this method, the tools with a weaker grasping capability let you remove only the free pieces that have overflowed into the canal, but the pieces deeply settled in between vertabrae can not be cleared off completely. Recurring hernias can be observed more frequently after the surgeries that were performed with the endoscopic technique. So, microdiscectomy helps surgeons attain their objectives with the least harm to tissues, thanks to the mini Taylor ecarteur with 1 cm in size, high speed drills and bone cutters running on air pressure.
The story of protecting the yellow ligament:
Helping our vertebrae to hold onto one another at the back, “the yellow ligament” (the ligamentum flavum in medical terms) is a tissue of ours that should be kept during a surgery to be performed with the microdiscectomy technique, which I had personally contributed to. Located over the sheath covering the spinal cord, this ligament can serve as a door to a room through which a surgeon would enter during a surgery for a lumbar disc herniation. I have had performed surgeries in a period of 27 years in which I kept the ligamentum flavum, and when I opened up those patients with recurring hernia for the second time, I could find very little fibrosis around a significant number of nerves. I found out this fact by video recording during the surgeries, however it might be missed by the radiologist writing the MRI report by failing to notice the surgery or the radiologist might refer to the same thing in the report as “minimal fibrosis was observed”. In medicine, an assertive approach “I did it my own way” would not be acceptable. Science requires proof and the evidence-based medicine is important in our field, too. Every single day, the MRI technology has been providing new information. In addition to the imaging capabilities, it also offers valuable knowledge such as tissue analysis, current measurement, functional data. Some day, it will be a daily work to be able to numerically measure the amount of scar tissue that forms in the surgical area after the surgery. We will be proven right when we get the results of a numeric detection of scar tissues along with a comparison -of them- between surgeries in which ligamentum flavum is kept and the surgeries (traditional ones) in which it is removed. For the young, this may be a thesis subject worth studying. Neither a patient nor a surgeon would desire a situation in which a surgery is needed on an area where a surgery was already performed previously. An analogy would be like this; the surgeon who performs the first surgery drives his car on a highway, which means that the tissues are in their natural state, surgical strip off is easy to do and there is no fibrosis between neighboring tissues. However, in the second surgery, the highway is no longer a highway anymore, it has probably now become a by-street or a pathway because the areas of the body where the knife had proceeded along have now been covered with the repairing tissue, so one would have to drive more slowly in such a situation. It is the fibrosis between the neighboring tissue and the nerve that frustrates or pressurizes surgeons, and this is quite natural. A surgeon has to work not only carefully but also under pressure in order not to cause any harm on any nerve.
I realized the importance of keeping ligamentum flavium when I was performing surgeries for recurrent hernias in the patients who had undergone surgeries in the traditional way. I met this situation in such patients while I was clearing the remnant ligamentum flavium that had been left behind in the marginal areas after the previous surgery. And it attracted my attention and got me into thinking “it would be useful to keep the ligamentum flavum”. In a surgery for a recurring case, the first and foremost target of a surgeon is to reach the healthy bone at the margin. I noticed the fact that although I could proceed slowly amongst dense scar tissue until I reached the healthy bone at the margin, when I reached at the point below the ligamentum flavum that had been left at margins, I was able to go faster and the tissues were splitting more comfortably as there was less fibrosis. To reach the outmost edge means to be outside the nerve and to get rid of the possibility of harming the nerve. No scar tissue was developed between the remnants of ligamentum flavum and the nervous tissue/surrounding tissue, which had actually helped me at the time. The overgrown scar tissue was not proceeding along between the nerve and the tissue that covers the nerve. The yellow ligamentum cover on the nerve was protecting the nerve like a blanket and was preventing the scar tissue from getting in between. It was the microchirurgia technique that helped me make these observations; in other words, it was the illumination and enhancement capabilities offered by the surgery microscope. From those observations on, I was sure that the ligamentum flavum was a structure to be kept, and that was exactly what I did. I have been keeping the ligamentum flavum for 27 years in the patients with a suitable anatomic structure, that is, the patients with a normal indent and angle of the bone channel which nerves fit into. This group of patients generally includes young people, and things change when one gets older.
When I was performing a surgery on the patients for the second time in whom I had kept the flavum ligamentum, I found out something that astonished me, and made me happy in a sense; the ligamentum flavum, which I had stripped off the bone in the previous surgery and had used as a door while entering the room of the nerve, had actually settled into its original location as if it had never been opened up. In the case of the patients who left behind a few years since the time of surgery; because the bone had grown a little bit more, it was necessary to take some of the bone and re-separate the ligamentfum flavum from the side of the bone which it had connected to, just like I had done in the first surgery. Another situation in favour of the patient and the surgeon in the room of the nerve which we entered after lifting the ligamentum flavum was that there was no scar tissue between the ligament and the nerve. Having a nearly natural look, this piece of finding was too small to compare to the thick scar tissue which we always found in the patients whose ligamentum flavum had been removed. And it was for this reason that the duration of the surgery was the same as those for the first time.
In order for our findings to sit on a scientific foundation, I assigned this subject as a thesis subject to one of my assistants a long time ago. We followed the patients on a going-forward basis (a prospective study in medical terms). After a period of one year, we compared the amounts of the scar tissues detected in the lumbar MRI with those of the control group whose ligamentum flavum had not been kept. The results were positive just like we expected. We published those results in one of the most respected peer-reviewed journal (USA).