Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 52. Spinal disorders are among the most common medical conditions with significant impact on health related quality of life, use of health care resources and socio-economic costs. Spinal surgery is still one of the fastest growing areas in clinical medicine. | 498 Section Degenerative Disorders Chemonucleolysis is effective based on RCTs gery became controversial because of the occurrence of rare but significant complications such as transverse myelitis and paraplegia 26 97 . Chemonucleolysis is the only minimally invasive technique shown to be effective in prospective randomized studies. A meta-analysis showed that chymopapain was more effective than placebo. But surgical discectomy produces better clinical outcomes than chemonucleolysis 48 . In this analysis approximately 30 of patients with chemonucleolysis had further disc surgery within 2 years and a second procedure was more likely after chemonucleolysis 124 126 . The indications for percutaneous techniques are limited Percutaneous Techniques These techniques have several theoretical advantages over open procedures less collateral damage to the back muscles shorter hospital stay less scar formation cosmetic result The percutaneous posterolateral approach to a herniated disc allows evacuation of extruded disc material and decompression of nerve root without entrance into the spinal canal and without destruction of the articular processes and ligamentum flavum. These procedures are limited in the extent to which migrated or sequestrated fragments can be retrieved or ablated and proper patient selection is critical to their success. The approach to the L5 S1 disc space is more difficult because of limitations imposed by the iliac crest. APLD is inferior to microdiscectomy Endoscopic discectomy is compelling but must still pass the test of time Automated Percutaneous Lumbar Discectomy Automated percutaneous lumbar discectomy APLD and laser discectomy are percutaneous techniques which indirectly decompress the neural structures 87 . Both procedures were performed in patients with contained disc herniations or protrusions. The method was applied especially in the 1990s and the success rate ranged between 55 and 85 . Automated percutaneous discectomy was compared to .
