A Non-Fusion Technique for Removal of Cervical Disk Prolapse using Minimally Invasive Anterior Cervical Transoseous Approach

Abstract

IntroductionIn Acute cervical disk prolapse, root compression is the source of pain. In all established techniques, the removal of cervical disk prolapse is performed either through the disk space or through the foramen or joint (microforaminotomy, Frykholm's procedure). So as a result of these techniques, either bradytrophic tissue with little healing potential is disturbed, or bone structures involved in weight bearing or movement are partiallly resected. Consequently, most of these decompression procedures have to be combined with fusion or disk replacement.Materials and MethodsThis prospective study included P114 patients (54 females and 46 males) with a mean age of 46.4 years and was operated from 2005 to 2010. Indications were cervical soft disk herniations causing symptomatic root compression. Contraindications included instability of the affected segment, central spine compression, fractures or advanced degeneration. A modified version of Oswestry index and the neck disability index (NDI) for neck and arm pain was recorded preoperatively as well as, 3 m and 1 year postoperatively. Also the visual analog scale (VAS) was recorded before and after the procedure. The approach via a 15 mm skin incision is performed by removing a bone cylinder of 6 mm in diameter from the cranial vertebra temporarily. The sequester is removed under direct visual control of the operating microscope. After decompression the bone cylinder is repositioned.ResultsThe mean operation time per 1 segment was 64.4 minutes and mean blood loss was 82.04 mL. Hospitalization period ranged from 2 to 3 days and patients were mobilized in the same day of operation. Total 98 (98%) patients showed complete recovery of neurological deficits postoperatively. The postoperative mean NDI was improved from 34 (preoperative) to 4.6 (postoperative). Also the mean Oswestry score was improved from 16.4 to 1.6. Corresponding improvement of the VAS for neck and arm pain was also recorded and was improved from 6 to 1.3. All 3 scores were statistically significant (p = 0.05). The 1-year postoperative functional radiographic assessment showed that there was no significant impairment of the stability of the operated segment according to the criteria of White and Panjabi. Complications: one patient (2%) suffered from recurrence after 4 weeks, that was resolved after reoperation with the same method. There was no dural or root sleeve injury. There was no neurological dificit. Neither an approach related postoperative problem nor an infection did occur.ConclusionRemoval of a lateral or foraminal disk prolapse through a bony channel proved to be possible and safe. Since the bone cylinder is put back in situ and proved to be incorporated in the vertebral body there is no permanent lesion of the approach. Short-term reduction of the corpus mechanical strength did not lead to any adverse side effect. Since no significant loss of disk height, kyphosis, or segmental instability did occur, this minimal invasive procedure may be a valuable additional option in the operative treatment of the cervical disk prolapse.I confirm having declared any potential conflict of interest for all authors listed on this abstractNoDisclosure of InterestNone declaredBöhm H, Greiner-Perth R, et al. A new minimally invasive posterior approach for the treatment of cervical radiculopathy and myelopathy. Surgical technique and preliminary results. European Spine Journal 2003;12:268–273Brunaeu M, Cornelius Jf, George B., et al. Microsurgical cervical nerve root decompression by anterolateral approach. Operative Neurosurgery 2006;2:108–113Cloward RB: The anterior approach for removal of ruptured cervical discs. Journal of Neurosurgery 1958;15:602–617Fontanella A. Endoscopy microsurgery in herniated cervical discs. Int Intradiscal Therapy Soc Inc Tenth Ann Meet, Naples, Florida, 1997 (Neurological Research 01 (1999) 21:31–38)Fontanella A. Minimally invasive neurosurgery. A convincing alternative to open surgery. Rivista di Neuroradiologia 1997; 10:541Fritsch EW, Pitzen T. Zervikale Bandscheibenprothesen. Der Orthopäde 3 2006;35:347–361Heidecke V., Vogel S., Beurkert W. et al. Ergebnisse nach ventraler Fusion mittels Carbon-bzw. Titancage bei zervikalen Bandscheibenvorfällen. Dissertation zur Erlangung des akademischen Grades Doktor der Medizin. (2004)Hilton L. Minimally invasive tubular access for posterior cervical foraminotomy with three dimensional microscopic visualizationand localization with anterior/posterior imaging. The Spine Journal 2007;7:154–158