Soft Disc Herniation Research Articles

Percutaneous Endoscopic Discectomy for Extraforaminal Lumbar Disc Herniations

A retrospective analysis of 41 patients operated for excision of soft lumbar extraforaminal disc herniation (EFDH) by percutaneous endoscopic extraforaminal approach under local anesthesia by a new technique. To describe a new and safer percutaneous endoscopic technique for the removal of soft EFDH and report the results on the basis of a new objective criterion modified from Oswestry Disability Index (ODI). EFDHs usually occur in older patients and present with atypical symptoms. Their diagnosis and treatment are still controversial, with various authors describing open midline or paraspinal approaches using the microscope with varying amounts of success. Percutaneous endoscopic techniques have traditionally been considered unsuitable for these herniations. Forty-one patients with a soft EFDH were subjected to percutaneous endoscopic discectomy with the new technique. In our technique, the skin entry point is medial and the angle of approach steeper as compared with the earlier described endoscopic techniques. This might help in avoiding exiting root injury and increasing the efficacy of the procedure. The results were analyzed on the basis of percentage change in ODI as compared with preoperative values. Mean follow-up was 34.1 month. Mean VAS score for radicular pain improved from 8.6 to 1.9, and mean ODI improved from 66.3 to 11.5. Overall, 92% of patients experienced satisfactory outcome. Two patients had poor outcome due to the need for subsequent open surgery. Percutaneous endoscopic discectomy using the "extraforaminal targeted fragmentectomy" technique is an effective and safe procedure for the select group of patients with a soft EFDH.

Indications & Experience with Percutaneous Endoscopic Cervical Discectomy (PECD)w/wo B-twin Stabilization

Introduction: Percutaneous endoscopic cervical discectomy (PECD) could be considered as a good alternative to the standard anterior cervical discectomy and fusion (ACDF) in dealing with soft cervical disc herniation. However, this procedure cannot be applied for patients with cervical disc herniation accompanied by segmental instability. Recently developed WSH cervical BTwin can be used as an interbody spacer to achieve stability without open discectomy. The purpose of the study is to evaluate the efficacy of PECD and percutaneous cervical stabilization (PCS) with or without dynamic cervical stabilization. Materials and Methods: The cervical working channel endoscope (WSH endoscopy set, Karl-Storz, Germany) for PECD has a working cannula that has integrated high-resolution endoscope, illumination, and irrigation. Therefore it allows surgeons to selectively remove the herniated disc via a Holmium: Yttrium-Garnet-Aluminum (Ho: YAG) laser and microforceps under endoscopic visualization. The PCS procedure also follows that of PECD. Under the fluoroscopic guidance, the reduced 3.3 mm cylindrical implant is inserted into the intervertebral disc space. Once expanded, its octagonal shape and fins prevents implant migration. Therefore, it restricts the excessive movement between endplates and to re-establish balance of cervical curvature. Results: From January 2001 to October 2006, a total of 105 patients (M:F=62:43) were included in this study. Mean age was 44.13 years (range; 24-67 years) and mean follow-up period was 36.4 months (range; 2-70 months). The clinical outcome was evaluated according to the Macnab criteria. The surgical outcomes were excellent in 39 patients (37.1%), good in 49 patients (46.6%), fair in 4 patients (3.8%) and poor in 13 patients (12.3%), thereby indicating an 83.7% rate of favorable outcome. A total of 45 patients underwent PCS with cervical B-Twin at our hospital. Among these, 33 patients who were available for follow up were retrospectively reviewed for their clinical outcome. There were 18 male and 15 female patients with mean age of 46.9 years (range; 28-78 years). The preoperative mean VAS of neck pain and back pain were improved from 6.09 to 4.72 and 3.19 to 1.7, respectively. Mean ODI was improved from 47.82% to 14.46%. Based on the Macnab criteria, the surgical outcomes were excellent in 10 patients (30.3%), good in 18 patients (54.5%), fair in 2 patients (6.1%) and poor in 3 patients (9.1%), indicating a favorable outcome of 84.8%. There were two additional surgeries at the affected level or adjacent levels. The rate of return to work after surgery was 93.9%. Conclusion: The procedure of direct fragmentectomy and manual decompression by microforceps and thermal effect of Ho: YAG laser under direct endoscopic view is safe and effective for the treatment of soft cervical disc herniations. In our experience, there is a very low associated morbidity with a rapid recovery resulting in a significant saving on expenditure. Biomechanically and clinically, PCS has potential to treat the angular instability. This technique prevents postoperative kyphosis and maintains anterior structures and stability unlike the conventional open procedures. In order to firmly establish the efficacy of B-Twin for treating segmental instability, further study requires large-scale trial long term follow-up.

PMMA versus Titanium Cage after Anterior Cervical Discectomy - A Prospective Randomized Trial

Nonautologous interbody fusion materials are utilised in increasing numbers after anterior cervical disc surgery to overcome the problem of donor site morbidity of autologous bone grafts. This study investigates the performance of two nonautologous materials, the bone cement Polymethylmethacrylate (PMMA) and titanium cages. This prospective randomised trial, with assessment of the results by an independent observer, evaluates whether a Polymethylmethacrylate (PMMA) spacer or a titanium cage provides a better fusion rate around the implant and a better clinical outcome. Between 2000 and 2002, 115 patients with monoradicular cervical nerve root compression syndrome caused by soft cervical disc herniation were eligible for this study. Myelopathy, excessive osteophyte formation, and adjacent level degeneration were exclusion criteria. A block-restricted randomisation was applied. The 2-year clinical outcome served as the primary endpoint of the study. Clinical outcome was assessed according to the Odom scale by an independent observer at the follow-up examination. Preoperative, postoperative, and follow-up radiographs were taken. The study was completed by 107 patients (53 with PMMA and 54 with titanium cage). No significant difference between the two groups could be established with respect to the clinical outcome. In each group, 26 patients scored excellent. Good results were found in 19 PMMA patients and 16 titanium cage patients; satisfactory results were found in 8 PMMA patients and 9 titanium cage patients; bad results were found in 3 titanium cage patients. In 47 titanium cage cases (87%), fusion occurred radiologically as bony bridging around the implant. The fusion rate was significantly lower (p=0.011) in the PMMA group, with 35 cases (66%) united at follow-up. The radiological result of the titanium cage is superior to that of PMMA with respect to the fusion rate. Although the titanium cage achieves a better fusion rate, there is no difference between titanium cages and PMMA with respect to the clinical outcome.

Immediate Pain Improvement Is a Useful Predictor of Long-Term Favorable Outcome after Percutaneous Laser Disc Decompression for Cervical Disc Herniation

The purpose of this study was to evaluate the long-term clinical outcome of percutaneous laser disc decompression (PLDD) for cervical disc herniation and to identify factors affecting long-term favorable outcome. PLDD using the Ho:YAG laser has been regarded as an effective alternative for soft disc herniation. However, little is known about long-term favorable outcome parameters. We retrospectively reviewed the clinical and radiological data of 60 patients who underwent PLDD with laser-assisted spinal endoscopy (LASE) for contained cervical soft disc herniation from January 1998 to January 2000. The clinical outcome was measured using the Macnab criteria. Statistical analysis was performed using Fisher's exact test. Sex, age, operated level and location of disc herniation, amount of laser energy, and time for symptom improvement were selected as parameters. The mean follow-up period was 71.0 months (range, 59-83 months). The mean age was 45.7 years (range, 26-68 years), and the mean symptom duration was 13.0 months (range, 2-60 months). The Visual Analogue Scale (VAS) score was significantly improved from 7.9 preoperatively to 2.6 at the final follow-up (p < 0.001). At the final follow-up, 51 (85.0%) patients achieved a favorable outcome. Immediate (within 24 h) pain relief was achieved in 19 patients, and it was strongly related to long-term success (p = 0.006). The long-term clinical outcome of PLDD with LASE was fairly good, with a success rate of 85%. Immediate pain relief is a useful prognostic factor predicting favorable outcome following the procedure.

Clinical Results of Total Lumbar Disc Replacement With ProDisc II

Prospective study analyzing midterm clinical results of total lumbar disc replacement (ProDisc II) for different indications. To assess functional outcome after total lumbar disc replacement (TDR) treated for varying indications. Despite its frequent use and increasing popularity, indications and contraindications for TDR have not been defined precisely at this stage and remain a matter of debate, leading to disc replacement procedures in a variety of pathologies that have not yet been evaluated and compared separately. Patients meeting inclusion criteria were evaluated prospectively according to Visual Analogue Scale (VAS), Oswestry Questionnaire, SF-36, and numerous clinical parameters. Indications included degenerative disc disease (DDD), DDD with accompanying soft disc herniation (nucleus pulposus prolapse, NPP), osteochondrosis following previous discectomy, and DDD with presence of Modic changes. Postoperative improvement was recorded and analyzed for influence of preoperative diagnosis. Overall, 92 patients from four groups with a mean follow-up of 34.2 months (minimum, 24 months) achieved significant and maintained improvement from preoperative levels (P < 0001). Patients with DDD + NPP achieved results significantly better than patients from the other groups (P < 0.05). Presence of Modic changes or previous discectomy did not influence outcome negatively. Improvement was achieved for both monosegmental and bisegmental disc replacements (P < 0.05), nevertheless with significantly inferior results for bisegmental interventions at 12- and 24-month follow-up and considerably higher complication rate. While older patients were still highly satisfied with postoperative outcome, better functional outcome was observed in younger patients. Present data suggest beneficial clinical results of TDR for treatment of DDD in a highly selected group of patients. Better functional outcome was obtained in younger patients under 40 years of age and patients with degenerative disc disease in association with disc herniation. Multilevel disc replacement had significantly higher complication rate and inferior outcome. Results are significantly dependent on preoperative diagnosis and patient selection, number of replaced segments, and age of the patient at the time of operation. Because of significantly varying outcomes, indications for disc replacement must be defined precisely.

Microsurgical Cervical Nerve Root Decompression by Anterolateral Approach

Cervical radiculopathy caused by a posterolateral soft disc herniation or spondylosis is a common pathology. Decompression of a stressed cervical nerve root is a routine neurosurgical procedure. Most of the time it is achieved through an anterior approach and, less frequently, through a posterior approach in specific indications. According to the principles that an anterolateral compression must directly be reached and that working in the vicinity of the vertebral artery is safe under visual control, we developed the anterolateral approach to the cervical intervertebral foramen and the nerve root using a minimally invasive technique to remove the offending process. Microsurgical cervical nerve root decompression by anterolateral approach is a minimally invasive technique, permitting one to remove the offending process staightforwardly. The disc and bone resections are minimal. This method avoids osteoarthrodesis or arthroplasty with disc prosthesis. This technique is efficient with good results and low morbidity.

Percutaneous endoscopic cervical discectomy for discogenic cervical headache due to soft disc herniation

A discogenic cervical headache is a subtype of cervicogenic headache (CEH) that arises from a degenerative cervical disc abnormality. The purpose of this study was to evaluate the clinical outcome of percutaneous endoscopic cervical discectomy (PECD) for patients with chronic cervical headache due to soft cervical disc herniation. Seventeen patients underwent PECD for intractable headache. The inclusion criteria were soft disc herniation without segmental instability, proven by both local anesthesia and provocative discography for headache unresponsive to conservative treatment. The mean follow-up period was 37.6 months. Fifteen of the 17 patients (88.2%) showed successful outcomes based on the Macnab criteria. Pain scores on a visual analog scale (VAS) improved from a preoperative mean of 8.35 +/- 0.79 to 2.12 +/- 1.17, postoperatively (P < 0.01). The mean disc height decreased from 6.81 +/- 1.08 to 5.98 +/- 1.07 mm (P < 0.01). There was no newly developed segmental instability or spontaneous fusion on follow-up radiography. In conclusion, PECD appears to be effective for chronic severe discogenic cervical headache under strict inclusion criteria.

Minimally invasive anterior contralateral approach for the treatment of cervical disc herniation

Background During the practice of ipsilateral approach to the offending lesion in anterior simple discectomy, the authors realized that it achieves better surgical exposure of the opposite foraminal area. In addition, it was also realized that routine procedures for better visualization of the foraminal area, such as stripping longus colli muscles, further excising of the anterior longitudinal ligament, or using a spreader, which cause more invasive surgery during the standard anterior approach, are not necessary because the contralateral approach already achieves sufficient exposure of the target foraminal area. Objective Evaluation of the results and effectiveness of this minimal invasive technique in patients with either soft or hard disc herniations. Methods Between January 1994 and April 2002, 216 patients underwent anterior contralateral microdiscectomy without fusion for cervical disc herniation at 1 or 2 adjacent levels. Anterior contralateral microdiscectomy is a less invasive technique than standard anterior simple discectomy in which longus colli muscles are not stripped, and the lateral part of annulus fibrosis at the side of intervention and ventrolateral part of it at the opposite side are not removed. In addition, a mini Zenker handheld retractor is used for retraction of paravertebral soft tissues and a spreader is not used during the discectomy procedure. There were 182 patients diagnosed with radiculopathy and 34 patients with myelopathy. Assessments of the neurological status of patients with radiculopathy were done by physical examinations, and of those with myelopathy according to the modified Japanese Orthopaedic Association cervical spine functional assessment scale. These neurological assessments were repeated in the 18th month after surgery. In the follow-up period, the outcomes of surgery were also assessed for all patients in 4 categories, from failure to excellent. Results Surgery outcomes generally have been good to excellent and none of the patients were made worse by the procedure. The outcomes were significantly better in the radiculopathy and soft disc herniation groups. Other positive outcome factors were short duration and sudden onset of symptoms, normal cervical curvature, and single-level disease. Follow-up radiological studies revealed fibrous healing with normal or slight loss of disc height in 199 (92.1%) patients and total obliteration of the involved disc space representing radiological fusion signs in 13 (6%) patients. The overall complications observed in this study were 2 spontaneous and 2 postinfection collapses of disc level, 1 excessive fibrosis of disc level, and 2 adjacent-level diseases. Conclusion Anterior contralateral microdiscectomy without fusion achieves better exposure for resection of the offending foraminal or far lateral lesions, ventral osteophytes, or a disc fragment under direct microscopic visualization. Collapse and instability of the involved disc level can also be avoided via this less invasive technique.

Clinical Outcomes of Percutaneous Endoscopic Laser Lumbar Discectomy

Background: Over the years, disc surgery has progressively evolved in the direction of decreasing trauma and its invasiveness. Conventional open surgery has many complications, such as scarring, instability, bleeding and a relative high mortality rate. Minimally invasive spinal surgery is now an alternative to a traditional discectomy. Herein, we present an operative technique, and the early results, for a percutaneous endoscopic lumbar discectomy in herniated lumbar disc disease. Methods: 43 patients, including 27 men and 16 women, with ages ranging from 18 to 66 years, were enrolled in this study. All the patients showed a protruded or extruded soft disc herniation at the lumbar level on magnetic resonance imaging and computed tomography. A percutaneous endoscopic lumbar discectomy was applied to the patients, and clinical responses evaluated using MacNab’s criteria. Results: 40 patients were regarded as showing successful responses (93.1%), and there were no severe complications, such as a hematoma, nerve injury, postoperative dysesthesia or death. One patient underwent fusion surgery for remnant back pain six month later. Conclusions: We conclude that, in properly selected patients, a percutaneous endoscopic lumbar discectomy is a safe, noninvasive and effective treatment modality for herniated lumbar intervertebral disc disease.

Factors predicting excellent outcome of percutaneous cervical discectomy: analysis of 111 consecutive cases.

Percutaneous cervical discectomy (PCD) has been developed as an effective treatment option for soft cervical disc herniation. However, no prognostic study of this procedure has yet been made. The purpose of this study was to evaluate the surgical outcome of PCD and to determine the factors predicting excellent outcome. A retrospective review was performed of 111 consecutive patients who underwent PCD with a mean follow-up period of 49.4 months (range, 29-64 months). Under local anesthesia, a percutaneous anterior approach was followed by discectomy with microforceps and endoscopic Ho:YAG laser. The surgical outcomes of the 111 patients based on the Macnab criteria were excellent in 52 patients (46.9%), good in 37 (33.3%), fair in 9 (8.1%), and poor in 13 (11.7%), thereby indicating a symptomatic improvement in 88.3% of the patients. In this study, the two major factors predicting an excellent long-term outcome were the symptom of radiating arm pain (P = 0.02) and the location of lateral disc herniation (P < 0.02). Proper patient selection remains critical for the success of this minimally invasive procedure.

P19. Spontaneous regression of soft disc herniation in patients with cervical myelopathy

P19. Spontaneous regression of soft disc herniation in patients with cervical myelopathy

Anterior Microforaminotomy for Treatment of Cervical Radiculopathy: Part 1—Disc-preserving “Functional Cervical Disc Surgery”

Anterior cervical microforaminotomy was developed by the senior author (H-DJ) under the concept of "functional spine surgery which directly eliminates compressive pathological factors while preserving functional anatomic features. The surgical results are reported. Among approximately 400 patients who underwent anterior cervical microforaminotomy at the University of Pittsburgh between March 1993 and May 1999, 104 patients met the inclusion criteria for this study. Forty-five patients were men and 59 were women. Patient ages ranged from 26 to 74 years (median, 46 yr). Compressive pathological lesions included spondylotic spurs in 44 cases (42.3%), soft disc herniation in 54 cases (51.9%), and a combination of the two in 6 cases (5.8%). Eighty-three patients (79.8%) experienced excellent results, 20 patients (19.2%) experienced good results, and 1 patient experienced fair results. No patient demonstrated a poor or unchanged outcome. All patients demonstrated excellent decompression in their postoperative magnetic resonance imaging scans, and all patients except one with discitis maintained their motion segments well, as indicated in postoperative dynamic roentgenograms. Two patients developed transient Horner's syndrome, one patient developed transient hemiparesis, and one patient developed discitis, resulting in spontaneous bone fusion. Anterior microforaminotomy provided good or excellent outcomes, with minimal morbidities, for 98% of 104 patients with cervical discogenic radiculopathy. The functional anatomic features were well preserved for 99% of the patients.

Anterior cervical discectomy without interbody fusion

BACKGROUND The use of an interbody bone graft during anterior cervical discectomy remains a controversial topic. This study presents the outcome of 64 consecutive patients who underwent anterior cervical discectomy without an interbody fusion. METHODS Sixty-four consecutive patients underwent anterior cervical discectomy without interbody fusion by one surgeon at Indiana University School of Medicine between April 1994 and February 1998. A retrospective analysis of these cases was performed to evaluate outcome of this procedure. Outcome was determined using the criteria of Odom and Finney. RESULTS In our series of patients, the mean age was 49.4 years, and the mean time of follow-up was 8.5 months. The presentation was as follows: 69% radiculopathy alone, 23% combined myelopathy and radiculopathy, and 8% myelopathy. Although 31% of the patients had symptoms for more than 1 year, the mean duration of symptoms of the remainder of patients was 3.2 months. The majority of patients had single-level disease (77%); however, 25% underwent 2 level discectomies, and 2% underwent 3 level discectomies. Twenty-four patients (38%) had soft disc herniation, and 40 patients (62%) had hard disc herniation. Of the 64 patients, 91% had either good or excellent outcomes, 9% had satisfactory outcomes, and none had a poor result. Ninety-six percent of the patients with soft disc herniation had good or excellent outcomes, whereas 88% of the patients with hard disc had good or excellent outcomes ( p = 0.217). Ninety-one percent of the patients who worked before surgery returned to work after their operation. None of the patients required reoperation at the operative level or exhibited instability at the operative level. Postoperative complications included transient intrascapular pain (13%), kyphotic deformity (3%), transient vocal cord paralysis (2%), and temporary dysphagia (2%). No significant difference in age or outcome existed when comparing males to females. CONCLUSION Satisfactory results can be attained by discectomy without an interbody fusion in the surgical management of cervical disc disease.

Anterior cervical fusion with carbon fiber cage containing coralline hydroxyapatite: preliminary observations in 45 consecutive cases of soft-disc herniation.

The purposes of bone substitutes for anterior cervical fusion (ACF) are immediate biomechanical support and osteointegration of the graft. The authors report their preliminary results in performing ACF in which carbon fiber cages (CFCs) containing coralline hydroxyapatite (HA) are used as bone substitute. During a 24-month period, anterior microsurgical discectomy was performed in 45 consecutive patients for soft-disc cervical herniation. In all cases ACF was performed using a CFC containing a core of granulated coralline HA. Fifty-seven CFCs were implanted in 33 single-level and 12 two-level procedures. The mean operative time was 83 minutes for one-level and 97 minutes for two-level procedures. The mean hospital stay was 1.51 days, and there were no permanent complications. At a mean follow up of 22.3 months, the pain had decreased or disappeared in all patients, and the patients' satisfaction rate was very high. Good results were also obtained in patients who smoked cigarettes. Patients underwent radiographic evaluation at Day 1, and 1, 3, 6, and 12 months postoperatively. Implant-related complications were not observed and revision surgeries were not performed. Twelve-month cervical x-ray films demonstrated complete fusion in all cases, without evidence of breakage, collapse, pseudarthrosis, subsidence, angular deformity, or protrusion. Signs of pathological absorption and necrosis were not found in contiguous vertebral bodies, and inflammatory reactions were never seen around cages. These preliminary results suggest that implants composed of CFC containing granulated coralline HA are promising bone substitutes to be used in ACF, with a good rate of incorporation and no significant complications.

Discectomía cervical y artrodesis intersomática mediante técnica de Cloward: Análisis retrospectivo de las complicaciones y los resultados radiológicos en 167 casos

Patients and methodsWe performed a retrospective analysis of complications and radiological results in 167 patients surgically treated, for discal or spondylotic disease of the cervical spine, with Cloward procedure. Using uni and multivariate analysis, we tried to identify risk factors that might be correlated with surgical complications or radiological results. ResultsSurgical treatment was indicated for cervical radiculopathy in 68% of the patients and for myelopathy or radiculomielopathy in the remaining 32%. The pathologic disease responsible of the symptomatology was soft disk herniation in 59% of the cases and spondylotic changes in 41%. The patients that underwent surgery because of myelopathy were one decade older, had a longer symptomatic period and presented multisegmentary spondylotic disease with higher frequency than patients afected of radiculopathy. The most common segments operated were CS–C6 (44.3%) and C6–C7 (30.5%). Surgical mortality was 0.6% and morbidity 29.3%. Most of the complications were transient, although 4.8% of the patients developed permanent neurological deterioration. ConclusionsComplications were most commonly seen in the group of the patients undergoing surgery because of long-lasting myelopathy with multisegmentary spondylotic disease, in those with vascular risk factors and in those operated of more than one segment. Surgeon anatomic knowledge and experience are critical for diminishing such complications. Non-union rate was 9.6%, and another 9.6% of the patients developed post-surgical kyphosis. Both factors correlated with the need of re-operation.

Pediculotomy as an adjunct to posterior cervical hemilaminectomy, foraminotomy, and discectomy

Currently the posterior approach undertaken to perform cervical hemilaminectomy and foraminotomy provides sufficient exposure to treat the majority of lateral soft-disc herniations or osteophytes causing radiculopathy. Limitations imposed by the surgical field, however, often necessitate excessive retraction of the nerve root and epidural venous plexus, which may potentially exacerbate a preexisting radiculopathy or increase intraoperative blood loss. Partial resection of the inferior pedicle augments exposure and enlarges the neural foramen, thus facilitating decompression while minimizing manipulation of the nerve root and epidural venous plexus. With the patient in the prone position, partial hemilaminectomy and foraminotomy are performed using a highspeed 3-mm diamond burr with continuous irrigation. The thecal sac and nerve root are exposed, and the overlying fibroareolar layer is coagulated and incised. With the nerve root protected and under direct vision, the superomedial portion of the inferior pedicle is removed. Nerve root decompression is then performed through this augmented exposure. Partial excision of the pedicle allows for more expeditious removal of the pathological elements causing cervical radiculopathy and requires minimal manipulation of the nerve root and epidural venous plexus. This procedure results in a potential decrease in transient postoperative radiculopathy and minimization of intraoperative blood loss. In addition, the resulting foraminal enlargement enhances the decompression provided by traditional foraminotomy, even if discectomy is not performed.

Relationships between outcomes of conservative treatment and magnetic resonance imaging findings in patients with mild cervical myelopathy caused by soft disc herniations.

A retrospective follow-up study of conservatively treated patients with mild cervical myelopathy caused by cervical soft disc herniation. To investigate the outcome of conservative treatment for patients with mild myelopathy caused by cervical soft disc herniation and to evaluate usefulness of magnetic resonance findings in the prediction of the outcomes. Recent studies on conservative treatment for cervical soft disc herniation have focused mainly on radiculopathy, and not on myelopathy. Twenty-seven patients with mild cervical myelopathy secondary to cervical soft disc herniation were treated conservatively for more than 6 months by cervical bracing and restriction of daily activities. Of the 27 patients, 17 patients (Group A) underwent conservative treatment only and it was associated with improvement in their neurologic deficits, while the other 10 patients (Group B) ultimately underwent decompression surgery because of neurologic deterioration. Comparisons between the two groups were made in regard to JOA scores, patient satisfaction, and magnetic resonance findings, including location of the disc herniation (focal or diffuse in the sagittal plane, median or paramedian in the axial plane). The JOA scores were 13.6 +/- 1.6 in Group A and 14.1 +/- 1.6 in Group B before treatment, 14.9 +/- 1.0 and 12.9 +/- 2.1, respectively, at 3 months, and 16.2 +/- 0.8 and 16.0 +/- 1.2, respectively, at the final follow-up. The JOA scores at 3 months were significantly lower in Group B than in Group A. Satisfaction with the results of treatment at the final follow-up was reported by 77% of the patients in Group A and 90% in Group B. Focal-type herniation was present in 47% of the patients in Group A and 70% in Group B, while median-type herniation was diagnosed in 77% in Group A and 30% in Group B. Follow-up magnetic resonance imaging of the patients in Group A showed spontaneous regression of a herniated mass in 10 patients (59%). Diffuse-type herniations were more likely to regress spontaneously than focal-type herniations (78% vs. 37%). Conservative treatment is an effective treatment option for mild cervical myelopathy caused by cervical soft disc herniation. A good outcome can be expected in patients with a median-type and/or diffuse-type herniation on magnetic resonance imaging.

Anterior cervical interbody fusion with hydroxyapatite graft and plate system

In cases of spondylosis or spine trauma, cervical interbody grafts are sometimes required after anterior discectomy. To avoid morbidity related to the harvesting of iliac crest bone, numerous materials have been developed such as allografts, methylmethacrylate, biocompatible osteoconductive polymer, and coralline grafts or cages. Some of these materials, however, are inefficient for fusion or are associated with specific complications. Conversely, hydroxyapatite (HA) grafts have numerous advantages. For example, their mechanical properties provide adequate load resistance and their porosity allows infiltration by newly formed bone, leading to complete fusion. The authors studied the results of using HA grafts combined with plating in patients who underwent anterior cervical discectomy. Fifty-four patients underwent 68 cervical interbody fusion procedures in which an HA graft and plating were used. Indications for surgery were radiculopathy (caused by soft-disc herniation or spondylosis) in 46 cases, spondylotic myelopathy in two cases, and spinal trauma in six cases. Postoperatively the patients were followed for a mean of 24.6 months. Patients underwent radiography to evaluate fusion, intervertebral disc height, and the degree of lordosis. Clinically, excellent or good results (based on the Odon classification) were demonstrated in 91% of patients who presented with radiculopathy. Complete interbody fusion was achieved in 99% of all cases. Preoperative kyphotic deformities were corrected in all cases after surgery. Intervertebral disc height was maintained throughout follow up. Surgery-related morbidity was low; only one patient suffered from a permanent dysphagia. Graft deterioration was observed in 13 cases and two graft fractures occurred but without adversely affecting fusion. There were no cases of graft extrusion. Hydroxyapatite grafts are very efficient in achieving cervical fusion, maintaining intervertebral disc height, and restoring lordosis. When combined with the placement of a cervical plate, immediate stability is achieved and graft displacement is prevented.

Posterior approach for soft cervical disc herniation: a neglected technique?

Background The ideal approach to the treatment of soft cervical disc herniation remains controversial. Recent reports emphasize several variations of anterior cervical approaches, including the introduction of instrumentation techniques. New issues have been raised and modern neurosurgeons seem to be less familiar with the posterior approach. The objective of this study was to analyze the results obtained by surgical treatment via a posterior approach of soft cervical disc herniation. METHOD Fifty-one patients who underwent laminectomy/flavectomy and disc removal for the treatment of soft cervical disc herniation in the period of 1990 to 1999 were analyzed retrospectively. Relief of pain and motor and sensory improvement were the criteria used to measure the success of the procedure. RESULTS Most of the patients presented with acute radiculopathy. Radicular involvement was as follows: 25 cases—C7 root, 19 cases—C6 root, 4 cases—C5 root, and 3 cases—C8 root. Total relief of pain was obtained in 49 of 51 patients (96%). Motor improvement was obtained in 35 of 46 patients (76%) and sensory improvement in 22 of 35 patients (62.8%) in the short term. The mean time of hospitalization was 3 days. There was no mortality and no morbidity. CONCLUSION The advantage of this method, in selected cases, over the classical anterior approach, is that there is no need for grafting, thus avoiding the additional pain and possible complications at the donor and receptor sites, while obtaining similar results.

Surgical Treatment of Cervical Myelopathy Due to Soft Disc Herniation

Surgical Treatment of Cervical Myelopathy Due to Soft Disc Herniation