Ventral Discectomy Research Articles

P198. Acute inflammatory demyelinating polyradiculoneuropathy after cervical spine surgery

A 62-year old underwent a ventral discectomy of C7/Th1, cage interposition and decompression of the spinal canal due to a pure sensory cervical syndrome caused by osteochondrosis and foraminal stenosis of C7/Th1 on both sides. During surgery a dural leakage was sealed with a TachoSilO-Patch. The following day the patient reported a lack of strength in his right leg and facial asymmetry. On the 2nd postoperative day the physical examination showed an incomplete palsy of the right facial nerve, of the iliopsoas, the tibialis anterior and the extensor digitorum comm. Moreover, the patient felt pain in his left shoulder. Apart from those findings, no other paralyses or sensory losses were detected, muscle reflexes were symmetrical and normal. The cerebral and spinal MRI showed a vague pathology of the spinal cord at C8 but to the dorsal left. Facial MEP showed a canalicular conduction block of the right facial nerve. MEP of the upper and lower limb were hardly evocable from the cortex and showed prolonged latencies when evoking cervically and lumbally. Initially, we assumed these findings to be due to a central palsy of the right leg and a peripheral facial nerve palsy. Steroid treatment with Prednisolon 50 mg/d was started. The following day the patient worsened: palsy of the right hypoglossal nerve, paralyses of both arms regarding muscles innervated by C5/C6/C8 radices, areflexia. The MEPs were still pathological. Electrophysiological findings: Motor neurography of Nn. tibiales: distal latencies 6.7–7.2 ms, CNV 33–36 m/s, lowering CMAP distally and chronodispersion proximally; moreover, symmetrical demyelinating neuropathy of the upper limb was detected. Assuming this to be due to an atypical Guillain–Barre-Syndrome (GBS), we started treatment with ivIg (0.4 g PrivigenO/kg for 5 days). CSF (on 4th postoperative day): 243 cells/μl, monocytes (50%), protein (total) 468 mg/dl. One day after starting ivIg treatment the patient complained about loss of hearing and a tinnitus of both ears. Sensorineural hearing loss was found. As recommended by the ENT-colleagues, a steroid treatment (Prednisolon 250 mg i.v./d for 3 days) was added. The patient’s condition improved and he was sent on the 12th postoperative day to rehabilitation. Postoperative neuropathies are usually caused by pressure or by trauma during the procedure itself. In this case we presume that the asymmetrical, demyelinating polyradiculoneuropathy is to be interpreted as an atypical GBS. The aetiology of these unusual clinical findings was finally detected by simple motor nerve conduction studies. There are only few case reports on immune neuropathies following surgery that include a wide range of time of onset and symptoms. The extraordinary aspects of the above case are the very early appearance of symptoms, within 48 h after surgery, and the asymmetric dissemination including cranial nerves. In conclusion, even though a postoperative GBS is a very rare condition, the diagnosis of an immune neuropathy at the appearance of unusual patterns of palsies should be considered.

Polymethylmethacrylate-assisted ventral discectomy: Rate of pseudarthrosis and clinical outcome with a minimum follow-up of 5 years

BackgroundPolymethylmethacrylate (PMMA) assisted ventral discectomy has been criticized for high rates of graft migration and pseudarthrosis when compared with various other fusion procedures for the treatment of cervical degenerative disc disease (DDD), therefore rendering it not the preferred choice of treatment today. Recently however spine surgery has been developing towards preservation rather than restriction of motion, indicating that fusion might not be necessary for clinical success. This study presents a long term comparison of clinical and radiological data from patients with pseudarthrosis and solid arthrodesis after PMMA assisted ventral discectomy was performed.MethodsFrom 1986 to 2004 416 patients underwent ventral discectomy and PMMA interposition for DDD. The clinical and radiological outcome was assessed for 50 of 127 eligible patients after a mean of 8.1 years. Based on postoperative radiographs the patients were dichotomized in those with a pseudarthrosis (group A) and those with solid arthrodesis (group B).ResultsPseudarthrosis with movement of more than 2 of the operated segment was noted in 17 cases (group A). In 33 cases no movement of the vertebral segment could be detected (group B). The analysis of the clinical data assessed through the neck disability index (NDI), the visual analogue scale (VAS) of neck and arm pain and Odom's criteria did not show any significant differences between the groups.Patients from group B showed a trend to higher adjacent segment degeneration (ASD) than group A (p = 0.06). This correlated with the age of the patients.ConclusionsPMMA assisted discectomy shows a high rate of pseudarthrosis. But the clinical long-term success does not seem to be negatively affected by this.

A single neurosurgical center’s experience of the resolution of cervical radiculopathy after dorsal foraminotomy and ventral discectomy

Monosegmental cervical disc herniation can be removed either by dorsal foraminotomy and sequesterectomy (Frykholm’s method) or by a ventral approach with extensive removal of the affected disc with subsequent segmental fusion (modified Cloward’s method). The choice of method largely depends on the surgeon’s individual preference and experience. We evaluated the neurological outcomes of both surgical methods in a retrospective series of 100 consecutive patients (50 male, 50 female; mean age = 47.7 years) who underwent surgery within a 3-year period. Fifty-one patients (30 male, 21 female; mean age = 50.1 years) underwent a dorsal foraminotomy and 49 patients (20 male, 29 female; mean age = 45.3 years) underwent surgery by the ventral approach with consecutive segmental fusion. We identified demographic data and analysed the postoperative neurological performance (motor and sensory activity) and the resolution of the radiating and local pain during the in-hospital stay. Patients in the Cloward Group recovered significantly better from cervicobrachialgia ( p = 0.02), neck pain ( p = 0.01) and sensory deficits ( p = 0.003). Furthermore, the Cloward Group showed a trend towards better outcomes for paresis. Complete removal of the affected cervical disc via a ventral approach and segmental fusion results in a superior neurological performance in the short-term compared to a dorsal foraminotomy and nerve root decompression by sequestrectomy. However, assessment of the long-term outcome is required and further studies are required to confirm our results.

Intervertebral disc replacement for cervical degenerative disease – clinical results and functional outcome at two years in patients implanted with the Bryan® cervical disc prosthesis

This is a prospective study of patients with degenerative cervical disease who underwent ventral discectomy and disc replacement with the Bryan((R)) cervical disc prosthesis. The objective was to investigate clinical outcome at 2 years of patients implanted with the Bryan disc and to evaluate function of the implant itself. Fifty-four consecutive patients with cervical disc herniation and/or spondylosis with preserved mobility in the affected spinal segments were enrolled. Patients presented clinically with cervical radiculopathy and/or myelopathy with or without neck pain. A standard anterior cervical discectomy was carried out and a Bryan disc was implanted in the affected levels. A total of 59 prosthetic discs were implanted, in 49 patients at a single level and in 5 at two adjacent levels. The neurological status was evaluated pre-operatively and at one and two years thereafter. Plain X-rays, CT, and MRI were used for pre-operative diagnostics. Post-operative follow-up was done by X-rays. All patients had an excellent or good neurological outcome according to the Odom criteria. Loss of function (motion range <3 degrees) was found in 7 (12%) out of 59 Bryan discs at two years after surgery. Heterotopic ossification (HO) of the McAffee grades 1-4 was seen in a total of 17 (29%) segments. There were no implant dislocations or migrations. Implantation of the Bryan disc resulted in excellent or good neurological outcome in all patients. The surgical technique was safe and without complications. Twelve percent of the implanted Bryan discs lost mobility at two years, mainly due to HO. A trend was seen towards development of HO in the operated segments. Further investigations with longer follow-up periods and with a control group (e.g. fusion with intervertebral cage) will be necessary for a definitive assessment of the long-term functionality and benefits of artificial cervical discs.

In vitro flexibility of the cervical spine after ventral uncoforaminotomy

Degenerative spine disorders are, in the majority of cases, treated with ventral discectomy followed by fusion (also known as anterior cervical discectomy and fusion). Currently, nonfusion strategies are gaining broader acceptance. The introduction of cervical disc prosthetic devices was a natural consequence of this development. Jho proposed anterior uncoforaminotomy as an alternative motion-preserving procedure at the cervical spine. The clinical results in the literature are controversial, with one focus of disagreement being the impact of the procedure on stability. The aim of this study was to address the changes in spinal stability after uncoforaminotomy. Six spinal motion segments derived from three fresh-frozen human cervical spine specimens (C2-7) were tested. The donors were two men whose ages at death were 59 and 80 years and one woman whose age was 80 years. Bone mineral density in C-3 ranged from 155 to 175 mg/cm3. The lower part of the segment was rigidly fixed in the spine tester, whereas the upper part was fixed in gimbals with integrated stepper motors. Pure moment loads of +/- 2.5 Nm were applied in flexion/extension, axial rotation, and lateral bending. For each specimen a load-deformation curve, the range of motion (ROM), and the neutral zone (NZ) for negative and positive directions of motion were calculated. Median, maximum, and minimum values were calculated for the six segments and normalized to the intact segment. Tests were done on the intact segment, after unilateral uncoforaminotomy, and after bilateral uncoforaminotomy. In lateral bending a strong increase in ROM and NZ was detectable after unilateral uncoforaminotomy on the right side. Overall, the ROM during flexion/extension was less influenced after uncoforaminotomy. The ROM and NZ during axial rotation to the left increased strongly after right unilateral uncoforaminotomy. Changes after bilateral uncoforaminotomy were marked during axial rotation to both sides. Following unilateral uncoforaminotomy, a significant alteration in mobility of the segment is found, especially during lateral bending and axial rotation. The resulting increase in mobility is less pronounced during flexion and least evident on extension. Further investigations of the natural course of disc degeneration and the impact on mobility after uncoforaminotomy are needed.

Anterior cervical spinal fusion with the Intromed ZWE System: preliminary experience

The implantation of a spacer is common practice after ventral discectomy in the cervical spine. Besides bone or bone cement (Palacos, Sulfix, and Allofix), the surgeon has the choice of a variety of factory-made implants (cages). We report on our experience with the Intromed ZWE [Zwischenwirbel-Ersatzsystem (Intervertebral Replacement System)] implant. The ZWE implant (Intromed Medizintechnik GmbH, 15754, Senzig, Germany), made from titanium 6AL 4V, consists of a flat quadrangular body with a large supporting surface on the bottom and top and a central hole. We report the first 100 cases treated with their 1- or 2-year follow-up completed (mean follow-up, 1.7 years). The mean age was 47+/-9 years (range: 27-73 years). The implantation was performed without filling the central hole. In addition to the clinical investigation of neurological alterations and the range of movement, X-rays were taken, and the clinical result was determined by an independent investigator according to the Odom Scale. After the minimum follow-up of 1 year, 32 patients scored excellent on the Odom scale, 38 patients good, 25 patients satisfactory, and 5 patients bad. In 74 cases, fusion occurred radiologically as bony bridging around the implant. In 21 cases, the cage showed no change and no radiolucency. In five cases, radiolucency around the implant occurred without instability at flexion-extension X-ray views. In CT scans done in two patients with complaints, we confirmed bony bridging inside the centre hole implanted empty. The Intromed-ZWE-System performs well in routine clinical use. Compared to bone or bone cement, the operating time is reduced. The Intromed System offers an easy fusion method for a competitive price.

Ventral discectomy with pmma interbody fusion for cervical disc disease: long-term results in 249 patients.

Retrospective study of patients who underwent ventral discectomy and polymethyl-methacrylate (PMMA) interbody fusion for cervical radiculopathy. To evaluate the long-term outcome after ventral discectomy and PMMA interbody fusion and to compare it with previous data from other surgical techniques for the treatment of cervical radiculopathy. Because PMMA interbody fusion after ventral discectomy does not result in solid bony fusion in all cases, a good long-term outcome using this surgical technique has been questioned. Long-term follow-up evaluation after surgery was performed in 249 patients (96 women and 153 men) with radicular signs only. The mean age was 46.0 +/- 8.7 years (range, 24-74 years), and the observation time ranged from 10-15 years (mean, 12.2 +/- 1.2 years). Clinical grading after surgery according to Odom's criteria was based on a questionnaire. The outcome was related to morphologic findings, lumbar symptoms, physical stress, duration of symptoms, age, sex, and cervical level involved. Complications related to surgery occurred in 13 (5.2%) patients, but only three (1.2%) had persistent problems. Of the 249 patients, 101 (40.6%) were without any symptoms (Odom I), 92 (36.9%) had a good outcome (Odom II), and 47 (18.9%) a fair outcome (Odom III). Only nine patients (3.6%) reported an unchanged or worse status than before surgery (Odom IV). Additional lumbar symptoms, high occupational physical stress, and discrepancy of preoperative findings were significantly correlated with a worse outcome. Short duration of symptoms and soft disc disease were favorable prognostic factors. PMMA interbody fusion after ventral discectomy in cervical disc surgery is a safe and reliable method with few complications and an outcome comparable with other ventral procedures.

The cervicogenic headache from the spiral surgery point of view--a pilot study

In a retrospective analysis of 299 consecutive patients with degenerative cervical spine disease the incidence of cervicogenic headache and the results of conservative and operative therapy have been investigated. Cervicogenic headache was noted in 117 of 299 patients (40%). 73 of those patients were treated conservatively. The cervicogenic headache resolved in 10% or improved in 27% and remained unchanged in 63% of the patients. 44 of these patients were operated by ventral discectomy, which was indicated in case of neurological deficit and painful shoulder-arm syndrome refractory to conservative treatment. In none of these patients the operation was indicated by the cervicogenic headache. In the postoperative follow-up with a mean of 6 months the headache resolved in 20%, improved in 60% and remained unchanged in 20% of the patients. These results suggest the existence of a cervicogenic headache, i.e. a headache due to disorders of the cervical spine, and the chance of successful operative treatment.

Herniated Cervical Intervertebral Discs with Radiculopathy

To study the functional outcomes of patients with cervical herniated intervertebral discs with radiculopathy but without signs of cervical myelopathy using a retrospective cohort study design. The patients were retrospectively identified by chart reviews. Inclusion criteria were (a) cervical radiculopathy with defined neurological disturbances (sensory disorder, reflex abnormalities, and motor weakness); (b) a spinal computed tomograph scan or magnetic resonance image demonstrating neuroradiologic abnormalities (soft or hard disc); and (c) completion of conservative physical and pharmacological treatment. Of 119 consecutive patients who were treated at the Departments of Neurology and Neurosurgery, University of Erlangen-Nuremberg, between January 1, 1985, and December 31, 1995, 60 patients met the inclusion criteria and were prospectively assessed, with an average follow-up time of 5.5 years. The patients were interviewed with regard to their daily activities, ability to work, and the surgical treatment they had undergone. A complete neurological examination also was performed. In 88.3%, the onset of disease was acute and in 11.7% subacute or chronic. The most common signs and symptoms were brachialgia (98.3%), neck pain (93.3%), sensory disorders (88.3%), reflex abnormalities (61.7%), and motor weakness (51.7%). The neuroimaging procedures demonstrated a disc prolapse (soft disc) in approximately 90% and spondylotic osteophytes (hard disc) in approximately 10%. During an average follow-up time of 5.5 years (range, 4.6 months-10.6 years) 39 (65%) patients had been treated using only conservative methods (COG = conservatively treated group), and 21 (35%) patients had undergone surgery (ventral discectomy) (SUG = surgically treated group). Brachialgia was completely or essentially improved in 100% of the COG and 95.1% of the SUG. Sensory disorders remitted completely or markedly in 97% of the COG and 75% of the SUG. The reflex abnormalities normalized or improved in 59.2% of the COG and in 53.3% of the SUG. Motor weakness improved in 94.1% of the COG and in 50% of the SUG. Neck pain was difficult to treat. It improved in only 36.1% of the COG and in 20% of the SUG. Occupational capacity was lost in 10% of the COG and in 38.9% of the SUG. In a self-rating scale, 89.7% of patients in the COG did not feel disabled in their everyday activities, compared with 66.7% of the patients in the SUG. Patients with a herniated cervical intervertebral disc with radiculopathy can be treated conservatively with good results, although a residual intermittent neck pain syndrome often persists. The patients in the SUG, who initially showed more severe and long-lasting neurological disturbances, were improved at the time of examination, although with more marked residual disorders. Surgery is indicated only when appropriate conservative treatment for a reasonable time has failed.

Herniated Cervical Intervertebral Discs with Radiculopathy

Summary: To study the functional outcomes of patients with cervical herniated intervertebral discs with radiculopathy but without signs of cervical myelopathy using a retrospective cohort study design. The patients were retrospectively identified by chart reviews. Inclusion criteria were (a) cervical radiculopathy with defined neurological disturbances (sensory disorder, reflex abnormalities, and motor weakness); (b) a spinal computed tomograph scan or magnetic resonance image demonstrating neuroradiologic abnormalities (soft or hard disc); and (c) completion of conservative physical and pharmacological treatment. Of 119 consecutive patients who were treated at the Departments of Neurology and Neurosurgery, University of Erlangen-Nuremberg, between January 1, 1985, and December 31, 1995, 60 patients met the inclusion criteria and were prospectively assessed, with an average follow-up time of 5.5 years. The patients were interviewed with regard to their daily activities, ability to work, and the surgical treatment they had undergone. A complete neurological examination also was performed. In 88.3%, the onset of disease was acute and in 11.7% subacute or chronic. The most common signs and symptoms were brachialgia (98.3%), neck pain (93.3%). sensory disorders (88.3%), reflex abnormalities (61.7%), and motor weakness (51.7%). The neuroimaging procedures demonstrated a disc prolapse (soft disc) in approximately 90% and spondylotic osteophytes (hard disc) in approximately 10%. During an average follow-up time of 5.5 years (range, 4.6 months-10.6 years) 39 (65%) patients had been treated using only conservative methods (COG = conservatively treated group), and 21 (35%) patients had undergone surgery (ventral discectomy) (SUG = surgically treated group). Brachialgia was completely or essentially improved in 100% of the COG and 95.1% of the SUG. Sensory disorders remitted completely or markedly in 97% of the COG and 75% of the SUG. The reflex abnormalities normalized or improved in 59.2% of the COG and in 53.3% of the SUG. Motor weakness improved in 94.1% of the COG and in 50% of the SUG. Neck pain was difficult to treat. It improved in only 36.1% of the COG and in 20% of the SUG. Occupational capacity was lost in 10% of the COG and in 38.9% of the SUG. In a self-rating scale, 89.7% of patients in the COG did not feel disabled in their everyday activities, compared with 66.7% of the patients in the SUG. Patients with a herniated cervical intervertebral disc with radiculopathy can be treated conservatively with good results, although a residual intermittent neck pain syndrome often persists. The patients in the SUG, who initially showed more severe and long-lasting neurological disturbances, were improved at the time of examination, although with more marked residual disorders. Surgery is indicated only when appropriate conservative treatment for a reasonable time has failed.

Anterior cervical discectomy without fusion in cervical disc herniation with radicular complaints.

Only cervical disc herniation that provokes root compression unresponsive to conservative treatment should be selected for operation. The operative technique must allow adequate removal of the disc and relieve any root pressure without distressing the patient. Operative decompression of the root can be attained via laminectomy and arthrotomy or by way of an anterior approach. With this second procedure, the ventral discectomy can be done in conjunction with an interbody fusion. We report our experience with 216 patients who unterwent anterior cervical microsurgical discectomy without fusion between 1980 and 1944. All these patients were suffering from compressive cervical radiculopathy caused by disc displacement without significant degenerative deformation of the motion segment and without manifest segmental instability. The follow-up ranged between 6 and 185 months (average 71 months) in the 175 patients in whom it was possible. Only in 7 patients (4 %) is the result unsatisfactory; 79 patients (45 %) are completely free of symptoms 99; (56.6 %) are very satisfied and 45 (25.7 %) satisfied with the result of the procedure.

Traumatische zervikale Bandscheibenvorfälle bei Ringern

Five wrestlers presented to our hospital with traumatic slipped disc of the cervical spine. Average age of the athletes was 25 years. They were just on top of their sporting career. In four cases the athletes were operated on via foraminotomy. In one case ventral discectomy and fusion of the operated segment was performed. Postoperative outcome was good in all patients. Clinical history, operative procedure, neuropathological and neuroradiological findings and pathogenesis were discussed.

Micro-technological anterior discectomy without fusion in cervical disk displacement with radicular symptoms

Only cervical disc herniation that provokes root compression unresponsive to conservative treatment should be selected for operation. The operative technique must allow adequate removal of the disc and relieve any root pressure without distressing the patient. Operative decompression of the root can be attained via laminectomy and arthrotomy or by way of an anterior approach. With this second procedure, the ventral discectomy can be done in conjunction with an interbody fusion. We report our experience with 216 patients who underwent anterior cervical microsurgical discectomy without fusion between 1980 and 1944. All these patients were suffering from compressive cervical radiculopathy caused by disc displacement without significant degenerative deformation of the motion segment and without manifest segmental instability. The follow-up ranged between 6 and 185 months (average 71 months) in the 175 patients in whom it was possible. Only in 7 patients (4%) is the result unsatisfactory; 79 patients (45%) are completely free of symptoms 99; (56.6%) are very satisfied and 45 (25.7%) satisfied with the result of the procedure.

The treatment of spondylotic cervical myelopathy by ventral discectomy. Long term results on 121 patients

The pathophysiology of spondylotic cervical myelopathy is still a matter of discussion. This paper presents a series of 126 patients operated on using a ventral approach. In 47% of the patients only a spondylotic narrowing of the spinal canal was present and in 35% an additional disc herniation was found. In 13% of the cases however a soft disc without spondylotic spures was found and in 5% a dislocation of vertebral bodies. We found a marked male preponderance of 77%, mean age was 51.6 years, ranging from 25-50 years. Most patients were operated on at the levels of C4/5 and C5/6. Observation time covered a period of 3-10 years. The outcome was rated relatively to the preoperative degree of disablement using a questionnaire for the patients and their family doctors. We found a marked difference in the answers, especially in rating deterioration, which was stated by patients in 34%, by physicians only in 12%. Another finding was the time-related outcome. We found best results with 75% improvement and 5% deterioration between 3-6 months postoperatively, with increasing time the results decreased to 33% improvement, 33% identical statys and in 33% a deterioration related to the preoperative status must be noted.

Ventral operations in cervical disk hernia. Neurosurgical experiences in 400 surgical patients

The indications for simple ventral discectomy as well as for the classical Cloward's operation, together with the surgical techniques employed and the results obtained, are compared in a group of 400 patients treated operatively for cervical disc hernia. The ventral approach is sparing for both the spinal cord and the nerve roots and gives satisfactory results from the point of view of stability. In more than one-half of the patients, luxated fragments of the nucleus pulposus were found epidurally, so that fairly frequent exploration of the epidural space was necessary. Simple microsurgical discectomy (performed in a total of 158 cases) is now more often used than the classical Cloward's operation (242 cases). In 1987 we carried out simple discectomy in 75% of cases. Cloward's operation with extirpation and bone grafting is, however, advantageous in patients with severe spondylosis as well as in cases of traumatic or degenerative instability.