Biomedical subjects
Publications and source records attributed to A Deburge.
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Chemonucleolysis is an effective treatment of sciatica due to herniated lumbar disc after conservative treatments have failed. Provided the proper technique is applied and the patients are well selected (complete herniation or herniation within a narrow spinal canal being excluded), surgery can be avoided in the majority of cases. Chemonucleolysis does not in any way complicate subsequent surgery if required and post-nucleolysis surgery gives the same results as first intention surgery. The method, therefore, should not be regarded as an alternative to surgery but as the last stage of conservative treatment. Allergic reactions are the only true side-effects and require special precautions.
Eight cases of progressive deterioration in spondylolisthesis in adults have been observed. In 7 cases, the displacement was between the 4th and 5th lumbar vertebra and only once between the 5th lumbar vertebra and the sacrum. The mean age of the patients was 37 years. Several factors leading to this deterioration are considered - disc degeneration, antero-posterior imbalance of the spine and inadequate fixation of the 4th lumbar vertebra to the ilium.
A case of a patient with spondylolisthesis between C4 and C5 is reported. There were neurological signs of spinal cord involvement and the lesions were essentially those of a posterior degenerative arthrosis with disc degeneration at other levels. This severe instability was cured by an anterior interbody fusion.
The authors have performed 180 posterolateral fusions of the lumbar spine for various conditions. A new method of evaluation of the results is proposed using a careful analysis of the pre-operative and post-operative condition of the patient. The overall ratio of fusion was satisfactory and the etiology did not influence the result. The rate of fusion was not improved when screws were inserted into the articular processes. The level and extent of the arthrodesis did not affect the rate of fusion. Both sides should be fused whenever possible. The functional results were better in cases of degenerative spondylolisthesis than in cases of narrowing of the spinal canal without slipping. They were also better when fusion was obtained. Two cases of pure lumbar pain had good results provided that sedentary work could be done by the patient. A preoperative psychiatric examination was useful. The presence of overweight and a long preoperative period of pain were not favourable. In 49 cases, the arthrodesis was made after one or more previous surgical procedures. The results were more satisfactory when the arthrodesis was made without any associated operation on the spinal canal.
In 39 cases of narrowed lumbar spinal canal associated with a scoliosis, the authors have studied the role played by deviation of the spine and the origin of the narrowing. It seemed that central stenosis with intermittent claudication was more frequent when a scoliosis was present. In more than half of the cases, the level of the compression was at the junction of the curves. After failure of conservative treatment, the surgical procedure performed was the same as in straight spines. The results were satisfactory in 90 p. 100 as regards root involvement and intermittent claudication. However 7 patients had increased low back pain after surgery, 3 of them being disabled. In young patients with curves of more than 30 degrees with noticeable rotation, straightening with arthrodesis appeared to be worthwhile rather than simple posterior laminectomy. In other cases a posterior liberation of the cord associated with limited posterolateral fusion is indicated.
The authors have reviewed 206 cases of sciatica treated by Chemonucleolysis. Thirty-two had to be operated on later. This treatment was more frequently needed at L4/L5 level than at the lumbosacral level. Most of the failures of Chemonucleolysis were related to lateral spinal stenosis (13 cases). In 4 cases it was due to disc extrusion either at the time of the Chemonucleolysis (2 cases) or appearing later (2 cases). Nine failures were due to subligamentous disc herniation. Two cases were operated on for the onset of sciatica at another level, repeated treatment with Chemonucleolysis being contra-indicated. In 3 cases, the surgical exploration did not discover the cause of the sciatica. The surgical cases were not impeded by the preceding Chemonucleolysis and no adhesions were found. The results were similar to those observed after primary surgery - about two-thirds of satisfactory results. They were better when a herniation at another level was found or in cases of disc extrusion than in cases of spinal cord stenosis or sub-ligamentous herniae. They were poor when the cause of the sciatica was not found.
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The authors report a retrospective study of 163 cases of degenerative or constitutional stenosis of the lumbar canal. In this series, the most frequent cause was osteoarthrosis and constitutional stenoses were relatively rare. The authors note that this is often a difficult aetiological distinction to make, especially in elderly patients and the anatomical deformities caused by osteoarthrosis lead to stenosis of the canal similar to that seen in constitutional malformations. Sensori-motor claudication is inconstant and was only found in one third of the cases in this series. More often, the lumbar stenosis presents as nerve root pain. It can be distinguished from root disease of disc origin by the frequent absence of Lasegue's sign and of spinal stiffness. When a herniated disc is associated with a stenosis, the clinical picture is altered and can then resemble that of disc sciatica. The diagnosis of stenosis depends on the radiological examination. This series confirms the diagnostic value of the abnormalities seen on standard X-rays, but the severity and the extent of the stenosis can only be assessed by performing tomography, water-soluble contrast myelography and C.T. scan. The authors discuss the limitations and degree of reliability of each of these investigations. The extent of the surgical decompression depends on the severity of the symptoms and on the results of this radiological survey.
163 patients were operated for degenerative lumbar stenosis (only 10 did not have osteoarthrosis), following the failure of medical treatment. The surgical decompression varied according to the anatomical type of the stenosis: central, lateral or mixed. In 13 p. cent of cases, it was followed by an arthrodesis. There were no deaths. The most frequent complications were: haematoma (6 p. cent), infection (5 p. cent), aggravation of the neurological disturbance (3 cases), breeches in the dura, practically inevitable in very tight stenosis (13 p. cent) and epidural fibrosis (4 re-operations). When there is no sliding prior to the operation, the risk of aggravation or appearance of sliding in cases of spondylolisthesis is somewhat higher (6 cases out of 64). The different symptoms are unequally improved by the decompression: root pain is the best relieved (69 p. cent cure, 20 p. cent improvement) together with intermittent claudication (75 p. cent cure, 14 p. cent improvement) and, to a lesser degree, back pain (48 p. cent cure, 32 p. cent improvement). There is a possibility of recovery even in the severe forms of motor disturbance.
A proteolytic enzyme was used to dissolve the nucleus pulposus in 140 cases of sciatica from herniated lumbar disc. The results were satisfactory in 75% of 120 patients followed up for more than 6 months. This percentage of success, similar to that obtained with surgical excision of the disc, can only be achieved with a rigourous technique and, more importantly, with strict selection of the patients. Chemonucleolysis is indicated only for patients with unquestionable clinical and radiological evidence of herniated disc, in which case it can be considered as the ultimate medical treatment of sciatica associated with this lesion. No serious complications were observed in our series, but the risk of allergic reaction must be borne in mind.
One hundred and twenty patients suffering some sciatica due to disc herniation have been treated by chemonucleolysis. All the patients had received conservative treatment for at least four months. The minimum followup after nucleolysis was six months. In 114 patients, radiculography was positive and in 6, radiculography was negative but phlebography was positive. Patients with symptoms of spinal stenosis, or with signs of sequestrated disc or who had been previously operated on by laminectomy were excluded from the study. By a lateral extradural approach, 4000 units of chymopapain were injected into the disc under general anaesthesia after discography. All patients except 3 had only disc injected. Results were good in 92 patients. 21 of the 28 failures were operated on. In 18 cases, a mechanical cause was found at operation with 16 good results. Complications were rare and benign. No neurological complication was noted. It is concluded that chemonucleolysis should be the last step in the conservative management of sciatica.
The diagnosis of an extruded prolapsed intervertebral disc is a contra-indication to chymonucleolysis. The authors tried to define the diagnosis by comparing clinical signs, radiculography and operative findings in 98 patients. There is no characteristic clinical sign. On radiculography, there is no pathognomonic sign of an extruded prolapsed intervertebral disc, which is difficult to distinguish from an extra-ligamentous prolapse. However, the image of compression or amputation situated above or below the disc, especially when it is irregular should make one strongly suspect the diagnosis.
Early and late results of Guepar hinge knee prosthesis have been evaluated on a serie of 184 operations performed before January 1st 1974. There were 3 immediate deaths and 26 before 5 years. 19 prosthesis were removed. 126 knees had degenerative osteoarthritis, 52 rheumatoid arthritis. 22 had been operated on before. Patellar displacement, present in 27 p. 100 of the cases was the most frequent cause of complaint: pain or instability, proportional to the severity of displacement made reoperation necessary in 10 p. 100 of the patients. Addition of a patellar prosthesis was the most successful treatment as far as pain is concerned: it is probably advisable as a primary procedure. Deep infections occurred in 8,3 p. 100 of the cases, unfrequently after 2 years. Healing was obtained in all cases either by revision or by removal and arthrodesis: but functional results were poor except when fusion was achieved, in half of the cases of arthrodesis. Loosening occurred in 16 p 100 of the cases mainly as the consequence of insufficient technique. It was frequently tolerated: reoperation was necessary in 6 p. 100 of the total. Late functional results were evaluated in 99 cases with a follow-up of 5 to 8 years. Apart from loosening, the results did not deteriorate. 60 p. 100 are evaluated as excellent or good, 29 p. 100 fair, and 11 p. 100 bad. With due consideration of these results election of this prosthesis should be limited to special cases. To prevent complications, the use of a patellar prosthesis, of reinforced models, and of cementing under pressure is advisable.
Sixty eight patients with degenerative lumbar stenosis have been operated on: 42 presented a degenerative spondylolisthesis (S.D) with predominantly central stenosis; while in 36 with arthrosic sciatica (S.A.), stenosis was rather lateral. In most cases clinical symptoms are different from those of disc herniation. Myelography with "amipaque" appears necessary to allow a really planified operation, with liberation of all the roots involved by bony compression. In these conditions, a high percentage of good results is obtained. Consequently, after failure of conservative treatment, open release of the compression is advisable, even in elderly patients. In some cases postero-lateral fusion should be performed in addition.
The authors report 56 cases of sciatica treated by chemonucleolysis with follow-up ranging from six months to two years. All patients presented with manifest clinical symptomes of intervertebral disc herniation, and the diagnostic was verified by myelography. In all cases myelographic findings corresponded to clinical topography when the topography was precisely defined. This group of patients, therefore, was highly selected, and the authors attempted to eliminate excluded herniations when the myelographic anomaly appeared at a distance from the intervertebral space. Cases of sciatica caused by stenosis, paralytic sciatica, and pure lumbar pain were not treated in this study. At the end of the second month, 70 percent of patients obtained good results; the authors, believe, therefore, that failure of treatment can be ascertained by the eighth week. Thirteen of the fifteen treatment failures in this study were operated. Results of this surgery performed after chemonucleolysis were similar to results obtained from surgery performed as initial treatment. No serious complications were observed. Chemonucleolysis, therefore, appears to be an effective means of treatment for sciatica caused by intervertebral disc herniation. Based on their own experience and reports in the literature, the authors believe that chemonucleolysis is the ultimate stage of conservative treatment when classical measures have failed. In addition, the authors' experience and careful review of the literature has shown that serious iatrogenic accidents are exceptionally rare and can be avoided by the use of rigorous technique.