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This is a retrospective review of 175 consecutive open lumbar diskectomies with a minimum 1-year follow-up (average follow-up, 54 months). Results of the diskectomies were: 91.0% good-to-excellent result, 3.4% fair, and 1.1% poor. Complications were few, and the overall recurrence rate was 4.6%. By multiple linear regression analysis, no one factor could predict the relief of leg pain.
Temporomandibular joint (TMJ) disk removal, or diskectomy, is a detrimental yet necessary surgery for patients with extremely displaced disks. Tissue engineering is an enticing methodology for improvement of the postoperative outcome of diskectomy. Unfortunately, the field of tissue engineering of the TMJ disk is only in the early stages of development. The initial objective of this investigation was to study the cellular response of TMJ disk cells in alginate culture. However, a marked decrease in cell population and the lack of detection of extracellular matrix (ECM) products did not support the use of alginate culture. The second objective was then to attempt TMJ disk cell culture in polyglycolic acid (PGA) nonwoven meshes. However, as suitable seeding methods for TMJ disk cells on PGA had not been determined, three techniques were selected for study: spinner flask, orbital shaker, and a novel pelleting technique. PGA constructs maintained cellularity throughout the culture period, and scaffolds seeded with the spinner flask produced about 35 microg of collagen per construct. Thus, as evidenced by the production of a major extracellular component, PGA nonwoven meshes seeded with TMJ disk cells, using a spinner flask, may be a first positive culturing step in tissue engineering the TMJ disk.
A prospective study of 15 patients who were scheduled to undergo various types of lumbar spine surgery was undertaken to assess the postoperative changes observable with magnetic resonance (MR) imaging. Patients underwent imaging preoperatively, immediately postoperatively (1-10 days), and late postoperatively (2-6 months). A retrospective review of MR images obtained in 62 patients who had undergone lumbar surgery but still had low back pain was also conducted. Epidural soft-tissue change and mass effect mimicking preoperative findings were present in nine of 13 patients who underwent laminectomy and diskectomy. Mass effect improved in appearance by the late postoperative period in eight of nine patients. T2-weighted sagittal images were best in demonstrating the site of anulus disruption immediately after diskectomy, which was seen in 11 of 13 patients, and the rent resolved on the late images in eight of ten cases. Sites of foraminotomy were seen as a loss of the normal foraminal fat signal. Extensive soft-tissue changes present in the immediate postoperative period severely limit the usefulness of MR imaging in that period for evaluating persistent symptoms. The exception may be hemorrhage, as its distinctive signal on T1-weighted images makes its identification possible.
To distinguish early magnetic resonance (MR) imaging findings in postoperative diskitis from normal postoperative changes, a prospective study was performed in 15 asymptomatic patients (17 disk levels) who underwent uncomplicated lumbar diskectomy and seven patients with proved postoperative diskitis. On postoperative MR images, four of the asymptomatic patients had a finding that could also be seen in patients with diskitis. Gadolinium enhancement was useful in making the distinction and occurred as follows: (a) vertebral bone marrow: all seven diskitis patients and one asymptomatic patient; (b) disk space: five diskitis patients and three asymptomatic patients; and (c) posterior anulus fibrosus: all seven diskitis patients and 13 asymptomatic patients (14 of 17 levels). This entire triad of findings, which is strongly suggestive of postoperative diskitis, was not seen in any of the asymptomatic patients. Changes in the disk space and adjacent bone marrow on pre- and post-contrast MR images after routine diskectomy are uncommon and should not be assumed to be normal postoperative changes without careful consideration and analysis for early diskitis.
One hundred four patients with preoperative diagnoses of lumbar canal stenosis, disk herniation, or a combination of both were evaluated with intraoperative sonography with the intent of (1) describing the sonographic characteristics of herniated disks and distinguishing these from bulging anuli, epidural fat, scar tissue, and spondylolisthesis; (2) establishing criteria for adequate decompression of canal stenosis; and (3) determining the usefulness of sonography in monitoring disk removal. Disk material demonstrates medium echogenicity, different in its sonographic features from bone, epidural fat, scar tissue, and epidural veins. A sonographic diagnosis of disk herniation was made in 43 cases, 41 of which were confirmed during surgery. Sonography established the presence or absence of disk herniation (confirmed by surgery) in 14 of 19 patients who had equivocal preoperative findings. After routine diskectomy, residual disk material was found in 17 (41%) of 41 patients, which led to further surgery in 16 patients with removal of the additional disk fragments. In 84 patients undergoing decompressive surgery for canal stenosis, sonography detected residual canal compression in 19 (23%), which led to a widened decompression in 15 of these patients. Sonography can differentiate disk material from other normal or abnormal structures in the canal; therefore, sonographic monitoring helps to ensure adequate bony decompression and complete diskectomy. We conclude that intraoperative sonography is an important tool in the surgical management of lumbar disk disease and stenosis.
One hundred and fourteen cases of lumbar herniated nucleus pulposus were studied retrospectively. I reviewed the clinical records and radiographs of patients treated with diskectomy and anterior interbody fusion. I followed the patients from 2 years up to 15 years, for an average of 2.9 years. The results were calculated statistically by Fisher exact test and Chi-square test. Among 114 patients, 69 patients (60.5%) were male and 45 patients (39.5%) were female. The most common age group was in its twenties (28.1%), while the whole study group ranged from 19 to 65 years. The most commonly involved level was L4-5 (73 cases, 60.4%). In clinical results, 83.3% of cases were excellent or good. The rate of solid fusion was 87.8%. The most common type of fusing pattern was type 1. The satisfying clinical result had statistical correlation with the solid union of grafted bone and the fusion state of maintained intervertebral disk height, respectively, by Fisher exact test (p < 0.001). The affecting factors in clinical results were the solid fusion and fusion with the state of maintenance of intervertebral disk height (fusing pattern type I and II). I concluded that anterior diskectomy and interbody fusion is a recommendable method of treatment for lumbar herniated nucleus pulposus.
An inevitable side effect of iliac crest bone graft harvesting is postoperative pain at the donor site. Bupivacaine hydrochloride is a long-acting local anesthetic that is clinically effective for approximately 8 hours. The present study was undertaken to assess postoperative pain relief with locally injected bupivacaine at the iliac crest bone graft harvest site. Pain relief with locally injected bupivacaine or saline at the iliac bone harvest site using an indwelling catheter was studied in 13 patients in a prospective, double-blind, crossover study. Twelve patients had cervical diskectomy and arthrodesis with autograft and one patient had a triple arthrodesis of the foot. There were no statistically significant differences between patients given bupivacaine and patients given saline with respect to pain relief ratings and hip-pain ratings at rest and motion during the first 24-hour postoperative period and the second 24-hour postoperative period (Mann-Whitney test). The single diabetic patient who had a triple arthrodesis developed a wound infection at the catheter placement site. The number of patients was too small to draw conclusions about the differences in pain-medication requirements between patients undergoing single versus multiple diskectomies and fusions. In view of the lack of improvement in pain relief and the risk of infection, local administration of bupivacaine at the iliac bone harvest site is not recommended in its present form for postoperative analgesia.
The indications of discography include situations in which there is inconsistency between the imaging and physical findings. Discography may also be performed prior to planned disc therapy such as percutaneous diskectomy or IDET. The diagnostic goal of the diskcogram is to reproduce the patient's original pain pattern by injection of the disc. If it is determined that the origin of the patient's back pain is diskcogenic, disc therapy can be provided by either surgical or non-surgical means. The non-surgical disc therapy includes steroid injections, IDET, or even percutaneous diskectomy.
Percutaneous diskectomy is a new treatment used in surgery of the spine for the treatment of herniated lumbar disks. The idea is to carry out an exeresis with a posterolateral percutaneous approach on a part of the herniated intervertebral disk; while always remaining outside the spinal canal. This technique eliminates the risks of fibrosis or arachnoiditis. It is carried out under local anesthesia, reduces the surgical insult and requires only a short stay in hospital. Between 1984 and 1988, 188 operations using this technique were carried out on L3-L4, L4-L5 and L5-S1. Of the first 100 cases studied, we note: 71% good and very good results for radiculalgia after a time lapse of more than a year, 51% good and very good results for low back pain; 16% of the patients required a surgical approach after percutaneous diskectomy. The authors specify the advantages and the indications of this surgical technique, which complements the traditional lumbar intervertebral disk surgery.
One-hundred-four patients with preoperative diagnoses of lumbar canal stenosis, disk herniation, or a combination of both were evaluated with intraoperative sonography with the intent of (1) describing the sonographic characteristics of herniated disks and distinguishing these from bulging anuli, epidural fat, scar tissue, and spondylolisthesis; (2) establishing criteria for adequate decompression of canal stenosis; and (3) determining the usefulness of sonography in monitoring disk removal. Disk material demonstrates medium echogenicity, different in its sonographic features from bone, epidural fat, scar tissue, and epidural veins. A sonographic diagnosis of disk herniation was made in 43 cases, 41 of which were confirmed during surgery. Sonography established the presence or absence of disk herniation (confirmed by surgery) in 14 of 19 patients who had equivocal preoperative findings. After routine diskectomy, residual disk material was found in 17 (41%) of 41 patients, which led to further surgery in 16 patients with removal of the additional disk fragments. In 84 patients undergoing decompressive surgery for canal stenosis, sonography detected residual canal compression in 19 (23%), which led to a widened decompression in 15 of these patients. Sonography can differentiate disk material from other normal or abnormal structures in the canal; therefore, sonographic monitoring helps to ensure adequate bony decompression and complete diskectomy. We conclude that intraoperative sonography is an important tool in the surgical management of lumbar disk disease and stenosis.
The authors report the results of automated percutaneous diskectomy in the treatment of the herniated disk. During an 18-month period this procedure was used on 39 patients with both evident radicular pathology that had not regressed even after 4-6 weeks of medical and physical therapy as well as clear disk herniation revealed by diagnostic imaging. The level of the herniated disk was L4-L5 in 30 cases. L5-S1 in 7 cases, and L3-L4 in 2 cases. The clinical diagnosis was confirmed by CAT scan in 20 cases, by both CAT scan and x-ray of the spinal region in 14 cases, and by x-ray only in 5 cases. The patients were reviewed 2, 6, and 12 months after surgery. The results were classified according to Watters' criteria based on both the relief of pain and the resumption of everyday work activity. The satisfactory results (excellent and good) totaled 59% at the 6-month follow-up, with no substantial variation at the 1-year follow-up. Hemilaminectomy was performed in 12 cases with unsatisfactory results, confirming the diagnosis of disk herniation in 10 cases (extruded in 9 cases and protruded in 1 case). Diskectomy is a non-invasive, atraumatic method which is indicated for both protruded (non-sequestrated) and subumbilical hernias and allows rapid functional recovery. The rate of success can be increased with more accurate selection of patients based on imaging diagnosis (CAT scan and MRI).
The common complications of cervical disk surgery using the posterior and the anterior approach are discussed. The advantages and disadvantages of diskectomy with and without fusion are also presented. Complications of cervical disk surgery are a function of the type of procedure, the specific anatomic approach, and the experience of the surgeon. Although the posterior approach may be used for posterolateral or lateral herniated disks and foramenal osteophytes, the anterior approach is safer for central herniated disks and osteophyte formation. At The Mount Sinai Hospital, anterior-approach cervical diskectomy, whether with or without fusion, is preferred to the posterior approach for all herniations.
Percutaneous laser diskectomy has recently been promoted as a viable alternative in treatment of the symptomatic lumbar disk herniation. Careful scrutiny of the literature, including the natural history of low back disorders and results of various surgical techniques in controlled studies, makes it clear that percutaneous laser diskectomy adds little to our surgical armamentarium. As surgeons, we should be encouraged to make treatment decisions in the best interests of our patients, based on unbiased, prospective scientific studies.
The Authors report their personal experience with postoperative neuroradiologic studies in surgical patients with a herniated disk and/or degenerative cervical spondylosis. Twenty-six patients were enrolled: 16 of them underwent anterior diskectomy, 7 posterior decompressive laminectomy and 3 vertebral body removal. The patients were submitted to pre- and postoperative MRI with high field equipment (Signa 1.5 T, General Electrics), using sagittal SE T1- (TR/TE 360/15), PD and T2-weighted (TR/TE/FA 2000/40/120) sequences and T2-weighted GE axial sequences (TR/TE/FA 400/34/30). FSE sequences (TR/TE/ETL 4000/95/8) were used in 15 cases instead of the above T2-weighted SE sequences. The main postoperative MR findings were analyzed. In particular, the morphological and signal features of bone grafts, of vertebral end-plates, of the subchondral bone and of the surgical site were studied. After anterior diskectomy, the most frequent MR features were massive signal changes in the bone graft and lower vertebral plates, which were hypointense in T1 and hyperintense in T2; the adjacent subchondral bone also exhibited signal changes. Other postoperative MR findings accounted for early postoperative mobility (4 cases of persistent myelomalacia and 3 of bone graft fracture with consequent spinal instability) and late mobility (2 cases of herniated disk, 5 of spinal stenosis and one pseudomeningocele). The main limitation of MRI in postoperative cervical spine studies was the presence of ferromagnetic artifacts during SE, and even more GE, sequences; these artifacts were the main cause of misdiagnoses. In our experience, this troublesome limitation was overcome with FSE sequences but diagnostic accuracy remained poor in 4 patients. MRI, thanks to its multiparametric and multiplanar yield, is the gold standard for the examination of several early and late postoperative features and of postoperative mobility in the cervical spine. Moreover, T2-weighted FSE acquisitions are better than conventional SE to this purpose, because examination time is shorter, myelographic effect is improved and the sensitivity to ferromagnetic artifacts reduced.
PURPOSE OF THE STUDY: Sciatica is very rare in children. We report a particular from due to traumatic avulsion of the posterior vertebral limbus. The purpose of this study was to give the principal clinical and radiological aspects of this entity and to discuss the treatment which should be different from that of common adult disk herniation. MATERIALS: From 1980 to 1992, 10 children were examined for a sciatica (7 boys and 3 girls aged from 10 years 1 month to 15 years 2 months). Sciatica appeared in all cases during sport activities and sometimes after a sport accident. Lumbar spine stiffness was encountered in all cases. Radiculalgia was unilateral in 7 cases, bilateral in 3 cases, in L5 territory in 3 and S1 in 7 cases. 4 children had deficitary neurological signs: 3 abolitions of achilles reflex, 1 weakness of foot dorsi-flexors. Standard x-rays showed in 4 cases the avulsed fragment in the vertebral canal. Spondylosis was encountered in 3 cases and spondylolisthesis in one case. Diagnosis was possible in all cases with CT Scan, M.R.I., when done showed a normal disk signal. Three children were managed by a conservative treatment by rest or brace. Seven had a surgical treatment: resection of the avulsed fragment in 6 and total diskectomy in one. The mean follow-up was five years (2 to 8 years). RESULTS: There was no complication. At last follow-up all children had a good result without sciatica recurrence. DISCUSSION: Many factors allow us to think that avulsion of the vertebral rim in children is of traumatic origin. CT Scan is the best exploration for this particular lesion. It enabled evaluation of fragment volume and location. Magnetic resonance imaging showed uninjured disks. Removal of the avulsed fragment without diskectomy seems possible in children.
Somatosensory evoked potentials (SEPs) were used for continuous monitoring of 210 patients during anterior surgery for cervical myeloradiculopathy, to test how effectively they help avoid irreversible neurological damage during surgery. The pathologies differed in severity and were treated by diskectomy or by extended corporectomy using the Senegas technique. Intraoperative SEP changes were recorded in 84 patients (40%); in 13 (6.2%) of these, changes in SEP amplitude and latency were caused by mechanical stress. SEPs revealed transient episodes of regional ischaemia or neurophysiological anomalies during anaesthesia (mainly hypotension) in 27 patients (12.8%). The traces detected incipient and potentially dangerous mechanical pressure on, or metabolic anomalies of, the spinal cord during manipulation and placement procedures of spinal fixation devices. They were particularly sensitive indicators of ischaemia; one of the most common causes of irreversible injury. The traces of 44 patients (21.0%) improved markedly during surgery. There were no false-negatives in this series and, thanks to the fact that SEPs gave immediate warnings of incipient ischaemia to the surgical team, we had no case of irreversible medullary or nerve-root deficit.
Morphometric evaluation of 54 dry cervical spines from C3 to C7 (a total of 270 cervical vertebrae) was performed to determine the bony boundaries of the uncinate process for resection of the uncinate process for access to posterolateral osteophytes or herniated disks at the time of anterior cervical diskectomy. The uncinate processes were significantly higher (p < 0.01) at the C4-C6 levels (5.8 +/- 1.1 mm to 6.1 +/- 1.3 mm) than at the C3 or C7 levels. The distance between the medial and lateral margins of the base of the uncinate process was significantly smaller (p < 0.01) at the C3 level (4.9 +/- 0.7 mm) than at the C7 level (6.3 +/- 0.7 mm). The anteroposterior diameter of the medial margin of the uncinate process decreased gradually from the C5 (12.5 +/- 1.5 mm) to C7 levels (11.6 +/- 1.3 mm) (p < 0.05). The inter-uncinate distance widened from the C3 (19.2 +/- 1.5 mm) to the C7 (24.6 +/- 2.1 mm) levels (p < 0.01). The mid-anteroposterior diameter of vertebral body increased gradually from the C3 (14.7 +/- 1.1 mm) to the C7 levels (16.1 +/- 1.5 mm) (p < 0.01). The width of the vertebra increased gradually from C3 to C7 (from 19.2 +/- 1.8 mm at C3 to 25.6 +/- 2.0 mm at C7) (p < 0.01). Knowledge of all the aforementioned data may be helpful during anterolateral cervical uncosectomy or uncoforaminotomy.
We review our two-team operative technique and results of anterior retroperitoneal lumbosacral spine exposure for diskectomy, partial corpectomy, and spinal instrumentation. Seventy-two patients with lumbar spondylosis and associated symptomatic radiculopathy had this exposure between January 1, 2000 and January 1, 2002. A single disc space was isolated in 54 patients. Multilevel exposure was achieved in 18 patients. Main outcome measures included intra- and postoperative complications, blood transfusion requirements, duration of ileus, incidence of erectile/sexual dysfunction, and length of hospital stay. A single small bowel enterotomy and iliac vein laceration, both repaired primarily, were the only intraoperative complications. Perioperative blood transfusions were required in 13 patients (18%). Mean length of postoperative ileus was 3.5 days and average length of hospital stay was 5 days. Postoperative complications occurred in 7 patients (9.7%). These included erectile dysfunction (2), transient unilateral lower extremity paresis (1), acute acalculous cholecystitis (1), femoral vein thrombosis (1), pneumonia (1), and acute myocardial infarction (1). There were no genitourinary or other major vascular injuries. A two-team approach for lumbosacral spine instrumentation via anterior retroperitoneal exposure capitalizes on unique specialty-specific surgical skills. This paradigm facilitates safe lumbosacral spine surgery and major perioperative complications are rare.