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The term "microdiskectomy" in the medical literature defines absolutely no surgical parameters or specific techniques for the treatment of the herniated nucleus pulposus. I attempt to clarify frequently used slang and to design a logical mental and microsurgical approach to the problem of lumbar disk herniations. The rigid surgical technique of microlumbar diskectomy is closely examined.
Thirty-five teenagers treated for herniation of the lumbar intervertebral disk are reviewed. In almost all cases the subjective symptoms were very minor compared to the physical signs. Radiologic examination revealed a high incidence of lumbosacral anomalies and, less frequently, anomalies of the dural sac or nerve roots. Conservative treatment failed to improve the symptoms in all cases, while surgery and various closed techniques (chemonucleolysis, percutaneous diskectomy) were successful.
In order to evaluate MR reliability in the therapeutic approach to lumbar disk herniation, 51 patients were examined. MR images revealed disk herniation with integrity of posterior longitudinal ligament in 25 subjects. These patients were then examined with diskography, that confirmed MR diagnosis in 23/25 cases. Percutaneous diskectomy according to Onik was successfully performed in 23/25 patients. MR imaging appears as a non-invasive method which allows exhaustive analysis of all components of lumbar spine, yielding reliable information for choosing the appropriate treatment.
In 45 lumbar hemilaminectomy/microdiskectomy patients, a control group of 23 patients had the standard operative procedure. The remaining 22 patients were treated with intraoperative irrigation of long-acting dexamethasone before incision closure. Age, weight, gender ratio, mean postoperative hospital stay, mean in-hospital narcotics usage, and incidence of perioperative complications among the two groups were compared. Age and gender ratios were comparable, although the control group was significantly heavier in body weight than the steroid-irrigated group. The steroid-irrigated group had a significant reduction in hospitalization and a marked reduction in narcotics usage compared with the control group. Postoperative fever occurred in one patient in the steroid group. The control group had three postoperative complications. These preliminary observations suggest that dexamethasone irrigation during lumbar diskectomy is a safe and effective adjunct to surgical management.
MR imaging after IV gadolinium-DTPA administration has demonstrated contrast enhancement in traumatized lumbar intervertebral disks. To characterize the morbid anatomy that correlates with the contrast enhancement, we developed a canine model of traumatized intervertebral disks. Diskectomy was performed with a nucleotome and the spines were imaged biweekly with MR and Gd-DTPA. The spines were studied at necropsy, and their anatomic abnormalities correlated with contrast enhancement detected by MR imaging. Our preliminary results indicate that contrast enhancement occurs where granulation tissue develops in traumatized intervertebral disks.
Percutaneous nucleotomy was developed in the late seventies. In the beginning special forceps were used to remove the nuclear tissue. However, because of the large diameter of the cannulas used there was a risk of nerve damage. In 1985 Onik et al. presented the 'automated percutaneous lumbar diskectomy'. The risk of damage to the surrounding tissues of the disc was low. The method proved to be successful. In this article we describe the method and analyse our first 40 patients treated for a disc protrusion between February and June, 1988. This pilot study also shows that CT discography is important for the selection of patients for treatment with this method.
For the purpose of observing the biomechanical relationship among intervertebral disk (D), intervertebral foramen (F) and vertebral canal (C), 11 sets of functional unit of lumbar spine from fresh cadavers were used as specimens in this experiment. The data showed that the DFC were closely related in dimensional changes with different loadings, a phenomenon we call it DFC variation reaction. It was shown that the loading axes in the disk and in the inter-articular joints worked together biomechanically as an isosceles triangle to accommodate the stresses applied. The mechanism of the relapsed symptoms of protruded intervertebral disk after diskectomy, and of that of spinal canal stenosis was discussed. A reasonable operation for treatment of these maladies has been suggested.
Thirty cases, who had been operated on under diagnosis of protrusion of lumbar intervertebral disk, were re-operated upon because of failure of relieving their sufferings or tardy recurrence of symptoms. The actual causes found at operation were: missing a preexisting schwannoma in 4 patients, failing in working on correct space in diskectomy in 3, leaving another co-existed protruded disk untouched in 2, and lastly, recurrence of disk protrusion at the previous space in 7. Causes of these mishaps were discussed and some preventive precautions and measures have been suggested.
A biomechanical study was performed comparing the stiffness and stability of the three-level combination spinal rod-plate and transpedicular screw (CSRP-TPS) fixation system with those of three anterior stabilization constructs that spanned three vertebral levels: iliac strut grafting, polymethylmethacrylate and anterior Harrington rod instrumentation (technique of Siegal et al.), and the Kaneda anterior device. The CSRP-TPS fixation system was also compared with five posterior instrumentation systems that spanned five vertebral levels: Harrington distraction rod instrumentation, segmentally wired Luque rectangular instrumentation, Cotrel-Dubousset transpedicular instrumentation. Steffee transpedicular screws and plates, and R. Roy-Camille plates under conditions of single-level instability. The relative stability of each instrumentation system was compared by mounting the fixation systems on calf spine segments containing five motion segments destabilized by complete L3 anterior corpectomies and L2-L3 and L3-L4 anterior diskectomies to simulate the two-column instability found clinically in spine fractures. Mechanical nondestructive cyclical testing in rotation, axial compression, and flexion was performed on 12 spines. All biomechanical tests were performed on a biaxial servo-controlled MTS 858 Bionix hydraulic materials testing device with a biaxial load cell. Intervertebral displacements between L2 and L4 were continuously recorded utilizing an extensometer with the knife edges placed directly adjacent to the L3 corpectomy defect during testing. This biomechanical study showed that CSRP-TPS instrumentation spanning three vertebral levels could restore the torsional, compressive, and flexural rigidity of the destabilized calf spines to that of the intact calf spines and provided more in vitro stability than either the traditional five-level Harrington distraction rod or the segmentally wired Luque rectangular instrumentation. The greatest torsional rigidity occurred with the five-level Cotrel-Dubousset instrumentation, the five-level Steffee plate and screw system, and the three-level Kaneda anterior device. In axial compression and flexural testing, the three-level CSRP-TPS system provided fixation comparable with the five-level Cotrel-Dubousset instrumentation, the five-level Steffee transpedicular screw and plate system, the five-level R. Roy-Camille plate and screw system, and the three-level Kaneda anterior device. Satisfactory levels of rigidity can be restored by three-level CSRP-TPS instrumentation under conditions of single-level instability in unstable thoracolumbar and lumbar spine fractures.
Forty-eight patients had 50 extraforaminal disk herniations (EFDHs) demonstrated on CT and/or MR by (1) presence of disk density or disk signal material lateral to the neural foramen, (2) displacement or obliteration of paravertebral fat, and (3) nerve root or ganglion compression or displacement. Forty-one of 50 EFDHs had a coexisting intraforaminal component; nine of 50 had an isolated far lateral herniated nucleus pulposus. EFDHs typically occurred in the absence of a coexisting intraspinal disk herniation. Migratory fragments were seen in 50% of all cases and were at or cephalad to the interspace of origin in all cases. Forty-six percent of EFDHs were at L2-L3 or L3-L4, although the most commonly affected level was L4-L5 (38%). EFDHs, which were often overlooked (15/50 scans reviewed), are an important preventable cause of failed intraspinal diskectomy. EFDHs can be readily identified on both CT and MR if appropriate scans are obtained from L2 through S1 and if the neural foramina and paravertebral spaces are carefully examined.
Despite the availability of excellent neuroradiological examination techniques, a decision to operate is usually still reached largely on the basis of a diagnosis of radical and/or medullary cervical compression syndrome made by clinical neurological examination. Computer tomography has allowed a decisive improvement in the diagnosis of these processes, since the position of parts of discs that have prolapsed or sequestrated dorsally or dorsolaterally relative to the spinal cord and the nerve roots can be visualized directly. Since core spin tomography does not yield information that is any more helpful in the diagnosis, despite the considerably higher level of technical sophistication and higher costs, we are of the opinion that there is no call to apply this procedure routinely for the diagnosis of medial and lateral cervical disc rupture. Since the neurological symptoms do not always allow localization of the radicular or medullary damage to the segment or segments affected, it is sometimes necessary to perform myelography with water-soluble contrast media for this purpose. The microsurgical procedures available are restricted foraminotomy for the relief of cervical nerve root compression and ventral diskectomy for the relief of spinal cord compression.
Chemonucleolysis with chymopapain is accepted by many surgeons as a reasonable alternative to lumbar diskectomy for the treatment of lumbar disk disease. Approximately 70 to 75 per cent of carefully selected patients are successfully treated following this therapy, but extreme care must be exercised for precise needle placement and prompt and vigorous management of major allergic reactions. Methods to avoid major complications and their management, should they occur, are discussed.
Recurrence of symptomatology after diskectomy was investigated in 37 patients by computed tomography imaging. Local complications were mainly fibrous scar tissue formation and recurrence of disk lesions. Results showed the CT scan to be the most reliable exploratory procedure available at the present time, based on the quality of images obtained after intravenous iodized contrast injection.
Of 100 consecutive patients with acute lumbosacral radiculopathy who were treated conservatively and the majority of whom were followed for at least 5 years, only 5% had to undergo laminectomy and diskectomy. Conservative management included complete bed rest for 2 to 3 weeks, with occasional use of anti-inflammatory drugs, and support of the lumbosacral spine, at first with a corset and later with vigorous abdominal strengthening exercises. Repeated electromyography was of value in assessing clinical weakness, providing objective guidance to management. It is concluded that in only rare instances is surgery indicated for lumbosacral radiculopathy secondary to disk derangement.
Every type of fusion has its enthusiastic supporters. Unfortunately, the literature includes comparative analyses of various fusion procedures. Much of the effort spent in the clinical assessment of spinal fusion must be reinvested; neither the indications for diskectomy nor spinal fusion have been sufficiently clear-cut and accurately recorded. Moreover, spinal fusions often have not been applied to treat the disorder or to correct the deformity. It is essential at the outset to establish the mechanical fault; this is achieved only by a thorough understanding of the underlying pathologic lesion. Diagnosis follows a careful history and physical examination assisted by plain radiographs, lateral radiographs in flexion and extension, radiographs (anteroposterior in left and right lateral bending), and by information obtained from the CAT scan. We have designed a protocol for a prospective investigation wherein a specific fault with a specific etiology and pathologic anatomy is identified and submitted to a surgical procedure in a specified sequence. In future reviews, emphasis must be paid to selection of patients, the individual joint requiring stabilization and the type of fusion performed. Only then can we put this theoretically effective procedure to the acid test of objective clinical evaluation.
One hundred twenty-four patients with herniated lumbar disks received intradiskal injections of chymopapain before the Food and Drug Administration's withdrawal of the drug. One year after injection, 90 patients (72.6%) experienced major improvement, 21 (16.9%) had slight improvement, and 13 (10.5%) had no improvement. Of those patients who had no previous back surgery and who were not compensation cases, 77 patients (81%) had marked improvement, 13 (13.7%) had slight improvement, and five (5.3%) had no improvement. Three- to six-year follow-ups were obtained by questionnaire. Of the 114 patients responding, overall 83 patients (72.8%) had marked improvement, and 75 (83.3%) of those with no previous surgery and who were not workmen's compensation cases had major improvement. Since all patients met objective criteria for diskectomy, favorable results from chemonucleolysis spared most the trauma of surgery and its attendant convalescence. These results indicate that chemonucleolysis can and should be considered an advantageous alternative to surgery in appropriately selected patients.
Ninety-three patients with persistent signs and symptoms of cervical disk disorder resistant to conservative therapy were treated surgically by anterior cervical diskectomy and fusion with a vertical self-locking T-graft. This surgical technique offers the following mechanical and physiological advantages: the load-bearing capability of the cortices of the vertical graft supports the cortices of the adjacent vertebral bodies, and prevents anterior wedging postoperative structural collapse; the surgical removal of the cartilaginous end plate and intimate relation between the cancellous bone of the graft and the vertebrae promotes early fusion; the posteriorly positioned prongs of the graft present extrusion; the posterior cortex and posterior longitudinal ligament are not removed, thus minimizing the spinal cord injuries. In a two- to ten-year follow-up, 90% of the patients obtained an excellent of good result. Those with a single level of fusion obtained a far better end result. Complications among these 93 patients were relatively minimal: no instance of anterior collapse or wedging, no evidence of extrusion, no wound or disk space infection, and no neurologic complications occurred. The author recommends this approach when managing selected patients.
An interinstitutional study on the failed back surgery syndrome (FBSS) has determined that failure to recognize or adequately treat lateral stenosis of the lumbar spine with resultant nerve irritation and/or compression comprised the primary etiology in 57% to 58% of patients. Other common causes were recurrent or persistent disk herniation and lumbosacral adhesive arachnoiditis. The diagnosis of stenosis was made either by high-resolution CT scan of the lumbar spine or by directly testing lateral canal and for animal patency at the time of surgery. It is now appreciated that the process of degenerative disk disease, particularly when enhanced by diskectomy, results in progressive loss of intervertebral disk volume and predisposes to future ipsilateral or contralateral lateral spinal stenosis. Degenerative disk disease is ultimately a bilateral process and therefore surgical exposure should be bilateral. The direct and indirect costs of FBSS to patients and to society as well as the toll in human suffering are very high. This is particularly a matter of concern when it is realized that for many FBSS patients, surgery could have been avoided in the first place by preventive care or by innovative conservative treatment. When surgery is indicated, adequate diagnostic tests and the execution of appropriate procedures based upon this information should largely prevent the failed back surgery syndrome.