Category Archives: Spine

Book: Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard

Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard
By Jkbc Parthiban

Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard

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Neuro Spinal Surgery Operative Techniques – Anterior Cervical Discectomy and Fusion is the latest book in the Neuro Spinal Surgery Operative Techniques series. This book covers Anterior Cervical Discectomy and Fusion (ACDF) in eight concise chapters. This surgical procedure involves decompressing the spinal cord and nerve roots in the neck. The first chapter covers the basic anatomy and approaches to ACDF, with illustrated guidance on microdiscectomy and bone grafting. Further chapters cover decompression of the nerve root and cord, interbody grafting technique, corpectomy and fusion, with the most current information on each procedure. The important technique of sinking’ the graft in the disc space to prevent graft migration is covered in detail. The final chapter provides information on instruments used in ACDF procedures. Neuro Spinal Surgery Operative Techniques – Anterior Cervical Discectomy and Fusion is enhanced by nearly 200 full colour images, making this an ideal quick reference guide for spine surgeons. Key Points Latest in Neuro Spinal Surgery Operative Techniques series Other topics in the series include Lateral Mass Fixation in Sub-axial Cervical Spine, and Cervical Laminoplasty 197 full colour images and illustrations


Product Details

  • Published on: 2017-08-01
  • Original language: English
  • Dimensions: 9.50″ h x .0″ w x 6.20″ l, 2.20 pounds
  • Binding: Paperback
  • 182 pages

Editorial Reviews

About the Author
JKBC Parthiban MCh (Neurosurgery) FNS Senior Consultant (Neurosurgery and Spine Neurosurgery), Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India

Update: Cervical arthroplasty

Cervical arthroplasty was developed with the goal of preserving mobility of the cervical segment in patients with cervical degenerative disc disease.

Cervical total disc replacement (TDR) has been shown in a number of prospective clinical studies to be a viable treatment alternative to anterior cervical discectomy and fusion (ACDF) for symptomatic cervical degenerative disc disease. In addition to preserving motion, evidence suggests that cervical TDR may result in a lower incidence of subsequent surgical intervention than treatment with fusion.

One reason for this trend is the observation that in clinical studies, patients with a history of cervical arthrodesis seem to have a higher incidence of adjacent segment degeneration 1) 2) 3).

Furthermore, in biomechanical investigations, most authors have reported an increase in the segmental range of motion (ROM) and the intradiscal pressure (IDP) in the levels proximal and distal to a simulated mono- or bisegmental arthrodesis 4) 5) 6) 7) 8) 9) 10) 11) 12) 13).

While anterior cervical discectomy and fusion (ACDF) has been the standard of care for 2-level disease, a randomized clinical trial (RCT) suggested similar outcomes.

There are also critical debates regarding the long-term effects of heterotopic ossification (HO) and the prevalence of adjacent-level degeneration.

Evidence

Several large-scale clinical trials demonstrate the efficacy of 1- and 2-level cervical disc arthroplasty (CDA) for degenerative disc disease (DDD) in the subaxial cervical spine, while other studies reveal that during physiological neck flexion, the C4-5 and C5-6 discs account for more motion than the C3-4 level, causing more degenerative disc disease (DDD).

The results of a observational study were in accordance with those of the published randomized controlled trials (RCTs), suggesting substantial pain reduction both after anterior cervical interbody fusion (AIF) and Cervical total disc replacement, with slightly greater benefit after arthroplasty. The analysis of atypical patients suggested that, in patients outside the spectrum of clinical trials, both surgical interventions appeared to work to a similar extent to that shown for the cohort in the matched study. Also, in the longer-term perspective, both therapies resulted in similar benefits to the patients 14).

The available evidence showed that most of the pre-selected factors had no effect on outcome after CTDR, and the range of motion (ROM) success rate, incidence of heterotopic ossification (HO) and radiographic adjacent segment degeneration (r-ASD)/adjacent segment disease (ASD), and surgery rate for ASD are acceptable. There is a lack of evidence for some factors 15).

With a significant exception of a Cochrane review, the methodological quality of systematic reviews evaluating the evidence of C-ADR versus ACDF has to be improved. 16).

Outcome

Cervical total disc replacement presented favorable functional outcomes, fewer adverse events, and fewer secondary surgical procedures. The efficacy and safety of cervical total disc replacement are superior to those of fusion. Longer-term, multicenter studies are required for a better evaluation of the long-term efficacy and safety of the two procedures.

Although cervical disc arthroplasty (CDA) at C3-4 was infrequent, the improved clinical outcomes of CDA were similar at C3-4 to that in the other subaxial levels of the cervical spine at the approximately 5-year follow-ups. In this Asian population, who had a propensity to have ossification of the posterior longitudinal ligament, there was more heterotopic ossification (HO) formation in patients who received CDA at the C3-4 level than in other subaxial levels of the cervical spine. While the type of artificial discs could have confounded the issue, future studies with more patients are required to corroborate the phenomenon 17).

Cost-effectiveness

A study is the first to report the comparative cost-effectiveness of cervical total disc replacement (cTDR) vs anterior cervical discectomy and fusion(ACDF) for 2-level degenerative disc disease at 5 years. Ament et al conclude that, because of the negative incremental cost-effective ratio (ICER), cTDR is the dominant modality 18)

Patients who underwent CTDR for single-level degenerative disease had lower readmission rates, lower reoperation rates, and reduced index and total costs than those treated with ACDF. Cervical disc arthroplasty (CDA) was effective in reducing the monthly cost of care compared with ACDF19).

Based on a modeling evaluation, CTDR was found to be more effective and less costly over a 7-year time horizon for patients with single-level symptomatic degenerative disc disease. These results are robust across a range of scenarios and perspectives and are intended to support value-based decision making 20).

The incremental cost-effectiveness ratio of CTDR compared with traditional ACDF is lower than the commonly accepted threshold of $50,000 per QALY. This remains true with varying input parameters in a robust sensitivity analysis, reaffirming the stability of the model and the sustainability of this intervention 21).

At the same time, while generating clinical results comparable to spinal fusion, TDR incurred significantly lower costs. Therefore, both from the medical and from the financial point of view, TDR is a viable choice in the treatment of DDP 22).

Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis 23).


Although cervical total disc replacement (TDR) has shown equivalence or superiority to anterior cervical discectomy and fusion (ACDF), potential problems include nonphysiological motion (hypermobility), accelerated degeneration of the facet joints, particulate wear, and compromise of the mechanical integrity of the endplate during device fixation.

There is no definitive evidence that TDR has better intermediate-term results than anterior cervical discectomy and fusion (ACDF) 24).


3D motion analysis data comparing patients after ACDF and AD replacement in ten patients who underwent C5-6 ACDF and 7 who underwent C5-6 AD replacement were enrolled. Using biplanar fluoroscopy and a model-based track technique (accurate up to 0.6 mm and 0.6°), motion analysis of axial rotation and flexion-extension of the neck was performed. Three nonoperative segments (C3-4, C4-5, and C6-7) were assessed for both intervertebral rotation (coronal, sagittal, and axial planes) and facet shear (anteroposterior and mediolateral). Results There was no difference in total neck motion comparing ACDF and AD replacement for neck extension (43.3° ± 10.2° vs 44.3° ± 12.6°, p = 0.866) and rotation (36.0° ± 6.5° vs 38.2° ± 9.3°, p = 0.576). For extension, when measured as a percentage of total neck motion, there was a greater amount of rotation at the nonoperated segments in the ACDF group than in the AD group (p = 0.003). When comparing specific motion segments, greater normalized rotation was seen in the ACDF group at C3-4 (33.2% ± 4.9% vs 26.8% ± 6.6%, p = 0.036) and C6-7 (28.5% ± 6.7% vs 20.5% ± 5.5%, p = 0.009) but not at C4-5 (33.5% ± 6.4% vs 31.8% ± 4.0%, p = 0.562). For neck rotation, greater rotation was observed at the nonoperative segments in the ACDF group than in the AD group (p = 0.024), but the differences between individual segments did not reach significance (p ≥ 0.146). Increased mediolateral facet shear was seen on neck extension with ACDF versus AD replacement (p = 0.008). Comparing each segment, C3-4 (0.9 ± 0.5 mm vs 0.4 ± 0.1 mm, p = 0.039) and C4-5 (1.0 ± 0.4 mm vs 0.5 ± 0.2 mm, p = 0.022) showed increased shear while C6-7 (1.0 ± 0.4 mm vs 1.0 ± 0.5 mm, p = 0.767) did not.

This study illustrates increased motion at nonoperative segments in patients who have undergone ACDF compared with those who have undergone AD replacement. Further studies will be required to examine whether these changes contribute to adjacent-segment disease 25).

The data from a investigational device exemption (IDE) study through 48 months signify a number of clinically relevant benefits for total disc replacement (TDR) over anterior cervical discectomy and fusion (ACDF). Patients experienced improved clinical outcomes with TDR—including improvement in pain and function outcomes and superiority in overall primary endpoint success. Additionally, incidences of adjacent segment degeneration and subsequent surgeries were reduced with TDR. Perhaps future studies and also longer-term followup of this patient cohort may continue to establish 2-level cervical TDR as a superior surgical option for symptomatic degenerative disc disease 26).


Cervical artificial disc replacement (ADR) is indicated for the treatment of severe radiculopathy permitting neural decompression and maintenance of motion.

The clinical and radiographic outcomes in cervical ADR patients using the ProDisc-C device (DePuy Synthes, West Chester, PA, USA) with a 5-9 year follow-up were collected through a prospective registry, with retrospective analysis performed on 24 consecutive patients treated with cervical ADR by a single surgeon. All patients underwent single- or two-level ADR with the ProDisc-C device. Outcome measures included neck and arm pain (visual analogue scale), disability (neck disability index [NDI]), complications and secondary surgery rates. Flexion-extension cervical radiographs were performed to assess range of motion (ROM) of the device and adjacent segment disease (ASD). Average follow-up was 7.7 years. Neck and arm pain improved 60% and 79%, respectively, and NDI had an improvement of 58%. There were no episodes of device migration or subsidence. Mean ROM of the device was 6.4°. Heterotopic ossification was present in seven patients (37%). Radiographic ASD below the device developed in four patients (21%) (one single-level and three two-level ADR). No patient required secondary surgery (repeat operations at the index level or adjacent levels). Fourteen out of 19 patients (74%) were able to return to employment, with a median return to work time of 1.3 months. The ProDisc-C device for cervical ADR is a safe option for patients providing excellent clinical outcomes, satisfactory return to work rates and maintenance of segmental motion despite radiographic evidence of heterotopic ossification and ASD on long-term follow-up 27).

Types

Biomechanical analysis

Scarce references could be found and compared regarding the cervical ADR devices’ biomechanical differences that are consequently related to their different clinical results.

One fusion device (CJ cage system, WINNOVA) and three different cervical artificial discs (Prodisc-C Nova (DePuy Synthes), Discocerv (Scient’x/Alphatec), Baguera C (Spineart)) were inserted at C5-6 disc space inside the FE model and analyzed. Hybrid loading conditions, under bending moments of 1 Nm along flexion, extension, lateral bending and axial rotation with a compressive force of 50 N along the follower loading direction, were used in this study. Biomechanical behaviors such as segmental mobility, facet joint forces, and possible wear debris phenomenon inside the core were investigated.

The segmental motions as well as facet joint forces were exaggerated after ADR regardless of type of the devices. The Baguera C mimicked the intact cervical spine regarding the location of the center of rotation (COR) only during the flexion moment. It also showed a relatively wider distribution of the contact area and significantly lower contact pressure distribution on the core compared to the other two devices. A ‘lift off’ phenomenon was noted for other two devices according to the specific loading condition.

The mobile core artificial disc Baguera C can be considered biomechanically superior to other devices by demonstrating no ‘lift off’ phenomenon, and significantly lower contact pressure distribution on core 28).

Revision surgery and explantation

Between November 2008 and July 2016, 16 patients with prior implantation underwent removal of the Galileo-type disc prosthesis (Signus, Medizintechnik, Germany) due to a call back by industry. In 10 patients C-ADR was replaced with an alternative prosthesis, 6 patients received an ACDF. Duration of surgery, time to revision, surgical procedure, complication rate, neurological status, histological findings and outcome were examined in two institutions.

The C-ADR was successfully revised in all patients. Surgery was performed through the same anterior approach as the initial access. Duration of the procedure varied between 43 and 80min. Access-related complications included irritation of the recurrent nerve in one patient and mal-positioning of the C-ADR in another patient. Follow up revealed two patients with permanent mild/moderate neurologic deficits, NDI (neck disability index) ranged between 10 and 42%.

Anterior exposure of the cervical spine for explantation and revision of C-ADR performed through the initial approach has an overall complication rate of 18.75%. Replacements of the Galileo-type disc prosthesis with an alternative prosthesis or conversion to ACDF are both suitable surgical options without significant difference in outcome 29).

Case series

2017

As part of an FDA IDE trial, a single center collected prospective outcomes data on 47 patients randomized in a 1:1 ratio to ACDF or arthroplasty.

Success of both surgical interventions remained high at the 10-year interval. Both arthrodesis and arthroplasty demonstrated statistically significant improvements in neck disability index, visual analog scale neck and arm pain scores at all intervals including 7- and 10-year periods. Arthroplasty demonstrated an advantage in comparison to arthrodesis as measured by final 10-year NDI score (8 vs. 16, P = 0.0485). Patients requiring reoperation were higher in number in the arthrodesis cohort (32%) in comparison with arthroplasty (9%) (P = 0.055).

At 7 and 10 years, cervical arthroplasty compares favorably with ACDF as defined by standard outcomes scores in a highly selected population with radiculopathy 30).

2016

A total of 200 subjects underwent single-level activC® (Aesculap AG) implantation between C-3 and C-7 for the treatment of symptomatic degenerative disc disease. Clinical and radiographic assessments were performed preoperatively, intraoperatively, at discharge, and again at 6 weeks, 6 months, 1 year, 2 years, and 4 years. Radiographic evaluations were done by an independent core laboratory using a specific software for quantitative motion analysis.

Neck Disability Index (NDI) and visual analog scale (VAS) score for neck and arm pain decreased significantly from baseline to the 4-year follow-up. The mean improvement for NDI was 20, for VAS severity and frequency of neck pain 26.4 and 28, and for VAS severity and frequency of arm pain 30.7 and 35.1, respectively. The neurological situation improved for the majority of patients (86.4%); 76.1% of cases were asymptomatic. Subsequent surgical interventions were reported in 7% of the cases, including device removals in 3%. In 2.5% a subsidence greater than 3 mm was recorded; 1 of these cases also had a migration greater than 3 mm. No device displacement, expulsion, disassembly, loose or fractured device, osteolysis, or facet joint degeneration at the index level was observed. Segmental lordotic alignment changed from -2.4° preoperatively to -6.2° at 4 years, and postoperative height was maintained during the follow-up. Advanced HO (Grade III and IV) was present in 27.1% of the cases; 82.4% showed segmental mobility. A progression of radiographic adjacent-segment degeneration occurred in 28.2%, but only 4.5% required surgical treatment.

The activ C is a safe and effective device for cervical disc replacement confirming the encouraging results after cTDR. Clinical trial registration no.: NCT02492724 ( clinicaltrials.gov ) 31)


A total of 225 patients received the Mobi-C cervical total disc replacement device and 105 patients received ACDF. The Mobi-C and ACDF follow-up rates were 90.7% and 86.7%, respectively (p = 0.39), at 60 months. There was significant improvement in all outcome scores relative to baseline at all time points. The Mobi-C patients had significantly more improvement than ACDF patients in terms of Neck Disability Index score, SF-12 Physical Component Summary, and overall satisfaction with treatment at 60 months. The reoperation rate was significantly lower with Mobi-C (4%) versus ACDF (16%). There were no significant differences in the adverse event rate between groups.

Both cervical total disc replacement and ACDF significantly improved general and disease-specific measures compared with baseline. However, there was significantly greater improvement in general and disease-specific outcome measures and a lower rate of reoperation in the 2-level disc replacement patients versus ACDF control patients. Clinical trial registration no. NCT00389597 ( clinicaltrials.gov ) 32).


Twenty patients (12 females, 8 males; median age 45.6 ± 6.9 years) treated by ACDA (BryanDisc®, Medtronic, Minneapolis, USA) underwent plain functional radiography and kinematic MRI of the cervical spine at 3T before and 6 and 24 months after surgery.

A sagittal T2-weighted (T2w) 2D turbo spin echo (TSE) sequence and a 3D T2w dataset with secondary axial reconstruction were acquired. Signal intensity of all nonoperated discs was measured in regions of interest (ROI). Disc heights adjacent to the operated segment were measured. Range of motion (ROM) was evaluated and compared to plain functional radiographs. Clinical outcome was evaluated using the visual analog scale (VAS) for head, neck and radicular pain, and the neck disability index (NDI).

Mean ROM of the cervical spine on functional plain radiographs was 21.25 ± 8.19, 22.29 ± 4.82 and 26.0 ± 6.9 degrees preoperatively and at 6-month and 24-month follow-up, respectively. Mean ROM at MRI was 27.1 ± 6.78, 29.45 ± 9.51 and 31.95 ± 9.58 degrees, respectively. There was good correlation between both techniques. Follow-up examinations demonstrated no signs of progressive degenerative disc disease of adjacent levels. All patients had clinical improvement up to 24 months after surgery.

After ACDA, kinematic MRI allows evaluation of the ROM with excellent correlation to plain functional radiographs. Mid-term follow-up after ACDA is without evidence of progressive DDD of adjacent segments 33).


A prospective, multicenter, randomized, unblinded clinical trial. Patients with symptomatic degenerative disc disease were enrolled to receive 1- or 2-level treatment with either TDR as the investigational device or ACDF as the control treatment. There were 260 patients in the 1-level study (179 TDR and 81 ACDF patients) and 339 patients in the 2-level study (234 TDR and 105 ACDF patients). RESULTS At 5 years, the occurrence of subsequent surgical intervention was significantly higher among ACDF patients for 1-level (TDR, 4.5% [8/179]; ACDF, 17.3% [14/81]; p = 0.0012) and 2-level (TDR, 7.3% [17/234]; ACDF, 21.0% [22/105], p = 0.0007) treatment. The TDR group demonstrated significantly fewer index- and adjacent-level subsequent surgeries in both the 1- and 2-level cohorts.

Five-year results showed treatment with cervical TDR to result in a significantly lower rate of subsequent surgical intervention than treatment with ACDF for both 1 and 2 levels of treatment. Clinical trial registration no.: NCT00389597 ( clinicaltrials.gov ) 34).

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Fleck S, Langner S, Rosenstengel C, Kessler R, Matthes M, Müller JU, Langner I, Marx S, Schroeder HW. 3 Tesla Kinematic MRI of the Cervical Spine for Evaluation of Adjacent Level Disease after Monosegmental Anterior Cervical Discectomy and Arthroplasty: Results of 2-Year Follow-up“”. Spine (Phila Pa 1976). 2016 May 23. [Epub ahead of print] PubMed PMID: 27220031.
34)

Jackson RJ, Davis RJ, Hoffman GA, Bae HW, Hisey MS, Kim KD, Gaede SE, Nunley PD. Subsequent surgery rates after cervical total disc replacement using a Mobi-C Cervical Disc Prosthesis versus anterior cervical discectomy and fusion: a prospective randomized clinical trial with 5-year follow-up. J Neurosurg Spine. 2016 May;24(5):734-45. doi: 10.3171/2015.8.SPINE15219. Epub 2016 Jan 22. PubMed PMID: 26799118.

XII PREMIO NEUROQUIRÚRGICO DE LA SONCAM “PEDRO MATA”

XII PREMIO NEUROQUIRÚRGICO DE LA SONCAM “PEDRO MATA”

Con el objeto de fomentar el estímulo al trabajo, al estudio y a la investigación básica o clínica en el campo de la Neurocirugía, la Sociedad de Neurocirugía de la Comunidad de Madrid convoca el

XII Premio Neuroquirúrgico de la SONCAM Dr. Pedro Mata

Fecha Límite de Presentación: 2 de octubre de 2017

http://www.soncam.org/premio_mata/premio_mata.php

Update: Lumbar discectomy

Lumbar discectomy is one of the most common spinal surgery worldwide.

The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction are being replaced by muscle sparing, targeted, stability-preserving surgical routes. The increasing speculation on LDHs and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results.

Through the analysis of papers by Lofrese et al. it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation.

The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions. 1).

Indications

Lumbar discectomy is an effective therapy for neurological decompression in patients suffering from lumbar disc herniation, which can be safely performed via minimal invasive procedures 2) 3).

History

In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in The New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined.

Microsurgery

The introduction of microsurgical techniques in 1977 and 1978 was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil 4) and Wolfhard Caspar 5) and so-called microdiscectomy was introduced and represented an important evolution in lumbar disc surgery.

see Lumbar microdiscectomy

Chemonucleolysis

Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures.

In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material.

Percutaneous discectomy

see also percutaneous endoscopic lumbar discectomy.

In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation 6).

Discectomy surgery has evolved from wide open to microscopic and now endoscopic.

Herniotomy

Microsurgery is considered a standard procedure. However, since the herniated fragment was identified as the offending agent, it has always considered necessary to remove fragment only or the entire disc. This dogma is based on the assumption that increased rates of recurrent disc herniations would follow sequestrectomy alone. For the small subgroup of patients with a free fragment compressing the nerve root, Williams was the first to report encouraging results following minimal removal of tissue from the intervertebral disc space 7).

The frequency of herniotomy is gradually increasing in LDH treatment. Herniotomy used to be synonymous with fragmentectomy or sequestrectomy. The term ‘herniotomy’ is defined as removal of the herniated disc fragment only, and the ‘conventional discectomy’ as removal of the herniated disc and degenerative nucleus from the intervertebral disc space.

Minimally invasive discectomy

Minimally invasive discectomy (MID) may be inferior in terms of relief of leg pain, LBP and re-hospitalisation; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD.

In the U.S., it has been estimated that the Medicare system spends over $300 million annually on lumbar discectomies.

Technique


In conjunction with the traditional discectomy, a laminotomy is often involved to permit access to the intervertebral disc. In this procedure, a small piece of bone (the lamina) is removed from the affected vertebra, allowing the surgeon to better see and access the area of disc herniation.

Types

Outcome

More than 10% of these patients report persistent pain after surgery.

Quality of Life (QOL), pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy 8).


From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being.

Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support 9).

see Lumbar discectomy in obesity

Reoperation

retrospective study includes 53 patients who underwent reoperation after failure of lumbar disc surgery to relieve pain. All patients had leg painbefore reoperation, which was successful in 28% of cases. Most clinical features, such as persistence or mode of recurrence of pain, radicular quality of pain, positive straight leg raise, and myelographic root sleeve defects, were not helpful in predicting successful and unsuccessful reoperations. However, a significantly larger percentage of women than men had successful reoperations. Patients who had past or pending compensation claims, who had sensory loss involving more than one dermatome, or who failed to have myelographic dural sac indentations resembling those caused by a herniated disc did poorly with reoperation. A very convincing myelographic defect appears to be needed to justify reoperation at a previously unoperated location. Excision of scar alone or dorsal rhizotomy was of no avail in these cases 10).

Rehabilitation

Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed 11).

Case series

2017

Fifty patients who were scheduled for lumbar disc surgery were divided into 2 groups, namely patients who accepted the surgery at the first offer and those who wanted to think over. Educational level information was obtained and patients were asked whether they had searched their disorder and offered surgery on the Internet. Then, a questionnaire was administered and the reliability of the websites was evaluated. Correction: The first 30 websites on the first 3 pages of Google® search engine, the most commonly used search engine in Turkey, were evaluated with the DISCERN® instrument.

Of 50 patients, 33 (66%) had conducted a search for the surgery on the Internet. All university graduates, 88.2% of high school graduates, and 18.7% of primary-secondary school graduates had conducted an Internet search. The quality and reliability of the information was high (4.5 points) for 2 (7.1%) websites, moderate (2.3 points) for 6 websites (21.4%) and poor (1 point) for 20 websites (71.4%) as scored with the DISCERN® instrument. The mean DISCERN® score of was 1.1 for websites of health-related institutions or healthcare news, 2.75 for personal websites of physicians and 2.5 for personal websites of non-physicians. The mean DISCERN® score of all websites was 1.5.

Most of the patients undergoing lumbar disc surgery at our clinic had searched information about the surgical procedure on the Internet. We found that 92.9% of the websites evaluated with the DISCERN® instrument had inadequate information, suggesting low-level reliability 12).

2016

The full set of prospectively gathered Medicare insurance data (2005-2012) was retrospectively reviewed. Patients who underwent primary lumbar discectomy for lumbar disc herniations from 2009 to quarter 3 of 2012 were selected. This cohort (n = 41,655) was then divided into two subgroups: those who were diagnosed with incidental durotomy on the day of surgery (n = 2,052) and those who were not (control population). To select a more effective control population, patients of a similar age, gender, smoking status, diabetes mellitus status, chronic pulmonary disease status, and body-mass-index were chosen at random from the control population to create a control cohort. In-hospital costs, length of stay, and rates of 30-day readmission, 90-day wound complications, and 90-day serious adverse effects were compared.

An incidental durotomy rate of 4.9% was observed. Higher rates of wound infection (2.4 vs 1.3%; OR 1.88; 95% CI: 1.31 – 2.70; p < 0.001), wound dehiscence (0.9 vs 0.4%; OR 2.39; 95% CI: 1.31 – 4.37; p = 0.004), and serious adverse events related to incidental durotomy (0.9 vs 0.2%; OR 4.10; 95% CI: 2.05 – 8.19; p < 0.0001) were observed in incidental durotomy patients. In-hospital costs were increased by over $4,000 in patients with incidental durotomy (p < 0.0001).

Incidental durotomies occur in almost one in every twenty elderly patients treated with primary lumbar discectomy. Given the increased hospital costs and complication rates, this complication must be viewed as anything but benign 13).


127 patients (of 148 total) with data collected 3 months postoperatively. The patients’ average age at the time of surgery was 46 ± 1 years, and 66.9% of patients were working 3 months postoperatively. Statistical analyses demonstrated that the patients more likely to return to work were those of younger age (44.5 years vs 50.5 years, p = 0.008), males (55.3% vs 28.6%, p = 0.005), those with higher preoperative SF-36 physical function scores (44.0 vs 30.3, p = 0.002), those with lower preoperative ODI scores (43.8 vs 52.6, p = 0.01), nonsmokers (83.5% vs 66.7%, p = 0.03), and those who were working preoperatively (91.8% vs 26.2%, p < 0.0001). When controlling for patients who were working preoperatively (105 patients), only age was a statistically significant predictor of postoperative return to work (44.1 years vs 51.1 years, p = 0.049).

In this cohort of lumbar discectomy patients, preoperative working status was the strongest predictor of postoperative working status 3 months after surgery. Younger age was also a predictor. Factors not influencing return to work in the logistic regression analysis included sex, BMI, SF-36 physical function score, ODI score, presence of diabetes, smoking status, and systemic illness. Clinical trial registration no.: 01220921 ( clinicaltrials.gov ) 14).

1)

Lofrese G, Mongardi L, Cultrera F, Trapella G, De Bonis P. Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes. Acta Neurochir (Wien). 2017 Jul;159(7):1273-1281. doi: 10.1007/s00701-017-3198-9. Epub 2017 May 22. Review. PubMed PMID: 28534073.

2)

Hansson E, Hansson T. The cost-utility of lumbar disc herniation surgery. Eur Spine J. 2007;16(3):329–337.

3)

Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. 2007;38(3):363–372.

4)

Yasargil M. Lumbar Disc Adult Hydrocephalus. Springer; 1977. Microsurgical operation of herniated lumbar disc; p.

5)

Caspar W, Campbell B, Barbier DD, Kretschmmer R, Gotfried Y. The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery. 1991;28:78–86. discussion 86-87.

6)

Gruber P, Böni T. [Sciatica : From stretch rack to microdiscectomy]. Unfallchirurg. 2015 Nov 16. [Epub ahead of print] German. PubMed PMID: 26573291.

7)

Williams RW. Microlumbar discectomy: a conservative surgical approach to the virgin herniated lumbar disc. Spine (Phila Pa 1976) 1978;3:175–182.

8)

Lubelski D, Senol N, Silverstein MP, Alvin MD, Benzel EC, Mroz TE, Schlenk R. Quality of life outcomes after revision lumbar discectomy. J Neurosurg Spine. 2015 Feb;22(2):173-8. doi: 10.3171/2014.10.SPINE14359. Epub 2014 Dec 5. PubMed PMID: 25478822.

9)

Dorow M, Löbner M, Stein J, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, König HH, Riedel-Heller SG. Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review. PLoS One. 2017 Jan 20;12(1):e0170303. doi: 10.1371/journal.pone.0170303. PubMed PMID: 28107402.

10)

Law JD, Lehman RA, Kirsch WM. Reoperation after lumbar intervertebral disc surgery. J Neurosurg. 1978 Feb;48(2):259-63. PubMed PMID: 146731.

11)

Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014 Mar 14;3:CD003007. doi: 10.1002/14651858.CD003007.pub3. Review. PubMed PMID: 24627325.

12)

Atci IB, Yilmaz H, Kocaman U, Samanci MY. An evaluation of internet use by neurosurgery patients prior to lumbar disc surgery and of information available on internet. Clin Neurol Neurosurg. 2017 Apr 25;158:56-59. doi: 10.1016/j.clineuro.2017.04.019. [Epub ahead of print] PubMed PMID: 28460344.

13)

Puvanesarajah V, Hassanzadeh H. The True Cost of a Dural Tear: Medical and Economic Ramifications of Incidental Durotomy During Lumbar Discectomy in Elderly Medicare Beneficiaries. Spine (Phila Pa 1976). 2016 Aug 31. [Epub ahead of print] PubMed PMID: 27584677.

14)

Than KD, Curran JN, Resnick DK, Shaffrey CI, Ghogawala Z, Mummaneni PV. How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry. J Neurosurg Spine. 2016 Mar 18:1-6. [Epub ahead of print] PubMed PMID: 26989977.

Update: Dural ectasia

Dural ectasia is widening or ballooning of the dural sac surrounding the spinal cord. This usually occurs in the lumbosacral region, as this is where the cerebrospinal fluid pressure is greatest, but the spinal canal can be affected in any plane.

Case courtesy of Dr Franco Ruales, Radiopaedia.org. From the case rID: 16114

Most common symptoms include low back painheadaches, weaknessnumbness above and below the involved limb, leg pain, and sometimes there can be rectal and genital pain. Bowel and bladder dysfunction, urinary retention or even incontinence may occur.

The symptoms are usually exacerbated by upright posture and often but not always relieved by lying down. However, in many patients it is asymptomatic.

It is common in Marfan syndrome, occurring in 63–92% of people with the syndrome. Dural ectasia may also occur in Ehlers-Danlos Syndrome, neurofibromatosis type I, ankylosing spondylitis, and trauma.

A “classic” picture of dural ectasia in the Marfan patient may consist of low back pain, headache, proximal leg pain, weakness and numbness above and below the knee, and genital/rectal pain. Symptoms, when present, are typically moderate to severe, occur several times per week (often daily), are commonly exacerbated by upright posture, and are not always relieved by recumbency 1).

Radiographic features

Dural ectasia is dilation of the dural sac. Anteroposterior diameter of the thecal sac at the S1 level greater than that of the thecal sac at the L4 level ref required.

Plain radiograph

Posterior vertebral scalloping may be an indirect indicator 2) 3). However, this is not specific, as it is seen in a significant percentage of the normal population and is also associated with several other conditions.

MRI

Increase in the AP diameter of the dural sac, usually in the lumbar region.

Differential diagnosis

Pathology

Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated spinal dura mater pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.

Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.

The majority of dural pathologies involving nerve root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Saccular dural diverticula (type I) and dissections between dural layers (type II) pathologies were treated with good long-term results occluding their dural defects, while dural ectasias (type III) were managed conservatively 4).

Complications

Dural ectasia is one of the likely causes of incomplete or failed spinal anaesthesia. Its association with diseases like Marfans syndrome, neurofibromatosis, osteogenesis imperfecta, vertebral fracture, postopertative adhesions, trauma etc., is often overlooked as a reason for inadequate spinal anaesthesia. Greater than normal volume of cerebrospinal fluid in the lumber theca in dural ectasia is postulated to restrict the spread of intrathecally injected Local anaesthetic 5).

1)

Foran JR, Pyeritz RE, Dietz HC, Sponseller PD. Characterization of the symptoms associated with dural ectasia in the Marfan patient. Am J Med Genet A. 2005 Apr 1;134A(1):58-65. PubMed PMID: 15690402.
2)

Habermann CR, Weiss F, Schoder V et-al. MR evaluation of dural ectasia in Marfan syndrome: reassessment of the established criteria in children, adolescents, and young adults. Radiology. 2005;234 (2): 535-41. doi:10.1148/radiol.2342031497
3)

Wakely SL. The posterior vertebral scalloping sign. Radiology. 2006;239 (2): 607-9. doi:10.1148/radiol.2392040224
4)

Klekamp J. A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias. Neurosurgery. 2017 Mar 17. doi: 10.1093/neuros/nyx049. [Epub ahead of print] PubMed PMID: 28327939.
5)

Gupta N, Gupta V, Kumar A, Kumar G. Dural ectasia. Indian Journal of Anaesthesia. 2014;58(2):199-201. doi:10.4103/0019-5049.130829.

Update: Propionibacterium acnes

Propionibacterium acnes is the relatively slow-growing, typically aerotolerant anaerobic, Gram positive bacteria linked to the skin condition of acne; it can also cause chronic blepharitis and endophthalmitis, the latter particularly following intraocular surgery. The genome of the bacterium has been sequenced and a study has shown several genes can generate enzymes for degrading skin and proteins that may be immunogenic (activating the immune system).

This bacterium is largely commensal and part of the skin flora present on most healthy adult humans’ skin.

It is usually just barely detectable on the skin of healthy preadolescents. It lives primarily on, among other things, fatty acids in sebum secreted by sebaceous glands in the follicles. It may also be found throughout the gastrointestinal tract in humans and many other animals.

It is named after its ability to generate propionic acid.


Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination

A study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination 1).


The presence of 36/46 modic changes in patients with lumbar disc herniation, positive for P. acnes suggests that P. acnes can lead to edema on the vertebrae endplates near to infected area 2).


In a study, 145 patients including 25 cases with cervical and 120 cases with lumbar disc herniation were enrolled. There was no significant difference in the age of male and female patients (p = 0.123). P. acnes infection was detected in nine patients (36%) with cervical disc herniation and 46 patients (38.3%) with lumbar disc herniation and no significant differences were reported in P. acnes presence according to the disc regions (p = 0.508.). Moreover, there was a significant difference in the presence of P. acnes infection according to the level of lumbar disc herniation (p = 0.028).

According to the results, the presence of P. acnes is equal in patients with cervical and lumbar disc herniation. There was a significant difference in the distribution of P. acnes infection according to level of lumbar disc herniation 3).

Case series

Clinical data obtained from 14 cases of P. acnes infection and 28 controls infected with other pathogens were analyzed. Craniotomy, malignancy, and prolonged duration of operation were significantly associated with the onset of P. acnes infection. No fatal cases were reported 4).

Case reports

2017

Hemiparesis may be the result of lesions in the contralateral pyramidal tract in the brain or, less frequently, in the ipsilateral pyramidal tract in the upper cervical spinal cord. However, although rare, multiple lesions that simultaneously occur in both of these regions may be the cause of acute hemiparesis, and the clinical symptoms can often be misdiagnosed as a stroke. In addition, the correct diagnosis of these multiple central nervous system (CNS) lesions is very challenging if they are caused by infection from an unexpected microorganism. We evaluated an elderly healthy woman who presented with acute hemiparesis and multiple brain and spinal cord lesions that were confirmed to occur from an infection with Propionibacterium acnes. In this report, the differential diagnosis and histopathological findings are discussed for these multiple CNS lesions in this healthy woman 5).

1)

Capoor MN, Ruzicka F, Schmitz JE, James GA, Machackova T, Jancalek R, Smrcka M, Lipina R, Ahmed FS, Alamin TF, Anand N, Baird JC, Bhatia N, Demir-Deviren S, Eastlack RK, Fisher S, Garfin SR, Gogia JS, Gokaslan ZL, Kuo CC, Lee YP, Mavrommatis K, Michu E, Noskova H, Raz A, Sana J, Shamie AN, Stewart PS, Stonemetz JL, Wang JC, Witham TF, Coscia MF, Birkenmaier C, Fischetti VA, Slaby O. Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy. PLoS One. 2017 Apr 3;12(4):e0174518. doi: 10.1371/journal.pone.0174518. eCollection 2017. PubMed PMID: 28369127; PubMed Central PMCID: PMC5378350.
2)

Aghazadeh J, Salehpour F, Ziaeii E, Javanshir N, Samadi A, Sadeghi J, Mirzaei F, Naseri Alavi SA. Modic changes in the adjacent vertebrae due to disc material infection with Propionibacterium acnes in patients with lumbar disc herniation. Eur Spine J. 2016 Nov 24. [Epub ahead of print] PubMed PMID: 27885471.
3)

Javanshir N, Salehpour F, Aghazadeh J, Mirzaei F, Naseri Alavi SA. The distribution of infection with Propionibacterium acnes is equal in patients with cervical and lumbar disc herniation. Eur Spine J. 2017 Jul 15. doi: 10.1007/s00586-017-5219-z. [Epub ahead of print] PubMed PMID: 28712017.
4)

Haruki Y, Hagiya H, Takahashi Y, Yoshida H, Kobayashi K, Yukiue T, Tsuboi N, Sugiyama T. Risk factors for Propionibacterium acnes infection after neurosurgery: A case-control study. J Infect Chemother. 2017 Apr;23(4):256-258. doi: 10.1016/j.jiac.2016.10.003. Epub 2016 Nov 23. PubMed PMID: 27889246.
5)

Lee JH, Heo SH, Lee JS, Chang DI, Park KH, Sung JY, Hong IK, Kim MH, Park BJ, Choi WS. Acute Hemiparesis in a Healthy Elderly Woman: Where and What Is the Lesion? Front Neurol. 2017 Mar 21;8:109. doi: 10.3389/fneur.2017.00109. eCollection 2017. PubMed PMID: 28377743; PubMed Central PMCID: PMC5359233.

Update: Sagittal Balance

The analysis of the sagittal balance appeared to be essential in the management of lumbar degenerative pathologies, especially when a spinal fusion is achieved.

Sagittal balance in adult spinal deformity is a major predictor of quality of life. A temporary loss of paraspinal muscle force and somatic pain following spine surgery may limit a patient’s ability to maintain posture.

A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balanceis vital to achieve optimum outcomes when treating spinal disorders.

The Scoliosis research society (SRS) has previously described1) normal sagittal balance as occurring when a plumb line drawn from the centre of the body of C7 lies within ±2 cm of the sacral promontory.

Different authors have described numerous indices for measuring changes in sagittal balance.

see Cervical sagittal balance.

Case series

2017

A retrospective review of a prospective observational database identified a consecutive series of patients with sagittal vertical axis(SVA) > 40 mm undergoing adult deformity surgery. Radiographic parameters and clinical outcomes were measured out to 2 yr after surgery.

A total of 113 consecutive patients met inclusion criteria. Mean preoperative SVA was 90.3 mm, increased to 104.6 mm in the first week, then gradually reduced at each follow-up interval to 59.2 mm at 6 wk, 45.0 mm at 3 mo, 38.6 mm at 6 mo, and 34.1 mm at 1 yr (all P < .05). SVA did not change between 1 and 2 yr. Pelvic incidence-lumbar lordosis (PI-LL) corrected immediately from 25.3° to 8.5° (16.8° change; P < .01) and a decreased pelvic tilt from 27.6° to 17.6° (10° change; P < .01). No further change was noted in PI-LL. Pelvic tilt increased to 20.2° ( P = .01) at 6 wk and held steady through 2 yr. Mean Visual Analog Scale, Oswestry Disability Index, and Short Form-36 scores all improved; pain rapidly improved, whereas disability measures improved as SVA improved.

Radiographic assessment of global sagittal alignment did not fully reflect surgical correction of sagittal balance until 6 mo after adult deformity surgery. Sagittal balance initially worsened then steadily improved at each interval over the first year postoperatively. At 1 yr, all clinical and radiographic measures outcomes were significantly improved 2).

2016

Farrokhi et al., performed a case-control study in which 48 patients with lumbar spine stenosis and 54 age- and sex-matched healthy subjects with back pain were eligible for participation. They used INFINITT picture archiving and communication systems (PACS) of the Chamran Hospital for selecting the patients for the study group. The sagittal balance, pelvic incidence, lumbar lordosis, and sacral slope were measured in all the patients and controls using thoracolumbosacral radiographies in the standing position.

There was no significant difference between the 2 groups regarding the baseline characteristics. The prevalence of sagittal imbalance was significantly higher in the patients with lumbar spine stenosis in comparison with the controls (31.2% vs. 14.8%; P<0.001). The sacral slope was significantly lower in patients with lumbar canal stenosis than the healthy controls (31.39°±11.2 vs. 43.7°±8.4; P<0.001). The lumbar lordosis was significantly lower in patients with lumbar canal stenosis than the controls (31.27°±12.4 vs. 45.8°±10.7; P < 0.001). The pelvic incidence was not significantly different between the 2 groups (50.16°±11.9 vs. 52°±9.6; P=0.342).

The degenerative lumbar canal stenosis is associated with increased sagittal imbalance and decreased lumbar lordosis and sacral slope in a sample of the Iranian adult population 3).

2015

Preoperative sagittal balance was not significantly correlated with clinical or HRQOL outcomes after decompression surgery in LCS patients without coronal imbalance. Decompression surgery improved the sagittal vertical axis (SVA) value in patients with preoperative sagittal imbalance; however, the patients with severe preoperative sagittal imbalance (SVA > 80 mm) had residual imbalance after decompression surgery. Both clinical and HRQOL outcomes were negatively affected by postoperative residual sagittal imbalance 4).

1)

Scoliosis Research Society. White paper on sagittal plane alignment

2)

McDowell MM, Tempel ZJ, Gandhoke GS, Khattar NK, Hamilton DK, Kanter AS, Okonkwo DO. Evolution of Sagittal Imbalance Following Corrective Surgery for Sagittal Plane Deformity. Neurosurgery. 2017 Apr 10. doi: 10.1093/neuros/nyx145. [Epub ahead of print] PubMed PMID: 28402485.

3)

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