Scarcely Invasive Interventions in Hernias
of Intervertebral Disks

Vasilyev A.Yu., Kaznacheev V.M., Pakhomov G.A., Luppova I.V., Shumailova T.M.

Chief Clinical Hospital of the Russian Ministry of Internal Affairs, Moscow

Vertebrogenic lesions of the nervous system are the most widespread chronic disease of a man. Every second inhabitant of the planet has clinical manifestations of this disease, which is a serious medicosocial problem due to its spread and a high rate of invalidism [6, 8].

There are no etiotropic methods, capable of arresting degeneration of spinal structures. Thus, pathogenetic therapy occupies a leading position. Surgical methods are aimed only at elimination of a local conflict [2, 5].

A number of interventions for degenerative lesions at the lumbar spine level, performed in developed countries every year, is 20-70/100000 men [1].

At the same time a rate of unsuccessful operations at this level varies from 15% up to 50% [12].

The last years are characterized by a smaller number of operations for discogenic compression syndrome. Achievements in the field of laser technologies promoted development of a new method, known as percutaneous laser decompression of a disk. It has many important advantages and demands further study [3, 4, 7, 9-11, 13].

Material and Methods

There were 120 patients with a radicular syndrome, caused by compression due to protrusion and prolapse of the lower lumbar disks. The results of surgical treatment were studied. Postoperative observation was carried out in all cases.

Mean age and duration of the disease were 39.4±6.7 and 3.5 years respectively. Surgical intervention was preceded by treatment in an outpatient department or hospital in the majority of cases: multimodality therapy (drug, physiotherapeutic and manual therapy, local radicular blocks) had been used in 82 patients (68.3%); 15 cases (21.4%) had been treated in different sanatoria.

Radicular syndrome, reduction of muscular tension and strength were watched in 89.2% of cases with hernia of an intervertebral disk.

MRT and CT examinations of the lumbosacral spine were carried out with the help of Picker M and Picker Q-2000 apparatus (USA). Their purpose was determination of a hernia level, localization and its interrelations with neural structures of the vertebral canal.

Distribution of disk lesions was as follows: L3 -L4 3 cases (2.5%), L4 -L5 - 59 patients (49.2%) and L5 -S1 - 58 cases (48.3%).

Paramedian, medial and lateral hernias were observed in 50.0%, 25.8% and 24.2% of patients respectively. A sagittal size of hernias was 6-7 mm (59 cases), 7-10 mm (36 cases), 10 mm and more (25 cases).

Paracentetic laser vaporization of a pulpous nucleus of one or two lumbar disks was performed in 70 patients under CT control. An angle of a needle dip, distance between a spinous process and a place of needle insertion, distance to a central part of a disk were calculated on the basis of a topogram and axial section after CT-scanning of the lumbar spine (Fig.1).

A disk was punctured to a depth of 2 cm under local anesthesia. A needle position and exact localization of its tip were watched with the help of CT (Fig.2).

A light guide was inserted into a disk via a needle aperture. Vaporization was carried out with a neodymium YAG laser (Dornier Medialas Fibertom 5060/5100), operating in a pulse mode (pulse duration of 1 sec, frequency of 0.5 Hz, power of 15 W). Laser irradiation of a disk was fractional. Total energy of an impact was calculated during a procedure for each individual patient. It varied from 900 up to 1500 J. A disk size was decreased by water vaporization and protein denaturation without vaporizing tissue of a pulpous nucleus. It helped to make intervention less traumatic. In multi-level lesions laser vaporization of "clinically sounding" disks was used.

A needle with a light guide was removed at the end of operation. A patient was allowed to walk in 3-4 hours after operation with a semi-rigid jacket on.

After laser vaporization a patient stayed in hospital during 5 days. It was necessary for revealing possible complications (diskitis, inflammation in a zone of a puncture channel), restoration of a volume of movements, mastering a complex of exercises for strengthening muscles of the back and ensuring good support of the spine by them. In case of gross static-dynamic disorders and muscle paresis restorative treatment was carried out under conditions of a neurologic hospital during 2-3 weeks.

Hernias with a sagittal size of 6-10 mm were vaporized in 53 cases (84.3%). This size was more than 10 mm in 11 patients (15.7%). Sequestrated hernias were watched in 6 cases (8.6%). Three of them underwent subsequent microdiscectomy because of preserved pain syndrome.

Microsurgical removal of an intervertebral disk by an intralaminar approach or via fenestration of an interarch space was performed in 50 patients (a control group).

Microdiscectomy was performed in hernias with a sagittal size of more than 7 and 10 mm; it was done in 40 (80%) and 19 (38%) of cases respectively. Sequestrated hernias were present in 12 patients (24%).

An intralaminar approach was used for removal of hernia in 12 cases (24%). Minimum marginal resection of adjacent arches was made in 38 patients (76.0%). It allowed to perform full-value removal of a hernia and degenerated part of a disk without additional trauma of nervous structures and damage of epidural veins.

Patients, who had undergone microdiscectomy, stayed in hospital within 10 days-3 weeks. They were allowed to leave their beds on the second day after operation. Remedial gymnastics, aimed at formation of strong muscles and restoration of a volume of movements in the spine, started on the same day as well. Patients were discharged after removal of sutures. In case of preserved pain syndrome, presence of gross static-dynamic disorders, muscle paresis treatment was continued in a neurologic hospital and lasted 2-3 weeks.

Results

Dynamics of pain syndrome regress from the first postoperative day up to discharge was as follows: pain syndrome regressed within three days after laser vaporization in 84% of cases; it should be noted, that radicular pain and Laseg's syndrome regressed just on an operating table in every tenth patient. (Fig.3).

Lumbar pain disappeared completely in 56 cases (60%). Microdiscectomy was performed in 3 (4.3%) out of 9 patients (12.9%) with preserved pain syndrome; 6 cases (8.6%) were satisfied with an achieved result. There was no aggravation of a state in any patient. Two cases (2.9%) developed aseptic diskitis at the intervention level in the nearest postoperative period.

Long-term results of puncture laser vaporization of an intervertebral disk (3-12 months) were positive in 61 patients (87.1%) (Fig.4).

Good results, manifesting themselves in absence of pain, restoration of muscular tension and a volume of movements in the spine, preservation of working capacity were watched in 47 patients (67.1%).

Satisfactory results in the form of considerable reduction of pain, its episodic character, partial regress of motor disorders as well as sense and reflex disturbances, preserved working capacity were typical of 14 cases (20%). The operation was ineffective in 9 patients (12.9%). There was no aggravation of a state in any patient.

Control MRT- examination was carried out in 43 patients. This or that degree of hernia retraction was observed in 67% of cases. A hernia size did not change in one third of patients. There was no distinct correlation between dynamics of neurologic manifestations and changes of a hernia size.

Female patient P., aged 49. Diagnosis: Hernias of L4 -L5 , L5 -S1 disks with L5 and S1 bilateral radicular syndrome. She was admitted to the hospital with complaints of acute pain in the lumbar spine, irradiating along posterior-lateral surfaces of both legs. The disease duration was more than five years, but the patient had underwent no treatment before. There had been acute intensification of pain 4 weeks before hospitalization, caused by an awkward movement. Complex conservative treatment in a neurologic inpatient department had been ineffective.

Examination revealed left-side scoliosis, flattening of the lumbar lordosis, tense rectal muscles of the back, restricted movements in the lumbar spine. There were absence of the ankle reflex on the left, hyperesthesia on the external surface of the left shin, Laseg's symptom (20 o on the left and 40 o on the right). MRT findings are given in Fig.5.

The radicular syndrome regressed immediately after laser vaporization of both disks. The patient began to walk in two hours after operation. Pain disappeared on the 4th day; statics and a volume of movements in the spine restored on the 6th day. The patient was discharged. She began to work in three weeks after operation. Control examination was carried out in 4.5 months (Fig.6).

At present the patient's mode of life remains the same. There are no restriction of movements and neurologic disorders.

Good results of microdisectomy (complete absence of radicular pain and symptoms of roots tension) were watched in 43 patients. Radicular pain disappeared in 47 operated cases. Complete regress of sense disturbances was present in 38 patients. Minor radicular pain was typical of 3 patients, but it did not limit their activity. The operation did not lead to aggravation of a state in any patient.

Patient M., aged 36. Diagnosis: Sequestrated median-lateral hernia of the L5 -S1 intervertebral disk with left-side radicular syndrome at the level of S1 . On admission the patient complained of pain in the lumbar spine, dull pain, spreading along the posterior surface of the left leg, restricted movements in the lumbosacral spine, foot weakness, numbness of the external surface of the left shin. Pain in the lumbar spine appeared five years ago. Before admission the patient had been treated in an outpatient department with a good positive effect. Physical load, experienced in October 2000, had resulted in resumption of pain syndrome with irradiation of pain into the left leg. Conservative treatment in a hospital, including physiotherapy, traction, massage, remedial gymnastics had given no effect.

Examination revealed left-side scoliosis, tense rectal muscles of the back, blocked movements in the lumbar spine. Muscular tension in the left shin and sole flexion of the left foot were reduced. There was marked Laseg's symptom on the left (20 o). Results of CT examination of the suprasacral disk are given in Fig.7.

General anesthesia was used for microdiscectomy via fenestration of L5 -S1 on the left. There were no complications.

Pain in the lumbar spine and leg reduced considerably immediately after operation. Statics of the spine was restored. The patient began walking on the following day after operation. Sutures were removed on the 8th day; the wound healed by first intention. Statics and a volume of movements in the lumbar spine restored on the 15th day. The patient was allowed to sit. He was discharged on the 17th day. The patient started to work in 5 weeks after operation.

At present the patient has no complaints (11 months after operation). His way of life has not changed. The spine axis is normal, There are no restricted or painful movements, as well as neurologic disorders. Findings of control CT examination are given in Fig.8.

Dynamics of pain syndrome regress from the first day of operation and up to a day of discharge is presented in Fig.9.

Long-term observation lasted 6-9 months and 9-12 months in 28 and 22 cases respectively. Estimation of remote results of treatment by patients is given in Fig.10.

Remote results were positive in 48 cases. Two patients, who estimated the operation result as unsatisfactory, had considerable excessive weight and psychologic instability.

Good results of surgical treatment (absence of pain, restoration of muscular tension and a volume of movements in the spine, preserved working capacity) were watched in more than 74% of cases. There was no pain of any type in 58% of patients. Absence of pain in legs was observed in 78% of cases. Satisfactory results (considerable reduction of pain, their episodic character, partial regress of motor disorders, sense and reflex disturbances, partial preservation of working ability) was typical of more than 22% of patients. Efficacy of operation in 2 cases was limited by preserved persistent pain syndrome in the lumbar spine and presence of static-dynamic disorders. There were complete restoration of muscular tension, a volume of movements in the spine in 37 cases, working capacity was preserved in 40 patients.

Thus, puncture laser vaporization of an intervertebral disk and microdiscectomy led to arrest of pain syndrome and elimination of focal neurologic deficit in 67.2% and 70.0% of cases respectively. Good and satisfactory results in a remote postoperative period were watched in 72.8% and 78.0% of patients respectively.

Conclusions

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