In 1838, Key (2) described the pathological findings of two cases of cord compression by "intervertebral substance." In the 1800s and early 1900s many cases of chondromas of the cervical spine were reported. In 1928 Stookey (50) described the clinical symptoms and anatomic location of cervical disk herniation. In 1934, Mixter and Barr documented four cervical disc protrusions. Before 1950, the standard approach to discs in this region was posteriorly with laminectomy. In the 1950s Bailey, Badgley, Cloward, (10,11) Smith and Robinson (48) popularized the anterior approach with interbody fusion. Hirsch (19) in 1960, then Robertson (44) in 1973, recommended cervical discectomy without fusion. Similar results were noted.

Open cervical discectomy is considered the standard. (19) However, open discectomy is associated with a significant morbidity, graft doner site symptoms and a significant period of convalescence. (49) Because no grafts are used in the percutaneous cervical discectomy ( 4-6, 12, 44) the absence of graft doner site symptoms results in a decrease in local morbidity and in period of convalescence.

The purpose of this study is to further assess the safety and efficacy of outpatient percutaneous (endoscopic) decompression discectomy (2-4, 23, 33, 29-47, 51, 53) in treatment for symptomatic cervical nonextruded herniated nucleus pulposus (Figs 1a-c).

Materials And Methods

Between 1994 and 1996, 77 prospective consecutive patients were treated with percutaneous (endoscopic) decompression discectomy. Their average age was 43.3 years of age (28 to 70) and all were diagnosed with nonextrudcd cervical herniated nucleus pulposus after 12 weeks of unsuccessful conservative care failed. The C3 was involved twice (2.6%), C4 21 times (27. 3%), Cs 47 times (61 %) and C6 22 times (28.6%) (Table 1).

Indications for Surgery:

• Pain radiating from neck downwards to the arm.
• Symptoms, and signs of sensory loss, tingling, numbness, muscle weakness and decreased reflexes in the upper extremities.
• A positive MRI or CT scan for disk herniation consistent with dermatome of clinical symptoms.
• No improvement of symptoms after a minimum of 12 weeks of conservative therapy.
• Positive electromyographic study was considered helpful.

Contraindications for Slurgery:

• Evidence of acute or progressive degenerative spinal cord diseases.
• Evidence of neurologic or vascular pathologies mimicking a herniated disc.
• Evidence of advanced spondylosis (significant bone spurs) with disk space narrowing, diffuse annular bulging and other spine irregularities.
• Evidence of significant bony spurs blocking entry into the disc space.
• Evidence of cervical spinal canal or lateral recess stenosis.
• Evidence of an extruded disc or a free fragment.
• Evidence of pathologies or conditions such as fractures, tumors, pregnancy or active infections.

The level of the cervical disc herniation was recorded in all patients. A history was taken of prior surgeries especially to the spine. The patients were queried as to the use of epidural injections, nonsteroidal anti-inflammatory medications, oral steroids, muscle relaxants, aspirin, analgesics, tranquilizers, oral morphine, or morphine analogues.

The presence of headaches and neck pain, weakness of muscles, muscle spasm, and the range of motion were all documented. Numbness was noted with consideration of the dermatome. Reflex changes were also recorded.

The findings of MRI scans and EMG/ NC5I studies were recorded. Intraoperative complications consisting of inability to access pertinent part of disk, and arterial or nerve compromise were assessed. Postoperative complications involving arterial or nerve compromise, infection, residual neck pain, and recurrent symptoms were noted.

Surgical Technique

After general anesthesia is administered, the patient is positioned in a supine position with a cushion placed beneath the shoulders and the chin is extended. A soft strap is placed over the forehead to stabilize it. The shoulders are distracted gently downwards by the use of tape. C-arm flouroscopy is used in both the AP and lateral planes. Using fluoroscopic imaging, a guide wire is placed over the center of the disk-space. The point of entry is adjacent to the medial border of the sternocleidomatold inuscile, usually on the right, slightly below the midline mark of the disk space. Firm but gentle pressure is applied digitally in the space between the sternocleidomastoid muscle and the trachea, pointing towards the center of the disk space. The larynx and trachea are displaced medially and the carotid artery laterally. The anterior cervical spine is palpable with fingertips. The esophagus may be made more prominent with the use of an esophageal tube. The pulse of the carotid artery may be augmented with use of sympathomimetics (e.g. Ephedrine).

A 2-mm incision is made and the guide wire is entered into the annulus fibrosis. Both We AP and lateral positions are checked. Following this, a cannula is introduced over the guide voice and is held in place with the use of a stopper. A mini-carette is utilized prior to the application of the mini-discectomy cutter-forceps, the mini-discectomy "rasper and the Discectome 5,6 A Discectome is introduced within the cannula and its position is confirmed by fluoroscope in both planes (Figs. 1, 3-7).

The disc material is removed with the combined use of a Discectome and mini-spinal discectomy instruments including mini-curettes, mini cutter-forceps and mini graspers. A critical fan sweep maneuver (6) with a 25-degree "rocking" excursion from side to side to increase the area of total disc removal can increase up to approximately a 50-degree critical fan sweep area (in a cone-shaped manner) (Fig. 8). This procedure is performed and monitored with fluoroscope and x-ray magnification and/or endoscopy (with a rigid or fiberoptic endoscope). endoscopy was utilized on the last 63 cases (Fig. 9).

Figure 8: Critical Fan Sweep Manuever

Figure 9. Hole in post-op disk.

Results (Table 2)

Preoperatively, three patients (3.9%) were treated with epidural pain injections. All patients were treated with nonsteroidal anti-inflammatory medications. Fourteen patients (18.2%) were treated with oral steroids. Fifty-three patients (69.8%) were treated with muscle relaxants. Twenty-six patients (33.8%) were treated with aspirin. Five patients (6.5%) were treated with tranquilizers. Two patients used morphine or morphine analogues For pain control, but not postoperatively.

Patient follow-up evaluation occurred at an average of 13 months postoperatively (1 to 18 months). Preoperatively, 77 patients (100%) reported neck pain and postoperatively 5 patients (6.5%) reported varying levels of pain and required occasional mild analgesic medication at the latest follow-up. However, all patients were able to resume a fully active lifestyle. Two patients had persistent mild neck and upper extremity pain, While 72 patients (93.5%) had had excellent recovery without pain. There were no postoperative complications involving arterial or nerve compromise; no infection was noted. Postoperatively, 44 patients (57.1%) were noted to have weakness from the dermatome, while three patients (3.9%) had persistent or residual decreased weakness at the latest follow-up. Seventy-seven patients (10(~%) demonstrated muscle spasm of the neck, preoperatively, while two patients (2.6%) continued to hay-c reduced muscle spasms postoperatively. Seventy-seven patients (100%) demonstrated dermatome specific numbness and decreased pain and touch sensation preoperatively while two patients (? 6%) reported persistent decreased pain and touch sensation associated with numbness and tingling after surgery. Postoperatively, 72 patients reported complete relief from subjective numbness and tingling, while five patients (6.5%) reported occasional or intermittent subjective numbness and tingling v. without a loss of pain and touch sensation. The average time that patients returned to work was 2 weeks (3 days to 4 weeks) for non-worker compensation patients.

A number of patients underwent other procedures at the time of the PCD procedure. One patient (1.3%) was treated with a prior anterior cervical decompression and fusion at level C s-6 Four patients (5.2%) were treated with appendectomies, one patient (1.3%) with a Magnuson-Stack procedure of the shoulder, two patients (2.6%) with arthroscopy of the knee joint, three patients (3.9%) with breast implants, two patients (2.6%) with removal of breast implants, one patient with a percutaneous lumbar discectomy, and three patients (3.9%) with liposuction.

MRI scans revealed non-extruded contained herniations that averaged 3 mm (range 2 to 5 mm) in size. EMG/NCV studies were performed in all cases and the findings were related to the affected nerve root.

Discussion

Our two failures were found in patients who reported persistent neck pain, paresthesias, and decreased pain and touch sensation. Both of these patients were young and there was no evidence of spondylosis or degenerative changes. One patient refused to have further evaluation and returned to work. The other patient was evaluated by a physical examination and EMG/NCV studies; neither evaluations determined the pathological source. However, this patient had a history of depression and migraine headaches and continued to lead an active life. Three other patients continued to have occasiona1 mild neck and upper extremity pain, but returned to normal life activities without objective neurological deficits.

These five patients used occasional mild analgesic medication

Our success rate of 93.5% reflects careful patient selection and that the diagnostic evaluations, including MRI scans and EMG/NCV, were consistent with the complaints and physical findings. The success rate reported in the litcrature varies from 40-77%. Our high success rates s may he attributed to proper patient selection and perhaps the youth of the patients.

Percutaneous decompression discectomy (PCD) performed for symptomatic cervical non-extruded herniated nucleus pulposus technique appears to he safe and efficacious, provided that patients are carefully selected and diagnostic evaluation is consistent with symptoms and physical findings. This type of less traumatic outpatient procedures (5,6, 54) can lead to significant economic savings and less morbidity.

The Koros Mini Spinal Discectome System and the mini-micro disecctomy instruments arc products of Koros Surgical instrument Corporation, Moorpark, California.

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