Endoscopic Spine Surgery

Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging, it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery. Initially, endoscopic technique was restricted to the lumbar region but now it also can be used for cervical and thoracic disc herniations. Previously endoscopy was used for disc herniations which were contained without migration but now days it is used for highly up and down migrated disc herniations as well. Use of endoscopic technique in lumbar region was restricted to disc herniations but gradually it is also used for spinal canal stenosis and endoscopic assisted fusion surgeries. Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable. From simple chemonucleolysis to current day endoscopic procedures the history of minimally invasive spine surgery is interesting. Appropriate indications, clear imaging prior to surgery and preplanning are keys to successful outcome. In this article basic procedures of percutaneous endoscopic lumbar discectomy through transforaminal and interlaminar routes, percutaneous endoscopic cervical discectomy, percutaneous endoscopic posterior cervical foraminotomy and percutaneous endoscopic thoracic discectomy are discussed.

Tratamiento percutáneo de hernias discales y dolor discogénico de columna cervical y lumbar con etanol gelificado radiopaco / Percutaneous treatment of cervical and lumbar disc herniation and discogenic pain with radiopaque gelified ethanol

This study documents the efficacy of chemonucleolysis with radiopaque gelified ethanol in the treatment of cervical and lumbar disc herniation and discogenic pain. Ten patients underwent this procedure between April 1 and June 30, 2010. Satisfactory results were obtained in 100 percent of patients. There were no adverse events reported during or post-procedure and a significant reduction in pain and analgesic intake after intradiscal injection was registered. This technique, simple and safe to perform, yielded satisfactory results; thus, it appears to be a good alternative in the treatment of herniated discs and discogenic pain.

Este estudio reporta el resultado de quimionucleolisis usando etanol gelificado radiopaco en el tratamiento de hernias discales o dolor discogénico en columna cervical y lumbar. La muestra de pacientes fue relativamente pequeña y corresponde al periodo del 1º de abril al 30 de junio de 2011. Los resultados fueron satisfactorios en el 100 por ciento de los pacientes. No hubo eventos adversos durante y luego del procedimiento. Se observó significativa reducción de analgésicos y dolor después del procedimiento. Esta técnica fue relativamente simple de realizar y segura en su aplicación mostrando buenos resultados. Promete ser una buena alternativa en el tratamiento de hernias discales o dolor discogénico.

Review of Preoperative Conservative Treatment Period and Evidence of Surgeries for Herniated Lumbar Disc

BACKGROUND: The purpose of this study was 1) to review the length of an adequate period of conservative treatment and the appropriate surgical indications for herniated lumbar disc(HLD), 2) to collate the scientific evidences on surgeries for HLD, and 3) to collect expert opinions on HLD. METHODS: We searched for articles in PubMed, the Cochrane Library and KoreaMed up to 1 October 2008, and these articles were concerned with the natural history of HDL, systemic reviews of HDL and expert opinions on HLD. We also searched for meta-analyses and randomized or quasi-randomized controlled trials(RCTs or QRCTs) of surgery for HLD. We performed a meta-analysis using the Cochrane method. The survey consisting of 21 questions was delivered to all the members of the Korean Spinal Neurosurgery Society(KSNS) via E-mail. RESULTS: A total of 59 articles were included in this study. There were 16 articles concerning the period of conservative management and the surgical indications. Among the 33 articles on surgery for HLD, there were 4 meta-analyses, 27 RCTs, and 2 QRCTs. Among the 938 members of the KSNS, 72 responded to the survey. A minimum of 1 to 3 months of conservative management was the most preferred answer(58%), followed by a conservative management period of less than 1 month(33%). Percutaneous endoscopic discectomy was more preferred by the hospitals that specialized in spinetreatment than by the university hospitals(p<0.05). CONCLUSION: Conservative management for a minimum of 2 weeks to 3 months is recommended for patients with tolerable pain only. The patients with neurological compromise or intolerable pain should be considered for surgery. There is strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is no scientific evidence on the effectiveness of any other form of minimally invasive procedure.

Quimionucleólise cervical associada à espondilectomia ventral em cães: aspectos clínico-cirúrgicos, radiográficos e histológicos / Cervical chemonucleolysis associated to ventral slot in dogs: clinical-surgical, radiological, and histological aspects

Foram avaliados aspectos clínico-cirúrgicos, radiográficos e histológicos de discos intervertebrais cervicais caninos após quimionucleólise com quimiopapaína associada à espondilectomia ventral em 24 cães. Em todos foi realizada a espondilectomia ventral na região do disco intervertebral C2-C3 e quimionucleólises nos demais discos cervicais. Os cães foram sacrificados às 24 horas, e aos 8, 30, 60, 90 e 120 dias após aplicação da enzima para a obtenção de cortes sagitais dos discos intervertebrais tratados e das estruturas cartilaginosas e ósseas adjacentes. Nos mesmos períodos, foram realizadas radiografias para monitoração da espessura dos espaços intervertebrais. Todos toleraram bem o procedimento cirúrgico e não apresentaram alterações clínicas significativas. Na avaliação radiográfica, observou-se marcada redução dos espaços intervertebrais 24 horas após o tratamento. Do oitavo ao 90º dia após aplicação da enzima, foi verificada ausência total de espaço intervertebral na região dos discos tratados. Aos 120 dias, as espessuras dos espaços intervertebrais corresponderam, em média, a 59,1 por cento da espessura anterior ao procedimento. Na avaliação histológica, foram observadas digestão nuclear e redução da intensidade de coloração pela safranina-O 24 horas após a quimionucleólise. A partir do 60º dia, havia material amorfo no espaço nuclear, que, aos 120 dias, tinha aparência fibrocartilaginosa. A quimionucleólise associada à espondilectomia ventral determinou a lise dos discos intervertebrais e lesões nas estruturas cartilaginosas e ósseas adjacentes, com tendência à reparação por tecido fibrocartilaginoso ao longo do tempo.

The clinical-surgical, radiological, and histological aspects of chemonucleolysis with chymopapain in canine cervical intervertebral disks associated to ventral slot in 24 dogs were evaluated. The ventral slot was accomplished in the area of the intervertebral disks C2-C3 and chemonucleolysis in the other cervical disks. The dogs were clinically and radiographically monitored for up to 120 days. Each group of four animals was submitted to euthanasia with an anesthetic overdose at 24 hours, and at 8, 30, 60, 90, and 120 days after the enzyme injection for the acquisition of sagittal sections of the treated disks, as well as adjacent cartilaginous endplates and bony structures. In this study, all dogs tolerated the surgical procedure, without detectable postoperative pain or neurological deficit. In the radiographic evaluation, it was observed consistent disk space narrowing 24 hours after the procedure and total absence of space from the 8th to the 90th day of postoperative in the area of all treated disks. However, 120 days after treatment, there was an increase in disk height, corresponding on average to 59.1 percent of the preinjection value. In the histological evaluation, it was observed nuclear digestion and decrease of safranin-O staining intensity 24 hours after disk injection. At eight days, the nuclear content was still vacuolated, but more fibrillar. An irregularly defined mass was observed in the nuclear space on days 60th and 90th, but it seemed fibrocartilaginous tissue on day 120th. Chemonucleolysis with chymopapain associated to the ventral slot in the cervical column of dogs determined lysis of intervertebral disks, cervical instability, and lesions of cartilaginous and bone adjacent structures that tend to repair with fibrocartilaginous tissue along the time.

Endoscopic Spinal Surgery for Herniated Lumbar Discs

OBJECTIVE: So called "minimally invasive procedures" have evolved from chemonucleolysis, automated percutaneous discectomy, arthroscopic microdiscectomy that are mainly working within the confines of intradiscal space to transforaminal endoscopic technique to remove herniated epidural disc materials directly. The purpose of this study is to assess the result of endoscopic spinal surgery and favorable indications in the thoracolumbar spine. METHODS: The records of 71 patients, 73 endoscopic procedures, were retrospectively analysed. Yeung Endoscopic Spine Surgery system with 7 mm working sleeve and 25degrees viewing angle was used. The mean follow up period was 6 months (range,3-9). RESULTS: Operated levels were from T12-L1 disc down to L5-L6 or S1 disc. Of 71 cases, 2 patients underwent transforaminal endoscopic surgery twice due to recurrence after initial operation. MacNab's criteria was used to assess the outcome. Favorable outcome, excellent or good, was seen in 78% (57 procedures) of the patients. Among 11 fair outcomes, only 1 procedure was followed by secondary open procedure, laminectomy with discectomy. Two of 5 poor outcomes were operated again by same procedure which resulted in fair outcomes. One patient with aggravated cauda equina syndrome remained poor and a lumbar fusion procedure was performed in other patient with poor outcome. There were 2 postoperative discitis that were treated with conservative care in one and anterior lumbar interbody fusion in the other. CONCLUSION: Evolving technology of mechanical, visual instrument enables minimal invasive procedure possible and effective. The transforaminal endoscopic spinal surgery can reach as high as T12-L1 disc level. The rate of favorable outcome is mid-range among reported endoscopic lumbar surgery series. Authors believe that the outcome will be better as cases accumulate and will be able to reach the rate of standard open microsurgery.

Chemonucleolysis in lumbar disc herniation: a meta-analysis

PURPOSE: To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation. METHODS: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command. RESULTS: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95 percent CI: 1.27-1.80). The summary estimate was 1.07 (95 percent CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95 percent CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant. CONCLUSIONS: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect.

OBJETIVO: Avaliar a eficácia da quimonucleólise no tratamento da hérnia de disco lombar por meio de uma metanálise de ensaios clínicos. MÉTODOS: Os ensaios clínicos foram selecionados de três bases de dados eletrônicas( Cochrane, MEDLINE, e EMBASE). Os dados foram analisados por intermédio do aplicativo STATA, com o comando meta. RESULTADOS: trabalhamos com 22 ensaios clínicos. Para a comparação entre quimonucleólise e placebo, a estimativa da razão de riscos, tendo melhora da dor como desfecho, foi de 1,51 (I 95 por cento C: 1,27-1,80). Aquela medida foi de 1,07 (I 95 por cento C: 0,95-1,20) para a comparação entre quimopapaína e colagenase. Em um modelo de efeitos fixos, a razão de risco, para melhora da dor, foi 0,93 (I 95 por cento C: 0,88-0,98), tendo a discectomia como grupo de referência. Nesse caso, um teste de heterogeneidade foi considerado estatisticamente significante. CONCLUSÕES: a eficácia da quimonucleólise foi superior à do placebo e semelhante à da colagenase. Os resultados dos estudos referentes à comparação entre quimonucleólise e cirurgia foram heterogêneos, o que implica interpretação não-trivial da medida de efeito.

La quimionucleolisis en el tratamiento de la hernia discal lumbar resultados clínicos y radiológicos / The chymonucleolysis in the treatment for discal hernia. Clinics and radiolgical results

En este trabajo se intenta demostrar la eficacia o inocuidad de la quimionucleolisis en el tratamiento de la hernia discal como alternativa a la cirugía convencional. Para ello se seleccionó un grupo de 91 pacientes a los cuales se aplica dicha técnica, consistente en la inyección bajo control radiológico y mediante punción intradiscal, del enzima quiomiopapaína en el núcleo pulposo, con el fin de conseguir la disolución química del mismo. Se valora la respuesta clínica al tratamiento, así como radiológica, al mes a los 6 meses del mismo, practicándose radiografía de columna vertebral para valorar las curvas de presión intradiscales. De los 91 pacientes seleccionados, se obtuvieron resultados excelentes en 25 casos (29.41 por ciento), Buenos en 37 casos (43.52 por ciento), aceptables en 11 casos (12.94 por ciento), malos en 5 casos (5.88 por ciento), apreciándose correlación entre la disminución del volumen intradiscal y los resultados clínicos obtenidos.

Surgical Treatments for Lumbar Disc Disease in Adolescent Patients; Chemonucleolysis / Microsurgical Discectomy/ PLIF with Cages

The herniated lumbar disc (HLD) in adolescent patients is characterized by typical discogenic pain that originates from a soft herniated disc. It is frequently related to back trauma, and sometimes it is also combined with a degenerative process and a bony spur such as posterior Schmorl's node. Chemonucleolysis is an excellent minimally invasive treatment having these criteria: leg pain rather than back pain, severe limitation on the straight leg raising test (SLRT), and soft disc protrusion on computed tomography (CT). Microsurgical discectomy is useful in the cases of extruded or sequestered HLD and lateral recess stenosis due to bony spur because the nerve root is not decompressed with chymopapain. Spinal fusion, like as PLIF, should be considered in the cases of severe disc degeneration, instability, and stenosis due to posterior central bony spur. In our study, 185 adolescent patients, whose follow-up period was more than 1 year (the range was 1 - 4 years), underwent spinal surgery due to HLD from March, 1998 to December, 2002 at our institute. Among these cases, we performed chemonucleolysis in 65 cases, microsurgical discectomy in 94 cases, and posterior lumbar interbody fusion (PLIF) with cages in 33 cases including 7 reoperation cases. The clinical success rate was 91% for chemonucleolysis, 95% for microsurgical disectomy, and 89% for PLIF with cages, and there were no non- union cases for the PLIF patients with cages. In adolescent HLD, chemonucleolysis was the 1st choice of treatment because the soft adolescent HLD was effectively treated with chemonucleolysis, especially when the patient satisfied the chemonucleolysis indications.

Ozone Chemonucleolysis on the Lumbar Intervertebral Disc of the Rabbit

OBJECTIVE: This study is aimed to evaluate the chemonucleolytic effect of medical ozone by investigating the change of the signal intensity on magnetic resonance imaging (MRI) scan after injection of medical ozone into the lumbar intervertebral disc of the rabbit. METHODS: A series of 21 intradiscal injections of 1ml of medical ozone(30microgram of ozone per ml of oxygen) was performed in 7 young adult rabbits. Two control series, which 20 intradiscal injections of 0.1ml of iodine contrast medium in 7 young adult rabbits and 21 intradiscal injections of 0.05ml of chymopapain in 7 young adult rabbits, were performed. T2 weighted MRI scan was performed pre-operatively and at 4 weeks after injection. RESULTS: T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series (n=21) of intradiscal injections of medical ozone at 4 weeks after injection, as compared with the control series of intradiscal injections of 0.1ml of iodine contrast medium. T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series(n=21) of intradiscal injections of chymopapain at 4 weeks after injection. Any neurologic deficit or complication was not found in all groups. CONCLUSION: Intradiscal injections of medical ozone into the lumbar intervertebral disc of the rabbits are proven to have chemonucleolytic effects.

Chondroitinase ABC Chemonucleolysis on Normal Rabbit's Lumbar Discs

OBJECTIVE: This study is aimed to evaluate the effect of chondroitinase ABC on normal rabbit lumbar discs. MATERIALS AND METHODS: A series of intradiscal injections of chondroitinase ABC was performed in 9 young adult rabbits. A control series of intradiscal injections of iodine contrast medium was performed in 6 young adult rabbits. Roentgenograms were taken preoperatively and were repeated at one, three, five, seven days after injection of chondroitinase ABC. Roentgenograms also were taken preoperatiely and at seven days after injection of contrast dye. Magnetic resonance imagings(MRI) scan was performed pre-operatively and at seven days after injection. Light microscopic examination of both groups was done at 7 days postinjection. RESULTS: Roentgenographic evidence of disc space narrowing showed significant correlation with time course in the series of intradiscal injections of chondroitinase ABC compared with the control series. T2 weighted MRI of disc space demonstrated significantly decreased signal intensity in the series of intradiscal injections of chondroitinase ABC at seven days after injection, as compared with the control series. Histologic evaluation revealed the stainability of nucleus pulposus and annulus to toluidine blue which was quite decreased. The cytoplasm of notochordal cells of nucleus pulposus appeared to be shrunken, and the large cytoplasmic vacuoles in hematoxylin-eosin stain were decreased in the series of intradiscal injections of chondroitinase ABC, which were not evident in the control series. CONCLUSION: Intradiscal injections of chondroitinase ABC on normal rabbit lumbar disc proven to have chemonucleolytic effects.

Clinical Results of Chemonucleolysis for the Far Lateral Lumbar Disc Herniation

The far lateral lumbar disc herniation occurs ten times less often than the classic posterolateral disc herniations. Its clinical presentation, the anatomy involved, and difficulty of surgical treatment are not well understood. The surgical approach and results also have not been clearly defined. Although there are limited number of reports and series in the literature, there is still no general consensus on the approach to surgical treatment. However, chymopapain, even with a history of controversy and troubling complications, has endured the test of time to show 30 years of clinical success in the treatment of herniated nucleus pulposus. Strict attention to indications, contraindications, and technique ensures safety and efficacy of treatment. Between 1984 and 1997, we treated with chymopapain injection in 69 patients with severe lumbar radiculopathy secondary to far lateral disc herniation. Average patient age was 38.5 years in the 47 male and 22 female patients involved. The L4-5 disc was the most commonly herniated level(44.9%) followed by L3-4(37.8%), L5-S1(13.0%), and L2-3(4.3%). They were assessed using standardized forms as well as the Mcnab classification and questioner. They were reviewed at an average of 5 years 8 months postoperatively. Relief of symptoms was obtained in 63 patients(91.3%) after injection. No one subsequently relapsed requiring operation. All 69 patients available for long-term follow-up had considerable and sustained relief from their symptoms. For ADL(activity of daily living), 50 patients(81.3%) answered that they had no limitation, and regarding the office or house work, 49 patients(71.0%) returned previous work without any difficulties. Based on these findings we recommend the chymopapain injection as the primary treatment for patients with severe radiculopathy secondary to far lateral herniation of a lumbar disc.

Correlation between Pain Scale and Infrared Thermogram in Lumbar Disc Herniations

Back pain and radiating leg pain due to compression of the nerve root by the lumbar disc herniation are subjective symptoms. Objective evaluation of pain site and severity is important for the diagnosis and the treatment. We evaluate the correlation between the severity of pain and the temperature changes in the patients of lumbar disc herniations using infrared thermograms. 174 consecutive patients who underwent operation or chemonucleolysis for single level unilateral disc protrusion with ipsilateral leg pain were included in this study. Subjective pain was divided four groups(Group I: mild pain, Group II: moderate pain, Group III: severe pain, Group IV: intractable pain). Thermal differences of each group were as follows: Group I was 0.26degreesC, Group II was 0.39degreesC, Group III was 0.60degreesC and Group IV was 0.98degreesC. Disc protrusions were divided three groups. Thermal differences of each group were as follows; mild protrusion group was 0.52degreesC, moderate protrusion group was 0.79degreesC and severe protrusion group was 0.95degreesC. Duration of symptom was divided four groups and each thermal differences were as follows: under 2 months was 0.87degreesC, 2 to 6 months was 0.71degreesC, 6 to 12 months was 0.50degreesC and more than 12 months was 0.47degreesC. All these data were statistically significant in p<0.01. In conclusion, infrared thermal imaging can demonstrate the subjective pain objectively. The discogenic pain is the more severe, or the disc herniation is the more protruded, or the symptom duration is the shorter, the thermal difference between the both legs is the more significantly prominent. Thermal difference between both legs is a useful pain scale in the herniated lumbar disc patients. Infrared thermal imaging is effective in the evaluation of lumbar discogenic pain.

Retrospective Outcome Evaluation of Cervical Chemonucleolysis with Digital Infrared Thermographic Imaging

The diagnostic efficacy and comparability of digital infrared thermographic imaging(DITI), computerized tomographic(CT) scan and magnetic resonance imaging(MRI) in the assessment of outcome of chemonucleolysis for herniated soft cervical disc patients with ce rvicobrachial neuralgia were evaluated. Forty seven patients of herniated cervical discs who were treated with nucleolysis using chymopapain for last 2 years were assessed by each studying modality and clinical examinations. All the cases received DITI, CT scan and/ or MRI, and the thermal difference of each patient between symptomatic and asymptomatic limb was analyzed pre- and post-operatively. The diagnostic efficacy of each technology was similar, and inter-rater comparability did not differ significantly. DITI showed significantly good correlation with clinical outcome although there existed a considerable inaccuracy in assessing individual subjects. Digital infrared thermographic imaging was shown to be very useful method in the outcome evaluation of cervical chemonucleolysis.

Minimally Invasive Surgery in Lumbar Disc Herniations with MicroEndoscopic Discectomy System: Technical Note

For lumbar disc herniation, conventional laminectomy and discectomy were used for a long time. Since chemonucleolysis was introduced as a treatment modality of lumbar disc herniation in 1964, other various minimally invasive surgical techniques like Percutaneous Nucleotome, Arthorscopic Microdiscectomy and laser discectomy were developed to minimize postoperative discomfort and morbidity. In conventional surgery with laminectomy, there is no limitation for surgical procedures, and the surgical result is very excellent over 90%. But it causes a postoperative wound pain due to muscle injury and a possibility of nerve root injury. Minimally invasive surgical techniques has advantages of minimal postoperative pain and morbidity. Also it has limitations of narrow indication like soft disc herniation without bony stenosis and comparatively low surgical result about 70%. Recently a new minimal invasive endoscopic discectomy system was developed which has advantages of conventional laminectomy and minimally invasive surgical techniques. It can decompress the nerve root like conventional open surgery and has the benefits of small incision, limited tissue disruption and faster recovery time. We have had 3 cases experiences of MicroEndoscopic Discectomy(MED) system in lumbar disc herniations and got excellent clinical result.

Comparison of Automated Percutaneous Lumbar Discetomy (APLD ) and Chemonucleolysis in the Treatment of Herniated Lumbar intervertebral Discs / 대한정형외과학회잡지

Automated percutaneous lumbar discectomy (APLD) and chemonucleolysis represent two major modalities of recently popularized minimally invasive surgical procedures for the treatment of herniated lumbar discs. However, the controversies concerning the safety and efficacy of the procedures are yet to be settled. The purpose of retrospective study was to determine the efficacy of these percutanous procedures and hence to establish a rational guideline for the treatment of lumbar disc herniations. Clinical review of 615 patients treated by percutaneous procedures revealed 81% success rate following chemonucleolysis and 83% following APLD, with a mean follow-up of 38 months (range 24- 60 months) and 30 months (range 24-38 months) respectively. APLD required less time for resolution of back pain, and resulted in less disc space narrowing than chemonulceolysis. Clinical failures of the procedures were associated with extruded or calcified discs, combined spinal stenosis and discitis. Reduction of herniation size in postoperative CT had no significant correlation to the clinical results. In conclusion, both procedures were effective in contained disc without calcification or associated spinal stenosis. This study suggests some advantages of APLD over chemonucleolysis in the aspect of rapidity of symptom relief, disc space narrowing and possible complications. Reduction in herniation size was not imperative for clinical success. Both procedures appear to be good alternatives to open discectomy in well selected patients, and may be good bridges for the wide gap between conservative treatment and open surgery.

A Clinical Study and Analysis of Chemonuecleolysis Versus Automated Percutaneous Lumbar Discectomy in Herniated Nucleus Pulposus of the Lumbar Spine

The authors reviewed the radiographs and medical records of 134 consecutive patients who underwent chemonucleolysis and automated percutaneous lumbar discectomy(APLD) between March 1990 and December 1994 at our institute. Among the 34 consecutive patients, 90 patients underwent chemonucleolysis and the other remaining patients underwent APLD using a nucleotome. The results are summarized as follows: 1) In both groups, predominent patients were of young age and males. 2) The most common lesion was in L4-5 interspace in both groups 3) The posteior lateral type showed high incidence in APLD group. 4) The results were better in the younger age group and when spinal CT demonstrated posterior lateral type in both groups. 5) The results showed relatively good success rate of 84.4% in chemonucleolysis group and 88.6% in APLD group. 6) Better results can be anticipated when patients are carefully selected and operated on with a higher skillful technique.

Can DITI Predict a Sequestered Lumbar Disc?

The purpose of this study is to assess the usefulness of digital infrared thermographic image(DITI) in patients with surgically treated lumbar disc disease. A series of 480 patients with lumbar herniated disc was studied. The mean age of the patients was 37 years, with a range of 18 to 64 years. Of which 126 cases of chemonucleolysis. 18 cases of percutaneous endoscopic laser discectomy, and 336 cases of laminectomy with discectomy were performed. Among these patients, 336 cases of laminectomy were assessed by DITI preoperatively. The thermal differences(delta T) between the symptomatic and asymptomatic limbs were evaluated. We have categorized the types of herniations into 3 classes: 200 protruded, 99 extruded, and 37 sequestered. The thermal differences were classified into 3 groups: 177 patients had delta T or = 0.8 degrees C. Among the group of patients with the sequestered disc, 30(i.e. 80%) had delta T > or = 0.8 degrees C. Among the surgically treated 336 patients, non-visualization of a part of the sciatic limb on preoperative DITI was the condition used to coin the term amputation sign by the authors. In the sequestered group, the "amputation sign" was observed in 28 cases(75%). We conclude that DITI can predict a sequestered disc disease, and it allows more precise indication regarding open surgery.

Clinical Analysis of Posterior Lymbar Apophyseal Ring Fractures in Young Adults

Lumbar apophyseal ring fracture occurs between the vertebral ring apophyses and the cartilaginous rim of the superior or inferior margins of the vertebral end plates. This fracture is an unusual disease that if typically seen in adolescents or young adults. We analyzed the clinical records and neuroradiologic imagings of 49 patients who were less than 29 years old diagnosed with posterior lumbar apophyseal ring fractures in regards to the age, trauma history, the type and distribution of the fracture, clinical presentation, and postoperative outcome. The posterior lumbar apophseal ring fractures were detected in 29(9.2%) out of 533 young adult patients with herniated lumbar discs. There was trauma history in 37(75.5%) out of the 49 patients. The main presenting symptoms in most of the patients were low back pain and radiating leg pain. In patients who presented with symptoms, thirty-five patients(75.5%) had a positive straight leg-raising test. According to classification by Takata, they were type I in 12 cas es(24.0%), type II in 9 cases(18.0%), and type III in 29 cases(58.0%). The type III with trauma history was more common than with non-trauma history(p<0.01). Twenty-one patients(42.0%) had bony fragments projecting into the spinal canal from the upper border of S1. Partial hemilaminectomy(18 patients) and total laminectomy(3 patients) were performed. We could easily remove the bony fragments in all of the surgical cases. Chemonucleolysis were done in three patients. The overall results were good. We conclude that knowledge of this entity and correct radiographic diagnosis will help to facilitate the operative planning.

A Clinical Study of Cervical Chemonucleolysis

For many years chemonucleolysis has been proven effective in the curative treatment of lumbar disc herniation. However, this technique is seldom popular in the herniated cervical disc. For several years microsurgery of the cervical disc has been effective in the treatment of refractory cervicobrachial neuralgia. To compete with this method which has been familiar to neurosurgeons, cervical nucleolysis using chymopapain for 1 year. Twenty two pateints(75%) had excellent outcomes, 5 pateints(15%) considered good while 3 sustained their symptom, but showed decreased intensity. The decision to intervene is made when the radiculagia is recurrent or resistant to medical treatment of several weeks duration, without myelopathy or bony abnormalities such as spondylosis or canal stenosis. The principal advantages of this method are : short stay in the hospital(3 days to 5 days on average), absence of general anesthesia, prompt resumption of previous activities, and long-term preservation of an intervertebral space. As a result, cervical nucleolysis has been shown to be an effective alternative to surgery for cervical soft disc herniations with refractory radicualgia.

Minimaly Invasive Spinal Surgery: Cinical analysis of Chemonucleolysis & Percutaneous Automated Lumbar Discectomy

The authors retrospectively analized the radiographs and medical records of 135 consecutive patients who underwent minimaly invasive spinal surgery from January, 1990 to December, 1994 at our institution. Among these, 72 patients have had chemonucleolysis and others percutaneous automated lumbar discectomy(PALD). The success rate was similar in both groups, ie, 75% in chemonucleolysis and 74.6% in PALD by Macnab's criteria. The higher success rate could be obtained in 1) younger age below 30, 2) predominant sciatica than lower back pain, 3) eccentric bulged disc with minimal degeneration, 4) abscent or minimal neurologic deficits. In conclusion, provided patients are carefully screened, minimal invasive spinal surgery is more preferable over conventional surgery, providing a safe and effective therapeutic alternative to many patients suffering from herniated lumbar disc.