[Indications for and choice of reintervention in failed back operations]. / Zur Indikation und Wahl der Reintervention bei fehlgeschlagenen Rückeneingriffen.

Is it true that even today, the results of reinterventions after unsuccessful spine surgeries are often unsatisfactory, despite major diagnostic and therapeutic advances in the field of spinal surgery. Based on our observations of cases with failed back surgery syndrome in the Department of Orthopaedic Surgery, the University of Balgrist Zürich, the indications for a reintervention and the choice of the surgical procedure are reported. The use of decompression as re-intervention is successful only in cases where there is an unequivocally demonstrable lack of space for the nervous system due to recurrent hernia or narrow spinal canal. In such cases it may be possible, subject to careful assessment of the criteria, to perform a percutaneous nucleotomy as an alternative to a conventional microsurgical discectomy. Nowadays decompression by means of instrumental spinal fusion is usually indispensable as re-intervention after unsuccessful surgeries.

Does percutaneous nucleotomy with discoscopy replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc.

Percutaneous nucleotomy was first described in 1975 by Hijikata in Japan. In 1979 the present authors adopted this method for the treatment of lumbar disc herniation and modified Hijikata's original instruments. Since 1982 additional intradiscal optical control has been included by means of an adapted arthroscopic kit for more accurate and effective removal of the nucleus pulposus under direct view. This procedure is called discoscopy. Between 1979 and late 1987, the method was applied to 109 patients with lumbar disc herniation. The indications included lumbar sciatica that (1) was resistant to conservative treatment and (2) in which myelography and/or examination by computed tomography proved a disc protrusion without dislocation in the spinal canal. The level most affected was L4-L5. Major operative complications encountered were one vascular lesion and two cases of secondary spondylodiscitis. Clinical results in patients with other additional causes of sciatica, such as spondylolisthesis or relapse of disc herniation, were nearly as favorable as in isolated first-time disc herniation. The overall success rate was 72.5% (79/109 patients).

[Percutaneous nucleotomy with discoscopy. 7 years' experience and results]. / Perkutane Nukleotomie mit Diskoskopie. 7jährige Erfahrung und Ergebnisse.

Percutaneous nucleotomy was first described in 1975 by Hijikata in Japan. We introduced this method since 1979 for the treatment of lumbar disc herniation at the Department of Orthopaedic Surgery, the University of Zürich, Balgrist, improved the original instruments of Hijikata and employ since 1982 various arthroscopes in order to remove nucleus pulposus more accurately and effectively under direct visual control (discoscope). This method was performed between 1979 and 1986 in our clinic in 75 patients with lumbar disc herniation. The clinical result was designated as excellent or good in 48 of 75 patients (65%). The 7 years experiences with this procedure are reported on this paper.

[Complex indications in surgery of the lumbar spinal canal]. / Komplexe Indikationen in der Chirurgie des lumbalen Spinalkanals.

Opinions on the treatment of disc herniation are very controversial and the results reported vary, very much indeed. Most often, one decided--and still decides--to excise the disc herniation in conjunction with hemilaminotomy or flavectomy; this method having been carried out from 1974 to 1983 on 598 patients, at the department of Orthopaedic Surgery, Balgrist, of the University of Zurich. A follow-up of over 400 patients has proved to be very informative: whereas very good or good clinical results can be reported in 73.6% of such cases with disc herniation, alone, these not having undergone operation before, similar results were only found in 27.2% of those who had also been suffering from additional causes of lumbalgia like a relatively narrow spinal canal, spondylolisthesis, spondylolysis or nearthrosis for instance. This finding is of paramount importance when attempting to improve the overall results. It is very necessary to separate the complex cases from the "simple" disc herniation ones. At the same time, those patients suffering from lumbalgia due not only to a herniated disc but also to other additional causes arising from alterations to the lumbar spinal canal must be judged and treated differentially. The present follow-up permits conclusions and considerations correspondingly.

Percutaneous nucleotomy. An alternative to spinal surgery.

As an alternative to the well-established surgical procedures for the treatment of disk herniation, percutaneous nucleotomy has proved to be very satisfactory. In several cases this approach has brought complete relief to the patient without sacrifice of bone and without causing soft tissue damage as would have been inevitable with the usual surgical methods. Percutaneous nucleotomy is also a true alternative to chemical nucleolysis when leakage of contrast agent into the spinal canal has already been observed during diskography. Furthermore, this method avoids disagreeable complications encountered in chemical nucleotomy, for example, anaphylactic shock or the escape of the nucleolytic agent into the spinal canal. The method basically consists of removing the nucleus pulposus (or a major part of it) by means of a forceps that is introduced to the site through a cannula. In this manner a reduction of volume of the disk is achieved. The procedure can easily be carried out under local anesthesia. This method should be avoided in the case of prolapse within the spinal canal and especially when displacement beyond the level of the disk has occurred. In the period between 1979 and 1985 we carried out percutaneous nucleotomies in 51 patients with herniation mostly combined with a narrow spinal canal or spondylolisthesis. The clinical results from 32 of 51 patients can be assessed as very good, good, or satisfactory. We consider the proportion of patients showing good clinical results to be high, bearing in mind that the indication was not just disk herniation alone but, in most cases, combined with other lumbar pathologies as well.

Lumbar and thoracic spinal fusion with transpedicular fixation (including a novel distraction and compression device). A preliminary report.

Experience with three different systems of transpedicular fixation in fusion of the lumbar and thoracic spine over 4 years is reported. The Roy-Camille plates, Louis plates, and the Balgrist turn-buckle arrangement are compared. The Balgrist device allows both extension and compression, and affords better stability. Far better clinical results were obtained with transpedicular fixation in general than with the Harrington method.

Transdiscoscopic percutaneous nucleotomy in disk herniation.

The authors describe their use of percutaneous nucleotomy in the treatment of lumbar disk herniation. They report on the first 40 patients so treated at the Department of Orthopaedic Surgery, University of Zurich, Switzerland. They note the procedure offers good possibilities and that in some cases, in combination with discoscopy (arthroscopy), has several advantages over conventional surgical techniques.

Preliminary report of 40 patients. Dorsal spinal fusion with a transpedicular distraction and compression system.

The authors, over a four-year period, carried out dorsolateral spine fusion with transpedicular fixation in 40 patients. In this preliminary report of the results that were obtained at follow-up, the authors compare three types of fixation used.

[Indication for the surgical correction of severe spondylolisthesis and modification of incorrect lumbar posture]. / Indikation zur operativen Korrektur der schweren Spondylolisthesis und Beeinflussung der lumbalen Fehlhaltung.

In the last few years, the operative treatment of severe spondylolisthesis has aimed to reduce the gliding movement between the vertebral bodies proceeding then to a spondylodesis. So far, various questions have remained open. When, with which techniques and with which patients should the reduction of the vertebral gliding be performed? How do these results compare with the spondylolisthesis fused operatively "in situ" without any correction at the same time? In order to answer the various questions raised, we examined patients operatively treated with spondylolisthesis of more than 50%, both clinically and radiologically. 20 patients with a ventral spondylodesis and reposition were compared with 98 patients having had a dorsal fusion without reposition. In most cases of progressive vertebral gliding, it is possible to effect alignment of the lumbar curvature even with complex procedures e.g. Halo-Pelvic Traction or usage of Harrington Instruments. The reposition of the spondyloptosis has a positive influence on the Pelvic Tilt.

Modification of microsomal lipid composition and electron transport enzyme activities in isovalerate-supplemented cells of novel Tetrahymena ISO.

Tetrahymena ISO cells, which have an unusually high level of iso odd-numbered fatty acids, were grown medium supplemented with various concentrations of isovalerate. There was a marked increase in the total proportion of iso odd-numbered fatty acids in supplemented whole cells (28.9 leads to 70.3%) and microsomes (37.7 leads to 84%), with a corresponding decrease in normal fatty acids, although no significant alteration of phospholipid composition was observed during 11 hr isovalerate-supplementation. Microsomal palmitoyl-CoA and stearoyl-CoA desaturase activities in isovalerate-supplemented cells decreased by 45.7% and 30.6% during 11 hr, respectively. NADH-cytochrome c reductase and NADH-ferricyanide reductase activities as well as the content of cytochrome b560ms, which is similar to mammalian microsomal cytochrome b5, were reduced in microsomes from 11 hr-supplemented cells, whereas NADPH-cytochrome c reductase activity was constant. It is suggested that the alteration of the cross-sectional area of lipid molecules in the bilayer, which results from the replacement of normal fatty acids with iso- 15:0 and iso- 17:1, would result in the decline of palmitoyl- and stearoyl-CoA desaturation in the isovalerate-supplemented cells, in order to maintain membrane fluidity at a functional level.

[Indications, methods and results in percutaneous nucleotomy in lumbar disk hernia]. / Indikation, Methodik und Ergebnisse der perkutanen Nukleotomie bei lumbaler Diskushernie.

To our knowledge, the method of percutaneous nucleotomy dates back to the first description made by Hijikata in 1975. Compared to the classical hemilaminotomy, the main advantage of this method is that it reduces bone and soft tissue damage in the segment to a minimum. Furthermore, this method avoids disagreeable complications encountered in chemical nucleotomy, for a example, anaphylactic shock, the escape of the nucleolytic agent into the spinal canal, etc. The indication for this method should be avoided in the case of a prolapse within the spinal canal and especially when it is displaced outside the level of the disc. In the period between 1979 and 1981 we carried out percutaneous nucleotomies in 20 patients with a disc herniation mostly combined with a narrow spinal canal or spondylolisthesis. The clinical results from 14 of the 20 patients were described as "very good" or "good". We consider the proportion of patients showing good clinical results to be high, bearing in mind that the indication was not just disc hernia alone but was in most cases associated with other lumbar pathologies.