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PubMed1981

[Antero-lateral, cervical microsurgical diskectomy].

We report 25 cases of cervical disc lesion, treated with antero-lateral microsurgical discectomy without intercorporal graft. The posterior osteophyts were removed and the posterior longitudinal ligament lateral resected. In the control period of 6 months to 4 years we have in 84% of cases excellent/good results clinically and radiologically and concerning the working capacity. Comparing the results with 51 other cases operated on with the fusions technique after Cloward, there are no significant differences. We give a short description of the technique and review the literature.

Adult↗
PubMed1996

[Comparison of percutaneous manual and endoscopic laser diskectomy with chemonucleolysis and automated nucleotomy].

The combination of percutaneous manual and endoscopic Ho:YAG laser discectomy (PELD) is a new minimal intervention technique in treating patients with herniated lumbar discs that do not penetrate the posterior longitudinal ligament. The results in 100 patients treated with PELD were compared randomly with those in 100 patients treated by chemonucleolysis with chymopapain (CN) and 100 patients treated by automated percutaneous lumbar discectomy (APLD) at the same hospital. We followed the 300 patients postoperatively for 1 year, with physical examination, postoperative plain lumbosacral radiography, CT, MRI and a self-assessment questionnaire. Some 68% of the patients in the PELD group considered the outcome as excellent or good and 23% as fair; the corresponding figures were 55% and 27% in the CN group, and 48% and 32% in the APLD group. Nine percent of the patients in the PELD group underwent open microdiscectomy or were suffering from back pain with sciatica, compared with 18% in the CN group and 20% in the APLD group. PELD showed better extraction of the hernia mass than APLD and a lower rate of low back pain and less decrease in disc height than CN.

Adult↗
PubMed2005

Verification of nerve root decompression during minimally-invasive lumbar microdiskectomy: a practical application of surgeon-driven evoked EMG.

Lumbar microendoscopic diskectomy (MED) has gained widespread acceptance as an alternative to conventional open microdiskectomy due to several potential advantages, including reductions in postoperative pain and recovery time. However, constraints in visualization and working space present technical difficulties in the verification of nerve root decompression and the identification of sequestered disc fragments. This study was undertaken to investigate whether a surgeon-driven, evoked EMG paradigm could be used for intraoperative verification of nerve root decompression within the technical and mechanical confines of lumbar MED. Twenty-two patients underwent intraoperative EMG stimulation threshold recordings during lumbar microendoscopic diskectomy. In this series, the EMG threshold recorded directly from the nerve root immediately prior to diskectomy was 8.6 +/- 4.4 mA. Following decompression, the threshold was 4.2 +/- 2.1 mA. The difference in pre- and post-decompression EMG stimulation threshold, 4.4 +/- 4.0 mA, was statistically significant (p < 0.001). In two of the 22 cases (9.1 %), the EMG threshold was initially unchanged following diskectomy, and further exploration revealed sequestered disc fragments. After removal of these fragments, an appropriate decrease in the EMG threshold was observed. The results from this study suggest that surgeon-driven, evoked EMG threshold testing may provide a simple, effective adjunct to lumbar microendoscopic diskectomy for intraoperative verification of nerve root decompression.

Adult↗
PubMed2003

Cervical disc replacement-porous coated motion prosthesis: a comparative biomechanical analysis showing the key role of the posterior longitudinal ligament.

STUDY DESIGN: Benchtop cadaveric biomechanical comparative testing and caprine animal model in vivo implantation. OBJECTIVE: To evaluate the role of the posterior longitudinal ligament in cervical arthroplasty and to understand the relative contribution of this ligament in nonfusion applications. SUMMARY OF BACKGROUND DATA: Rauschning refers to the posterior longitudinal ligament as "The Kleenex Ligament" due to its apparent anatomic insignificance. White and Panjabi found the posterior longitudinal ligament ranked only fourth in importance in tensile load-to-failure biomechanical testing. In the postoperative situation following anterior cervical diskectomy fusion, posterior longitudinal ligament integrity is overlooked by physicians because the entire disc space usually fuses into a homogeneous block of bone. PURPOSE: This biomechanical study was undertaken to determine the relative importance of the posterior longitudinal ligament following two different degrees of anterior decompression, anterior disc replacement, and anterior arthrodesis procedures. METHODS: A total of seven fresh frozen human cadaveric cervical spines (C3-C7) (mean age 68 +/- 19 years) were used for biomechanical testing. Each vertebra was equipped with three non-colinear light emitting diodes designed for detection by an optoelectronic motion measurement system (3020 Optotract System). To determine the multidirectional flexibility, six pure moments (flexion, extension, right + left lateral bending, right + left axial rotation) and axial compression were applied using a servohydraulic 858 Bionix testing device configured with a six-degree-of-freedom spine simulator. Range of motion was defined as the peak displacement from the initial neutral position to the maximum load, whereas the neutral zone represents the motion from the initial neutral position to the unloaded position at the beginning of the third cycle. Seven groups of (N = 7 each) constructs at C5-C6 were: 1) intact "native" C5-C6 level; 2) anterior diskectomy (posterior longitudinal ligament intact); 3) a Low Profile Porous Coated Motion cervical disc replacement; 4) posterior longitudinal ligament resected; 5) Porous Coated Motion cervical disc replacement fixed with anterior flanges and screws; 6) tricortical structural allograft; and 7) an anterior cervical translational plate + allograft. The caprine model was evaluated for suitability as an animal model with 12 goats undergoing C3-C4 anterior cervical Porous Coated Motion disc replacement. RESULTS: Group 2 (anterior diskectomy alone) was significantly more stable than Group 4 (anterior diskectomy + posterior longitudinal ligament resection) in flexion-extension, 18.7 +/- 4.76 degrees versus 24.8 +/- 4.42 degrees (P < 0.05) and in lateral bending, 5.9 +/- 1.79 degrees versus 10.7 +/- 2.8 degrees (P < 0.05). The comparison for the two conditions for axial rotation, 10.4 +/- 13.9 degrees versus 13.9 +/- 2.7 degrees, and axial compression, 1.19 +/-.98 degrees versus 1.52 +/- 1.14 degrees, showed the same trend. Twelve goats undergoing porous coated motion cervical disc replacement had no evidence of prosthesis loosening, neurologic complications, or experienced inflammatory reactions from particulate wear debris after 6 months of implantation. DISCUSSION: This study confirms the pivotal role of the posterior longitudinal ligament in postsurgical stability of the cervical spine following anterior diskectomy. This is because the lateral anulus, uncovertebral ligaments, and lateral capsular ligaments are stretched and plastically deformed in the surgical distraction process of restoring the disc space height following anterior surgical decompression. There should be a separate determination of the range of motion of cervical disc replacements depending of the integrity and the amount of the posterior longitudinal ligament that has been resected. CLINICAL RELEVANCE: There are two basic types of total knee replacements, posterior cruciate ligament-preserving and posterior cruciate ligament-sacrificing designs. In the cervical spine, an analogous situation exists biomechanically depending on whether the posterior longitudinal ligament needs to be removed in its entirety as part of the spinal cord decompression part of the procedure--it may be helpful to conceptually differentiate between posterior longitudinal ligament-preserving and posterior longitudinal ligament-sacrificing total cervical disc replacements.

Aged↗
PubMed2001

A biomechanical comparison between anterior and transverse interbody fusion cages.

STUDY DESIGN: Human cadaveric lumbar spines underwent placement of threaded fusion cages (TFCs) in either an anterior or transverse orientation. Spines underwent load testing and angular rotation measurement in the intact state, after diskectomy, after cage placement, and after fatiguing. Angular rotations were compared between cage orientations and interventions. OBJECTIVE: To determine which cage orientation resulted in greater immediate stability. SUMMARY OF BACKGROUND DATA: There has been extensive biomechanical study of interbody fusion cages. The lateral orientation has been increasingly used for intervertebral fusion, but a direct biomechanical comparison between cages implanted either anteriorly or transversely in human cadaveric spines has not been performed. METHODS: Fourteen spines were randomized into the anterior group (anterior diskectomy and dual anterior cage placement) and the lateral group (lateral diskectomy and single transverse cage placement). Pure bending moments of 1.5, 3.0, 4.5, and 6.0 Nm were applied in flexion, extension, lateral bending, and axial rotation. Load testing was performed while intact, after diskectomy, after cage placement, and after fatiguing. Angular rotation was compared between anterior and lateral groups and, within each group, among the different interventions. RESULTS: Segmental ranges of motion were similar between spines undergoing either anterior or lateral cage implantation. CONCLUSIONS: These results demonstrate few differences between angular rotation after either anterior or lateral TFC implantation. These findings add to data that find few differences between orientation of implanted TFCs. Combined with a decreased risk of adjacent structure injury through a lateral approach, these data support a lateral approach for lumbar interbody fusion.

Cadaver↗
PubMed1995

Quantification of lumbar nerve root decompression using somatosensory-evoked potentials.

Intraoperative somatosensory-evoked potential (SSEP) data were collected prospectively in a consecutive series of patients with an acute lumbar herniated nucleus pulposus (HNP). Each patient underwent an open limited diskectomy, hemilaminotomy, and partial foraminotomy. The sequence of diskectomy and bony decompression was randomized, and the extent of foraminotomy was standardized. SSEP data were recorded after each operative procedure and were coded for blind interpretation. SSEP tracings were compared with each patient's baseline for changes in latency and amplitude. In the overall study, changes in amplitude and latency produced by diskectomy versus bony decompression were not statistically significant. In the six patients with lateral recess stenosis (LRS), a statistically significant reduction in latency was observed after bony decompression (averaging -2.05 ms) compared with diskectomy (-0.62 ms). In patients with underlying LRS and a HNP, minimally invasive techniques addressing the disc only may be inadequate to decompress a lumbar nerve root.

Adolescent↗