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MINISTRY OF EDUCATION AND TRAININGMINISTRY OF DEFENCE VIETNAM MILITARY MEDICAL UNIVERSITY TRAN THANH TUYEN A STUDY ON TREATMENT FOR HERNIATED DISC IN THE CERVICAL SPINE BY SURGICAL METHO

MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF DEFENCE

VIETNAM MILITARY MEDICAL UNIVERSITY

TRAN THANH TUYEN

A STUDY ON TREATMENT FOR

HERNIATED DISC IN THE

CERVICAL SPINE BY SURGICAL

METHOD BY ANTERIOR INCISION

PLACING CESPACE INSTRUMENT

Major: Neurosurgeon and brain

Code: 62.72.07.20

SUMMARY OF MEDICAL DOCTOR THESIS

HANOI – 2012

THE WORK IS COMPLETED IN VIETNAMMILITARY MEDICAL UNIVERSITY

Scientific Advisor:

A.P Ph.D VO TAN SON

Panellist 1: Tran Manh Chi Panellist 2: Nguyen Tho Lo Panellist 3: Ha Kim Trung

The thesis will be defended against the council of the thesis defense at 8.30 of 26 July 2012

The thesis can be found at:

- The national library

- The library of Vietnam Military Medical University

Herniated disc in the cervical spine is a disease caused

by disc degeneration and herniation in the cervical spine,spines created by degradation pinching neck marrow ornerve root cause This disease is often characterized byneck pain, shoulder pain or pain in the spinal nerve roots.Therefore, this disease reduces nerve function, therebyreducing the ability to work and quality of life

Treatment for herniated disc in the cervical spine is forthe purpose of recovery of nerve function, and reducingpain so the patient returns to normal life with quality Thetreatment is also very diverse, from physical therapymethods and internal medicine When internal medicinetreatment fails or neurological signs appear, it will betreated with surgery About classics, anterior incisionsurgical treatments welds disc in associated withvertebral body bone from autologous iliac crest, but thismethod has disadvantages such as: requiring anothersurgery, prolonged surgical time, falling bone graftcausing cervical spine hunchback or complications in thebone graft Thus, there have been many methods ofimproved surgery and the latest surgical procedures bytaking the disc stem and joint welding using artificialmaterials such as carbon fiber, titanium, PEEK hasshowed effective results such as pain treatment andprevention of complications after surgery, such as narrowforamen intervertebrale leading to the cervical spinehunchback Nowadays, many devices with differentmaterials are used and it is difficult to prove thepreeminence of a device or materials over the others

Selection depends on the familiarity and availability, costand high compatibility of the materials used.

In the Department of neurosurgeon of People'sHospital 115, tools Cespace with Titanium which arequite common in Vietnam at reasonable price and high

inertness are often used So we made the topic "Research

on treatment of herniated disc in the cervical spine by way of anterior incision surgery method of placing tools Cespace."

Research objectives:

1 To determine some standards for surgicalindications in the treatment of disc herniation in thecervical spine by way of anterior incision surgery andplacing tools Cespace

2 To assess results of treatment of herniated disc inthe cervical spine by way of anterior incision surgeryusing operating microscope and placing tools Cespace

New contributions of the thesis:

Treatment for Herniated disc in the cervical spine byway of anterior incision surgery and placing toolsCespace has good results and can be easily implemented

to apply multiple layers of new patients using operatingmicroscope which helps main dissection, good bloodholding to avoid complications during and after surgery

The layout of the thesis:

The thesis consists of 109 pages with 27 tables, 21charts and 41 figures The thesis constitutes the basic 4chapters: Introduction 2 pages, Chapter 1 – Overview 29Pages, Chapter 2 - Subjects and Methods 17 pages,

Chapter 3 - Research Results 29 Pages , Chapter 4 –Discussion 29 pages, Conclusions 2 pages andRecommendations 1 page; references 122 (28Vietnamese, 94 English), including material publishedfrom 2005 to present.

CHAPTER 1 - OVERVIEW

1.1 DIAGNOSIS

Need to study case history thoroughly, examineclinically and radiology should be done to confirm thediagnosis

The diagnostic tests are suggested:

- Spurling test solution

- Pulling the neck by hand can be regarded as aphysical examination, the patient in the position of backneck, gently pulling by hand often significantly reducessymptoms in the neck and hands in patients withpathological root

- Shoulder stretch measure

- L'hermitte signs found in patients with neck marrowrelated diseases

1.2 RADIOLOGY

Radiology diagnosis is used to determine: whether ornot there is injury; lesion location, lesion extent, lesionnature

1.2.1 Conventional X-ray

Cervical spine radiographs are radiology diagnosticmethod which is the first choice for patients withsymptoms of pain in the neck, spreading to limbs andoften used to diagnose neck disc diseases causingsymptoms of root nerve

Tilt radiographs: to evaluate the disc slot height,spines at the anterior and rear borders of the vertebralbody and the curvature of the cervical spine

450 oblique radiographs: see foramen intervertebrale

at suspected positions of pathological root, compared to

contralateral foramen intervertebrale, articular facet andzygapophysus.

1.2.2 Computerized tomography (CT Scanner)

CT examines bone composition and is useful in theassessment of adduction fracture It is also useful whenC6 and C7 are not visible on X-ray of tilt cervical spine.The accuracy of the cervical spine CT limits from 72% -91% in the diagnosis of disc herniation The accuracyreaches 96% when combined CT with electrospinogram,which allows view of the subarachnoid space andevaluation of the spinal marrow and nerve roots

Computerized tomography with contrastmedium injected into the spinal canal: CT capture technique

with contrastmedium injected into subarachnoid space isconsidered to be good assessment and positioning of neckmarrow compression In some cases, especially, ofinvasion of foramen intervertebrale and lateral surface,cross-sectional images reconstruct 3D very well

1.2.3 Magnetic resonance imaging (MRI)

As soft tissues provided by MRI is visible, CT isreplaced by MRI for most cervical spine diseases

MRI has now become the first choice method todiagnose symptoms of neck root or symptoms ofcombined marrow

1.2.4 Electromyogram (EMG) (only when there is a movement disorder)

Little was done, however, they also provide evidence ofroot compression in patients at little clinical presentation

1.3 TREATMENT OF HERNIATED DISC IN THE CERVICAL SPINE (HDITCS)

Treatment methods of HDITCS now include: internalmedical treatment, surgical treatment and non-surgicalinterventions

1.3.1 Internal medical treatment

Internal medical treatments of HDITCS include:Immovability: an important stage, immovability ofneck is completely maintained, at least during the period

of severe pain, often 3-4 weeks, with limited neckmovement and stay in bed wearing a neck fixed belt.Most commonly used drugs are non-steroidal anti-inflammatory anodyne, muscle relaxants, otherpainkillers or steroids

Other methods such as using heat in place, stretchingthe cervical spine are also good practice to avoidparamyotonus, only for simple root compression Thereare also stimulation by small electrical current,acupressure, acupuncture but with limited efficacy

1.3.2 Surgical treatment

* Surgical indications

The authors have indicated that surgical indicationsshould be based on two factors of clinic and radiology, inwhich clinical plays an important role Most authorsrecommend surgical indications when one of thefollowing occurs:

- Constant pain, not responding to conservative treatment(3-6 months)

- Progressive muscle weakness or muscle atrophyalready

- There is a presence, or appearance, or increase ofsymptoms of myelopathy.

1.3.2.1 Surgery of herniated disc in the cervical spine by Anterolateral incision

- Smith and Robinson methods

- Cloward method

- Bailley and Badley method

1.3.2.2 Herniated disc surgery by rear incision

Rear surgery is done according to the following threemain techniques: Cutting rear arcus, spinal canal plasty,taking disc through foramen intervertebrale

1.3.2.3 Coordinate neck anterolateral incision and rear incision

In some cases, especially as HDITCS with longitudinaleligament ossification following canalis spinalis stenosis

or canalis spinalis stenosis by back cause, an incision isoften not enough to release compression, the combination

of two anterior and rear incisions is necessary For theanterior incision, implementation techniques may beremoving vertebral bodies or merely taking disc,releasing compression through hernia For the rearincision common techniques are spinalis stenosis plasty

or cutting rear arcus to release compression

1.3.3 The method of minimal intervention treatment

1.3.3.1 Chemonucleolysis

Suggested by Lyman in 1963, Chymopapain or Aprotinin(trasylon) injection into the disc to differentiate discnucleus pulposus has been widely used in France andAmerica in the 1970s and 1980s This method isendicated for HDITCS causing recurrent persistent neck

root pain with aggressive medical therapy for weekswithout improvement Contraindicated in cases ofsequestration hernia, a large block, marrow compression,transdural, herniated disc with neck canalis spinalisstenosis, heavily degenerative disc and especially whendetecting vascular taken into loops on disc.

1.3.3.2 Percutaneous Laser Disc Decompression

It was first implemented in 1986 by Choy and Ascher.Based on the principle of using laser energy to ignite asmall volume of mucus, thus reducing the pressure insidethe disc suddenly, making the herniated disc shrink,reducing nerve root compression Although it was amethod of minimal intervention, but it also has very tightindications of treatment

1.3.3.3 Percutaneous disc decompression using radio waves

This method was implemented by Singh and Derby forthe first time in 2001 Using radio waves to create apicture of the mucous disc using coblation technology(this method is called nucleoplasty) Nucleoplasty is aminimally invasive technique to reduce the pressureinside the disc using coblation technology community

1.3.3.4 Surgical endoscopic microsurgery disc

Endoscopic has been applied to surgery of herniated discfor a long time In 1986, Schreiber used endoscopicinstruments to improve techniques of percutaneous disctaking by Hijikata.The author used 2 lines: a line to getthe disc, the other opposite line to put endoscopicinstruments These techniques allow observation ofherniated discs and nerve roots in the canalis spinalis

CHAPTER - SUBJECTS AND METHODS OF

2.1.2 Criteria for selection of patients

- Patients with a herniated disc in the cervical spine fromone to two layers with clinical syndrome of root ormarrow compression or root-marrow compressionsyndrome and are diagnosed with appropriate images

- Clear addresses (for easy follow-up)

- Adults, no muscle pathology

- All patients were explained and consented to placement

of Cespace after getting disc, spine to decompressmarrow and root

- 12-month follow-up period

2.1.3 Exclusion criteria

- All patients with myelopathy due to degenerative neck

canalis spinalis stenosis and ligamentum longitudinaleposterius ossification of three layers or more

- Patients with severe medical conditions such as severeheart failure, progressive tuberculosis and under 16years of age

- Addresses are not clear

2.2 METHODS OF RESEARCH

2.2.1 Research Design

Research Method: To describe the clinical, sectional, not controlled study.

cross-2.2.2 Sample size

We use the calculation formula of sample size:

In which: n: Minimum sample size with Z(1-/2)= 1,96(= 0.05)

p: estimated proportion of the target population, p =3.5% (according to SalemiG)

p = 0.035, q = 1 – p p = 0.965; d (Estimateddeviation) = 5%

Therefore n ≥52 in reality, 89 cases are collected

2.3 USED MATERIALS

2.3.1 Researched Materials Cespace

Cespace graft: basic elements of cervical vertebral graft are solid Titanium core, this core is filledwith microporous Plasmapore material to increase thesurface area by 16 times, thereby increasing the contactarea between the graft living with canalis spinalis

inter-2.3.2 Surgical Instruments

People's Hospital 115 is currently using specializedmicrosurgical system dedicated for neurosurgery: LeicaMS3 M520 manufactured by Federal Republic ofGermany

2.4 EVALUATION CRITERIA AFTER SURGERY HERNIATED DISC IN THE CERVICAL SPINE WITH CESPACE

Evaluation criteria are based on the general scale ofJapan Orthopedic Association (JOA) and radiology

- Recovery rate (RR) has the maximum pointaccording to JOA: 17:

o Exercise: upper limb movement disorder (4 points),lower limb movement disorder (4 points)

o Sensation: upper limb (2 points), lower limb (2points), body (2 points)

o Sphincter function (3 points)

RR = (JOApostoperative or re-examination – JOApreoperative) x 100/(17 – JOApreoperative)

Recovery rate: 75% very good

50% good20% acceptable20% bad

- Pre-and postoperative evaluation of radiograph:shooting in four positions: straight, tilt and right obliqueand left oblique Tilt position is used to assess height ofdisc, degenerative spine and physiological curves of thecervical spine Right and left oblique positions is used toassess foramen intervertebrale, articular facetandzygapophysus Radiograph is used to assess thecervical spine stiffness and bone welding

- Evaluation of spinal hyperextension: draw a straightline from the rearest point of tip to posterior inferior point

of the C7 body, measure the distance from this line to the

posterior inferior border of the body of C4, this gapnormally # 11.8 mm ± 5.

- Evaluate Cespace settlement in two adjacentvertebral bodies: measuring height of disc slot/ height ofCespace if <0.7 mm there is settlement

2.5 SURGICAL TREATMENT

Indications for surgery:

- Pain in shoulders neck, arms which is continuouslyrecurrent and does not respond to medical therapy

- Progressive muscle weakness or muscle atrophyalready (root compression syndrome)

- There is the presence, or appearance or increase ofsymptoms of marrow (marrow compression syndrome)

- Radiograph diagnosis: There is an image of discherniation, canalis spinalis stenosis caused by spinesleading to root or marrow compression in accordancewith clinical syndrome

Evaluating of clinical signs such as pain, RLCG,RLVD, RLCT, root HCCE and marrow HCCE therebycalculating points according to JOA score and calculatingthe recovery rate (RR)

CHAPTER 3 – FINDINGS

Our study was conducted on 89 patients with discherniation in the cervical spine with root compressionsyndrome, marrow compression syndrome and marrow-roots compression syndrome who were surgically treated

in People’s Hospital 115 from April 2007 to November

2010 All patients had imaging diagnosis consistent withclinical standards and sampling criteria The results are asfollows:

3.1 EPIDEMIOLOGY

3.1.1 Distribution of patients according to age (n = 89)

Average age: 51.58 ± 10:13, minimum 34, maximum

85 years old and the most common age 40-50 years old

3.1.2 Distribution by sex

In our study plots male patients approximate tofemale patients, 46 male patients (51.69%), 43 femalepatients (48.31%)

Table 3.2 Distribution by history (n = 89)

There are injuries (head, neck) 9 10.11

3.2.1 Clinical signs of root disease

Table 3.3 Clinical symptoms of root disease (n =

3.2.2 Clinical signs of myelopathy

Table 3.4 Clinical signs of myelopathy (n = 65)

Table 3.5 Routine radiography (n = 89)

Loss of physiological curve 58 65.16

Narrow foramen intervertebrale 19 21.34

Comment: Common herniated disc C5C6 40.09%.

Table 3.8 Type of hernia by magnetic resonance

imaging (n = 88)The image on magnetic resonance

Hypointense on T2w on disc 88 100.00Herniation causing increased

3.3.4 Picture computerized tomography (CT Scanner)

There is one patient taking CT 64 to diagnose aherniated disc, the other patients taking CT to evaluatesoft tissues and bones

3.4 DISTRIBUTION BY LOCATION OF HERNIATED DISC

Table 3.10 Distribution by location of disc herniation

74.1525.84

Marrow Pathology 29 32.58General marrow

Patients with endotracheal anesthesia, supine,neck slightly extended, horizontal skin incision, the neckskin folds prevent scarring for patients Skin incision isapproximately 3 - 4 cm long for hernia 1-2 layer andinjuries Incision location is based on neck surfaceanatomical landmarks, the thyroid cartilage markers ashorizontal as C5C6

In 89 cases of surgery there are 57 cases ofherniation below ligamentum longitudinale posterius and

32 cases of herniation via ligamentum longitudinaleposterius, of which 19 cases have sequestration There are

62 cases of soft hernia and 27 cases of hard hernia whichneed diamond drill bit to whet spines

3.6.2 Complications

Table 3:13 The rate of complications (n = 89)

Surgical site infections

Adjacent disc

12

1.122.24