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 VIETNAM MILITARY 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 QUESTION 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 or nerve root cause This disease is often characterized by neck pain, shoulder pain or pain in the spinal nerve roots Therefore, this disease reduces nerve function, thereby reducing the ability to work and quality of life Treatment for herniated disc in the cervical spine is for the purpose of recovery of nerve function, and reducing pain so the patient returns to normal life with quality The treatment is also very diverse, from physical therapy methods and internal medicine When internal medicine treatment fails or neurological signs appear, it will be treated with surgery About classics, anterior incision surgical treatments welds disc in associated with vertebral body bone from autologous iliac crest, but this method has disadvantages such as: requiring another surgery, prolonged surgical time, falling bone graft causing cervical spine hunchback or complications in the bone graft Thus, there have been many methods of improved surgery and the latest surgical procedures by taking the disc stem and joint welding using artificial materials such as carbon fiber, titanium, PEEK has showed effective results such as pain treatment and prevention of complications after surgery, such as narrow foramen intervertebrale leading to the cervical spine hunchback Nowadays, many devices with different materials are used and it is difficult to prove the preeminence of a device or materials over the others Selection depends on the familiarity and availability, cost and high compatibility of the materials used In the Department of neurosurgeon of People's Hospital 115, tools Cespace with Titanium which are quite 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: To determine some standards for surgical indications in the treatment of disc herniation in the cervical spine by way of anterior incision surgery and placing tools Cespace To assess results of treatment of herniated disc in the cervical spine by way of anterior incision surgery using operating microscope and placing tools Cespace New contributions of the thesis: Treatment for Herniated disc in the cervical spine by way of anterior incision surgery and placing tools Cespace has good results and can be easily implemented to apply multiple layers of new patients using operating microscope which helps main dissection, good blood holding to avoid complications during and after surgery The layout of the thesis: The thesis consists of 109 pages with 27 tables, 21 charts and 41 figures The thesis constitutes the basic chapters: Introduction pages, Chapter – Overview 29 Pages, Chapter - Subjects and Methods 17 pages, Chapter - Research Results 29 Pages , Chapter – Discussion 29 pages, Conclusions pages and Recommendations page; references 122 (28 Vietnamese, 94 English), including material published from 2005 to present CHAPTER - OVERVIEW 1.1 DIAGNOSIS Need to study case history thoroughly, examine clinically and radiology should be done to confirm the diagnosis The diagnostic tests are suggested: - Spurling test solution - Pulling the neck by hand can be regarded as a physical examination, the patient in the position of back neck, gently pulling by hand often significantly reduces symptoms in the neck and hands in patients with pathological root - Shoulder stretch measure - L'hermitte signs found in patients with neck marrow related diseases 1.2 RADIOLOGY Radiology diagnosis is used to determine: whether or not there is injury; lesion location, lesion extent, lesion nature 1.2.1 Conventional X-ray Cervical spine radiographs are radiology diagnostic method which is the first choice for patients with symptoms of pain in the neck, spreading to limbs and often used to diagnose neck disc diseases causing symptoms of root nerve Tilt radiographs: to evaluate the disc slot height, spines at the anterior and rear borders of the vertebral body 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 and zygapophysus 1.2.2 Computerized tomography (CT Scanner) CT examines bone composition and is useful in the assessment of adduction fracture It is also useful when C6 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 accuracy reaches 96% when combined CT with electrospinogram, which allows view of the subarachnoid space and evaluation 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 is considered to be good assessment and positioning of neck marrow compression In some cases, especially, of invasion 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 is replaced by MRI for most cervical spine diseases MRI has now become the first choice method to diagnose symptoms of neck root or symptoms of combined marrow 1.2.4 Electromyogram (EMG) (only when there is a movement disorder) Little was done, however, they also provide evidence of root compression in patients at little clinical presentation 1.3 TREATMENT OF HERNIATED DISC IN THE CERVICAL SPINE (HDITCS) Treatment methods of HDITCS now include: internal medical treatment, surgical treatment and non-surgical interventions 1.3.1 Internal medical treatment Internal medical treatments of HDITCS include: Immovability: an important stage, immovability of neck is completely maintained, at least during the period of severe pain, often 3-4 weeks, with limited neck movement and stay in bed wearing a neck fixed belt Most commonly used drugs are non-steroidal antiinflammatory anodyne, muscle relaxants, other painkillers or steroids Other methods such as using heat in place, stretching the cervical spine are also good practice to avoid paramyotonus, only for simple root compression There are 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 indications should be based on two factors of clinic and radiology, in which clinical plays an important role Most authors recommend surgical indications when one of the following occurs: - Constant pain, not responding to conservative treatment (3-6 months) - Progressive muscle weakness or muscle atrophy already - There is a presence, or appearance, or increase of symptoms 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 three main 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 longitudinale ligament ossification following canalis spinalis stenosis or canalis spinalis stenosis by back cause, an incision is often not enough to release compression, the combination of two anterior and rear incisions is necessary For the anterior incision, implementation techniques may be removing vertebral bodies or merely taking disc, releasing compression through hernia For the rear incision 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 disc nucleus pulposus has been widely used in France and America in the 1970s and 1980s This method is endicated for HDITCS causing recurrent persistent neck root pain with aggressive medical therapy for weeks without improvement Contraindicated in cases of sequestration hernia, a large block, marrow compression, transdural, herniated disc with neck canalis spinalis stenosis, heavily degenerative disc and especially when detecting 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 a small volume of mucus, thus reducing the pressure inside the disc suddenly, making the herniated disc shrink, reducing nerve root compression Although it was a method of minimal intervention, but it also has very tight indications of treatment 1.3.3.3 Percutaneous disc decompression using radio waves This method was implemented by Singh and Derby for the first time in 2001 Using radio waves to create a picture of the mucous disc using coblation technology (this method is called nucleoplasty) Nucleoplasty is a minimally invasive technique to reduce the pressure inside the disc using coblation technology community 1.3.3.4 Surgical endoscopic microsurgery disc Endoscopic has been applied to surgery of herniated disc for a long time In 1986, Schreiber used endoscopic instruments to improve techniques of percutaneous disc taking by Hijikata.The author used lines: a line to get the disc, the other opposite line to put endoscopic instruments These techniques allow observation of herniated discs and nerve roots in the canalis spinalis Comment: The recovery rate after 12 months in group of root pathology is 95.87%, in marrow pathology group is 70.77% 3.7.7 Aggregate final results by JOA scale Very good: 69 cases, accounting for 77.52%, good: 10 cases accounting for 11.24%, average: cases, accounting for 8.99%, less: 2% cases accounting for 2.25 CHAPTER - DISCUSSION 4.1 EPIDEMIOLOGY CHARACTERISTICS 4.1.1 Gender Table 4.1 Comparing gender ratios of some authors Author Male Female Ratio Dubuisson (1993) Cloward (2007) Ilkko (1996) Vo Xuan Son (2000) Nguyen Cong To (2007) We (2011) 67 29 81 64 18 46 33 18 39 32 43 2:1 3:2 2:1 2:1 3:1 # 1:1 4.1.2 Distribution by age Meet the most aged from 30 to 50 From 50 years of age or higher, the cracks in the fibrous ring are more, the buffer is still good in expansion capabilities and consequently hernia occurs more often After the age of 50, the ability to get out of the buffer is down and although the cracks of fiber ring are more, the hernia is rare Regarding the distribution by age, our results are also comparable to some other authors, more common age is from 40-50 The average age in our study plots is 51.58 ± 10.3, according to K Radhakrishnan (1994) it is 47.6, Nguyen Cong To (2007) is 53.35, Nguyen Duc Hiep (2000) is 45.8, Nguyen Dinh Hung (2008) average age is 53.9 4.1.3 And occupational history Herniated disc in the cervical spine is the most popular among office workers, who account for 32.58%, followed by workers at 21.31%, retirement staff at 16.85% the least is home-makers who accounted for 13.48% (Table 3.2) It usually occurs in people who work in a constant position, or repeat an action many times In our study plots the percentage of patients with a history of trauma accounted 10.11% (Table 3.3), lower than 18.26% of Nguyen Thi Tam with 115 patients HDITCS, Nguyen Thi Anh Hong met in 300 cases of neck canalis spinalis stenosis, with 23% of soft herniated disc in the cervical spine occuring after injury This difference may be due to our patients less than the two authors 4.2 CLINICAL SYMPTOMS OF HERNIATED DISC IN THE CERVICAL SPINE 4.2.1 Neck pain In our study the rate of neck pain, pain and dominated radicular paresthesias is 100% (Table 3.4, chart 3.5), 92.31% (Table 3.4) shows clinical symptoms due to nerve root pain, marrow was pinched Pain in the cervical spine, pain spreading to shoulders, down the arms and hands is often the first manifestation of HDITCS Increased neck pain behind the back neck and neck rotation limits should make people think of disc disease in the cervical spine Then symptoms such as sensation disorders of hand ingenuity, limb weakness, difficulty walking and toileting disorders shall gradually increase HDITCS pathological manifestations can be divided into two main groups: root compression syndrome and marrow compression syndrome 4.2.2 Root compression syndrome Root compression syndrome of herniated disc disease in the cervical spine is because herniated discs pinch the nerve root In addition, the mechanical and biological impact of repetitive phenomena of movements over the neck or folded back into injured foramen intervertebrale to reduce the diameter of the foramen intervertebrale, leading to the accumulation of post-result of root compression In our study, 24 cases of root pathology (Table 3.4), symptoms of neck pain, pain and dominated radicular paresthesias are met in all cases (100%), decreasing hand dexterity accounts for 58.33%, weak hand 29.16%, Spurling test methods 79.16% and muscle atrophy 8.33% According to Nguyen Dinh Hung, neck pain is seen in 100% of cases, pain spreading to the shoulders is 62.5% and the pain spreading down the arm is 87.5% Henderson et al (1983) Clinical studies of 736 patients with pathology of radicular neck, with 99% of cases with arm pain, 85% had feeling disorder, 80% neck pain, 68% have weak movement 4.2.3 Marrow compression syndrome Marrow compression syndrome of herniated disc disease in the cervical spine is due to compression of hernia block to the marrow McCulloch and Young said that four elements are needed to cause marrow disease in the herniated disc in the cervical spine, including: The presence of congenital canalis spinalis stenosis The progressive compression to canalis spinalis by the osteophyte and soft disc herniation The ischemia of the foster system for nerve roots and spinal marrow The mechanical impact of mechanical and biological movement repeats on the spinal marrow, nerve roots and their vascular foster system In 89 cases we studied, there is a movement disorder in varying degrees accounting for 79.77% (Table 3:17), compared with Kukobun (1996) 61% of movement disorders and Nguyen Dinh Hung dyskinesias up to 87.5% The rate of movement disorders in our group and Nguyen Dinh Hung is higher than Kukobun, this difference may be due to our patients often arriving late Table 4.2 Comparing the ratio of mere root compression syndrome and common marrow compression syndrome with other authors Root Marrow compressio Authors compression Ratio n syndrome syndrome Gaetani (1995) Dubuison (1993) Vo Xuan Son (2000) 108 85 36 31 15 60 3,5 5,7 0,6 Nguyen Cong To (2007) We (2011) 24 17 65 0,3 0,37 4.3 DISTRIBUTION BY SURGERY LEVELS In our study compared with patients of foreign authors in the distribution of the level of disc herniation The author of Europe, America and Japan have a herniated disk that is concentrated in the C6 and C5-6-7, are rare at C3-4 Meanwhile, the herniated disk in our research plots focusing C5C6, C4C5, little happens at C6-7 (10.11%) and the rate of appearance at C3-4 (19.1 %), than at C6-7 Compared Dubuisson, the difference in the distribution is very clear on the C3-4 and C6-7 (Table 3:11) shows differences in distribution between the groups of patients our patient group of Dubuisson Besides the coincidence in the distribution in the C5-6 level, at all other levels, the distribution totally different curve of our patients tend to shift to the higher levels, but compare with Nguyen Thi Tam Vo Xuan Son we found no difference Table 4.3 Comparison of the distribution for all disc herniation with other authors Authors C3C4 C4C5 C5C6 C6C7 C7N1 Dubuison (1993) Vo Xuan Son (2000) Nguyen Thi Tam (2002) We (2011) 3% 6% 36% 54% 17,9% 35,1% 44,8% 4,1% 20,23% 30,34% 37,64% 8,99% 15,18% 30,36% 46,42% 8,04% 1% 4.4 RADIOGRAPHICAL DIAGNOSIS 4.4.1 Routine radiography Including 89 cases in our study (Table 3.6), there are 58 cases (65.16%) losing normal physiological curvature of the cervical spine, 21 cases of narrow discs slit (23.59%), 19 cases of narrow foramen intervertebrale (21.34%) and 29 cases of spines (32.58%) 4.4.2 Computerized tomography In our 89 patients there are patients who have taken CT, including patients taking normal CT to assess bone degeneration, such as spines, narrow foramen intervertebrale There is a case to take 64 CT for diagnosis, because this patient had metal fragment in the neck and could not take the MRI and the patient was diagnosed and successfully operated Taking CT with contrastmedium injection can accurately diagnose a herniated disk from 70 to 90% 4.4.3 Magnetic resonance imaging In our study of 89 patients, 88 patients were taken MRI before surgery, only one patient could not take the MRI due to metal fragment in the neck and had to take CT to diagnose before surgery The longitudinal images (sagital) allows assessment on the entire cervical spine, the location and number of layers of hernia In 88 cases taking MRI, those who were diagnosed posterius herniated disc accounted for 100% All the herniated disc are hypointense on T2w 100%: a manifestation of reduced water content in the disc due to degeneration Image hyperintense fluid in the hernia location on the image T2-w was seen in 44.31%, reduced disc height is 23.86% and 10.22% sequestration hernia (Table 3.9) On cross-sectional (axial) shows location of central herniation 29.5, next-to-central 48.9%, and lateral heriation 21.6% (Table 3.10) We not have a hernia cases in the vertebral body and the foramen intervertebrale, due to structural characteristics of arthroscopy Luschka keeping disc not herniated in foramen intervertebrale 4.5 SURGICAL TREATMENT INDICATIONS 4.5.1 Specify surgery Most authors have recommended surgical indications in one of the following cases: Constant pain in neck, shoulder, arm does not respond to conservative treatment Progressive muscle weakness or muscle atrophy already There is the presence, or appearance, or increase of the symptoms of myelopathy Disorders sensation, movement disorders, round muscle disorders 4.5.2 The surgical treatment In 1955, Smith and Robinson presented techniques of surgery to get disc by anterior incision, in 1958, Cloward demonstrated techniques of surgery to get disc by anterior incision for herniated disc in the cervical spine, marrow compression Then, in 1960, Bailey and Badley also reported a technique of surgery to get buffer by other anterior incision The basic difference of these techniques is the grafts An et al, Emery et al said that not using osteoplasty makes the foramen intervertebrale smaller, nerve root which is not free and pain is not reduced, back bone is likely to be hunched and likelihood of the disc herniation at the adjacent level is higher Some other authors present innovative techniques which reduce the incidence of graft complications and some others advocates using grafts of the same species or other species or synthetic graft which not only limits complications of grafts, but also prevents the complications of surgical area to get grafts in harvesting bone graft in hip-bone After techniques of surgery by anterior incision were invented, along with the widely used surgical microscopes, many authors advocate surgery by the posterius incision to get herniated block in the case of lateral hernication with root compression 4.5.3 Specifies the operating method Currently, the development of treatment facilities, as well as good tools convenient for surgery we carry out surgery by anterior lateral incision our surgical incision using Caspar balls, creating large enough surgical space and all operations when removing buffer are performed under operating microscope, the spines are whetted with high-speed drill, decompress marrow and roots We weld joint vertebral bodies by Cespace, because of the following advantages: Solid Titanium core, impervious to the host, this core is covered with plasmapore microporous on the surface to increase the surface area by 16 times Plasmapore layer is effective for developing the internal development of bone on the surface of the graft Cespace piece is designed in accordance with the characteristics of the disc compartment There are cementation components of surfaces of Cespace piece, after attaching these components to the cartilaginous end plate making Cespace solid to limit graft displacement 4.6 COMPLICATIONS OF SURGICAL TREATMENT Complications of surgery + Damage to blood vessels + Organ Damage + Nerve damage Postoperative Complications + Postoperative Bleeding + Difficulty swallowing after surgery + Postoperative infections + Other complications: inflammation of graft, pseudarthrosis and complications at the graft taking In addition complications when using metal pieces in the cervical spine: (table 3.14) we had cases of Cespace settlement into the vertebral body (6.74%), cases of adjacent vertebra degenerative disc (2:24%) and two cases of anterior displaced Cespace (2:24%) Anterior displaced Cespace, there are cases in our research plots (2.24%) In these cases, the patients returned for follow-up of neck pain and case of swallowing choking sensation Both these cases were researched again and it may be due to technical fault: one is due to selecting Cespace which is bigger than the height of disc compartment, the other is because we had not placed Cespace not to fit into concave vertebral bodies Therefore, when patients moved their neck many times, Cespace was subsided, in these two cases we operated to get Cespace Long-term complications are the most talked about is the degeneration of the adjacent levels above and below the surgical floor The rate of degeneration in adjacent vertebra in our study plots (2.24%) after one year had no difference from the above author 4.7 SPINAL FLEXION RECOVERY AFTER SURGERY The majority of cases of 58 patients losing physiological curvature (65.17%), we operated to place Cespace to weld joint vertebral body and recreate the height of the disc compartment In cases disc slit was too narrow due to high degeneration, or due to prolonged illness disc slit height could not be restored to normal We chose medium-sized grafts to fit the disc slit and did not choose the too large grafts to cause excessive stress, which would increase pressure on the discs above and below and quickly degenerate adjacent layer causing postoperative pain In our study we recorded pretty good recovery of the physiological hyperextension of cervical spine, after 12 months, radiographs recorded recovery of spinal hyperextension to normal of 46 patients (79.31%), only 10 patients (11.24%) lost physiological flexion but no case was angle humpbacked 4.8 RESULTS OF RECOVERY AFTER 12 MONTHS According to the JOA scale in the normal sense is points, in our lots of research we have 67 cases of preoperative sensation disorders, 63 cases of mild sensation disorders and cases of severe severe disorders (table 3.15) For the postoperative results we found recovery of sensation pretty good and there was no case of severe sensation disorders In our study there were only cases of mild sensation disorders after 12 months and the average mark of sensation disorders after surgery after 12 months recovered significantly 5.21 with p 0.05 But after months of recovery there was a difference between the root and the marrow groups, root pathology group with 16 cases (79.17%) and marrow pathology group with 31 cases (47.69%) with p