The December 2022 Spine Roundup. 360. looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Purpose of the Study. Assessment of long term results of Chemonucleolysis vs. surgery for soft disc herniation. Material and Methods. From 1982 to 1985, 100 patients with symptomatic disc herniation were randomly allocated to receive either Chemonucleolysis(48) or surgery(52) after a three months trial of conservative treatment. Ten of the chemonucleolysis had surgery. At 10–13 year follow up, Sixty one of the original 100 patients responded, (32 chemonucleolysis; 29 surgery). At 25–27 year Forty four patients responded (24 chemonucleolysis; 20 surgery). Clinical outcome at one year was according to a self-assessment questionnaire: Completely, better improved, the same, or worse, and at the later follow up periods, according to the Macnab criteria. The results of two groups of patients were compared using Chi square and T test for independent samples. The disc height of the affected disc was measured from the lateral lumbar spine radiograph taken pre-operatively, and at the later two time points, and compared to a normal adjacent disc expressed as a percentage. Results. The intent to treat clinical outcome results showed a high success rate at one year (93% chemonucleolysis; 96% surgery completely better or improved); and also at the later two time points with no significant difference between the groups. The radiological data showed no difference in disc height between the groups at any of the time points with some reduction over time with aging. Conclusion. There is no difference between the groups in either clinical or radiological outcome over time. Chymopapain, presently not widely available, should be made available again. No conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Assessment of long term results of Chemonucleolysis vs. surgical enucleation in soft disc herniation. From 1982 to 1985, 100 patients with symptomatic disc herniation were randomly allocated to receive either Chemonucleolysis or disc enucleation after all these patients had a trial of conservative treatment for three months. The outcome of result was measured using MacNab Criteria with the help of. Questionnaire. Assessing the patients in clinic. 44 patients out of original 100 patients were followed up in the clinic 25 years later. 24 were from chemonucleolysis group and 20 from the surgical group. According to MacNab criteria 62.5% had excellent or good results and 25% poor results in chemonucleolysis group and in surgery group 70% had excellent or good results and 10% poor results. Patients with poor result in Chemonucleolysis group consisted of: a) 1 had poor result post TKR, b) 4 were offered surgical enucleation subsequent to failed Chemonucleolysis though they did not seem to benefit from surgery and 1 out of these 4 also had fibromyalgia. c) 1 had poor result after sustaining fracture neck of femur. Poor results in surgical group were due to persistent back pain. The results at 25 year follow-up have shown no statistically significant difference between the patients treated by either chemonucleolysis or surgery. The added benefit of using the chymopapain injection is that it is of lower cost. Chemonucleolysis should have a wider role in treatment of intervertebral disc herniation

Purpose of the study: The endoscopic transforaminal approach to the lumbar disc proposed by A.T. Yeung has achieved world-wide acceptance. The Yeung endoscopic spinal system (YESS) used with a specific instrument set enables direct magnified optical control of discectomy performed under local anesthesia and neurolepanalgesia in the outpatient setting. We began our experience in 2003 and report here the results obtained in a consecutive series of 100 patients reviewed retrospectively. Material and methods: The inclusion criteria were patients with lumbar disc herniation-related lumbosciatic or crural pain non-responsive to well conducted medical care (including epidural or periradicular injections) for at least three months. The patients also had to display a concordant clinical and radiographic picture with confirmation of the symptomatic level by discography. Exclusion criteria were: excluded herniation with a fragment which had migrated into the canal; caudia equina syndrome; lower limb paralysis with muscle force scored less than 3; advanced-stage degernerative central bony stenosis affecting the clinical expression; pregnancy. The levels treated were: L3–L4 (n=6), L4–L5 (n=72), and L5–S1 (n=22). Herniation was forminal and extraforaminal in 53 cases, posterolateral in 31, and median in 16. There was an associated constitutional central stenosis in ten cases and in thirteen others, herniation was a recurrence after conventional surgery. Results: One hundred patients were reviewed at mean 18 months (range 12–34 months) follow-up. There were no serious neurological, vascular, or infectious complications. According to the McNab criteria outcome was good for 71 cases, fair for 16 and poor for 13 with 11 requiring revision with conventional surgery. Patients with foraminal and extraforminal herniation accounted for more than half of our series and responded best to treatment (84.9% good outcome) compared with posterolateral herniation (48%) (p< 0.05). Patients with median herniation had an intermediary outcome (68% good results). The least satisfactory outcome was observed at the L5–S1 level (63% fair and poor outcome), but the difference did not reach statistical significance compared with the higher levels. In patients with recurrent herniation after conventional surgery, there were four cases of failure. Discussion: These results are less satisfactory than those found in the literature. This might be explained by the less satisfactory outcome obtained with posterolateral herniations, probably because more than halve had migrated, generally above the plane of the disc, which in our experience cannot be accessed via the transforaminal approach. In addition, comparison of our first 50 cases with the last 50 showed an improvement in outcome to a mean 82%, expressing a learning curve for this type of technique. The most frequent error early in our experience was to insert the working endoscopic canula too anteriorly compared with the disc. The point of insertion must be very lateral determined by the discography in order to enter at least 30° posterior to the posterior part of the disc. Progressive fine-tuning of patient selection also helped improve outcome. YESS improves the work of the intradiscal instruments which can be control by direct view, explaining the the better results compared with the older mechanical or automatic (blind) methods. YESS is a very effective alternative to chemonucleolysis since papaine is no longer available. Compared with other endoscopic techniques for disectomy via an interlaminar approach, YESS offers the possibility of treatment patients in an outpatient setting with a local anesthesia. In addition the quality of the visual control of the foramen is better. These methods can be used in association with intradiscal Holmium-Yag laser which can also be applied to the bony walls of the foramen for a widening foraminoplasty. This transformainal endoscopic approach also offers a way to perform an exclusively foraminoscopic spondylodesis using an intersomatic cage. Conclusion: YESS is an excellent technique for non-migrated subligament posterolateral foraminal and extraforaminal herniations where conventional access to the foramen is known to be very difficult

We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery.

There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.

Aim: The aim of the study was to analyse the long-term follow-up of patients who were treated with chemonucleolysis for single level disc prolapse. Method: In our retrospective study we reviewed 112 cases that underwent chemonucleolysis for single level lumber disc herniation during the period of 1988–1996. Mean follow up was 9.5 years. In order to estimate the functional outcome of chemonucleolysis Oswestry Disability Index questionnaire was used. Results: An excellent or good response occurred in 79 patients (70.5%); 12 patients (10.7%) showed moderate response with minimal disability. Treatment failed in 21 patients (18.5%) who showed poor response and 12 of these 21 patients went for surgery within a mean period of 6 months. One patient had surgery at different level than chemonucleolysis. There was only one incident of procedure termination because of epidural contrast leak. There was no case of anaphylaxis or discitis. Conclusion: We conclude on the basis of our results that chemonucleolysis is a safe and effective treatment modality for lumber disc herniation in carefully selected patients

Objective: To analyse the incidence and gravity of reported complications that arise in spinal surgery and assess the comparative safety, or otherwise, of Endoscopic Laser Foraminoplasty. Design: Prospective independently analysed study of complications arising during the six weeks following Endoscopic Laser Foraminoplasty was correlated and compared to a meta-analysis of reported data on complications in conventional spinal surgery. Subjects: Nine hundred and fifty-eight procedures performed on 716 patients. Outcome measures: Occurrence of complications. Results: The cohort integrity of operative and review records at six weeks after surgery was 100%. Twenty four complications occurred in 23 patients: nine cases of discitis (one infective) (0.9%), one dural tear (0.1%), one deep wound infection (0.1%), two patients suffered a foot drop (one transient) (0.2%), one myocardial infarction (0.1%), one erectile dysfunction (0.1%) and one post operative panic attacks (0.1%). MRI later demonstrated eight residual disc herniations (0.8%). The overall surgical complication rate was 1.6%. Meta-analysis of conventional spinal surgery reported overall complication rates for fusion (11.8%), decompression (7.6%), discectomy (6.0%) and chemonucleolysis (9.6%). Conclusions: The complication rate of Endoscopic Laser Foraminoplasty is significantly lower than that reported following conventional spinal surgery (P < 0.01)

Objective: To analyse the incidence and gravity of reported complications that arise in spinal surgery and assess the comparative safety, or otherwise, of Endoscopic Laser Foraminoplasty. Methods: The Spinal Foundation, Rochdale, has performed 958 Endoscopic Laser Foraminoplasty procedures and holds a comprehensive database of the results of all operations carried out in this manner. The records of these procedures provided the basis for a comparison of the safety of Endoscopic Laser Foraminoplasty to that found for other spinal surgical techniques as reported in the literature. Nine hundred and fifty eight procedures have been performed on 716 patients. Complications that arose during the operation and the postoperative phase of six weeks following the procedure were elicited from patient records. This data was correlated and compared to a meta-analysis of randomised controlled trial data available on complications arising during and after conventional spinal surgery. The ‘SPSS’ and ‘CIA’ statistical packages were used to draw conclusions as to the safety of endoscopically assisted laser spinal surgery. Results: The cohort integrity of operative and review records at six weeks after surgery was 100%. In 958 ELFs performed, 24 complications occurred in 23 patients. There were nine cases of discitis (one infective) (0.9%), one dural tear (0.1%), one deep wound infection (0.1%), two patients suffered a foot drop (one transient) (0.2%), one myocardial infarction (0.1%), one erectile dysfunction (0.1%) and one patient who developed panic attacks post-operatively (0.1%). This amounts to an overall surgical complication rate of 1.6%. MRI follow up of clinically symptomatic patients highlighted eight residual disc herniations (0.8%). Meta analysis of randomised controlled trials of conventional spinal surgery for adult onset degenerative disc disease and/or sciatic pain reported overall complication rates for fusion (11.8%), decompression (7.6%), discectomy (6.0%) and chemonucleolysis (9.6%). Conclusions: The complication rate of Endoscopic Laser Foraminoplasty is shown to be significantly lower than that reported following conventional spinal surgery (P < 0.01). From these results it must therefore be concluded that ELF as a treatment for chronic low back pain and sciatica presents less risk to a patient than conventional methods of spinal surgery

Purpose: Since 1990, we have used specific material, presented to us by T. Tajima (Japan) during his visit in 1989 for percutaneous surgical cervical discectomy. French material was developed in 1992. The purpose of this work is to present our experience with this technique over the last ten years. Material and methods: Indications were cervicobrachial neuralgia unresponsive to medical care and secondary to MRI or CT documented cervical disc herniation. We used the right anterolateral approach guided with the image amplifier for patients under local anaesthesia and neuroleptanalgesia ou general anaesthesia. A guide wire was positioned in the centre of the anterior aspect of the disc to insert a 2.5 mm working tube in the middle of the disc. A special trephin with an inverted inside thread induced an aspiration effect when turned into the disc, in line with the posterior wall of the vertebra. This enabled removal of several “carrots” measuring 1 to 2 cm long of discal or even disco-osteophytic material. The removal of the posterior third of the disc and the herniation was completed with a fine disc forceps. Results: There were 85 procedures in 82 patients, mean age 42 years (35 women, 47 men): 57 at one level, mainly C5C6, 27 at two levels simultaneously, and one at three levels during the same operation. Mean follow-up for the 80 results known was 15 months (3–90 months). There were nine failures (two required conventional surgical fusion), 14 fair results, and 57 good results, giving a total of 88.75% good and fair results. Unlike percutaneous surgical lumbar discectomy, where good results at three months may deteriorate at two years, good results at three months after percutaneous cervical discectomy remained good at two years. Discussion: This technique provides results as good as chemonucleolysis. An advantage of the technique that allergy or disco-osteophytic protrusions are not contraindications. We did not have any infection or injury to neighbouring tissue. Conclusion: When rigorous operative procedures are used in this area with potential risk, percutaneous surgical cervical discectomy can be a useful routine therapeutic tool

Purpose of the study: Discal herniation is an exceptional cause of lumbar canal stenosis. When surgery for this disorder was first performed in the sixties, discectomy was not exceptional because discal protrusions were frequent. It was rather rapidly observed however that these protrusions were actually osteoarthitic discal rims that do not cause root compression. Discectomy was thus almost completely abandoned for lumbar stenosis surgery. Consequently, the development of true discal herniation after surgery for lumbar canal stenosis is highly exceptional. To our knowledge, this situation has not been reported in the literature. Among several hundred procedures for decompression of the lumbar canal practised in our unit over the last thirty years, we have observed seven cases. Material and methods: The patients were aged 43 to 74 years at the time of reoperation (mean 61 years). The stenosis was at the L4-L5 level in all patients and extended to L3-L4 in three and to L5-S1 in two and was bilateral in one patient. The L4-L5 disk had been removed at the prior surgery in three patients. Delay to recurrent pain was variable, from six months to eleven years. The sciatic pain was associated with motor disorders in one patient. Discal herniation was observed at the L4-L5 level in all patients and was often voluminous, excluded in three patients. Reossification was present in one patient but did not have a compressive effect. Treatment after recurrence was chemonucleolysis in three patients, with two successes and one failure. Surgical treatment by discal excision was used in four cases associated with instrumented fusion in one patient. Results: The patients were reviewed at one to ten years after the second operation. Nucleolysis was successful in two and a failure in one. The patient with failure of nucleolysis was treated by a new decompression with fusion and achieved an excellent result at ten years. Pain relief was achieved after surgery in all patients though only partial in one. Discussion and conclusion: Discal herniation is rare in elderly subjects and can cause problems late after surgical decompression of lumbar canal stenosis. It is important to search for discal herniation which is not always easy to confirm radiologically due to postoperative remodeling. Chemonucleolysis is an effective and economical solution when the disk has not been resected during the first procedure. When an operation is necessary, spinal fusion is not useful except in case of associated instability

We reviewed two comparable groups of patients who had been treated for lumbar disc herniation by chymopapain chemonucleolysis (145) or conventional surgical discectomy (91). They were reviewed 10 years after treatment by questionnaire, followed by a personal interview by an independent observer. The results of the surgically treated groups were slightly better than those treated with chymopapain. In particular, there was significantly better early relief of leg and low back pain, and fewer patients needed a second procedure. Complications were few in both groups

We report the cases of teenage twin girls presenting within months of each other with severe symptoms from lumbosacral disc prolapses, requiring laminectomy in one and chemonucleolysis in the other. CT scans showed similarities in spinal configuration, including the presence of disc bulges at the L4-5 level. This suggests a strong hereditary factor in prolapse of intervertebral discs, but a review of the literature showed little information on that aspect

Magnetic resonance imaging (MRI) of the spine produces images which reflect the chemical composition of the intervertebral disc. We have conducted a prospective study of the serial changes in the MRI appearance of the intervertebral disc after chemonucleolysis with the enzyme chymopapain. Fourteen patients were studied after single-level chemonucleolysis and the results compared with a control group of 17 discs in six patients who had diagnostic discography without enzyme insertion. A consistent pattern of gradual loss of signal from the nucleus pulposus culminating in complete loss of nuclear signal was seen in all cases after chemonucleolysis. Chymopapain therefore produced MRI changes analogous with premature gross disc degeneration. The rate at which this occurred varied; complete loss of signal took at least six weeks. Transitory minor end-plate changes were present in five patients, probably representing a mild chemical discitis. No similar changes were seen in the discography group

Computerised tomography (CT) was performed in 30 patients with herniated lumbar discs; this was done both before chemonucleolysis and three months after. In 20 of the 28 patients who were CT positive, the compression produced by the herniated disc was eliminated or reduced. Twenty-three of the 28 patients developed diffuse bulging of the annulus. There was good correlation between the clinical results at three months and the alteration in compression as shown by the CT scan. No evidence of alteration in the bony relationship was seen in the scan and none of the patients developed epidural fibrosis. Chemonucleolysis has thus been shown to be an effective treatment of herniated lumbar discs, but it is definitely not indicated in cases where compression of the nerve root or dural sac is due to a bulging annulus

A prospective study of 480 patients who underwent enzymatic dissolution of the nucleus pulposus with chymopapain is reported. Seventy per cent of patients with the clincial criteria for a disc herniation had a favourable response to chemonucleolysis. The commonest cause of failure was persistent back pain. In patients with sequestered discs or lateral recess stenosis surgical intervention was not made more difficult by chemonucleolysis. Those with a previous operation, spinal stenosis or psychogenic components to the disability had very poor results. Complications were few and easily managed