Cervical intervertebral disc protrusion in an RAAF F-111C pilot: a case report

This case report describes a serious cervical spine injury occurring in an F-111 pilot of the RAAF. The pilot developed a significant cervical intervertebral disc protrusion with severe, progressive neurological signs and symptoms in his right arm for a period of 4 mo. Multiple investigations including MRI and myelography established the site of the lesion as C6/7. He eventually responded to bed rest and made a complete recovery. The aeromedical disposition of this aviator and the roles of different treatment modalities in the aviation environment are discussed. The need for more research into +Gz-related neck injuries and the requirement for preventive strategies to protect the cervical spines of high performance pilots are also highlighted.

[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.

The natural history of herniated nucleus pulposus with radiculopathy

STUDY DESIGN

The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis.

OBJECTIVES

The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur.

SUMMARY OF BACKGROUND DATA

The study population consisted of 77 patients with radiculopathy.

METHODS

All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times.

RESULTS

Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence.

CONCLUSION

Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.

Cervical chymopapain nucleolysis: MR imaging assessment of chymopapain efficacy

Soft cervical disc herniations can be treated by minimally invasive procedures with excellent results. Chemonucleolysis with chymopapain is one alternative to surgery that is shown to be innocuous within a strict technical framework. MR imaging allows an accurate diagnosis of the cause of cervical root compression, thus facilitating the choice of conventional surgery or minimally invasive procedures.

Lumbar chymopapain nucleolysis

Chemonucleolysis with chymopapain is indicated in the majority of patients who are candidates for surgery for intractable sciatica due to herniated nucleus pulposus. It is safer, as effective, and cheaper than standard surgical discectomy, providing that patients are well selected and the procedure is properly performed. Because the indication for chemonucleolysis is not limited to contained discs, it has proved to be more effective than percutaneous discectomy. At present, of all percutaneous methods, lumbar chymopapain nucleolysis is the only procedure that has withstood the test of time. It is an attractive alternative to surgical discectomy and should be presented for consideration to patients who meet the criteria for the procedure.

Chemonucleolysis versus laminectomy. A cohort comparison of effectiveness and charges

STUDY DESIGN

A prospective cohort study was done comparing 100 consecutive chemonucleolysis patients with 100 consecutive laminectomy patients.

OBJECTIVES

The effectiveness and cost of chymopapain chemonucleolysis was compared with that of laminectomy to manage herniated lumbar discs.

SUMMARY OF BACKGROUND DATA

Although the efficacy of chemonucleolysis has been established, controversy regarding the relative benefits of chemonucleolysis and laminectomy continues to arise. The relative cost-effectiveness of the two procedures has not been evaluated previously in a cohort study.

METHODS

Patients in both treatment groups were of comparable age, height and weight, and worker's compensation status. Patients with migrated disc were not considered for chemonucleolysis. Improvement in pain, paresthesia, straight-leg raising, reflexes, motor loss, and sensory function, self-reported overall improvement, ability to maintain employment, and charge of treatment were used to measure treatment success.

RESULTS

Clinical assessment after 6 weeks showed 92% of laminectomy patients compared with 82% of chemonucleolysis patients compared with 82% of chemonucleolysis patients had successful results (P = 0.058). Chemonucleolysis patients had greater improvement in numbness (P = 0.014) and sensory and motor functions (P = 0.002). After 6 months, 88% of chemonucleolysis patients and 85% of laminectomy patients had successful results, with a greater improvement in sensory status of chemonucleolysis patients and 82% of laminectomy patients had successful results, and more chemonucleolysis patients than laminectomy results, the average charge savings for chemonucleolysis patients was +5365 when chemonucleolysis was performed instead of laminectomy.

CONCLUSION

This study shows that chemonucleolysis is an effective as laminectomy in appropriately selected patients but at lower charge and can contribute substantially to reducing short-and long-term health costs.

Outcome of unoperated discogram-positive low back pain

STUDY DESIGN

No previous discography study has addressed the nonoperative outcome of low back pain.

OBJECTIVES

This study was undertaken to retrospectively analyze the outcome of patients with documented single-level discogenic pain who were considered candidates for surgery but did not receive it.

SUMMARY OF BACKGROUND DATA

The natural history of "discogenic" low back pain is unknown, and its treatment is controversial. Although positive discography is viewed as a valid diagnostic technique, the results of fusion surgery are often disappointing.

METHOD

Twenty-five individuals (16 women, 9 men) underwent comprehensive evaluation (examination, radiography, objective disability determination). Study criteria included incapacitating low back pain, single-level + morphologic + provocative discogram, no surgery, and a minimum follow-up period of 3 years.

RESULTS

Average age of patients at discography was 43 years and at study was 48 years; level of involvement in 10 patients was L4-L5 and in 15 patients were L5-S1. The mean follow-up period was 4.9 years (range, 3.3-7.0 years). The condition of 17 (68%) patients improved, two (8%) stayed the same, and six (24%) worsened. Improved patients had a shorter history of low back pain (3.5 yr vs. 11.0 yr) and older age at onset (45 versus 33 yrs.) Psychiatric disease was present in 66.7% (4 of 6) patients whose conditions worsened. Eighty percent (12 of 15) of patients receiving workers' compensation improved. There was no correlation between disc level, gender, smoking, and outcome.

CONCLUSIONS

Discogenic low back pain improved in patients without psychiatric disease. Older age at onset and shorter duration of low back pain were favorable indicators. These results are comparable with or better than those reported for surgical treatment of this condition.

Intraoperative chemonucleolysis as an adjunct to lumbar discectomy

STUDY DESIGN

This is a report of a series of 104 patients who underwent lumbar discectomy and chemonucleolysis at the University of Virginia between 1985 and 1989.

OBJECTIVE

The primary objective was to determine the safety of this procedure. A secondary objective was to begin studying its efficacy.

SUMMARY OF BACKGROUND DATA

This is the first report on the use of chymopapain during open surgery.

METHODS

Patients with low back pain and radicular symptoms not cured with conservative therapy were selected for participation in the study. Intraoperatively, disc spaces were injected with 2 ml of chymopapain. Patients were followed-up for an average of 5 years. Patients were surveyed regarding pain relief, and failures of the procedure were analyzed.

RESULTS

Seventy percent of patients reported good or excellent pain relief. Operative failures, characterized by reoperation at the same level, totaled 9.6%. Recurrent disc herniation at the time of reoperation occurred in 4.8%.

CONCLUSION

The procedure is safe and the relief of pain was similar to that in other published series. The suggestion is that the rate of recurrent disc herniation is reduced.

Magnetic resonance imaging before chemonucleolysis for lumbar disc prolapse

Chemonucleolysis is an established non-operative treatment of a prolapsed symptomatic lumbar disc. It was introduced as a form of treatment in the early 1960s by Smith [18]. One of the main causes of failure is the difficulty in pre-operative assessment of a contained disc prolapse. Reducing failure rates is very important for the morale of surgeon and patient alike. We investigated 58 patients with magnetic resonance imaging (MRI) to select those with a contained protrusion prior to chemonucleolysis. Per-operative discography confirmed contained protrusion in 96.5% (56/58) of cases, increasing the specificity of selection. At 6 months post chemonucleolysis 86% of our patients were asymptomatic. We would commend MRI as the investigation method of choice prior to chemonucleolysis for a prolapsed symptomatic lumbar disc, thus avoiding separate diagnostic discography, thereby reducing inconvenience to the patient and wastage of prepared chymopapain.

Serial changes on MRI in lumbar disc herniations treated conservatively

Using serial MRI, we studied 32 patients with herniated lumbar discs, treated conservatively, to clarify the natural history of this condition. MRI was performed in the acute stage, then 6 months and 1 year later. On axial images, the proportion of the cross-sectional area of the spinal canal occupied by the herniated disc was 31.9% on the average on the initial scan, 28.7% 6 months and 25.3% 1 year later. The size of the herniation decreased by more than 20% in 11 patients (34%), by 10-20% in 8 (28%) and was unchanged in 12 (38%). The height of the disc slightly decreased with time, but there was no significant change in the angle of lordosis in the affected segment. The initial MRI revealed degeneration of all affected discs, and progressive degeneration was observed in 9 patients. The more degenerate the disc and the larger the initial herniation the more the size of the herniated fragment decreased.

Low-dose chemonucleolysis combined with percutaneous nucleotomy in herniated cervical disks

The combination of low-dose chemonucleolysis with 500 IU chymopapain followed by an automated percutaneous nucleotomy of the cervical spine is a new procedure. A follow-up of at least 1 year of the first 22 patients showed in 19 patients good or excellent results. In one patient a fair result was obtained, and in two patients the symptoms were unchanged; one of these patients subsequently underwent diskectomy and anterior cervical spine fusion. Preoperatively, all patients showed a clear cervical disk herniation with predominantly radicular pain. The procedure has been performed so far in approximately 100 patients. No intra- or postoperative complications have been noted.

Chemonucleolysis: correlation of results with the size of the herniation and the dimensions of the spinal canal

The aim of this study was to determine whether the results of chemonucleolysis are related to the size of the disc herniation and to the dimensions of the spinal canal. Short and long-term results (average follow-up 4 and a half years) of 148 patients were evaluated. Measurements made with a divider included the size of the disc herniation related to the sagittal diameter of the spinal canal at the discal level and the transverse interligamentous diameter at the level of the facet joints. The morphology of the lateral recess was also assessed. Measurements were initially made by five observers and were repeated eight times and on eight computed tomography (CT) scans in order to assess intra- and interobserver variability. Measurements of the entire series were then made by the two observers demonstrating a good intra- and interobserver reproducibility. Of the 148 patients 74% had an overall successful result. No significant difference was disclosed when comparing the various parameters of the clinical results with the size of the herniation. Similarly, a lack of correlation was also found between the clinical results and the dimensions of the spinal canal and of the lateral recess. In this series, the results were not significantly influenced by the size of the herniation or the morphology of the spinal canal.

Magnetic resonance imaging findings 10 years after treatment for lumbar disc herniation

STUDY DESIGN

Fifty-six patients with lumbar disc herniation who had participated in a double-blind study comparing chymopapain with saline were invited to undergo a magnetic resonance imaging assessment of the lumbosacral spine more than 10 years later.

OBJECTIVE

The aim of this study was to assess the long-term morphologic changes after treatment of disc herniation by chemonucleolysis and laminectomy and to compare these findings with the natural history of the disorder.

SUMMARY OF BACKGROUND DATA

There is little information on the effects of different treatment methods for lumbar disc herniation on the long-term morphologic changes in the disc.

METHODS

Of the original 56 patients, 39 were entered into the study: 12 had been treated by saline injection alone, 14 by chemonucleolysis alone, and 13 had subsequently required laminectomy for a failed intradiscal injection. Each sequence of magnetic resonance images was examined by a radiologist who was unaware of the treatment given. The signal strength was assessed on T2-weighted images in the sagittal plane and disc morphology on T1- and T2-weighted sagittal and T1-weighted axial images.

RESULTS

The signal of the treated disc was absent in all cases in each group. Thirty-seven percent of patients were found to have a persistent herniated disc and the incidence was similar in all three treatment groups. The presence or absence of herniation at 10 years had no significant bearing on a successful outcome.

CONCLUSION

The findings of this study indicate that long-term improvement of a patient's symptoms after treatment of disc herniation may occur with or without resolution of the hernia. This and the similar morphologic findings in the different groups is consistent with the 10-year clinical results after the treatment of disc herniation reported by Weber.

Effect of massotherapy on the in vivo free radical metabolism in patients with prolapse of lumbar intervertebral disc and cervical spondylopathy

The endogenous free radical scavenger superoxide dismutase (SOD) and blood catalase (CAT) in 2 groups of patients with prolapse of lumbar intervertebral disc and cervical spondylopathy were lower than that of the healthy control group, while the -SH reflecting the metabolic disturbance of free radical was higher. After massotherapy, blood SOD and CAT were increased, while lipid peroxide (LPO), -SH in urine were decreased, demonstrating that there are distinct parallel relationships existing in the changes of these enzymes in blood and urine.

Schmorl's nodes and low-back pain. Analysis of magnetic resonance imaging findings in symptomatic and asymptomatic individuals

Magnetic resonance imaging (MRI) findings in cases with symptomatic and asymptomatic Schmorl's nodes have been analysed. In all symptomatic cases, the vertebral body marrow surrounding the Schmorl's node was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. It was confirmed by histological examination that the MRI findings indicated the presence of inflammation and oedema in the vertebral bone marrow. These MRI findings were not seen in asymptomatic individuals. Inflammatory changes in the vertebral body marrow induced by intraosseous fracture and biological reactions to intraspongious disc materials might cause pain. We postulate that after fracture healing and subsidence of inflammation, the Schmorl's nodes become asymptomatic, in analogy with old vertebral compression fractures. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes.

Does postcontrast MR enhancement in lumbar disk herniation have prognostic value?

OBJECTIVE

The aim of our study was to evaluate the prognostic value, if any, of Gd-enhanced MR in patients with lumbar disk herniation.

MATERIALS AND METHODS

Fifteen patients undergoing conservative treatment for acute lumbar disk herniation were included in a prospective Gd-DTPA follow-up MR study. In each patient, the size of the herniation was measured, and, according to the changes in pathology that occurred, patients were divided into four categories. In addition, on the basis of the clinical outcome patients were divided into three classes.

RESULTS

In 11 of 15 patients, MR performed in the acute phase of the disease showed Gd-DTPA enhancement around the herniated disk; in all cases, disk herniation was markedly reduced at follow-up MRIs. The clinical outcome was good. In the remaining four cases, no enhancement was evident in the acute phase or at follow-up MRIs; no modification in the size of disk herniation was demonstrated at follow-up in two. Symptoms were unchanged in two patients and mildly improved in one.

CONCLUSION

Epidural enhancement, which is likely related to an inflammatory process, seems to play a role in the modification of the size of disk herniation.

Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome

STUDY DESIGN

The current prospective longitudinal study examined the predictive value of psychological, somatic and social variables for the prediction of the short- and long-term follow-up in 111 consecutively selected patients with acute radicular pain and a lumbar disc prolapse or protrusion.

OBJECTIVES

The criteria for the therapy outcome were the intensity of persistent pain at the time of the discharge from the hospital and 6 months later and the application for early retirement at the 6 month follow-up.

METHODS

As for the psychological predictors, we examined depression (Beck Depression Inventory BDI), daily hassles (Kiel Interview of the Subjective Situation KISS), pain coping strategies (Kiel Pain Inventory KSI), and Health locus of control (GKU). As somatic predictors, we assessed the duration of pain before treatment, previous operations, paresis, disc displacement, scoliosis, adipositas, treatment, and age. As social predictors, we assessed the social status, occupational characteristics, and the duration of inability to work.

RESULTS

The results indicated that persistent pain was best predicted by a combination of somatic (degree of disc displacement), psychological (depression and the pain coping strategies avoidance behavior, endurance strategies, nonverbal pain behavior and search for social support), and social parameters (social status and sitting position) with a correct prediction in 86%. The application for early retirement at the 6 month follow-up was best predicted by depression and stress at work.

CONCLUSIONS

The results lead to several hypotheses about biopsychosocial interrelations within the chronification of radicular pain and provide the clinician with a short screening instrument for early diagnosis of chronification.

Efficacy of chymopapain in chemonucleolysis. A review

STUDY DESIGN

This study was designed to determine the current experience in the use of chymopapain injection in the treatment of herniated intervertebral discs by analyzing reports appearing between 1985 and 1993. Forty-five clinical studies included 7,335 patients treated worldwide, some including comparisons to open laminectomy/discectomy and others to percutaneous discectomy.

OBJECTIVES

Because controversy persists after 30 years of clinical use of chymopapain, the results of current experience should establish the efficacy for those who want to consider chemonucleolysis as a treatment for a herniated nucleus pulposus.

SUMMARY OF BACKGROUND DATA

There is the suggestion that use of other than conservative treatment is made only to achieve a better result in the short term. The selection of type of treatment will depend on contraindications, with failures of chemonucleolysis found largely in those having spinal stenosis or sequestrated discs. Worker compensation patients respond less successfully than those with better motivation.

METHODS

The 45 studies were analyzed for determination of successful outcome and divided into 16 with more than 100 patients, 13 with less than 100 patients and 16 with comparison to other treatments.

RESULTS

Individual success rates exceeded 60% whereas cohort total averaged 76%. In studies comparing chemonucleolysis with open discectomy, success rate averaged 76.2% as compared with 88% for open surgery. In two other studies, percutaneous discectomy was less successful than chemonucleolysis. Where included, duration of hospitalization showed less time and thus less costs for chemonucleolysis. Return to work complications showed time off slightly less for chemonucleolysis than for laminectomy.

CONCLUSIONS

Chemonucleolysis, though somewhat less effective than open discectomy, can be successfully and safely used in about four of five carefully selected patients without the trauma, risks, and subsequent fibrosis associated with lumbar disc surgery.