An observation of massive lumbar disc prolapse

Background

The aim of this study was to investigate whether massive lumbar disc herniations (LDH) can be managed safely with non-operative treatment. Whilst most LDH are treated successfully with analgesia and physiotherapy, there is little literature regarding the treatment of massive LDH. Their impressive size raises the suspicion that they may cause cauda equina syndrome and are therefore often treated surgically.

Methods

Patients were referred to our tertiary unit by either their general practitioner or the musculoskeletal service. To be included in the study, patients had to have a diagnosis of massive LDH on their initial magnetic resonance imaging (MRI) and opt for non-operative treatment. Seventeen patients with a diagnosis of massive LDH with an average follow-up of 209 days (0 to 1,005 days) were reviewed.

Results

One patient was listed for surgery due to persisting radicular pain only. However, they were deemed unfit for surgery and this was therefore cancelled. One patient developed impending cauda equina syndrome and underwent urgent discectomy with no complications. All remaining patients were managed safely non-operatively with no complications.

Conclusions

We conclude that the massive LDH can be safely managed non-operatively, providing patients are examined for cauda equina syndrome and are fully educated on the need to represent urgently should red-flag symptoms develop.

Activ C cervical disc replacement for myelopathy

Background:

Cervical disc replacement is becoming an increasingly popular treatment option for cervical myelopathy. It retains motion at the affected segment, unlike anterior cervical discectomy and fusion. The aim of this study is to assess the outcomes of a series of patients who underwent Activ C disc replacement for cervical myelopathy.

Materials and Methods:

A series of patients at the above Trust with clinical and radiological evidence of cervical myelopathy who were suitable for cervical disc replacement from 2007 to 2009 were included. Implants were inserted by one of two consultant surgeons {IMS, MO’M}. Patients were assessed preoperatively and at six, 12 and 24 months, postoperatively, with a visual analogue score (VAS) for neck and arm pain severity and frequency, the Neck Disability Index questionnaire (NDI) and the Centre for Epidemiologic Studies Depression questionnaire (CES-D).

Results:

Ten patients underwent surgery between May 2007 and July 2009, 6 women, and 4 men. Average age was 54 years (40-64). Disc levels replaced were: four at C4-5; eight at C5-6; seven at C6-7. Three patients had one disc replaced, five patients had two discs replaced, and two patients had three discs replaced. The VAS for neck pain improved from 5.9 pre-operatively to 1.4-24 months postoperatively and the VAS arm pain improved from 5.4 to 2.6. The NDI improved from 51% preoperatively to 26.8% at 24 months postoperatively. The CES-D showed a slight increase from 19.5 preoperatively to 21.7 at 24 months, postoperatively.

Conclusion:

Cervical decompression and disc replacement improves pain and function in patients with cervical myelopathy. This benefit is maintained at 24 months post op, with no cases requiring revision.