Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach

Anterior cervical fusion was initially described in the 1950s for cervical spondylotic radiculopathy. The indications for this procedure in the management of soft disc herniation have not been clearly defined. In addition, controversy exists as to whether a cervical soft herniation should be managed by an anterior approach or a posterior cervical laminotomy-foraminotomy. The authors report the results of a prospective study comparing anterior discectomy and fusion to posterior laminotomy-foraminotomy for the management of soft cervical disc herniation. Twenty-eight patients underwent anterior discectomy and fusion (Robinson horseshoe graft) while 16 patients underwent posterior laminotomy-foraminotomy. The disc herniations were classified into two types. Type I were single level anterolateral herniations (33 patients) while type II were central soft disc herniations (11 patients). Clinically, patients with type I herniations manifested signs and symptoms of radiculopathy while patients with type II herniations manifested signs of myelopathy or neck pain and bilateral upper extremity paresthesias in 4 patients. Confirmatory studies were myelography in 12 patients, myelography combined with computed tomography (CT) in 26 patients, and magnetic resonance imaging (MRI) in 6 patients. For type I herniations, 17 patients underwent anterior fusion while 16 patients had a posterior laminotomy-foraminotomy. The 11 patients classified as type II herniation all underwent anterior discectomy and fusion. There were 27 men and 17 women. The age range was 21 to 52 years (mean, 41 years). The follow-up was 1.6 to 8.2 years (mean, 4.2 years).(ABSTRACT TRUNCATED AT 250 WORDS)     

经胸腔侧前方入路治疗胸椎间盘突出症

本文报告经胸腔侧前方入路切除椎间盘治疗胸椎间盘突出症９例。均为中央型和旁中央型，经过脊髓造影、ＣＴＭ或ＭＲＩ检查确诊。随访１～４年，平均２年１０个月。根据Ｏｔａｎｉ分级方法标准，结果为优３例，良５例，一般１例，优良率达８９％，获得较满意效果。采用ＣＴＭ或ＭＲＩ诊断胸椎间盘突出有较高价值。该手术方法直接、充分地显露硬膜囊和神经结构，切除突出的椎间盘和刮除骨赘，减压较安全有效，同时对脊柱的稳定性和脊髓的血供影响较小。作者认为经胸腔侧前方入路进行椎间盘切除减压是治疗胸椎间盘突出症的一种安全有效的方法。     

颈椎前路椎间融合术后邻近节段的病变研究

[目的]研究颈椎前路椎间融合术后症状性邻近节段病变的发生率以及预测其发生的因素。[方法]112例颈椎间盘突出症或颈椎病接受颈椎前路椎体问融合术患者，行术后症状的评价，神经学检查及系列放射学检查，分析症状性邻近节段病变的发生率与临床和影像学参数的关系。症状性邻近节段病变的发生率通过Kaplan-Meier生存分析法进行统计，各参数与症状性邻近节段病变的发生率之间的关系通过u检验和t检验分析。[结果]随访时间2—19a，平均9．4a。112例患者中有19例（17％）出现了症状性邻近节段病变，其中男12例，女7例。Kaplan-Meier生存分析法分析未出现症状邻近节段病变的患者比率，5a时比率为89％，10a时为84％，17a时为67％。出现症状性邻近节段病变的病例中，术前脊髓造影上邻近节段硬膜有明显压迹或MRI上邻近节段椎间盘突出的发生率明显高于未出现症状性邻近节段病变的病例（P分别为0．0087及0．0299，双样本t检验）。而其他参数没有显著性差异。7名患者因保守治疗无效而进行了手术。[结论]当术前脊髓造影或MRI显示该节段存在无症状性椎间盘退变时，颈椎前路椎体间植骨融合术后症状性邻近节段病变的发生率明显高，与融合的节段数、术前颈椎曲度、椎管的直径或融合节段的曲度都无关。     

Contrast-enhanced MRI versus myelography and contrast-enhanced CT in postdiskectomy problems

Summary The differentiation between scar tissue and disk herniation is essential in postdiskectomy problems of the lumbar spine, since reoperation on scar tissue alone is often unfavourable. Epidural scar is a vascularized tissue, and enhancement can be seen after intravenous contrast injection, allowing differentiation from avascular disk material. Ten patients who had previously undergone surgery for lumbar disk herniation and with recurrent symptoms severe enought to warrant repeat surgery were examined by myelography, magnetic resonance imaging (MRI), and computed tomography (CT) before reoperation. MRI was performed with T1- and T2-weighted sequences in sagittal and axial projections before and after intravenous contrast injection. CT scans were obtained before and during intravenous contrast infusion. Reoperation revealed scar tissue, alone or together with disk, in 9 of 10 patients. Enhancement of scar but not of disk material was observed on MRI in 8 cases, but in none on CT. No enhancement of disk was seen with either modality. The correct diagnosis was given by MRI in 9 of 10 patients and by CT in 3 of 10. CT was superior to MRI in only 1 patient, who had a bony stenosis. Myelography could not separate disk from scar in any case. In conclusion, contrast-enhanced MRI was superior to MRI without contrast, CT before and after contrast, as well as myelography in discriminating disk from scar tissue.     

A case of idiopathic spinal cord herniation with duplicated dura mater

The patient was a 48-year-old man in whom a slow progression in walking difficulty occurred over a year. Magnetic resonance imaging (MRI) and computed tomography myelography (CTM) revealed duplicated dura mater from T1 to T12 and spinal cord herniation in the inner layer of the dura at the T4-T5 level. Idiopathic spinal cord herniation with duplicated dura mater was diagnosed, and surgery was performed. Intraoperative findings were of an elliptical defect of about 1 cm in the inner layer of the dura at the T4-T5 level, into which the spinal cord was herniated. A 1.5-cm cephalocaudal incision was created in the inner layer of the dura, and the incarcerated spinal cord was released, resulting in resolution of gait disturbance and an excellent postoperative clinical course. We reviewed the reports of 11 cases of idiopathic spinal cord herniation with duplicated dura mater and summarized the clinical and imaging characteristics as follows: 1) A hernial orifice was found at the T4-T6 level, 2) cross-sectional MRI or CTM showed a "snowman-like" deformation of the spinal cord, and 3) symptoms were often improved by widening the hernia orifice.     

Adjacent segment disease after anterior cervical interbody fusion

BACKGROUND CONTEXT: There have been many follow-up studies on anterior interbody fusion for cervical nerve root and spinal cord compression, and excellent neurological outcomes have been reported. However, postoperative degenerative changes at adjacent discs may lead to the development of new radiculopathy or myelopathy. In the previous reports, the incidence of symptomatic adjacent segment disease has ranged from 7% to 15%. PURPOSE: The present study was undertaken to investigate the incidence of symptomatic adjacent segment disease after anterior cervical interbody fusion (ACIF) and to identify the factors that are related to the development of this disease. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: A total of 112 patients were followed up clinically and radiologically for more than 2 years. OUTCOME MEASURES: Follow-up evaluation was primarily by means of clinical visits. The postoperative course of any symptoms, the findings of neurological examination and serial follow-up radiographs were performed in all patients. METHODS: The diagnosis of symptomatic adjacent segment disease was based on the presence of new radiculopathy or myelopathy symptoms referable to an adjacent level, and the presence of a compressive lesion at an adjacent level by magnetic resonance imaging or myelography. We evaluated the correlation between the incidence of symptomatic adjacent segment disease and the following clinical parameters (age at operation, sex, number of the levels fused) and radiological parameters (preoperative cervical spine alignment, preoperative range of motion of C2-C7 cervical spine, anteroposterior spinal canal diameter, preoperative existence of an adjacent segment degeneration on plain radiograph, myelography and magnetic resonance imaging [MRI]). RESULTS: Symptomatic adjacent segment disease developed in 19 of 112 patients (19%) followed. A Kaplan-Meier survival analysis was performed in order to follow the disease-free survival of the entire series of patients. The disease-free survival rates were 89% at 5 years, 84% at 10 years and 67% at 17 years. The incidences of indentation of dura matter on preoperative myelography or disc protrusion on MRI at the adjacent level were significantly higher in disease cases (p=.0087, .0299, respectively; chi-squared test). However, the other parameters did not show a statistically significant difference. There were seven cases (37%) who had failure of nonoperative treatment and additional operations were performed. CONCLUSIONS: The incidence of symptomatic adjacent segment disease after ACIF was higher when preoperative myelography or MRI revealed asymptomatic disc degeneration at that level regardless of the number of the levels fused, preoperative alignment, spinal canal diameter or fusion alignment.     

脊髓造影加CT与MRI对颈椎病及后纵韧带骨化诊断价值的比较

本文通过对３８例脊髓型颈椎病术前脊髓造影加ＣＴ和ＭＲＩ结果的比较分析，就此二种检查方法的诊断价值做出了评价。结果提示在显示颈椎间盘突出方面，ＭＲＩ明显优于脊髓造影加ＣＴ；在显示颈椎骨质增生、ＯＰＬＬ、颈神经很受压方面，ＭＲＩ不如脊髓造影加ＣＴ；在显示颈椎管狭窄蛛网膜下腔和脊髓受压方面，ＭＲＩ和脊髓造影加ＣＴ无明显差异。     

脊髓造影与CTM联合应用诊断腰椎间盘突出症46例报告

本文报告手术证实的46例腰椎间盘突出症术前经正位、侧位的中立、过伸、过屈位脊髓造影符合率为87%,CTM的符合率为97.7%,而两者联合应用则诊断准确率可提高到100%.     

颈椎前路融合术后发生症状性邻近节段退变的临床研究

目的:探讨分析与颈椎前路融合术后发生症状性邻近节段退变相关的因素。方法:自2001年3月-2006年7月共收治354例颈椎病患者,获得随访的263例,其中男185例,女78例,手术时年龄35~76岁,平均51岁,其中神经根型颈椎病54例,脊髓型颈椎病183例,合并两者的有26例。所有患者均接受前路减压、自体髂骨植骨、前路钢板内固定。根据门诊随访,综合评估所有患者的术后临床表现、神经系统及术前术后影像学表现,评价对象包括年龄,性别,融合椎体数,术前颈椎的曲度、活动度,椎管的前后径以及邻近节段的椎间盘突出和椎体前缘骨赘形成等,并根据随访时的侧位X线片将头尾两端邻近椎间隙的骨赘形成程度分为4级,统计学分析引起症状性邻近节段退变的相关因素以及邻近节段退变与骨赘形成程度的关系。结果:263例患者中有39例(14.8%)出现了症状性邻近节段病变,其中男23例,女16例,手术时年龄42~65岁,平均55岁,从手术后到出现邻近节段病变的时间为4~11年,出现邻近节段病变的平均年龄为61岁。这些症状表现为原有颈椎病症状部分或完全缓解后再次出现与邻近节段椎间盘突出相对应的神经症状与体征,而在原手术节段没有脊髓受压的表现。术前脊髓MRI上邻近节段硬膜有压迹或融合节段头侧邻近节段椎间盘低信号的患者,术后发生症状性邻近节段退变的概率明显高于未出现症状的患者,而年龄,性别,融合椎体数,术前颈椎的曲度,活动度,椎管的前后径等研究对象与症状性邻近节段退变没有明显的相关性(P>0.05)。对于发生症状性邻近节段退变的患者,有26例(67%)钢板头端邻近节段发生了骨化,与尾端骨化相比,P<0.01,骨化程度随临床症状的加重而加重。结论:对于因颈椎病而行颈椎前路融合钢板内固定的患者,术前脊髓MRI示有邻近节段硬膜有压迹或融合节段头侧邻近节段椎间盘退变表现者,术后容易发生症状性邻近节段退变,这种退变在侧位X线上可表现钢板头端邻近椎间隙骨化。     

脊髓造影、CT及CTM对腰椎间盘突出症的诊断评价（附62例报告）

本文分析比较了脊髓造影、CT及CTM的诊断效果。本组62例中单纯造影19例,手术后符合率为89％,单纯CT扫描16例,手术符合率为94％,同时作了CT扫描和脊髓造影27例,手术符合率为93％。认为对不典型病例或脊髓造影出现多处压迹难以确定时,应采用CT扫描检查,造影后CT扫描效果更好。     

Myelopathies caused by dorsal spinal canal spondylotic stenosis. 3 cases and a review of the literature

Thoracic spondylotic myelopathies are exceptional, only 29 observations could be found in the literature; we intend to describe three new cases here. The patients, two women and one man, 64, 69 and 72 years old, complained of weakness of the lower limbs, more marked on one side, which had been progressing slowly from several months to eight years. Examination revealed asymmetrical paraparesis with distal sensitivity deficits without thoracic sensory level. In the first case, the myelography remained virtually unchanged in front of T11, T12; in the second and third cases, there was slight extradural compression at T9 and T10 respectively. Magnetic Resonance Imaging (M.R.I.) performed in two patients was evocative of a thoracic disk herniation. A chest CT scan enabled us to establish correct diagnosis: in the three cases irregular hypertrophy of the posterior elements was evident at T11 and T12, T9 and T10, T10 and T11 respectively, with osteophytes originating in the articular process and deeply embedded in the spinal canal. Decompressive laminectomy associated with medial facetectomy resulted in the gradual improvement of walking in all three patients. Myelography and MRI are both useful in demonstrating the level compression, usually situated in the low thoracic spine, however only the CT allows differential diagnosis with other etiologies, especially anterior compression such as disk herniation.     

动态脊髓造影诊断腰椎间盘突出症

目的：探讨动态脊髓造影对于腰椎间盘突出症的诊断价值。方法：对186例腰椎间盘突出症患者进行脊髓造影，动态观察，拍摄不同体位的X线片。186例均经CT检查，110例经CTM检查，106例经手术治疗。结果：186例中213个椎间隙诊断为腰椎间盘突出，96个椎间隙诊断为腰椎间盘膨出，动念脊髓造影检查结果与手术诊断符合率为93．62％，CT检查结果与手术诊断符合率为86．74％，CTM检查结果与手术诊断符合率为96．88％。结论：动态脊髓造影检查克服了传统脊髓造影、CT、MRI检查静态观察的缺陷，降低了假阳性率和假阴性率，对L5／S1间盘突出诊断效果更为明显，并可鉴别诊断腰椎问盘突出和膨出。     

Magnetic resonance imaging of lumbar disc herniation. Comparison with myelography

Fifty-three patients with surgically confirmed lumbar disc herniation at 55 levels were studied retrospectively to compare the diagnostic accuracy of high-field strength surface coil magnetic resonance imaging (MRI) with that of myelography. Disc herniation was classified into three groups according to MRI findings, namely, unilateral single-disc herniation, central single-disc herniation, and multilevel disc herniation. Magnetic resonance imaging diagnosis of unilateral single-disc herniation was extremely reliable, so myelography was considered to be unnecessary. Conversely, MRI findings of central single-disc herniation and multilevel disc herniation were less definite, in that myelography was necessary in locating the disc causing symptoms.     

先天性颈椎融合伴颈椎间盘突出症12例报告

本文报告１２例先天性颈椎融合伴颈椎间盘突出症，探讨了其发生机理，诊断和治疗方法。指出此种类型颈椎间盘突出与先天性颈椎融合有密切关系。当存在先天性颈椎融合时，未融合的节段活动增加，使椎间盘较早和较容易发生退行性改变而引起颈椎间盘突出症。ＭＲＩ对其明确诊断具有重要价值。本病以采用手术疗法为主，其中以颈前路减压术为首选。     

盘内注射胶原酶治疗脊髓型颈椎病

目的：评价椎间盘内注射胶原酶治疗椎间盘突出引起脊髓型颈椎病的疗效及安全性。方法：35例（男19例，女16例）经CT、MRI证实由椎间盘突出引起的脊髓型颈椎病患者，病史3个月～4年，椎间盘突出0．20～0．40cm，平均0．24cm，采用盘内注射胶原酶的方法并结合颈椎牵引治疗。32例得到随访，随访3～38个月。分别按病史、年龄分组。结果：采用日本骨科学会（JOA）颈椎病评定标准进行手术前后随访评分，本组优12例，良7例，好转6例，无效7例。结论：颈椎间盘内注射胶原酶治疗由间盘突出引起的脊髓型颈椎病手术简单、效果明显、安全。     

急性创伤性无骨折脱位型颈髓损伤的临床研究

目的　探讨急性创伤性无骨折脱位型颈脊髓损伤的机制及治疗方法。方法　 75例患者行常规 X线摄片、CT扫描及 MRI检查。结果　常规 X线摄片及 CT扫描均不能确切了解颈脊髓损伤的病因及机理。根据 MRI检查分为两种类型 ,a)颈椎间盘突出颈脊髓损伤型 ,本组 6 2例。4 9例脊髓受压明显者予以手术治疗 ,13例脊髓受压较轻者予以非手术治疗。b)无颈椎间盘突出颈脊髓损伤型 ,13例均予以非手术治疗。随访 6 7例 ,随访时间 1～ 10 a,平均 4 a,除2例 Frankel A级、1例 Frankel B级无恢复外 ,其余患者神经功能均有不同程度恢复。结论　无骨折脱位型颈脊髓损伤应尽早行 MRI检查 ,以明确临床类型。对颈脊髓受压明显的颈椎间盘突出者 ,应尽早手术治疗 ,对无颈椎间盘突出者采用大剂量甲基强的松龙等非手术治疗 ,亦具有较好的疗效。     

Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers

An association between progression of cervical disc degeneration and that of lumbar disc degeneration has been considered to exist. To date, however, this association has not yet been adequately studied. Age-related changes in the cervical intervertebral discs were evaluated by magnetic resonance imaging (MRI) in patients with lumbar disc herniation, and compared with the MRI findings of healthy volunteers without lower back pain. The purpose of this study was to clarify whether the prevalence of asymptomatic cervical disc degeneration is higher in patients with lumbar disc herniation than in healthy volunteers. The study was conducted on 51 patients who were diagnosed as having lumbar disc herniation and underwent cervical spine MRI. The patients consisted of 34 males and 17 females ranging in age from 21–83 years (mean 46.9 ± 14.5 years) at the time of the study. The control group was composed of 113 healthy volunteers (70 males and 43 females) aged 24–77 years (mean 48.9 ± 14.7 years), without neck pain or low back pain. The percentage of subjects with degenerative changes in the cervical discs was 98.0% in the lumbar disc herniation group and 88.5% in the control group (p = 0.034). The presence of lumbar disc herniation was associated significantly with decrease in signal intensity of intervertebral disc and posterior disc protrusion in the cervical spine. None of the MRI findings was significantly associated with the gender, smoking, sports activities, or BMI. As compared to healthy volunteers, patients with lumbar disc herniation showed a higher prevalence of decrease in signal intensity of intervertebral disc and posterior disc protrusion on MRI of the cervical spine. The result of this study suggests that disc degeneration appears to be a systemic phenomenon.     

骶部硬膜外囊肿的临床影像学表现与外科治疗(18例报告及文献综述)

[目的]结合文献探讨骶部硬膜外囊肿（SEC）的临床表现、影像学特点与外科治疗，以便提高对该病的临床诊断和治疗水平。[方法]本组18例，其中腰骶部钝痛17例（95％）、下肢放射性疼痛和间歇性跛行16例（90％）、神经功能损害14例（77％）、盆腔或下腹部无痛渐进性肿块并压迫临近器官2例（11％）。18例均行腰骶部及骨盆X线片检查，其中17例行CT扫描、11例行MRI检查、7例行脊髓造影、4例行CTM扫描。[结果]本病临床误诊率为78％，X线诊断率17％，CT诊断率72％；MRI检查、脊髓造影、CTM扫描诊断率100％。18例均手术切除，病理报告为硬膜外囊肿，椎管内型、积液型、单发囊肿为多数；随访15～32个月，平均24个月，未发现症状加重和复发病例。[结论]骶部硬膜外囊肿临床与影像学具有特征性表现；微创术和腹腔镜、脊髓或椎管镜摘除骶椎管内囊肿的临床应用疗效有待于定论；显微外科技术的应用提高了SEC全切除率，手术是治疗和防止本病复发的最主要和最可靠方法。     

Outcomes of cervical and lumbar disk herniations in Major League Baseball pitchers

The effects of disk herniations on the career and performance outcomes of Major League Baseball (MLB) pitchers are unknown. The purpose of this study is to determine the outcomes after a cervical or lumbar disk herniation for MLB pitchers. Forty MLB pitchers from 1984 to 2009 with a cervical disk herniation or lumbar disk herniation were identified using a previously established protocol. Cervical disk herniation was identified in 11 pitchers, 8 of which were treated operatively. The majority of pitchers with cervical disk herniation (8/11) returned to play at an average of 11.6 months. Lumbar disk herniation was identified in 29 pitchers, 20 of which were treated operatively. All pitchers with lumbar disk herniation (29/29) returned to play at an average of 7.3 months after diagnosis.     

Posterolateral transforaminal interbody fusion for thoracic disc herniation: a retrospective study of 38 cases

Objective: To evaluate the clinical results of posterolateral transforaminal interbody fusion (PTIF) for the treatment of thoracic disc herniation (TDH). Methods: Thirty‐eight patients with TDH were treated with PTIF in our hospital from November 1999 to November 2003. The mean follow‐up period was 5.8 years (range, 4.2 to 6.5 years). There were 24 men and 14 women, ranging from 30.5 to 67.5 years, with an average of 46.5 years. The interval between onset of symptoms and surgery ranged from 5 to 12 months with an average of 9 months. In this group, the disc herniation involved T_9‐10 or T_10‐11 in 26 (68.5%) patients, T_8‐9 in 4 (10.5%), T_11‐12 in 4 (10.5%) and T₁₂L₁ in 4 (10.5%). All patients underwent X‐ray and magnetic resonance imaging (MRI) examination. Twenty‐two patients underwent myelography, while 25 patients underwent computer tomography (CT) or CT myelography (CTM) examination. The clinical results were evaluated using the Otani scoring system. Results: The outcome according to the Otani scoring system was excellent in 16 patients, good in 18, fair in 2 and poor in 2. No neurological symptoms, wound infection or clinical or radiographic evidence of instability were found; and the fusion rate was 100% by final follow‐up. An excellent or good outcome was achieved in 89.5% of patients. Conclusion: PTIF is an effective strategy for the treatment of TDH.