Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging, it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery. Initially, endoscopic technique was restricted to the lumbar region but now it also can be used for cervical and thoracic disc herniations. Previously endoscopy was used for disc herniations which were contained without migration but now days it is used for highly up and down migrated disc herniations as well. Use of endoscopic technique in lumbar region was restricted to disc herniations but gradually it is also used for spinal canal stenosis and endoscopic assisted fusion surgeries. Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable. From simple chemonucleolysis to current day endoscopic procedures the history of minimally invasive spine surgery is interesting. Appropriate indications, clear imaging prior to surgery and preplanning are keys to successful outcome. In this article basic procedures of percutaneous endoscopic lumbar discectomy through transforaminal and interlaminar routes, percutaneous endoscopic cervical discectomy, percutaneous endoscopic posterior cervical foraminotomy and percutaneous endoscopic thoracic discectomy are discussed.
Adolescent ; Athletes ; Cicatrix ; Constriction, Pathologic ; Diagnosis ; Diskectomy ; Diskectomy, Percutaneous ; Endoscopy ; Fibrosis ; Foraminotomy ; Humans ; Intervertebral Disc Chemolysis ; Length of Stay ; Lumbosacral Region ; Magnetic Resonance Imaging ; Quality of Life ; Spinal Canal ; Spinal Dysraphism ; Spine* ; Sports

BACKGROUND: The purpose of this study was 1) to review the length of an adequate period of conservative treatment and the appropriate surgical indications for herniated lumbar disc(HLD), 2) to collate the scientific evidences on surgeries for HLD, and 3) to collect expert opinions on HLD. METHODS: We searched for articles in PubMed, the Cochrane Library and KoreaMed up to 1 October 2008, and these articles were concerned with the natural history of HDL, systemic reviews of HDL and expert opinions on HLD. We also searched for meta-analyses and randomized or quasi-randomized controlled trials(RCTs or QRCTs) of surgery for HLD. We performed a meta-analysis using the Cochrane method. The survey consisting of 21 questions was delivered to all the members of the Korean Spinal Neurosurgery Society(KSNS) via E-mail. RESULTS: A total of 59 articles were included in this study. There were 16 articles concerning the period of conservative management and the surgical indications. Among the 33 articles on surgery for HLD, there were 4 meta-analyses, 27 RCTs, and 2 QRCTs. Among the 938 members of the KSNS, 72 responded to the survey. A minimum of 1 to 3 months of conservative management was the most preferred answer(58%), followed by a conservative management period of less than 1 month(33%). Percutaneous endoscopic discectomy was more preferred by the hospitals that specialized in spinetreatment than by the university hospitals(p<0.05). CONCLUSION: Conservative management for a minimum of 2 weeks to 3 months is recommended for patients with tolerable pain only. The patients with neurological compromise or intolerable pain should be considered for surgery. There is strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is no scientific evidence on the effectiveness of any other form of minimally invasive procedure.
Diskectomy ; Electronic Mail ; Evidence-Based Medicine ; Expert Testimony ; Humans ; Intervertebral Disc Chemolysis ; Natural History ; Neurosurgery

Adult ; Female ; Humans ; Intervertebral Disc Chemolysis ; Intervertebral Disc Displacement ; surgery ; Lumbar Vertebrae ; surgery ; Male ; Middle Aged ; Recurrence

OBJECTIVE: So called "minimally invasive procedures" have evolved from chemonucleolysis, automated percutaneous discectomy, arthroscopic microdiscectomy that are mainly working within the confines of intradiscal space to transforaminal endoscopic technique to remove herniated epidural disc materials directly. The purpose of this study is to assess the result of endoscopic spinal surgery and favorable indications in the thoracolumbar spine. METHODS: The records of 71 patients, 73 endoscopic procedures, were retrospectively analysed. Yeung Endoscopic Spine Surgery system with 7 mm working sleeve and 25degrees viewing angle was used. The mean follow up period was 6 months (range,3-9). RESULTS: Operated levels were from T12-L1 disc down to L5-L6 or S1 disc. Of 71 cases, 2 patients underwent transforaminal endoscopic surgery twice due to recurrence after initial operation. MacNab's criteria was used to assess the outcome. Favorable outcome, excellent or good, was seen in 78% (57 procedures) of the patients. Among 11 fair outcomes, only 1 procedure was followed by secondary open procedure, laminectomy with discectomy. Two of 5 poor outcomes were operated again by same procedure which resulted in fair outcomes. One patient with aggravated cauda equina syndrome remained poor and a lumbar fusion procedure was performed in other patient with poor outcome. There were 2 postoperative discitis that were treated with conservative care in one and anterior lumbar interbody fusion in the other. CONCLUSION: Evolving technology of mechanical, visual instrument enables minimal invasive procedure possible and effective. The transforaminal endoscopic spinal surgery can reach as high as T12-L1 disc level. The rate of favorable outcome is mid-range among reported endoscopic lumbar surgery series. Authors believe that the outcome will be better as cases accumulate and will be able to reach the rate of standard open microsurgery.
Discitis ; Diskectomy ; Diskectomy, Percutaneous ; Follow-Up Studies ; Humans ; Intervertebral Disc Chemolysis ; Intervertebral Disc Displacement ; Laminectomy ; Microsurgery ; Polyradiculopathy ; Recurrence ; Retrospective Studies ; Spine

OBJECTIVE: This study is aimed to evaluate the chemonucleolytic effect of medical ozone by investigating the change of the signal intensity on magnetic resonance imaging (MRI) scan after injection of medical ozone into the lumbar intervertebral disc of the rabbit. METHODS: A series of 21 intradiscal injections of 1ml of medical ozone(30microgram of ozone per ml of oxygen) was performed in 7 young adult rabbits. Two control series, which 20 intradiscal injections of 0.1ml of iodine contrast medium in 7 young adult rabbits and 21 intradiscal injections of 0.05ml of chymopapain in 7 young adult rabbits, were performed. T2 weighted MRI scan was performed pre-operatively and at 4 weeks after injection. RESULTS: T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series (n=21) of intradiscal injections of medical ozone at 4 weeks after injection, as compared with the control series of intradiscal injections of 0.1ml of iodine contrast medium. T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series(n=21) of intradiscal injections of chymopapain at 4 weeks after injection. Any neurologic deficit or complication was not found in all groups. CONCLUSION: Intradiscal injections of medical ozone into the lumbar intervertebral disc of the rabbits are proven to have chemonucleolytic effects.
Chymopapain ; Humans ; Intervertebral Disc Chemolysis* ; Intervertebral Disc* ; Iodine ; Magnetic Resonance Imaging ; Neurologic Manifestations ; Ozone* ; Rabbits ; Young Adult

The diagnostic efficacy and comparability of digital infrared thermographic imaging(DITI), computerized tomographic(CT) scan and magnetic resonance imaging(MRI) in the assessment of outcome of chemonucleolysis for herniated soft cervical disc patients with ce rvicobrachial neuralgia were evaluated. Forty seven patients of herniated cervical discs who were treated with nucleolysis using chymopapain for last 2 years were assessed by each studying modality and clinical examinations. All the cases received DITI, CT scan and/ or MRI, and the thermal difference of each patient between symptomatic and asymptomatic limb was analyzed pre- and post-operatively. The diagnostic efficacy of each technology was similar, and inter-rater comparability did not differ significantly. DITI showed significantly good correlation with clinical outcome although there existed a considerable inaccuracy in assessing individual subjects. Digital infrared thermographic imaging was shown to be very useful method in the outcome evaluation of cervical chemonucleolysis.
Chymopapain ; Extremities ; Humans ; Intervertebral Disc Chemolysis* ; Magnetic Resonance Imaging ; Neuralgia ; Retrospective Studies* ; Tomography, X-Ray Computed

Back pain and radiating leg pain due to compression of the nerve root by the lumbar disc herniation are subjective symptoms. Objective evaluation of pain site and severity is important for the diagnosis and the treatment. We evaluate the correlation between the severity of pain and the temperature changes in the patients of lumbar disc herniations using infrared thermograms. 174 consecutive patients who underwent operation or chemonucleolysis for single level unilateral disc protrusion with ipsilateral leg pain were included in this study. Subjective pain was divided four groups(Group I: mild pain, Group II: moderate pain, Group III: severe pain, Group IV: intractable pain). Thermal differences of each group were as follows: Group I was 0.26degreesC, Group II was 0.39degreesC, Group III was 0.60degreesC and Group IV was 0.98degreesC. Disc protrusions were divided three groups. Thermal differences of each group were as follows; mild protrusion group was 0.52degreesC, moderate protrusion group was 0.79degreesC and severe protrusion group was 0.95degreesC. Duration of symptom was divided four groups and each thermal differences were as follows: under 2 months was 0.87degreesC, 2 to 6 months was 0.71degreesC, 6 to 12 months was 0.50degreesC and more than 12 months was 0.47degreesC. All these data were statistically significant in p<0.01. In conclusion, infrared thermal imaging can demonstrate the subjective pain objectively. The discogenic pain is the more severe, or the disc herniation is the more protruded, or the symptom duration is the shorter, the thermal difference between the both legs is the more significantly prominent. Thermal difference between both legs is a useful pain scale in the herniated lumbar disc patients. Infrared thermal imaging is effective in the evaluation of lumbar discogenic pain.
Back Pain ; Diagnosis ; Humans ; Intervertebral Disc Chemolysis ; Leg

OBJECTIVE: This study is aimed to evaluate the effect of chondroitinase ABC on normal rabbit lumbar discs. MATERIALS AND METHODS: A series of intradiscal injections of chondroitinase ABC was performed in 9 young adult rabbits. A control series of intradiscal injections of iodine contrast medium was performed in 6 young adult rabbits. Roentgenograms were taken preoperatively and were repeated at one, three, five, seven days after injection of chondroitinase ABC. Roentgenograms also were taken preoperatiely and at seven days after injection of contrast dye. Magnetic resonance imagings(MRI) scan was performed pre-operatively and at seven days after injection. Light microscopic examination of both groups was done at 7 days postinjection. RESULTS: Roentgenographic evidence of disc space narrowing showed significant correlation with time course in the series of intradiscal injections of chondroitinase ABC compared with the control series. T2 weighted MRI of disc space demonstrated significantly decreased signal intensity in the series of intradiscal injections of chondroitinase ABC at seven days after injection, as compared with the control series. Histologic evaluation revealed the stainability of nucleus pulposus and annulus to toluidine blue which was quite decreased. The cytoplasm of notochordal cells of nucleus pulposus appeared to be shrunken, and the large cytoplasmic vacuoles in hematoxylin-eosin stain were decreased in the series of intradiscal injections of chondroitinase ABC, which were not evident in the control series. CONCLUSION: Intradiscal injections of chondroitinase ABC on normal rabbit lumbar disc proven to have chemonucleolytic effects.
Chondroitin ABC Lyase* ; Cytoplasm ; Humans ; Intervertebral Disc Chemolysis* ; Iodine ; Magnetic Resonance Imaging ; Notochord ; Rabbits ; Tolonium Chloride ; Vacuoles ; Young Adult

The far lateral lumbar disc herniation occurs ten times less often than the classic posterolateral disc herniations. Its clinical presentation, the anatomy involved, and difficulty of surgical treatment are not well understood. The surgical approach and results also have not been clearly defined. Although there are limited number of reports and series in the literature, there is still no general consensus on the approach to surgical treatment. However, chymopapain, even with a history of controversy and troubling complications, has endured the test of time to show 30 years of clinical success in the treatment of herniated nucleus pulposus. Strict attention to indications, contraindications, and technique ensures safety and efficacy of treatment. Between 1984 and 1997, we treated with chymopapain injection in 69 patients with severe lumbar radiculopathy secondary to far lateral disc herniation. Average patient age was 38.5 years in the 47 male and 22 female patients involved. The L4-5 disc was the most commonly herniated level(44.9%) followed by L3-4(37.8%), L5-S1(13.0%), and L2-3(4.3%). They were assessed using standardized forms as well as the Mcnab classification and questioner. They were reviewed at an average of 5 years 8 months postoperatively. Relief of symptoms was obtained in 63 patients(91.3%) after injection. No one subsequently relapsed requiring operation. All 69 patients available for long-term follow-up had considerable and sustained relief from their symptoms. For ADL(activity of daily living), 50 patients(81.3%) answered that they had no limitation, and regarding the office or house work, 49 patients(71.0%) returned previous work without any difficulties. Based on these findings we recommend the chymopapain injection as the primary treatment for patients with severe radiculopathy secondary to far lateral herniation of a lumbar disc.
Chymopapain ; Classification ; Consensus ; Female ; Follow-Up Studies ; Humans ; Intervertebral Disc Chemolysis* ; Male ; Radiculopathy

For lumbar disc herniation, conventional laminectomy and discectomy were used for a long time. Since chemonucleolysis was introduced as a treatment modality of lumbar disc herniation in 1964, other various minimally invasive surgical techniques like Percutaneous Nucleotome, Arthorscopic Microdiscectomy and laser discectomy were developed to minimize postoperative discomfort and morbidity. In conventional surgery with laminectomy, there is no limitation for surgical procedures, and the surgical result is very excellent over 90%. But it causes a postoperative wound pain due to muscle injury and a possibility of nerve root injury. Minimally invasive surgical techniques has advantages of minimal postoperative pain and morbidity. Also it has limitations of narrow indication like soft disc herniation without bony stenosis and comparatively low surgical result about 70%. Recently a new minimal invasive endoscopic discectomy system was developed which has advantages of conventional laminectomy and minimally invasive surgical techniques. It can decompress the nerve root like conventional open surgery and has the benefits of small incision, limited tissue disruption and faster recovery time. We have had 3 cases experiences of MicroEndoscopic Discectomy(MED) system in lumbar disc herniations and got excellent clinical result.
Constriction, Pathologic ; Diskectomy* ; Intervertebral Disc Chemolysis ; Laminectomy ; Pain, Postoperative ; Surgical Procedures, Minimally Invasive* ; Wounds and Injuries