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cervical_disc_herniation_surgery

Cervical disc herniation surgery

see also Intraoperative electrophysiological monitoring during surgery for cervical spondylotic myelopathy.

Surgery is indicated for those that fail to improve or those with progressive neurological deficit while undergoing non-surgical management.

Mnagement of myelopathy/ central cord syndrome associated with acute cervical disc herniation is controversial, since the natural history is favorable in most cases.

The postoperative course is favorable in some patients; others, however, exhibit poor recovery and permanent deficits even when emergency surgery is done 1).

Depending on the location of the compression, the amount of axial pain, and the cervical lordosis, an anterior or posterior approach is used.

Operative indications for cervical disc herniation (CDH) are progressive or severe neurologic deficits or intractable radiating pain not responding to conservative treatment. The surgery for CDH is intended to relieve radiating pain and to relieve motor or sensory loss 2) 3).

Approaches

Anterior

Surgical decompression for cervical radiculopathy includes:

1.- Anterior cervical discectomy without any prosthesis or fusion: rarely used today.

2.- Anterior cervical discectomy and fusion with interbody fusion: the most common approach.

a.- without anterior cervical plate.

b.- with anterior cervical plate or with zero profile.

3.- with artificial disc AKA cervical disc arthroplasty.

Posterior

1.- Cervical laminectomy not typically used for cervical disc herniation, more common for cervical spinal stenosis, OPLL.

a.- without posterior fusion.

b.- with lateral mass fusion.

2-. Keyhole laminotomy (Posterior cervical foraminotomy).


Percutaneous cervical discectomy, percutaneous cervical disc nucleoplasty, and a combination of the two for the treatment of cervical disc herniation achieved good clinical outcomes. In addition, no postoperative risk of cervical instability was found 4).

Although anterior cervical discectomy and fusion (ACDF) is an effective treatment option for patients with cervical disc herniation, it limits cervical range of motion, which sometimes causes discomfort and leads to biomechanical stress at neighboring segments.

Cervical artificial disc replacement

Total disc replacement is used for soft discal hernia resulting in cervicobrachial neuralgia.

Cervical artificial disc replacement (ADR) is supposed to preserve normal cervical range of motion than ACDF. A biomechanical measurement is necessary to identify the advantages and clinical implications of ADR. However, literature is scarce about this topic and in those available studies.

Three-dimensional motion analysis could provide useful information in an objective and quantitative way about cervical motion after surgery. In addition, it allowed to measure not only main motion but also coupled motion in three planes. ADR demonstrated better retained cervical motion mainly in sagittal plane (flexion and extension) and better preserved coupled sagittal and coronal motion during transverse plane motion than ACDF. ADR had the advantage in that it had the ability to preserve more cervical motions after surgery than ACDF 5).


Education of patients about receiving neurosurgical procedures is becoming an important issue, as it can reduce anxiety and uncertainty while helping to hasten decisions for undergoing time sensitive surgeries. Chuang et al evaluated a new integrated education model for patients undergoing cervical disc herniation surgery using a quasi-experimental design.

The participants were grouped into either the new integrated educational model (n = 32) or the standard group (n = 32) on the basis of their ward numbers assigned at admission. Anxiety, uncertainty, and patient satisfaction were measured before (pre-test) and after the educational intervention (post-test-1) and post-surgery (post-test-2) to assess the effectiveness of the model in this intervention.

They found that the generalized estimating equation modeling demonstrated this new integrated education model was more effective than the conventional model in reducing patients' anxiety and uncertainty (p <0.05). Patients were also more satisfied with our newly developed model as it takes a more holistic approach to individual health.

This novel systemic educational model enhances patient's understanding of the medical condition and surgery while promoting patient-caregiver interaction for optimal patient health outcomes. We present a comprehensive and consistent platform for educational purposes in patients undergoing surgery as well as reducing the psychological burden from anxiety and uncertainty. Integrating medicine, nursing, and new technologies into an e-practice and e-learning platform offers the potential of easier understanding and usage. It could revolutionize patient education in the future 6).


Surgery for cervical radiculopathy is often approached by either anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). ACDF is more common; however, recent single center studies suggest comparable efficacy and significant cost savings with PCF in appropriately selected patients.

Adults undergoing single level ACDF or PCF for cervical radiculopathy were included from a US commercial health insurance claims database spanning 2003 to 2014. Outcomes consisted of mortality, adverse events, length of stay, and total payments to the health provider. Propensity score matching balanced the groups on observed baseline covariates.

RESULTS: The PCF cohort comprised 4851 subjects and the ACDF cohort included 46 147. A greater proportion of PCF cases were discharged on the same day (70.6% vs 46.1%; P < .001). Mortality (0.1/1000, P = .012), vascular injury (0.2/1000, P = .001), postoperative dysphagia/dysphonia (14.5/1000, P < .001), cutaneous cerebrospinal fluid leak (0.2/1000, P = .002), and deep venous thrombosis (0.9/1000, P = .013) occurred more frequency in the ACDF cohort. Conversely, wound infections (14.6/1000, P < .001) and 30-d readmissions (9.8/1000, P < .001) were more frequent in the PCF cohort. Mean unadjusted total payments for the PCF cohort were $15 281 ± 12 225 and $26 849 ± 16 309 for ACDF. Matched difference was -$11 726 [95% confidence interval: -$12 221, -$11 232, P < .001] favoring PCF.

Within the inherent limitations of administrative data, our findings suggest an opportunity for value improvement in managing cervical radiculopathy and indicate a need for large-scale comparative study of clinical outcomes and costs 7).

1)
Joanes V. Cervical disc herniation presenting with acute myelopathy. Surg Neurol. 2000 Aug;54(2):198. PubMed PMID: 11203373.
2)
Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011;7:265–272.
3)
Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976) 2012;37:E109–E118.
4)
Yang B, Xie J, Yin B, Wang L, Fang S, Wan S. Treatment of cervical disc herniation through percutaneous minimally invasive techniques. Eur Spine J. 2013 Oct 19. [Epub ahead of print] PubMed PMID: 24141953.
5)
Lee JH, Kim JS, Lee JH, Chung ER, Shim CS, Lee SH. Comparison of cervical kinematics between patients with cervical artificial disc replacement and anterior cervical discectomy and fusion for cervical disc herniation. Spine J. 2013 Oct 30. pii: S1529-9430(13)01457-5. doi: 10.1016/j.spinee.2013.08.010. [Epub ahead of print] PubMed PMID: 24183464.
6)
Chuang MF, Tung HH, Clinciu DL, Huang JS, Iqbal U, Chang CJ, Su IC, Lai FC, Li YC. The effect of an integrated education model on anxiety and uncertainty in patients undergoing cervical disc herniation surgery. Comput Methods Programs Biomed. 2016 Sep;133:17-23. doi: 10.1016/j.cmpb.2016.05.003. Epub 2016 May 18. PubMed PMID: 27393796.
7)
Witiw CD, Smieliauskas F, O'Toole JE, Fehlings MG, Fessler RG. Comparison of Anterior Cervical Discectomy and Fusion to Posterior Cervical Foraminotomy for Cervical Radiculopathy: Utilization, Costs and Adverse Events 2003 to 2014. Neurosurgery. 2018 Mar 14. doi: 10.1093/neuros/nyy051. [Epub ahead of print] PubMed PMID: 29548034.
cervical_disc_herniation_surgery.txt · Last modified: 2018/08/19 12:04 by administrador