Docteur Gastambide

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Specialist in the treatment of lumbar and cervical discal hernias

 

This website is about the treatment of degenerative disc disease (with or without discal hernia), using endoscopic spine surgery, assisted with Holmium-YAG laser. It presents Daniel Gastambide’s activity in this field and in its scientific basis. The hernias can be median, paramedian, or foraminal, contained or excluded. Their removal can be done under sedation and local anaesthesia.The lumbosciatica disappears immediately after operation in the great majority of cases: you can stand up a few hours after the operation, and you get out of the hospital the day after. The results are very favourable in most cases, and relapses are about 3 to 5%, as with other techniques. You go back to work after 8 days if your work is sedentary, after 2 months and half if you are a heavy worker.

 

Other lumbar surgical techniques are described: discectomy by microsurgery, intersomatic grafts under local or general anaesthesia, with or without spondylolisthesis.

 

In the neck, a discal hernia causes cervicobrachial neuralgia. It can be soft, and then it usually cures spontaneously after three months, but, if not, there is a surgical procedure for the treatment. The problem can be also “disco-osteophytic”, that means a discal hernia together with osteophytes. It then very often requires surgical treatment. A minimal invasive procedure is described, and also the intersomatic arthrodesis.

 

The last section on “FAQs” (frequently asked questions), is on  scoliosis, the mechanism of disc degeneration and on debilitating chronic pains and their treatment by electrical medullary stimulation.

 



Titles and qualifications

 



· Address

 

· Centre Tourville

· 17 Avenue de Tourville

· 75007 Paris

· Téléphone: 01 53 59 32 06

· Fax : 01 45 51 23 62

· E.mail: unitedos@free.fr

· Métro : Ecole Militaire

· Bus : 82, 92                                                             RER : Invalides                                                 

§       

 



· The secretary

 

· Our kind assistant, Laurence, welcomes you

 

 

 

 

 


 

 
Surgical Operations at the Clinique de l’Alma (Alma Hospital)

 

166 Rue de l’Université

75007 Paris

 

Paris metro stations: Pont de l’Alma, Latour Maubourg

 

 

Please do not send inquiry letters directly to this address


Scientific publications:

Minimal invasive surgery : Minimal Invasive Cervical and Lumbar Surgery Future - Daniel Gastambide

Open surgery, lumbar :

Surgical Anatomy of the Neck


 

 

Percutaneous fusion :

A new technique of percutaneous PLIF (Percutaneous lumbar Interbody Fusion)

Background and purpose : The purpose of this paper is to present a new technique of percutaneous inter body fusion (P-PLIF). The technique is bilateral, and needs the use of an endoscopy probe under local anaesthesia and sedation for root control at the time of cage positioning. A C arm gives a live control on AP and lateral views. The necessary skin incision is no more than 1.5 cm, on each side. Incisions are made about 10cm out of the medial line, and the tilting of progression is deduced from measurement of vertebral body height on lateral X-rays views. A Kirschner wire is then pushed down to the inter-vertebral disc, under fluoroscopic guidance, in the same way as the needle used in standard discography. Coaxial dilatators, internal diameter ranging from 2.2mm to 13.2mm are then used, depending of the inter-vertebral space height and allowing accurate choice of cage size, ranging from 4x6mm to 10x12mm section (cage length is always the same: 25mm). Disc removal is done in standard manner, using the usual pituitary forceps. Endoscopic verification is allowed, before removing any disc material or positioning of the cage, to avoid root injury, even through, with experience, this part may be avoided, patients being awake all through the procedure. The cages are then set in place, always under fluoroscopic guidance, first filled either with autogenic bone when necessary or, more commonly, with substitute. Final positioning is done after rotation of the cages of 90°, allowing good restoration of inter-body space height and anchoring of the cages according to their specific shape.

To date, 13 patients (10 with cages only and 3 with cages and per-cutaneous plates) have benefited from this new procedure until now, over a period of 18 months.

Discussion : Although patient follow-up is short  (below one year), the technique would seem to give good results. The cages can restore the inter-somatic space, and give good relief of radicular pain. The learning curve is relatively steep, and a rigorous patient selection is mandatory. To the best of our knowledge, so far there has been only one paper published about inter-somatic cages set by a posterior per-cutaneous approach, using another system, far more complex than ours, and done under general anaesthesia.


 

Technique/first results of percutaneous plates/postero-lateral fusion with french cages PEPLIF: 22 cases (Buenos Aires, SICOT 2006)

 

D. GASTAMBIDE*, P.J. FINIELS**, P. MOREAU***

*Chirurgie Orthopédique, Centre Tourville (Paris),

**Neurochirurgie Polyclinique Chirurgicale Kennedy (Nîmes),

***Unité de Recherche et Développement (Neuro-France Implants) (Boursay).

 

The aim of this paper is to present a percutaneous technique of fusion.

The technique is bilateral, and can be done without endoscopy if it is limited to the osteosynthesis by plates. An endoscopy under local anaesthesia and sedation is necessary for root control when cages are placed. Osteosynthesis material is made with pedicular cannulated screws and plates with two or three holes, specifically developed. The surgical technique is particularly simple, necessitating a reduced ancillary set, which is familiar to every spine surgeon

Results: on 22 patients operated from September 2004, from 28 to 78 years old, sex ratio 13/10, 16 presented with degenerative disc disease, localized to one or two segments, associated in one case with a scoliosis, in another case with a spondylolisthesis, and one after an open surgical procedure; 3 presented an isolated degenerative spondylolisthesis, 2 a fracture (74 and 75 years old). The osteosynthesis involved one level 17 times (9 L5S1, 6 L4L5), and two levels 5 times (3 on L4L5S1). With the same approaches, cages were associated because of the presence of a spondylolisthésis L4L5. Mean preoperative visual analogical scale (VAS) was 6.45, and post operative 1.59, otherwise 75% of improvement. Post operative Prolo score was 8.22, 10 being the maximum.

Discussion: although patient follow-up is short, below one year, the technique gives good results. The cages can restore the intersomatic space.

Conclusion: this technique of percutaneous  pedicular screwing with the possibility of interposing intersomatic cages by the same approach, is very promising.

 

 

 


 

Percutaneous extraforaminal lumbar interbody fusion for the treatment of degenerative spondylolisthesis and discogenic low-back pain (Eisenach, Germany, 2006)

.Daniel GASTAMBIDE, MD, Pierre-Jacques FINIELS, M.D, Patrice MOREAU

 

Neurosurgery Unit, Kennedy Medical Center, Nîmes, Department of Orthopaedic Surgery, Tourville Center, Paris, and Unit of Research and Development, Neuro-France Implants Laboratories, Boursay, France

 

 

 

 

Posterior lumbar interbody fusion (PLIF) was thought to achieve both neural decompression by a posterior approach and spinal stabilization through an anterior column support. Although this technique has shown excellent clinical results, it has its own complications. Transforaminal lumbar interbody fusion (TLIF) was originally described by Blume in the mid 1980’s. Whether done in a classic way, or by using only a unilateral approach as described by Lowe et al. in 2002, it always needs at least removal of a unilateral facet joint, as well as the ligamentum flavum. Sohn and co-workers have recently demonstrated that extraforaminal lumbar interbody fusion (ELIF) allows a lower rate of subsidence and a more physiologically  favourable load distribution in a cadaveric model compared with the traditional anterior lumbar interbody fusion (ALIF) method. They pointed out the value of preserving a ventral annulus and lateral placement of cages in their study.

We have reported our technique of percutaneous placement of pedicular screws (PS) and plates elsewhere. The way of thinking that has driven us to the conception of this device has led us to a new procedure for ELIF, avoiding the side effects of classic open surgery.

The purpose of this study was to describe this new surgical technique and report the preliminary results of the procedure.

 

 

Clinical material and methods:

 

15 patients with degenerative spondylolisthesis or discogenic low-back pain underwent percutaneous ELIF in one or other of  our institutions on a period of 18 months. 12 were men and three were women whose mean age was 62. All patients had severe low-back pain or true radicular pain without compressive lesion inside the spinal canal at CT or MRI evaluation. None of them exhibited motor deficit in the territory of the concerned nerve, even though sensory disturbance could be seen in the same dermatome.

 

Surgical technique:

 

The patient is placed prone on a standard frame dedicated to spinal surgery. The whole procedure is carried out  under sedation, the patient being conscious throughout of the intervention. Local anaesthesia, with adrenalized lidocain 2% is given in the usual muscular pathway, additional local anaesthesia without adrenalin O.5% being used, if needed, intra operatively in close contact to the extraforaminal zone. Radioscopic equipment-a standard mobile “C” arm, allowing two planes permanent control-is used in all cases. After tracing skin landmarks, a 18G, 15cm long needle is placed in the inter-vertebral disc, to use as a guide for a K-wire, but placed as close as possible to the inferior end-plate of the inferior vertebral body of the level to be instrumented. The Europa* system (Neuro-France Implants, Boursay, France) is then used for the entire procedure. A set of sequential dilatators increasing progressively in internal diameters to 13.2mm, depending on the height of the inter-vertebral space, is used, owning the choose of a cage with specific design, coming in size from 4x6mm to 10x12mm, the length being always the same: 25mm. At that time, an endoscope may be set in place to look at the exiting and traversing nerve root, avoiding direct lesion by dilator contact. A discectomy with special forceps passed through the last dilator is followed by meticulous endplate cleaning up with curettes. Then  the cage,  packed with bone substitute, is set in place.

The final positioning of the cage is effected by making a quarter rotation of the cage, enabling by its special design, 2mm more distraction and widening of the disc space. The same procedure is repeated on the opposite side.

Percutaneous placement of plates and PS can be then done in addition, using the WSH* system (Neuro-France Implants, Boursay, France) as first described.

Patients are allowed to stand up the day following surgery, without need for bracing, discharge from hospital being authorized on the third or fourth day.

 

 

Results:

 

All the patients experienced immediate pain relief, most of them being able to notice it intra-operatively. Post operative X-rays and CT-control show good positioning of the cages and wide opening of the foramens. At the last follow-up examination (at least 3 months- 3 to 15- after) the improvement of the clinical symptoms was maintained in all the patients except for four patients, one being impaired by radicular pain coming from partial extra pedicular positioning of a screw, the second one showing unilateral pseudarthrosis on X-rays coming from a cage too small in size, the third and the fourth having an instable cage too lateral on the abnormally convex lateral end plate. The first two problems were resolved by new placement with the same technique, and the third and forth complications needed an open PLIF.

Mean VAS scoring of the first 13 patients was 7.2 before surgery and 1.7 after, operating time was 117 minutes, and blood loss was always under 50ml.

 

 

Discussion:

 

To the best of our knowledge, this is the first time that such a percutaneous ELIF technique has been described. Its more important interest lies in minimizing surgical trauma, especially in old impaired patients, in whom the risks of general anaesthesia and excessive bleeding can exclude them from this kind of surgery, even if it might be in theory a good indication.

 

 

Conclusion:

 

We have put forward a new technique for ELIF surgery, using percutaneous setting of cages with or without the addition of percutaneous plates, without the need for facettectomy.

 


 

Interbody Fusion with Percutaneous Cages

VERSION POWER-POINT

· Daniel GASTAMBIDE(1), MD, Pierre-Jacques FINIELS(2), M.D, Patrice MOREAU(3) (ISMISS, Zurich, 2007)

·  (1)Centre Tourville, Paris; (2)Neurosurgery Unit, Kennedy Medical Center, Nîmes; (3)Department of Orthopaedic Surgery, and Unit of Research and Development, Neuro-France Implants Laboratories, Boursay, France

 

·  We have reported our technique of percutaneous placement of pedicular screws (PS) and plates at the previous meeting in Zürich. The way of thinking involved into the conception of this device has led us to a new procedure for ELIF, avoiding the side effects of classic open surgery.

· The purpose of this study is to describe this new surgical technique and report the preliminary results of the procedure.

· Clinical material and methods: Combining patients from both institutions, 15 patients with degenerative spondylolisthesis or discogenic low-back pain underwent percutaneous ELIF over a period of 18 months. 12 were men and three were women whose mean age was 62. All patients had severe low-back pain or true radicular pain without compressive lesion inside the spinal canal at CT or MRI evaluation. None of them exhibited motor deficit in the territory of the concerned nerve, even though sensory disturbance could be seen in the same dermatome.

· Surgical technique: the patient is placed prone on a standard frame dedicated to spinal surgery. The whole procedure is carried out under sedation, the patient being conscious throughout  all the time of the intervention. Local anaesthesia, with adrenalized lidocain 2% given by the usual expected muscular route, additional local anaesthesia without adrenalin O.5% being used, if needed, intra operatively in close contact to the extraforaminal zone. Radioscopic equipment -a standard mobile “C” arm, allowing two planes permanent control- is used in all the cases. After tracing skin landmarks, a 18G, 15cm long needle is placed in the inter-vertebral disc, used as a guide for a K-wire, as close as possible to the inferior end-plate of the inferior vertebral body of the level to be instrumented. The Europa* system (Neuro-France Implants, Boursay, France) is then used for the entire procedure. A set of sequential dilators increasing progressively in internal diameters to 13.2mm, depending on the height of the inter-vertebral space, is used, owning the choice of a cage with specific design, coming in size from 4x6mm to 10x12mm, the length being always the same: 25mm. At that time, an endoscope may be set in place to look at the exiting and traversing nerve root, avoiding the risk of a direct lesion by dilator contact. A discectomy made with special forceps passed through the last dilator is followed by meticulous endplate cleaning up with curettes. Then, the cage,  packed with bone substitute, is set in place.

· The final positioning of the cage is effected by making a quarter rotation of the cage, enabling by its special design, 2 mm more widening of the disc space. The same procedure is repeated on the opposite side.

· Percutaneous placement of plates and PS can be then done in addition, using the WSH* system (Neuro-France Implants, Boursay, France) as first described. Patients are allowed to stand up the day following surgery, without need for bracing, the discharge being authorized on the third or fourth day.

· Results: all the patients experienced immediate pain relief, most of them being able to notice it intra-operatively. Post operative X-rays and CT-control show good positioning of the cages and wide opening of the foramens. At the last follow-up examination (at least 3 months- 3 to 15- after) the improvement in clinical symptoms was maintained in all the patients excepted for four of them, one being impaired by radicular pain coming from partial extra pedicular positioning of a screw, the second one showing unilateral pseudarthrosis on X-rays coming from a cage too small in size, the third and the fourth having an instable cage too lateral on the abnormally convex lateral end plate. Both of the first problems were resolved by new placement with the same technique, the both the last complications needed an open PLIF.

· Mean VAS scoring of the first 13 patients was 7.2 before surgery and 1.7 after, operating time was 117mn, and blood loss was always under 50ml.

· Discussion: To the best of our knowledge, this is the first time that such a percutaneous ELIF technique has been described. Its more important interest lays in minimizing surgical trauma, especially in old impaired patients, in whom risks of general anaesthesia and excessive bleeding can exclude them from this kind of surgery, even if it could be in theory a good indication.

· Conclusion: We have put forward a new technique for ELIF surgery, using percutaneous setting of cages with or without the addition of percutaneous plates, without the need for facettectomy.

   

 


Surgical Anatomy of the Neck

All the operation is based on the fact that all the prevertebral content is very mobile due to compartmentalization of the neck for direct access to the herniated portion. The visceral axis (thyroid, trachea, Pharynx, larynx, and esophagus) is easily displaced on the opposite side of the operator away from the lesion with one or two fingers (fig. 5 A and B), and it is kept away from critical neural structures. The cervical spine can even be palpated with the index and/or middle finger while the vascular axis (carotid artery, internal jugular vein) is displaced outside.

Fig 5a

Fig 5b

Fig 5 A and B: Imaging approach simulations: A: MRI simulation of approach with a small ball pen pushing trachea, showing a clear way toward cervical discs. B: Simulation of cervical anatomy by CT scan with operator finger in touch with disc anterior border. The right carotid artery is surrounded with red

 

Because the esophagus lies slightly to the left of the spine at C7 in most patients, we prefer an anterior approach to the disc from the right side at an acute angle to the midline, on the skin incision. Tools penetrate to the middle of the disc, in strict avascular zone. If a paramedian approach (2 to 5 mm from the anterior border disc midline) is preferred, one has to remember that the way to homolateral foraminal zone can be blocked by the homolateral uncus. Consequently, a paramedian approach on the opposite side of a foraminal hernia may be preferred in order to pass diagonally more easily behind the controlateral uncus, as far as possible away from the medullar axis. A  left anterior approach may be chosen  in the case of right foraminal or posterolateral herniation although the risk of esophageal puncture might be slightly increased, but usually the visceral axis is “mobilizable” enough to allow anterior border disk penetration on the middle with right side skin incision.

On the cadaver dissection there is about 2mm of safe zone which consists of an epidural subdural subarachnoïdal space before reaching the spinal cord parenchyme.

 

Surgical Technique

When the forefinger of the operator pushes the trachea or the larynx toward opposite side to clear a way which exposes the vasculo-visceral axis on the patient, he can see perfectly the beats of the carotid artery outside. The carotid artery can be protected under the other fingers. The index and long fingers are used to palpate the anterior aspect of the vertebra in the cleavage between trachea and carotid artery (fig. 5 A and B)

The pulp of index finger of the operator then slips inside towards the front of vertebral body and locates the prominence of the anterior edge of the disc to be treated, between two depressions corresponding to the concavity of adjacent vertebral bodies.

The entry point is usually 1.5 cm lateral to the lateral margin of the visceral axis.  After a short skin incision, the operator passes the guide needle together with the first dilation tube or an 18 gauge spinal needle at the edge of the forefinger. The guide needle penetrates the disc just in the middle, controlled by the AP view, oriented at about 25 ° to the opposite side. After a last check of the front scopy, a slight pressure makes the needle enter the anterior wall of the disc. The C-arm of the fluoroscope is placed in profile, the correct level is checked and the needle is entered on around 5mm to the midline under lateral radiographic view.

The discography and the provocation test may be performed in order to differentiate the type or presence of the soft disc hernia and know the origin of pain [1, 25]. 0.5 ml to 1ml of contrast media can be injected to opacify the posterior part of the disc (fig. 6). If the provocation test shows a positive response, it is a very good indication of PCD. The guide needle alone is withdrawn alone, leaving in place the first 1 mm dilation tube which has been introduced together with the needle (fig 1A) or a Kirschner wire is pushed through the 18 G needle and the needle is pulled. If you have used a single use needle, you can cut its distal part and use it like a Kirschner wire.

Fig 6: Discography allows showing hernia exact contour on lateral C-arm fluoroscopic view :

 

 

The operator may have checked to confirm that the pulsation of carotid artery is well clear of the working tube or wire

The second 2-mm dilation tube and/or third 3-mm dilation tube then are introduced against the annulus for progressive dilation under guidance of fluoroscopy in the lateral projection. Small movements of axial rotation and some pressure applied on the first 1-mm metallic tube allow a passage through the anterior wall of the disc on 1 or 2 mm. Intradiscal hyperpressure can drive back (or push the instruments out of place from the disk) if a firm pressure is not applied. The working tube or sheath is introduced over the dilation tube. Sometimes an anterior bony spur impedes the insertion of the instrument, so that we must use a hammer carefully to hit the tube. A 1.7 mm rigid endoscope with saline irrigation may be used to see and confirm there is no other tissue except the disc.

Fig 7 A, B, and C: Discal hernia fragments taken only with the trephine; 7A: trephine tip with teeth and inside threading; 7B: white disc fragments in saline; 7C: discal substance cores of another disk, aligned in order from left to right ; the last are reddish, near the vascularized disk edge .

 

A core of discal substance is pulled using the inside threading trephine (fig 7A) entered through the working tube to cut the annulus. The internal spire of trephine with interior thread allows automatic extraction of several "carrots" of disc [23]. You try to take five cores of 5 (fig 7B) to 15 mm long (fig 7C), and stop when the discal substance seems too reddish, meaning that we are on the uncus or near the epidural space.

Verify with the small forceps that all free discal fragments are taken off.

Try to extract the tail of the hernia mass, which is more fibrotic and collagenous.

Do not try to remove the anterior part of disc in order to avoid a localized kyphosis. We rinse the intradiscal space with saline fluid mixed with cefazoline.

If discography is done the contrast image of protruded disc beyond the posterior body line becomes visible on the C-arm monitor, so, it is a good indicator of depth for small disc forceps to remove herniated fragments of the disc close to the posterior longitudinal ligament

If the patient is not intubated, we ask him directly to confirm if the abnormal pain disappears or decreases. Mostly, the cervicobrachial neuralgia decreases or disappears simultaneously with PCD. The amount of removed disc is 200 to 1590mg (920mg in average), but the success rate is not proportional to the removed disc weight.

At the end of the operation, an abundant rinsing is performed using a washing canula or a needle. After the instrument is removed, a slight compression can be applied with fingers on the surgical area for a short time to prevent hematoma. The skin closure can be made with stitches or adhesives. The average duration of the PCD is about 45 min. Cervical brace such as Miami collar is attached around neck in the operating room.

 

 

6 Optional Holmium-YAG laser associated with endoscopy in the same fiber (fig 8)

Fig 8 Endoscope with one way for optical fibers for associated light, vision and laser, and two ways for saline irrigation (Storz)

A working scope with passage of the laser probe or thin instruments can be used : laser is more delicate, works precisely with 0.3-0.5 mm cutting depth in the continuous saline irrigation and safely ablates the tissue near or inside the hernia mass close to the posterior longitudinal ligament so that it can protect the spinal cord or nerve root from energy transmission.  In order to ablate tissue near or inside the hernia mass instead of endplate and posterior longitudinal ligament you should look inside the disc with small endoscope.

You aim the laser beam as posteriorly as possible to ablate and shrink directly the herniated part of the discs against the posterior longitudinal ligament in the set of 0.5-0.8 Joule of 10Hz under control of 1.7 mm endoscope with saline irrigation and fluoroscopy. You decompress and partially vaporize large contained subligamentous fragments (fig 9A). In A-P x-ray projection the laser probe should be correctly positioned toward the herniated portion. Total energy of the laser is about 5000 Joule. You may see inside the disc, the ablated defect of the posterior disc and annulus under the pumping irrigation of the normal saline 1000 cc mixed with cefazoline 2 grams. When the endoscopic laser does not meet any resistance in the posterior part of the disc or can not see the hernia mass anymore under the posterior longitudinal ligament, the intervention is finished.

  Fig 9a Fig 9b

Fig 9 A and B Before PCD sagittal MRI of a C6C7 hernia: A:; B: control 3 months after PCD showing hernia complete by disappearing; note disk height minimal lessening

 

Postoperative Management

The patient is observed for 3 to 24 hours in the clinic to see if he or she is developing any complications. The patients can be permitted to go home on the same day. The patients do not need bed rest for more than one night.

Postoperative antibiotics and analgesics are recommended by mouth for three to ten days. A cervical collar is recommended for 3 to 14 days according to patient improvement. Physical therapy such as head traction with a mildly flexed neck and TENS might be helpful to recover faster within two weeks postoperatively if the cervicobrachialgia does not disappear completely.

Rehabilitation exercise for neck muscle strengthening and improvement of neck motion range is recommended two times a week for three months after four to six weeks postoperatively.

Fig 10: Roentgenographic evidence of spontaneous fusion and marked collapse of the interspace at operated level 1 year after open surgery, facilitating emergence of hernias below and above the C5C6 level.

 

 

Errors and potential hazards

Incision

One has to be able to make a new short incision if the first incision is not appropriate for needle course

Complications (21) (table 1)

 

The complications of PCD were mainly potential.

The possible immediate complications were:

vascular injury (1 case)- right carotid artery perforation due to inability to detect carotid pulsation through the patient‘s thick and short neck. The artery was sutured after conversion to open discectomy-,

prevertebral hematoma, laryngeal edema,

esophageal perforation,

lesion of recurrent nerve (1 case)(transient hoarseness due to deep Xylocaine infiltration around laryngeal nerve which became normal after several hours), or lesion of superior laryngeal nerve or of large hypoglossal nerve.

cervical cord compression with neurological disorders (1 case: transient pyramidal symptoms due to compressing the cord from passing the pituitary forceps beyond the posterior vertebral body lines. He recovered immediately after conversion to open discectomy with fusion)

Secondary complications could be postulated;

worsening of the initial symptoms: delayed aggravation of herniation  which needed open discectomy one month after PCD (1 case)

subacute discitis and epidural abscess with neurological disorders.

Late complications are worsening of osteoarthritis, accelerated by disc height diminution (mean 15%) (21)

Special problems: recurrence

If the patient has been already operated for cervical discal hernia at the same side or the other side, at the same level or at an other level, either with percutaneous (2 personal cases) or open surgery (3 personal cases), there is no special risk of operative complication if the visceral axis has a normal mobility.

 

Results

On one series of more than 170 patients, the mean preoperative duration of symptoms was 22 months (range 1-240 months).

There were 76% of cervicobrachial neuralgias (dominant radiculalgia 55%, dominant cervicalgia 21%), 18% of isolated radiculalgia, 6% of isolated cervicalgia.

The vertebral levels of soft cervical disc herniations ranged from the C3-C4 level to the C6-C7 level. 127 patients had 1 level operated (5 C3C4, 13 C4C5, 83 C5C6, 25 C6C7, 1 C7D1), 42 patients had 2 levels operated (5 C3C4 + C4C5, 15 C4C5 + C5C5C6, 17 C5C6+C6C7, 5 C4C5+ C6C7), 1 had 3 levels operated (C3C4 + C4C5 + C6C7).

The mean duration of the operation was 45 min.

A provocation pain test by injecting 1/2cc of non ionic dye is very significant for a good result if positive (reproduction of the same topography of pain). Epidural leakage, initial size and location of the hernia, presence of bony spurs ≤ 2 mm do not modify significantly the results. An important size lessening of the hernia improves significantly the results (21)

The mean follow-up was 37 months (1 to 13 years)

The rate of success is 92% (81% excellent and good, 11% fair. Among the 14 poor results (8%), 4 were reoperated by fusion after 3 to 24 months.

Comparison with open surgery

The clinical success rate is the same in open and percutaneous procedures. Complication rate seems to be quite different, favoring PCD in table 1. PCD complications occurred in four patients of our series (1 carotid wound, 1 reversible recurrent nerve impairment, 1 transient pyramidal syndrome, 1 secondary symptoms worsening). There were no infection, no pulmonary embolism, no thromboplebitis, no perforation of esophagus and no death.

Another advantage of PCD is avoidance of disc space collapse after discectomy.(fig 8)

In open surgery, there are the same complications (4 recurrent nerve impairments, 3 transient pyramidal syndromes, 2 secondary symptoms worsening), and 3 other types of complications (Claude Bernard Horner syndrome: 2, superficial complications on cervical incision or on donor site: 17, graft mobilizations: 12, graft collapse: 18). The ratio of complications between open surgery and percutaneous procedures is 9.44. In other words, there are nearby ten times more complications in open surgery.

Discussion

The advantages of this cervical percutaneous surgical procedure are numerous:

Performed either under sedation associated with local anesthesia, or under general anesthesia,

confirmation of symptomatic level during the operation  if performed under local anesthesia.

Reduced operation time

No epidural bleeding

No post-operative periradicular fibrosis

No risk of instability, nor postoperative kyphosis, nor complications of donor site, graft migration or collapse

Reduced risk of discal hernia relapse on anterior percutaneous surgical window

ablation of hernia mass with inverted trephine, forceps,  and eventually with the endoscopic Ho:YAG laser,

No difficulty if a further open approach is needed

Complications rate high reduction compared with open surgery (table 1)

Hospital stay shortened to 24 hours or less

Faster return to work

Better cost/efficiency ratio

Per-operative complications fears, particularly oesophagal lesions or hematoma, are not confirmed in our series of 227 operations. This percutaneous cervical discectomy widens and broadens indication of percutaneous cervical approach and might become the treatment of choice in future because of possibility of direct ablation of the hernia mass with less serious complication.

 

In the treatment of soft cervical hernias, when the surgeon chooses a simple discectomy procedure, without graft nor arthrodesis, the first choice is the minimal invasive approach of percutaneous cervical discectomy, followed, in case of failure, by open anterolateral approach.


 

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9. Dunsker SB: Anterior cervical discectomy with & without fusion, Clin Neurosurg 24:16-521, 1977
10. Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine; 61: 537-539, 1982.
11. Griosoli F, Graziani M, Fabrizi AP, et al.: Anterior discectomy without fusion for treatment of cervical lateral soft disc extrusion: A follow-up of 120 cases. Neurosurgery;24:853-859,1989.
12. Grob D: Anterior discectomy with interbody fusion for soft cervical disc herniation, in AL-Mefty O, Origitano T. C. , Louis Harkey H (eds): Controversies neurosurgery, New York, Thieme, pp 232-233, 1996.
13. Hellinger J: Non endoscopic percutaneous 1064 Nd:YAG laser decompression, 3rd symposium on laser-assisted endoscopic & arthrosopic intervention in orthopaedics, Balgrist, Zürich, 1994
14.
Herman S. Nizard RS. Witvoet J: La discectomie percutanée au rachis cervical, Rachis cervical degeneratif et traumatique, Monographie, Cahier N° 48, 1994, pp 160-166, Expansion Scientifique Francaise, pp 160-166
15. Hirsch D: Cervical disc rupture: Diagnosis and therapy, Acta Orthop Scand. 30: 172-186, 1966
16. Hoogland T. Scheckenbach C: Low-dose chemonucleolysis combined with percutaneous nucleotomy in herniated cervical disks. J Spinal Disord Vol 8, No 3, pp 228-32, 1995
17. Jho HD: Microsurgical anterior cervical foraminotomy for radiculopathy: a new approach to cervical disc herniation. J neurosurg 84: 155-160, 1996
18. Kadoya A, Nakamura T, Kwak R: A microsurgical anterior osteophytectomy of cervical spondylotic myelopathy. Spine 9:437-441,1984
19. Knight M.T., Goswami A., Patko J.T., Cervical percutaneous laser disc decompression: preliminary results of an ongoing prospective outcome study.
J Clin Laser Med Surg. 2001 Feb;19(1):3-8.
20. Krause D et al: Nucleolyse cervicale: indication, technique, resultats. 190 patients. J. Neuroradiol, 20,42. 1993
21. Lee S.H.., Gastambide D.: Perkutane endoskopische Diskotomie der Halswirbelsäule, in „Minimal-invasive Verfahren in der Orthopädie und Traumatologie“, Springer Verlag, Berlin, Heidelberg, New-York, 2000, pp 41-61
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Robertson JT: Anterior operations for herniated disc and for myelopathy. Clin Neurosurg 25: 245-250, 1978
23. Rosenorn J, Hansen EB, Rosenorn MA: Anterior cervical discectomy with and without fusion. A prospective study. J Neurosurg 59: 252-255,1983
24. Simeone FA: Posterior discectomy for soft cervical disc herniation, in AL-Mefty O, Origitano T.C., Louis Harkey H(eds): controversies in neurosurgery, New York, Thieme, pp 227-228, 1995
25. Smith GW, Nichols P(1957) The Technique of Cervical Discography; Radiology 68:718-720
26. Snyder GM. Bernhardt M: Anterior cervical fractional interspace decompression for treatment of cervical radiculopathy. Clin Orthop 246: 92-99, 1989
27. Sonntag VKH, Klara P(1996) Controversy in spine care: Is fusion necessary after anterior cervical discectomy? Spine 21:1111-1113
28. Stein E et al: Acute and chronic effects of bone ablation with a pulsed Holmium laser. Lasers in surgery and medicine, 10: 384-388, 1990
29. Thorell W, Cooper J, Hellbusch L, Leibrock L(1998) The long-term clinical outcome of patients undergoing anterior cervical discectomy with and without intervertebral bone graft placement.
Neurosurgery ; 43:268-274

 

o       Poster (version pdf)

· Open surgery, lumbar :

o       101 PLIF trussed with a titanium intersomatic parallelepipedic cage and a posterior instrumentation
Daniel Gastambide, MD, Orth. Surg. (Centre Tourville, Paris)



                     The operations

 

Lumbar surgery

Discal hernia by endoscopic transforaminal discectomy, assisted by Holmium-YAG laser

· Indications:

· discal hernias, medial, paramedial and foraminal, without associated stenosis

· Obligatory anesthaetic assessment, at least 48 hours before the operation

· Hospitalisation: admission during the afternoon of the day before the operation

· Antibiotic preparation the evening before

· Shower with Betadine® the evening before and the morning of the operation

· Surgical operation on the day following admission

· First out of bed on the evening of the operation

· Discharge the day after operation

· Operation Procedure:

· By a 5 mm opening approach, at the level of the herniated disc, in the lumbar region, slightly to the side of the midline at 13 cm, an endoscopic tube is introduced, which enables the surgeon to see both the hernia and  the compressed nerve, and then to decompress it removing the hernia with the laser Holmium-YAG; the painful region is cleansed of the inflammatory debris.

· Operation timing:

· The operation is performed under local anaesthesia, in orthopaedic OP room, with sedation (=tranquillizers + derived morphines) monitored by an anaesthetist medical doctor, and with the patient lying on one side; direct endoscopic control is maintained by a special monitor, and radioscopic control using a C arm and another special monitor.

· The disc pathology is examined with systematic discography to identify the hernia..

· The operation’s duration: about 1 hour

· Recovery in the post-OP room. Return to the patient’s own room a short time later.

· The patient gets out of bed  on the evening of the day of the operation.

· Discharge the day following.

· Back to sedentary work after 8 days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Discal hernia by microsurgery without endoscopy or laser

Indications:

The discal hernias, medial, paramedial and foraminal, associated with stenosis

The anaesthesiologist sees the patient for assessment, at least 48 hours before the operation

Hospitalisation: admission during the afternoon of the day before the operation

Antibiotic preparation the evening before

Shower with Betadine® the evening before and the morning of the operation

Surgical operation the next day after

Patient first gets out of bed during the evening of the day of operation.

Discharge the day after operation

Operation Principles:

A midline approach at the level of the herniated disc is made through a 25 mm opening, using microsurgical techniques to penetrate on the side of the spinal canal. The discal hernia is then removed and also some of the bone which is narrowing the spinal canal.

Operation timing:

In orthopaedic OP room, the operation is performed under general anaesthesia  with the patient lying prone; direct microscopical approach is used, with radioscopic control with a C arm.

Duration: the operation takes about 1 hour

Stay in the post-OP recovery room. Back to patient’s own room a short time later.

The patient gets out of bed on the evening of the same day.

Drain removed the next day after.

Discharge the day following.

Back to sedentary work after 8 days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Kinesiology after 1 month if necessary

Sports : rapidly authorized : walking, back crawl swimming, bicycle; caution with tennis, jogging.

 

Intersomatic graft trussed with titanium for advanced degenerative disc disease

Indications

Advanced degenerative disc disease causing heavy back pain intractable to all medical treatments;

Some intractable sciatica

 

Consultation with the anaesthetist, at least 48 hours before the operation

Hospitalisation: admission during the afternoon of the day before the operation

Antibiotic preparation the evening before

Shower with Betadine® the evening before and the morning of the operation

Surgical operation the next day

Operative Procedure:

Under general anaesthesia, with the patient lying prone;  radioscopic control with a C arm. By a median opening approach, in the lumbar region, in the middle, an excision is made on the posterior bone of the vertebra (lamino-arthrectomy), which will be used for the intersomatic graft. Release of the compressed nerve roots, ablation of the disc. Placement of truss with titanium grafts.

Duration: about 2 hours

Stay in the post-OP recovery room. Back to the patient’s own  room a short time later.

Patient gets out of bed on the evening of the same day.

Drain removed 2 days after

Discharge on the 5th day

Back to sedentary work after 21days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Kinesiology after 1 month if necessary

Sports : rapidly authorized : walking, dorsal crawl swimming, bicycle; caution with tennis, jogging, footing.

 

The equivalent of this operation can be performed by percutaneous approach under sedation and local anaesthesia with the “Europa” system. 

 

 

Cervical surgery

 The minimal invasive cervical discectomy

Indications

The cervical discal hernias, which cause cervicobrachial neuralgia, , intractable to all medical treatments.

Consultation with the anaesthetist, at least 48 hours before the operation

Hospitalisation: admission during the afternoon of the day before the operation

Antibiotic preparation the evening before

Shower with Betadine® the evening before and the morning of the operation

Surgical operation next day

First get out of bed during the evening of the operation

Discharge the day after operation

Operative Procedure

By a 3 millimeters large incision, at the level of the herniated disc, on the anterior part of the neck, slightly lateral, at 3 centimeters from the midline, A tube of 2 millimeters diameter is passed which enables the surgeon to excise the hernia and to decompress the nerve root. Endoscopy and treatment with laser are possible at the same time. Cleansing the disc of all inflammatory debris then follows.

Operation timing:

In the orthopaedic OP room, the operation is performed under general anaesthesia with the patient lying on the back; a direct approach and radioscopic control with a C arm.

Duration: about 1 hour

Stay in the post-OP room. Back to the patient’s own room a short time after..

Get up on the evening of the same day as the operation.

Drain removed the next day

Discharge the day following n with a rigid cervical collar to be worn for 2 weeks;

Back to sedentary work after 8 days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Kinesiology after 1 month if necessary

Sports : rapidly authorized : walking, back crawl swimming, bicycle; caution with tennis, jogging.

During 3 months, if a long trip in a car is necessary, wear the rigid cervical collar for the whole trip.

 

 

Intersomatic cervical graft

Indications: cervicobrachial neuralgias after failure of all, other treatments;

Consultation with the anaesthetist, at least 48 hours before the operation

Hospitalisation: admission during the afternoon of the day before the operation

Antibiotic preparation the evening before

Shower with Betadine® the evening before and the morning of the operation

Surgical operation the day after

First getting up during the evening of the operation

Discharge 2 days after operation

 Operation principles

By a 3 millimeters large incision, at the level of the herniated disc, on the anterior part of the neck, slightly lateral, at 3 centimeters from the middle, one pass a tube of 2 millimeters diameter with authorizes to take off the hernia and to decompress the nerve root at the same time. Endoscopy and treatment with laser arte possible at the same time. Washing up the disc of all inflammatory debris is always done.

Operation timing:

In orthopaedic OP room, under general anaesthesia  patient lying on the back; direct approach, and radioscopic control with a C arm.

Duration: about 1 hour

Stay in the post-OP room. Back in the normal room a few time after.

Getting up on the evening of the same day.

Drain ablation the day after

Discharge the day after with a rigid cervical collar for 2 weeks;

Back to sedentary work after 8 days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Kinesiology after 1 month if necessary

Sports : rapidly authorized : walking, dorsal crawl swimming, bicycle; caution with tennis, jogging, footing.

During 3 months, if a long trip in a car is necessary, wear the rigid cervical collar for the whole trip.

 

Cervical fusion

Operative procedure

By a 3 centimeters horizontal incision, the operation is performed at the level of the herniated disc, on the anterior part of the neck, slightly lateral, at 3 centimeters from the midline, the disc and the hernia are removed, and the nerve decompressed at the same time. Then a cage of titanium filled with bone substitute is put in place

Operation timing:

In orthopaedic OP room, under general anaesthesia  with the patient lying on the back; direct approach, and radioscopic control with a C arm.

Duration: about 1 hour

Stay in the post-OP recovery room. Back to patient’s own  room a short time later.

The patient gets up on the evening of the same day.

Drain removed the next day

Discharge the day with a rigid cervical collar to be worn for 2 weeks;

Back to sedentary work after 8 days; back to intermediary work (with car trips) after one month and half; heavy work after 2 to 3 months.

Kinesiology after 1 month if necessary

Sports : rapidly authorized : walking, back crawl swimming, bicycle; caution with tennis, jogging.

During 3 months, if a long trip in a car is necessary, wear the rigid cervical collar for the whole trip.


Surgery for chronic incapacitating pain

Electrical medullary stimulation is now done by our specialist from pain Center of Paris West (Centre Antidouleur de l’Ouest Parisien CADOP http://www.douleur-paris.fr/ )


 


FAQs

(EDTL= Endoscopic Transforaminal Discectomy assisted by Holmium YAG laser)

 

About discal lumbar hernias

1.      When do we have to operate for a discal hernia?

After failure of medical treatment for sciatica; this treatment has to be well managed during at least several weeks. It is necessary that the imaging corresponds with the symptoms.

2.      Does ETDL work for previously operated discs after chemonucleolysis with papaïne?

Yes, if the previous operation is followed by a real improvement during several months before the relapse. The EDTL can remove the fibrosis or scarring tissue due to the previous operation, and simultaneously the relapse of hernia.

If the previous operation was followed by only a small improvement after some weeks, it is necessary to reassess the whole state of the intervertebral segment in question so as to decide on the treatment best suited to the patient.

3.      Why has chemonuleolysis been abandoned?

Papaïne, a product which dehydrates and stretches the disc and the hernia, is no longer sold now in Europe since 2002 January, because of manufacturing problems.

4.      What about the treatment of discal hernia by laser alone?

The laser used for stretching the disc and the hernia is usually a Diode laser; its fiber is passed through a large needle going into the disc. The effect is to stretch the disc and the hernia, and not to remove the hernia directly.

5.      Why don’t you advise a brace after an EDTL?

I did not notice any difference between bracing and not bracing when operating with EDTL in simple hernias in a cooperative  patient during the post-OP period.

6.      What is a degenerated disc?

It is a disc which has lost its water (dehydration). The effect of this is like losing its shock absorbing  power.

Several mechanisms are involved :

o       mechanical overloading, either from the weight above or below to beneath by, or by twisting with one creation of fissures;

o       violent trauma generating fissures;

o       lack of oxygenation and hyperacidity in people who smoke (the disc is not vascularised, -its coloration is white- and can receive any oxygen only indirectly from the neighbouring blood vessels);

o       congenital or hereditary factor

Usually, disc degeneration is beginning at the age of about 40, fissures are created, facilitating a discal hernia’s emergence.

It is slowed by good health, avoiding long sessions in the front of a computer or in a car, and by regularly walking.

7.      Does EDTL help avoid hernia recurrence?

Systematic association of the EDTL with a thermomodulation, which shrinks the fragments between two fissures and which can weld the fissures, facilitates a frank reduction of the recurrences of hernia. However, the discal degenerative disease which provoked the hernia may continue its evolution on its own. Its continues to fissure the rest of the disc, and there is no means now of preventing this evolution. It is happily very slow, and the new fissures usually stay symptom free.

 

8.      What is the percentage of good results of the technique?

For a recent hernia, less than 2 to 3 months old, the result is usually very satisfying, immediately in 95% of cases; the improvement persists if you are careful in the month after the EDTL. When the compressed nerve has been crushed, for too long or too severely, the recovery is slower.

 

9.      What are the advantages of the transforaminal endoscopic surgery beside open surgery or microsurgery, or beside the interlaminar endoscopic technique (between the two vertebral laminas, from behind instead of being at 10, 15 cm laterally)?

o       A very small scar of the skin of less than some millimeters;

o       When open surgery or microsurgery is done, the surgeon has to displace the compressed root to remove the hernia; this produces bleeding and irritation of the neighbouring tissues, and makes likely  the emergence of fibrotic scarring around the nerve or fibrosis. Endoscopic transforaminal surgery removes the hernia with a minimum of bleeding.

o       Muscular damage is reduced as much as possible, and the recovery is faster.

o       For patients with heavy comorbidity, the mildness of this surgical treatment seems very advantageous compared with a more invasive technique.

 

10.  I would have preferred a general anaesthesia. Why is a local anaesthesia necessary?

Local anaesthesia, on the operation site, is reinforced or “potentiated “ by an intravenous sedation, which gives a feeling of well being, and greatly reduces feeling any eventual pain. It is impossible to do a ETDL under general anaesthesia, because the surgeon has to have information from the patient at the beginning of the procedure as to whether he can feel any pain or not so as to identify the discal fissures, and discal degeneration grade. During hernia removal, the surgeon has to verify that he does not provoke any “unpleasant tugging” on the nerves.

 

11.  I was told that the ETDL might be done in only certain types of hernia

The limitation of the ETDL indication to hernias of foraminal site, i. e. located in the foramen, has not any justification. With improvement of the techniques and with the perfecting of endoscopes, the ETDL can now be used to treat every type of hernia, central, paramedian or foraminal, contained or not contained in the disc, migrated or not migrated.

 

12.  If my hernia is associated with a spondylolisthesis (sliding of one vertebra on the other), can it be cured by ETDL?

Yes, if the sliding is not the cause of the symptoms, for which the hernia is the only cause.

No, if the sliding provokes part or all of the symptoms.

 

13.  I have been satisfied with the result of the surgical treatment of my previous hernia ( by ETDL or open microsurgery). I have a new discal hernia at a different level. What will be the imaging of the previous operated disc?

o       In one third of the cases, about, the hernia picture disappears completely;

o       in another third, the pocket of the hernia is persisting, but diminished;

o       in the last third, hernia pocket picture is seems to be the same, even though symptoms have disappeared.

 

14.  Is EMG (Electromyography) useful?

It is really useful when the nerve to be decompressed is not well localized by symptoms or imaging, or when one has to evaluate a deterioration or diminution of the nerve compression, from the previous EMG.

 

15.  Are big hernias emergencies?

Not at all. The size of the hernia is not at all proportional to the symptoms. They are the result of the inflammation between hernia and nerve. This flare-up  is more important if the osseous medullary canal is narrow, and if the dura is large. In other words, the small hernias can be very painful, and more so if the osseous canal is narrow, and the big hernias can cause a minimum pain, and less if the osseous canal is large.

 

16.  Why is a complete imaging panel necessary for the check-up of a discal hernia to be operated on, assembling standard X-rays, TDM, and MRI?

The standard radiography, made with a standing patient anteroposterior, lateral, then in neutral sitting, finally in a flexed sitting position in some cases, shows:

o       the global bending of the spine,

o       immediately an anterior or posterior lessening of intervertebral height,

o       an abnormal mobility between 2 vertebras (instability),

o       or, unlike, an abnormal immobility at the level of a very painful disc.

o       It never shows the hernia, except if it is calcified.

Computerized X-ray tomodensitometry (TDM) shows the surrounding of the discal hernia, and eventual calcifications.

Magnetic Resonance Imaging (MRI) does not present the hazards of the X rays, and shows the smallest details of the hernia, and more: the state of the vertebral osseous tissue, which can be inflammatory or congestive, and may explain many lumbalgias resistant to medical treatment. Its only inconvenience is to be not feasible on patients with cardiac pacemaker or on claustrophobic patient.

Saccoradiculography, or myelography, involving injection of an iodized liquid, opaque to X-rays, in the spine meninges, is now well tolerated because of the sharpness of the needles used. It gives good information on the behaviour of the hernia in a standing position, and about an eventual intervertebral instability. Its disadvantage is

§         that it cannot be done on patients allergic to iodine,

§         and it does not show the foraminal hernias.

 

17.  What are called “Scheuermann disease sequellas” or “growing spine dystrophy”?

This is a disease of the growing spine of teen-agers. The vertebrae present a small deformity with a diminished height in their anterior part and irregularities of the vertebral plates. Sometimes, intraspongious hernias can be worrying. They are rarely the cause of symptoms.

 

18.  What is a paralysis?

It is usually a complete motor deficit, for example of the foot elevators. Most frequently, if there is a motor deficit, it is incomplete. It is then a paresis. The complete deficit, absolutely exceptional, or well documented paralysis, is a true surgical emergency. Most often the motor deficit is incomplete (paresia), appears progressively and cures progressively after the ETDL or the microsurgery.      

 

Questions about lumbar fusion by titanium trussed intersomatic graft in heavy degenerative disc diseases

 

19.  Is the post anesthetic awakening painful?

Anaesthetic progress and the operative technique help to reduce the chances of a painful  awakening, as much as possible. Don’t hesitate to ask the nurses to help you if you notice pain. Drugs are systematically administered before pain onset, which can help you to avoid any suffering.

 

20.  Will it be necessary to remove implants in titanium?

No, they are in titanium and biological tolerance is excellent.

 

21.  Are the implants disturbing?

Absolutely not with the new sizes of implants.

 

22.  Will I have drains?

.With the new “Europa” cages with minimal invasive technique, there is not any drain.

.With the open operation, which can be necessary, drains are placed in a way so as to be not painful. They permit the bleeding to be evacuated and prevent nerve compression by an expansive collection of blood (compressive hematoma). They are removed at about the third day.

 

23.  Can implants break?

For 8 years, I have not seen any breakage in the implants that I put in by operation.

 

24.  Have the discs above the fusion to be watched?

A clinical and radiological follow-up is necessary on the upperlying discs which have to work to compensate the loss of mobility of the underlying intervertebral segment. A good lumbar muscular locking is prevents this deterioration.

 

25.  Why to not put a disc prosthesis which can keep a good mobility on the same manner than a hip prosthesis?

The advantage of a disc prosthesis is to maintain mobility, but it brings with it a lot of risks: important mechanical overload of the posterior joints (or zygapophysal joints), which “work” two or three times more with a prosthesis than normally, risk of subsidence in the vertebral plate, and overall risk of calcifications around the prosthesis, which take away the benefits of mobility. Finally the prosthesis is not reimbursed by the social security.

 

 

Questions about spondylolisthesis (SPL, sliding of a vertebra over the other)

26.  What is a congenital SPL?

It is a sliding of the fifth lumbar vertebral body over the sacrum; the vertebra is made of the vertebral body, two zygapophysal joints on the left and on the right, and the posterior arch. In congenital SPL, the zygapophysal joint has grown sufficiently, but does not unite at the level of the intermediary zone or isthmus.; the vertebral body can then slide in the anterior direction, and is not retained by the L5S1 disc. The sliding takes then its own course and is usually not very important. It is rarely painful. If it does become painful, a surgical fixation is necessary if functional rehabilitation or kinesiology does not give improvement.

27.  What is a degenerative SPL?

It is the sliding of the vertebral body of the forth vertebra over the fifth, or of the third over the forth. Zygapophysal joints are worn by the osteoarthritic phenomenona, and it may not stop the sliding. All the posterior arch of L4 (or L3) remains rigid, and it may come forward against the dural sac and put strain on the nerves which become stretched, then painful, and can be paralyzed.

 

Cervical Surgery

Minimal invasive cervical discectomy

28.  Can this operation be done under local anesthesia?

Yes, if you wish for this.

 

29.  Is association hernia-osteoarthritis a contra-indication to this technique?

For me, not, because nervous compression symptoms are recent, and because osteophytes of the osteoarthritis  took a very longer time than the hernia to form. Compression symptoms are generally caused by a recent discal hernia.

 

30.  What are the hazards?

“Noble” tissues neighbouring is well discerned by the surgeon. Except by people with an important fat layer in the anterior part of the neck, the risk of  hurting an important structure is practically zero, and in all cases 10 times less important than an open surgery.

 

Surgery of chronic invalidating pain par Electrical Medullar Stimulation

31.  What is the action mechanism?

The electrical stimulations, at regular intervals, provoke a soft tickling sensation in the corresponding pain territory, and replace the pain, so as the patient is no more suffering.

 

32.  When the battery is in place, how long is its duration?

It depends of the intensity of the stimuli, and of the duration of the periods of stimulation.

 

33.  What are intervals of control visits to doctor?

At 1 month, 3 months, 6 months, and then every 6 months.

 

34.  Will I have to take medications against pain after battery setting?

Usually, no, and you will have to diminish progressively the morphinic toxics to avoid withdrawal symptoms.