An Improved Surgical Outcome with the Use of Intraoperative Discography

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1 Med. J. Cairo Univ., Vol. 78, No. 1, September: , An Improved Surgical Outcome with the Use of Intraoperative Discography MOHAMAD AMR EL-TAYEB, M.D. and AHMAD HEGAZY, M.D. The Department of Neurosurgery, Faculty of Medicine, Cairo University. Abstract Cervical disc degeneration is the most common cause of cervical cord and nerve root dysfunction. The standard procedure for their treatment today remains the anterior cervical decompression and interbody fusion. Anterior cervical discectomy and fusion (ACDF), first described by Smith and Robinson and by Cloward in the 1950s, is the most common surgical procedure proven successful in the treatment of symptoms caused by cervical degenerative disc disease including disc herniations and other compressive pathologies. The aim of our study was to assess the surgical and clinical outcome with the use of intraoperative discography in cervical disc surgery. Twenty-four patients with cervical disc were randomized to one of either groups, Group A, which comprimized ACD with the use of intra operative discography to asses completeness of removal or Group B, in which ACD was performed without discography. In group A, 11 (92%) patients had excellent outcome while 1 patient (8%) had good outcome. In group B, In group A, 10 patients (84%) had excellent outcome while 2 patients (16%) had good outcome. The use of intraoperative discocgraphy in anterior cervical discectomy assists in the complete removal of disc material and osteophytes especially laterally. Key Words: Cervical discectomy Discography Outcome. Introduction CERVICAL disc disease is one of the most common degenerative spinal problems causing both medical, social and economically disabilties. Ever since Cloward [1] and Smith and Robninson [2] performed the first cervical anterior discectomy, an increasing number of anterior cervical discectomies are being performed today by spine surgeons. However, despite the relative simplicity of the procedure a significant percentage of patients Correspondence to: Dr. Mohamad Amr El-Tayeb, The Department of Neurosurgery, Faculty of Medicine, Cairo University. remain unsatisfied and with residual symptoms following surgery. Surgical decompression remains the key to achieving desirable clinical outcomes after cervical discectomy for radiculopathy [3]. One of the main causes for patients to remain unsatisfied after ACDs is the presence of residual discs and osteophytes that pass undetected during surgery. Many surgical techniques have been devised along with many modifications of the original surgical techniques described by Cloward and Smith and Robinson to achieve a more complete disc and osteophyte resection. Though the use of intraoperative fluroscopic imaging has been used in cervical disc surgery and lumbar disc surgery and trauma, the use of intraoperative imaging with discography in cervical disc surgery has not been widely used although it represents an attractive cost effective idea. Accordingly the aim of our study was to asses the surgical and clinical outcome with the use of intraoperative discography in cervical disc surgery. Material and Methods Twenty-four patients with cervical disc disease were operated upon at Cairo University Hospitals in the period between 2005 and Patients were randomized to one of either groups: Group A, which comprimized ACD with the use of intra operative discography to asses completeness of removal or Group B, in which ACD was performed without discography. All clinical, radiological and surgical information were prospectively collected and at the end of the study retrospectively analysed, paying particular attention to the reflection of the use of intraoperative discography in cervical disc disease on the surgical and radiological and clinical outcome. 225

2 226 An Improved Surgical Outcome with the Use of Intraoperative Discography Surgical technique: GA while the patient in neck collar position and neck in slight extention. A transverse incision is made according to the disc level. The skin is incised followed by the paltysma. The general investiging fascia of the neck is opened followed by identification and dissection of the plane between the carotid sheath laterally and the esophagus and trachea medially. The omohyoid muscle was divided if nesceecary if it is in the direct route of the approach. The prevertebral tissues are dissected, initially with a peanut and then with low-power monopolar cauterization. The longus colli muscles are identified and are dissected from the vertebral body approximately 2 to 3mm laterally. The self-retaining retractor blades are placed beneath the dissected longus colli muscles The Caspar retractor is placed in the vertebrae above and below the disc in the center of the body. A spinal needle is inserted into the disc space and the level is confirmed by radiofluoroscopy. The annulus is opened and the disc material is initially removed with curettes. Distraction with the casper retractor is done. Any anterior osteophytes are removed with Kerisson rongeours flush with the endplate. The microscope is brought into the surgical field, and the rest of the disc is removed. Identification of the posterior ligament. Using microcurettes and a micro-kerrison rongeur, bilateral foraminotomy is performed and all osteophytes and disc material are removed. After complete microsurgical discectomy and osteophyte removal using high speed electrical drill, 3-5cc of radio-opaque material Urographin were injected into the disc space and the extent of disc and osteophyte removal was assessed fluroscopically using and intra-operative C arm. Disc and osteophyte were said to be completely removed when 2 paralell lines extending from the anterior border of the disc space to the anterior border of the disc space without tapering in addition to an escape of the dye superiorly and inferiorly anterior to the cord in the epidural space. For assessment of the completeness of the lateral aspect of the disc an antro-posterior view was performed by rotating the C arm to be placed in antroposterior plane. Once decompression is completed, insertion of a fibre carbon cage is done. Closure is performed in layers. All patients were clinically examined in the immediate postoperative period and all neurological deficits were documented. Clinical outcome was also documented. All patients were asked about the degree of clinical satisfaction achieved by surgery. Patients were followed-up on an outpatient basis at monthly intervals and follow-up was continued in some patients for 2 years. Two months following surgery, MRI imaging was done to determine radiological outcome. Clinical outcome was classified into excellent outcome, where there was complete improvement of symptoms, good outcome where there was partial improvement of symptoms and poor outcome where there was no improvement or worsening of symptoms (according to the visual analougue score). Results The study included 24 patients, 12 patients were assigned to each group. There were 11 males (46%) and 13 females (54%) almost equally distributed between both groups. The youngest patient was 29 years old and the oldest was 57 years old. The mean age at presentation was 42.7 years. In group (A), all patients complained of radiculopathy in 12 patients (100%), while myelopathy was found in 5 patients (42%). 11 patients complained of neck pain (92%). In group (B), the most common presenting symptom was also radiculopathy in 23 patients (96%), followed by myelopathy in 10 patients (42%). 10 of the 12 patients complained of neck pain (84%). In group (A), the most commonly affected level was C5-C6 in 5 patients (42%) followed C3-C4 in 3 patients (25%). C4-C5 and C6-C7 occurred in 2 patients each (17%). In group (B), the most commonly affected level was C5-C6 in 5 patients (42%) followed C6-C7 in 3 patients (25%). C4-C5 and C3-C4 occurred in 2 patients each (17%). There were no significant intergroup differences regarding age, sex, presenting symptoms and signs or levels affected.

Mohamad A. El-Tayeb & Ahmad Hegazy 227 Regarding clinical outcome, there was a dramatic improvement in pre-operative presenting symptoms and signs in both groups.

All 12 patients in the discography group showed a dramatic improvement of radiculopathy (100%) while myelopathy improved in 4 of the 5 patients (80%).

11 out of the 12 patients had an improvement in the radiculopathy (92%) while only 3 of the 5 patients with myelopathy improved (60%). No patients had poor outcome in the series.

There were no serious neurological complications in both groups except one patient (4%), who complained from postoperative radiculopathy but improved after 2 weeks.

3 Mohamad A. El-Tayeb & Ahmad Hegazy 227 Regarding clinical outcome, there was a dramatic improvement in pre-operative presenting symptoms and signs in both groups. In group (A), 11 (92%) patients had excellent outcome while 1 (8%) patient had good outcome. All 12 patients in the discography group showed a dramatic improvement of radiculopathy (100%) while myelopathy improved in 4 of the 5 patients (80%). The patient who did not improve had cord signal preoperatively. In group B, 10 (84%) patients had excellent outcome while 2 (16%) patients had good outcome. 11 out of the 12 patients had an improvement in the radiculopathy (92%) while only 3 of the 5 patients with myelopathy improved (60%). No patients had poor outcome in the series. Radiologically, there was evidence of complete removal of disc and osteophytes in all 12 patients in Group A while this occurred in only 9 of the 12 patients (75%) in group B. There were no serious neurological complications in both groups except one patient (4%), who complained from postoperative radiculopathy but improved after 2 weeks. Other minor complications, such as hoarsness of voice, dysphagia and superficial wound infection occurred in 3 patients and all improved. Fig. (2): Intraoperative fluoroscopic image of disc space after metrizamide injection. Fig. (3): Intraoperative fluoroscopic image of disc space after metrizamide injection showing flow of the dye. Discussion Fig. (1): Intraoperative fluoroscopic image of disc space before metrizamide injection. Cervical disc degeneration is the most common cause of cervical cord and nerve root dysfunction. The standard procedure for their treatment today remains the anterior cervical decompression and interbody fusion [4].

4 228 An Improved Surgical Outcome with the Use of Intraoperative Discography Anterior cervical discectomy and fusion (ACDF), first described by Smith and Robinson [2] and by Cloward [1] in the 1950s, is the most common surgical procedure proven successful in the treatment of symptoms caused by cervical degenerative disc disease including disc herniations and other compressive pathologies. The main goal of these techniques is to decompress the neural structures, to establish segmental stability and restore the physiologic curvature of the treated segment [5,6]. Indications for cervical total disc removal and replacement are variable and include; symptomatic disc, which leads to arm and/or neck pain and/or radiculopathy with sensorimotor deficits. These symptoms can be caused by herniated disc and/or osteophytes compressing adjacent nerves or spinal cord [5]. This can only be achieved by complete removal of disc and any osteophytes to ensure decompression of the exiting nerve roots. Failure of removal is one of the most important reasons of reccurence and patient dissatisfaction. In our study, after complete microsurgical discectomy and osteophyte removal, 3 to 5cc of radioopaque material (Urographin) were injected into the disc space and the extent of disc and osteophyte removal was assessed fluoroscopically using and intra-operative C arm. Disc and osteophyte were said to be completely removed when 2 paralell lines extending from the anterior border of the disc space to the anterior border of the disc space without tapering in addition to an escape of the dye superiorly and inferiorly anterior to the cord in the epidural space. For assessment of the completeness of the lateral aspect of the disc, an antero-posterior view was performed by rotating the C arm to be placed in anteroposterior plane. This aided in making sure that the disc and osteophytes have been completely removed both centrally and laterally on both sides. In addition, flow of the dye superiorly and inferiorly showed complete decompression of both the upper and lower lips of the adjacent posterior ends of the vertebral bodies. Ever since its first description in 1948, provocative discography has been regarded as a controversial procedure [7]. Discography has been used more in the lumber region as a diagnostic procedure. Lumbar discography is an invasive diagnostic procedure that involves, under fluoroscopic guidance, the puncturing of a disc for the instillation of iodinated contrast into the nucleus pulposus. It provides direct radiographic information concerning the nuclear morphological features and integrity of the vertebral endplates and annulus [8]. Even though it is an invasisve procedures but it is generally considered to be safe, with very rare complications of discitis and nerve injury. The primary indication for lumbar discography is chronic low-back pain with or without radicular pain in the absence of MR imaging-documented neural compression [8]. It is also used in assessment of post-surgical failed back syndrome of patients in whom MR imaging is non-diagnostic [9,10,11]. Cervical discography is also a controversial procedure with recommendations against its use as the information obtained from cervical discography does not outweigh the increased risks of complications reported to occur in up to 13% of cases. These complications include discitis, epidural abscess, haematoma, myelopathy and quadriplegia. However, others have found cervical discography to be a safe and useful procedure in selected patients with chronic intractable neck pain with negative or indeterminate imaging findings, and are being considered for surgery [12,13]. These studies state that the complication rate of discography is low, and is accepted to be less than 1% and ranging from 0.94% to 0.25% with the conclusion that the risk of post-discography discitis was minimal [14]. The most serious and frequently encountered complication is discitis. Broadspectrum antibiotics can be administered prophylactically as a precaution against possible discitis [9]. Our study included 24 patients with patients randomized to either Group A (ACD with use of discography) or group B (ACD without discography), 12 patients to each group. The study included slightly more females (Male to female ratio was 0.8 : 1) almost equally distributed between both groups. The mean age at presentation was 42.7 years (29-57). This was similar to other studies (mean age, years; age range, yrs) [15] but slightly lower than others (48 ± 10 years) [16,17]. The most common complaint was radiculopathy in both groups (group A No % group B No 11-96%), followed by neck pain (group A No 11-92% Group B No 10-92%), myelopathy (group A No 5-42% Group B No 5-42%).

5 Mohamad A. El-Tayeb & Ahmad Hegazy 229 The most commomnly affected level was C5- C6 (No 5-42%). This is similar to the findings of Park et al., where C5-C6 was the most commonly affected level in 51% of patients [17]. Postoperative infection rates are low in ACD (0% to 6.7%). Other complaints including temporary hoarseness, odynophagia, dysphagia and swallowing difficulties can occur up to 13% but usually improve withing days to weeks [3]. There were no serious neurological complications in both groups except one patient 4%, who complained from postoperative radioculopathy but improved after 2 weeks. Other minor complications, such as hoarsness of voice, dysphagia and superficial wound infection occurred in 3 patients and all improved. Graft or cage related complications are minimal if proper application teqcniques are done [15]. Park et al. [17] and Moreland et al. [18] reported no graft or cage related complications. In our study, there were no cage related complications. Regarding clinical outcome there was a dramatic improvement in pre-operative presenting symptoms and signs in both groups. In group A, 11 patients (92%) had excellent outcome while 1 patient (8%) had good outcome. In group B, 10 patients (84%) had excellent outcome while 2 patients (16%) had good outcome. No patients had poor outcome in the series. Radiologically, there was evidence of complete removal of disc and osteophytes in all 12 patients in Group A while this occurred in 11 of the 12 patients (93%) in group B. This was comparable with the results of Fredric et al., who had excellent outcome results in 95% of patients at 12 months [19]. Jing reported a 93% improvement of radicular pain in patients performing ACD alone and 100% in patients undergoing ACD with fusion, with neck pain improving in 83% and 80% respectively [3]. Bartocher et al., had similar results, with excellent clinical outcome in 91% of cases [20]. Chen and colleagues reported a better clinical outcome in near 98% of their study [21]. There was a significant improvement in both neck and arm pain and demonstrated good clinical and radiologic outcomes with improvement of the visual analogue score [15,17]. However, Zevgaridis et al., reported good and excellent clinical outcome in only 83% at 12 months postoperative follow-up [22]. Similarly, Payer et al. [23] reported an 80% clinical improvement after 12 months following surgery, while Thome and colleagues reported a 79% clinical improvement at 12 months postoperative [24]. Others reported less satisfactory outcome (78%) and neck pain relief in 73% [18]. Radiologically, their was evidence of complete removal of disc and osteophytes in all 12 patients in Group A while this occurred in 11 of the 12 patients (92%) in group B. Bony fusion occurred in 11 patients in group (A) and 11 patients in group (B) (93%). This was similar to others e.g., Moreland and collegues reported 95% bony fusion (though this was not correlated to the clinical outcome) [18]. Chen reported radiological fusion in 98% of their study [21]. Fredric et al., had a fusion rate of 96% [19]. Similar results were mentioned by Payer et al., 96% fusion rates after 12 months following surgery [23]. Lower fusion rates were reported in other studies (93% at one year) [3]. Bartocher et al., had a a fusion rate (86%) [20]. Zevgaridis et al., radiological fusion of 87% at 12 months postoperative followup [22]. Thome and colleagues reported a (74% fusion rates at 12 months postoperative [24]. Conclusion: The use of intraoperative discography in anterior cervical discectomy assists in the complete removal of disc material and osteophytes especially laterally. In addition it is simple, cheap and with minimal, if any, complications. Although the results of the clinical outcome were similar between both groups but we found that this tecqnique aided in assuring complete disc and osteophyte removal. We believe that it improves the surgical outcome and increases the chances of the patient for better results. References 1- CLOWARD R.B.: The anterior approach for removal of ruptured cervical disks. J. Neurosurg., 15: , SMITH G.W. and ROBINSON R.A.: The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J. Bone Joint Surg. Am., 40: , JING-CHENG XIE and R. JOHN HURLBERT: Discectomy versus discectomy with fusion and instrumentation: A prospective randomized study. Neurosurgery, 61: , 2007.

6 230 An Improved Surgical Outcome with the Use of Intraoperative Discography 4- WIGFIELD C.C. and NELSON R.J.: Non autologous interbody fusion materials in cervical spine surgery: How strong is the evidence to justify their use? Spine, 26: , MCAFEE P.C.: The indications for lumbar and cervical disc replacement. Spine J., 4: 177S-81S, MEHREN C. and MAYER H.M.: Neurology Artificial cervical disc replacement-an update Neurology India, Vol. 53, Issue , PEH E.: Provocative discography: Current status WCG Biomed Imaging Interv. J., 1 (1): e2, FRANK J.T., SCOTT A.C., BOXELL C. and WARREN J.: Discography interpretation and techniques in the lumbar spine C.N.S. Neurosurg Focus, 13 (2): Article 13, ANDERSON M.W.: Lumbar discography: An update. Semin Roentgenol., 39: 52-67, BINI W., YEUNG A.T., CALATAYUD V., et al.: The role of provocative discography in minimally invasive selective endoscopic discectomy. Neurocirugia (Astur), 13: 27-31, FENTON D.S. and CZERVIONKE L.F.: Discography. In: Fenton D.S., Czervionke L.F. (eds) Image-guided spine intervention. Saunders, Philadephia, pp , GRUBB S.A. and KELLY C.K.: Cervical discography: Clinical implications from 12 years of experience. Spine, 15: , ZHENG Y., LIEW S.M. and SIMMONS E.D.: Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine, 29: , WILLEMS P.C., JACOBS W., DUINKERKE E.S., et al.: Lumbar discography: Should we use prophylactic antibiotics? Study of 435 consecutive discograms and a systemic review of the literature. J. Spinal Disord Tech., 17: , ROHE S.M., ENGELHARDT M., HARDERS A. and SCHMIEDER K.: Anterior cervical discectomy and titanium cage fusion 7-year follow-up. Nov., 70 (4): 180-6, ISHIHARA H., KANAMORI M., KAWAGUCHI Y., NAKAMURA H. and KIMURA T.: Adjacent segment disease after anterior cervical interbody fusion. Spine J. (United States), 4: 624-8, PARK H.W., LEE J.K., MOON S.J., SEO S.K., LEE J.H. and KIM S.H.: The efficacy of the synthetic interbody cage and Grafton for anterior cervical fusion. Spine Aug., 1; 34 (17): E591-5, MORELAND D.B., ASCH H.L., CLABEAUX D.E., CASTIGLIA G.J., CZAJKA G.A., LEWIS P.J., EG- NATCHIK J.G., CAPPUCCINO A. and HUYNH L.: Anterior cervical discectomy and fusion with implantable titanium cage: Initial impressions, patient outcomes and comparison to fusion with allograft. Spine J., FREDERIC S., BENEDICT R. and PAYER M.: Implantation of an empty carbon fiber cage or a tricortical iliac crest autograft after cervical discectomy for single-level disc herniation: A prospective comparative study. J. Neurosurg. Spine, 4: , BARLOCHER C.B., BARTH A., KRAUSS J.K., BINGGELI R. and SEILER R.W.: Comparative evaluation of microdiscectomy only, autograft fusion, polymethylmethacrylate interposition and threaded titanium cage fusion for treatment of single-level cervical disc disease: A prospective randomized study in 125 patients, Neurosurg Focus, Vol. 12 (1), CHEN J.F., WU C.T., LEE S.C. and LEE ST: Use of a polymethylmethacrylate cervical cage in the treatment of single-level cervical disc disease. J. Neurosurg. Spine, 3: 24-28, ZEVGARIDIS D., THOME C. and KRAUSS J.: Prospective controlled study of rectangular titanium cage fusion compared to iliac crest autograft fusion in anterior cervical discectomy. Neurosurg Focus, 12 (1), PAYER M., MAY D., REVERDIN A. and TESSITORE E.: Implantation of an empty carbon fiber composite frame cage after single level anterior cervical discectomy in the treatment of cervical disc herniation: Preliminary results. J. Neurosurg. Spine, 2 (98): , THOME C., LEHETA O., KRAUSS J. and ZEVGARIDIS D.: A prospective randomized comparison of rectangular titanium cage fusion and iliac crest autograft fusion in patients undergoing anterior cervical discectomy. J. Neurosurg. Spine, 4: 1-9, 2006.

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