Cervical Percutaneous Discectomy with Low Dose Chemonucleolysis

Horst Dekkers, M.D.

Alpha Klinik,

Munich, Germany

Purpose of the study:

Purpose of this prospective study was to evaluate the effectiveness and complication rate of this minimal invasive procedure for herniated cervical discs.

Material and methods:

From 1994 until 1998 in 196 patients with a cervical disc herniation proven by MRI or CT-scan and predominantly radicular symptoms, not responding to conservative treatment, a combined treatment of a low dose chemonucleolysis followed by a automated percutaneous nucleotomy was performed on an out-patient basis. Follow-up was performed 3 months after surgery by physical examination and one year and three years after surgery by questionnaire. 244 patients (91%) completed the study. Complications were registered for the whole group. 62% were male and 38 % were female patients with a average age of 45 years.

Results:

After three years 90% of the patients were very satisfied or satisfied. 7% of the patients had a fair result and 3% of the patients were unchanged or needed further surgery.

Complications:

There was one significant bleeding in the cervical area, there was one puncture lesion of the spinal cord and there were two hematomas. Out of these four complications, only one patient was left with minor residual symptoms.

Conclusion:

This procedure is a delicate but save and effective treatment of cervical disc herniations. even in the case of spondylosis and foraminal stenosis.

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Alpha Klinik

Drs. Horst Dekkers

Effnerstraße 38

D-81925 München

E-mail: kohl@alphaklinik.de

Tel.: 0049-89998384163

In the Alpha Klinik, Munich, more than 1.000 herniated discs are operated every year. Since September 1998 all types of disc herniation have been removed through a transforaminal cannula with endoscopic assistance. In most cases foraminal enlargement with special instruments is performed. The technique enables the removal of far caudally or cranially sequestrated fragments.

In the past two years, the senior author only experienced one case (0,06%) in which subsequent microscopic midline re-operation was necessary, due to a retained fragment. This video/power point presentation demonstrates the technical high-lights and pitfalls in order to reach the epidural space through the foramen in a save way. At the end of the procedure the treated nerve root is always visualized.

Purpose of the study:

Aim of this prospective randomized study was to evaluate if a combined endoscopic transforaminal discectomy (ETD) with low dose Chymopapain is more effective than EDT without Chymopapain in the operative treatment of a disc herniation.

Material:

From September 1995 to June 1997 280 patients underwent an endoscopical transforaminal discectomy for herniated discs. The patients were quasi randomized. 138 patients (group 1) with an uneven birthday received additional chemonucleolysis and 142 patients with an even birthday underwent EDT without enzyme (Group 2).

Methods:

First a discography was done to confirm the herniation and sequestration and to exclude a massive dye leakage. In 8 cases of the combination group the contrast medium massively leaked out, these patients received no Chymopapain and were dropped out from the study. The other patients of the first group received 1000U Chymopapain injected into the disc and after 10 minutes the procedure went on. Then cannulas with increasing diameters are pushed over wire. With special hollow-fasers up to 7.5 mm the lateral foramen was enlarged in the direction of the herniation. A endoscope was inserted and the herniation, respectively the sequestration could be inspected and discharged with special forceps. Afterwards, the neighbouring part of the disc was examined for loose fragments and cleaned out. Dura and nerve root were controlled endoscopically and then the instrumentation was removed.

Results:

After 1 year 94,8% in group 1 had an excellent or good result; 0,8% a fair and 4,2% an unsatisfactory result. In group 2, 85,8% had an excellent or good result; 5,5% fair and 8,6% unsatisfactory. The postoperative complication rate was 2,1% in group 1 and 2,8% in group 2. After 2 years 95,2% of the patients in group 1 had an excellent or good result; 2,9% a fair and 1,9% a poor outcome. In group 2, 89,5% had an excellent or good result; 6.7% a fair and 3,8% a poor outcome. In group 1 there were 2 recurrences and in group 2 there were 8 recurrences, a significant difference.

Conclusions:

The addition of a low dose Chymopapain results in significant better results in endoscopical transforaminal discectomy.