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Journal of Craniovertebral Junction and Spine
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EDITORIAL
Year : 2018  |  Volume : 9  |  Issue : 3  |  Page : 133-134  

Prolapsed, herniated, or extruded intervertebral disc-treatment by only stabilization


Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India

Date of Web Publication8-Oct-2018

Correspondence Address:
Prof. Atul Goel
Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvjs.JCVJS_84_18

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How to cite this article:
Goel A. Prolapsed, herniated, or extruded intervertebral disc-treatment by only stabilization. J Craniovert Jun Spine 2018;9:133-4

How to cite this URL:
Goel A. Prolapsed, herniated, or extruded intervertebral disc-treatment by only stabilization. J Craniovert Jun Spine [serial online] 2018 [cited 2018 Dec 16];9:133-4. Available from: http://www.jcvjs.com/text.asp?2018/9/3/133/242826



Prolapsed, herniated, or extruded intervertebral disc (PIVD) is a commonly encountered clinical entity. The surgical treatment by resection of the PIVD and decompressing the compressed nerve root has been the most accepted surgical treatment for several decades. The familiarity of the surgical procedure to most spine surgeons and the quick and lasting relief following the treatment are the hallmarks. Even though the treatment is defined and streamlined and scope of controversy is limited, postoperative and delayed complications following attempts at removal of the disc are well known. Our impression on the basis of understanding of the subject suggests that the last word about the treatment options has not yet been said.

In 2010, we suggested that the nodal point of pathogenesis of spinal “degeneration” is instability of the spinal segment/s related to abuse, misuse, or injury to the muscles of the spine.[1],[2],[3],[4] Standing human position and lifelong stress on the muscles and related wear and tear lead to instability that is manifested at the facets that are the fulcrum of all spinal movements. Oblique profile of the articular surfaces of the facets in the cervical spine and near vertical alignment in the lumbar spine results in “vertical” spinal instability wherein there is listhesis or slippage of the superior facet over the inferior facet.[5] Lateral location that is away from neural structures and its subtle nature makes recognition of the instability by radiological techniques difficult. Even dynamic images do not clarify the presence or absence of instability. Vertical reduction in the distance between adjacent vertebrae results in circumferential buckling of all the intervertebral ligaments that include the ligamentum flavum and posterior longitudinal ligament. Ligamentum flavum “hypertrophy,” osteophyte formation, and disc space reduction are not the primary pathological events but the secondary effects of spinal instability. The net effect is reduction in the spinal canal and root canal dimensions. We identified that facetal distraction and stabilization result in restoration of spinal alignment and reversal of all spinal alterations that are attributed to spinal degeneration.[1],[2],[3],[4] We identified that even the disc “water” content can be restored and the disc height can return toward normal. It was observed that there is a potential for osteophytes to regress and bone fusions to “unfuse.”[6],[7] Essentially, we described that restoration of spinal height and spinal stabilization are the forms of treatment that are necessary for spinal degeneration, rather than spinal decompression. It was concluded that the surgical procedures such as laminectomy, discectomy, and resection of the osteophytes are not necessary and could even be harmful surgical procedures.

As we mature further in the subject of spinal degeneration, we realize that more than neural compression or deformation, it is subtle instability-related micro-injuries that result in symptoms.[8] Accordingly, we now resort to only stabilization of the spinal segments as a treatment for spinal degeneration without any attempt of decompression and without any specific attempt toward facetal distraction.[9] Our clinical results of treatment of radiculopathy and myelopathy for single and multilevel spinal degeneration are testimony of effectiveness of “only spinal fixation” as treatment.

PIVD is a common clinical ailment. Acute-onset radicular or myelopathy-related symptoms on sudden exertion or lifting heavyweights are the hallmarks of the disease. Disc herniation and disc bulge are two discrete clinical entities. Disc bulge is an outcome of vertical spinal instability and reduction of vertical height of the spinal segments. Disc bulge is generally associated with buckling of the posterior longitudinal ligament and related osteophyte formation. Spinal canal stenosis, cervical or lumbar, is a usual radiological and clinical manifestation. Disc bulge/s and osteophyte formation are usually the result of multi-segmental spinal instability and are generally observed in the “elderly” population. Inability of the muscles to keep the spinal segments in distracted position is the basis of such multi-segmental disease process. Symptoms on exertion that are related to early muscle fatigue are frequent and are manifested by claudication pain in the lumbar spine and radiculopathy/myelopathy symptoms in the cervical spine.

PIVD is a discrete clinical entity wherein the posterior longitudinal ligament gives way and the disc material herniates into the spinal canal. Incompetence of the posterior longitudinal ligament can be a result of vertical spinal instability or can be a result of an acute stretch related to sudden exertion or bending. Sudden or acute symptoms are the hallmarks of the disease. Conservative observation by deploying complete bed rest and restriction of all movements and external arthrodesis in the form of a lumbar belt or a cervical collar are well-known and established techniques of immediate care. Intermittent traction is also an accepted modality of conservative therapy. A significant subgroup of patients, respond to such forms of treatment and progressively improve in the symptoms and surgery can be avoided. However, in the other group where severe pain persists and the patient develops neural symptoms, surgical treatment is advocated. The very fact that immobilization and limitation of movements are the effective forms of treatment suggests the presence of factor of instability. In cases with acute PIVD, it is unclear if the spinal instability is the cause or if it is the effect of disc herniation.

It appears that more than neural compression or deformation, it is subtle spinal instability-related micro-trauma to the neural tissue that causes symptoms. On the basis of this concept, we resorted to an alternative form of treatment that involved only fixation of the spinal segments. We recently identified that “only fixation” of the affected spinal segments without any attempt toward “decompression” of the bones, soft tissues, and disc is an effective method of surgical treatment. Essentially, the treatment is “internal” arthrodesis. Trans-articular screw fixation forms a solid form of fixation and provides “zero” movement situation that external arthrodesis is not able to provide. The effectiveness of the treatment can be assessed by the immediate postoperative recovery from symptom of radiculopathy. Spontaneous resorption of the disc over the months is a rule.

We recently reported our results of treatment of only spinal fixation for cervical PIVD presenting with symptom of myelopathy.[7] The symptoms resolved in the immediate postoperative phase and the resolution of herniated disc material was observed on follow-up assessment.

It appears that even though treatment of PIVD by direct surgical removal of the herniated disc material is universally accepted, the remarkably successful results of “only fixation” of the affected spinal segments suggest that this surgical strategy could be rational, effective, and safe.[9],[10],[11]



 
   References Top

1.
Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96.  Back to cited text no. 1
    
2.
Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2.  Back to cited text no. 2
    
3.
Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6.  Back to cited text no. 3
    
4.
Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2013;19:672-7.  Back to cited text no. 4
    
5.
Goel A. Vertical facetal instability: Is it the point of genesis of spinal spondylotic disease? J Craniovertebr Junction Spine 2015;6:47-8.  Back to cited text no. 5
    
6.
Goel A, Shah A, Patni N, Ramdasi R. Immediate postoperative reversal of disc herniation following facetal distraction-fixation surgery: Report of 4 cases. World Neurosurg 2016;94:339-44.  Back to cited text no. 6
    
7.
Goel A, Dharurkar P, Shah A, Gore S, More S, Ranjan S, et al. Only spinal fixation as treatment of prolapsed cervical intervertebral disc in patients presenting with myelopathy. J Craniovertebr Junction Spine 2017;8:305-10.  Back to cited text no. 7
    
8.
Goel A. Not neural deformation or compression but instability is the cause of symptoms in degenerative spinal disease. J Craniovertebr Junction Spine 2014;5:141-2.  Back to cited text no. 8
    
9.
Goel A. 'Only fixation' as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6.  Back to cited text no. 9
    
10.
Goel A. Only fixation for cervical spondylosis: Report of early results with a preliminary experience with 6 cases. J Craniovertebr Junction Spine 2013;4:64-8.  Back to cited text no. 10
    
11.
Goel A. Alternative technique of cervical spinal stabilization employing lateral mass plate and screw and intra-articular spacer fixation. J Craniovertebr Junction Spine 2013;4:56-8.  Back to cited text no. 11
    




 

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