Annals of Musculoskeletal Disorders

Cite this article: Özer AF, Çevik OM, Sasani M, Öktenoğlu T, Süzer T (2018) Evaluation of the Patient with Lumbar Disc Herniation for Drawing Treatment Strategy. Ann Musc Disord 2(1): 1009.

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*Corresponding authorAli Fahir Özer, Department of Neurosurgery, Koç University, Turkey, Tel: 9021-233-8140; Fax: 902-123-381-559; Email:

Submitted: 16 May 2018

Accepted: 25 June 2018

Published: 28 June 2018

ISSN: 2578-3599

Copyright© 2018 Özer et al.

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Keywords•Lumbar disc herniation•Lumbar discectomy•Dynamic stabilization

Review Article

Evaluation of the Patient with Lumbar Disc Herniation for Drawing Treatment StrategyAli Fahir Özer1*, Orhun Mete Çevik2, Mehdi Sasani1, Tunç Öktenoğlu1, and Tuncer Süzer1

1Department of Neurosurgery, Koç University, Turkey2Department of Neurosurgery, Bakırköy Psychiatric Hospital, Turkey

Abstract

Lumbar discectomy operation is one of the most common procedures of neurosurgery. Therefore, although the complication rates are comparatively lower, the numbers of cases are high as expected. The musculotendinous system is the structure that poses high importance in the aftermaths of the discectomy surgery; however the system is widely disregarded by the surgeons. A considerable portion of the discectomy cases with poor outcome could be foreseen and further can be handled better when the evaluation of the musculotendinous system is taken into consideration. It is also important reflect upon the importance of the dynamic stabilization systems for the support of the musculotendinous system where a simple discectomy is risky and a fusion is too much.

INTRODUCTIONUndoubtedly one of the most problematic topics of the

spinal surgery is the lumbar discectomy operation. Some failed lumbar discectomy operations are performed everyday around the world. Many of those patients are unfathomably sanctioned to physiotherapy and algology clinics after. In this chapter, foreseeability of these cases is discussed as how many of the failed operations are actually unfathomable. All neurosurgeons have a modus operandi conducted from their mentors. These are all continuation of the lumbar discectomy technique which Caspar [1], standardized grosso modo, turned state of the art by Yasargil [2], with the inclusion of the operative microscope. It is vital to recognize the answer we give to the question ‘what are we actually doing’ which is, ‘the same thing’ we open a window in the lamina, take out the ligamentum flavum and excise the herniated disc material by retracting the root medially. The fundamental problem regarding the operation is that the same operation is done to all patients, however, the results vary.

What is the theme that has to be known?

The main theme that has to be known is the segmental instability which has been pointed out by Panjabi [3]. Segmental instability is the loosening of motion in a single segment of the spine. The primary element causing the instability is the disc which constitutes the most naive structure in the complex, concordantly making it the single structure that has to be respected most by the surgeons. When physiological aging put aside, the only reason left that can cause bone or ligament damage in daily life is trauma. The primary tissue absorbing all

light and heavy loading is the disc. Owing to its special structure the disc absorbs the primary loading and lessens the transferred load to the next segment by its rotational movement. In a way the action can be compared to a suspension. In time, the structure fatigues and the hydraulic pump inside starts to lose its water. In magnetic resonance imaging (MRI) we can see this effect by the normal near to white hyper intense image of the disc tissue turning darker (Figure 1). The exact reasoning behind this effect is still further investigated. With the loss of water its resistance power is dampened. The ongoing load is transferred to the surrounding capsule more and more which causes the tearing of the capsule from inside out. The herniation process is therefore started and can end in many ways. Three types of mechanisms try to manage this disrupted movement segment: Musculotendinous system, neural system and osteoligamentous system. Neural system provides the connection between the other two systems. Osteoligamentous system sets up the anatomical base inherited genetically. It is not possible to manipulate these two systems. However, the musculotendinous system is important for it is the only system we have the ability to improve and help turn our fate in our favor. The experienced physiotheraphy and rehabilitation doctors, physiotherapists and sports medicine specialists are aware of this situation, and push this system to help stabilize the degenerating movement segment. Numerous exercise modalities have been defined.

Let’s assume our patient is indifferent to all the efforts of treatment and have developed disc herniation; and we have made the decision to go to surgery for the patient. Therefore, is it not possible to foresee to a point how the patient will recover

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or the problems that could arise postoperatively; in other words, how postoperative period of a disrupted movement segment will turn out? Is it possible to predict how the patient will manage the disrupted movement segment by looking through radiographic imaging?

Musculature

The musculature is the primary element in the musculotendinous system but the least regarded by the neurosurgeons however. With the advances in MRI, although numerous studies have been conducted [4,5] it is not clear that how the fatty degeneration of the musculature, the fat deposits within the muscles, or the intensity changes with the muscular cells quantitatively affect the moving segment (Figure 2). The main downside of the biomechanical work-up is the lack of musculature implementation. Although lately, the effect of the musculature is trying to be added to the studies with finite element methods, the variance of the musculature to each individual makes this effect still a variable in the equation. Despite all the aberrancy, roughly many things could be said. For example, the amount of muscle volume, the intensity of the muscle tissue and the deposition of fat within could give us an approximation if the segmental instability after a simple discectomy could be managed or not.

Sacralization or fusion in the lower segment

This state can be directly compared to adjacent segment disease and the same arguments can be practically applied here. We have to discuss further why a disc herniation occurs above an in moving segment. Adjacent segment studies in cadaver or finite elements have shown the presence of hypermobility [6-9]. If the musculotendinous system is insufficient the hypermobility would not be kept in control and the disc inevitably degenerates (Figure 3). What else beyond occurs? Painful black disc occurs and further degenerative spondylolisthesis is possible. If we commemorate our daily practice, we can indubitably recall many similar clinics we encounter.

Thus, which treatment have we agreed upon? Simple discectomy. Are we addressing the possible hypermobility? No. What will follow for the patient when the hypermobility in the

segment is further increased? Probable debacle. The old maritime proverb can be applied here “A village already in sight obviates any guide to be directed by”. The surgeon in question accepts the expected complication from the start. Leastwise, a reoccurrence or expected pain should be explained thoroughly beforehand. In this example, even the resection of the free fragment if the capsule rupture is minimal, is a preferable treatment option.

Modic degeneration and disc herniation

Modic degeneration is a pathologic state that advances with disc malnourishment from the cartilaginous end plates. It is divided into three types and the first two types can clinically go with both pain and disc herniation (Figure 4). If the musculotendinous system is sufficient in these patients, the process can be eluded with only pain as the internal disc destruction happens. However in patients without the proper support from this system, significant lower back pain and disc herniation may occur. What happens if disc herniation occurs and it is treated with simple discectomy? The malnutrition of the area continues and further herniation can occur from the iatrogenic tear in the capsule. If a radical discectomy is performed, the patient will go through a painful period until the fusion is developed. Therefore, we must inform the patient accordingly and offer stabilization for this segment.

The size of the defect in the disc capsule

The first to point to this subject is Carrage [10]. He has studied the relation between the tear defect and the success

Figure 1 On T2-weighted MR images, normal (a) and degenerative (b) L4-5 disc.

Figure 2 In T2-weighted MR images, the normal muscle (a,b) and a muscle section with fatty degeneration.

Figure 3 The sacralized L5 vertebra. The L5 transverse processes appear to be fused to the sacrum and ileum a) X-ray b) Disc degeneration due to hypermobility of the congenital fused L5 vertebra on T2-weighted MR sections.

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of the discectomy, and has categorized the defect into four. In type I, the capsule has a small tear with a free fragment outside, whereas in type III, the tear is big and again with a free fragment in outside. In type II, the inner tears of the capsule layers are causing the bulging and the clinical symptoms, and in type IV, the capsule is maintaining its integrity but the defect is large. In his study Carrage advises fragmentectomy for Type I and III, in which we agree. However, in Type II, radical discectomy is advised for preventing reoccurrence, and in type IV it is advised to avoid surgery until there are clinic symptoms, and do radical discectomy if any is present. The problem here is Type II and IV (Figure 5). It is explained that the patients have a postoperative painful period and resolve later on. The resolving comes when the fusion of the heavily damaged disc comes. It should be understood here that patients with a strong supporting musculotendinous system for the segmental instability have this period with less pain but the others have to endure the painful period until the fusion occurs; if the fusion occurs. The conclusion we have to draw from this is that if the defect of the capsule is large or the weakening is severe, our simple discectomy operation could end with less than content results.

Which path to take on speculative cases?

There are a couple of important questions that are asked to the patient while taking history. The first one is if the pain is limited to the lower back or includes the legs. The second is if there is a painful period where the pain is dominant in the lower back before the pain hits the legs. The aims of these questions are actually checking the musculotendinous system. It should be further investigated if these questions are enough to maintain a solid opinion, however if the answer to both of these inquiries are yes, then there is a serious problem. Furthermore, if the advised radical discectomy is performed on these cases, even if the lower back is not evident before the surgery, it will be a major symptom afterwards.

Thus, what is the correct option for these cases? Is the fusion only option? Isn’t fusion a very heavy surgery for a simple microdiscectomy patient? These are all valid points. Mixter and Barr [11], likewise did not get the same results they did as the preliminary cases. Cloward [12], back in the time since the instrumentation wasn’t as advanced have advised towards bone graft implementation in between the vertebrae. With the advancing technology, the consensus was that the less damage we inflict on the anatomy, the better, and on started the increase in microdiscectomy. However, the studies showed minimal differences with the older method [13,14]. After seeing numerous endoscopic microdiscectomy cases in the clinic, it was more evident that removing the fragment was fine until an intervention to the disc; at that point the segmental instability is unavoidable. The outcomes will not differ much from the microdiscectomy. The main reason for the lower success rates is not addressing the underlying problem properly.

At this point, it should be noted that from here on out, the advised routes will solely be our opinions and still naturally under investigation. We should first focus on what we need. For example, we have a limited, not overt like in trauma, instability on hand; therefore, we don’t need a very strong stabilization to correct the instability. Lab and finite element studies have shown us that a simpler support for the segment will be sufficient. Taken this into account, on those risky cases we have used a

Figure 4 In T2-weighted MR sections, type I and type II Modic degeneration can be seen that prevent diffusion through the cartilage endplate. The metabolism of the disk is disrupted and the herniation can occur from those discs. It should be remembered that the recurrence rate is high in discs with evident Modic degeneration.

Figure 5 T2, T1-weighted MR scans a) The L5-S1 disc has a fairly large complete layer defect and herniation through the posterior annulus (Carragee type II). These discs have a very high recurrence rate after discectomy and also cause serious instability which will lead to the continuation of the back pain b) Carragee type IV is an annular defect completely enclosing the posterior annulus within the canal, with the outer layers of the annulus left intact. The herniated nucleus pulposus has penetrated into the canal but is still maintained with the disk integrity. In these patients, there is no clinical evidence of midline herniation, postoperative instability is unlikely to be operated by doctors because of lower back pain and high recurrence probability, and however these cases do not benefit from pain therapies.

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dynamic stabilization and have gotten satisfactory results. The postoperative needs for the physical treatment and rehabilitation and algology departments have substantially lowered. We have seen that postoperative abnormal fibrosis did not pose a threat to us.

If we use the term soft stabilization, two solutions come to mind. The first one is the interspinous devices. We believe that the theory under these devices has always been not as strong and therefore we have not implanted the uses of these devices. We believe that removing the live boney structure and implementing a fixed device instead will lead to resorption of the bone and loosening of the system. We have further investigated the system’s integrity with finite element study and concluded that the support of the device would not be satisfactory [15]. However, as proposed with the system, for the limited number of patients where a bigger intervention is impossible, the device becomes a viable option.

The second solution for the soft stabilization is the transpedicular dynamic stabilization. We have further increased the elasticity of the system by implementing dynamic rods to dynamic screws. We have seen with lab tests and finite element studies that such a system brings the unstable segment back to the anatomically normal stability. The preliminary results have encouraged us to implement the system in clinic and results we got from the patients have been more than satisfactory [16]. We have experienced that for a single level stabilization almost any system in the market showed remarkable results [17]. It should not be dismissed here that our subject is disc herniation on instability on single segment, therefore single level dynamic stabilization is the adequate solution.

The main criticism toward the dynamic system is the screw loosening, breakage of the rods due to metal fatigue, and finally the fact that there is no standardization on the rigidity of the system. Those are valid points. If we contemplate on the loosening or breakage, this process takes time and not imminent. Therefore, the time allowed for the natural healing of the disc capsule with the less load on the anterior colon, is enough to justify the treatment (Figure 6). As it is previously established, a minimum of two months are required for the connective tissue to regain its supportive properties [18]. The average screw

loosening or breakage time is longer than this, therefore when the loosened screws are removed; the treated segment will have a healthier disc. The recurrent removal procedure is still simpler than a re-discectomy or fusion procedures. Furthermore, these complication rates for a single level operation are very low [16]. At this point, a commonly misunderstood point needs to be clarified. The dynamic systems do not claim for the preservation of the movement. In a heavily damaged segment, the segment will fuse even if you use the dynamic system for stabilization. This is the ordinance of the organism. Therefore, you create the fusion with the same stability with less labored surgery. The gains are the same with less effort [19].

The fact that the above mentioned route creates a more rigid segment compared to a normal segment does not change the result that a fusion is created with an easier procedure. It should also not be forgotten that with the advancing technology the dynamic systems will advance as well.

CONCLUSIONIf the required care is not given to the risky simple discectomy

patients, the situation can easily change into a nightmare for both the patient and the surgeon. It should be kept in mind that dynamic stabilization is one of the most current solutions for this risky group.

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Figure 6 a) In T2-weighted MR sections, L4-5 midline tear is present, while L5-S1 has disc herniation that compress the right S1 root b) the S1 screws are seen to be loosened in the CT image taken at the 8th month after the operation c) In T2-weighted MR sections, the patient’s screws were removed, replaced with larger-diameter screws but not connected to the system. If a surgery is needed future due to the re-degeneration of the L5-S1 disk, we will have firm screws to add to the main system. The L5-S1 disk is seen to be recovered at a later stage. The defect on the L4-5 disk shrank considerably.

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Özer AF, Çevik OM, Sasani M, Öktenoğlu T, Süzer T (2018) Evaluation of the Patient with Lumbar Disc Herniation for Drawing Treatment Strategy. Ann Musc Disord 2(1): 1009.

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