Nazan Canbulat

Anterior cervical microdiscectomy with or without fusion.

Background Anterior cervical microdiscectomy (ACD) is commonly applied in the surgical treatment of cervical disc herniation. However, following discectomy procedure to perform a fusion process is still controversial. Therefore, a controlled, multicentric, prospective, randomized study was designed. Material and Method Totally 20 patients were operated. Eleven patients were operated with applying simple anterior microdiscectomy technique. Nine patients were operated via ACD and fusion with a semirigid plate technique. Preoperative and postoperative [immediate; postoperative first day and postoperative 1 y (mean 13.95 mo)] computed tomography studies and plain x-rays were obtained. The cervical disc and bilateral neural foramen heights of the operated level and adjacent segments were calculated. Pain assessment was performed using visual analog pain scale. Mann-Whitney statistical analysis method was applied to compare the outcomes for both groups. Results Satisfactory result was achieved in both groups. The pain scores for major complaint (arm pain) were decreased significantly in all patients after surgery regardless of the type of technique applied. The improvement in neck pain scores was significant only in patients who were treated with fusion procedure. There were no significant changes in disc height and neural foramen height measurements for both groups in adjacent levels in immediate and 1-year postoperative periods. The patients who were operated with simple ACD technique showed no significant decrease at postoperative first day in disc height and neural foramen height. However, the 1-year postoperative radiologic studies showed a significant decrease in disc height and neural foramen dimensions compared with preoperative values. The patients who were treated with fusion process showed a significant increase in disc height and nonsignificant increase in neural foramen heights at immediate postoperative study. However, with time, all dimensions showed significant decrease compared with preoperative values. Conclusions ACD technique offers satisfactory outcome regardless of whether fusion process is applied or not. Fusion with semirigid plate offers an advantage at operated level in immediate postoperative period in regard of disc height and neural foramen height. However, semirigid anterior plates by definition do not stop subsidence and the advantage that is offered by this technique is not persistent. On the other hand, to apply fusion process with semirigid plate system offers significantly less narrowing in disc height compared with simple ACD technique.

A Rehabilitation Protocol for Patients With Lumbar Degenerative Disk Disease Treated With Lumbar Total Disk Replacement

OBJECTIVES To evaluate the efficacy of the rehabilitation protocol designed by the Physical Medicine and Rehabilitation Department on the patients with lumbar degenerative disk disease after lumbar disk replacement surgery. DESIGN Open prospective auto-controlled trial. SETTING Physical medicine and rehabilitation department, neurosurgery department, and anesthesiology and pain management department. PARTICIPANTS Patients (N=20) with single level lumbar degenerative disk disease were recruited for this study. INTERVENTIONS Lumbar disk prosthesis surgery with metal on metal lumbar disk prosthesis; preoperative, provocative, diskography; and a postoperative rehabilitation program were used. MAIN OUTCOME MEASURES Change in the functional status and pain intensity in patients was evaluated by the Oswestry Disability Index (ODI) and visual analog scale (VAS) during rest and movement. The ODI and VAS during rest and movement were primary outcome criteria, while return to work and duration of hospital stay were secondary outcome criteria. The results for the various scoring systems were statistically analyzed using the t test. RESULTS Preoperative mean VAS scores ± SD at rest and movement were initially in the range of 6.00±2.47 and 8.65±1.08, respectively. The scores decreased to 1.70±1.12 and 2.60±1.72 at 3 months postsurgery, respectively (P<0.01). The scores decreased to 1.20±0.69 and 1.90±1.07 at 12 months postsurgery, respectively (P<0.01). The mean preoperative ODI score was 73.3±15.5; the postoperative scores were 35.0±15.5 and 20.4±12.9 at 3 and 12 months, respectively (P<0.01). The mean duration of hospital stay ± SD was 3.5±1.6 days, and return to work was achieved after a mean ± SD period of 14.1± 4.3 days with no complications related to surgery or the rehabilitation protocol. CONCLUSIONS The protocol was designed for postoperative rehabilitation program after artificial lumbar disk replacement surgery for degenerative disk disease patients. The good outcomes are the result of a combination of very careful and restrictive patient selection, surgical technique, and presented rehabilitation program. These parameters provide early pain relief and return to activities of daily living after surgery.

Thoracoscopic surgical approaches for treating various thoracic spinal region diseases.

AIM Minimally invasive surgery is currently a goal for surgical intervention in the spine. The effectiveness of endoscopic thoracic spine surgery and technological improvements are two factors that are always under consideration in the practice of spinal surgery. MATERIAL AND METHODS We present twenty-five patients whose thoracoscopic spinal surgeries were performed between 2002 and 2008 for the treatment of various spinal diseases. Eleven patients with thoracic disc herniation, five patients with traumatic thoracic spinal compressive fracture, six patients with metastatic thoracic spinal tumors and three patients with tubercular spondylitis underwent thoracoscopic spine surgery. Clinical evaluations were performed at 3, 6,12 and 24 months post-surgery. The Oswestry disability questionnaire and linear visual analog scale (VAS) were used for the evaluation of pain. RESULTS Postoperatively, two patients had lung contusions, one patient had pneumonia and one patient had instability. There were significant initial improvements in both the Oswestry score and the VAS pain score up to 6 months (p<0.05). The average relative difference in pain scores in all groups was not significant at 12 and 24 months (p>0.05). CONCLUSION The favorable results of thoracoscopic spinal surgery encourage its application to situations in which a conventional thoracic approach is indicated. Thoracoscopic spine surgery is applicable to all patients with various spinal diseases.

Unusual cause of acute low-back pain: sudden annulus fibrosus rupture.

Low-back pain is a common problem in neu-rosurgery practice, and an algorithm has been developed for assessing these cases. However, one subgroup of these patients shares several clinical features and these individuals are not easy to categorize and diagnose. We present our observations for 8 of these patients, individuals with low-back pain caused by atypical annulus fibrosus rupture (AAR). The aim of this study is to show the consequences of overlooked annular tears on acute onset of low back pain. Eight patients with acute-onset severe low-back pain were admitted. Physical examinations were normal and each individual was examined neurologically and assessed with neuroradiologic studies [plain x-rays, magnetic resonance imaging (MRI), discography and computed tomography (CT) discography]. AAR was ultimately diagnosed with provocative discography. In all cases, MRI showed a healthy disc or mild degeneration, whereas discography and CT discography demonstrated disc disease. Anterior interbody cage implantation was performed in 3 of the 8 cases and posterior dynamic stabilization was carried out in 3 cases. The other 2 individuals refused surgery, and we were informed that one of them developed disc herniation at the affected level 1 year after our diagnosis. Clinical and radiological outcomes were evaluated. In cases where AAR is suspected, MRI, discography, and CT discography should be performed in addition to routine neuroradiologic studies.

A Rehabilitation Protocol for Patients with Lumbar Degenerative Disk Disease.

AIM To evaluate the efficacy of the rehabilitation protocol on patients with lumbar degenerative disc disease after posterior transpedicular dynamic stabilization (PTDS) surgery. MATERIAL AND METHODS Patients (n=50) with single level lumbar degenerative disc disease were recruited for this study. Patients had PTDS surgery with hinged screws. A rehabilitation program was applied for all patients. Phase 1 was the preoperative evaluation phase. Phase 2 (active rest phase) was the first 6 weeks after surgery. During phase 3 (minimal movement phase, 6-12 weeks) pelvic tilt exercises initiated. In phase 4 (dynamic phase, 3-6 months) dynamic lumbar stabilization exercises were started. Phase 5 (return to sports phase) began after the 6th month. The primary outcome criteria were the Visual Analogue Pain Score (VAS) and the Oswestry Disability Index (ODI). Patients were evaluated preoperatively, postoperative 3rd, 12th and 24th months. RESULTS The mean preoperative VAS and ODI scores were 7.52±0.97 and 60.96±8.74, respectively. During the 3rd month, VAS and ODI scores decreased to 2.62±1.05 and 26.2±7.93, respectively. VAS and ODI scores continued to decrease during the 12th month after surgery to 1.4±0.81 and 13.72±6.68, respectively. At the last follow-up (mean 34.1 months) the VAS and ODI scores were found to be 0.68±0.62 and 7.88±3.32, respectively. (p=0.0001). CONCLUSION The protocol was designed for a postoperative rehabilitation program after PTDS surgery for patients with lumbar degenerative disc disease. The good outcomes are the result of a combination of very careful and restrictive patient selection, surgical technique, and the presented rehabilitation program.AIM To evaluate the efficacy of the rehabilitation protocol on patients with lumbar degenerative disc disease after posterior transpedicular dynamic stabilization (PTDS) surgery. MATERIAL AND METHODS Patients (n=50) with single level lumbar degenerative disc disease were recruited for this study. Patients had PTDS surgery with hinged screws. A rehabilitation program was applied for all patients. Phase 1 was the preoperative evaluation phase. Phase 2 (active rest phase) was the first 6 weeks after surgery. During phase 3 (minimal movement phase, 6-12 weeks) pelvic tilt exercises initiated. In phase 4 (dynamic phase, 3-6 months) dynamic lumbar stabilization exercises were started. Phase 5 (return to sports phase) began after the 6th month. The primary outcome criteria were the Visual Analogue Pain Score (VAS) and the Oswestry Disability Index (ODI). Patients were evaluated preoperatively, postoperative 3rd, 12th and 24th months. RESULTS The mean preoperative VAS and ODI scores were 7.52±0.97 and 60.96±8.74, respectively. During the 3rd month, VAS and ODI scores decreased to 2.62±1.05 and 26.2±7.93, respectively. VAS and ODI scores continued to decrease during the 12th month after surgery to 1.4±0.81 and 13.72±6.68, respectively. At the last follow-up (mean 34.1 months) the VAS and ODI scores were found to be 0.68±0.62 and 7.88±3.32, respectively. (p=0.0001). CONCLUSION The protocol was designed for a postoperative rehabilitation program after PTDS surgery for patients with lumbar degenerative disc disease. The good outcomes are the result of a combination of very careful and restrictive patient selection, surgical technique, and the presented rehabilitation program.

Effect of Posterior Dynamic Instrumentation on High-Intensity Zone in Lumbar Degenerative Disc Disease.

AIM To investigate high-intensity zone (HIZ) changes after lumbar posterior dynamic instrumentation. MATERIAL AND METHODS Our study included 53 patients: 27 patients in group 1, 26 patients in group 2. All patients had one or two levels of degenerative disc disease with an HIZ confirmed by magnetic resonance imaging (MRI). Group 1 underwent one- or two-level dynamic lumbar posterior instrumentation. Group 2 was treated conservatively with an exercise program. Patients were evaluated using MRI, a numerical visual analog pain scale (VAS), and the Oswestry Disability Index (ODI) at baseline, at 1 year after surgery, and at final follow-up evaluation. RESULTS The mean duration of follow-up was 49.3 months in group 1 and 47.19 months in group 2. The baseline VAS and ODI scores were similar for both groups. The mean VAS score of group 1 was significantly improved at 1 year after surgery and at final follow-up. The mean ODI value was lower in group 1 than in group 2 at 1 year and at final follow-up. Pfirrmann grades in group 1 significantly differed at 1 year and at final follow-up but did not change in group 2. The number of HIZs significantly decreased in from baseline to 1 year and from baseline to final follow-up in group 1 but did not differ in group 2. CONCLUSION Dynamic lumbar stabilization systems are promising. Observations such as Pfirrmann grade improvements and disappearance of HIZs are concordant with improvements in VAS and ODI scores demonstrate that dynamic stabilization systems may provide an environment for regeneration.