- Chief of Neurosurgical Spine/Education, NYU Winthrop Hospital, Mineola, New York, USA
Correspondence Address:
Nancy E. Epstein
Chief of Neurosurgical Spine/Education, NYU Winthrop Hospital, Mineola, New York, USA
DOI:10.4103/sni.sni_164_17
Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Nancy E. Epstein. Percutaneous cervical laser diskectomy, thermoannuloplasty, and thermonucleoplasty; comparable results without surgery. 21-Jun-2017;8:128
How to cite this URL: Nancy E. Epstein. Percutaneous cervical laser diskectomy, thermoannuloplasty, and thermonucleoplasty; comparable results without surgery. 21-Jun-2017;8:128. Available from: http://surgicalneurologyint.com/surgicalint-articles/percutaneous-cervical-laser-diskectomy-thermoannuloplasty-and-thermonucleoplasty-comparable-results-without-surgery/
Abstract
Background:Utilizing the literature, the results of three different minimally invasive surgery (MIS) anterior cervical percutaneous operations for neck/mild radicular pain and magnetic resonance (MR)-documented “contained” (not extruded/sequestrated) discs were evaluated. Results were compared with patients treated nonsurgically for comparable/greater neurological compromise, and even more severe cervical disc disease.
Methods:There were three MIS percutaneous anterior cervical discectomy procedures. Anterior cervical laser discectomy ablated and vaporized disc tissue. The thermoannuloplasty used heat to contract collagen fibers to reduce disc volume. Thermonucleoplasty employed a low-temperature resister probe to promote disintegration and evacuation of small volumes of disc (e.g., some studies cited an average of just 0.09 mL of disc removed). These results were compared to those for the nonsurgical management of patients with comparable/greater neurological deficits, and more severe cervical disc herniations.
Results:The three MIS anterior cervical operations resulted in 80–90%+ improvement using Macnab's criteria. However, although the literature demonstrated similar 80–90+% improvement without cervical surgery, the latter patients were more neurologically compromised.
Conclusions:For patients with pain alone/mild radiculopathy and “contained” discs on MR, three MIS percutaneous anterior cervical disc operations resulted in 80–90%+ improvement. Notably, similar 80–90%+ improvement was observed for comparable/more neurologically impaired patients with even larger cervical disc herniations treated nonsurgically. With such findings, where is the “value added” for these three MIS cervical operations?
Keywords: Cervical, laser discectomy, minimal indications, cervical nucleoplasty, percutaneous, thermoannuloplasty
INTRODUCTION
Utilizing the literature, outcomes of three percutaneous minimally invasive surgery (MIS) anterior cervical operations were evaluated. Patients presented with neck pain/mild radiculopathy and MR-documented “contained” (e.g., neither extruded or sequestrated) cervical disc herniations. The anterior cervical laser discectomy ablates, vaporizes, and decompresses the posterior/central nucleus pulposus. The thermoannuloplasty heats the posterior disc near the annulus, producing contraction of collagen fibers, and thereby, reduces the disc volume. The thermonucleoplasty low-temperature resister probe promotes disintegration and evacuation of disc material (e.g., reported in some studies to average just 0.09 mL) [Tables
Early clinical and animal studies for minimally invasive anterior cervical laser disc ablation
Between 1995–1998, three studies evaluated the early experience with cervical laser disc ablations in patients with pain alone/mild radiculopathy without focal neurological deficits for “contained cervical discs” [Tables
Comparable efficacy of two lasers for anterior cervical disc ablation
In 2000 and 2001, Knight et al. documented that two lasers were comparably effective in performing anterior cervical laser disc ablations in patients with neck pain alone with MR-documented “contained” discs [
Percutaneous laser discectomy, thermoannuloplasty, thermonucleoplasty
Several studies utilized percutaneous laser discectomy, thermoannuloplasty, or thermonucleoplasty to treat patients with pain alone/mild radiculopathy and MR-documented “contained” discs; in these series, patients exhibited 85–88.3% improvement [Tables
One commercial device for percutaneous laser disc ablation
In two studies without control groups, Deukmedjian et al. (2012, 2013) introduced the Cervical Deuk Laser Disc Repair® for percutaneous laser disc ablation utilized in patients with pain/mild radiculopathy and “contained discs” [
Minimal changes in disc height or variable improvement following anterior cervical laser discectomy or thermonucleoplasty
Three studies looked at the results of anterior cervical percutaneous laser discectomy or nucleoplasty [
Low/moderate clinical relevance of percutaneous cervical nucleoplasty/coblation
Utilizing multiple databases to identify randomized clinical trials (RCTs), Wullems et al. (2014) evaluated the outcomes for patients with pain/mild radiculopathy and “contained” cervical discs undergoing percutaneous anterior cervical nucleoplasty/coblation [Tables
Review of comparable results for nonsurgical management of cervical discs
A review of multiple studies documented the successful nonsurgical management (e.g., up to 80 –90%+ improvement) of cervical disc herniations in patients with pain alone/more severe neurological deficits, and larger cervical disc herniations [
CONCLUSION
Utilizing the literature, we compared the outcomes for patients with neck pain/mild radiculopathy and MR-documented “contained” cervical disc herniations treated with three MIS percutaneous anterior cervical operations versus those managed nonsurgically. Notably, those treated without surgery originally demonstrated even greater neurological deficits and radiographic/MR neurological compromise. For both groups, outcomes were comparably good/excellent up to 80–90%+ of the time. Since nonsurgical management was so successful in these patients, shouldn't we question whether there is a “value added” or in fact, any value for the three MIS for any of the three MIS cervical disc operations under discussion?
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Ahn Y, Lee SH, Lee SC, Shin SW, Chung SE. Factors predicting excellent outcome of percutaneous cervical discectomy: Analysis of 111 consecutive cases. Neuroradiology. 2004. 46: 378-84
2. Birnbaum K. Percutaneous cervical disc decompression. Surg Radiol Anat. 2009. 31: 379-87
3. Bonaldi G, Baruzzi F, Facchinetti A, Fachinetti P, Lunghi S. Plasma radio-frequency-based diskectomy for treatment of cervical herniated nucleus pulposus: Feasibility, safety, and preliminary clinical results. AJNR Am J Neuroradiol. 2006. 27: 2104-11
4. Cesaroni A, Nardi PV. Plasma disc decompression for contained cervical disc herniation: A randomized, controlled trial. Eur Spine J. 2010. 19: 477-86
5. Chiu JC, Clifford TJ, Greenspan M, Richley RC, Lohman G, Sison RB. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. Mt Sinai J Med. 2000. 67: 278-82
6. Choy DS. Percutaneous laser disc decompression (PLDD): Twelve years' experience with 752 procedures in 518 patients. J Clin Laser Med Surg. 1998. 16: 325-31
7. Corniola MV, Tessitore E, Schaller K, Gautschi OP. Cervical disc herniation--diagnosis and treatment. Rev Med Suisse. 2015. 11: 2023-9
8. Cvetanovich GL, Hsu AR, Frank RM, An HS, Andersson GB. Spontaneous resorption of a large cervical herniated nucleus pulposus. Am J Orthop (Belle Mead NJ). 2014. 43: E140-5
9. Deukmedjian AJ, Cianciabella A, Cutright J, Deukmedjian A. Cervical Deuk Laser Disc Repair(®): A novel, full-endoscopic surgical technique for the treatment of symptomatic cervical disc disease. Surg Neurol Int. 2012. 3: 142-
10. Deukmedjian AJ, Jason Cutright ST, Augusto Cianciabella PC, Deukmedjian A. Deuk Laser Disc Repair(®) is a safe and effective treatment for symptomatic cervical disc disease. Surg Neurol Int. 2013. 4: 68-
11. Heckmann JG, Lang CJ, Zöbelein I, Laumer R, Druschky A, Neundörfer B. Herniated cervical intervertebral discs with radiculopathy: An outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999. 12: 396-401
12. Knight MT, Goswami A, Patko JT. Comparative outcome of Holmium: YAG and KTP laser disc ablation in degenerative cervical disc disease: Results of an ongoing study. Ortop Traumatol Rehabil. 2000. 2: 39-43
13. Knight MT, Goswami A, Patko JT. Cervical percutaneous laser disc decompression: Preliminary results of an ongoing prospective outcome study. J Clin Laser Med Surg. 2001. 19: 3-8
14. Lee SH, Ahn Y, Choi WC, Bhanot A, Shin SW. Immediate pain improvement is a useful predictor of long-term favorable outcome after percutaneous laser disc decompression for cervical disc herniation. Photomed Laser Surg. 2006. 24: 508-13
15. Lee SH, Lee JH, Choi WC, Jung B, Mehta R. Anterior minimally invasive approaches for the cervical spine. Orthop Clin North Am. 2007. 38: 327-37
16. Lee JH, Lee SH. Clinical and radiographic changes after percutaneous endoscopic cervical discectomy: A long-term follow-up. Photomed Laser Surg. 2014. 32: 663-8
17. Li J, Yan DL, Zhang ZH. Percutaneous cervical nucleoplasty in the treatment of cervical disc herniation. Eur Spine J. 2008. 17: 1664-9
18. Nardi PV, Cabezas D, Cesaroni A. Percutaneous cervical nucleoplasty using coblation technology. Clinical results in fifty consecutive cases. Acta Neurochir Suppl. 2005. 92: 73-8
19. Olivero WC, Dulebohn SC. Results of halter cervical traction for the treatment of cervical radiculopathy: Retrospective review of 81 patients. Neurosurg Focus. 2002. 12: ECP1-
20. Ren L, Guo B, Zhang T, Bai Q, Wang XH, Zhang L. Medium-term follow-up findings in imaging manifestation after percutaneous laser disc decompression. Photomed Laser Surg. 2013. 31: 247-51
21. Siebert W. Percutaneous laser discectomy of cervical discs: Preliminary clinical results. J Clin Laser Med Surg. 1995. 13: 205-7
22. Thoomes EJ, Scholten-Peeters W, Koes B, Falla D, Verhagen AP. The effectiveness of conservative treatment for patients with cervical radiculopathy: A systematic review. Clin J Pain. 2013. 29: 1073-86
23. Turgut M, Onol B, Kiliniç K, Tahta K. Extensive damage to the end-plates as a complication of laser discectomy. An experimental study using an animal model. Acta Neurochir (Wien). 1997. 139: 404-9
24. van Middelkoop M, Rubinstein SM, Ostelo R, van Tulder MW, Peul W, Koes BW. Surgery versus conservative care for neck pain: A systematic review. Spine J. 2013. 22: 87-95
25. Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: A systematic review of the literature. Spine J. 2014. 14: 1781-9
26. Wullems JA, Halim W, van der Weegen W. Current evidence of percutaneous nucleoplasty for the cervical herniated disk: A systematic review. Pain Pract. 2014. 14: 559-69
27. Yang B, Xie J, Yin B, Wang L, Fang S, Wan S. Treatment of cervical disc herniation through percutaneous minimally invasive techniques. Eur Spine J. 2014. 23: 382-8