History Of Surgical Management Of Sciatica

In the early twentieth century, laminectomy was being performed for the treatment of a variety of spinal disorders. In 1911, Goldthwait (16) described the management of a 39-yr-old male who underwent spinal manipulation, and then he developed paralysis in

Goldthwait Procedure
Fig. 5. Potrait of Domenico Cotugno.

the lower extremities. His conservative management included plaster immobilization and rest. The patient failed to show improvement, and 6 wk later he underwent extensive decompressive laminectomy, extending from L1 to S2. The patient responded to the operative procedure and showed improvement. Goldthwait (16) attributed the patient's neurological deficit to detachment and protrusion of the fibrotic annulus into the spinal canal, slippage of the articular processes, and abnormality of the transverse process of the lumbar segment.

In 1913, Dr. Elsberg of the New York Neurological Institute and Mt. Sinai Hospital, reported on his findings on 60 consecutive laminectomies. However, he did not believe disc pathology was responsible for the presenting symptomatology in any of the patients described (17). In 1928, in a paper entitled a "Extradural Spinal Tumors, Primary, Seconary, Metastisis," Dr. Elsberg attributed compression of the cauda equina to the presence of cartilaginous tumors (chondromas) (18).

In 1927, Putti (8) reported on one of his patients who underwent laminectomy and facetectomy to decompress the L5 and S1 nerve roots and relieve sciatic pain. He further elaborated on the contribution of Sicard, who performed laminectomy from L3 to the sacrum to provide relief from sciatic pain.

Other investigators, including Stookey in 1928 (19) and Bucy in 1930 (20), also reported on the removal of chondroma-type tumors from the intervertebral discs that were causing pressure on the neural structures. Alajouanine, a neurologist residing in Paris, reported on two patients who underwent laminectomy and discectomy in 1928 (21,22). A brief translation of his article is as follows:

It is a very specific type of radiculomedullary compression that we call "a fibrocartilaginous nodule of the posterior aspect of the intervertebral discs." This compression is manifested by radicular signs, more rarely medullary, most often unilateral. Surgical ablation, although sometimes laborious, like all premedullary tumors, usually results in the rapid regression of compressive disorders. Their first presentation was made in 1928 to the Surgical Society of a unilateral cauda equina syndrome due to a curious formation related to an intervertebral disc (ref. 2: Bull et Mem de la Soc nat de chir 12 Oct 1928, 54: 1452). Now we have seen a second case, absolutely identical to the first.

Case 1. Male, 37 years old, complained of left lumbosacral pain with root, sensory and sphincter problems for 4 years. The flow of Lipiodol was blocked below L5-S1. Ablation of fibrocartilaginous nodule from L5-S1 intervertebral disc. Rapid and complete cure.

Case 2. Female, 20 years old, had a 3-year history of pain in the left leg and while walking. There was foot drop, absence of achilles and medial plantar reflexes. Anesthesia of L4-L5 and all sacral roots. Positive Lipiodol test at L3-L4. On July 18, 1929, disc protrusion, transdural approach, removal of fibrocartilaginous nodule in comparison to the first case. Partial recovery of the foot drop but not the ankle reflex. Notes probable compression of nerve roots by rongeurs in the course of laminectomy.

These nodules are neither tumors, chondromas nor fibrochondromas and are distinctly different from chordomas. Basically, they are always related to the intervertebral disc. We have shown that these curious formations should be considered to result from herniation of the central pulp of the disc across the latter, the hernia produced either by trauma or by pathological changes in the disc; in addition, the effects of these two causes can be combined.

The use of Lipiodol is indispensable, not only with radiography but also with fluo-roscopy. The prognosis depends upon surgical treatment which is midline through the dura. If the protrusion is very lateral, the dura mater should be incised laterally. There is a problem with retraction of the spinal cord in the neck and thorax, particularly evident when the nodule is calcified and embedded in the cord. Such nodules should be suspected in refractory lumbalgia and sciatica.

In 1931, Crouzon et al. (23) gave credit to the contribution of Alajouanine and further detailed and described the clinical outcome of patients who underwent laminectomy and discectomy. A translation of their publication is as follows.

This is a new example of a fibrocartilaginous nodule on the posterior aspect of the intervertebral disc, producing a very specific type of root compression that one of us, with Alajouanine, has called attention to in a recent report. [Alajouanine T, Petit-Dutaillis D. Le nodule fibrocartilageneux de la face posterieure des disques intervertebraux. Presse Medicale nos. 98 and 102 of 6 and 20 September 1930]. The favorable results obtained by surgical intervention make it possible to emphasize once more its clinical and therapeutic value in such a disorder.

[There follows a case history, summarized here.]

A brickmaker, 44 years old, was hospitalized by Dr. Crouzon for refractory sciatica that had kept him out of all work for 6 months. There was no special precipitating factor, but there was a history of an acute injury to the lumbar region 7 years earlier when he fell 4 meters onto his back and kidneys. After severe pain immobilized him for some days, he was able to go back to work, but with intermittent episodes of "lumbago" making him rest for 3 to 4 days. Only after 7 years did he begin to have (In June 1930) pains in the left leg that became increasingly severe and frequent. Examination on 20 February 1931 showed areas of pain in the lumbar region, calf and left heel. These were aggravated by the slightest movement, cough or strain. When he stood, his weight was placed on the intact right extremity. There was an antalgic spasm of the lumbar muscles, but hypotonia of the quadriceps and calf on the left side. His body was held forward when he walked with obvious pain. The spine was held flexed forward and to one side. There was some atrophy of the left thigh and calf, the latter measuring 3 cm less than the healthy calf. There was a slight decrease in strength of flexion and extension of the foot on the left side. Knee reflexes were equal, but the achilles and medial plantar reflexes were absent on the left. Sensory exam showed sharp pain on pressure all along the left sciatic nerve and sharp pain on Lasegue's maneuver.

There was pain on pressure and percussion over the spinous processes of L4 and L5. The sensory exam of the plantar aspect of the foot was consistent with anesthesia for all modalities on the plantar aspect of the foot and posterior aspect of the left calf, extending 5 cm onto the posterior of the thigh. There was also a band of sensory loss on the lateral aspect of the foot and adjacent leg, ascribed to L5, S1 and S2. There was some sphincter dysfunction with pain on defecation and difficulty in urination. Lumbar puncture on February 25, 1931 showed normal fluid and normal pressure, slight dissociation between albumin and cells (40 g albumin and 2 cells). Wasserman tests of blood and CSF were negative. X-rays showed some narrowing at L4-L5. A Lipiodol study showed temporary blockage at L4-L5 under the fluoroscope, but by the time the patient reached the radiography room, the oil had all fallen to the bottom. The temporary blockage was pronounced enough to induce Dr. Alajouanine to operate on the patient on 7 March 1931. Laminectomy of L3-L5 showed ossification of the ligamentum flavum at L4-L5; the dura was indented, and the ligament was removed. The dura was opened to show displacement of the nerve roots by a whitish nodule compressing the left L5 root. The root was compressed to a thread at the level of the intervertebral foramen, as if it had been partially destroyed by stretching. In order to free it without further damage, the dura was cut transversely. This made it possible to displace the root of L5 to the left and the rest of the roots to the right. The dura was incised anteriorly over the nodule, and a specially designed spatula was used to hold the root while the fibrocartilaginous nodule was removed. Because of the transverse cut in the dura, no attempt was made to suture it, and the wound was closed in layers with catgut and without drainage.

The postoperative course was uneventful; sutures were removed on Day 9. The outcome of surgery was very good and recovery was rapid. The day after surgery the patient said the left leg no longer hurt, and re-examination showed a return of sensation in the areas of L5, S1 and S2. He could now feel the bedsheets on his foot. Fifteen days after surgery he had no complaints and could get out of bed; 25 days after surgery he stood straight and walked normally without pain or fatigue.

Examination on April 25, 7 weeks after surgery, showed normal posture, with weight equally distributed on the two legs. Flexion and extension of the left foot were normal. Mild hypotonia persisted in the left thigh as did slight atrophy of the calf and thigh on the left. The achilles and medial plantar reflexes were still absent. There was no pain on pressure over the course of the left sciatic nerve. There was no pain on straight-leg raising. Objective examination of sensation showed a slight decrease in tactile sensation on the lateral border of the left foot. The sphincter problems had resolved, and the patient's general health was excellent.

Histological study of the specimen by Dr. I. Bertrand showed fibrocartilaginous tissue with abundant interstitial stroma containing amorphous tissue with some collagen bundles. There were only a few cells, but those seen resembled cartilage cells. An examination for Virchow's physaliferous cells was negative. There were few vessels, and in some places the absence of staining indicated some necrosis.

This case should be added to similar cases published in France by Alajouanine and Petit-Dutaillis, by Robineau and, in the foreign press, by Adson, Stookey, then Bucy and P. Bailey, and, very recently, by Katzenborn, making a total of 23 operated cases. The new case reported appears to prove that this is not a very rare condition and that the numbers will soon increase now that attention has been directed to these facts.

In view of this new case, it seems appropriate to emphasize certain points: the role of trauma is beyond doubt, even though in this case it may be dismissed, for in this case the injury occurred 7 years previously. Emphasis is placed on the occasionally long latent period before symptoms become manifest. Some temporary lumbar symptoms of an apparently common type may occur in this period, as if the lesion, only produced by the initial trauma, gradually becomes more pronounced, undoubtedly affected by repeated strains in those whose occupations are strenuous. There is a notable incidence of unilateral symptoms. The lumbar region is not the only site of pathological disc changes; the first cases dealt with those in the neck. Although Stookey initially thought these fibrocartilaginous lesions were exclusively cervical, it is clear that they may occur elsewhere, although they do appear to be rare in the thoracic region.

In addition to clinical signs and symptoms, compression is also manifested by a dissociation between albumin and cells and by a blockage of Lipiodol. The blockage of the oil may be quite temporary and be seen only on fluoroscopy. For this reason the authors emphasize the need for this diagnostic procedure as well as radiography. The absence of the disc in radiograms was similar to that in long-standing Pott's disease. However, it should be noted that there is no sign of herniation into the vertebral bodies. It seems likely that in compression phenomena of traumatic origin the compression, or even absence, of the disc might promote the development of fibrocartilaginous nodule formation.

The histological study also shows that these nodules should not be considered to be tumors (neoplasms) as has been thought to be the case by those authors who called them fibrochondromas, ecchondromas or even chondromas of the disc. These structures are an integral part of the intervertebral disc with no neoplastic characteristics, but should be considered protrusions of the disc or of the nucleus pulposus across a break in the posterior part of the intervertebral disc into the spinal canal. This interpretation (Schmorl, Andrae) seems the only logical one.

It is more painstaking to surgically remove these pathological structures than other intraspinal tumors. In the region of the cauda equina the compressed roots must be freed very gently and very slowly. Even if the size of the nodule is small, its consistency is very hard and it exerts a very firm compression. In our case the left root at L5 had already been heavily compressed and stretched. Sometimes the root may be in contact with the lamina, and care must be taken in removing the lamina to avoid injuring the root.

Dandy (24) independently reported on the removal of a detached fragment of cartilaginous tissue from the intervertebral disc for treatment of sciatic pain.

Mixter and Barr are credited for establishing a clear causal connection between the herniated disc and sciatica. They provided a detailed description of disc herniation and popularized laminectomy and discectomy for surgical management of herniated lumbar discs (25).

Between the 1930s and 1950s, orthopedic and neurological surgeons followed the traditional teaching of Mixter and Barr that consisted of wide exposure, bilateral dissection of the paraspinal muscles, laminectomy, and extensive epidural hemostasis and coagulation in the course of extraction of herniated disc fragments.

The traditional surgery described by Mixter and Barr was later modified and became less invasive with the introduction of the microscope to the surgical field by Yasargil, a Turkish surgeon, in 1972 (26,27). This concept was further advanced by other investigators (28).

EMERGENCE OF THE MINIMALISTS' CONCEPT

Annular Fenestration and Reduction of Hydrostatic Pressure in the Intervertebral Disc

The earliest recorded departure from the concept of traditional laminectomy and dis-cectomy in the treatment of a herniated lumbar disc is found in an article published by Hult (29) in 1950, in which he advocated an anterior retroperitoneal annular fenestration for decompression of herniated lumbar discs. The relationship between hydrostatic pressure of the intervertebral disc and the size of the annular bulge and protrusion has been a subject of interest to many investigators. Virgen (30) demonstrated that the height of the intervertebral disc is decreased and the annulus bulged outward when intervertebral discs were subjected to axial loading. Brown et al. (31) showed that the annular bulge was increased on the side on which the spine was flexed and the annulus was flattened on the opposite side. Nachemson (32,33) also demonstrated bulging of the annulus associated with increased intradiscal pressure under load, particularly in the sitting position and with forward bending and lifting. Kambin and colleagues reported on their in vivo evaluation of hydrostatic pressure in the intervertebral disc prior to and following annular fenestra-tion via a 4.9-mm-outer diameter (od) trephine and partial nuclear resection. A considerable reduction of intradiscal pressure was observed when patients were instructed to extend and rotate the trunk following annular venting (34,35). However, long-term patency of the annular fenestration remains highly questionable. Although Sakamoto et al. (36) showed that the reduction of intradiscal hydrostatic pressure may be maintained up to 21 mo postoperatively, Hampton et al (37) reported healing and closure of the surgically created defect in the annulus between 3 and 12 wk after surgery. This phenomenon was also confirmed in the my own experience when a repeated surgery was required a few months following the original percutaneous arthroscopic discectomy. It was found that the original site of annular fenestration was closed with scar tissue.

Concept of Nuclear Mass Reduction

Lyman Smith should be recognized as a champion of the minimally invasive movement (38). Learning from the experience of Lewis Thomas in rabbits (39), he introduced the concept of dissolving the nucleus pulposus by intradiscal injection of chymopapain. The simplicity of the procedure and the fact that the operative technique did not violate the content of the spinal canal attracted the attention of many orthopaedic and neurological surgeons, both in the United States and abroad. This was followed by many presentations, hands-on seminars, and publications in the ensuing years.

Encouraged by previously reported satisfactory outcomes of chemonucleolysis, in the early 1970s, following institutional approval, Kambin (Fig. 6) initiated a feasibility study on the efficacy of mechanical nuclear debulking for the treatment of herniated lumbar discs via a Craig cannula inserted into the intervertebral disc dorsolaterally (40,41).

Clinical research conducted by my colleagues and I in the ensuing years was directed toward establishing the effect of central nucleotomy on the size of the bulge or hernia-tion. In 1973, at The Graduate Hospital of Philadelphia, we combined the central nucleotomy via a Craig biopsy cannula with laminectomy in patients who demonstrated signs, symptoms, and imaging evidence of disc herniation (Fig. 7) (35). In 1973, a 60-yr-old male with myelographic and clinical evidence of disc herniation at L3-L4 and

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Responses

  • senait
    What are the problem faces by a patient who treatment under fenestration and excision of l5s1 disc?
    2 years ago

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