Objectives: To evaluate the results of a single-level cervical disc herniated surgery using articulated intervertebral discs. Subjects and methods: Prospective, descriptive, uncontrolled study on 46 cases of herniated disc cervical spine surgery in Department of Neurosurgery, 175 Military Hospital from 11 - 2011 to 12 - 2016.
Jourrnal of military pharmaco-medicine n09-2019 ASSESSMENT OF RESULTS OF ARTIFICIAL DISC REPLACEMENT FOR SINGLE-LEVEL CERVICAL DISC HERNIATED TREATMENT Nguyen Trung Kien1; Vu Van Hoe2 Nguyen Hung Minh2; Quach Thi Can3 SUMMARY Objectives: To evaluate the results of a single-level cervical disc herniated surgery using articulated intervertebral discs Subjects and methods: Prospective, descriptive, uncontrolled study on 46 cases of herniated disc cervical spine surgery in Department of Neurosurgery, 175 Military Hospital from 11 - 2011 to 12 - 2016 Results: Average surgical time was 65.33 ± 16.38 minutes, no need for blood transfusion in the surgery with a little blood loss of 65.87 ± 26.21 mL The symptoms of neck pain and arm pain improved, after 12 months VAS neck and arms (1.73 and 1.30, respectively) was significantly different compared to before treatment (6.74 and 6.33, respectively) with p < 0.001 The index of decreased spinal function after surgery 12 months (8.86%) was significantly different from before surgery (43.52%) (p < 0.001) Myelosuppression in patients with myelophathy and myeloradiculophathy syndrome recovered well, before surgery was 10.55, after 12 months surgery was 16.12 Conclusion: Surgical treatment of articulated intervertebral disc replacement for single-level cervical disc herniated had good results with short surgical time, less blood loss, good improvement of neck and arms pain, well restored spine function as well as medicine cabinet functions * Keywords: Single-stage herniated disc; Artificial disc; Artificial disc replacement INTRODUCTION Cervical disc herniation is a disease caused by degenerative cervical spinal disc that compresses the nerve root or cervical spine, with the second highest incidence rate after lumbar disc herniation The clinical symptoms of cervical herniated disc are diverse and plentiful depending on the location, type, and extent of herniation [12] Treatments for preserving the disc herniation include resting, physiotherapy, muscle relaxants, anti-inflammatory pain, nerve root injection Surgical treatment is mentioned when proper medical treatment is ineffective, with a duration of about weeks The purpose of surgical treatment is to release root and spinal cord compression by a herniated disc, ensuring the structure of the cervical spine to limit the process of progressive degeneration [2] Until now, the basic treatment method that has been widely applied is the removal of intervertebral discs, extractions, and joint welding 175 Military Hospital 103 Military Hospital National Otorhinolaryngology Hospital Corresponding author: Nguyen Trung Kien (drkienbv175@gmail.com) Date received: 10/10/2019 Date accepted: 10/12/2019 312 Jourrnal of military pharmaco-medicine n09-2019 The introduction of replacement materials for autologous bone has helped to minimize painful complications in the area of the bone, however, the treatment results are still not reaching the ideal due to the partial hardening of bone welding, exercise cervical spine, increasing the risk of adjacent vertebral diseases The technique of replacing the artificial disc has been created in recent decades, it has been effective in solving the causes of the pathology, at the same time maintaining the height of the burning space, maintaining the physiological curve of the spine, keeping the movement of the vertebrae and has been shown to yield positive yield positive results [3, 4] Artificial disc replacement method for treatment of cervical spinal disc herniation has been applied in the country since 2009 and its effectiveness has been proved by several reports However, up to now, no domestic studies have focused on singlestage herniated disc herniation Therefore, we conduct the project with the aim: Evaluating some clinical effects of surgical treatment on single-spinal cervical herniated disc using artificial disc SUBJECTS AND METHODS Subjects Patient was diagnosed with single-stage spinal disc herniated disc, surgery to replace articulated artificial disc in Neurosurgery Department, 175 Military Hospital from November 2011 to December 2016 * Selection criteria: Patients were diagnosed to identify single-stage spinal disc herniation based on clinical criteria and magnetic resonance images, and have been replaced with DiscocervTM artificial disc replacement * Exclusion criteria: Instability of the cervical spine, infection of the anterior cervical area, osteoporosis (measurement of bone density index T-score ≤ -2.5), a history of surgery for herniated spine disc, no full research records Patients did not agree to participate in the study Methods The prospective study, longitudinal follow-up, no control * Research indicators: - Results of surgery: + Operating time: From the time of skin incision to the end of the incision + Blood loss: Calculated by the amount of fluid including irrigation water and blood collected at the end of the operation minus the amount of irrigation water during surgery - Complications: Bleeding, organ damage to the front neck, infection - Comparison of pain level (neck, arm), index of decreased vertebral function, level of marrow injury after treatment at the time of discharge, after and 12 months compared to before surgery: + Pain level on a VAS scale + The index of cervical spine reduction (NDI), dividing the degree of cervical spine function by Vernon and Mior [5] 313 Jourrnal of military pharmaco-medicine n09-2019 + The degree of bone marrow damage the longest 120 minutes) [8] Thus, in general, was based on the Benzel JOA scale (1991) our research results were quite similar to in patients with cervical spondylosis syndrome the above studies and bone marrow suppression syndrome In fact, in addition to the pathological factors, the proficiency of the main surgeon and the assistant is also a factor that affects the time of surgery and the amount of blood lost during surgery Therefore, in the first time we applied the technique, we had longer operation time and more blood loss We also found that the support of microsurgical glasses made it easier to observe lesions during surgery and the use of high-speed drill to address other causes of pinched nerve and spinal cord roots (overgrowth bones, ligaments, mucous hernia into the spinal canal ) were factors that facilitated the operation, shortening time and blood loss [6] - Data analysis was based on SPSS 22.0 medical statistics software RESULTS AND DISCUSSION Research included 46 patients with a single-stage spinal disc herniation who underwent surgery to replace a total artificial disc with an average age of 50.70 ± 10.97; male: 43.47%; female: 56.53%, 37/46 patients (80.43%) were re-examined after surgery 12 months, we obtained some results as follows: Results of peri-operation and early complications * The time of surgery, the amount of blood lost during surgery: The average surgical time was 65.33 ± 16.38 minutes (the longest time was 120 minutes, the shortest time was 45 minutes) We did not have to give any patient blood during surgery with an average blood loss of 65.87 mL (at least 50 mL, at most 150 mL) Pimenta studied 53 patients from 2002 to 2003, replacing a single spinal disc with a 50-minute surgical procedure and about 50 mL of blood loss [7] In 2007, Ramadan replaced ancient Discocerv disc pads for 17 patients, with an average operation time of 67.1 ± 20.2 minutes (the shortest 35 minutes; 314 During surgery, we did not experience bleeding complications, organ damage or floor surgery Results of other authors also showed a low rate of complications, although the anterior neck area was quite complicated anatomically [7, 8, 9] Postoperative process, there was case of wound hematoma Patients with sore throat, shortness of breath, swollen neck in the neck, had been reopened for surgical treatment After that, stabilize and leave the hospital without any sequelae O’Neill remarked that up to 35% of the surgical site hematoma occurred late on average about the sixth day after surgery, and he also recommended placing a drainage to prevent this complication [10] Jourrnal of military pharmaco-medicine n09-2019 Assessment of pain level according to VAS 6.74 6.33 VAS 3.78 3.2 1.89 1.73 1.13 1.3 After months After 12 months Before surgery Discharge VAS neck VAS arms Figure 1: Comparison of VAS neck, arms before surgery and at discharge, after and 12 months Before surgery, VAS scale measured in neck and arms were 6.74 and 6.33, respectively; at the time of discharge, the VAS scale decreased to 3.78 at the neck and 3.20 points at the arms At the time of examination again after and 12 months, VAS neck and arms continued to decrease Comparison of VAS score before surgery and at the time after surgery, the difference was statistically significant with p < 0.001 This demonstrated that effective interventions, eliminating the stimuli on the nerve root system helped the signs of pain subside with time after surgery However, in our research group there were still some cases of patients feeling pain, not very satisfied, neck VAS index was still high (7 points) at the time of discharge In our opinion, pain is a symptom of rapid reduction after surgery but in some patients it is not possible to completely relieve the pain, which is not only a symptom of cervical herniation but also has many other causes such as degenerative spine, osteoporosis… Zhao (2019) also gave results VAS of neck, arms before surgery (4.8 ± 2.3 and 5.4 ± 1.8) decreased by 1.7 ± 1.7 and 1.0 ± 1.7, respectively at the time of the final examination [9] Du J et al had replacement surgery of 26 discs for 25 patients, follow-up period an average of 15.3 months, noticed improvement in pain immediately after the surgery and the next stage and he concluded: Artificial disc brings clinically good results and preserves some postoperative motions [11] 315 Jourrnal of military pharmaco-medicine n09-2019 The improvement of the degree of NDI 50 45 43.52 40 35 30 25 20 15 15.74 10 10.09 8.86 After months After 12 months Before surgery Discharge Figure 2: Comparison of NDI before surgery and at discharge, after and 12 months Regarding improvement of cervical function, before surgery, the average NDI was estimated at 43.52 ± 1.57%, of which the majority of patients were at the average level of influence (NDI: 30 - 50%) The degree of neck pain affecting the daily activities and activities of the patient had been resolved, the patient was no longer uncomfortable due to the feeling of neck pain, the daily activities had been performed by themselves Clinical manifestations of the previous days were now gone or greatly improved After 12 months, we assessed that the NDI decreased to 8.86 ± 6.05%, mainly at the level of no effect This was also a subjective assessment of the patient, so it depended on many other factors In our opinion, the index of NDI was not only affected by the cervical herniation but also many other influencing factors such as joint degeneration of the torso bone, the muscular cap, etc 316 According to Pimenta et al, NDI at the time of preoperative, after surgery week, months and year was respectively 45%; 17%; 15% and 15% [7] Ramanda followed 17 patients after months, NDI decreased from 25 ± before surgery to 11 ± [8] Thus, after surgery, the authors had shown that the analgesic effect after nerve compaction intervention improved the function of the cervical spine Our results were similar to those of the above authors’ researches, assessed at the time of discharge, after and 12 months, the difference was statistically significant with p < 0.001 Rehabilitation of marrow function function on a JOA scale Evaluation of myelosuppression on an improved JOA scale in patients with syndrome (n = 25) and radiculomyelophathy syndrome (n = 8) at months (n = 33) and after 12 months (with 26/37 patients had re-examination), we had the results according to the following table: Jourrnal of military pharmaco-medicine n09-2019 Table 1: Comparison of JOA scores before and after surgery and 12 months JOA score Before surgery (1) 10.55 ± 2.19 p After months (2) After 12 months (3) p(1-2) p(1-3) 15.91 ± 2.07 16.12 ± 2.16 < 0.001 < 0.001 Comparing JOA scores before surgery with postoperation at and 12 months, there was a statistically significant difference with p < 0.001 The group of myelophathy syndrome and mixed syndrome had a clinical severity, the clinical symptoms that made people most worried were the awkward symptoms in their hands and walking anhydrous because of the foot feeling tense, heavier than motor paralysis, difficulty urinating The main reason was that the herniated disc compresses directly into the spinal cord, causing a level of spinal stenosis Early disc herniation surgery resolved the cause of spinal cord compression and gave good results Our study showed a significant improvement in myelosuppression after months and the time of re-examination of the majority of patients had a very good recovery This reflected the correct diagnosis of lesions and the effective treatment of neuromuscular suppression However, in the study, we still had cases who were in the group of re-examined patients after 12 months, did not see a clear recovery in nerve function and still faced with many difficulties in living Both cases were late to the hospital, the medullary lesion on MRI images was due to long-term compression of the hernia Thus, in order to achieve effective intervention, a thorough early detection of symptoms was extremely necessary Our results were similar to a number of studies in the country and abroad for very good results in bone marrow rehabilitation Le Trong Sanh (2010) with the results of recovery from 12.76 ± 1.79 to 16.04 ± 1.88 at the last examination [1] Du J et al showed a JOA score before surgery 7.5 ± 2.3 to 15.6 ± 4.3 after 15.3 months [11] Zhao’s (2019) results after 10 years followed-up, rehabilitation of marrow function improved from 12.8 ± 2.1 to 15.9 ± 1.1 [9] CONCLUSION Surgical treatment method of replacement of articulated intervertebral disc for the 1-floor spinal disc herniation had good results in improving clinical manifestations The average time of surgery was 65.33 ± 16.38 minutes, there was no blood transfusion in the surgery with the average amount of blood loss was 65.87 ± 26.21 mL, there were no complications during surgery After surgery, improving symptoms of neck and arms pain: VAS of neck and arms after surgery 12 months compared with before treatment Good rehabilitation of spinal function: NDI after surgery 12 months, markedly different from before surgery Myelosuppression very well and well, the JOA score before surgery was 10.55, after surgery 12 months averagely was 16.12 317 Jourrnal of military pharmaco-medicine n09-2019 REFERENCES Lê Trọng Sanh Nghiên cứu chẩn đoán kết điều trị phẫu thuật thoát vị đĩa đệm cột sống cổ đường cổ trước bên Bệnh viện Hữu nghị Việt Đức Luận án Tiến sỹ Y học Trường Đại học Y Hà Nội 2010 Pimenta L, McAfee P.C, Cappuccino A et al Clinical experience with the new artificial cervical PCM (Cervitech) disc Spine J 2004, (6 Suppl), pp.315s-321s Kaiser M, Haid R, Shaffrey C et al Degenerative cervical myelopathy and radiculopathy Springer International Publishing 2019 Ramadan A.S, Mitulescu A, Schmitt P Total cervical disc replacement with the Discocerv® (Cervidisc Evolution) cervical prosthesis: Early results of a second generation European Journal of Orthopaedic Surgery & Traumatology 2007, 17 (6), pp.513-520 Kim H.K, Kim M.H, Cho D.S et al Surgical outcome of cervical arthroplasty using bryan J Korean Neurosurg Soc 2009, 46 (6), pp.532-537 Zhao Y, Zhou F, Sun Y et al Singlelevel cervical arthroplasty with ProDisc-C artificial disc: 10-year follow-up results in one centre Eur Spine J 2019 Fay L.Y, Huang W.C, Wu J.C et al Arthroplasty for cervical spondylotic myelopathy: Similar results to patients with only radiculopathy at years' follow-up J Neurosurg Spine 2014, 21 (3), pp.400-410 10 O'Neill K.R, Neuman B, Peters C et al Risk factors for postoperative retropharyngeal hematoma after anterior cervical spine surgery Spine (Phila Pa 1976) 2014, 39 (4), pp.E246E252 Vernon H The neck disability index: State-of-the-art, 1991 - 2008 J Manipulative Physiol Ther 2008, 31 (7), pp.491-502 11 Du J, Li M, Liu H et al Early follow-up outcomes after treatment of degenerative disc disease with the discover cervical disc prosthesis Spine J 2011, 11 (4), pp.281-289 Benzel E.C, Lancon J, Kesterson L et al Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy J Spinal Disord 1991, (3), pp.286-295 12 Dubuisson A, Lenelle J, Stevenaert A Soft cervical disc herniation: A retrospective study of 100 cases Acta Neurochir (Wien) 1993, 125 (1 - 4), pp.115-119 318 ... curve of the spine, keeping the movement of the vertebrae and has been shown to yield positive yield positive results [3, 4] Artificial disc replacement method for treatment of cervical spinal disc. .. on singlestage herniated disc herniation Therefore, we conduct the project with the aim: Evaluating some clinical effects of surgical treatment on single- spinal cervical herniated disc using artificial. .. Instability of the cervical spine, infection of the anterior cervical area, osteoporosis (measurement of bone density index T-score ≤ -2.5), a history of surgery for herniated spine disc, no full