A long-term review of 50 patients out of 506 treated with automated percutaneous nucleotomy according to onik for lumbar-sacral disc herniation

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Acta Neurochir (2005) [Suppl] 92: 103–105 6 Springer-Verlag 2005

Printed in Austria

A long-term review of 50 patients out of 506 treated with automated percutaneous nucleotomy according to onik for lumbar-sacral disc herniation

A. Degobbis, M. Crucil, M. Alberti, and A. Bortolussi

Orthopaedics and Traumatology Unit of the Palmanova Hospital, Udine, Italy

Summary

At the Orthopaedics and Traumatology Unit of the Palmanova Hospital, between 27 October 1989 and 31 December 2003 we performed 506 automated percutaneous nucleotomies according to Onik [6] for the treatment of lumbar disc hernia.

The survey of 50 reviewed cases after evaluation of the subjective and objective clinical pictures according to the Cabot method al- lowed us to come to the conclusion that this percutaneous methodology is suitable to relieve damaged discs from compression. It is also well accepted by patients because it is not too traumatic, it requires short-term hospitalisation, presents no risk of post-operative ﬁbrosis and does not create complications for the eventual traditional operation when unsuccessful.

It is extremely important to accurately select the candidates keep- ing in mind the original indications given by Onik for percutaneous discectomy for which – in case of contained disc herniation – leg pain (sciatalgia) is more severe than low back pain a¤ecting the lumbar region.

Keywords: Nucleotomy; lumbar disc herniation; automated.

Introduction

At the Orthopaedics and Traumatology Unit of the Palmanova Hospital, between 27th October 1989 and 31st December 2003 we performed 506 automated percutaneous nucleotomies according to Onik [6] for the treatment of lumbar disc herniation.

With this method good results are achieved particularly when patients are accurately selected [1] and when the original indications given by Onik [4, 5] for percutaneous discectomy are retained. According to these indications, leg pain (sciatalgia) is more severe than low back pain a¤ecting the lumbar region when in connection with a contained disc herniation.

Already in October 1991, at the 2nd Meeting on

‘‘Percutaneous Discectomy According to Onik’’, held in Santa Margherita Ligure, we could report excellent or good results achieved in 93% of 75 cases we had

treated. Since we had become absolutely enthusiastic about this method, we started also applying it in the treatment of patients considered out of the suggested limits and in fact, at the SERTOT meeting in the spring of 1992 in San Marino, we referred about good results we had achieved with this method in 17 cases not ﬁtting the protocol of Onik, out of 121 patients treated before March 1992, which caused great per- plexity in the audience.

Materials and methods

Only with di‰culty we were able to randomly review 50 cases of patients aged between 33 and 74 years, treated in 1993 and 1994, that out of the 506 patients treated with the methodology proposed by Onik between October 1989 and December 2003.

Disc spaces involved were (Table 1):

in 4 cases L3-4 (3 on the right and 1 on the left) resulting in a total of 8% (Table 2)

Table 1. Disc spaces involved were

L3-4 4 cases (8%)

L4-5 30 cases (60%)

L5-1 13 cases (26%)

L3-4/L4-5 2 cases (4%)

L4-5/L5-1 1 case (2%)

Table 2. L3-4

Right Left %

3 1 8

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in 2 cases L3-4/L4-5 on the left resulting in a total of 4% (Table 5) in 1 case L4-5/L5-1 on the left resulting in a total of 2% (Table 6)

Results

Given the low availability, patients were evaluated on the subjective and objective clinical pictures following the methodology according to Cabot [2].

We considered (Table 7):

28 cases as excellent (resulting in a total of 56%) which means all patients who in the last 10 years did not present any episode of low back pain, had recovered to normal working life and had never turned to pe- riodic physiokinetic therapy even though suggested when dismissed;

10 cases as good (resulting in a total of 20%) which means all patients who referred periodical low back pain that diminished after medical treatment and physiokinetic therapy or simply by using an ortho- paedic corset;

6 cases as fairly good (resulting in a total of 12%) which means all patients who presented with partial re- gression of the symptoms, periodically took FANS and underwent physiokinetic therapy, hydrotherapy or fangotherapy.

The 6 cases we considered as bad (resulting in a total of 12%) underwent microdiscectomy according to Casper [3] with excellent results, respectively 1 after 7 days, 1 after 15 days, 2 after 1 month, and 2 after 1 year with periodical low back pain alternated with periods of reasonable well being.

Of these 6 cases,

2 presented a peridural extrusion at the moment of the discography

2 presented a CT report with L4-5 disc herniation, on the right and on the left respectively, and vertebral stenosis with the symptomatology localized on S1 (Lase`gue, pain and paresthesia);

1 presented a CT report with large L4-5 disc herniation on the left with symptomatology localized along the root of SI and at the moment of the discography a ﬁliform peridural extrusion ﬂoating towards the higher part of the root;

1 presented a CT report with L4-L5 disc herniation on the left and lateral recess stenosis.

Discussion

In conclusion, we achieved excellent and good results in 76% of the treated cases (compared to 93% of the 75 cases treated between 1989 and 1991).

We were presented with very few complications and the unsatisfactory results were corrected by performing microdiscectomy according to Caspar.

Our opinion on automated percutaneous nucleolisis according to Onik remains positive overall (and is, in our opinion, equivalent to other percutaneous treat- ments such as discectomy, discography, and nucleo- plasty using radiofrequency energy which we also use, but have a limited number of casistics) particularly when patients are accurately selected according to the following symptoms:

unilateral pain in the lower limb more severe than in the lower back; positive Lasegue’s sign;

Table 3. L4-5

Right Left %

15 15 60

Table 4. L5-1

Right Left %

5 8 26

Table 5. L3-4/L4-5

Right Left %

– 2 4

Table 6. L4-5/L5-1

Right Left %

– 1 2

Table 7. Results

Excellent 28 cases 56%

Good 10 20

Fairly good 6 12

Bad 6 12

104 A. Degobbis et al.

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alteration at the neurological level and no improve- ment after six weeks of conservative therapy;

paresthesia in a speciﬁc portion of the dermatome.

The main means of survey, apart from taking a complete x-ray of the lumbosacral region, are surely CT (without or with contrast medium) and MR scans which conﬁrm the presence of subligamental herniation (contained disc herniation) as indicated in the clinical reports, in dubious cases also an EMG scan.

Nevertheless, the ultimate preoperational evaluation is based on a discogram test which allows us to evalu- ate the disc referring to the following 4 parameters:

mass evaluation

manometric evaluation, if needed

radiographic evaluation (how the contrast medium ﬂows within the nucleus pulposus of a disc);

evaluation of the type of pain

Relying on our twenty years of experience (in consid- eration of the fact that from 1985 through to 1992 we satisfactorily treated 450 disc herniation performing chemonucleosis [7] resulting in a total of 77% of the cases), we can a‰rm that the contraindications of this method are:

pure low back pain, x-ray evidence of severe arthrosis of the articular facets, vertebral canal and lateral recess stenosis, hypertrophy of the yellow ligament, presence of spondylolysis and spondylolisthesis, congenital and acquired anomalies particularly lumbosacral transi- tion disorders, severe degenerative discopathies such as the narrowing of some intervertebral spaces due to spondyloarthrosis, tumoral localisations, evidence

of displaced fragment in the vertebral canal, cauda equina syndrome, disc extrusion, disc calciﬁcation.

In conclusion, the automated percutaneous nucleotomy methodology according to Onik is conceptually as suitable as other percutaneous methods to relieve damaged discs from compression and therefore to prevent formation of disc extrusion. It is well accepted by patients because it is not too traumatic, it requires short-term hospitalisation, there is no risk of post- operative ﬁbrosis and does not create complications for a possible traditional operation when unsuccessful.

Finally, after ten years, we are still able to conﬁrm the enduring beneﬁts.

References

1. Bocchi L, Ferrata P, Passatello F (1991) La nucleotomia percutanea secondo Onik: criteri di selezione, tecnica e valutazione dei risultati. Giorn Ital Ortop Traumatol XVII: 5–21

2. Cabot JR (1977) Chirurgia del dolor lumbosacro. Valladolid 3. Caspar W (1977) A new surgical procedure for lumbar disc her-

niation causing less tissue damage through a microsurgical ap- proach. Adv Neurosurg 4: 74–77

4. Negri V, Belledi G (1996) La nucleotomia percutanea secondo Onik: indicazioni e risultati su 76 pazienti. Chir Org Mov LXXKI: 49–54

5. Onik G, Helms CA et al (1985) Percutaneous lumbar discectomy using a neo aspiration probe. Am J Neuradiol 6: 290–293 6. Onik G, Helms CA (1988) Automated percutaneus lumbar dis-

cectomy. Radiology Research and Education Foundation, San Francisco

7. Vasciaveo F, Degobbis A, Regeni O (1989) Valutazione com- parativa fra chemonucleolisi ed approccio chirurgico tradizionale nell’ernia discale lombare. Rivista di Neuroradiologia 2 [Suppl] 1:

113–117

Correspondence: Marina Crucil, Via Fratelli Rosselli 20, 34074 Monfalcone, Italy. e-mail: [email protected]

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