Lumbar Disc Height Changes in Pre and Post- Operatives of degenerative lumber disorders

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Radiological Evaluation of the Lumbar Disc Height Changes in Pre and Post- Operatives of degenerative lumber disorders underwent Computer navigated MIS- TLIF

Abstract:

Objective: This retrospective study to assessment the disc height changes pre and post-operation for the patients with degenerative lumber disease whether the disc height improved by discectomy and cage implantation by MIS-TLIF procedure.

Methods: Between the periods of January to June 2016 a retrospective study of 40 patients (21 Female, 19 Male) with mean age 52.6 years old who underwent MIS-TLIF were compared pre and postoperation of MIS-TLIF through calculating disc height by digital tool using X-ray image.

Results: This study includes 56 segments of lumbar spine. The X-Ray post-operatively showed significant physiological changes in disc height with the disc height average 14.38mm compared with the disc height pre-operatively with the average disc height 9.83mm in addition the T-test result was 2.050. The disc height improve significantly after MIS-TLIF, P0>.001, There was no serious complication found after performing the operation.

Conclusion: The MIS-TLIF procedure elevates the disc gap. Supported with cage and bone graft can restore the disc height to keep the normal lumber function that may play an important role in relive the symptoms of degenerative lumber disorders.

Keywords: MIS-TLIF, Disc height, computer navigation system, Disc degenerative disease.

Introduction:

   First of all, a short overview of spinal anatomy so that can understand how a lumbar herniated disc can cause lower back pain and leg pain. In between each of the vertebrae is a disc. The disc shapes look like circle and from outside is fibrous covering the gel substance disc. Herniation occur when the gel substance bulge out and press the nerve root or the spine itself.

   Disc degeneration disorders are the most common reason for low back pain. Many cases require operation if the conservative treatment doesn’t improve the symptoms, dynamic stabilization implant systems to fuse the vertebral bodies with or without supplementary devices. And dynamic stabilization devices are employed with the assumption that they will decrease the inter-vertebral disc loading at the treated level thereby decreasing pain and restrict more degeneration while reducing the degenerative influence on the adjacent levels. Various design concepts ranging from loaded springs to articulating type devices to the nucleus and annular repair devices have been proposed recently. The prevalence of spine surgery has steadily been on the rise over the last two decennium and this direction in prospect to spread over the next twenty-five years. In addition, the number of implanted medical devices that have been developed and the clinical indications for their use have expanded over the last ten years.

   Disc height is racial for the patient with the lumbar degenerative disease. Restore the disc height is important in keeping the normal structure of the lumbar spine.  MIS-TLIF assisted by computer navigation system could accurately play the role in restores the disc height with the satisfied clinical outcome. This method has some obvious advantages over traditional surgeries but few kinds of literature report the disc changes after operation, so we aim in this study to declare that disc height restored and the patients symptoms disappear after MIS-TLIF.

Methods:

Patient’s characteristics:

   This retrospective study between the period of January-June 2016 included 40 patients (21 F, 19 M) with mean age 52.6 years .56 segments of lumbar vertebra were treated by MIS-TLIF divided as (12 segments L3-L4, 32 segments L4-L5, 12 segments L5-S1). 40 patients were with a clear history, no previous spinal operation, no hypertension or diabetes, none of the patients was having a disease prevent the MIS-TLIF to be performed.

Operative technique:

     Using the minimally invasive procedure involves a two small incision in the backside. Using a portable X-ray machine, the surgeon locates the diseased vertebral levels. Making the smallest incision possible, the surgeon uses a combination of dilators and tubular re-tractors to access the vertebra and remove the degenerative disc. An implant with bone graft in place in of the degenerative disc, this procedure relieves pressure on the nerve roots.

   Minimally invasive transforaminal lumbar interbody fusion depends on the use of micro-tools and graduated dilators to approaches the spine, and then cut through the muscle tissue to gateway the influenced vertebras. With MIS technique, the incision is made to side the spine with minimal incision size about 4-5cm. Graduated dilators are used to aside the vertebral muscle in the stand of cutting them. MIS- TLIF needs a part of the vertebral bone to be removed. This is the lamina of the vertebra-and a part of the phacet joint. Through this opening can do the discectomy so the fusion can take place. Minimally invasive TLIF usually depend on using the pedicle screws and rods to fix the vertebral bodies.

    A cage is placed in the inter-body space and packed with bone graft to help stimulate bone growth. It restores the height of the spine and stabilizes the vertebrae as they fuse together. In a successful fusion, the bone grows around and through the cage over time, making it the only place in the body where a material is implanted and active in the reparative process which elevates the disc height after the MIS-TLIF procedure. In other words, the cage and the material it is made out of play an active role in the growth of the bone that forms the fusion.

   Bone graft material come in many kinds often, the patient’s bone is taken from the hip bone, and sometimes the surgeon will use the allograft to reduce the recovery time for the patient. Bone morphogenetic protein can also be used.

Radiological assessment:

    Radiographic examinations were performed pre and postoperative, Radiographic data were collected and evaluated by the same observer. In all patients, X-Ray performed in our radiology department in order to calculate the inter vertebral height index (DHI) preoperative and postoperative using digital tools. The inter vertebral disc height is expressed as an average of the sum of the measurements at the anterior and posterior regions of the disc (anterior line + posterior line/2).

                   This X-Ray showing the disc height pre and post MIS-TLIF :

               Secondary spinal stenosis due to lumbar disc herniation L5-S1

               Disc height pre=(5.6+11.1)/2=8.35mm

               Disc height post=(7.4+22.2)/2=14.8mm

                    MIS-TLIF operation of 2 segments (L3-L4, L4-L5(

                  Disc height is calculated by using digital tool (Anterior line + posterior line)/2

Statistical analysis:

   For comparing the differences between the preoperative and postoperative disc height we use the T-test. Statistical significance was set at a P value < 0.001. The statistical analysis was performed using SPSS software.

RESULTS:

   All the cases showed improvement on the disc height after MIS-TLIF. Though the average of the posterior line pre-post (6.76mm – 10.61mm), and the anterior disc line average was pre-post (12.9mm – 18.16mm), and the mean of disc height pre- MIS-TLIF was 9.83mm compared with the disc height post MIS-TLIF with average 14.38 the patient’s complaints improved after MIS-TLIF with no complication .the postoperative X-ray showed no subsidence or collapse of the cage or bars, and none of the pedicle screws show a sign of loosening position‏.

PLA: posterior line after the operation.

PLB: posterior line before the operation.

ALA: anterior line after the operation.

ALB: anterior line before the operation.

DHB: disc height before the operation.

DHA: disc height after the operation.

DHA

DHB

ALA

ALB

PLA

PLB

10

8.95

14.3

12.4

5.7

5.5

11.75

5

16.8

5.6

6.7

4.4

14.1

8.45

16.7

12.8

11.5

4.1

14.8

8.35

22.2

11.1

7.4

5.6

13.25

10.7

14.9

9.3

11.6

12.1

12.5

9.1

15

10.3

10

7.9

15.75

11.45

23.5

13.5

8

9.4

15.75

11.35

18.9

14.5

12.6

8.2

14.4

8.7

17.7

10

11.1

7.4

12.15

10.7

15.1

12.5

9.2

8.9

8.5

4.45

10.4

5.5

6.6

3.4

11.4

2.75

13.2

3.2

9.6

2.3

13.9

6.3

14.6

10.2

13.2

2.4

11.6

10.65

12.6

15.8

10.6

5.5

14.75

11.7

19.6

16.7

9.9

6.7

17.6

13.2

23.5

19.9

11.7

6.5

14.95

10.85

16.6

10

13.3

11.7

13.7

9.4

18.4

15.1

9

3.7

13.3

12.1

17.4

16.6

9.2

7.6

12.8

9.45

15.8

11.7

9.8

7.2

10.55

7.7

13.2

11.1

7.9

4.3

17.4

11.65

19.5

15.6

15.3

7.7

11.6

10.2

13.1

11.4

10.1

9

18.95

11.55

27.2

17.4

10.7

5.7

15.2

9.75

17.6

12.4

12.8

7.1

16.85

9.15

23.2

14.8

10.5

3.5

12.95

4.6

18.9

5.4

7

3.8

12.65

9.7

13

7.9

12.3

11.5

11.85

7.2

14.6

8.7

9.1

5.7

13.35

9.25

17.6

11.4

9.1

7.1

12.15

10.85

15.8

14.7

8.5

7

14.05

12.35

19.3

18.5

8.8

6.2

14.95

9.7

15.5

13.4

14.4

6

12.5

7.3

16.5

10.4

8.5

4.2

14.4

10.4

18

14.9

10.8

5.9

17

11.75

19.3

13.7

14.7

9.8

12.35

7.7

15.9

12.3

8.8

3.1

16.6

11.25

20.6

13

12.6

9.5

14.75

9.1

19.1

11.3

10.4

6.9

17.6

11.15

19.9

11.1

15.3

11.2

10.3

6.5

13.8

10

6.8

3

16.25

12.1

18.8

18.1

13.7

6.1

18.95

5.9

25.7

7.2

12.2

4.6

19.5

14.5

25.1

20.2

13.9

8.8

16.5

11.4

22.2

17.1

10.8

5.7

14.5

13.4

17.3

18.4

11.7

8.4

19.55

13.35

23.4

16.4

15.7

10.3

18.2

12.65

21.1

17.1

15.3

8.2

17.45

12.65

24.1

15

10.8

10.3

11.8

10.55

15

14

8.6

7.1

12.2

9.55

15.4

14.8

9

4.3

16.6

10.25

21.3

15

11.9

5.5

15.3

9.05

20.2

12.3

10.4

5.8

13.35

7.5

19.1

10.3

7.6

4.7

14.5

11.55

18.6

12.7

10.4

10.4

Discussion:

    Inter vertebral discs undergo age-related degenerative changes that contribute to some of the most common causes of impairment and disability for middle aged and older people: spine stiffness, neck pain, and back pain. Potential causes of the age-related degeneration of inter vertebral discs. Most of the reason for disc loses is the disc aging.

 Disc aging lead to overall loss of water content and conversion to fibrocartilage especially there is a decrease in the water content, nutritional support, proteoglycans and PH. Many ligaments and muscle attack to the back of the spine to provide power movement which will help the disc tissue to stand longer any disorder will affect the anatomical structure will lead to more pressure on the disc tissue and end with disc degeneration. Degenerative disc disease can occur in any place in the spinal cord, but mainly its happen in the low back and it’s a condition more than disease cause the disc will lose their flexibility of courser age related to disc tissue include the disc dry and shrink small tears occur in the annulus, bone spurs appear and the disc became thinner in addition to spinal cord stenosis.

  Degenerative disc disease develops as a result of the effects of aging on your spine and specifically on your inter vertebral discs. It can also be associated with an injury to the back, but even in that scenario, your discs have usually become weak because, with age, discs lose water content, may become thinner; both of which can alter the strength and shape of one or more discs. Before you can feel the result of Degenerative disc disease, pain and other symptoms your discs and other spine structures are changing. This is simply the natural result of the stress and strain each of us puts our backs through every day.

     In this prospective study used forty patients pre and post MIS-TLIF and after calculating the disc height it’s clear that MIS-TLIF is a success procedure to treat the patients complain of low back  pain and the disc height showed significant improvable Some of the spine degenerative disorders that require surgical intervention such as degenerated discs. The surgical process providing a solution to remove the problem of lower-back pain only more than fix it. The perfect treatment technique would include returning the physical and mechanical functionality of the disc. However, current research has been able to identify only MIS-TLIF to solve this complaint.  MIS-TLIF is also an effective method to treat lumbar spine deformity and avoid complications compare with TLIF, provide pleasant clinical outcomes. This method has some clear advantages over convention surgeries. It is a technique with more advantages than other procedure treats spinal disorders. In the treatment of patients with spinal disorders the cage can be placed between the vertebral bodies which prevent the pressure on the nerve root. After inducing the supplementary instrumentation, it can result in convenient postoperative stability. For surgical procedures in lumbar spine disorders, MIS-TLIF has the advantages over other surgeries with minimum blood loss and short time surgical procedure and early discharge from the hospital. MIS-TLIF is important surgery in reconstructing spinal stenosis to attain a considerable surgical outcome. The MIS-TLIF can achieve significant post-operation results; most of the authors support the use of MIS-TLIF in the treatment of the lumbar spinal disorders results in significant improvement of disc height.

   Advantages of the minimally invasive TLIF procedure over traditional spine surgery include short time hospital stay, smaller incision and less damage to the tissue. Most patients can return home directly after the operation with some exceptions which need more time for examination, many patients will show improvement on their symptoms directly after the operation. Patients will need to start the exercise and TLIF is a beneficial procedure that can provide an improvement in spinal stability and reduce pain.

   Disc degenerative diseases are one of the main problems which can be treated by MIS-TLIF and the disc height will show improvement, and the symptoms will decrease.

   In this prospective study we hypothesized not to find any subsidence or collapse, and any worse outcome, any complication during the operation, the patients who performed the MIS-TLIF have shown improvements after the operation and the symptoms disappear and they get back to their normal life after a short hospital stay. The drawback of MIS are prolonged learning period, it demands a specialist with considerable experience, the medical instruments which are used in the operation is very expensive not every hospital can have it, short the time compare with the open procedure and increase the risk of surgery failure from this all points we can find the MIS-TLIF is more convenient for the patients and that’s what we are looking for improving it. There is a criteria before the operation room. If the patients will not improve with the conservative treatments, there was no improvement of the patient’s symptoms and need surgical intervention, the surgical procedures for all the patients were transforaminal lumbar inter body fusion. 

Conclusion:

   The MIS-TLIF procedure evaluate the disc gap sported with cage and bone graft can restore the disc height to keep the normal lumber function .MIS-TLIF operation is highly safe procedure in treating the disc degenerative d conditions, and improve the patients symptoms with less blood loss during the operation, less pain, short healing time, and the patient can get back to his normal life after short period, MIS-TLIF is a  successful procedure for primary cases as well as for revision cases with expressive increase in disc height and reduce  in patients complaints.

Abbreviations:

MIS: minimal invasive Surgery, Tlif: transforaminal interbody fusion

DHI: intervertebral height index.

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