Percutaneous cervical laser diskectomy, thermoannuloplasty, and thermonucleoplasty; comparable results without surgery.

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?

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 1–4]. Results of these three procedures were compared to the literature for patients with comparable/more severe cervical disc disease and greater neurological impairment treated. Of interest, outcomes for both the operative and nonoperative groups were similar, demonstrating 80–90%+ improvement utilizing Macnab's criteria (good/excellent outcomes) [Tables 1–5].[7811192223] With such findings, where is the value added” for the three MIS cervical operations?

Table 1

Macnab's outcome criteria

Table 4

Three randomized controlled trials utilizing cervical nucleoplasty coblation techniques

Table 5

Favorable responses to nonsurgical treatment for cervical pain/radiculopathy

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 1 and 2].[62123] Siebert et al. (1995) treated 31 patients with cervical percutaneous laser disc decompression (PLDD)/ablation initially with a Nd:YAG laser (1990), followed by the Ho:YAG laser (1991-1993); 28 of 31 patients experienced pain relief 6 weeks later [Table 2].[21] Turgut et al. (1997) later documented the damage produced by the neodymium YAG laser (Nd:YAG laser) to the vertebral end-plates in 32 guinea pigs (randomly divided into a control group, and the Nd:YAG laser group) [Table 2].[23] Subsequently, in a large nonrandomized, non-blinded clinical series, Choy (1998) evaluated 752 PLDD performed in 518 patients over a 12-year period [Table 2].[6] The author claimed the laser removed a small volume of disc material sufficient to drop intradiscal pressure, allowing for the “disc to move away from the nerve root,” resulting in a 94.5% incidence of good-to-excellent results [Table 1].

Table 2

Percutaneous cervical laser discectomy 1995-2010

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 [Table 2].[1213] Using one of two side-firing laser probes (e.g., the Holmium 2100: YAG versus KTP532 laser), they performed 108 procedures in 105 patients (note no control group); 1 year postoperatively (minimum), 50% of patients demonstrated good/excellent outcomes.

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 2 and 3].[13141517] Ahn et al. (2004) performed 11 anterior percutaneous cervical discectomies (PCD) using an endoscope/Ho:YAG laser; 88.3% improved [Table 2].[1] Bonaldi et al. (2006) performed anterior cervical thermoannuloplasty in 55 patients using the Perc-DC SpineWand; at 6 months 85% improved [Table 2].[3] In 2006, Lee et al. evaluated 60 cervical PLDD [Ho:YAG laser assisted spinal endoscopy (LASE)]; 85.0% (51 patients) improved [Table 2].[14] Li et al. (2008) used the Perc-D Spine Wand in 126 patients; 87.3% improved [Table 2].[17]

Table 3

Percutaneous cervical laser diskectomy 2012-2014

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” [Table 3].[910] In 2012, they operated on 142 adults and found, over 4 years, all patients were “successfully treated without any complications.”[9] Notably, however, the mean volume of disc material removed was just 0.09 mL. In their second study (2013) they used the same device in 66 consecutive patients undergoing 1–2 level cervical disc operations; pain improved over 3 postoperative months in 94.6% of patients, and there were no adverse events [Table 3].[10]

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 [Table 3].[162027] Ren et al. (2013) found no alternation of disc height before and after cervical and lumbar PLDD (all 22 patients with “contained” discs) [Table 3].[20] Lee and Lee (2014) documented 37 patients undergoing percutaneous cervical laser disc ablations (no control group); all improved (e.g., using the neck disability index (NDI)) [Table 3].[16] Yang et al. (2014) compared the results for cervical percutaneous discectomy (97 cases), disc nucleoplasty (50 cases), and combined procedures (24 cases) (note; no control group); all resulted in comparable outcomes (Odom criteria) [Table 3].[27]

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 3 and 4].[241826] Three randomized controlled trials (RCTs), and seven nonrandomized studies identified a total of 823 patients (≥892 disks) undergoing nucleoplasty/coblation [Table 4].[26] In the RCT by Nardi et al. (2005), 50 consecutive patients underwent nucleoplasty/coblation versus 20 patients treated nonsurgically; in the surgical group, 80% completely recovered, 10% had residual complaints, and 10% failed to improve [Table 4].[18] Notably, they observed less success for those managed nonsurgically. Using the PercCD-Spine Wand coblation technique, Birnbaum et al. (2009) compared outcomes for 26 patients undergoing surgery versus 30 controls (randomized study) [Table 4].[2] Using the Visual Analog Scale (VAS), the average 2-year improvement for the surgical group was better (2.3) compared with the nonsurgical group (5.1). In the 2010, RCT by Cesaroni and Nardi, 62 patients were treated with the CD-Spine Wand versus a control group of 58 patients; 1 year later, the surgically treated patients exhibited better outcomes [Table 4].[4]

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 [Table 5].[7811192223] Heckmann et al. (1999) evaluated the results of conservative management for 60 patients with cervical discs; over an average of 5.5 years, 39 (65%) had no surgery versus 21 (35%) who had ventral discectomies [Table 5].[11] Outcomes for both the nonsurgical versus surgical groups were nearly comparable in all categories. In 2002, Olivero and Dulebohn compared the efficacy of using a collar versus halter traction in the management of 81 patients with cervical radiculopathy; 75% of patients improved without surgery [Table 5].[19] Thoomes et al. (2013) also documented the success of conservative management (e.g., collar versus physiotherapy versus traction) for patients with radiculopathy and cervical disc herniations; they concluded “patients seem to improve over time, indicating a favorable natural course” [Table 5].[22] When van Middelkoop et al. (2013) performed a meta-analysis of adults with neck pain without radiculopathy or myelopathy, comparable results were observed with/without surgery [Table 5].[24] Wong et al. (2014) also confirmed the success of nonsurgical management of cervical disc herniations; patients substantially improved within 4–6 months, with 83% showing complete recoveries within 24–36 months. [Table 5].[25] In a case report, Cvetanovich et al. presented a 76-year-old patient with an acute right upper extremity radiculopathy and a large cervical herniation at the C6–C7 level; the patient fully recovered 7 months later and the MR documented full resolution of the disc herniation [Table 5].[8] Finally, in 2015, Corniola determined; “the majority of cervical disc herniations can be supported by means of (a) conservative treatment” [Table 5].[7]

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.