Surgical Experience of Gas-Containing Disk Herniation - PDF Document

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  1. Neurol Med Chir (Tokyo) 50, 905¿909, 2010 Surgical Experience of Gas-Containing Disk Herniation Kyung-Chul CHOI, Jin-Sung KIM*, and Sang-Ho LEE* Department of Neurosurgery, Wooridul Spine Hospital, Daegu, R.O.K.; *Department of Neurosurgery, Wooridul Spine Hospital, Seoul, R.O.K. Abstract Disk herniation with gas or gas-containing disk herniation (GCDH) is rare, although epidural gas is as- sociated with the vacuum phenomenon. The clinical, radiologic, and surgical findings were retrospec- tively analyzed of 18 patients with GCDH. The demographic, clinical, and radiologic findings including computed tomography and magnetic resonance imaging, as well as operative methods were examined. The mean age was 64.4 years (range 51–84 years). All patients presented with acute radiculopathy or ex- acerbation of chronic pain associated with GCDH of the lumbar spine. All lumbar GCDHs were related to the vacuum phenomenon. Ruptured disks predominantly compressed the nerve root with gas in 17 cases, except in one with only compressed nerve root by gas without disk herniation. All patients had confirmed GCDH at surgery. All patients underwent removal of GCDH and five with another level of spinal stenosis or disk herniation underwent selective decompression. The six patients with instability underwent fusion. Visual analogue scale score of radicular pain was improved from 7.4 ± 0.9 before surgery to 3.2 ± 0.7 at the 3-month follow-up examination. No recurrence occurred after surgery. GCDH can occur as a space-occupying lesion in epidural space as well as a cause of radiculopathy. GCDH may indicate the source of clinical symptoms in the degenerative spine, especially combined with spinal stenosis or multiple spinal disk herniations. Key words: gas-containing disk herniation, vacuum phenomenon, radiculopathy Introduction or other hospitals. No patient had any history of tumors, infection, or trauma, and had undergone previous diagnostic or therapeutic procedures. The patients were preoperatively evaluated with comput- ed tomography (CT) and magnetic resonance (MR) imaging. The following demographic, clinical, and radiologic findings, and operative methods were as- sessed: age, sex, symptoms, diagnosis, presence of the vacuum phenomenon, level of the gas-containing disk, radiologic findings, methods of operation, and pre/postoperative visual analogue scale (VAS) score for radiculopathy (Table 1). Gas in the spinal canal results from various causes associated with tumors, infections, trauma, dis- kography, and disk degeneration.13,19)Disk degenera- tion is intimately related to the vacuum phenomen- on, which is relatively common in old age. The gas associated with the vacuum phenomenon has been found in the spinal canal, intervertebral foramen, epidural space, and subarachnoid space,8,17)but disk herniation with gas has rarely been reported. The majority of these cases have been the result of non- operative treatments.5,23)The present study analyzed 18 cases of disk herniation with gas associated with gas-containing disk herniations (GCDH) confirmed at surgery. Results The 18 patients included 5 males and 13 females aged 51 to 84 years (mean 64.4 years). Eight GCDHs were located at L4-5, five at L5-S1, two at L3-4, two at T12-L1, and one at L2-3. The follow-up period was 4 to 15 months (mean 6.3 months). All patients presented with radiculopathy associ- ated with GCDH. Seven patients presented with acute radicular pain due to GCDH, 5 patients had underlying chronic symptoms of radicular pain, neurogenic claudication, or back pain associated with spinal stenosis, degenerative spondylolisthesis, Materials and Methods This study reviewed the records of 18 consecutive patients who underwent surgical treatment for GCDH between January 2006 and August 2008. All patients were treated conservatively with analgesics and physical therapy over 3 months at our institute Received 2010 November 10, 2009; Accepted April 15, 905 905

  2. K.-C. Choi et al. 906 906 ALIF: anterior lumbar interbody fusion, DDD: degenerative disk disease, decom.: decompressive laminectomy, degen.: degenerative, HNP: herniated nucleus Postoperative 4 3 3 3 2 4 3 4 3 3 4 4 2 2 3 3 4 3 VAS Preoperative pulposus, LDK: lumbar degenerative kyphosis, NIC: neurogenic intermittent claudication, TLIF: transforaminal lumbar interbody fusion. 8 8 7 7 8 7 8 8 7 8 9 7 7 7 8 8 5 7 decom. at bil L2-3, L3-4, ALIF at L4-5 and L5-S1 discectomy at rt L5-S1; discectomy at lt L5-S1; discectomy at rt L5-S1 ALIF at L3-4 and L4-5 discectomy at lt L5-S1 discectomy at rt L2-3; discectomy at rt L4-5; discectomy at lt L3-4; discectomy at T12-L1 discectomy at T12-L1 discectomy at rt L3-4 discectomy at rt L4-5 discectomy at rt L4-5 discectomy at rt L4-5 ALIF at L2-3, L3-4, decom. at bil L3-4 decom. at bil L4-5 L4-5, and L5-S1 Operation decom. at lt L4-5 TLIF at L5-S1 TLIF at L3-4 TLIF at L4-5 and L4-5 and L4-5 intradural disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk ruptured disk Radiologic finding +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas +gas gas T12-L1 T12-L1 GCDH L5-S1 L5-S1 L5-S1 L5-S1 L5-S1 Level L4-5 L4-5 L3-4 L4-5 L2-3 L3-4 L4-5 L4-5 L4-5 L4-5 L4-5 of Clinical data of patients with gas-containing disk herniation (GCDH) phenomenon Vacuum yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes low back pain low back pain low back pain low back pain low back pain Preoperative both leg pain bil leg pain, symptom paraparesis rt leg pain, rt leg pain, rt leg pain, rt leg pain, rt leg pain, lt leg pain, lt leg pain, rt leg pain rt leg pain rt leg pain rt leg pain rt leg pain rt leg pain rt leg pain lt leg pain lt leg pain (rtÀlt) NIC NIC degen. spondylolisthesis at HNP at rt L4-5 and L5-S1; HNP at rt extraforaminal HNP at rt extraforaminal HNP at lt extraforaminal HNP at rt L2-3 and L3-4; degen. spondylolisthesis; degen. spondylolisthesis HNP at L3-4, L4-5, and spinal stenosis at L2-3, spinal stenosis at L4-5; spinal stenosis at L4-5 post fusion at L4-5 Diagnosis HNP at rt L5-S1; HNP at rt L5-S1; L3-4, and L4-5 HNP at lt L5-S1; degen. scoliosis; HNP at T12-L1; HNP at rt L4-5; HNP at rt L4-5; HNP at rt L4-5; HNP at rt L4-5; HNP at lt L3-4; HNP at lt L3-4; HNP at T12-L1 HNP at L5-S1; HNP at L4–5; and L5-S1; instability instability instability instability instability instability instability instability instability at L4-5; L5-S1; L5-S1 L3–4; L4-5 L4-5 DDD DDD LDK Sex M M M M M F F F F F F F F F F F F F (yrs) Age 60 51 61 59 51 67 70 59 68 84 71 70 56 83 71 52 56 70 Table 1 Case No. 10 11 12 13 14 15 16 17 18 1 2 3 4 5 6 7 8 9 Neurol Med Chir (Tokyo) 50, October, 2010

  3. Symptomatic GCDH 907 907 degenerative scoliosis, degenerative disk disease, and disk herniation of another level exacerbated by GCDH, and 6 patients presented with radicular pain of the GCDH and mechanical back pain due to insta- bility in the affected level. CT revealed the vacuum phenomenon on the level of the disk in all lumbar GCDHs. CT and MR imaging showed the ruptured disks were compressing the nerve root in 17 patients. Only gas without disk herniation occupied the neural foramen and spinal canal, and the gas ap- peared to compress the nerve root in one patient. At surgery, all 18 GCDHs were revealed as rup- tured disks in accordance with the radiologic fea- tures, but also confirmed as gas-containing disk her- niations compressing or displacing the nerve root. If ruptured disk material was encountered, the surgi- cal field was filled with saline. The ruptured disk was meticulously manipulated with a probe, and the air bubble was found and released. Seven patients underwent removal of the fragment only through multiple approaches following GCDH. Five patients with spinal stenosis or another level of disk herniation required additional selective decompression including removal of the GCDH. Six patients with instability required fusion. Preopera- tive VAS score of radicular pain was improved from 7.4 ± 0.9 to 3.2 ± 0.7 at the 3-month follow-up ex- amination. No recurrence was observed during the follow-up period. Fig. 1 with right L4 radicular pain. tomography scan of the L4-5 level showing gas in the right neural foramen. B: Axial T1-weighted magnetic resonance image showing ruptured disk herniation (ar- row) at the neural foramen at the L4-5 level and oblitera- tion of the exiting nerve root. Representative Case 10 of an 84-year-old woman A: Axial computed location of the Fig. 2 with right S1 radicular pain. tomography scans at the L5-S1 level showing a round gas-containing lesion (A) and the vacuum phenomenon (B). C: Sagittal T1-weighted magnetic resonance image showing that the ruptured disk herniation had migrated downward. The much darker signal area (arrow) in the ruptured disk herniation is well correlated with the com- puted tomography findings. Representative Case 11 of a 52-year-old woman A, B: Axial computed Representative Cases Case 10: An 84-year-old woman was admitted with a 3-month history of severe right leg pain radiating down the anterolateral Radiography showed degenerative changes and CT revealed gas in the right extraforaminal area at L4-5 with the vacuum phenomenon. MR imaging showed a herniated disk containing a signal void in the presence of gas. The gas-containing disk fragment had compressed the right exiting nerve (Fig. 1). The disk herniation was successfully removed using the microscopic paraspinal approach. The radicular pain was resolved after surgery. Case 11: A 52-year-old housewife was admitted to our institute complaining of back and right leg pain as well as numbness persisting for one year. Radiography showed narrowing of the disk space and segmental instability at L5-S1. CT showed an 8.2 × 6.3 mm gas-containing disk at the right paracen- tral upper portion of the spinal canal at S1 and the vacuum phenomenon at the intervertebral disk at L5-S1. MR imaging demonstrated a round and signal void lesion at the right paracentral portion of the spi- nal canal at S1 (Fig. 2). Considering the instability, we decided to fuse the L5 and S1 levels. After laminectomy, the gas-containing lesion appeared as a bluish ruptured disk herniation that was adherent to the right subarticular disk herniation. Her sym- aspect of the leg. ptoms markedly improved after surgery. Case 14: A 70-year-old woman presented with radiating pain in the bilateral lower extremities. She complained of more severe pain in the right an- terolateral aspect of the thigh and leg. CT showed a 6.2 × 4.8 mm gas lesion occupying the entire right neural foramen at the L2-3 level. Mid-sagittal T2- weighted MR imaging showed disk extrusion of the L3-4 level had obliterated the thecal sac. Sagittal and axial T1-weighted MR imaging showed a signal void in the right neural foramen at the L2-3 level (Fig. 3). The patient underwent removal of the ruptured disk and foraminotomy at L2-3 and L3-4. The gas at L2-3 was revealed as a ruptured disk herniation with gas in the neural foramen. After surgery, the patient's radicular symptoms disappeared. Discussion GCDHs are common in elderly patients (mean age 63 Neurol Med Chir (Tokyo) 50, October, 2010

  4. K.-C. Choi et al. 908 908 GCDH were associated with the degenerative vacu- um phenomenon. The development of GCDH re- quires this vacuum phenomenon. Gas-containing cysts in the degenerative originate from the ligamentum flavum and facet.14,25) Many asymptomatic patients have presented with gas within the spine. Several cases of symptomatic gas within the spine manifesting as radiculopathy, myelopathy, or foot drop were reported to compress the nerve root.1,18,22)The successive resolution of radicular pain after needle puncture of the gas pseu- docyst may be followed by recurrence of the gas cyst with radicular pain 2 years afterwards, followed by absorption of the gas.2,26)Gas can produce radicular symptoms, but disk herniation with gas and opera- tive findings is rare. In our series, CT and MR imag- ing patterns of gases revealed mostly a mixture of ruptured disk and gas, called the gas-containing disk. Whereas simple gas-containing cyst or cystic gas with disk herniation was described previous- ly,15,26)all GCDHs consist of a predominant ruptured disk that includes a small amount of gas. We found that the ruptured disk compressed or displaced the nerve root in the operative field. Disk herniations of the 18 symptomatic GCDHs were removed and the symptoms improved. GCDH does not actually carry high risk of recurrence of symptomatic GCDH or epidural gas, although the vacuum disk can com- municate with the epidural space after removal of GCDH. This study has the limitation of short follow- up period. Therefore, we are concerned about the recurrence rate of GCDH in the long term. Many gas collections in the spine have been reported with only CT findings.1,6,9,16,23,26)CT is definitely the most valuable neuroimaging method for identifying gas in the spinal canal and this modality demonstrates air more effectively than MR imaging. In particular, MR imaging has some limita- tions in the assessment of structures that contain air and calcification, which typically appear as signal void areas. However, MR imaging is a diagnostic tool capable of the evaluation of degenerative spinal changes with detailed information about lesion mor- phology, disk condition, and the status of adjacent neurologic structures. MR imaging is useful in the assessment of other spinal diseases that are oc- casionally perplexing in surgical consensus in GCDH, especially in old age. MR imaging can also distinguish intradural disk herniation with gas from extradural lesion (Case 13). CT and MR imaging are useful for the detection of gas collection and disk herniation, respectively, in GCDH. Several surgical experiences of gas in the spinal canal have been reported. Intraoperative findings demonstrated simple gas cyst, granulation, and rup- tured disk herniation.9,10,16,26)One study documented 19 cases of disk herniation with gas in the lumbar spine with CT findings, and only 6 patients required surgery.9)In our series of 18 GCDHs, seven patients cervical spine may Fig. 3 with radicular pain in the bilateral lower extremities. A: Axial computed tomography scan at L2-3 showing that gas occupies the entire right neural foramen. Axial T1-weighted magnetic resonance image showing a signal void (arrow) at the L2-3 level in the right neural foramen. C: Mid-sagittal resonance image showing that the disk extrusion of the L3-4 level obliterates the thecal sac. Representative Case 14 of a 70-year-old woman B: T2-weighted magnetic years) whereas disk herniation tends to occur in the age range of 30 to 50 years.24)GCDH occurs predominantly in females (female to male ratio 3.5:1), whereas disk herniation is more common in males (1:1.4).7)The vacuum phenomenon was first observed in 1910 and the radiologic findings of gas within the disk space were described in 1942.3,11) The vacuum phenomenon of an intervertebral disk is commonly noted in old age. The vacuum pheno- menon appears on CT in 46% of patients over 40 years old, and on radiography in 12% of patients.13) Gas in the spinal canal may involve degenerative spi- nal changes, especially the vacuum phenomenon. Gas within the spine is actually associated with col- lections of epidural-leaked gas from the adjacent disk. Typically, patients with gas from degenerative spinal changes are asymptomatic. A few symptomat- ic cases of gas within the spine, the so-called in- traspinal gas, epidural gas, or gas-containing pseu- docysts, were identified by CT, MR imaging, or both.5,6,12,26)Many patients have had a good response to conservative treatments or percutaneous proce- dures.5,9,23)The present series of 18 patients with symptomatic GCDH were all treated successfully with surgery. In degenerative disk disease, progressive dehydra- tion of the central disk produces enlarging clefts that are subsequently filled with gas released from the surrounding tissues.19,20) predominantly of nitrogen and is enclosed in a mem- brane of cartilage fragments that communicate with the disk.4)The cause of gas development within the spine is still unknown. One case of radiculopathy with gas-associated disk herniation in the spinal canal has been reported.21)The case was suggested to involve outflow of gas from the disk space through a tear in the annulus fibrosus, and pneumat- ic squeezing of gas from the intervertebral space into the encapsulated sac. In our series, all cases of The gas consists Neurol Med Chir (Tokyo) 50, October, 2010

  5. Symptomatic GCDH 909 909 underwent removal of only the GCDH and five patients with another level of spinal stenosis or disk herniation underwent removal of the GCDH and selective decompression. These five patients had long-standing claudication or leg pain. Leg pain as- sociated with GCDH abruptly occurred or exacer- bated. Six patients with instability underwent fusion with removal of the GCDH. The postoperative VAS score for radicular pain was improved in all patients. We believe that GCDH was a source of clin- ical symptoms or of acute exacerbation of chronic pain in our series, especially in multi-level spinal ste- nosis or disk herniations. GCDH may indicate a source of clinical symptoms in the degenerative spine, especially if abrupt ex- acerbation of symptoms is experienced combined with spinal stenosis or multiple spinal disk hernia- tions. 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