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Percutaneous Endoscopic Cervical Discectomy with insertion of Platelet Rich Fibrin (Derwan) plug

Authors:
  • BKL Walawalkar medical college
  • Dr. D.Y.Patil Medical College, Hospital and Research Centre, Pimpri, Pune

Abstract

Background: IThe forward tilt of the head results in an increasing eccentric loading of the spine. World over we are likely to see therefore an increasing incidence of failure of the disc causing radicular pain at a younger age. Also decrease in fitness & poor muscular control may contribute to multifactorial genesis of spinal disc disease disorders. Whereas most of these would respond to conservative treatment& postural training, for the non responders who are treated surgically, we need to be able to develop a reliable, surgical modality of treatment which is targeted, causes minimum long term morbidity & can be performed with minimum hospitalisation especially in the younger age group.
Original Article
Percutaneous Endoscopic Cervical Discectomy with insertion of
Platelet Rich Fibrin (Derwan) plug
Sunil M Nadkarni, Pawankumar Kohli, Satishchandra Gore, Bhagyashree Kulkarni, Bhupesh Patel D
Abstract
Background: IThe forward tilt of the head results in an increasing eccentric loading of the spine. World over we are likely to see
therefore an increasing incidence of failure of the disc causing radicular pain at a younger age. Also decrease in fitness & poor
muscular control may contribute to multifactorial genesis of spinal disc disease disorders. Whereas most of these would
respond to conservative treatment& postural training, for the non responders who are treated surgically, we need to be able to
develop a reliable, surgical modality of treatment which is targeted, causes minimum long term morbidity & can be performed
with minimum hospitalisation especially in the younger age group.
PECD is a minimally invasive treatment modality for radicular pain caused by a soft cervical disc herniation through a 5mm
incision under local anaesthesia.
Many in vitro studies have shown the regenerative potential of PRF. We hypothesised that the use of PRF, promoting annular
healing reduces post operative radicular pain by plummeting local inflammation can induce the possible regeneration of
intervertebral disc followed by PECD.
At our hospital over the last 2 years we have been combining the two. This is the first reported use of PRF in spine surgery
&Endoscopic spine surgery. The DERVAN plug or modified PRF plug is also perfectly suited for insertion through the 2.5 mm
cannula of endoscopic spine surgery.
Materials & Methods: 5 consecutively treated patients with soft cervical disc herniation with unilateral radiculopathy by
PECD with insertion of Platelet rich fibrin plug (Derwan plug) over a period of 2 years wherein a follow up MRI was possible and
available are being reported. Inclusion and exclusion criteria are fulfilled as described below. PECD enables removal of
offending fragment under vision with irrigation which along with Platelet rich fibrin plug helps to reduce inflammation with few
complications. All patients followed minimum for 6 months with Visual Analogue Score (VAS) and Neck Disability Index (NDI)
and a follow up MRI.
Results: All treated patients have good outcome in terms of pain relief (VAS) and functional recovery (NDI). The follow up
MRIs were encouraging in terms of disc height, hydration annular healing and endplate changes.
Conclusions: Unique combination of percutaneous endoscopic cervical discectomy and insertion of PRF plug (Derwan plug)
may offer a way forward to avoid fusion and preserve segmental motion. This in turn would prevent the adjacent segment
degeneration and avoid the risk related to hardware (non union, pseudoarthrosis) especially in younger patients with
maintained disc architecture.
Key-words: PECD, minimally invasive spine surgery, cervical radiculopathy, Soft disc herniation, decompression.
Foot note: PECD= Percutaneous Endoscopic Cervical Discectomy, VAS= Visual Analog Score, NDI = Neck Disability Index.
Introduction
Stookey first described clinical symptoms and anatomical
location of cervical disc herniation [1]. Cervical disc
herniation presents in form of headache, neck pain,
unilateral or bilateral arm pain (radiculopathy) or motor
and sensory deficit [2]. Symptomatology of cervical disc
herniation is due to mechanical compression and
chemical irritation of nerve roots [3]. Mechanical
compression (herniated fragment) can be diagnosed by
imaging study (MRI or CT scan) and chemical irritation
by clinical examination by locating dermatomal
distribution of pain [2,3,4]. Majority of patients responds
well with conservative treatment and remaining patients
requires some form of intervention [2].
Cervical disc herniation may be soft disc herniation or
hard disc hern iation. Hard herniation is due to
collagenisation and subsequent osteophyte formation
[2,5]. Current treatment options are anterior cervical
discectomy only, anterior cervical discectomy with fusion
(ACDF) mainly for soft herniation [6,7].
Percutaneous Endoscopic Cervical Discectomy (PECD) is
a stitchless procedure performed under local anaesthesia
providing relief from radicular pain. It is performed under
local anaesthesia in an awake state improving patient
safety. However for some time in the immediate post
1Department of Spine Surgery, Shree Vithalrao Joshi Charities Trust's
B.K.L. Walawalkar Hospital and Rural Medical College.
A/p Kasawadi, Sawarde, Tal. Chiplun, Dist. Ratnagiri- 415606,
Maharashtra, India.
Address for correspondence:
Dr. Sunil M. Nadkarni,
Ankur, 12 ShantaSociety, 394/B Kusalkar Road, Pune 411016 India.
Email: sunilnadkarni@gmail.com
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Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23
Copyright © 2016 by The Maharashtra Orthopaedic Association |
19
operative period, there may be radicular pain due to
increase in local inflammation from the intervention
[8].
Through a fortuitous association with my colleague who
was using the platelet rich fibrin (PRF) to accelerate
healing in sports injuries led to the present novel
practice [9]; in the beginning with the idea that a fibrin
mesh around the root on completing the procedure of
PECD would decrease early postoperative discomfort
by keeping away the RBCs (Red blood cells) from the
root and later in the hope that it would stimulate local
healing [10-12].
PRF is an autologous derivative of platelet concentrates.
Fibrin is an activated molecule of fibrinogen. This
autologous derivative releases number of cytokines and
growth factor accelerates the collegen system and
promotes the local healing. PRF enhances the cell
proliferation of different cells like fibroblast, adipocytes,
osteoblasts, keratinocytes. The strong organisation of
the fibrin mesh, great concentration of leucocytes, slow
release of growth factor this synergic effect enhances the
healing of soft tissue and hard tissue [10,13,14,18,19,23].
The initial experience with the use of the PRF was very
encouraging in terms of the speed of patients recovery
(pain, spasm and function) to the extent that it became
standard practice at our hospital over the last 2 years. In
the first few months a standardised protocol and
equipment to obtain a reasonable quality plug was
evolved.
There is no report in literature that has shown the use of
Platelet rich fibrin (PRF) in cervical spine surgery
[15,16,17]. However from in-vitro studies & other work
in dentistry etc [18,19,20], it was expected to be the
perfect bio composite to enhance healing, increase
infection resistance & provide substrate for exiting root
protection.
To the best of our knowledge, this study is the first in
literature of in vivo use of PRF following cervical
discectomy and shares our experience since last 12
months in the use of a PRF plug (known as Dervan Plug)
in inducing healing of the torn annulus and degenerate
nucleus pulposus.
Material and Methods
5 patients who underwent PECD with the insertion of
Dervan plug at our hospital with a minimum follow-up
of 12 months and who were amenable to a postoperative
MRI form the subjects of this study.
Percut aneous Endosc opic Cer vical Discectomy
procedure is performed in a supine position with neck
extended by placing pillow under shoulders and a soft
silicon ring placed below the head to prevent rotation of
the head. Shoulders are pulled by applying adhesive tape
to visualise lower cervical spine. The neck is then
painted with iodine solution and draped with sterile
sheets [8].
Under C-arm guidance the needle was inserted medial
to the anterior border of sternocleidomastoid between
carotid sheath and midline viscera from the opposite
side of the herniation. With the use of three fingers the
space between the carotid sheath and midline viscera is
opened to feel the cervical vertebra with the middle
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Nadkarni SM et al
Photograph 1: Dervan Plug (PRF
plug) after the centrifugation of
3000 r.p.m. for 10 mins followed
by the 10 mins of standing time in
centrifuge is ready for insertion
Photograph 2: Preoperative Magnetic
Resonance Image of Cervical Spine of 42
years old patient shows degenerative
changes in the disc at C5-C6 level
Photograph 3: Post operative MRI of cervical spine
of same patient after 12 months of PECD followed
by the use of Dervan Plug (PRF plug) shows
regeneration of soft tissue and healing of the
ruptured annulus of the same disc at C5-C6 level
finger. After infiltration with local anaesthetic (1:1 mix
of 0.5% Lignocaine and 0.5% Bupivacaine total of about
10 mls) the needle is inserted into the centre of desired
disc space under C-arm guidance. A guide wire was then
passed, over which dilators were inserted. Working
sheath of desire shape was then passed over dilator and
position was confirmed under C-arm. Dilator was then
removed once the position of dilators and working
sheath was appropriate (with respect to the fragment)
under the C-arm [8].
Endoscope (Karl Storz, Germany) with working channel
of 2.5mm introduced and fragment was identified.
Fragmentectomy was done with different types of
grasper. If fragment cannot be grasped with the forceps
then hook can be used to tease the fragment and allows
easy removal with the grasper. Hook was also used to
palpate the nerve root and confirm the complete
removal of offending fragments. Fresh epidural
bleeding, palpation and visualisation of nerve root and
subsidence of pain are the signs of complete removal of
the fragment [8].
Blood is rapidly (before clotting cascade is triggered i.e.
less than a minute) transferred to a suitable plain glass
tube with a cap(Micro-Aid) and centrifuged at 3000 rpm
for 10 minutes (REMI R-303). Thereafter a standing
time in the centrifuge of about 10 minutes is allowed [10-
16]. Using sterile precautions the tube is then uncapped
by the circulating theatre personnel and the plug is lifted
from the tube and is ready for insertion (Photograph 1)
[10-16].
At the end of the procedure the Dervan plug is placed in
the cannula and by using the dilator/ obturator pushed
into the disc at the mouth of the annulus. Patients are
mobilised after 2 hours and discharged from the hospital
on the same /next day with cervical soft collar.
Outcome was measured using the VAS scale and the
Neck Disability Index (NDI) [4,6]. Clinical records were
scanned for any unusual or adverse events. Post
operative MRI was evaluated for disc height, hydration,
annular healing, endplate changes and any kyphosis
(Table 1) [5,21].
Results
VAS score showed a consistent decrease as shown in
(Graph 1). NDI showed reduced neck disability form
100% to 0% in the postsurgical period recorded at 1
month, 3 months and 6 months (Graph 2). Out of 5
patients we were able to get the post operative MRI scan
in 4patients at minimum 6months and 12 months post
surgery. There was regeneration of soft tissue and
healing of the ruptured annulus in the post operative
MR I as compared to pre operative MRI scans
(Photograph 2,3). No complications were observed in
any of the patient because of the use of Dervan plug
(PRF) followed by the percutaneous endoscopic cervical
discectomy. PECD has its own advantages but the use of
Dervan plug as a bioactive healant may have the added
benefits of disc regeneration, healing [11,13,23] and
reducing long term morbidity & pain.
Discussion
Her n i at e d di s cs lead oft e n to s y mp t o ma t ic
radiculopathy. Percutaneous Endoscopic Cervical
Discectomy (PECD) procedure is successively proven
treatment for soft disc herniation [6,7,8].
This particular procedure has many advantages such as
local anaesthesia, awake patient procedure & feedback,
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21
Nadkarni SM et al
Nadkarni SM et al
Graph 1: Outcome of Surgery by VAS with the use
of Dervan plug (PRF) followed by PECD: Shows
decrease in post surgical pain within the post
surgical period of 1 week, 1 month, 3 months and 6
months
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OPD procedure, using a small 5 mms incision and
successfully approaching and removing the herniated
disc fragment by leaving minimum footprint [7,8].
On this background platelet rich fibrin plug displayed
very useful in vivo characteristics to accelerate healing
of tissues. It was firstly introduced by Choukren et.al. in
year 2001 in dentistry that PRF enhances the bone
matrix formation in implantation [19,20,21].
In Vitro studies evidence emphasized that it is expected
to orchestrate and accelerate local healing of tissue
[13,18,24].
The procedure is very economic, simple and reliable in
terms of cost of preparation. The portable centrifuge
costing about Rs 5000 and glass test tubes about Rs 15
make the procedure very cost effective [16].
It is a speedy, safe and very credible method of getting a
bioactive plug for healing of the annulus.
In this small series the changes on MRI strongly suggest
that the promise of PRF as a orchestrator of healer of a
damaged disc in in vitro studies may also hold true in
vivo.
Nadkarni SM et al
Table 1: Evaluation of post-operative MRI, Abbreviation: No – no of patient, DOPr – Duration between
preoperative MRI and Surgery, DOPo – Duration between post-operative MRI an Surgery, Pre-op –
Preoperative, Post op- Post operative, HIZ – High intensity zone annular tear present, H – Healed annular
tear
Graph 2: Outcome of Surgery by NDI with the use
of Dervan Plug followed by PECD: Shows decrease
in post surgical pain within the post surgical period
of 1 week, 1 month, 3 months and 6 months.
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References
How to Cite this Article
Nadkarni SM, Kohli PK, Gore S, Kulkarni B, Patel B. Percutaneous
Endoscopic Cervical Discectomy with insertion of Platelet Rich Fibrin
(Derwan) plug. Journal of Trauma and Orthopaedic Surgery July - Sep
2016;11(3):19-23.
Conflict of Interest: NIL
Source of Support: NIL
Nadkarni SM et al
... These complications are totally avoided with sPECD. 22 The access related annular weakening is proposed to be dealt with the use of platelet-rich fibrin, and work is underway to study the growth of nucleus and annulus under the effect of platelet-related growth factors. It is already reported for lumbar spine. ...
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Background STITCHLESS percutaneous endoscopic cervical discectomy s[PECD] is safe, precise, targeted, and a complete endoscopic procedure to treat soft cervical disc herniation with unilateral radiculopathy. It allows direct visualization of herniated fragment and its removal, inspection of decompressed nerve root in an awake and aware patient. It reduces the risk related to general anesthesia and to the neurological structures. However, all the patients treated with PECD can be candidates for anterior cervical discectomy and fusion (ACDF). ACDF requires a longer period of stay, expense, and more risk to neurological structures and ultimately loss of the disc space by fusion. Materials and Methods Twenty consecutively treated patients by sPECD over a period of 2 years with soft cervical disc herniation and unilateral radiculopathy were included in the study. PECD enables removal of offending fragment under vision and irrigation and ablation of inflammation with few complications. All patients were followed for minimum of 6 months with visual analog score (VAS) and neck disability index (NDI). Results All treated patients had a good outcome in terms of pain relief (VAS) and functional recovery (NDI). One patient had episodes of cough lying in the supine position and another patient had transient hoarseness of voice, (both recovered). Conclusion Potential benefits of sPECD include safety as it is done under local anesthesia, smaller incision, short hospitalization, fewer complications, avoidance of fusion, preservation of segmental motion, preventing the adjacent segment degeneration, and avoidance of the risk related to the hardware (nonunion and pseudarthrosis). sPECD is an effective treatment modality for soft cervical disc herniation.
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