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

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


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
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.
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.
Journal of Trauma & Orthopaedic Surgery 2016; July - Sep; 11(3):19-23
Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23
Copyright © 2016 by The Maharashtra Orthopaedic Association |
operative period, there may be radicular pain due to
increase in local inflammation from the intervention
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
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
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
Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23 20
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)
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].
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.
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,
6Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23
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
Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23 22
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 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
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
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
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.
Journal of Trauma & Orthopaedic Surgery | July - Sep 2016 | Volume 11 |Issue 3 | Page 19-23 23
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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
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. ...
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.
Full-text available
Wound healing is a staged process which involves the activity of leukocytes and platelets. For this process to work efficiently, the platelets play a vital role. The growth factors present in platelets are important to guide the regenerating cells to the area of healing. Platelet-rich-fibrin (PRF) is one such material that holds on to these growth factors enmeshed in the fibrin network resulting in their sustained release over a period of time that can accelerate the wound healing process. With this knowledge, research has been carried out for a past few years for the clinical application of PRF. Various platelet concentrates have been studied including the platelet-rich-plasma (PRP). However, the short duration of cytokine release and its poor mechanical properties have resulted in the search of a new material with adequate properties for clinical application and ease of preparation. PRF has found a place in the regenerative field owing to its advantages over PRP. This review focuses on the properties and various applications of PRF in the clinical practice.
Purpose: To compare the structural healing and clinical outcomes of triple-loaded single-row with suture-bridging double-row repairs of full-thickness rotator cuff tendons when both repair constructs are augmented with platelet-rich plasma fibrin membrane. Methods: A prospective, randomized, consecutive series of patients diagnosed with full-thickness rotator cuff tears no greater than 3 cm in anteroposterior length were treated with a triple-loaded single-row (20) or suture-bridging double-row (20) repair augmented with platelet-rich plasma fibrin membrane. The primary outcome measure was cuff integrity by magnetic resonance imaging (MRI) at 12 months postoperatively. Secondary clinical outcome measures were American Shoulder and Elbow Surgeons, Rowe, Simple Shoulder Test, Constant, and Single Assessment Numeric Evaluation scores. Results: The mean MRI interval was 12.6 months (range, 12-17 months). A total of 3 of 20 single-row repairs and 3 of 20 double-row repairs (15%) had tears at follow-up MRI. The single-row group had re-tears in 1 single tendon repair and 2 double tendon repairs. All 3 tears failed at the original attachment site (Cho type 1). In the double-row group, re-tears were found in 3 double tendon repairs. All 3 tears failed medial to the medial row near the musculotendinous junction (Cho type 2). All clinical outcome measures were significantly improved from the preoperative level (P < .0001), but there was no statistical difference between groups postoperatively. Conclusions: There is no MRI difference in rotator cuff tendon re-tear rate at 12 months postsurgery between a triple-loaded single-row repair or a suture-bridging double-row repair when both are augmented with platelet-rich plasma fibrin membrane. No difference could be demonstrated between these repairs on clinical outcome scores. Level of evidence: I, Prospective randomized study.
Within the past few years an unusual group of tumors of the spinal cord, not heretofore recognized as a definite clinical entity, has come under observation. They are discrete, sharply circumscribed, ventral, extradural chondromas lying in the midline or slightly to one side of the midline, usually in the region of the fourth, fifth or sixth cervical vertebrae. The more typical of these tumors present sufficiently defined clinical signs to permit recognition before operation. The most characteristic picture is that of marked unilateral spasticity, with atrophy and weakness of the muscles of one or two cervical segments at the level of the tumor and on the side of the spasticity, and changes in pain and temperature sense on the opposite side. Muscle, joint, vibratory and discriminative sensations are unaltered. The upper limit of the sensory changes is usually several segments lower than the atrophy and motor weakness, which, as has
Anterior cervical spine surgery is an established surgical intervention for cervical degenerative disease and high success rate with excellent long-term outcomes have been reported. However, indications of surgical procedures for certain conditions are still controversial and severe complications to cause neurological dysfunction or deaths may occur. This review is focused mainly on five widely performed procedures by anterior approach for cervical degenerative disease; anterior cervical discectomy, anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, anterior cervical foraminotomy, and arthroplasty. Indications, procedures, outcomes, and complications of these surgeries are discussed.
Objective: Results following anterior cervical discectomy (ACD) without fusion are not well reported because of skepticism that the disturbed cervical spine anatomy after ACD might compromise clinical outcome. The purpose of this study was to determine whether ACD without fusion prompts the degenerative process significantly, and whether it is necessary to preserve disc height and cervical alignment for the sake of better clinical outcome following cervical spine surgery. Background data: Out of 56 consecutive patients, 37 patients who replied and consequently underwent postoperative MRI from April to June 2009 were included in this study. Material and methods: A total of 37 consecutive patients diagnosed as having cervical monoradiculopathy and treated with percutaneous endoscopic cervical discectomy (PECD) were investigated. Angle of cervical lordosis, change in cervical range of motion, disc height change, and degree of degenerative changes at the corresponding level were evaluated. The visual analogue scale (VAS) score for neck and arm pain and the neck disability index (NDI) were compared preoperatively and at the final follow-up. The mean follow-up period was 45.5 months. Results: Despite prompted radiological deterioration such as loss of disc height (the posterior disc heights and central disc height ratio were significantly decreased from 3.6 to 2.6 mm, from 30.3% to 24.5%, respectively, p<0.05) or degenerative progression (from average grade of 2.8 to 4.1, p<0.05), the patients achieved significant improvement in clinical outcomes (VAS for neck and arm dropped from mean 6.3 and 7.5 to 2.7 and 2.6, respectively, and NDI score improved from 46.8% to 17.2%, p<0.05) after PECD. Conclusions: Neither loss of disc height nor progression of degeneration at disc space compromised clinical outcome after PECD without fusion on long-term follow-up.
The aim is to review and discuss the strategies available for use of platelet rich fibrin as healing aid in dentistry. Platelet rich fibrin (PRF) is a fibrin matrix in which platelet cytokines, growth factors, and cells are trapped and may be released after a certain time and that can serve as a resorbable membrane. Choukroun and his associates were amongst the pioneers for using PRF protocol in oral and maxillofacial surgery to improve bone healing in implant dentistry. Autologous PRF is considered to be a healing biomaterial, and presently, studies have shown its application in various disciplines of dentistry. By using specific keywords, electronic search of scientific papers was carried out on the entire PubMed database with custom range of 5 years. The electronic search yielded 302 papers; based on inclusion and exclusion criteria which were specifically predetermined, 72 papers were identified as suitable to the inclusion criteria and the remaining 230 papers were excluded. After adding three more selected papers through hand search, full text of all the articles retrieved and review was done. By pooling the extracted data from selected papers, the reviewed data was synthesized. Recently by showing good promising results with use of the PRF, it has proved to have a good prospect for its use as healing aid in various aspects of the dentistry.
Platelet-rich fibrin (PRF) prepared by Choukroun's technique is derived from an autogenous preparation of concentrated platelets without any manipulation. PRF was found to increase osteoblast growth and proliferation. However, the underlying mechanisms are not yet completely understood. This study aimed to determine the effects of PRF on cell attachment, proliferation, phosphorylated Akt, heat shock protein 47 (HSP47) and lysyl oxidase (LOX) expression on human osteoblasts. Blood collection was carried out from 10 healthy volunteers. Cell attachment and proliferation were measured by colorimetric assay with WST-1 and alamar blue in human osteoblast cell line U2OS cells, respectively. Western blot was employed to evaluate the expression of p-Akt, HSP47 and LOX. PRF alone was found to stimulate U2OS cell attachment compared with untreated controls (p < 0.05). PRF was found to increase osteoblast proliferation during a 5-day incubation period (p < 0.05). PRF was found to increase Akt phosphorylation in a time-dependent manner (p < 0.05). Collagen-related proteins HSP47 and LOX were significantly elevated by stimulation with PRF compared with untreated controls (p < 0.05). It is suggested that PRF is capable of increasing osteoblast attachment, proliferation and simultaneously upregulating collagen-related protein production. These actions in combination would effectively promote bone regeneration.
The aim of this work was to determine the relevance of Choukroun's platelet-rich fibrin (PRF) in dental implantology by determining the in vitro effects of soluble factors released by PRF clot. We used 3 different cell lines implicated in dental implantology: osteoblast, keratinocyte, and fibroblast. Cellular viability, cell proliferation, and gene expression were analyzed using PRF conditioned medium. Three different cells lines were used: SaOS2 (osteoblast), MRC5 (fibroblast), and KB (epithelial cell). The sulforhodamine B assay showed a significant increase in cell number for the undiluted and 1:3 diluted conditioned medium after 24 and 48 hours. There was no effect for the 1:9 dilution. Cell cycle analysis by flow cytometry confirmed the viability test results. After 48 hours, PRF conditioned medium induced gene expression in osteoblasts. Expression of osteopontin and osteocalcin, late osteogenic markers, was observed using reverse transcriptase-polymerase chain reaction (RT-PCR). This study establishes a model to evaluate, in vitro, the effects of soluble growth factors released by PRF clot. Our work confirmed PRF is useful in stimulating tissue healing and bone regeneration. This work should recommend Choukroun's PRF in numerous implantology clinical applications.