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Surgical Procedures: Discectomy and Herniectomy
Erik Van de Kelft
CONTENTS 14.1 14.2 14.3 Introduction 361 Pathology of Lumbar Disc Herniation Pathophysiology of Lumbar Disc Herniation 362 361
ment of a lumbar disc herniation depends increasingly on radiological images. The decision on how to treat the so-called failed back surgery syndrome (FBSS) also depends largely on the speciﬁc postoperative imaging ﬁndings.
14.4 Surgical Treatment 363 14.4.1 Indications 363 220.127.116.11 Absolute Indications for Surgical Treatment 363 18.104.22.168 Relative Indications for Surgical Treatment 364 14.4.2 Risks and Beneﬁts 364 14.4.3 Surgical Technique 365 22.214.171.124 Percutaneous Disc Decompression 366 126.96.36.199 Micro-endoscopic Discectomy 367 188.8.131.52 Resection of Extraforaminal Disc Herniations 368 14.5 Conclusions 369 References 369
14.2 Pathology of Lumbar Disc Herniation
Joints are subjected to the ravages of aging, degeneration and trauma. The degeneration of the intervertebral disk is a complex process that involves changes in both composition and function of the disk. This degenerative process most frequently manifests itself as spondylosis, the development of osteophytes and disc herniation. Indeed, a symptomatic disc herniation without any other sign of disc degeneration is rarely noticed. Even so-called post-traumatic disc herniations usually have an underlying degenerative process. Sudden strains, particularly if associated with rotational torque, may cause tearing and ultimately rupture of the annular ring. More commonly the annulus ﬁbrosus deteriorates more gradually, as a product of cumulative stresses over time, causing microscopic tears rather than a single explosive rupture. A signiﬁcant compressive force at the level of a healthy disc will cause a fracture of the vertebral body before tearing the annulus. This is important when considering the relationship of a traumatic event to a herniated disc that may manifest itself several years later. Many procedures have been developed to treat abnormalities and degeneration of the intervertebral disc. The associated pathological entities include disc herniation, degenerative disc disease (DDD) and segmental instability (Mouw and Hitchon 1996; Dowd et al. 1998). Over the past three decades, much attention has been given by clinicians and
In this chapter we will discuss the pathology of lumbar disk herniation. The clinical symptoms of a lumbar disk herniation will be discussed as well as the different therapeutical options, especially surgical therapy. The different surgical techniques will be described in detail with the intention to help the radiologist in interpreting both pre- and postoperative lumbar spine imaging studies. The choice of treat-
E. Van de Kelft, MD, PhD Department of Neurosurgery, Nikolaas General Hospital, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium
E. Van de Kelft
b Indications for surgery in patients with lumbar b Surgical techniques: disc herniation: b Percutaneous disc decompression b Absolute indications: b Micro-endoscopic discectomy – Cauda equina syndrome b Resection of extraforaminal disc herniations – Weakness and sensory loss b Risks and beneﬁts of surgery compared to con– Persistent pain servative therapy: b Relative indications: b Risks – complications: – Failure of symptom relief after 2–4 weeks of – Spondylodiscitis appropriate conservative therapy – Hemorrhage – Radicular pain in a dermatomal pattern – Wound infection – Sensory loss in the same dermatome – Nerve root damage – Weakness in the correct distribution – FBSS – Depressed tendon reﬂex appropriate to pain, b Beneﬁts: weakness and sensory loss – Early pain relief – Limited straight-leg raising with reproduction of radicular pain – Abnormal neuro-imaging (CT or MRI) consistent with the neurological deﬁcit
radiologists to the degeneration of the disc itself as a result of the growing awareness of the clinical entity “lumbar disc herniation”, its surgical treatment and the impact this treatment has on national health services. Lumbar discectomies are among the most common elective surgical procedures performed in North America (Taylor et al. 1994). In Belgium, the incidence of lumbar discectomies was 1 in 1000 in 2004. In the near future, however, pathology of the facet joints will become as important as that of the disc itself. Spine surgeons all over the world are becoming increasingly interested in total disc replacement strategies. The use of lumbar disc prosthesis is already common in Europe and will soon explode in North America, as soon as clinical results can demonstrate its superiority over other surgical treatment options (Geisler et al. 2004). Total disc replacement by a disc prosthesis can only be of any use if the facet joints are intact and are as such not responsible for any clinically relevant pain. When both the intervertebral disc and the facet joints are degenerated and both are responsible for pain, they should both be replaced. Some facet joint implants have already been designed and patented. They are currently undergoing mechanical testing but have not been used in clinical trials. Thus the three degenerated joints (one disc and two facets) will be re-
placed by three artiﬁcial joints (one disc prosthesis and two facet joint prostheses).
14.3 Pathophysiology of Lumbar Disc Herniation
Although the incidence of low back pain is about 60%, the incidence of low back pain with sciatica is only 1%. Sciatica is most commonly due to herniation of parts of a lumbar disc. Since 90% of disc herniations occur at the level of the two lowest lumbar discs, the referred pain is within the distribution of the sciatic nerve, hence the name sciatica. Such a disc herniation, however, may not be a prerequisite for radicular pain. Root entrapment syndrome may affect the lumbar root in the spinal canal, in the foraminal canal or even outside this foraminal canal. In our own series, we reported such “extraforaminal” location in 13% of all lumbar disc herniations (Van de Kelft et al. 1994). The radiologist, when he has no clinical information, often overlooks this pathology, especially on poor resolution CT images. A clear L4 pathology with a normal spinal canal at L3–L4 should urge the radiologist to look for an extraforaminal location of
Surgical Procedures: Discectomy and Herniectomy
an extruded disc fragment at L4–L5. It is also important to notice that a disc bulging or protrusion seldom reaches the root at a foraminal and never at its extraforaminal location. This is only possible for an extruded disc fragment. In an extreme situation there may be a massive nuclear protrusion in which a large volume of disc material is suddenly thrust into the spinal canal, producing a “profound neurological catastrophe”, such as a cauda equina syndrome. In this case progressive sensory loss and motor weakness of the legs is associated with sphincter disturbances. The physician on duty will urge the radiologist for an immediate diagnosis, since this condition has to be treated surgically as soon as possible. The best option for the correct diagnosis is MRI. If unavailable, a CT myelogram should be carried out, even at night, since a poor resolution CT scan may give false negative results; the herniation may be so large that it completely ﬁlls the spinal canal making the differentiation from its normal content extremely difﬁcult. The initial symptoms of sciatica often occur without a precipitating event or following a seemingly trivial movement or maneuver and are typically not particularly incapacitating. At this moment, a tear in the annular ring appears which can be well demonstrated on MRI. As the inﬂammation (as a result of the annular tear) progresses, the symptoms crescendo in a relentless fashion. Most patients experience paraspinal muscle spasms directed at stabilizing the affected level. At that time the sciatica appears with irradiating pain in the leg according to the dermatomal distribution of the affected nerve root. Through the annular tear, the nucleus pulposus has protruded as a herniated fragment compressing the nerve root. The irradiating pain is the result of mechanical compression of the nerve root. The precise distribution of leg pain varies according to the root involved. Compression of the S1 nerve root usually starts as a dull pain in the back or the thigh or buttock, but can later involve the posterior or lateral aspects of the calf, as well as the heel and the sole of the foot. Compression of the L5 nerve root is characterized by pain that runs more at the anterior side of the leg into the big toe. A typical L4 pain runs more in front of the leg and around the knee, to end half way the tibia. This typical pain is often caused by an extraforaminal disc herniation at L4–L5. Following mechanical compression, the root becomes inﬂamed due to this mechanical trauma. This inﬂammation can be dealt with during the conservative treatment, but is often responsible for a long-
lasting dull aching or burning limb pain, even when the nerve root is fully decompressed. The initial goal of conservative therapy is to diminish the pain caused by inﬂammation. Usual conservative treatment consists of bed rest, non-steroidal anti-inﬂammatory drugs, muscle relaxation and, if necessary, epidural steroids. There seems to be no signiﬁcant difference in outcome when conservative treatment is compared to the natural history of sciatica. After the acute onset of sciatica, more than 50% of patients will improve signiﬁcantly under conservative treatment after 2 months (Saal 1996).
14.4 Surgical Treatment
14.4.1 Indications There is some controversy about the usefulness of surgery versus nonoperative treatment in managing these patients. The majority of patients with lumbar disc herniations and sciatica will improve over time with conservative treatment. There is a tendency, however, to operate on these patients a few weeks after the onset of their initial symptoms. The surgical technique becomes minimally invasive (nucleoplasty, micro-endoscopic discectomy) and can be performed on an outpatient basis (Foley and Smith 1997; Smith and Foley 1998). It is our task to return a patient with sciatica in a prompt and effective manner to his or her previous level of function as soon as possible. Indications for surgery can be divided into absolute and relative indications (Table 14.1).
184.108.40.206 Absolute Indications for Surgical Treatment
There are three absolute indications for surgical treatment of acute sciatica due to a herniated lumbar disc which will be discussed in the following sections.
220.127.116.11.1 The Cauda Equina Syndrome
In cauda equina compression with bladder and/or bowel incontinence, which is often not obvious at
E. Van de Kelft
Table 14.1. Indications for surgery in patients with a herniated lumbar disc Absolute indications Cauda equina syndrome Weakness and sensory loss Persistent pain Relative indications Failure of symptom relief after 2–4 weeks of appropriate conservative therapy Radicular pain in a dermatomal pattern Sensory loss in the same dermatome Weakness in the correct distribution Depressed tendon reﬂex appropriate to pain, weakness and sensory loss Limited straight-leg raising with reproduction of radicular pain Abnormal neuro-imaging (CT or MRI) consistent with the neurological deﬁcit
the more this surgery can be done on an outpatient basis, the more it becomes an attractive alternative for relief of symptoms, even after the ﬁ rst week of symptoms. As will be discussed later, the beneﬁt of surgery is the swift relief of symptoms. The longterm outcome is comparable to that of conservative treatment and even with that of natural evolution.
18.104.22.168 Relative Indications for Surgical Treatment
the time of admission, urgent decompression of the cauda is mandatory. This is the only indication for urgent lumbar disc surgery. Every attempt to treat this disorder conservatively will end in court. Often, even after adequate surgical decompression with complete relief of pain, the bowel or bladder incontinence persists for months or becomes permanent.
22.214.171.124.2 Weakness and Sensory Loss
The American Association of Neurological Surgeons (AANS) and the American Academy of Orthopaedic Surgeons have listed seven indications for surgical treatment of a herniated lumbar disc disease: ¼ Failure to relieve symptoms after 2–4 weeks of appropriate conservative therapy ¼ Radicular pain in a dermatomal pattern ¼ Sensory loss in the same dermatome ¼ Weakness in the correct distribution ¼ Depressed tendon reﬂex appropriate to pain, weakness and sensory loss ¼ Limited straight-leg raising with reproduction of radicular pain ¼ Abnormal neuro-imaging (CT scan or MRI) consistent with the neurological deﬁcit (Long et al. 1988) In these cases it is up to the patient whether he decides to resolve the pain by surgery or whether he prefers to wait for the results of conservative treatment. Weber (1983) reported a prospective, randomized study in which surgery was compared to conservative therapy. The study showed that, although surgery of lumbar disc herniations was superior to nonoperative treatment at 1 year, results at 4- and 10-year followup showed no statistical difference (Weber 1983). Although surgery may provide more rapid relief of pain, the ultimate result is approximately the same regardless of treatment, with long-term resolution of sciatica approaching 87%. This study was undertaken 25 years ago; conservative treatment did not change spectacularly in this period; surgery, however, did.
The presence of signiﬁcant neurological deﬁcits such as weakness and/or sensory loss, which affects 5%– 20% of patients with acute sciatica, is a good indication for surgery without delay. It seems obvious that a neurological deﬁcit due to mechanical compression of the nerve root will resolve better the earlier the root can be liberated. Some authors showed, however, that delays of up to 3 months had a minimal effect on the ultimate recovery of strength (Hakelius 1970).
126.96.36.199.3 Severe Persistent Pain
Clearly not all patients have the opportunity to rest and undergo conservative treatment of their sciatica. Busy people with severe incapacitating leg pain due to a herniated disc fragment often urge us to ﬁnd an immediate yet elegant solution for their problem. The more surgery becomes minimally invasive due to microsurgical and endoscopic techniques, and
14.4.2 Risks and Benefits If, according to a 25-year-old study, there is no difference in outcome when surgery is compared to conservative therapy, and if surgery always carries some operative risk, what then is its beneﬁt (Fig. 14.1)
Surgical Procedures: Discectomy and Herniectomy
Fig. 14.1. Evolution of pain in patients with a lumbar disc herniation. According to Weber’s study, there is no statistical difference in outcome after 4 years when comparing natural history, percutaneous techniques or surgery in the treatment of a lumbar disc herniation. It is obvious, however, that surgery is able to relieve symptoms more quickly. Degenerative disc disease can be responsible for recurrent low back pain in all non-disc-replacing therapeutic options
(Weber 1983)? Clearly there is a beneﬁt in terms of the so-called absolute indications, especially the cauda equina syndrome. For the relative indications the beneﬁt lies in early pain relief in comparison to conservative treatment. Therefore, it is better to operate a patient with acute sciatica of 4 weeks’ duration, than one with chronic sciatica over a period of 6 months, since the latter may be close to the spontaneous resolution of his problems. The relative beneﬁt of surgery will be comparatively small in this case. Additionally, recovery of the root might also be problematic after mechanical compression of 6 months’ duration. Most patients are afraid of lumbar disc surgery and many have heard stories of someone who was left plegic following surgery. Although the theoretical risk of serious nerve root damage exists, in practice it almost never occurs. The most serious risk of lumber surgery, with an incidence of 0.04%, is spondylodiscitis (Van Goethem et al. 2000). This involves extreme low back pain occurring weeks to months after surgery and a hospital stay of several weeks since the treatment consists of antibiotics over at least a 6-week period. Wound hematoma and superﬁcial wound infection are minor risks. Procedures for removal of the herniated disc fragment have two major goals: to relieve pain immediately and to prevent recurrence. The ﬁrst goal can be accomplished in more than 90% of cases. The second is more difﬁcult. The more the surgeon tries to prevent any recurrence, implying near total disc removal, the more the intervertebral disc will collapse, resulting
in facet joint pain. Furthermore, recurrence of a herniated disc is not typical in operated patients: there is no difference in recurrence between operated and non-operated patients (Weber 1983). The disc itself will degenerate once an annular tear has appeared. Consequently, low back pain can occur due to disc degeneration in operated as well as in non-operated patients. Therefore, in the author’s opinion, recurrence and persistent low back pain after conservative or surgical therapy is not a complication, but rather a logical consequence of the natural history of disc degeneration (Van de Kelft et al. 1996). In 2004 we started a phase three clinical trial as part of a multicenter study using a mixture of elastin and silk injected into an operated disc to seal the annular tear or the surgically created annular opening. This procedure has two goals: to prevent recurrent herniation of previously operated discs and to restore the disc height by replacing the amount of resected nucleus with the product mentioned above. A major “complication” after surgery is the socalled FBSS occurring in less than 1% of all operated patients (Samy Abdou and Hardy 1999). Its origin is unknown, but the syndrome consists of a dull burning pain in the limbs, occurring weeks to months after surgery. Successful treatment of these patients requires a correct diagnosis of the underlying process prior to further intervention. Surgery may beneﬁt patients with recurrent disc herniation, segmental instability, or spinal stenosis, but patients with epidural ﬁbrosis and arachnoiditis (together accounting for about 20% of all FBSS patients) are less likely to obtain a satisfactory outcome from surgical re-intervention (Van de Kelft and De La Porte 1994). Spinal cord stimulation may beneﬁt about half of these patients (Samy Abdou and Hardy 1999). Today, there are neither technical guidelines nor products available to prevent peridural scarring (Robertson et al. 1999).
14.4.3 Surgical Technique As indicated earlier, there is a strong tendency to minimize tissue damage and to operate patients early in order to rehabilitate them faster. Therefore, many percutaneous techniques have been developed in recent years. Other than the chemical dissolution of the nucleus (chymopapain), a technique that is no longer in use, new techniques focus on the mechanical treatment of the pathological disc. It is of extreme importance to notice that all of these
E. Van de Kelft
techniques have the same clinical indications as the classical surgical one (i.e. microdiscectomy), but can only be carried out with a reasonable success rate if the herniation is contained by an intact outer annular ring. Even discography cannot help establish this diagnosis. Minimally invasive intradiscal techniques that provide percutaneous access to the discs are chemonucleolysis, percutaneous nucleotomy, automated percutaneous lumbar discectomy, intradiscal laser discectomy, and intradiscal radiofrequency ablation. Nucleoplasty is a non-heat driven process that employs coblation technology using bipolar radiofrequency technology applied to a conductive medium (i.e. saline) to achieve tissue removal with minimal thermal damage to collateral tissues (Nazariaz 1985).
188.8.131.52 Percutaneous Disc Decompression
The technique we use in our department is a nucleoplasty based on coblation (Robertson et al. 1999; Nazariaz 1985; Singh et al. 2003; Mochida
et al. 2001). Percutaneous disc decompression using coblation (nucleoplasty) is performed on an outpatient basis under monitored anesthesia care in the operating room. All procedures are performed under strict sterile conditions using ﬂuoroscopic guidance with the patient in a prone or semi-oblique position. A 17-gauge 6-in. Crawford-type spinal access cannula is placed at the junction of the annulus and nucleus. A PercDLE wand (ArthroCare, Inc., Sunnyvale, CA) is advanced into the disc via the spinal access cannula. After conﬁrming that proximal and distal channel limits are within the disc, decompression is initiated. The decompression process involves advancing the wand, in ablation mode, to the distal channel limit at a speed of 0.5 cm/s and retraction of the wand in coagulation mode, to the proximal channel limit at the same speed (Fig. 14.2). Six channels are created at the twelve, two, four, six, eight, and ten o’clock positions. Postoperatively, patients are allowed limited walking, standing and sitting as needed in daily-life activities; however, they are instructed to limit bending, stooping and
Fig. 14.2a–c. Disc coblation. a The coblation technique is based on a heat producing canula that coagulates and aspirates parts of the nucleus. b Under ﬂuoroscopic guidance, a 17-gauge spinal cannula is placed in the center of the nucleus. c In a forward-backward mode, six channels are created in the nucleus
Surgical Procedures: Discectomy and Herniectomy
lifting more than 5 kg (10 lbs) for 2 weeks. Patients with sedentary or light work environments are allowed to return to work after 2 weeks. A qualiﬁed instructor provides patients with home exercise instructions.
184.108.40.206 Micro-endoscopic Discectomy
Annular integrity is an important variable in achieving a beneﬁcial outcome in patients undergoing disc decompression. Annular repair occurs very gradually and a large incision into a degenerated-herniated disc will result in a decrease in annular strength during the healing process (Ahlgren et al. 2000). Analysis of proteoglycan synthesis and degradation indicate that replacement of proteoglycan molecules within the disc may take up to 3 years (Stathopoulos and Cramer 1995). Three separate analyses have concluded that the box incision method leads to signiﬁcantly poorer healing, a decrease in strength of 40%–50%, and an increase in severe and early disc degeneration (Ahlgren et al. 1994; Ethier et al. 1994). Another study indicates that square, circular, cross, and slit incisions each produce a larger range in motion during axial moment loading (Ahlgren et al. 2000). Annular entry with a 2.5-mm OD trocar maintained disc integrity during biomechanical loading (Natarajan et al. 2002). Once the annular ring has been opened, subtotal or total discectomy can be carried out. Biomechanical studies show, however, that translational as well as rotational instability is less following subtotal discectomy (Nazariaz 1985). It is these ﬁndings that have further lent support to the approach of discectomy without curettement. In special indications we do remove the total nucleus with the intention of replacing it with a prosthesis like the prosthetic disc nucleus (PDN) (Fig. 14.3). This technique, while very challenging, is also very promising. It is not always obvious to see the PDN on MR, especially if the surgical procedure is not known while interpreting the images. The most important goals for surgical treatment of lumbar disc herniation are therefore: ¼ Removal of the herniation causing symptoms. ¼ If unnecessary, try to avoid making holes in the annulus. ¼ Remove as little as possible of the remaining disc material. ¼ Choose a minimally invasive access to promote early recovery and rehabilitation and to minimize hospital stay and cost.
Fig. 14.3. Prosthetic disc nucleus (PDN device). Note the PDN device in the center of the L5–S1 disc (white arrow). Without relevant clinical information, recognizing the device itself can be problematic
Bearing these goals in mind, we actually perform a micro-endoscopic discectomy in all patients with an indication for surgical treatment and a contraindication for percutaneous nucleoplasty. The main advantage of the METRx system (Medtronic Sofamor Danek, Memphis, TN) in comparison to a traditional discectomy is a smaller incision and less damage to the muscles of the spinal column (Foley and Smith 1997). This advantage is achieved by allowing the surgeon to expose the area where the herniated disc is located without making a large incision. A discectomy that is done with the METRx system begins with the surgeon precisely localizing the level of the herniated disk with a very small needle that is inserted through the muscles of the back down to the area where the disk fragments are located (Fig. 14.4). The correct position of this needle is conﬁrmed by ﬂuoroscopy, after which a series of soft-tissue dilators are used to create a small tunnel measuring 16 mm in diameter (less than ¾ of an inch) through the muscles of the back, enabling a hollow tube to be inserted down to the level of the spinal column. This tube, which is called a tubular retractor, contains a highly specialized video camera with a magnifying lens and a ﬁber optic light source that illuminates the tissues and relays the im-
E. Van de Kelft
d Fig. 14.4a–d. Micro-Endoscopic Discectomy. a K-wire inserted percutaneously at the L4–L5 junction. The correct position of this needle is conﬁ rmed by ﬂuoroscopy. b After the correct position of the needle has been conﬁ rmed with ﬂuoroscopic guidance, a series of soft-tissue dilators are used to create a small tunnel that measures 16 mm in diameter (less than ¾ of an inch) through the muscles of the back so that a hollow tube can be inserted down to the level of the spinal column. c This tube, which is called a tubular retractor, contains a highly specialized video camera with a magnifying lens and a ﬁberoptic light source that illuminates the tissues and relays the images to a separate video screen so that the surgeon can operate safely. Once the tubular retractor is in the correct place the surgeon is able to visualize the area where the herniated disk is located. d After a small laminotomy and ﬂavectomy, he or she is able to remove the fragments of the disk with special instruments that ﬁt down the inside of the tubular retractor. (Reproduced with permission from Medtronic Sofamor Danek)
ages to a separate video screen so that the surgeon can operate safely. Once the tubular retractor is in the correct place the surgeon is able to visualize the area where the herniated disc is located. After a small laminotomy and ﬂavectomy, he or she is able to remove the fragments of the disc with special instruments that ﬁt into the tubular retractor. When the operation is ﬁnished, the tubular retractor is removed and the incision, which is less than 16 mm (1 in). in length, is closed and the wound is allowed to heal.
220.127.116.11 Resection of Extraforaminal Disc Herniations
It is a relatively common phenomenon to encounter extreme lateral nerve root entrapment in patients with L4 symptoms when one is looking for it (Van de Kelft et al. 1994). In 1994 we presented a surgical technique that approaches the disc fragment not from intraspinally, but from outside the spinal structures (Van de Kelft et al. 1994). In this microsurgical approach the incision is centered on the
Surgical Procedures: Discectomy and Herniectomy
spinous process of the upper vertebra, i.e. slightly more upwards compared to the classical interlaminar approach. We prefer a paramuscular approach and therefore retract the muscle by a self-retaining retractor. We then aim for the junction between the pedicle and the transverse process. The nerve root in these cases is always pushed cranially against the pedicle. Once the pedicle is identiﬁed, the nerve root can be easily tracked. Caudally we ﬁnd the extruded fragment. In fact, we only remove this fragment and perform a non-classical discectomy. Once the nerve root is no longer compromised between the disc fragment and the pedicle, we retract the retractor and close the skin. This technique has the advantage of seeing the herniated fragment clearly, as well as the nerve root, while preserving all spinal structures. If one aims for an extraforaminal disc fragment by the classical intraspinal interlaminar approach, one ends up with a destroyed or even removed facet joint, because the herniated fragment can otherwise not be seen or reached. More recently we carry out the same procedure in an endoscopic way, with the tools as described earlier.
Once a trial of conservative treatment has been attempted, it may be wise to proceed with a surgical intervention on a patient suffering from sciatica due to a herniated lumbar disc. With the exception of the absolute indications, we see that the relative indications become more popular because of the advent of minimally invasive disc surgery that is performed on an ambulatory basis. Given this, the patient can beneﬁt maximally from surgery as a result of early relief of symptoms and full resumption of previous functions. Nevertheless, the patient should be informed that the long-term outcome is comparable to the outcome of conservative therapy.
Ahlgren BD, Lui W, Herkowitz HN et al. (2000) Effect of anular repair on the healing strength of the intervertebral disc: a sheep model. Spine 25:165–170
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