MINISTRY OF EDUCATION AND TRAINING
MINISTRY OF DEFENCE
VIETNAM MILITARY MEDICAL UNIVERSITY
TRAN THANH TUYEN
A STUDY ON TREATMENT FOR
HERNIATED DISC IN THE
CERVICAL SPINE BY SURGICAL
METHOD BY ANTERIOR INCISION
PLACING CESPACE INSTRUMENT
Major: Neurosurgeon and brain
Code: 62.72.07.20
SUMMARY OF MEDICAL DOCTOR THESIS
HANOI – 2012
THE WORK IS COMPLETED IN VIETNAM
MILITARY MEDICAL UNIVERSITY
Scientific Advisor:
A.P. Ph.D VO TAN SON
Panellist 1: Tran Manh Chi
Panellist 2: Nguyen Tho Lo
Panellist 3: Ha Kim Trung
The thesis will be defended against the council of the
thesis defense at 8.30 of 26 July 2012
The thesis can be found at:
- The national library
- The library of Vietnam Military Medical University
QUESTION
Herniated disc in the cervical spine is a disease caused
by disc degeneration and herniation in the cervical spine,
spines created by degradation pinching neck marrow or
nerve root cause. This disease is often characterized by
neck pain, shoulder pain or pain in the spinal nerve roots.

on treatment of herniated disc in the cervical spine by
way of anterior incision surgery method of placing
tools Cespace."
Research objectives:
1. To determine some standards for surgical
indications in the treatment of disc herniation in the
cervical spine by way of anterior incision surgery and
placing tools Cespace.
2. To assess results of treatment of herniated disc in
the cervical spine by way of anterior incision surgery
using operating microscope and placing tools Cespace.
New contributions of the thesis:
Treatment for Herniated disc in the cervical spine by
way of anterior incision surgery and placing tools
Cespace has good results and can be easily implemented
to apply multiple layers of new patients using operating
microscope which helps main dissection, good blood
holding to avoid complications during and after surgery.
The layout of the thesis:
The thesis consists of 109 pages with 27 tables, 21
charts and 41 figures. The thesis constitutes the basic 4
chapters: Introduction 2 pages, Chapter 1 – Overview 29
Pages, Chapter 2 - Subjects and Methods 17 pages,
Chapter 3 - Research Results 29 Pages , Chapter 4 –
Discussion 29 pages, Conclusions 2 pages and
Recommendations 1 page; references 122 (28
Vietnamese, 94 English), including material published
from 2005 to present.

CHAPTER 1 - OVERVIEW

at suspected positions of pathological root, compared to
contralateral foramen intervertebrale, articular facet and
zygapophysus.
1.2.2. Computerized tomography (CT Scanner)
CT examines bone composition and is useful in the
assessment of adduction fracture. It is also useful when
C6 and C7 are not visible on X-ray of tilt cervical spine.
The accuracy of the cervical spine CT limits from 72% -
91% in the diagnosis of disc herniation. The accuracy
reaches 96% when combined CT with electrospinogram,
which allows view of the subarachnoid space and
evaluation of the spinal marrow and nerve roots.
Computerized tomography with contrastmedium
injected into the spinal canal: CT capture technique
with contrastmedium injected into subarachnoid space is
considered to be good assessment and positioning of neck
marrow compression. In some cases, especially, of
invasion of foramen intervertebrale and lateral surface,
cross-sectional images reconstruct 3D very well.
1.2.3. Magnetic resonance imaging (MRI)
As soft tissues provided by MRI is visible, CT is
replaced by MRI for most cervical spine diseases.
MRI has now become the first choice method to
diagnose symptoms of neck root or symptoms of
combined marrow.
1.2.4. Electromyogram (EMG) (only when there is a
movement disorder)
Little was done, however, they also provide evidence of
root compression in patients at little clinical presentation.
1.3. TREATMENT OF HERNIATED DISC IN

symptoms of myelopathy.
1.3.2.1. Surgery of herniated disc in the cervical spine by
Anterolateral incision
- Smith and Robinson methods.
- Cloward method.
- Bailley and Badley method.
1.3.2.2. Herniated disc surgery by rear incision
Rear surgery is done according to the following three
main techniques: Cutting rear arcus, spinal canal plasty,
taking disc through foramen intervertebrale.
1.3.2.3. Coordinate neck anterolateral incision and rear
incision
In some cases, especially as HDITCS with longitudinale
ligament ossification following canalis spinalis stenosis
or canalis spinalis stenosis by back cause, an incision is
often not enough to release compression, the combination
of two anterior and rear incisions is necessary. For the
anterior incision, implementation techniques may be
removing vertebral bodies or merely taking disc,
releasing compression through hernia. For the rear
incision common techniques are spinalis stenosis plasty
or cutting rear arcus to release compression.
1.3.3. The method of minimal intervention treatment
1.3.3.1. Chemonucleolysis
Suggested by Lyman in 1963, Chymopapain or Aprotinin
(trasylon) injection into the disc to differentiate disc
nucleus pulposus has been widely used in France and
America in the 1970s and 1980s. This method is
endicated for HDITCS causing recurrent persistent neck
root pain with aggressive medical therapy for weeks

RESEARCH
2.1. SUBJECTS OF RESEARCH
2.1.1. Researched patients
Including 89 patients diagnosed herniated disc in the
cervical spine, under surgical treatment in People's
Hospital 115 from April - 2007 to November - 2010
2.1.2. Criteria for selection of patients
- Patients with a herniated disc in the cervical spine from
one to two layers with clinical syndrome of root or
marrow compression or root-marrow compression
syndrome and are diagnosed with appropriate images.
- Clear addresses (for easy follow-up)
- Adults, no muscle pathology.
- All patients were explained and consented to placement
of Cespace after getting disc, spine to decompress
marrow and root.
- 12-month follow-up period.
2.1.3. Exclusion criteria
- All patients with myelopathy due to degenerative neck
canalis spinalis stenosis and ligamentum longitudinale
posterius ossification of three layers or more.
- Patients with severe medical conditions such as severe
heart failure, progressive tuberculosis and under 16
years of age.
- Addresses are not clear.
2.2. METHODS OF RESEARCH
2.2.1. Research Design
Research Method: To describe the clinical, cross-
sectional, not controlled study.
2.2.2. Sample size

lower limb movement disorder (4 points)
o Sensation: upper limb (2 points), lower limb (2
points), body (2 points)
o Sphincter function (3 points)
RR = (JOA
postoperative or re-examination
– JOA
preoperative
) x 100/
(17 – JOA
preoperative
)
Recovery rate: 75% very good
50% good
20% acceptable
20% bad
- Pre-and postoperative evaluation of radiograph:
shooting in four positions: straight, tilt and right oblique
and left oblique. Tilt position is used to assess height of
disc, degenerative spine and physiological curves of the
cervical spine. Right and left oblique positions is used to
assess foramen intervertebrale, articular facet
andzygapophysus. Radiograph is used to assess the
cervical spine stiffness and bone welding.
- Evaluation of spinal hyperextension: draw a straight
line from the rearest point of tip to posterior inferior point
of the C7 body, measure the distance from this line to the
posterior inferior border of the body of C4, this gap
normally # 11.8 mm ± 5.
- Evaluate Cespace settlement in two adjacent

- The welding of bones based on the motive cervical
spine radiographs
- The level of release of compression on MRI film.
2.7. RESEARCH ETHICS
- The subject is approved and agreed by Council of
Science and Technology of People's Hospital 115
- The subject is agreed by the Council of Research
Studentof Military Medical Academy to conduct research
- Patients are explained and agree to cooperate.
2.8. DATA PROCESSING
Data in the study is processed by statistical methods:
statistical tables, diagrams, using Stata software
programs, treatment results are evaluated after 1 year of
tracking.
CHAPTER 3 – FINDINGS
Our study was conducted on 89 patients with disc
herniation in the cervical spine with root compression
syndrome, marrow compression syndrome and marrow-
roots compression syndrome who were surgically treated
in People’s Hospital 115 from April 2007 to November
2010. All patients had imaging diagnosis consistent with
clinical standards and sampling criteria. The results are as
follows:
3.1. EPIDEMIOLOGY
3.1.1. Distribution of patients according to age (n =
89)
Average age: 51.58 ± 10:13, minimum 34, maximum
85 years old and the most common age 40-50 years old.
3.1.2. Distribution by sex
In our study plots male patients approximate to

Pain and radicular paresthesias 24 100
Hand dexterity reduction 14 58.33
Weak hands 7 29.16
Muscle atrophy 2 8.33
Spurling test 19 79.16
Comment: neck pain and pain spread by roots
(100%), Spurling test is in the majority of root diseases
(79.16%).
3.2.2. Clinical signs of myelopathy
Table 3.4. Clinical signs of myelopathy (n = 65)
Symptoms No. Ratio %
Neck pain 60 92.31
Headache 18 27.69
Increased tendon reflexes 63 96.92
Hand dexterity reduction 18 27.69
Difficult walking 31 47.69
Micturition disorder 15 23.07
Weak quadriplegic 1 1.53
Comment: The increased tendon reflexes up to
96.92%, neck pain 92.31%.
3.3. IMAGING DIAGNOSIS
3.3.1. Routine X-ray
Table 3.5. Routine radiography (n = 89)
X-ray image
No. of p. Ratio %
Loss of physiological curve 58 65.16
Narrow disc slit 21 23.59
Narrow foramen intervertebrale 19 21.34
Spine 29 32.58
Total 89 100

C
4
C
5
, C
5
C
6
14 15.91
C
4
C
5
11 13.63
C
3
C
4
10 11.36
C
6
C
7
7 7.95
C
3
C
4
, C
4

posterius hernia.
Table 3.9. Position of hernia by magnetic resonance
images (n = 88)
Position No Ratio %
Next-to-central herniation 42 47,7
Central herniation 27 30,7
Lateral herniation 19 21,6
Comment: Next-to-central herniation are the most (47.7).
3.3.4. Picture computerized tomography (CT
Scanner)
There is one patient taking CT 64 to diagnose a
herniated disc, the other patients taking CT to evaluate
soft tissues and bones.
3.4. DISTRIBUTION BY LOCATION OF
HERNIATED DISC
Table 3.10. Distribution by location of disc herniation
(n = 89)
Location of herniated disc No. Ratio %
C
5
- C
6
52 46.42
C
4
- C
5
34 30.36
C
3

General marrow 65 73.03
Pathology
Comment: myelopathy occupies 73.03% and root
pathology occupies 26.97%.
3.6. SURGICAL TECHNIQUES AND
COMPLICATIONS
In 89 cases studied in our research receiving
surgery by anterolateral incision, according to Smith and
Robinson methods.
Patients with endotracheal anesthesia, supine,
neck slightly extended, horizontal skin incision, the neck
skin folds prevent scarring for patients. Skin incision is
approximately 3 - 4 cm long for hernia 1-2 layer and
injuries. Incision location is based on neck surface
anatomical landmarks, the thyroid cartilage markers as
horizontal as C5C6
In 89 cases of surgery there are 57 cases of
herniation below ligamentum longitudinale posterius and
32 cases of herniation via ligamentum longitudinale
posterius, of which 19 cases have sequestration. There are
62 cases of soft hernia and 27 cases of hard hernia which
need diamond drill bit to whet spines.
3.6.2. Complications
Table 3:13. The rate of complications (n = 89)
Pathology No. Ratio %
Surgical site infections
Adjacent disc
degeneration
Displaced Cespace
1

surgery
After 3
months
After 6
months
After 12
months
n % n % N % n % n %
Normal 22 24.72 57 64.04 78 87.64 83 93.26 87 97.75
Light 63 70.79 32 35.96 11 12.36 6 6.74 2 2.25
Severe 4 4.49
Total
89 100 89 100 89 100 89 100 89
Comment: slight sensation disorders accounted for 63
cases (70.79) and after 12 months only 2 cases (2.25%)
also felt disorders.
Table 3.15. Change to the average value of the
sensation disorders before and after surgery
Sensatio
n
disorder
Before
surgery
Early
postope
rative
After 3
months
After 6
months

Early
postoperative
After 3
months
After 6
months
After 12
months
N % n % N % n % n %
0 – 1 6 6.74 6 6.74
2 28 31.46 22 24.72 7 7.87 2 2.25 2 2.25
3 37 41.57 43 47.19 41 46.07 22 24.7 14 15.7
4 18 20.22 19 21.35 41 46.07 65 73.0 73 82.0
Total 89 100 89 100 89 100 89 100 89
Comment: only 18 cases (20:22%) don’t have dyskinesia.
After 12 months of exercise, 73 cases (82.02%) return to
normal.
Table 3.17. Change the average value of movement
disorders before and after surgery (n = 89)
Moveme
nt
disorder
Before
surger
y
Early
postope
rative
After 3
months

postoperative
After 3
months
After 6
months
After 12
months
Ischuria 2 (2.25)
Urinating
not all 4 (4.49)
Repeated
urination 9(10.11) 4 (4.49)
Normal 74(83.15) 85(95.51) 89(100.00) 89(100) 89(100)
Total 89 89 89 89 89
Comments: 15 cases of sphincter dysfunction, after 3
months no such case.
3.7.3. The JOA before and after surgery
Table 3:19. Changing the ratio of JOA before and after
surgery (n = 89)
JOA
Before
surgery
Early
postoperat
ive
After 3
months
After 6
months
After 12

0
46 51.69 41
46.0
7
18
20.2
2
16 17.97
15– 17 9 10.11 37
41.5
7
66
73.0
3
71 79.77
Total
8
9
100 89 100 89 100 89 100 89
Comment: Early postoperative only 4.49% heavy and
after 12 months the recovery is very good 79.77%, good
at 17.97% and little recovery at 2.24%.
Table 3.20. Changing the average JOA before and
after surgery
JOA
Before
surgery
Early
postopera
After 3