Jho Institute for Minimally Invasive Neurosurgery Department of Neuroendoscopy  
Spine Diseases
     Brain Diseases
        neuralgia


Cervical Disc Herniation Surgery: Dr. Jho's Disc-preserving,  Functional Cervical Disc Surgery

Dr. Jho's Minimally Invasive, Disc Preserving, Functional Cervical disc Surgery: Anterior Microforaminotomy (Jho Procedure) , Percutaneous Anterior
Cervical Discectomy, Endoscopic Posterior
Cervical Foraminotomy

Professor & Chair,  Department of Neuroendoscopy
Jho Institute for Minimally Invasive Neurosurgery

Did your spine surgeons say you need spinal fusion for your neck problems?  And you are concerned of spinal fusion.
The doctors' recommendation to you is current classic surgical treatments for cervical disc disorders.  Dr. Jho agrees with your concerns because he believes that spine surgery should be a minimally invasive, anatomy-maintaining and function-preserving treatment (it can be named "functional spine surgery").  Current conventional treatments such as bone fusion and metal plate-screw implantation in the spine are not anatomical, not physiological, and thus, not functional.  Such functional cervical disc surgery has been developed by Dr. Jho.  Thus, this novel surgical treatment is called the Jho procedure.  The Jho procedure for cervical disc herniation achieves direct removal of the herniated disc or protruded bone spurs, while preserving the remaining normal disc and spine motion intact.  It is performed through a small foraminotomy hole (5 mm) made at the side of the cervical spine via a small skin incision made at the anterior neck.  Normally, the nerve root branches out from the spinal cord through a side hole, neural foramen, to go to the arm.  The Jho procedure involves enlargement of this neural foramen at the side of the cervical spine.  Through an enlarged neural foramen, herniated portion of the disc or protruded discogenic bone spurs are removed.  Because the remaining disc is intact, fusion is not necessary.  Spinal motion is preserved.  Wearing a brace is not necessary postoperatively.   Occasionally, Dr Jho also performs other alternative minimally invasive cervical disc surgery such as percutaneous anterior discectomy or posterior endoscopic foraminotomy.   

1: Anterior microforaminotomy (Jho procedure) for cervical disc herniation
       Jho procedure for cervical disc herniation was developed in order to accomplish direct removal of the herniated disc or protruded bone spurs while preserving the remaining normal disc and spine motion intact.  In his initial report in Journal of Neurosurgery in 1996, surgery was performed by making neural foramen large at the side of the cervical spine.  Since then, his surgical procedure has evolved into three subtypes with much smaller anterior foraminotomy hole than the initial report.  Basically, it is performed through a small foraminotomy hole (5 mm) made at the side of the cervical spine via a small skin incision made at the anterior neck.  The square in the spine model (A) and the arrows in the postoperative roentgenogram (B) indicate a foraminotomy hole site at the C5-6.  This technique is one of three subtypes Dr Jho has further refined.  Herniated disc material or bone spurs are removed through this hole.  Bone fusion is not necessary. Postoperatively, patients do not wear a cervical collar and will have normal neck motion immediately.  
     A:            B:      
Figure 1 : The square at the left C5-6 in the spine model is an area where an anterior foraminotomy hole is made for left C5-6 disc disorder (A).  This is one of three subtypes of Jho procedure.  Herniated disc or bone spurs are removed through this tiny foraminotomy hole.  The arrows in the postoperative roentgenogram (B) indicate a foraminotomy hole site at the C5-6.

     A:          B:  
Figure 2 : A preoperative MR scan, axial view (A), shows nerve root compression by herniated disc material at C5-6 (arrow). A postoperative MR scan, axial view (B) displays a widened nerve root canal after disc removal via the Jho procedure.

                            
 Figure 3:  An intraoperative magnified picture shows the decompressed nerve root (long arrows) from its origin at the spinal cord (short arrows) to the exit site behind the vertebral artery.  The microforaminotomy hole is approximately 5 mm in size.  

A:  B: C:  D:  E:
Figure 4. Postoperative MR scan and X-rays after Jho procedure at left C5-6.
A: A postoperative MR scan, sagittal view, depicts preservation of the remaining disc at C5-6 (arrow).
B: An oblique x-ray taken postoperatively reveals the widely opened neural foramen at the left C5-6 (arrows).
C: The opened nerve passage at the left C5-6 can be viewed in this anteroposterior view x-ray (arrows).
D, E: Postoperative flexion and extension dynamic x-rays demonstrate maintenance of the motion segment as well as spinal stability following left C5-6
microforaminotomy.

2. Percutaneous endoscopic anterior cervical discectomy
Dr. Jho's alternative minimally invasive cervical disc surgery
                                   
         When the herniated disc is a soft fragment, the herniated disc fragment can be removed via a percutaneous endoscopic approach.  Through a small skin incision at the anterior neck, a small trocar is placed at the anterior aspect of the cervical spine.  A small trocar is advanced through the disc space towards the herniated disc.  An endoscope is inserted through the trocar. Under direct endoscopic visualization, herniated disc fragments are excised.  Unlike the Jho procedure described above, this surgical approach is made through the intervertebral disc space. Thus, the intervertebral disc is partially disrupted by the surgical procedure.

2. Posterior endoscopic foraminotomy
Dr. Jho's alternative minimally invasive cervical disc surgery
                      
      Posterior foraminotomy is a classic conventional treatment for cervical disc disease.  In order to make this surgery minimally invasive, Dr. Jho has adopted the use of an endoscope instead of the operating microscope for this surgery.  Through a small skin incision at the posterior neck, a small trocar is placed at the target area where the nerve is pinched.  The nerve decompression is performed with an endoscopic foraminotomy.  Unlike the Jho procedure described above, this operation does not eliminate the compressing bone spurs anterior to the nerve root, but provides extra room posteriorly for the compressed nerve root.  However, this operation does not require bone fusion, thereby maintaining motion at the operated level.  A schematic drawing demonstrates this posterior endoscopic foraminotomy (left), and an Intraoperative photo reveals the decompressed nerve root (right).

ANATOMY OF THE CERVICAL SPINE: The spine generally consists of columnar-shaped vertebral bones and discs in-between.  The cervical spine refers to the spinal column in the neck region which consists of seven vertebrae.  Intervertebral discs do not exist between the cranium and the first vertebra or between the first vertebra (called the atlas) and second vertebra (called the axis).  Intervertebral discs are present between C2-3 (between the second and third vertebra), C3-4, C4-5, C5-6, C6-7 and C7-T1 (between the seventh cervical vertebra and the first thoracic vertebra).  Because most bending motion in the cervical spine occurs at the C4-5, C5-6 and C6-7, disc displacement or disc herniation occurs most commonly at those levels.  The intervertebral disc is composed of four elements: the nucleus pulposus at the very center, the annulus fibrosus as a thick envelope that contains the gelatinous nucleus pulposus at the center, the cartilaginous plate superiorly and inferiorly at the vertebral bone side, and the ligaments that surround the annulus fibrosus circumferentially.

TYPES OF CERVICAL DISC HERNIATION: Although the term "disc herniation or herniated nucleus pulposus (HNP)" has been commonly used for cervical disc disease, the displacement of the nucleus pulposus is not always the cause of cervical disc disease.  Cervical disc herniation can be categorized into three different types: (1) a soft disc herniation that involves herniation of the nucleus pulposus through a tear at the annulus fibrosus, (2) a hard disc protrusion that is bone spur formation, or (3) a combination of both.  When soft disc materials of the nucleus pulposus herniates out through a tear of the annulus fibrosus, it is called "soft disc herniation" because the herniated disc material is soft in its consistency.  However, without a tear or defect at the annulus fibrosus, symptoms of cervical disc disease can still occur due to bone spurs (or overgrowth of bone spicules) developing over time at the edge of the vertebra which compresses the nerve root or spinal cord.  This is called "hard disc herniation" because it is made of bony spurs.  A combination of both conditions can occur as well.     

CLINICAL SYMPTOMS: Symptoms can be categorized into three different groups.  The first group of symptoms include neck pain, pain between wing bones, scapular pain, posterior head pain, difficulty in neck motion, and dizziness, especially when the neck is bent backward or turned to the side.  These symptoms are thought to be produced by local compression of the ligaments and the surrounding anatomy.  The second group of symptoms include pain along the shoulder, arm and hand, numbness in the hand and fingers, and weakness of the arm (radiculopathy).  This second group of symptoms is produced by compression of the passing nerve root.  The third group of symptoms includes numbness in the arms, torso and/or legs, difficulty in balance, gait disorder, clumsy spastic legs, and difficulty in bowel and bladder control (myelopathy). This third group of symptoms is caused by compression of the spinal cord.

TREATMENTS: Disc disease in the spine is one of the common problems that people experience.  Treatments consist of conservative treatments and surgical treatments.  Conservative treatments include physical therapy, chiropractic manipulation, nerve block, steroid treatment, pain medications, etc.  When symptoms do not improve with conservative treatments, surgical treatments have to be considered.  Current conventional surgical treatments fall into two different types: (1) anterior discectomy with bone fusion, and (2) posterior foraminotomy.  Anterior discectomy and fusion will sacrifice the spinal motion at the herniated disc level.  The posterior foraminotomy technique avoids bone fusion but often does not efficiently eliminate the herniated disc materials.  In order to overcome drawbacks of the current conventional surgical treatments for cervical disc herniation, a new surgical treatment called ďanterior cervical microforaminotomy (Jho procedure)?/B> was developed by Dr. Jho.
     Dr. Jhoís anterior microforaminotomy provides an effective elimination of the compressing herniated portion of the disc or bone spurs, while preserving the remaining disc between the vertebrae and maintaining spinal motion.  Figure 2A demonstrates a herniated disc at the C5-6 in an axial view of an MR scan, and Figure 2B displays complete removal of the herniated disc material postoperatively.  Figure 3 shows the nerve root and spinal cord after removal of the herniated disc material.  Figure 4A reveals preservation of the intervertebral disc between C5 and C6 vertebra in a postoperative MR scan sagittal view.  Figure 4B is a postoperative oblique x-ray demonstrating a left C5-6 anterior foraminotomy hole.  Figure 4C shows a small bone opening site at the C5-6 level in order to enlarge the nerve foramen.  Flexion and extension dynamic X-rays demonstrate good normal motion at the C5-6 postoperatively (Figure 4D).

Facts About the Jho Procedure for Cervical Disc Herniation
Prior to surgery, MR scans and dynamic X-rays of the cervical spine are required in all patients.  After surgery, all patients will obtain follow-up MR scans and dynamic X-rays 6 weeks postoperatively.  Surgery is indicated only if their clinical symptoms fit the pathology documented in MR scans and do not improve by conservative treatments.   
The operation is performed with a one- or two-inch skin incision at the anterior neck under general anesthesia.  The operation time for a one-level disc herniation is approximately one hour.
The Jho procedure for Cervical Disc Herniation is less invasive because it preserves the anatomy and function by conserving most of the remaining disc between the vertebrae.
The Jho procedure is innovative because it offers an alternative to conventional procedures and does not require bone fusion or the use of metal implants.
This minimally invasive procedure focuses on the bony spur or disc material compressing the nerve so that bone removal is minimized. Hence, there is a little disruption to the surrounding anatomy.
The Jho procedure does not require patients to wear a cervical collar following surgery and has been done on an outpatient or overnight basis.  Patients maintain normal movement of the neck immediately following the operation.
Recovery is quick, with most patients being able to do routine daily activities starting the day following the operation.  Although office workers may return to work in a few days following surgery, most patients prefer return to work within 4 to 6 weeks.

Discussion
     The focus of this newly developed surgery centers on removal of the bony spur or disc material that is pressing on the nerve root causing "electric," "numbing," or "shooting" pains, that often start in the neck and travel into one or both arms.  Through a small skin incision at the front of the neck, the source of the problem (the disc material or bony spur) can be clearly seen through a small hole made at the side of the intervertebral disc.  Only the protruding disc material or bone spur is trimmed away, leaving the majority of disc material and bone undisturbed.
     This is a less invasive method (which is able to preserve the neck joint or motion segment) than the conventional anterior discectomy procedure (which eventually leads to fusion of the bone).  Patients are most often able to go home without neck braces on the day of surgery or the day following surgery, with noticeable relief from the nerve pain in their arms.  Candidates for this surgery include patients who have herniated cervical discs or bony spurs pinching the nerve root causing neck pain and radiating pain to one or both arms, not relieved by at least three weeks of conservative treatment.  This does not necessarily exclude patients who have undergone previous neck surgeries.

Definitions
foraminotomy - enlargement of an opening or passageway for a nerve.
myelopathy-pertaining to symptoms and signs caused by the spinal cord.
radicular pain - pertaining to pain caused by a nerve root.

References
Jho HD: Microsurgical anterior cervical foraminotomy for radiculopathy : A new approach to cervical disc herniation. Journal of Neurosurgery 84:155-160, 1996
Jho HD: Anterior microforaminotomy for cervical radiculopathy: A disc preservation technique. In Rengachary SS, Wilkins RJ (eds), Neurosurgical Operative Atlas, Williams & Wilkins Vol.7, 43-52, 1998
Jho HD: Anterior cervical microforaminotomy. In Kang JD (guest ed), Fu F (ed), Current Techniques in Cervical Spine Surgery, Operative Techniques in Orthopaedics 8(1): 46-52, 1998 W.B. Saunders
Jho HD, Kim WK, Kim MH: Anterior microforaminotomy for cervical radiculopathy (Part 1): Disc-preserving "functional cervical-disc surgery." Neurosurgery 2002 (in press)


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