Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach.

Anterior cervical fusion was initially described in the 1950s for cervical spondylotic radiculopathy. The indications for this procedure in the management of soft disc herniation have not been clearly defined. In addition, controversy exists as to whether a cervical soft herniation should be managed by an anterior approach or a posterior cervical laminotomy-foraminotomy. The authors report the results of a prospective study comparing anterior discectomy and fusion to posterior laminotomy-foraminotomy for the management of soft cervical disc herniation. Twenty-eight patients underwent anterior discectomy and fusion (Robinson horseshoe graft) while 16 patients underwent posterior laminotomy-foraminotomy. The disc herniations were classified into two types. Type I were single level anterolateral herniations (33 patients) while type II were central soft disc herniations (11 patients). Clinically, patients with type I herniations manifested signs and symptoms of radiculopathy while patients with type II herniations manifested signs of myelopathy or neck pain and bilateral upper extremity paresthesias in 4 patients. Confirmatory studies were myelography in 12 patients, myelography combined with computed tomography (CT) in 26 patients, and magnetic resonance imaging (MRI) in 6 patients. For type I herniations, 17 patients underwent anterior fusion while 16 patients had a posterior laminotomy-foraminotomy. The 11 patients classified as type II herniation all underwent anterior discectomy and fusion. There were 27 men and 17 women. The age range was 21 to 52 years (mean, 41 years). The follow-up was 1.6 to 8.2 years (mean, 4.2 years). The results were graded as excellent (complete relief of pain and weakness), good (improvement of pain and weakness requiring occasional analgesics without lifestyle restrictions), fair (improvement in pain and weakness requiring analgesics with lifestyle restrictions), and poor (no improvement in preoperative pain and weakness). In the group of patients with type I herniations (33 patients), 17 patients had excellent results, 11 had good results, 4 had fair results, and 1 had a poor result. Of the 17 patients in the anterior fusion group, 11 patients had excellent results, 5 had good results, and 1 a fair result. Of the 16 patients in the laminotomy-foraminotomy group, 6 patients had excellent results, 6 patients had good results, 3 patients had fair results, and 1 patient had a poor result. Comparing the two groups, excellent-good results were noted in 94% (16 of 17) in the anterior fusion group while in the laminotomy-foraminotomy group, excellent-good results were noted in 75% (12 of 16). In the type II group, 6 patients had excellent results, 4 patients had good results, and 1 patient had a fair result (excellent-good 90% [10 of 11]). Results show that 1) although both anterior fusion and cervical laminotomy-foraminotomy provide satisfactory results in the surgical management of anterolateral soft disc herniation, anterior fusion provides better long-term improvement; and 2) anterior cervical fusion provides safe and effective results for the management of central disc herniation.