the standard treatment of choice is anterior cervical discectomy and fusion ( acdf ) . although most patients wish to treat both the posterior neck pain and associated arm pain , some patients wish to be treated with less invasive methods , even though some tolerable symptoms may persist , due to their social / physical situations . here
all of the patients primarily complained of radiating arm pain , which was associated with a tolerable degree of neck pain .
in korea , only physically healthy persons are allowed to serve in the military , and if a soldier was to undergo cervical spine surgery with implantation , the soldier discharged from the military against their will according to the military regulation .
a pension after retirement is not enough to provide for a middle - aged father and his family .
if they want to keep their job after undergoing surgery , they should be able to perform their military drills after the operation .
therefore , many doctors have agonized over how to treat middle - aged soldiers without forcing them to sacrifice their jobs and how to help them to maintain a level of physical fitness that is sufficient for soldiers .
he had been suffering from radiating pain in the left c7 sensory dermatome ( sd ) for 2 yr . the pain intensity , measured by the visual analogue scale ( vas ) , was 8/10 .
he had been waiting for a promotion and endured the pain for 2 yr in hopes of getting the promotion .
physical examination revealed weakness in the right triceps ( motor grade iv / v ) , and triceps jerk could not be elicited .
magnetic resonance imaging ( mri ) revealed disc protrusion in the right c6 - 7 foramen associated with disc degeneration at c5 - 6 ( fig .
although he had already been promoted , he wanted to keep his job until he reached the retirement age of 54 yr .
he has one son and one daughter , both of whom are in high school .
he is a healthy man , and he did not want to be discharged from the army while in his socially and physically active stage of life
. he complained of radiating pain at the left c7 sd ( vas 7/10 ) and posterior neck pain ( vas 2/10 ) that had lasted for 2 months .
physical examination revealed weakness in the left triceps ( motor grade iv / v ) , and triceps jerk could not be elicited .
he had been suffering from severe radiating arm pain at the left c7 sd ( vas 10/10 ) for 2 weeks .
physical examination revealed weakness in the left triceps ( motor grade iii / v ) , and triceps jerk could not be elicited .
mri showed disc rupture on the left posterior lateral side of the c6 - 7 disc space ( fig .
he wanted to treat the arm pain first , but he also wanted to keep his job as a soldier .
all operations were performed after listening to the patients ' needs and explaining the anticipated medical and social / physical outcomes .
mri was performed one week after the operations . during the follow - up period ,
motor grade was evaluated and flexion / extension films of the cervical spine were also checked .
each patient was situated in the prone position , and the neck was flexed without fixation .
the entry point was 1 cm from the midline and just above the post - articulation .
gentle palpation of the inter - laminar space was made possible after the obturator ( 6.9 mm outer diameter ) was introduced .
the opened bevel of the working channel was directed toward the medial side in order to avoid accidentally compressing the spinal cord .
drilling was performed from the medial to lateral margin of the inter - laminar space , and the superior facet was drilled first .
the ligamentum flavum was removed , and the lateral margin of the dura and exiting root was visualized .
decompression was confirmed by the lack of compressed lesion inferior and superior to the nerve root .
all of the instruments used in the operations and the video system were manufactured by wolf ( richard wolf gmbh , knittlingen , germany ) .
all of the patients primarily complained of radiating arm pain , which was associated with a tolerable degree of neck pain .
in korea , only physically healthy persons are allowed to serve in the military , and if a soldier was to undergo cervical spine surgery with implantation , the soldier discharged from the military against their will according to the military regulation .
a pension after retirement is not enough to provide for a middle - aged father and his family .
if they want to keep their job after undergoing surgery , they should be able to perform their military drills after the operation .
therefore , many doctors have agonized over how to treat middle - aged soldiers without forcing them to sacrifice their jobs and how to help them to maintain a level of physical fitness that is sufficient for soldiers .
he had been suffering from radiating pain in the left c7 sensory dermatome ( sd ) for 2 yr . the pain intensity , measured by the visual analogue scale ( vas ) , was 8/10 .
he had been waiting for a promotion and endured the pain for 2 yr in hopes of getting the promotion .
physical examination revealed weakness in the right triceps ( motor grade iv / v ) , and triceps jerk could not be elicited .
magnetic resonance imaging ( mri ) revealed disc protrusion in the right c6 - 7 foramen associated with disc degeneration at c5 - 6 ( fig .
although he had already been promoted , he wanted to keep his job until he reached the retirement age of 54 yr .
he has one son and one daughter , both of whom are in high school .
he is a healthy man , and he did not want to be discharged from the army while in his socially and physically active stage of life
. he complained of radiating pain at the left c7 sd ( vas 7/10 ) and posterior neck pain ( vas 2/10 ) that had lasted for 2 months .
physical examination revealed weakness in the left triceps ( motor grade iv / v ) , and triceps jerk could not be elicited .
he had been suffering from severe radiating arm pain at the left c7 sd ( vas 10/10 ) for 2 weeks .
physical examination revealed weakness in the left triceps ( motor grade iii / v ) , and triceps jerk could not be elicited .
mri showed disc rupture on the left posterior lateral side of the c6 - 7 disc space ( fig .
he wanted to treat the arm pain first , but he also wanted to keep his job as a soldier .
all operations were performed after listening to the patients ' needs and explaining the anticipated medical and social / physical outcomes .
mri was performed one week after the operations . during the follow - up period ,
motor grade was evaluated and flexion / extension films of the cervical spine were also checked .
each patient was situated in the prone position , and the neck was flexed without fixation .
the entry point was 1 cm from the midline and just above the post - articulation .
gentle palpation of the inter - laminar space was made possible after the obturator ( 6.9 mm outer diameter ) was introduced .
the opened bevel of the working channel was directed toward the medial side in order to avoid accidentally compressing the spinal cord .
drilling was performed from the medial to lateral margin of the inter - laminar space , and the superior facet was drilled first .
the ligamentum flavum was removed , and the lateral margin of the dura and exiting root was visualized .
decompression was confirmed by the lack of compressed lesion inferior and superior to the nerve root .
all of the instruments used in the operations and the video system were manufactured by wolf ( richard wolf gmbh , knittlingen , germany ) .
trimming of the protruded annulus was also performed after nucleus fragment removal in the first patient . after the operation ,
a computed tomography scan was obtained in order to determine the extent of the foraminotomy and to evaluate facet joint violation . in all patients ,
the patients were required to wear a neck brace for 7 days , and free neck motion was allowed from the 8th day after operation after the stitches were removed .
the first and second patients showed significant improvement in radiculopathy within 1 day after the surgery , and both patients reported more than 90% improvement from the preoperative state , with slight improvements in neck discomfort ( excellent outcome by macnab 's criteria ) .
the weakness in their triceps improved to motor grade v / v within 7 days after the operation .
dynamic film of the cervical spine taken one week after the operation showed no instability or change in disc height with preservation of motion ( fig .
they returned to their military base and were able to perform their military drills without difficulty within 10 days and 1 month of the surgery , respectively .
the third patient complained of residual radicular pain ( vas 4 ) 1 day after the operation . during the operation , a large disc fragment ( 10.8 cm )
the direction of the herniated nucleus was posterior and lateral , and it was impossible to trim the annulus ( capsule of ruptured nucleus ) on the medial side because the spinal cord was not retractable . on follow - up mri , although the ruptured disc was removed , the thick residual of the annulus that formed a capsule around the herniated nucleus remained , and the nerve root was still compressed ( fig .
the patient was comfortable since the severe arm pain in his arm had disappeared , and further rehabilitation was continued one week after the operation .
dynamic film of the cervical spine taken one week after the operation showed no instability or change in disc height with preservation of motion .
trigger point injection relieved most of the myofascial pain around the shoulder and some of the arm pain .
the weakness in his left triceps improved ( motor grade v / v ) within two weeks of the operation .
his symptoms improved over time , and the severity of his arm pain was vas 1 ( excellent outcome by macnab 's criteria ) 2 months after the operation .
follow - up mri performed two months after the operation showed slight shrinkage of the capsule ( fig .
he returned to his base two months after the surgery , and he is currently able to perform his military duties without difficulty .
there are several treatment options for patients with cervical disc herniation when the pathology is located on the lateral or posterior lateral side and the primary symptom is radiculopathy .
the first treatment option is traditional acdf , followed by cervical arthroplasty , anterior cervical endoscopic discectomy , anterior transcorporeal or transuncal anterior cervical discectomy , traditional posterior microforaminotomy with or without tubular retractor , and posterior endoscopic discectomy .
however , this mode of treatment requires an anterior approach and fusion of the diseased segment , which leads to motion limitation and increased adjacent segment stress / degeneration ( 2 - 7 ) .
some authors have reported that the rate of complications , such as recurrent laryngeal nerve injury or dysphasia , was higher than expected ( 8 , 9 ) .
implantation could be burdensome to physically and socially active people , such as soldiers because of the military regulation . despite the development of improved operative procedures , postoperative scars on the anterior neck
the artificial disc was invented to preserve the motion of the diseased segment and to reduce the amount of stress on the adjacent segment ( 3 ) . however
, biomechanical studies have shown that artificial discs are not a true substitute for original discs , as the range of motion on the implanted segment is greater than normal physiologic motion and the motion of the adjacent segment is mostly decreased ( 3 ) . moreover
, the cost of this procedure is very high in comparison to other procedures . until now
, the artificial disc has not been a true solution for the replacement of human discs . as with acdf
. the risk of approach - related complications and the cosmetic results could be similar to those of acdf .
there are several other options for removing the pathology while preserving functional motion of the involved level .
anterior cervical endoscopic discectomy is a good choice for the treatment of lateral disc protrusion .
this operation can be performed under local anesthesia and can be used to preserve the motion of the involved level ( 5 - 7 ) .
excellent results were achieved in more than 90% of patients ( 5 - 7 ) .
ahn and lee et al . reported that further instability did not occur , even though the height of the disc was decreased ( 5 - 7 ) .
however , this procedure requires access through the disc anterior to the pathology with violation of the anterior structure , such as the annulus and nucleus .
radiological confirmation is necessary during the approach , and the operation can not be performed if the c - arm does not show an involved level , such as the c6 - 7 or c7-t1 level ( 5 - 7 ) .
there is also a risk of major vessel complication or nerve injury with this approach ( 5 - 7 , 10 ) .
anterior transuncal microforaminotomy , developed by jho has a patient satisfaction rate higher than 95% , with functional preservation of the involved level ( 11 , 12 ) .
however , the problems of disc space narrowing and anterior column violation still remain , even though there were no symptoms ( 2 , 4 - 7 ) .
the transcorporeal approach was developed to solve the problem of uncovertebral joint violation ( 4 , 13 ) .
comparative study of the anterior transcorporeal approach and transuncal approach revealed that patients subjected to the anterior transuncal approach showed a significant decrease in disc height during the follow - up period in comparison to those subjected to the transcorporeal approach ( 13 ) .
although different operations performed by different surgeons may have different results , the removal of an uncovertebral joint or the medial wall of the foramen exposing the vertebral artery might be a problem . although the transcorporeal approach could resolve this problem , this procedure also has the risk of complication during the anterior approach and leaves a scar on the anterior side of the neck ( 4 , 13 ) .
the procedure is similar to traditional foraminotomy , except that an endoscope is used instead of a microscope , with or without a tubular retractor ( 1 , 2 ) .
published their 2-yr results and reported a success rate of approximately 96% ( 2 ) . a laterally localized herniated cervical soft disc without instability
the complication rate was very low , and there was no operationinduced neck pain or instability ( 2 ) .
contrary to the previous suggestion ( 4 , 16 ) , direct removal of the offending pathology is possible without violation of the nucleus or bone of the anterior column ( 2 , 4 , 15 ) .
moreover , this procedure is possible , even at the c7-t1 level , with direct visualization during the approach ( 2 , 15 ) .
the greatest difference between this procedure and conventional posterior foraminotomy is the lack of access - induced muscle injury ( 1 , 2 , 14 - 16 ) .
muscle injury can also be reduced by microforaminotomy with the use of a tubular retractor system ( 1 , 14 , 16 ) .
there is hardly any difference between the operative skills necessary for this procedure and endoscopic discectomy , with the benefit of less traumatization of the paraspinal muscle ( 1 , 2 , 14 , 16 ) .
the difference between the cosmetic result and accessinduced muscle pain associated with those two procedures may be regarded as minimal .
however , the most distinguishing feature of endoscopy is its excellent magnification and illumination ( 2 ) .
minimal manipulation of the root , facet joint and spinal cord are possible with the help of this feature of endoscopy ( 2 , 15 ) .
however , although minimal , there is also the risk of disc narrowing , which occurs in 32% of patients without symptoms or instability ( 2 ) .
this procedure is not optimal for the removal of a centrally located pathology , hard disc or spur ( 2 , 4 , 15 )
. a single method of operation would not be sufficient for all types of cervical disc pathology .
a recent trend in disc surgery is ' functional preservation ' with a minimally invasive technique , and posterior endoscopic discectomy may be a good alternative choice for this reason ( 1 , 2 , 4 - 7 , 11 , 12 , 14 ) .
the authors expect that stability will be maintained in the present cases because there was no violation of components in the anterior column and the extent of facetectomy was minimal ( 1 , 15 , 16 ) .
further comparative study with a longer follow - up period in a larger patient group is warranted . in conclusion ,
the gold standard technique for the treatment of cervical nucleus herniation has been anterior cervical discectomy and fusion , until now . even though the follow - up period in the present study was short , considering the physical / social activity levels and anticipated physical / social loads in some patients such as soldiers , posterior cervical endoscopic discectomy may be a promising alternative for selected cases .
 anterior cervical discectomy and fusion ( acdf ) is currently the standard treatment for cervical disc disease . 
 some patients wish to be treated with a less invasive method , because of their social / physical situations . here 
 we present one method of treatments for socially / physically active patients . 
 three patients had triceps weakness and mild posterior neck pain . 
 the offending lesions were at the c6 - 7 level . 
 all were middle - aged soldiers with families . 
 if conventional acdf were performed , they would have to retire from the military according to the regulation . 
 they had to be able to perform military drills after the treatment if they were going to be able to keep their jobs . because of their social / physical situations , all wanted to choose method with that they could treat the disease and keep their jobs . 
 for these reasons , the posterior cervical endoscopic discectomies were performed . 
 ruptured fragments were successfully removed in all . the arm pain improved by more than 90% in two patients by 7 days and in the other patient by 2 months , respectively ( excellent outcome by macnab 's criteria ) . 
 none of the operations caused instability . 
 all of the patients are currently able to successfully perform their military drills without difficulty . 
 the posterior cervical endoscopic discectomy may be a promising alternative for the physically / socially active patients . 