Wooridul Spine Hospital 

It is one of the largest privately owned spine specialized hospitals in Korea. Following its inception in the city of Busan in 1982, Wooridul Spine Hospital(WSH) has taken great strides and established others spine care hospitals in the cities of Seoul, Gimpo Airport and Daegu. Jeju island WSH will be opened by year 2008.

The motto has been to provide total spine care, utilizing modern state of art diagnostics and operating facilities. The hospitals have a comprehensive spine care program that includes all investigational facilities as well as pain management and physiotherapy.

The last two decades have seen great developments in the philosophy of minimal invasive spine surgery. Reduced disability and discomfort are making them more popular with the local population. It establishes their techniques and simultaneously trains the local spine surgeons to propagate them further.

W.S.H is rapidly becoming recognized as one of the world leading authorities in spine care and treatment. With over 17,000 cases being performed annually among 3 centers (Seoul, Busan, and Gimpo Airport) W.S.H is the largest spine health care group in Asia. W.S.H has over 108 Spine Specialists, over 600 beds, 48 operation rooms among 4 centers (Seoul, Busan, Gimpo Airport, and Daegu). Throughout Asia, WSH has become recognized as a center of excellence in research for minimally invasive and endoscopic spine surgery techniques with over 100 clinical papers published up to date.

W.S.H offers the complete range of Spine Care Solutions including:

 
•   Endoscopic Spine Surgery
•   Microendosopic Discectomy
•   Laser-Assisted Spine Surgery
•   Image-Guided Spine Surgery
•   CT-Guided Spine Surgery
•   Artificial Disc Replacement
•   Anterior/Posterior Lumbar Interbody Fusion with Fixation
•   Laparoscopic Surgery
•   Throracoscopic Surgery
•   Soft Stabilization with Ligamentoplasty
•   Vertebroplasty / Kyphoplasty
•   Deformity Correction
•   & more...

Non Surgical Offerings include:

Radiology (CT, MRI and dynamic radiograph), Rehabilitation, Pain Management, Internal Medicine, Conservative care, Physiotherapy and well being treatments.

  Definition of Disc Herniation

Disk herniation means herniation of the nucleus pulposus through the annular fibrosus. Most herniation takes place in the lumbar area of the spine. The next frequent herniation is occurred in the neck.

Intervertebral disc herniation is a condition in which part of the soft, gelatinous nucleus pulposus of an intervertebral disc is protruded through a weakened part of the annulus, resulting in back pain and leg pain.

Disc herniation occurs more frequently in 30~40 aged people, especially those involved in strenuous physical activity. However, the frequency in 10 or 20 aged is increasing in these days. And these disc may herniate from trauma, especially if degenerative changes have occurred in the involved disc.

   Causes and risk factors

It has been known that disc herniation may occur by natural degeneration as growing older. Human spine is imposed on a heavy burden through lack of exercise, obesity by supernutrition, lack of exercise and so forth.

Most frequent risk factor is lumbar sprain by lifting heavy material in the house or the office. In case of women, the bending activity such as lifting baby is predisposing factor.

Besides, lumbago can occur with poor carriage of posture in some people who keep standing or sitting continuously. Safe work and exercises, proper lifting techniques, and weight control may help to prevent back problems.

   Symptoms of Lumbar Disc Herniation

Major symptoms of lumbar disc herniation are lumbago and radicular pain in legs.

Radicular pain can be expressed as like "pins and needles in legs" etc.

Under pressure of nerve root, patients feel radicular pain in buttock and legs when they bend their body. And also by cough, the patients can feel pain.

If the spinal nerve root is pressed by protruded disc, leg pain appear.

   Symptoms of Cervical Disc Herniation  

In the early stage, patients feel pain when they move the neck. But in advanced case, neck pain accompany with arm numbness. Some time later, when nerve root is pressured markedly, the pain will increase in shoulder and arms than neck.

It may occur in every age group. This is closely concerned in trauma. On the other hand, in case of induration, it is usually chronic and it may occur in more 40 aged, 50~60 aged people.

Cervical disc herniation is more risky than lumbar disc herniation, because cervical disc herniation can cause parapelgia or paralysis. Paralysis is progressed acutely in case of disk rapture or slight trauma, but usually the paralysis is progressed slowly, little by little.

Patients who have paralysis must be operated as soon as possible for complete cure.

Percutaneous Endoscopic Cervical Discectomy(PECD):

Percutaneous Cervical Microdecompression Endoscopic Cervical/Lumbar Discectomy with Laser Thermodiscoplasty, is a new procedure to shrink and remove a herniated disc. Using brief general (cervical) or local (lumbar) anesthesia and the help of x-rays for guidance, specially designed micro-instruments, the discectome and a laser probe are inserted into the herniated disk space, and a portion of the offending disk is removed with suction and then vaporization with a laser to shrink the disc further, instead of open surgery.
Percutaneous cervical/lumbar discectomy is different from standard disk surgery because there is no muscle dissection, bone removal, bone fusion, or incision, except for a puncture wound to accommodate the micro-instruments that are inserted into the herniated disk. Most complications that occur with conventional surgery, therefore, are eliminated with this procedure.
The procedure is performed under brief general (cervical) or local (lumbar) anesthesia with the patient awake and in a supine (cervical) or lateral (lumbar) position. A small needle is inserted into the disc.
Over this probe, a slightly larger sleeve is inserted to permit a 2mm incision to be made in the disk itself. Using x-ray fluoroscopy control, the micro-instruments (forceps, currets, cutters), the discectome (which is a hollow probe with a cutting knife inside), and the laser probe are inserted into the disk space through a sleeve. Very small pieces of the disk material are removed and suctioned. The laser shrinks the disk bulge further. The procedure takes about 20 minutes, on average. X-ray exposure is minimal.
The amount of disk removed varies. The supporting structure of the disk is not affected. Upon completion, the needle is removed and a small Band-Aid is applied over the probe incision.
The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerves in the neck or back areas. Since insertion of the probe through the muscle is the only wound, there is no scarring in or around the nerves postoperatively. Additionally, it is an outpatient procedure. Unfortunately, patients who have large free fragments of disk in the spinal canal, as determined by the x-ray, cannot benefit from this procedure. However, the laser can shrink the bulging disc further for disc decompression.
It is essential to understand that all patients are not relieved of their pain with this procedure. Approximately 90 percent of patients will experience pain relief. Patients who do not obtain relief within three to six weeks may be considered for micro-cervical disc removal and fusion, depending on the circumstances. There does not appear to be any detrimental effect from performing percutaneous cervical discectomy before micro-cervical procedure to remove bony discs and bony fusion.

Under local or general

anesthesia, the patient was placed in a supine position with the neck extended by placing a rolled towel under the shoulders. A soft strap was placed over the forehead for stabilization. The shoulders were gently distracted downward with tape. C-arm fluoroscopy was used in anteroposterior and lateral planes to direct the placement of a spinal needle onto the disc surface. Initially, at the point of entry adjacent to the medial border of the right sternocleidomastoid muscle, firm pressure was applied digitally in the space between the muscle and the trachea and pointed toward the vertebral surface. The larynx and trachea were displaced medially and the carotid artery laterally. The esophagus was made more prominent with the insertion of an endotracheal tube. The pulse of the carotid artery was augmented with sympathomimetics. The anterior cervical spine was palpated with the fingertips, and a #18-gauge spinal needle was passed into the disc space. The position was confirmed fluoroscopically. A 2 ? 3 mm skin incision was made, and a narrow guide wire was passed through the needle. The needle was then removed. A blunt trocar was introduced over the guide wire down to the interspace, followed by a cannula. A trephine inserted through the cannula cut the annulus in a circular fashion. Minicurettes loosened and removed disc material prior to introduction of a suction-irrigation system and the discetome with a guillotinecutting blade (Fig. 1). The instruments included a probe, grasper forceps, and laser fiber (Fig. 2). Movement in a critical fan sweep maneuver, a 25° rocking excursion of the cannula hub from side to side, increased the removal up to a 50° coneshaped area within the disc space (Fig. 3). The procedure was closely monitored with the fluoroscope (Fig. 4) and an endoscope (Figs. 5A, B). The holmium: yttrium-aluminum-garnet laser with right angle or side-fire probe facilitated the discectomy. In addition, nonablative levels of holmium laser energy (500 joules) or thermodiskoplasty added shrinking of collagen and fibrocartilage; the tightening effect further decompressed and hardened the herniated cervical disc.

Anterior cervical foraminotomy (ACF):

This surgical technique was studied and practiced on cadavers before it was applied in living patients. The goal was to achieve direct and effective anatomical decompression of the spinal cord with maintenance of spinal stability, thus eliminating the need for bone fusion and immobilization. The surgical technique of microsurgical anterior foraminotomy has been reported elsewhere.[4]
The operation is performed after general endotracheal anesthesia has been attained in the patient. Somatosensory evoked potentials (SSEPs) are obtained by stimulating the upper and lower extremities immediately after induction of general anesthesia. Once the baseline SSEPs are obtained, SSEP monitoring is used continuously until the end of the operation. Positioning of the patient is similar to that for the conventional anterior approach to the cervical spine. With the patient supine, a bolster is placed behind both shoulders to maintain gentle extension of the cervical spine. When the patient is properly positioned, the baseline spinal cord function is reconfirmed with SSEP monitoring. The head is positioned with the midline upright. Both shoulders are gently pulled and fixed caudally with tape to facilitate a lateral view of the cervical spine on intraoperative roentgenogram. A cervical traction device is not used. The entire anterior neck is prepared with antiseptic solution and draped.
A 3- to 6-cm long transverse incision is made at the anterior neck along a skin crease that is similar to the incision made for an anterior approach to the cervical spine. The skin incision is made ipsilaterally to the radiculopathy or to the narrower side of the spinal canal. The first two-thirds of this incision is made medially to the sternocleidomastoid muscle and the remaining one-third is kept lateral to the medial border of the sternocleidomastoid muscle. The subcutaneous tissue and the platysma muscle are incised along the line of the skin incision. The loose connective tissue layer under the platysma muscle is cleanly undermined to provide space to operate. A combination of sharp and blunt dissection is used to access the anterior column of the cervical spine to keep the carotid artery and the sternocleidomastoid muscle lateral and the strap muscle, trachea, and esophagus medial. The prevertebral fascia is opened, and the anterior column of the cervical spine is exposed. The correct level is then confirmed with a radiographic lateral view of the cervical spine. Up to this point, the procedure is similar to that for an anterior approach to the cervical spine.

An anterior cervical discectomy retractor system is then applied; only smooth-tipped retractor blades are used. Retraction naturally exposes the ipsilateral longus colli muscle rather than the midline anterior disc surface. An operating microscope is used at this stage. The medial portion of the longus colli muscle is excised to expose the medial parts of the transverse processes of the upper and lower vertebrae. The vertebral artery (VA) is located anterior to the C-7 transverse process and beneath the longus colli. Therefore, when operating at the C67 level, care must be taken not to injure the VA while removing the medial portion of the longus colli. Because the VA occasionally enters the transverse foramen at another level, the longus colli is incised carefully under the operating microscope. For operations above the C67 level, the VA is not exposed purposefully at this point.
Once the medial portions of the transverse processes of the upper and lower vertebrae have been identified, the ipsilateral uncovertebral joint between them can be seen; however, advanced spondylosis may obscure the anatomical landmark of the uncovertebral joint and transverse processes. Anterior spondylotic spurs at the intervertebral disc can act as a guide, leading to the uncovertebral joint superolaterally. Although the interface of the uncovertebral joint will be angled approximately 30° cephalad from the horizontal line of the intervertebral disc in the normal cervical spine, advanced spondylotic changes may obscure the normal anatomy. The uncovertebral joint is drilled between the transverse processes using a high-speed microsurgical drill attached to an angled hand piece (Fig. 1). To prevent injury to the VA, a thin layer of cortical bone is left attached to the ligamentous tissue covering the medial portion of this artery. Drilling continues down to the posterior longitudinal ligament. As drilling advances posteriorly, the direction of the drill is gently inclined medially. When the posterior longitudinal ligament is exposed, a piece of thin cortical bone is left attached laterally to the periosteal and ligamentous tissue covering the VA. This lateral remnant of the uncinate process is dissected from the ligamentous tissue and fractured at the base of the uncinate process. It is further dissected from the surrounding soft tissue and removed, which enables identification of the VA by its pulsation between the transverse processes of the vertebrae. It is necessary to proceed cautiously with drilling at the base of the uncinate process because the nerve root lies just adjacent to it. After the uncinate process becomes loosened at its base, it is safer to remove the thin layer of remaining bone of the uncinate process by fracturing it rather than by continued drilling. When the remaining piece of the uncinate process is removed, the posterior osteophytes are drilled by crossing the midline diagonally toward the opposite margin of the spinal cord dura mater. The size of the hole made by the drilling at the uncovertebral joint is usually approximately 5 to 6 mm wide transversely and 7 to 8 mm vertically.
The posterior longitudinal ligament is incised and resected to achieve decompression of the ipsilateral nerve root and spinal cord. The beginning of the contralateral nerve root is identified for adequate decompression of the spinal canal in the transverse axis (Fig. 2). Multiple anterior foraminotomies are performed as needed. Using the holes of anterior foraminotomies, the spinal cord canal is enlarged in the longitudinal axis by removing the posterior portion of the vertebral bodies with Kerrison rongeurs and a long-armed up-biting curet. The bone bleeding is controlled with the application of bone wax. Epidural bleeding from the posterior longitudinal ligament can be controlled with bipolar coagulation. Hemostatic agents are not used in the epidural space.
Finally, the platysma is closed with interrupted No. 3-0 absorbable stitches, and the skin is approximated with subcuticular sutures. To minimize postoperative incisional pain, a local anesthetic (a few milliliters) is injected subcutaneously. A cervical collar is not used. Although microsurgical anterior foraminotomy for cervical radiculopathy has been performed as outpatient surgery, this group of patients with myelopathy stayed in the hospital overnight to observe their spinal cord function clinically; they were discharged home the next morning.

The surgery was performed with patients supine, and a prevertebral surgical exposure of the affected cervical disc level was accomplished on the affected side as described by Cloward.1 Figures 1 and 2 (A?E) illustrate the site of surgical decompression and summarize the steps of the procedure. The anterior cervical retractor naturally tends to maintain exposure centered over the medial border of the longus colli muscle. A long segment of the colli muscle was mobilized laterally to expose the transverse processes above and below the affected disc space without removal of the muscle (Figure 2A). Dissection around the circumference of the vertebral body between the transverse processes and lateral to the uncus with a curet or Freer type instrument was accomplished. Fluoroscopic imaging (Figure 3) was helpful to guide the placement of a 1?4-in. or 3?8-in. malleable blade retractor inserted between the vertebral body and vertebral artery that maintained retraction of the colli muscle and protected the artery. The malleable retractor was attached to a table-mounted (Greenburg type) retractor to maintain the exposure (Figure 2B). The lateral view fluoroscopic image showed correct placement of the retractor inserted to the midvertebral body to avoid compression of the nerve root posteriorly. The remainder of the procedure was then completed with microscopic magnification. The lateral portion of the uncovertebral joint was drilled (Figures 1 and 2C) until a thin posterior cortical rim was left posteriorly that was removed with curettage and Kerrison rongeurs to expose the lateral posterior longitudinal ligament overlying the exiting nerve root. Further exploration for removal of any compressive ligament, herniated disc, and osteophytes on the adjacent endplates allowed removal (Figure 2D). The small remaining por-tion of the uncus was then removed to complete the anterior foraminal decompression (Figure 2E).

Cervical corpectomy and fusion:

Displaced bony disk material will be removed from your neck. This displaced material is causing a problem by pressing on nerves. It will be replaced with bone taken from your hip or the fibula bone in your lower leg. During the operation, an incision (cut) will be made on your neck (see the diagram below). The size of this incision will depend on the extent of your problem. A second incision will be made on the front of your hip or leg (see the diagram). Bone will be removed from your hip or leg and will be placed in your neck. This transfer is called a bone graft. The surgery may take about four hours. If you have one or two vertebras repaired (a single-level corpectomy), you will probably be sent directly to a general patient unit after surgery. Your hospital stay will be two to three days. If you have two or more bones removed (a multiple-level corpectomy), you will probably be sent to the intensive care unit (ICU). During surgery a plastic breathing tube will be inserted down your throat, to keep your airway open. This is necessary because of swelling in your neck. You will remain in the ICU while you have a breathing tube. Most patients stay in the ICU one to two days. Then you will be sent to a general patient unit for two to five days. Incisions are usually closed with stitches and may be secured with Steri-strip tapes, paperlike strips that stick to your skin and help keep the sides of the incision from shifting. The stitches will dissolve completley. The Steristrips will fall off by themselves, usually within two weeks of surgery.


All patients underwent preoperative MR imaging and CT studies. The position of the manubrium and the great vessels relative to the level of the pathological entity was assessed in each patient. In two patients, both of whom underwent a C-7 corpectomy, a standard horizontal cervical incision was used. The other six patients underwent surgery via an extended cervical approach, which required that an incision be made along the medial border of the sternocleidomastoid muscle, ending at the manubrium. In two patients, the incision was continued caudally in the midline to allow for resection of the rostral third of the manubrium. A left-sided incision was used in seven patients; the anatomical position of one tumor necessitated the use of a right-sided incision in a single case. A left-sided incision was preferred because of the course of the RLN. A standard cervical dissection along the medial border of the sternocleidomastoid muscle, medial to the carotid sheath, was performed to expose the anterior surface of the lower cervical spine. The dissection was extended caudally, angling beneath the manubrium or accompanied by a partial resection of the manubrium. When required, up to 3 cm of the manubrium was resected using a Leksell rongeur. Although resection of the head of the clavicle was not necessary in this series, it has been described and may increase exposure as well.[13,14] A table-mounted self-retaining retractor system, used in all cases, proved to be very helpful in retracting mediastinal contents. The thoracic duct may be ligated and divided if it cannot be retracted out of the field. A narrow, malleable blade was used for caudal retraction. The use of corpectomy, in contrast to discectomy, allowed for visualization of the thecal sac following bone removal. A nearly "end on" view of the caudal VB may be obtained. Following decompression of the spinal cord and nerve roots, a fibular allograft was used as a load-bearing strut. In all cases an anterior cervical plate was implanted to provide immediate rigidity to the construct. The use of variable-angle screws was helpful for the placement of the plates caudally. The angle required for screw placement often required contouring of the plate in addition to the use of variable-angle screws. Four of the eight patients also underwent posterior stabilization procedures for the treatment of gross instability. Postoperative immobilization therapy consisted of a rigid cervical collar in six patients and a Minerva brace in two. The duration of immobilization therapy was 6 weeks in all patients.

Anterior Cervical Discectomy and Fusion (ACDF):

Surgery for anterior cervical fusion is performed with the patient lying on his or her back. A small incision is made in the front of the neck, to one side. After a retractor is used to pull aside fat and muscle, the disc is exposed between the vertebrae. Part of it is removed with a forceps. Then a surgical drill is used to enlarge the disc space, making it easier for the surgeon to empty the intervertebral space fully and remove any bone spurs. Afterwards, only a single ligament separates the surgical instruments from the spinal cord and nerve roots. A small section of bone is obtained from the patient's iliac crest (i.e. hip), through a separate incision and used as a bone graft. The bone graft is placed in the disc space, where it will begin to fuse the vertebrae it lies between. Placing a bone graft between the two vertebral bodies is done in order to create a fusion between these bones. The fusion is a direct result of the bone graft, but small, specialized metal plates are also placed on the front of the cervical spine in order to increase the stability of the spine immediately after the operation. Surgeons use cervical hardware to decrease the amount of time that you will have to wear a collar after surgery, and also to increase your chances of getting a solid fusion between the two vertebral bodies. The operation is completed when the neck incision is closed in several layers. Unless dissolving suture material is used, the skin sutures (stitches) or staples will have to be removed after the incision has healed.
Anterior cervical fusion is an operation performed on the upper spine to relieve pressure on one or more nerve roots, or on the spinal cord. The term is derived from the words anterior (front), cervical (neck), and fusion (joining the vertebrae with a bone graft). When an intervertebral disc ruptures in the cervical spine, it puts pressure on one or more nerve roots (often called nerve root compression) or on the spinal cord, causing pain and other symptoms in the neck, arms, and even legs. In this operation, the surgeon reaches the cervical spine through a small incision in the front of the neck. After the muscles of the spine are spread, the intervertebral disc is removed and a bone graft is placed between the two vertebral bodies. Over time, this bone graft will create a fusion between the vertebrae it lies between.

Cervical Laminoplasty

Its popularity in Japan arises from the formidable challenges of anterior decompression for ossification of the posterior longitudinal ligament. These anterior multilevel surgeries would be frequently complicated by dural tears as the dura is usually intimately associated with the ossified ligament. There was also a significant risk of instrumentation or graft failure. It has been reported that the rate of these complications including cerebrospinal fluid leakage and dislodgment or pseudarthrosis of the strut grafted bone was 24% and the rate of the salvage operation required was 12.5%. In the past, laminectomy has been the most common method to achieve posterior decompression of the cervical spine in these patients. However, the procedure has been complicated by postoperative instability resulting in deformity, particularly kyphosis, which may exacerbate neurological symptoms. Kyphosis and instability may leave the spine more vulnerable to cervical spine trauma, especially flexion injuries. In addition, postlaminectomy membranes have been implicated in arachnoiditis and restenosis after simple laminectomy. To avoid the disadvantages of laminectomy, several authors have described the technique of cervical laminoplasty whereby decompression is achieved without removal of the posterior spinal elements, maintaining the biomechanical integrity of the cervical spine and the spinal cord-protective features of the posterior elements. This is a more physiological solution. Expansive open-door laminoplasty was first described by Hirabayashi et al as a development of the air drill laminectomy technique of Kirita and has since been modified by Hirabayashi et al. and many others.

TDR for cervical spine

Initial surgical positioning was similar to that for a standard anterior cervical decompression and fusion. A roll was placed behind the shoulders and the head placed on a foam donut. The neck was extended slightly to facilitate exposure and an image intensifier was draped into the field. A transverse cervical incision was made in the neck over the C5-6 disc space and a standard extensile exposure of the C5-6 disc space was performed. Similarly routine diskectomy was performed. The Bryan Cervical Disc System was utilized. The size of the implant (14 mm) and angle of the disc space was calculated precisely prior to placement of the implant. Using custom drill bits, and a milling wheel, a reciprocal concavity was cut into the endplates of C5 and C6. This is shown in Figures 4 and 5. After the endplates were precisely drilled and the decompression effected, the correct size prosthesis was placed into the defect (see Figure 6-9). At the completion of this stage closure was affected over a suction drain. The patient was transferred to the intensive care unit and extubated uneventfully.