ENDOSCOPIC CERVICAL DISCECTOMY IN AUTISTIC PATIENT: A CASE REPORTABSTRACT
Autism Spectrum Disorder (ASD) is a complex neurological condition that can make it difficult to identify symptoms such as pain and neurological changes due to communication limitations. This article reports a case of a 21-year-old autistic patient with cervical disc herniation, treated with posterior endoscopic discectomy. The diagnosis was challenging due to the patient’s inability to clearly express his symptoms, leading to episodes of self-harm. After conservative treatment failed, the endoscopic discectomy was successfully performed using a personalized hospital protocol to minimize the patient’s stress. The procedure was successful, significantly improving quality of life and pain control. This case highlights the importance of considering orthopedic conditions in patients with ASD. It demonstrates the effectiveness of endoscopic discectomy as a minimally invasive option for treating cervical disc herniation in patients with neurological conditions. Level of Evidence IV; Case Report.
Keywords:
Autism Spectrum Disorder; Endoscopic Surgical Procedure; Intervertebral Disk Herniation; Humanization of Care.
RESUMO
O Transtorno do Espectro Autista (TEA) é uma condição neurológica complexa que pode dificultar a identificação de sintomas, como dor e alterações neurológicas, devido às limitações na comunicação. Este artigo relata o caso de um paciente autista de 21 anos com hérnia discal cervical, tratado com discectomia endoscópica por via posterior. O diagnóstico foi desafiador devido à incapacidade do paciente em expressar claramente seus sintomas, levando a episódios de autoagressão. Após falha no tratamento conservador, foi realizada a discectomia endoscópica com sucesso, utilizando um protocolo hospitalar personalizado para minimizar o estresse do paciente. O procedimento foi bem-sucedido, resultando em uma melhora significativa da qualidade de vida e do controle da dor. Este caso reforça a importância de considerar a possibilidade de doenças ortopédicas em pacientes com TEA e destaca a eficácia da discectomia endoscópica como uma opção minimamente invasiva para o tratamento de hérnias discais cervicais em pacientes com condições neurológicas. Nível de Evidência IV; Relato de Caso.
Descritores:
Transtorno do Espectro Autista; Procedimentos Cirúrgicos Endoscópicos; Hérnia de Disco Intervertebral; Cuidado Humanizado.
RESUMEN
El Trastorno del Espectro Autista (TEA) es una condición neurológica compleja que puede dificultar la identificación de síntomas como dolor y cambios neurológicos debido a las limitaciones en la comunicación. Este artículo reporta el caso de un paciente autista de 21 años con hernia discal cervical, tratado con discectomía endoscópica posterior. El diagnóstico fue desafiante debido a la incapacidad del paciente para expresar claramente sus síntomas, lo que llevó a episodios de autoagresión. Tras el fracaso del tratamiento conservador, se realizó con éxito la discectomía endoscópica utilizando un protocolo hospitalario personalizado para minimizar el estrés del paciente. El procedimiento fue exitoso, resultando en una mejora significativa en la calidad de vida y el control del dolor. Este caso refuerza la importancia de considerar posibles condiciones ortopédicas en pacientes con TEA y demuestra la eficacia de la discectomía endoscópica como una opción mínimamente invasiva para el tratamiento de hernias discales cervicales en pacientes con condiciones neurológicas. Nivel de Evidencia IV; Reporte de Caso.
Descriptores:
Trastorno del Espectro Autista; Procedimientos Quirúrgicos Endoscópicos; Hernia del Disco Intervertebral; Humanización de los Servicios.
INTRODUCTION
Autism Spectrum Disorder (ASD) is a complex neurological condition that can range from mild to severe, resulting in difficulties in social interaction, communication, and behavior1.
In the most severe cases of autism, identifying symptoms such as pain and sensory neurological changes can be difficult for family members. In addition, performing imaging exams, physiotherapy or acupuncture treatment, anesthesia, and post-operative rehabilitation represent a challenge in cases of patients with TE2. Early identification of orthopedic conditions in these patients is challenging, as communication and pain perception deficits can delay diagnosis and/or treatment3,4.
In this context, we aim to report a case of an autistic patient diagnosed with cervical disc herniation treated with posterior endoscopic discectomy, describing important details throughout their care journey.
CASE REPORT
The patient signed the informed consent form (ICF), and the report was approved by the Ethics Committee (CAAE 70416223.8.0000.5487, opinion number 6.339.106).
Male patient, 21 years old, diagnosed with ASD level 3, presenting severe impairment in verbal communication, making it difficult to describe symptoms. The mother reported that the patient frequently brought his hand to the right lateral region of the cervical spine, associated with episodes of psychomotor agitation. During the night period, the patient exhibited episodes of self-harm directed towards the neck region and the right side of the face. He underwent previous treatment for caries, trigeminal neuralgia, and right temporomandibular dysfunction without improvement of symptoms. Complementary investigation with computed tomography (CT) and magnetic resonance imaging (MRI) showed right foraminal disc protrusion at C3-C4, with foraminal stenosis (Figures 1 and 2).
The patient underwent conservative treatment, including analgesic physiotherapy and muscle strengthening for six months, without satisfactory clinical response. Faced with refractoriness to conservative treatment, surgical intervention was chosen, with right posterior foraminotomy and discectomy at C3-C4 indicated via endoscopic approach.
Given the patient’s cognitive condition, a personalized hospital protocol was developed to minimize stress from admission to discharge. The patient remained inside the family member’s car during hospital admission. He was taken to the surgical center with relaxing music in the headphones, accompanied by his mother and two caregivers. The patient, even though anxious, allowed the venipuncture. One of the caregivers performed a humanized immobilization technique to puncture the venous access.
The procedure was performed under general anesthesia, with continuous intraoperative neurophysiological monitoring. The patient was positioned in the prone position, with silicone pads under the chest and slight flexion of the cervical spine. Fluoroscopy was used for precise localization of the C3-C4 level. The dilator, the working cannula, and the ENDOLINE endoscope with a 4.3mm working channel and a 30-degree angle were sequentially introduced. After identifying point “V”, a partial resection of the ipsilateral upper and lower lamina was performed, as well as of the lower articular processes of the cranial vertebra and the upper of the caudal vertebra. A cutting drill without protection was used during the foraminotomy. Hemostasis was achieved with retractable bipolar. Next, the nerve root was retracted and the disc space was inspected, with removal of a small foraminal disc fragment. No significant changes were observed in the somatosensory evoked potential during the procedure.
The surgical wound was sutured with an intradermal stitch using absorbable Monocryl 3-0 thread, eliminating the need for stitch removal. The patient was discharged from the hospital 3.5 hours after the end of the surgery, staying only about 6 hours inside the hospital (Figure 3).
A hospital flowchart was created to manage patients with ASD who stayed inside the hospital for only about 6 hours.
In the immediate postoperative period, sleep quality significantly improved, and self-harm episodes stopped. On the third day after surgery, the patient began physical rehabilitation with physiotherapy, showing progressive improvement. He returned to his usual physical activities, such as swimming, 14 days postoperatively after the surgical wound completely healed. The patient remains asymptomatic after 12 months of outpatient follow-up. Postoperative control CT can be seen in Figure 4, with the right C3-C4 bony foraminotomy.
DISCUSSION
There is no clear relationship in the literature between cervical disc herniation and autism. The main objective of this case report is to draw the attention of everyone involved in the treatment and management of autistic patients to the fact that even if the patient is unable to report the symptoms, they may be present and cause significant distress. Endoscopic discectomy has been compared to conventional open discectomy in terms of efficacy, recovery, and complications. While the open approach is widely used in the cervical spine, the endoscopic approach has advantages such as less soft tissue injury, less intraoperative bleeding, and shorter hospitalization time. Comparative studies show that, although both methods are effective for the treatment of cervical disc hernias, endoscopic discectomy presents lower rates of postoperative pain and complications related to healing, especially in patients with concomitant neurological conditions5, as we can consider in cases of ASD.
The creation of humanized protocols for patients with ASD who require surgical intervention has shown promising results. These protocols include measures to reduce preoperative anxiety, minimize the use of invasive devices postoperatively, and adapt healthcare professionals’ approach to the specific behavioral needs of each patient. Studies indicate that humanized management, in addition to improving the patient experience, contributes to a faster recovery and more efficient adherence to treatment4.
Our case reinforces the importance of considering orthopedic diseases in patients with cognitive deficits, who often cannot report their symptoms. The episodes of self-harm were only possible to be identified through the analysis of the images from the patient’s room camera by the family members. Many cases of spinal diseases are amenable to conservative treatment with satisfactory results. However, in the failure of clinical treatment, we must consider the least invasive surgical strategy possible to minimize soft tissue injury postoperative pain and allow atraumatic rehabilitation for patient with ASD and their families6.
The evolution of endoscopic spine surgery increasingly seeks to offer patients a less invasive, effective, and safe procedure. The first endoscopic accesses occurred in the lumbar spine to treat disc herniations and stenoses. Experienced surgeons can approach other spine segments, such as the cervical and thoracic, endoscopically. In this way, there was an increase in the indications and possibility of use in more complex cases, allowing for a quick recovery7.
CONCLUSION
Posterior endoscopic discectomy has proven to be an effective approach for the treatment of cervical disc herniation in our patients with ASD. The minimally invasive technique, combined with humanized hospital management and a short hospital stay, significantly contributed to the patient’s comfort and rapid recovery.
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Study conducted by the Atualli Spine Care Clinic, São Paulo, SP, Brazil.
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