Ambulatory microsurgical lumbar discectomy

Microsurgical technique was used for lumbar disc herniation in 132 patients. The procedure was preferably performed under spinal block in a simple prone position. In the first series 68 patients left the hospital 3 days postoperatively while in the second series 64 patients were treated ambulantly. Based on self-rating, 87% of the patients expressed an excellent or good result of the operation. A higher rate, 96%, was obtained for patients operated on within 6 months from the onset of symptoms. No complications were encountered due to the ambulation and the patients were satisfied with the early discharge from hospital which may facilitate an earlier return to normal activity.     

Results of microsurgical lumbar discectomy

Summary 485 patients with a lumbar disc herniation were operated upon microsurgically. The results, the rate of complications and true recurrent herniations will be presented. The results of the microsurgical technique are compared to the results of the conventional technique.The final outcome after the microsurgical operation was excellent in 39%, good in 34% and satisfactory in 19%, 9% of the patients had a poor final outcome.The results obtained with microsurgery are attained with the standard techniques only by few groups, probably highly experienced surgeons. Following microsurgery a uniformly high percentage (88–98%) of results are reported as being satisfactory, whereas the analogous figures range between 40 and 98% following the standard technique.The operations were performed in the Department of Neurosurgery, Ravensburg.     

显微腰间盘切除术与椎间盘镜治疗单节段腰椎间盘突出症对比体会

[目的]通过比较显微腰间盘切除术（MSLD）与椎间盘镜（MED）治疗单节段腰椎间盘突出症（LDH）的方法和疗效，为微创治疗提供经验参考和治疗依据。[方法]回顾性分析本院单节段LDH微创治疗病例，其中MSLD治疗45例，MED治疗32例，比较手术时间、术中情况、并发症、住院日、疗效等指标。[结果]2组疗效优良率均达到了90％以上，无显著差异，MED切口长度明显短于MSLD，而后者在手术时间上明显少于前者。[结论]此两种微创方法疗效满意，但比较之下MED适应证明显受限，技术方法未见明显优势，MSLD是目前更为理想的微创手术方法。     

Clinical analysis of 270 cases of microsurgical lumbar discectomy]

Since 1983, the authors encountered 270 cases of lumbar disc hernia, which were operated on with the microsurgery. In the present study, the operative procedures were described and the results, especially the results of the reoperations were examined. Good results were obtained in 252 patients (93%). In nine patients, some kind of lumbago continued, which required other treatments, such as epidural block (3.3%). Reoperations were performed in nine patients (3.3%). In lumbar discectomy, extent of removal of the bony structures and the disc material seemed important. In "microlumbar discectomy", which was advocated by Williams, only the flavectomy with no bony structure removal was performed. In this procedure, discectomy is limited to the protruded disc material. On the contrary, some authors, who also adopt microsurgical lumbar discectomy as Wilson and Hudgins do, perform subtotal removal of the disc material with removal of some bony structures. In the present series, microsurgical lumbar discectomy following the procedures advocated by Wilson et al was performed. Reoperations after lumbar discectomy have been reported after all kinds of operations. In the present series, the rate of reoperation was 3.3%. As to the reasons for reoperations, true recurrence of disc hernia was the most prevalent. The hernias recurred at the same level and on the same side. Adhesion or fibrosis around the nerve root also played an important role. From the results of the present study, microsurgical lumbar discectomy with good illumination and high magnification has proved to bring satisfactory results. Recurrence, however, can occur after this procedure, so further inventions are required to ensure more satisfactory results.     

手术显微镜下与椎间盘镜下治疗腰椎间盘突出症的比较研究

 目的 对比研究手术显微镜下腰椎间盘切除术(microsurgical lumbar discectomy, MSLD)与椎间盘镜下腰椎间盘切除术(microendoscopic discectomy, MED)治疗单节段腰椎间盘突出症的方法、特点与疗效。方法 2006年 1月至 2009年 12月, 900例单节段腰椎间盘突出症患者被随机分为两组, MSLD组与 MED组各 450例, 术后分别平均随访 36个月和 38个月。比较两组手术病例的平均切口长度、手术时间、出血量、并发症、住: 天数及恢复情况。结果 MSLD组及 MED组的切口长度分别为(3.8±1.1) cm和(2.4±0.7) cm, 手术时间分别为(51.0±14.2) min和(62.0±16.3) min, 术中出血量分别为(60±35) ml和(106±43) ml, 以上指标两组间差异均有统计学意义(P 0.05)。末次随访时, MSLD组及 MED组的疼痛视觉模拟评分(visual analogue scales, VAS)改善率和 Oswestry功能障碍指数(Oswestry disability index, ODI)改善率差异均无统计学意义(P >0.05)。 MSLD组硬脊膜撕裂、急性竖脊肌血肿、神经根及马尾损伤等并发症及术后复发的发生率均明显少于 MED组(P< 0.01)。两组均未出现定位错误、大血管损伤和术后感染。结论 MSLD与 MED治疗单节段腰椎间盘突出症均可获得满意的远期疗效, 但 MSLD操作简单、并发症少、学习曲线短。     

内窥镜下椎间盘切除术与显微椎间盘摘除术的比较研究

目的比较内窥镜下椎间盘切除术（MED）与显微镜下椎间盘切除术（MSLD）治疗腰椎间盘突出症的临床疗效。方法2004年10月-2007年6月,手术治疗腰椎间盘突出症91例,其中MED组46例,MSLD组45例。前瞻性比较2组术中出血量、手术时间、住院费用及功能评价等指标。结果MSLD组较MED组出血少、手术时间短、费用低,2组差异有统计学意义（P〈0．05）。MED组3例硬膜撕裂,MSLD组0例;MED组5例术中转开放手术,MSLD组0例。下床活动时间、住院时间及功能评定结果2组间差异无统计学意义（P〉0．05）。结论MSLD组较MED组手术创伤小、费用低、视野清晰、立体感强,是治疗腰椎间盘突出症更为安全的微创方法。     

Microsurgical versus standard lumbar discectomy

Two hundred seventy consecutive patients operated upon by standard discectomy were compared to 270 patients treated with microlumbar discectomy. All patients had back and leg pain, as well as positive clinical findings and positive myelograms suggestive of disc herniation. The results demonstrated a 98% success rate in the microsurgical group as compared to a 95% success rate in the standard laminectomy group. Of microdiscectomy patients, 95% had an excellent result, as compared to 89% of the standard laminectomy group. Patients with pending compensation cases did only slightly poorer than those with no secondary gain regardless of what procedure was used. The postoperative hospital stay of the microsurgical patients averaged 3.7 days as compared to 7.1 for the standard technique. The time before return to work was significantly shorter in patients undergoing microdiscectomy. Microdiscectomy proved to be superior in both clinical results and cost effectiveness.     

Transdural cauda equina incarceration after microsurgical lumbar discectomy: case report

OBJECTIVE AND IMPORTANCE: Complications usually occur when they are least expected. We present an unusual case of nerve entrapment after microsurgical discectomy. CLINICAL PRESENTATION: A patient undergoing uneventful first lumbar microsurgical discectomy developed severe back and leg pain and a progressive neurological deficit during the first postoperative night. Herniation of cauda equina nerve roots had occurred through an unnoticed minimal defect in the dura, which had not caused cerebrospinal fluid leakage. The roots were incarcerated and swollen, and they filled the space of the resected nucleus pulposus. It was presumed that elevation of intra-abdominal pressure and consequent increased intraspinal pressure during extubation led to the herniation of arachnoid and cauda equina roots. The nerve roots were then trapped and incarcerated in the manner of bowel loops in an abdominal wall hernia. INTERVENTION: During reoperation, the nerve roots were repositioned into the dural sac. The patient recovered without further complications and without long-term sequelae. CONCLUSION: All dural tears that occur during intraspinal surgery, even if they are small and the arachnoid is intact, should be closed with stitches or at a minimum with a patch of muscle or gelatin sponge with fibrin glue. Care should be taken to avoid increased intra-abdominal pressure during extubation. Excessive pain and progressive neurological dysfunction occurring shortly after microsurgical lumbar discectomy or any intraspinal procedure is indicative of possible hemorrhage with subsequent compression of nerve roots. The case reported here provides anecdotal evidence that this situation can also be caused by a herniation of cauda equina nerve roots through a small dural defect that was not evident during the initial operation.     

Patient satisfaction with outpatient lumbar microsurgical discectomy: a qualitative study

Objective

Lumbar microsurgical discectomy was traditionally done as an inpatient procedure, but over the last decade, there has been an ever-expanding shift toward outpatient lumbar microdiscectomy (OLM). We have been performing OLM since 1997 (MB) and 2002 (EMM), but no study of patient satisfaction has been carried out to date. the objective of our study was to investigate patient satisfaction with the experience

Methods

Between September 2004 and March 2005, we carried out a qualitative case study at Toronto Western Hospital, involving interviews with 28 patients who had recently undergone OLM. The protocol was approved by the institutional Research Ethics Board, and informed consent was obtained from each participant. Interviews were transcribed and stored anonymously and subjected to modified thematic analysis by 5 reviewers.

Results

Analysis of the interviews yielded several overarching themes: 1) patients are surprised that back surgery can be done on an outpatient basis; 2) the amount and quality of information they receive is satisfactory; 3) the overall experience is positive; 4) trust in one''s surgeon is important; and 5) some patients have significant back pain in the early postoperative period.

Conclusions

Most patients appreciate the need for the health care system to save money where possible so that it can be spent in other, more resource-intensive areas. Outpatient lumbar microdiscectomy satisfies this goal while retaining high patient satisfaction rates. Qualitative research can yield substantial insight, which will improve the experience for future patients. Qualitative research is rare in the surgical literature and can answer questions quantitative research methods cannot.     

Comparison of chemonucleolysis and microsurgical discectomy for the treatment of herniated lumbar disc

A series of 126 patients with symptomatic herniated lumbar disc who were treated by either chemonucleolysis (CN) or microsurgical lumbar discectomy (MLD) was reviewed retrospectively. Of the 45 patients who chose chemonucleolysis, 27 (60%) reported a good outcome. The minor morbidity in this group was 52% and the major morbidity (infection) was 2.2%. Of the 81 patients who selected microsurgical discectomy, 72 (89%) reported a good result. The minor morbidity was 5%, and the major morbidity (infection) was 1.2%. The lower incidence of treatment success and higher percentage of patients suffering morbidity in the chemonucleolysis group make this procedure less desirable in the treatment of patients with herniated lumbar disc.     

Retrospective report of symptomatic postoperative discal pseudocyst after lumbar discectomy

Background  

Rarely, a symptomatic discal pseudocyst can develop after discectomy. Only very recently one clinical article and one case report about this type of pseudocyst were published: Kang and Park (J Korean Neurosurg Soc 49(1):31–36, 2011); Young PM, Fenton DS, Czervionke LF (Spine J. 9(2):e9-e15, 2009). Here, in an attempt to more clearly discriminate this peculiar cyst, the authors retrospectively report the clinical, radiological, and histological findings in 12 symptomatic patients with cystic lesions attached to an operated disc.     

Prognostic criteria for work resumption after standard lumbar discectomy

The purpose of this study was to determine prognostic criteria for return to work 9–12 years after standard nucleotomy for herniated nucleus pulposus confirmed by CT. From 1985 until 1988, 182 patients (102 male, 80 female, mean age 45 years) with a single-level herniated nucleus pulposus were operated on for the first time. In summer 1997, an average of 10.2 years after the operation, 101 of 182 patients (55.5%) returned a standardised questionnaire. Eighteen patients (9.8%) had died during the intervening years, while 63 patients (34.6%) were lost to follow-up because of moving to other cities. Two groups could then be distinguished: group I worked full time in their usual job; group II did not. The influence of the degree of the paresis, time elapsed since the occurrence, intraoperative findings, age, sex, weight, type of work and re-operations were analysed statistically. Group I consisted of 44 patients who still worked full time in their usual job. Group II contained 57 patients, of whom 18 worked only part of the time, 9 had changed to a lighter full-time job, 23 had taken early retirement, and 7 were receiving a pension. Patients in group I were significantly younger (38 vs 51 years), had a smaller proportion of patients with more than 20% overweight (27% vs 44%), had a smaller proportion of severe, grade 0 and 1, motor dysfunction (0% vs 16.3%), had been operated sooner (within 3 days: 52.3% vs 19.3%), had undergone fewer re-operations for recurrence of the herniation (4.5% vs 21.1%), and had worked less frequently in physically demanding jobs (6.7% vs 22.8%). We concluded that when there is a relative indication for herniated nucleus pulposus surgery, it should be limited to patients aged below 40 years, with slight motor dysfunction, who work in physically undemanding jobs, so as to make a satisfactory long-term result more likely. Received: 23 March 1998 Revised: 4 December 1998 Accepted: 28 December 1998     

Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy.

Intraoperative epidural corticosteroids have been used by some surgeons to decrease pain following surgery for a herniated lumbar disc. In this study, 84 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively assigned randomly to receive either epidural corticosteroids (40 mg methylprednisolone acetate) or saline at the conclusion of the operative procedure. The postoperative morbidity of these two groups was evaluated by tabulating the following parameters: pain relief as measured by consumption of postoperative pain medications; the length of hospital stay; postoperative functional status; and the time interval from surgery until return to work. The mean postoperative analgesic medications consumed was 12.2 +/- 1.9 mg of morphine equivalents in the corticosteroid group versus 12.2 +/- 1.8 mg of morphine equivalents in the control group. The mean hospital stay was less than 2 days in each group, and the mean interval until return to work was 21.2 +/- 2.7 days in the corticosteroid group versus 25.4 +/- 3.1 days in the control group. Moreover, no statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. The mean outcome scores, which are derived from a postoperative assessment of pain relief resulting from surgery, functional status, and interval until return to work, were identical in the corticosteroid and control groups. This study concludes that epidural corticosteroid administration after microsurgical lumbar discectomy for unilateral disc herniation does not lessen postoperative morbidity or improve functional recovery.     

腰椎间盘突出症传统手术方式与内窥镜(MED)疗效的回顾性分析

目的探讨传统开放的椎板间隙"开窗"手术方式(A组)和MED(B组)治疗腰椎间盘突出症的临床效果及相关问题。方法根据临床表现结合影像学检查结果确定手术方式,625例施行开放手术,其中单间隙开窗482例、单侧双间隙开窗65例、双侧开窗78例;546例施行MED。根据Nakai标准评价疗效,并对手术时间、出血量、并发症、术后恢复时间进行比较分析。结果开放手术组优良率为94.2%,MED手术组优良率为98.3%,差别无统计学意义(P0.05),两组手术时间、并发症无显著性差异,出血量、术后恢复时间有统计学意义。结论两种手术方式疗效相近,传统开放手术仍然是治疗腰椎间盘突出症的主要手段,MED作为现代微创技术,具有手术创伤小、恢复快的优点,但手术并不简便,且技术要求更高,只要具备熟练的开放手术技术,在严格选择适应证的前提下才能获得优良效果。     

腰椎间盘突出症术后下腰痛及再突出的临床分析

[目的]探讨腰椎间盘摘除术后下腰痛以及腰椎间盘再突出的情况。[方法]在采用后路腰椎板开窗突出椎间盘摘除手术的患者中，随机选择200例，对其中获得5a以上随访的84例患者进行回顾性分析，对手术前后下腰痛JOA评分以及影像学结果进行统计处理。[结果]（1）79．8％的患者残留下腰痛，其中14．3％患者存在严重的下腰痛（JOA 1），75％的严重下腰痛患者在35岁以下；（2）13例患者行二次手术，其中12例为腰椎间盘再突出，1例为腰椎不稳，13例患者中主要是50岁以下的成年男性。[结论]年轻患者更易发生严重的下腰痛以及腰椎间盘再突出，在年轻患者首次手术时可以根据情况适当考虑脊柱融合。