Preoperative sport improves the outcome of lumbar disc surgery: a prospective monocentric cohort study

A lumbar disc herniation resulting in surgery may be an incisive event in a patient’s everyday life. The patient’s recovery after sequestrectomy may be influenced by several factors. There is evidence that regular physical activity can lower pain perception and improve the outcome after surgery. For this purpose, we hypothesized that patients performing regular sports prior to lumbar disc surgery might have less pain perception and disability thereafter. Fifty-two participants with a single lumbar disc herniation confirmed on MRI treated by a lumbar sequestrectomy were included in the trial. They were categorized into two groups based on their self-reported level of physical activity prior to surgery: group NS, no regular physical activity and group S, with regular physical activity. Further evaluation included a detailed medical history, a physical examination, and various questionnaires: Visual Analog Scale (VAS), Beck-Depression-Inventory (BDI), Oswestry Disability Index (ODI), Core Outcome Measure Index (COMI), and the EuroQoL-5Dimension (EQ- 5D). Surgery had an excellent overall improvement of pain and disability (p < 0.005). The ODI, COMI, and EQ-5D differed 6 months after intervention (p < 0.05) favoring the sports group. Leg and back pain on VAS was also significantly less in group B than in group A, 12 months after surgery (p < 0.05). Preoperative regular physical activity is an important influencing factor for the overall satisfaction and disability after lumbar disc surgery. The importance of sports may have been underestimated for surgical outcomes.     

Prediction of lumbar disc herniation resorption in symptomatic patients: a prospective,multi-imaging and clinical phenotype study

BACKGROUND CONTEXTSymptomatic lumbar disc herniations (LDH) are very common. LDH resorption may occur by a “self-healing” process, however this phenomenon remains poorly understood. By most guidelines, if LDH remains symptomatic after 3 months and conservative management fails, surgical intervention may be an option.PURPOSEThe following prospective study aimed to identify determinants that may predict early versus late LDH resorption.STUDY DESIGN/SETTINGProspective study with patients recruited at a single center.PATIENT SAMPLENinety-three consecutive patients diagnosed with acute symptomatic LDH were included in this study (n=23 early resorption and n=67 late resorption groups) with a mean age of 48.7±11.9 years.OUTCOMES MEASUREBaseline assessment of patient demographics (eg, smoking status, height, weight, etc.), herniation characteristics (eg, the initial level of herniation, the direction of herniation, prevalence of multiple herniations, etc.) and MRI phenotypes (eg, Modic changes, end plate abnormalities, disc degeneration, vertebral body dimensions, etc.) were collected for further analysis. Lumbar MRIs were performed approximately every 3 months for 1 year from time of enrollment to assess disc integrity.METHODSAll patients were managed similarly. LDH resorption was classified as early (<3 months) or late (>3 months). A prediction model of pretreatment factors was constructed.RESULTSNo significant differences were noted between groups at any time-point (p>.05). Patients in the early resorption group experienced greater percent reduction of disc herniation between MRI-0-MRI-1 (p=.043), reduction of herniation size for total study duration (p=.007), and percent resorption per day compared to the late resorption group (p<.001). Based on multivariate modeling, greater L4 posterior vertebral height (coeff:14.58), greater sacral slope (coeff:0.12), and greater herniated volume (coeff:0.013) at baseline were found to be most predictive of early resorption (p<.05).CONCLUSIONSThis is the first comprehensive imaging and clinical phenotypic prospective study, to our knowledge, that has identified distinct determinants for early LDH resorption. Early resorption can occur in 24.7% of LDH patients. We developed a prediction model for early resorption which demonstrated great overall performance according to pretreatment measures of herniation size, L4 posterior body height, and sacral slope. A risk profile is proposed which may aid clinical decision-making and managing patient expectations     

Adolescent lumbar disc prolapse

87 adolescents with lumbar disc prolapse treated from 1978 to 1985 were reviewed. The clinical pattern was different from that usually seen in adults, as 41 patients had no leg pain; and signs of neurologic deficit were often absent. Nonoperative treatment was successful in 57/61 patients, and 26 patients underwent discectomy with eventual return to full activity in 23 patients.     

Adolescent lumbar disc prolapse

87 adolescents with lumbar disc prolapse treated from 1978 to 1985 were reviewed. The clinical pattern was different from that usually seen in adults, as 41 patients had no leg pain; and signs of neurologic deficit were often absent. Nonoperative treatment was successful in 57/61 patients, and 26 patients underwent discectomy with eventual return to full activity in 23 patients.     

Radiographic appearances in lumbar disc prolapse

The pre-operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for prolapsed intervertebral disc were reviewed. Prolapse was recognized as bulging or sequestration of the disc with consequent root compromise. Measurement of the lumbar level of the interiliac line was shown to correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacral junction was significantly higher than normal. A pathological value for the lumbosacral angle could not be identified.     

Transtubular versus microsurgical approach for single lumbar disc herniation: a prospective study

Earlier studies have compared transtubular discectomy with microsurgical discectomy in the treatment of lumbar disc herniations, but a few prospective studies with homogeneous groups of patients have been conducted. The aim of this study was to compare intraoperative and immediate postoperative results in a group of patients submitted to discectomy with the use of a tubular retractor (TTD) to the one operated with standard microdiscectomy as described by Caspar (MSD). A total of 83 patients were prospectively observed and reviewed. Two homogeneous groups of patients were compared. All patients were preoperatively examined by the operating surgeon and the anaesthesiologist. All surgical data and constatations were collected on the operative summary. Several parameters like operative time, morphinic consumption in recovery room, length of hospital stay and peri- and post-operative complications were compared. Results show that both procedures lead to excellent recovery and that TTD is a viable alternative to MSD. There was no statistically significant difference in most of the examined parameters between the two techniques.     

Percutaneus nucleotomy procedures in lumbar spinal disc prolapse

The discussion on the results of open spinal surgery, in particular, on complications as a result of open surgery, e.g., the so-called post-discotomy syndrome, has led to the development of less invasive methods, especially for treatment of lumbar disc prolapses. Percutaneous nucleotomy procedures are based on a variety of intradiscal diagnostic and therapy methods, such as discography, retroperitoneal spinal disc fenestration or chemonucleolysis. Since the 1970s, various methods such as mechanical percutaneous nucleotomy, automated percutaneous nucleotomy, intradiscal laser procedures and, in part, endoscopic intradiscal procedures have been developed and also used clinically. The clinical results vary from 30% good/very good results to almost 100% good/very good results, depending on the author and study. It is obvious that not many prospective randomized studies using either conservatively or surgically treated control groups have been conducted. The results of these studies on intradiscal therapy methods are often analyzed more critically and with lower success rates than the partially retrospective stuides of a single method, which often have large case numbers, but do not always meet the demanding criteria for scientific study design. To attain good results, percutaneous nucleotomy procedures can only be used to treat select cases of lumbar disc disorders according to strict indication criteria. At the present time it can be concluded that, in comparison to endoscopic und microsurgical methods, percutaneous nucleotomy procedures must be restricted to a small number of cases.     

Intervertebral lumbar disc prolapse in children and adolescents

The radiographs and records of 58 cases of lumbar disc prolapse in children and adolescents were reviewed, and 28 cases were followed up after an average of 6.8 years. Trauma was not a significant aetiological factor, but there was a high incidence of back pain in relatives of affected patients. The clinical picture is similar to that in the adult except for a relative paucity of neurological signs. This review of patients treated by surgical or conservative methods suggests that good results may be obtained in patients with a short history who are offered surgery early. Preoperative radiculography is considered to be essential because of the inaccuracy in localising the level of disc prolapse by clinical signs. The result of treatment in patients with long histories is usually disappointing.     

Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients.

BACKGROUND: Extraforaminal disc herniations represent up to 11% of all lumbar herniated discs. Numerous surgical approaches have been described. Percutaneous endoscopic discectomy (PED) is one of the minimally invasive techniques; after mastering this procedure it is a practical method that is used for treatment of foraminal or extraforaminal disc herniation. The outcome of PED for treatment of foraminal or extraforaminal disc herniation has been studied. METHOD: A total of 66 patients with foraminal or extraforaminal lumbar disc herniation was treated by applying the PED technique between January 1998 and June 2005. The positions of the herniated disc levels were L2-3 (n=5, 8%), L3-4 (n=19, 28%) and L4-5 (n=42; 64%). The selected patients had no previous surgery, appropriate conservative therapies were done before the operations, and MRI was the main diagnostic method with the clinical findings. Evaluation of the patients with clinical examinations, visual analogue pain scale (VAS) and Oswestry scale was performed preoperatively, on postoperative day 7 and in the postoperative 6-12 months period. RESULTS: In two patients (n=1, L4-5 and n=1, L3-4) disc material could not be removed with PED, so discectomy was performed with microscopic visualization during the same session. Three patients (n=3, L4-5) were reoperated on three to six months after primary surgery due to recurring disc problems with microscope visualization. In two patients (n=2, L4-5) root nerves were partially damaged, and in two patients (n=2, L4-5) root nerves were impinged by the working channel. These 4 patients had dysesthesias from just after surgery to a mean of 45 days after surgery. One of recurrent cases was among these patients. Neurological examinations showed minimal muscle weakness of the quadriceps femoris and diminished sensation of the L4 dermatomal area in patients with partial nerve root damage. This patient improved and the neurologic examination became normal with disappearance of the dysesthesia. There was no sign of reflex sympathetic dystrophy (RDS). With these two patients VAS and Oswestry scales scores decreased significantly early in the postoperative follow-up. The postoperative 6-month average scores are favourable in comparison with the average score at postoperative day 7. The postoperative 12-month scores showed no significant differences to those of postoperative month 1. CONCLUSION: Percutaneous endoscopic discectomy is a minimally invasive method and offers many benefits to the patient, but extensive surgical practice is needed to become a capable surgeon. Consequently this technique can only be a treatment option on appropriate patients. This study reconfirmed that the removal of fragmented disc material is achieved and offers a pain-free status.     

Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse

Purpose

The purpose of this study is to present a new endoscopic procedure, aiming to achieve the success rate equivalent to microsurgical discectomy, while addressing the drawbacks and limitations of other percutaneous techniques.

Methods

A series of 43 patients with uncontained lumbar disc herniation underwent surgery with irrigation endoscopic discectomy (IED). The endoscope and instruments are placed directly over the surface of the lamina through two posterior skin portals 5 mm each without any muscle retraction or dilatation. Pump irrigation is used for the opening of a potential working space. The rest of the procedure is performed endoscopically like the standard microsurgical discectomy.

Results

Outcome according to modified Macnab criteria was excellent in 78 %, good in 17 %, and poor in 5 % of patients. VAS for leg pain dropped from 78 preoperatively to 7, and the Oswestry Low-Back Pain Disability Questionnaire dropped from 76 to 19. The mean time for postoperative ambulation was 4 h, hospital stay was 8 h, and for return to work was 7 days.

Conclusions

Preliminary clinical experience with IED shows it to be as effective as microsurgical discectomy, and in comparison to other percutaneous procedures addressing noncontained herniations, a reduction in the cost, technical difficulty and surgical invasiveness has been demonstrated.     

Influence of lumbar intervertebral disc degeneration on the outcome of total lumbar disc replacement: a prospective clinical, histological, X-ray and MRI investigation

Introduction

The role of fusion of lumbar motion segments for the treatment of axial low back pain (LBP) from lumbar degenerative disc disease (DDD) without any true deformities or instabilities remains controversially debated. In an attempt to avoid previously published and fusion-related negative side effects, motion preserving technologies such as total lumbar disc replacement (TDR) have been introduced. The adequate extent of preoperative DDD for TDR remains unknown, the number of previously published studies is scarce and the limited data available reveal contradictory results. The goal of this current analysis was to perform a prospective histological, X-ray and MRI investigation of the index-segment’s degree of DDD and to correlate these data with each patient’s pre- and postoperative clinical outcome parameters from an ongoing prospective clinical trial with ProDisc II (Synthes, Paoli, USA).

Materials and methods

Nucleus pulposus (NP) and annulus fibrosus (AF) changes were evaluated according to a previously validated quantitative histological degeneration score (HDS). X-ray evaluation included assessment of the mean, anterior and posterior disc space height (DSH). MRI investigation of DDD was performed on a 5-scale grading system. The prospective clinical outcome assessment included Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores as well as the patient’s subjective satisfaction rates.

Results

Data from 51 patients with an average follow-up of 50.5 months (range 6.1–91.9 months) were included in the study. Postoperative VAS and ODI scores improved significantly in comparison to preoperative levels (p < 0.002). A significant correlation and interdependence was established between various parameters of DDD preoperatively (p < 0.05). Degenerative changes of NP tissue samples were significantly more pronounced in comparison to those of AF material (p < 0.001) with no significant correlation between each other (p > 0.05). Preoperatively, the extent of DDD was not significantly correlated with the patient’s symptomatology (p > 0.05). No negative influence was associated with increasing stages of DDD on the postoperative clinical outcome parameters following TDR (p > 0.05). Increasing stages of DDD in terms of lower DSH scores were not associated with inferior clinical results as outlined by postoperative VAS or ODI scores or the patient’s subjective outcome evaluation at the last FU examination (p > 0.05). Conversely, some potential positive effects on the postoperative outcome were observed in patients with advanced stages of preoperative DDD. Patients with more severe preoperative HDS scores of NP samples demonstrated significantly lower VAS scores during the early postoperative course (p = 0.02).

Conclusion

Increasing stages of DDD did not negatively impact on the outcome following TDR in a highly selected patient population. In particular, no preoperative DDD threshold value was identified from which an inferior postoperative outcome could have been deduced. Conversely, some positive effects on the postoperative outcome were detected in patients with advanced stages of DDD. Combined advantageous effects of progressive morphological structural rigidity of the index segment and restabilizing effects from larger distraction in degenerated segments may compensate for increasing axial rotational instability, one of TDR’s perceived disadvantages. Our data reveal a “therapeutic window” for TDR in a cohort of patients with various stages of DDD as long as preoperative facet joint complaints or degenerative facet arthropathies can be excluded and stringent preoperative decision making criteria are adhered to. Previously published absolute DSH values as contraindication against TDR should be reconsidered.     

Clinical history in lumbar disc herniation: A prospective study in 160 patients

In a prospective study of 160 consecutive patients who underwent primary surgery for lumbar disc herniation, we investigated the value of clinical history for diagnosing the degree of herniation-the main prognostic factor for the postoperative outcome. At surgery, the patients were classified into two groups: intact anulus (negative exploration or protruding disc) and ruptured anulus (subligamentary perforation or complete perforation). The strongest variables predicting the degree of herniation were duration of leg pain, progressive leg pain, educational level and whether or not the patient had previously undergone non-spinal surgery. In patients with ruptured anulus, the median durations of low back pain and sciatica were 16 and 10 weeks, respectively. The corresponding figures for the group with intact anulus were 79 and 50 weeks. 18% of those with ruptured anulus and 39% of those with intact anulus were undergoing medical or psychiatric treatment for other diagnoses; 32% and 55% had previously undergone non-spinal surgery. Thus the two groups differed not only in disc pathology but also in medical, behavioral and social factors that must be taken into account in the preoperative assessment and that may explain discrepancies between impairment and disability.     

Alcaptonuria with lumbar disc prolapse: case study and review of the literature.

BACKGROUND CONTEXT: Patients with alcaptonuria frequently complain of pain in the large joints and the spinal column, this condition is being assumed to be normal. It is very rare for patients with ochronosis to undergo lumbar surgery since the disk protrusion is not characteristic for them and overlaps with the general complaints due to the spondiloarthritic and stenotic changes. PURPOSE: To prove the possibility of a lumbar disc herniation in a patient with alcaptonuria as a real entity that causes lumbar and radiculalgic complaints. STUDY DESIGN: A case of a 33-year old patient with alcaptonuria and lumbar disc herniation is presented. METHODS: The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histological results and the treatment outcome. RESULTS: After the surgical treatment the patient's complaints were alleviated and almost no complaints were registered, during the next follow-up. CONCLUSIONS: The most common symptoms seen in alcaptonuria are complaints of pain in large joints and back pain. They are usually associated with the main disease. The case we present demonstrates that even there is a small likelihood for a prolapsed lumbar disk, it should be sought in such patients as the surgical treatment is able to yields a positive results.     

Ten-year survival and clinical outcome of the AcroFlex lumbar disc replacement for the treatment of symptomatic disc degeneration

Background contextWe have previously reported on the osseointegration, stability, and preserved motion of the AcroFlex lumbar disc replacement (LDR) in a nonhuman primate model. Detailed biomechanical testing of the device predicted implant survival for at least 10 years of in vivo use. Significant improvements in the clinical outcome were reported at 2 years. However, mechanical failure of the polyolefin rubber was detected by fine-cut computed tomography (CT) in a number of subjects within 2 years. As a result, no further devices were implanted.PurposeTo report on the 10-year survival and clinical outcome of the AcroFlex elastomeric LDR when used for the treatment of one- or two-level symptomatic disc degeneration between L4 and S1.Study designProspective nonrandomized clinical trial with a mean 10-year follow-up.Patient sampleTwenty-eight patients with symptomatic disc degeneration who underwent AcroFlex LDR at one or two levels.Outcome measuresClinical: Visual Analog Score for back pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), and Short Form-36 (SF-36). Survival: Kaplan-Meier analysis over 10 years with first revision surgery as the end point. Radiographic: Dynamic flexion/extension radiographs at 2 years. Magnetic resonance imaging (MRI) and CT scans at 10 years.MethodsTwenty-eight subjects (14 male, mean age 41 years) with symptomatic disc degeneration unresponsive to nonsurgical treatment were enrolled into a prospective nonrandomized trial of the AcroFlex LDR. Visual analog score for back pain, ODI, LBOS, and SF-36 questionnaires were administered preoperatively at 6 months, 1, 2, and 10 years after the index procedure. All subjects were invited to undergo an MRI and for those with the device remaining in situ, a lumbar CT scan. Kaplan-Meier survival analysis was performed with first revision surgery as the end point.ResultsAt a mean of 9 years, 8 months (range, 8 years, 8 months–11 years, 3 months) after surgery, 17 of 28 patients did not require a revision surgery, representing a cumulative survival of 60.7%. In contrast, 11 of 28 patients (39.3%) underwent a total of 14 revision procedures; 9 of 11 patients underwent a conversion to anterior lumbar interbody fusion supplemented with pedicle screw fixation. Indications for a revision included device failure in seven and disabling pain in four patients. Mean time to revision was 3 years, 10 months (range, 23 months–8 years, 4 months). Mean ODI at 10 years for nonrevision cases was 27.5 (±17.6) compared with 41.8 (±26) for revision cases. Mean improvement over 10 years in the ODI for nonrevision cases was 17.9 (±16.9) compared with 12 (±16.1) for revision cases. Similar trends were observed in LBOS and SF-36 scores. Radiographic findings in the revision group included midsubstance tears in the rubber, osteolysis, and implant displacement. CT findings in 11 of 17 survivors included heterotopic bone formation (85%), osteolysis (50%), and subsidence (14%). Magnetic resonance imaging in 14 of 23 subjects at the final follow-up demonstrated an adjacent-level disc degeneration in 68% of those with the AcroFlex LDR in situ and in 40% of those who had been converted to fusion. Skip-level disc degeneration was present in 44% of those with AcroFlex device in situ and in 20% of those who had been converted to fusion.ConclusionsThe cumulative survival was 60.7% at 10 years when the first revision surgery was taken as the end point. The etiology of the implant failure prompting the revision included failure of osseointegration, midsubstance elastomeric tears, and osteolysis. Further use of this implant is not justified. The incidence of adjacent-level disc degeneration for the AcroFlex was comparable with that observed adjacent to the spinal fusion. Salvage procedures involving conversion to spinal fusion are technically demanding, but appear to improve outcomes modestly.