Conservative management of a 31 year old male with left sided low back and leg pain: a case report

Objective:

This case study reported the conservative management of a patient presenting with left sided low back and leg pain diagnosed as a left sided L5-S1 disc prolapse/herniation.

Clinical features:

A 31-year-old male recreational worker presented with left sided low back and leg pain for the previous 3–4 months that was exacerbated by prolonged sitting.

Intervention and Outcome:

The plan of management included interferential current, soft tissue trigger point and myofascial therapy, lateral recumbent manual low velocity, low amplitude traction mobilizations and pelvic blocking as necessary. Home care included heat, icing, neural mobilizations, repeated extension exercises, stretching, core muscle strengthening, as well as the avoidance of prolonged sitting and using a low back support in his work chair. The patient responded well after the first visit and his leg and back pain were almost completely resolved by the third visit.

Summary:

Conservative chiropractic care appears to reduce pain and improve mobility in this case of a L5-S1 disc herniation. Active rehabilitative treatment strategies are recommended before surgical referral.     

Surgical techniques for sciatica due to herniated disc, a systematic review

Introduction

Disc herniation with sciatica accounts for five percent of low-back disorders but is one of the most common reasons for spine surgery. The goal of this study was to update the Cochrane review on the effect of surgical techniques for sciatica due to disc herniation, which was last updated in 2007.

Materials and methods

In April 2011, we conducted a comprehensive search in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDRO, ICL, and trial registries. We also checked the reference lists and citation tracking results of each retrieved article. Only randomized controlled trials (RCT) of the surgical management of sciatica due to disc herniation were included. Comparisons including chemonucleolysis and prevention of scar tissue or comparisons against conservative treatment were excluded. Two review authors independently selected studies, assessed risk of bias of the studies and extracted data. Quality of evidence was graded according to the GRADE approach.

Results

Seven studies from the original Cochrane review were included and nine additional studies were found. In total, 16 studies were included, of which four had a low risk of bias. Studies showed that microscopic discectomy results in a significantly, but not clinically relevant longer operation time of 12 min (95 % CI 2–22) and shorter incision of 24 mm (95 % CI 7–40) compared with open discectomy, but did not find any clinically relevant superiority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration.

Conclusions

Due to the limited amount and quality of evidence, no firm conclusions on effectiveness of the current surgical techniques being open discectomy, microscopic discectomy, and tubular discectomy compared with each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were found are clinically insignificant. Large, high-quality studies are needed, which examine not only effectiveness but cost-effectiveness as well.     

Is Sequestrectomy a Viable Alternative to Microdiscectomy? A Systematic Review of the Literature

Background

Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief.

Questions/purposes

This systematic review was designed to pose two questions: (1) Does performing a sequestrectomy only without conventional microdiscectomy lead to an increased reherniation rate; and (2) is there a difference in the patient-reported levels of radicular pain?

Methods

Systematic MEDLINE and EMBASE searches were carried out to identify all articles published in peer-reviewed journals reporting the outcomes of interest for conventional microdiscectomy versus sequestrectomy for lumbar disc herniation from L2 to the sacrum (Level III evidence and above); hand-searching of bibliographies was also performed. A minimum of Level II evidence was required with a followup rate of greater than 75%. Followup in all studies was from 18 to 86 months. Seven studies met the inclusion criteria for this review. The studies were analyzed for operating time, hospital stay, pre- and postoperative visual analog scale, and reherniation rate.

Results

Patients in both the microdiscectomy and sequestrectomy groups showed comparable improvement of visual analog scale (VAS) score for leg pain. VAS score improvement ranged from 5.6 to 6.5 points in the microdiscectomy groups and 5.5 to 6.6 in the sequestrectomy group. The reherniation rate in the microdiscectomy group ranged from 2.3% to 11.8% and in the sequestrectomy groups from 2% to 12.5%.

Conclusions

This review of the available literature suggests that, compared with conventional microdiscectomy, microsurgical lumbar sequestrectomy can achieve comparable reherniation rates and reduction in radicular pain when a small breach in the posterior fibrous ring is found intraoperatively.     

Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes

Background

Long-term postdiscectomy degenerative disc disease and low back pain is a well-recognized disorder; however, its patient-centered characterization and quantification are lacking.

Questions/purposes

We performed a systematic literature review and prospective longitudinal study to determine the frequency of recurrent back pain after discectomy and quantify its effect on patient-reported outcomes (PROs).

Methods

A MEDLINE search was performed to identify studies reporting on the frequency of recurrent back pain, same-level recurrent disc herniation, and reoperation after primary lumbar discectomy. After excluding studies that did not report the percentage of patients with persistent back or leg pain more than 6 months after discectomy or did not report the rate of same level recurrent herniation, 90 studies, which in aggregate had evaluated 21,180 patients, were included in the systematic review portion of this study. For the longitudinal study, all patients undergoing primary lumbar discectomy between October 2010 and March 2013 were enrolled into our prospective spine registry. One hundred fifteen patients were more than 12 months out from surgery, 103 (90%) of whom were available for 1-year outcomes assessment. PROs were prospectively assessed at baseline, 3 months, 1 year, and 2 years. The threshold of deterioration used to classify recurrent back pain was the minimum clinically important difference in back pain (Numeric Rating Scale Back Pain [NRS-BP]) or Disability (Oswestry Disability Index [ODI]), which were 2.5 of 10 points and 20 of 100 points, respectively.

Results Systematic Review

The proportion of patients reporting short-term (6–24 months) and long-term (> 24 months) recurrent back pain ranged from 3% to 34% and 5% to 36%, respectively. The 2-year incidence of recurrent disc herniation ranged from 0% to 23% and the frequency of reoperation ranged from 0% to 13%.

Prospective Study

At 1-year and 2-year followup, 22% and 26% patients reported worsening of low back pain (NRS: 5.3 ± 2.5 versus 2.7 ± 2.8, p < 0.001) or disability (ODI%: 32 ± 18 versus 21 ± 18, p < 0.001) compared with 3 months.

Conclusions

In a systematic literature review and prospective outcomes study, the frequency of same-level disc herniation requiring reoperation was 6%. Two-year recurrent low back pain may occur in 15% to 25% of patients depending on the level of recurrent pain considered clinically important, and this leads to worse PROs at 1 and 2 years postoperatively.     

Outcomes of Lumbar Discectomy in Elite Athletes: The Need for High-level Evidence

Background

Although lumbar discectomy for treatment of lumbar disc herniation in the general population generally improves patients’ pain, function, and validated outcomes scores, results of treatment in elite athletes may differ because of the unique performance demands required of competitive athletes.

Questions/purposes

We performed a systematic review to answer the following questions: (1) What proportion of athletes return to play after lumbar discectomy, and what is the effect of sport? (2) What is the expected recovery time after lumbar discectomy in elite athletes? (3) What is the expected career length and performance of elite athletes after lumbar discectomy?

Methods

We performed a systematic literature review of articles of lumbar discectomy in the elite athlete population through the MEDLINE and EMBASE databases from 1947 to 2013. Elite athletes were defined as professional, Olympic, or National Collegiate Athletic Association Division I collegiate level. A hand search of the references of all key articles was performed to ensure inclusion of all relevant studies. Information regarding study design, types of athletes, level of sport, recovery time, return to sport, length of career after surgery, and career performance after surgery was extracted. Ten articles met the inclusion and exclusion criteria for this review. These articles consisted of levels III and IV data and were graded based on the Methodological Index for Non-Randomized Studies (MINORS) scale.

Results

Overall, the studies included in this review found that 75% to 100% of athletes were able to return to elite competition after operative treatment. In general, a higher proportion of baseball players returned to elite competition compared with other athletes. The reported recovery period after lumbar discectomy ranged from 2.8 to 8.7 months. The average career length after lumbar discectomy ranged from 2.6 to 4.8 years. Elite athletes reached an average of 64.4% to 103.6% of baseline preoperative statistics after lumbar discectomy with variable performance based on sport.

Conclusions

A high proportion of elite athletes undergoing lumbar discectomy return to play with variable performance scores on return. Future prospective studies are needed to compare the recovery time, career longevity, and performance for athletes undergoing lumbar discectomy versus nonoperative treatment for lumbar disc herniation.     

High degree of kinesiophobia after lumbar disc herniation surgery: a cross-sectional study of 84 patients

Background and purpose

Several studies have investigated outcomes after disc surgery. However, the occurrence of kinesiophobia has not been investigated previously in patients after disc herniation surgery. In this cross-sectional study, we investigated kinesiophobia in patients who had been treated surgically for lumbar disc herniation, and we related the results to established outcome measures.

Patients and methods

10–34 months after surgery, questionnaires were sent to 97 patients who had undergone standardized open discectomy. Outcome measures included Tampa scale for kinesiophobia (TSK); Oswestry disability index (ODI); European quality of life in 5 dimensions (EQ-5D); visual analog scale (VAS) for leg and back pain, work disability, and patient satisfaction; Zung self-rating depression scale (ZDS); pain catastrophizing scale (PCS); and a self-efficacy scale (SES).

Results

36 of 80 patients reported having kinesiophobia. There were statistically significant differences in ODI, EQ-5D, VAS leg and back pain, ZDS, PCS, and SES between patients with and without kinesiophobia.

Interpretation

Half of the patients suffered from kinesiophobia 10–34 months after surgery for disc herniation. These patients were more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients without kinesiophobia.Numerous studies have investigated outcomes after disc surgery and found poor results in 10–35% of the patients, depending on what outcome measure was used (Loupasis et al. 1999, Gotfryd and Avanzi 2009, Lundin et al. 2009). In a summary of outcome assessments for treatment of spinal disorders, the following domains were recommended to be included: back-specific function, generic health status, pain, work disability, and patient satisfaction (Bombardier 2000). Results from a systematic review indicated that socio-demographic, clinical, work-related, and psychological factors predict outcome of lumbar surgery outcome (den Boer et al. 2006).In addition, affective factors, particularly fear, have proven to be central in explaining and in understanding of persistent musculoskeletal pain. 3 terms are used to describe fear in relation to pain: pain-related fear, fear of movement, and kinesiophobia. Pain-related fear is a broad and general term that covers all kinds of fears related to pain (Crombez et al. 1999). Fear of movement/(re)injury is described as “a specific fear of movement and physical activity that is (wrongfully) assumed to cause reinjury” (Vlaeyen et al. 1995a). In the most extreme situation of fear of movement, the expression “kinesiophobia” is used (Kori et al. 1990).Kinesiophobia is considered to play a negative role in the outcome of rehabilitation for patients with low back pain, and a high prevalence of kinesiophobia has been observed in patients with persistent low back pain (Picavet et al. 2002, Lundberg et al. 2004). Since physical activity/exercise is a crucial part of the rehabilitation program after surgery, kinesiophobia is probably a factor that prevents recovery. However, a subgroup analysis of kinesiophobia has not been investigated previously in patients who have undergone disc herniation surgery. We studied kinesiophobia in patients who were treated surgically for lumbar disc herniation, and related the results to established outcome measures.     

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

Background

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.

Questions/purposes

In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.

Methods

We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.

Results

Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.

Conclusions

The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3490-4) contains supplementary material, which is available to authorized users.     

Experimental Disc Herniation in the Rat Causes Downregulation of Serotonin Receptor 2c in a TNF-dependent Manner

Background

During recent decades, the knowledge of the pathophysiology of disc herniation and sciatica has drastically improved. What previously was considered a strict biomechanical process is now considered a more complex interaction between leaked nucleus pulposus and the tissue in the spinal canal. An inflammatory reaction, with tumor necrosis factor (TNF) playing an essential role, has been demonstrated. However, the exact mechanisms of the pathophysiology of disc herniation remain unknown.

Questions/purposes

In this study we use an animal model to investigate (1) if and/or how experimental disc herniation affects gene expression in the early phase (24 hours postsurgery) in the dorsal root ganglion; and (2) if TNF inhibition can reduce any observed changes.

Methods

A rat model of disc herniation was used. Twenty rats were evenly divided into four groups: naïve, sham, disc herniation, and disc herniation with TNF inhibition. The dorsal root ganglion of the affected nerve root was harvested 24 hours after surgery and analyzed with a TaqMan Low Density Array^® quantitative polymerase chain reaction assay. Gene expression levels in sham were compared with disc herniation to assess question 1 and disc herniation to disc herniation with TNF inhibition to assess question 2.

Results

Experimental disc herniation caused a decrease in the expression of the serotonin receptor 2c gene (p = 0.022). TNF inhibition was found to reduce the observed decrease in expression of serotonin receptor 2c (p = 0.037).

Conclusions

Our results suggest that a decrease in the expression of the serotonin receptor 2c gene may contribute to the pathophysiology of disc herniation. Further research on its involvement is warranted.

Clinical Relevance

This pilot study gives a brief insight into cellular changes that may contribute to the pathophysiology of disc herniation. This knowledge may contribute to the development of more and better treatment options for patients with disc herniation and sciatica.     

Spinal infection: a case report

Objective:

To present a case of a patient with spinal infection (SI) and highlight the chiropractor’s role in the prevention or minimization of devastating complications of SI.

Background:

Recent literature trends suggest an increasing prevalence of SI. Patients with SI most commonly present with unremitting progressive back pain and may or may not have fever or neurological signs. To avoid negative post-infection sequelae, establishing an early diagnosis and treatment is crucial.

Clinical Features:

A 29-year-old female diagnosed with L5-S1 disc herniation with impingement of the right S1 nerve root opted for surgical management. Iatrogenic bowel perforation during her spinal surgery resulted in contamination of the spinal surgical site, and findings in keeping with disco-osteomyelitis with epidural and paraspinal phlegmon formation were visualized on contrast enhanced MRI.

Conclusion:

Recent trends of increased spinal infection urge a heightened awareness by the chiropractor. The chiropractor can provide early diagnosis and supportive multidisciplinary care for such patients.     

Modic type I changes and recovery of back pain after lumbar microdiscectomy

Purpose

To investigate whether the presence of Modic changes type I (MC I) found on preoperative MRI scans represent a risk factor for persistent back pain 12 months after surgery amongst patients operated for lumbar disc herniation.

Methods

Cohort study of 178 consecutive patients operated with lumbar microdiscectomy. Preoperative MRI scans were evaluated by two independent neuroradiologists. Primary outcome measure was the visual analogue scale (VAS) for back pain. Secondary outcome measures were; VAS for leg pain, physical function (Oswestry Disability Index), and health-related quality of life (EQ-5D), self-reported benefit of the operation and employment status. The presence of MC I was used as exposition variable and adjusted for other risk factors in multivariate analyses.

Results

The Modic classification showed a high inter-observer reproducibility. Patients with MC I had less improvement of back pain 12 months after surgery, compared to those who had no or other types of MC, but this negative association no longer showed statistical significance when adjusted for smoking, which remained the only independent risk factor for persistent back pain.

Conclusions

Patients with preoperative MC I can expect less but still significant improvement of back pain 1 year after microdiscectomy, but not if they smoke cigarettes.     

Unilateral right occipital condyle to C2 level spinal cord infarction associated with ipsilateral vertebral artery stenosis and contralateral vertebral artery dissection: a case report

Objectives

To illustrate the clinical presentation, diagnosis, management, and outcome of unilateral right occipital condyle to C2 level spinal cord infarction.

Setting

A teaching hospital in Taiwan.

Findings

A 37-year-old man presented with acute-onset severe right neck pain before weakness developed in both right limbs. Early diagnosis was delayed due to mild intervertebral herniation of the C4–C5 disk. Magnetic resonance imaging revealed unilateral right occipital condyle to C2 level infarction. Angiography showed stenosis of the right vertebral artery (foraminal and intradural segments), and dissection of the left vertebral artery at the C1–C2 level. At discharge, he walked with assistance; 2 weeks later, he walked independently.

Conclusions

An early diagnosis is difficult but important, as it facilitates appropriate treatment for better functional and survival outcomes. Accurate early diagnosis can be made with adequate knowledge of spinal cord infarction and high index of suspicion for this condition.     

Anterior discectomy and total disc replacement for three patients with multiple recurrent lumbar disc herniations

Background context

Although results of primary discectomy are generally excellent with relief of leg pain, recurrent lumbar disc herniation is relatively common ranging from 5% to 25%. Patients with recurrent herniation may undergo revision surgery; however, this carries with it increased risks and lower success rates. Many surgeons will advocate a fusion in addition to repeat discectomy after the third recurrent herniated disc. With the approval of lumbar total disc arthroplasty, there now exists another option for the patient with three or more recurrent disc herniations to preserve motion, theoretically decrease the rate of adjacent-level disease, and ameliorate the patient’s symptoms.

Purpose

The purpose of this case report is to describe our experience using total disc replacement (TDR) in three patients after prior partial hemilaminectomy and discectomy for the treatment of a third and fourth recurrent lumbar disc herniation.

Study design

This article is a report of three cases from a spine specialty center describing an alternative surgical technique for patients with multiple recurrent lumbar disc herniation.

Methods

Comprehensive chart review of three patients with recurrent lumbar herniation who underwent TDR.

Results

Anterior discectomy and TDR were undertaken, and at most recent follow-up (8–12 months), all patients had improvement of their visual analog scale and Oswestry Disability Index. No patient had postoperative complications or reoperation.

Conclusions

Recurrent disc herniation is a relatively common problem that may be difficult to treat. Traditionally, a patient presenting with three or more recurrent disc herniation may likely have undergone revision discectomy with fusion. The current case report suggests that TDR may be an alternative option in select patients.     

Paraspinal muscle asymmetry and fat infiltration in patients with symptomatic disc herniation

Purpose

To investigate asymmetry in size and composition of the multifidus and erector spinae in patients with posterolateral disc herniation and concordant radicular symptoms, and determine whether symptom duration is associated with degree of asymmetry.

Methods

Thirty-three patients diagnosed with posterolateral disc herniation at L4–L5 verified on imaging and concordant leg pain were included. Multifidus and erector spinae cross-sectional area (CSA), functional cross-sectional area (FCSA, fat-free area), signal intensity and ratio of FCSA to total CSA were measured bilaterally from T ₂-weighted axial magnetic resonance imaging (MRI) at L3–L4, L4–L5, L5–S1 and S1 levels.

Results

No side-to-side differences in multifidus CSA, FCSA, and ratio of FCSA/CSA reached statistical significance at any spinal level. The multifidus signal intensity at L5–S1 was significantly greater (more fatty infiltration) on the side of the disc herniation. The erector spinae FCSA (lean muscle mass) at L5–S1 was found to be significantly smaller on the side of the herniation and the ratio of FCSA/CSA was smaller (more fatty infiltration) on the side of the herniation at L4–L5 and L5–S1. The degree of muscle asymmetry was not associated with symptoms duration.

Conclusions

There was no significant asymmetry of the multifidus at spinal level above, same or level below the disc herniation. Instead, variations in muscle composition were observed, with greater fat infiltration on the side and at spinal levels adjacent to the disc herniation. Muscle asymmetry was not correlated with symptom duration.

     

Minimally invasive transforaminal lumbar interbody fusion: Results of 23 consecutive cases

Background:

The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.

Materials and Methods:

This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.

Results:

The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.

Conclusion:

The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.     

Back pain improves significantly following discectomy for lumbar disc herniation

Background Context

Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain.

Reoperation after lumbar disc surgery in two hundred and seven patients

Purpose

The purpose of this study was to compare the causes and characteristics of reoperations after different primary operations for lumbar disc herniation (LDH).

Methods

Out of a series of 5,280 patients who underwent operations for LDH between 2001 and 2012, 207 patients (135 male and 72 female, mean age 47.7 years) underwent primary and revision operations, which were included in this study. The following clinical parameters were retrospectively assessed: the primary surgical methods, the intervals between primary and revision operations, and surgical findings in the revisions.

Results

In total, 232 lumbar discs underwent reoperations. One hundred and nineteen reoperations were performed after microendoscopic discectomy (MED group), 68 after percutaneous endoscopic lumbar discectomy (PELD group) and 45 after open disc surgery (open group). The locations of revision operations had priority over those of primary surgery, with a moderate correlation (kappa coefficient = 0.533). A total of 46.6 % of reoperations were performed within 0.5 years after primary surgery, and 35.3 % were performed between one and five years. Real recurrent herniation (homolateral herniations at the same level) was significantly more common than other reoperative surgical findings (70.6 % in PELD group, 47.1 % in MED group, 37.8 % in open group). The overall mean interval until revision surgery was 18.9 months (8.1 months in the PELD group vs. 19.7 months in the MED group vs. 33.1 months in the open group, p < 0.01).

Conclusions

For LDH, real recurrent herniation was the most common cause of reoperations, and more reoperations for real recurrent herniations and shorter intervals were found after minimally invasive endoscopic discectomy than after open disc surgery.     

Conservatively treated massive prolapsed discs: a 7-year follow-up

INTRODUCTION

The natural history of a lumbar hernia of the nucleus pulposus (HNP) is not fully known and clear indications for operative intervention cannot be established from the literature. Several studies have shown that the largest discs appear to have the greatest tendency to resolve. The aim of this study was to investigate whether massive prolapsed discs can be safely managed conservatively once clinical improvement has occurred.

PATIENTS AND METHODS

Thirty-seven patients were studied by clinical assessments and serial magnetic resonance imaging (MRI) over 2 years. Patients had severe sciatica at first, but began to show clinical improvement despite the large disc hernia-tions. Clinical assessment included the Lasegue test and neurological appraisal. The Oswestry Disability Index was used to measure function and changes in function. Serial MRI studies allowed measurement of volume changes of the herniated disc material over a period of time.

RESULTS

Initial follow-up at an average of 23.2 months revealed that 83% had a complete and sustained recovery at the initial follow-up. Only four patients required a discectomy. The average Oswestry disability index improved from 58% to 15%. Volumetric analysis of serial MRI scans found an average reduction of 64% in disc size. There was a poor correlation between clinical improvement and the extent of disc resolution.

CONCLUSIONS

A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.     

Postdural disc herniation at L5/S1 level mimicking an extradural spinal tumor

Introduction

Postdural disc herniation has been documented rarely and the pathogenesis is still unknown. The average age of postdural disc herniations is between 50 and 60 years, and the sites most frequently affected by postdural lumbar disc herniations are L3–L4 and L4–L5, only less than 10 % in L5–S1. Although magnetic resonance imaging (MRI) is a useful tool in the diagnosis of this disease, the postdural disc herniation is usually misdiagnosed as extradural spine tumor preoperatively. The definitive diagnosis is made during operation or according to the postoperative pathology.

Methods

In this article, we described here a 48-year-old male patient who presented with intermittent pain in the low back and frequent urination for 4 years as well as hypesthesia and pain of the left lower extremity for 1 month.

Results

A standard total laminectomy was performed and the histopathological diagnosis was consistent with a degenerated intervertebral disc. The patient presented significant relief of the pain and of the neurological symptoms, but no improvement of frequent urination, in the postoperative period.

Conclusions

The diagnosis of postdural disc herniations is very difficult and mainly based on intraoperative and histopathological results. Early surgical intervention is important to relieve symptoms and prevent severe neurological deficits.