Postoperative Pain Therapy After Lumbar Disc Surgery

Summary  Object. This study was undertaken to determine whether a special postoperative pain administration of tramadol and diclofenac provides any benefits in patients who underwent microsurgical lumbar discectomy.  Methods. The study consisted of 60 patients undergoing microsurgical lumbar discectomy. Patients were randomly divided into two groups based on the postoperative pain management: 1) Group A (n=30): no standardized pain therapy; these patients received on demand different analgesics and at variable dosages which were selected by the neurosurgeons; 2) Group B (n=30): standardized pain therapy with specific dosages of tramadol and diclofenac in regular time intervals during the first 48 hours after surgery. After surgery follow-up data from a special standardized questionnaire were obtained for all 60 patients during the first 48–72 postoperative hours. The patients were asked for course and intensity of pain as well as about some specific circumstances of clinical therapy after surgery.  The postoperative pain intensity of patients treated with the special combination of tramadol and diclofenac was significantly diminished (24 hours after surgery: p=0.0002, 48 h: p=0.0047, 72 h: p=0.0034) in relation to the group without standardized pain therapy. Similarly, the frequency of breakthrough pain was significantly reduced (24 h: p=0.0001, 48 h: p=0.003, 72 h: p=0.004).  Conclusions. The results suggest that the application of tramadol and diclofenac during the first 48 hours after lumbar microdiscectomy results in a reduction in postoperative pain without complications. We suggest that the use of this combination can be a beneficial adjunct to lumbar disc surgery.     

不同手术方式治疗腰椎间盘突出症的网状Meta分析

文题释义：网状Meta分析：Meta分析通常只能比较2个干预措施,面对多种干预措施时却束手无策。网状Meta分析方法提供了一种有效、安全的筛选多种干预措施的方法,其是基于多个研究分析2个以上干预措施之间间接比较结果或直接比较结果与间接比较结果的合并结果的Meta分析。标准化均数差(SMD)：Meta分析会遇到相同指标而计量单位不同的情况,文中的疼痛评分为连续型资料,对于连续型资料的效应量可采用标准均数差表示,其不仅消除了绝对值大小的影响,还消除了度量衡对结果的影响。背景：目前用于治疗腰椎间盘突出症的手术方式较多,治疗效果各有优势,虽然已有许多Meta分析比较两两手术方式的疗效,但缺乏几种手术方式疗效的比较。 目的：应用网状Meta分析方法比较不同手术方式治疗腰椎间盘突出症的差异。方法：检索PubMed、Embase、Cochrane Library、Ovid和中国知网数据库,收集有关不同手术方式治疗腰椎间盘突出症的随机对照试验或回顾性研究。按预先制定的纳入排除标准进行筛选,并对纳入的随机对照试验进行质量评价,采用STATA 15.0软件进行数据分析。结果与结论：共纳入42个研究,5 156例患者,涉及9种手术治疗方式,包括腰椎间盘置换术、腰椎间盘融合术、标准椎间盘切除术、椎间盘镜下髓核摘除术、显微镜下髓核摘除术、经皮内窥镜腰椎间盘切除术、化学溶核术、自动经皮腰椎间盘切除术和经皮激光椎间盘减压术。网状Meta分析显示(从优至劣)：①缓解腿痛疗效方面排序为经皮激光椎间盘减压术>椎间盘镜下髓核摘除术>经皮内窥镜腰椎间盘切除术>标准椎间盘切除术>显微镜下髓核摘除术>腰椎间盘融合术>腰椎间盘置换术,差异无显著性意义;②缓解腰痛疗效方面排序为腰椎间盘置换术>腰椎间盘融合术>椎间盘镜下髓核摘除术>经皮内窥镜腰椎间盘切除术>显微镜下髓核摘除术>经皮激光椎间盘减压术>标准椎间盘切除术,部分差异有显著性意义;③改善Oswestry功能障碍指数方面排序为椎间盘镜下髓核摘除术>经皮内窥镜腰椎间盘切除术>标准椎间盘切除术>显微镜下髓核摘除术>腰椎间盘置换术>腰椎间盘融合术,差异无显著性意义;④手术成功率方面排序为腰椎间盘置换术>腰椎间盘融合术>椎间盘镜下髓核摘除术>经皮内窥镜腰椎间盘切除术>标准椎间盘切除术>经皮激光椎间盘减压术>显微镜下髓核摘除术>化学溶核术>自动经皮腰椎间盘切除术,部分差异有显著性意义;⑤再次手术率方面排序为腰椎间盘置换术>腰椎间盘融合术>显微镜下髓核摘除术>椎间盘镜下髓核摘除术>标准椎间盘切除术>经皮内窥镜腰椎间盘切除术>经皮激光椎间盘减压术>化学溶核术>自动经皮腰椎间盘切除术,差异无显著性意义;⑥并发症发生率方面排序为经皮内窥镜腰椎间盘切除术>自动经皮腰椎间盘切除术>标准椎间盘切除术>显微镜下髓核摘除术>经皮激光椎间盘减压术>椎间盘镜下髓核摘除术>腰椎间盘置换术>腰椎间盘融合术>化学溶核术,部分差异有显著性意义。结果表明,椎间盘镜下髓核摘除术和经皮内窥镜腰椎间盘切除术在各方面具有较好的疗效,腰椎间盘置换术和腰椎融合术在手术成功率方面较好,化学溶核术在手术成功率、再手术率及并发症发生率方面疗效均较差,经皮自动椎间盘切除术在手术成功率及再手术率方面疗效较差。 ORCID: 0000-0001-6307-8532(向熙) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Lumbar microdiscectomy as a day-case procedure: Scope for improvement?

Background and purpose

There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients.

Partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy in a patient with Crohn's disease

Cauda equina syndrome is a serious condition resulting from dysfunction of the lumbosacral nerve roots and characterized by impairment of bladder, bowel, sexual and lower limb functions. We report the case of a 48-year-old woman who had Crohn's disease for more than twenty years. The patient was undergoing immunotherapy with infliximab and developed a partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy (L₅–S₁) that completely cured her sciatica. A postoperative magnetic resonance imaging examination showed root clumping but no compressive lesion. We discuss a possible relationship between the cauda equina syndrome and the patient's active Crohn's disease, treatment and surgery.     

“Standard” microsurgical lumbar discectomy vs. “conservative” microsurgical discectomy A preliminary study

Summary The conservative microsurgical lumbar discectomy described by Williams for the treatment of herniated lumbar disc is compared in a retrospective study with the standard microsurgical technique of Caspar and Loew. In order to enable such a retrospective comparison, a special randomization had to be chosen. The data concerning outcome are based on a questionnaire, in which the patient can describe his actual health situation. The result in the group of 56 patients operated on by the Williams technique with a mean follow-up of 27 months is excellent or good in 89% vs. 74% in the standard technique group. Reoperations due to a recurrence were identical in both groups (3.6% and 3.9%).     

Mini posterior lumbar interbody fusion with presacral screw stabilization in early lumbosacral instability

Background:Surgical options for the management of early lumbosacral spondylolisthesis and degenerative disc disease with instability vary from open lumbar interbody fusion with transpedicular fixation to a variety of minimal access fusion and fixation procedures. We have used a combination of micro discectomy and axial lumbosacral interbody fusion with presacral screw fixation to treat symptomatic patients with lumbosacral spondylolisthesis or lumbosacral degenerative disc disease, which needed surgical stabilization. This study describes the above technique along with analysis of results.Results:We had nine females and three males with a mean age of 47.33 years (range 26–68 years). Postoperative assessment revealed three patients to have screw placed in anterior 1/4^th of the 1^st sacral body, in rest nine the screws were placed in the posterior 3/4^th of sacral body. At 2 years followup, eight patients (67%) showed evidence of bridging trabeculae at bone graft site and none of the patients showed evidence of instability or implant failure.Conclusion:Presacral screw fixation along with micro discectomy is an effective procedure to manage early symptomatic lumbosacral spondylolisthesis and degenerative disc disease with instability.     

Minimally invasive microscopically assisted lumbar discectomy using the METRx X-Tube system

Background and purposeLumbar discectomy with the METRx X-Tube system and operating microscope is a modification of microendoscopic discectomy. The aim of this study was to describe this method and present the results of treatment of the first 13 patients.Material and methodsUnder general anaesthesia and fluoroscopic guidance, a guidewire was placed over the inferior aspect of the superior lamina. A 2.5–3 cm midline skin incision was made, followed by paramedian lumbar fascia incision. Then, dilators were sequentially introduced (muscle-splitting approach). Finally, a tubular retractor was fixed directly over the interlaminar space. Further stages of the procedure were performed using an operating microscope and standard microdiscectomy equipment. The first 13 consecutive patients operated on using this method were analysed. Twelve patients were operated on at one level and 1 at two levels. Disc herniation was centro-lateral in 10 cases, lateral in 2 and central (broad-based) in 2 patients.ResultsRegression of radicular pain was noted in all patients. No postoperative complications were observed except for prolongation of wound healing in 2 patients. According to modified MacNab criteria, excellent late outcome was achieved in 8 patients and good in 4 patients. There were no cases of recurrent radicular pain or need for surgical revision for herniation recurrence. One patient was reoperated on because of low back pain (implantation of an interspinous spacer).ConclusionsMicroscopically assisted lumbar discectomy using the METRx X-Tube system seems to be safe and effective. This method combines the advantages of modern minimally invasive techniques while avoiding the limitations of endoscopy.     

Effect of Duration of Symptoms on the Clinical and Functional Outcomes of Lumbar Microdiscectomy: A Randomized Controlled Trial

ObjectivesThe objective is to determine whether the preoperative duration of symptoms can affect the clinical and functional outcomes after microdiscectomy.MethodThis study is a single blind randomized controlled trial with level 1 evidence. From 3 January 2016 to 15 February 2017, 122 adult patients with symptomatic lumbar disc herniation were divided randomly by computer system into three groups were treated by microdiscectomy at 6 weeks, 3 months and 6 months from onset of symptoms respectively. Ninety‐seven patients, age (19–47) years, 42 males and 55 females, were analyzed at the end of this study with 3 years of follow up. Primary outcome measures are Oswestry Disability Index (ODI), Roland‐Morris Questionnaire (RMQ) and Visual Analogue Scale (VAS) for back pain and leg pain. Secondary outcome measures are post‐operative complications, length of hospital stay and time of return to daily activities.ResultsThere was significant difference in VAS for back pain among study groups (P = 0.002) at 2 weeks). There were significant differences in VAS for leg pain among study groups (P < 0.001) at 2 weeks and at 3 months (P = 0.003). There was significant difference in ODI among study groups at 2 weeks, 3, 6 months, 1, 2 and 3 years (P = 0.037 at 2 weeks and P < 0.001 at other periods of assessments) and we found that the mean of ODI in group 6 weeks was better than group 3 months and this was better than group 6 months in all periods of assessment. Group 6 weeks was better than group 3 months and this was better than group 6 months in postoperative improvements regarding RMQ with significant difference at 2 weeks postoperatively (P < 0.001) and at 3 months postoperatively (P < 0.001).ConclusionDuration of preoperative symptoms, in patients with lumbar disc herniation, can affect the clinical and functional outcomes after lumbar microdiscectomy as the shorter duration of symptoms resulted in better postoperative clinical and functional outcomes.     

Lumbar microdiscectomy

Lumbar disc herniations are seen frequently in pain management practices. Specialists are well versed in the nonsurgical treatments for lumbar radiculopathy. Although most disc herniations would resolve without the need for surgery; it should be considered when patients have refractory pain or motor deficit. The following article discusses the surgical treatment for lumbar disc herniation—microdiscectomy. Pertinent literature has been reviewed and the surgical outcomes are highlighted.     

Long term results of lumbar sequestrectomy versus aggressive microdiscectomy

It remains unknown whether aggressive microdiscectomy (AD) provides a better outcome than simple sequestrectomy (S) with little disc disruption for the treatment of lumbar disc herniation with radiculopathy. We compared the long term results for patients with lumbar disc herniation who underwent either AD or S. The patients were split into two groups: 85 patients who underwent AD in Group A and 40 patients who underwent S in Group B. The patients were chosen from a cohort operated on by the same surgeon using either of the two techniques between 2003 and 2008. The demographic characteristics were similar. The difference in complication rates between the two groups was not statistically significant. During the first 10 days post-operatively, the Visual Analog Scale score for back pain was 4.1 in Group A and 2.1 in Group B, and the difference was statistically significant (p < 0.005). The Oswestry Disability Index score was 11% in Group A and 19% in Group B at the last examination. The reherniation rate was 1.5% in Group A and 4.1% in Group B (p < 0.005). We argue that reherniation rates are much lower over the long term when AD is used with microdiscectomy. AD increases back pain for a short time but does not change the long term quality of life. To our knowledge this is the first study with a very long term follow-up showing that reherniation is three times less likely after AD than S.