Disc height and segmental motion as risk factors for recurrent lumbar disc herniation

Radiological risk factors for recurrent lumbar disc herniation after percutaneous transforaminal endoscopic discectomy: a retrospective matched case-control study

PURPOSE

To investigate radiological risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous transforaminal endoscopic discectomy (PTED).

METHODS

Patients who underwent PTED due to a single-level L4-L5 or L5-S1 disc herniation from January 2013 to May 2019 were enrolled in this study. A matched case-control design was carried out in a single institution. Cases were defined as those who developed rLDH, and controls were matched from those patients without rLDH according to corresponding clinical characteristics. The radiological parameters were compared between two groups. The radiological risk factors for rLDH after PTED were identified by univariate and multivariate logistic regression analysis.

RESULTS

A total of 2186 patients who underwent PTED at L4-L5 or L5-S1 level were enrolled in this study. Sixty-eight patients were diagnosed with rLDH, and 136 patients were selected from the remaining 2118 nonrecurrent patients as matched controls. Univariate analysis demonstrated that herniation type (P = 0.009), surgical-level disc degeneration (P < 0.001), adjacent-level disc degeneration (P = 0.017), disc height index (DHI) (P = 0.003), and sagittal range of motion (sROM) (P < 0.001) were significantly related to rLDH. Multiple logistic regression analysis showed that low grade of surgical-level disc degeneration (P < 0.001), senior grade of adjacent-level disc degeneration (P < 0.001), a high DHI (P = 0.012), and a large sROM (P < 0.001) were the radiological independent risk factors.

CONCLUSION

This study showed that low grade of surgical-level disc degeneration, senior grade of adjacent-level disc degeneration, a high DHI, and a large sROM were the radiological independent risk factors for rLDH after PTED.

Risk factors for early reherniation after lumbar discectomy with or without annular closure: results of a multicenter randomized controlled study

BACKGROUND

Reherniation after lumbar discectomy is classified as a failure and occurs in 3 to 18% of cases. Various risk factors for reherniation such as age, sex, body mass index, smoking, and size of annular defect have been reported. The aim of this study was to identify risk factors for early reherniation after one-level lumbar discectomy with or without annular closure within 3 months after surgery.

METHODS

This study is based on data analysis of a prospective, multicenter randomized controlled trial in Europe. Patients included underwent standard lumbar discectomy-with or without implantation of an annular closure device (ACD). Enrollment of 554 patients in 21 centers in Europe (Germany, Switzerland, Austria, Belgium, The Netherlands, and France) started in 2010 and was completed in October 2014. A total of 276 patients were randomized to the ACD group (ACG) and 278 patients to the control group (CG).

RESULTS

Four (1.5%) symptomatic reherniations occurred in the ACG and 18 (6.5%) in the CG. In the overall population, a significant correlation was found with recurrent herniation for disc degeneration (Pfirrmann p = 0.009) and a trend for current smoker status (p = 0.07). In CG, age ≥ 50 years (p = 0.05) and disc degeneration (Pfirrmann p = 0.026, Kellgren and Lawrence p = 0.013) were predictive factors for reherniation.

CONCLUSION

In the current study, risk factors for early recurrent disc herniation after lumbar discectomy were age ≥ 50 years and moderate disc degeneration. The annular closure device reduced the risk of early reherniation.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01283438.

Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases

Background

Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.

Purpose

This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).

Methods

A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.

Results

The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle-disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.

Conclusion

Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.

Full endoscopic interlaminar discectomy (FEID) for recurrent lumbar disc herniation: surgical technique, clinical outcome, and prognostic factors

Background

The objective of this study is to determine the effectiveness and prognostic factors of revisional full endoscopic interlaminar discectomy (FEID) for recurrent herniation after conventional open disc surgery. The major concerns of the repeated discectomy for recurrent lumbar disc herniation (RLDH) are the epidural scar and postoperative segmental instability. Compared to open discectomy, endoscopic method has advantages of less tissue traumatization, clearer visualization and better tissue identification. With the improvement of endoscopic technique and instrument, the problems related to adhesive scar tissues or postoperative instability could be overcome.

Methods

From June 2014 to December 2016, FEID was performed in consecutive 24 patients for RLDH. The age ranged from 25 to 60 years (mean 44.6 years). The level operated was L5-S1 in 16 cases and L4-5 in 8 cases. To avoid injury to the neural tissue, we started with the bony structure. A small part of facet or lamina might be resected in severe stenotic or adhesive condition. Aggressive separation of the scar from the neural tissue might lead to dural tear and should be avoided. The herniated disc material was removed after neural tissue had been clearly identified and protected.

Results

The follow-up period was at least 24 months. The visual analog scale (VAS) for leg pain and back pain, and Oswestry disability index (ODI) showed significant improvement after treatment. Excellent or good outcome by the modified Macnab's criteria was obtained in 22 of 24 patients at two years follow-up. Excellent outcome was noted in 100 percent patients younger than 50 years. Small durotomy occurred in 2 patients and no visible cerebrospinal fluid (CSF) leakage was detected despite repair was not performed. Two additional surgery was performed including one repeated FEID for re-recurrence of disc herniation and one fusion surgery for postoperative back pain.

Conclusions

FEID is a safe and effective alternative for recurrent disc herniation. The successful rate was greater than 90 percent, especially in the younger patients with the advantages of early recovery and no need for fusion.

Long-Term Clinical Outcomes and Pain Assessment after Posterior Lumbar Interbody Fusion for Recurrent Lumbar Disc Herniation

Objectives

The aim of this study was to investigate the long term effects of posterior lumbar interbody fusion (PLIF), applied after recurrent lumbar disc herniation (rLDH), on pain relief and clinical outcome improvement.

Methods

The current study is a retrospective study. We observed 22 cases from 85 patients that had undergone PLIF during February 2003 to October 2012 and all patients were followed for at least 5 years. The average age of those patients were 53 years, among them there were eight men and 14 women. Plain radiography and dynamic plain films were obtained, pre‐operation, for every patient. Magnetic resonance imaging (MRI) or computed tomography (CT) was conducted to confirm the diagnosis of rLDH before the operation. All surgeries were performed from posterior approach by the same surgeon using PLIF. Quality of life (QOL) and clinical outcomes were assessed by Numerical Rating Scale (NRS), Japanese Orthopaedic Association (JOA) scoring system, and Oswestry Disability Index (ODI) before revision surgery and at 1 week, 3 months, 12 months, and 24 months postoperative. These were also examined every time they came back to the hospital for a review.

Results

All patients were discharged and no serious comorbidities occurred. Three cases with wound infections and one case with dural laceration were cured and discharged. The end point of follow‐up was August 2018 and the mean follow‐up after revision surgery was 85 months. There were significant differences in NRS. It decreased from 7.32 ± 1.17 to 2.77 ± 1.31 (P < 0.05). The mean postoperative NRS score was 2.27 ± 1.48 (P < 0.05), 1.90 ± 1.51 (P < 0.05), and 2.36 ± 1.36 (P < 0.05) at 3, 12, and 24 months after surgery. There were no statistically significant differences (P > 0.05) in ODI scores. The average JOA score improved from 5.00 ± 1.08 to 8.18 ± 1.59 (P < 0.05) 1 week after revision surgery. RR was between 50% and 70%. Overall satisfaction rates were beyond 80%. Only one patient required subsequent lumber surgery during the follow‐up period.

Conclusion

If surgical indications are mastered, undergoing PLIF after rLDH may induce efficient pain relief and major improvements in clinical outcome scores, as well as quality of life scores.

Risk Factors and Surgical Treatment for Recurrent Lumbar Disc Prolapse: A Review of the Literature

We aim to present the current evidence on various risk factors and surgical treatment modalities for recurrent lumbar disc herniation (rLDH). Using PubMed, a literature search was performed using the Mesh terms "recurrent disc prolapse," "herniated lumbar disc," "risk factors," and "treatment." Articles that were published between January 2010 and May 2017 were selected for further screening. A search conducted through PubMed identified 213 articles that met the initial screening criteria. Detailed analyses showed that 34 articles were eligible for inclusion in this review. Sixteen articles reported the risk factors associated with rLDH. Decompression alone as a treatment option was studied in seven articles, while 11 articles focused on different types of fusion surgery (anterior lumbar interbody fusion, posterior lumbar interbody fusion, open transforaminal lumbar interbody fusion [TLIF], and minimally invasive surgery-TLIF). Management of the rLDH requires consideration of the possible risk factors present in individual patients before primary and at the time of second surgery. Both, minimally invasive and conventional open procedures are comparably effective in relieving leg pain, and minimally invasive techniques offer advantage over the other technique in terms of tissue sparing. Non-fusion surgeries involve the risk of lumbar disc herniation re-recurrence, and the patient may require a third (fusion) surgery.

Revision after failed discectomy

PURPOSE

Recurrent lumbar disc herniation is the most common complication after discectomy. Due to the altered anatomy with the presence of scar tissue, the surgical revision of already operated patients could be a surgical challenge.

METHODS

We describe the microsurgical revision technique step by step with the evaluation of our own clinical results in comparison with primary lumbar disc surgeries. The clinical data are based on a clinical register with 2576 recorded primary surgeries (PD) and 592 cases of revisions (RD) with 12- and 24-month follow-up (FU). The intraoperative dura lesion rates of the surgeries between 2016 and 2018 were recorded retrospectively. Data from 894 primary disc surgeries and 117 revisions were evaluated.

RESULTS

The ODI and the VAS for leg and back pain improved in both groups significantly with slightly inferior outcome of the revision group. The ODI improved from 46.3 (PD) and 45.9 (RD), respectively, to 12.6 (PD) and 22.9 (RD) at the 24-month FU. The VAS dropped down as well in both group [VAS back: 47.8 (PD) and 43.9 (RD) to 19.9 and 32.2 at the 24-month FU; VAS leg: 62.9 (PD) and 65.5 (RD) to 15.6 and 26.8 at the 24-month FU]. During the primary interventions, we observed 1.5% (11/894) and during revisions 7.7% (9/117) of dura lesions.

CONCLUSIONS

There is no clear guideline for the surgical treatment of recurrent disc herniations. In most cases, a pure re-discectomy is sufficient and can be performed safely and effectively with the help of a microscope. These slides can be retrieved under Electronic Supplementary Material.

Relationship of endplate changes and low back pain after discectomy

OBJECTIVES

Discectomy is a conventional surgery for lumbar disc herniation. However, recurrence and residual back pain are the main postoperative complications. The contribution of endplate changes to the occurrence of these complications remains controversial. This study aimed to investigate the effect of endplate changes after discectomy.

PATIENTS AND METHODS

We conducted a retrospective evaluation of 128 patients who had endplate changes after undergoing discectomy in our hospital. The patients were divided into three groups according to severity of abnormality according the Weishaupt classification (mild, moderate, and severe). The Oswestry Disability Index (ODI) and visual analog scale (VAS) were used to evaluate the efficacy of different surgical methods.

RESULTS

Seventeen patients dropped out of the follow-up study. Satisfactory efficacy was observed in most patients, but 16 patients underwent reoperation. Significant differences were observed among the three groups in terms of low back pain severity and ODI (p < 0.05), but not radicular leg pain severity. The severe group had a higher recurrence rate of disc herniation (23.5%) than the mild and moderate groups (10.3% and 10.4%, respectively).

CONCLUSION

Discectomy had a noticeable efficacy. However, severe endplate changes, which indicated fissures on the endplate, damaged the lumbar stability and resulted in a higher recurrence rate and residual back pain. For such cases, internal fixation surgery should be considered.

Recurrent Lumbar Disc Herniation: A Review

STUDY DESIGN

Narrative review.

OBJECTIVES

To identify the risk factors and surgical management for recurrent lumbar disc herniation using a systematic review of available evidence.

METHODS

We conducted a review of PubMed, MEDLINE, OVID, and Cochrane Library databases using search terms identifying recurrent lumbar disc herniation and risk factors or surgical management. Abstracts of all identified articles were reviewed. Detailed information from articles with levels I to IV evidence was extracted and synthesized.

RESULTS

There is intermediate levels III to IV evidence detailing perioperative risk factors and the optimal surgical technique for recurrent lumbar disc herniations.

CONCLUSIONS

Multiple risk factors including smoking, diabetes mellitus, obesity, intraoperative technique, and biomechanical factors may contribute to the development of recurrent disc disease. There is widespread variation regarding optimal surgical management for recurrent herniation, which often include revision discectomies with or without fusion via open and minimally invasive techniques.

Does Adequate Lumbar Segmental Motion Reflect Recovery Process in Acute Lumbar Disc Herniation?

Objective

To investigate if the extent of lumbar segmental motion is correlated with the recovery process in the form of pain intensity in patients with acute single level lumbar disc herniation (LDH).

Methods

A retrospective review of medical records was performed on patients presented with acute low back pain from January 2011 to December 2017. With prerequisites of undergoing both lumbar spine magnetic resonance imaging and functional radiography, patients with etiologies other than single level LDH were excluded. A total of 46 patients were selected, including 27 patients with disc herniation at L4-5 level and 19 patients at L5-S1 level. Pearson correlation analysis of pain intensity against segmental range of motion (sROM) and percentage of sROM of each lumbar segment was performed at the initial evaluation point and follow-ups.

Results

Serial documentation of pain intensity and functional radiography exhibited an inverse correlation between changes in visual analogue scale (VAS) and sROM in single level LDH at L4-5 level (r=-0.69, p<0.05). In addition, percentage of sROM showed a negative correlation with pain intensity at the aforementioned segment (r=-0.74, p<0.05). Initial pain intensity was also inversely correlated to sROM of the affected segment (r=-0.83, p<0.01 at L4-5; r=-0.82, p<0.05 at L5-S1).

Conclusion

Improvement in sagittal mobility of the affected segment in LDH adequately reflected mitigation of low back pain during the recovery process. This conjunction could illustrate that the involved segment is overcoming natural immobilization, evidently demonstrating an inverse relationship between initial pain intensity and limitation of sagittal range of motion.

Prevention of lumbar reherniation by the intraoperative use of a radiofrequency bipolar device: A case-control study

Objective:

The most common complication after lumbar discectomy is reherniation. Although many studies have investigated factors that may increase the reherniation risk, few are agreed upon all. It has been suggested that limited nucleus removal is associated with higher reherniation risk, while more aggressive nucleus removal can result in increased disc degeneration. Here, we assessed the efficacy of a coblation-assisted microdiscectomy in adult patients undergoing single-level disc surgery.

Methods:

We prospectively compared the reherniation rate in 75 patients (Group 1) undergoing single-level lumbar disc surgery completed with the radiofrequency bipolar system Aquamantys^® (Medtronic, Minneapolis, MN, USA) to that of a historical control group (n = 75) matched for variables related to herniation level and characteristics (Group 2). Patients were followed up to 4 years. Reherniations were assessed, pain and function were monitored throughout, and imaging was performed at annual follow-up.

Results:

The overall symptomatic reherniation rate was 4%. In particular, one case (1.3%) was observed in Group 1 and five (6.7%) in Group 2 (P < 0.05). Magnetic resonance imaging identified a total of 4 (2.7%) asymptomatic reherniations at 12 months, 6 (4%) at 24 and 36 months, and 7 (4.7%) at 48 months. Overall, Group 1 contained one (1.3%) asymptomatic reherniation case, while six (8%) were observed in Group 2 (P < 0.05).

Conclusions:

The low reherniation rate in patients treated by the coblation-assisted microdiscectomy suggests that this technique may reduce the reherniation risk. Clinical outcomes for pain and function at 4 years follow-up compared favorably with literature data. Randomized controlled trial could confirm these results.

Clinical and Radiological Outcomes of Foraminal Decompression Using Unilateral Biportal Endoscopic Spine Surgery for Lumbar Foraminal Stenosis

Background

Since open Wiltse approach allows limited visualization for foraminal stenosis leading to an incomplete decompression, we report the short-term clinical and radiological results of unilateral biportal endoscopic foraminal decompression using 0° or 30° endoscopy with better visualization.

Methods

We examined 31 patients that underwent surgery for neurological symptoms due to lumbar foraminal stenosis which was refractory to 6 weeks of conservative treatment. All 31 patients underwent unilateral biportal endoscopic far-lateral decompression (UBEFLD). One portal was used for viewing purpose, and the other was for surgical instruments. Unilateral foraminotomy was performed under guidance of 0° or 30° endoscopy. Clinical outcomes were analyzed using the modified Macnab criteria, Oswestry disability index, and visual analogue scale. Plain radiographs obtained preoperatively and 1 year postoperatively were compared to analyze the intervertebral angle (IVA), dynamic IVA, percentage of slip, dynamic percentage of slip (gap between the percentage of slip on flexion and extension views), slip angle, disc height index (DHI), and foraminal height index (FHI).

Results

The IVA significantly increased from 6.24° ± 4.27° to 6.96° ± 3.58° at 1 year postoperatively (p = 0.306). The dynamic IVA slightly decreased from 6.27° ± 3.12° to 6.04° ± 2.41°, but the difference was not statistically significant (p = 0.375). The percentage of slip was 3.41% ± 5.24% preoperatively and 6.01% ± 1.43% at 1-year follow-up (p = 0.227), showing no significant difference. The preoperative dynamic percentage of slip was 2.90% ± 3.37%; at 1 year postoperatively, it was 3.13% ± 4.11% (p = 0.720), showing no significant difference. The DHI changed from 34.78% ± 9.54% preoperatively to 35.05% ± 8.83% postoperatively, which was not statistically significant (p = 0.837). In addition, the FHI slightly decreased from 55.15% ± 9.45% preoperatively to 54.56% ± 9.86% postoperatively, but the results were not statistically significant (p = 0.705).

Conclusions

UBEFLD using endoscopy showed a satisfactory clinical outcome after 1-year follow-up and did not induce postoperative segmental spinal instability. It could be a feasible alternative to conventional open decompression or fusion surgery for lumbar foraminal stenosis.

Clinical Characteristics and Risk Factors of Recurrent Lumbar Disk Herniation: A Retrospective Analysis of Three Hundred Twenty-One Cases

STUDY DESIGN

Retrospective clinical series.

OBJECTIVE

To investigate the clinical features and the risk factors for recurrent lumbar disc herniation (rLDH) in China.

SUMMARY OF BACKGROUND DATA

rLDH is a common cause of poor outcomes after lumbar microdiscectomy surgery. Risk factors for rLDH are increasingly being investigated. However, results in these previous studies were not always consistent.

METHODS

Between June 2005 and July 2012, 321 consecutive patients with single-level LDH, who underwent surgery, were enrolled in this study. We divided the patients into the recurrent group (R group) and the nonrecurrent group (N group) and compared their clinical parameters and preoperative radiologic parameters. The relationships between the variables and rLDH were evaluated by univariate analysis and multiple logistic regression analysis.

RESULTS

There was significant difference between groups in sex (P = 0.003), age (P = 0.003), current smoking (P = 0.004), body mass index (BMI) (P = 0.04), occupational lifting (P < 0.001), trauma history (P = 0.04), procedures (P = 0.04), herniation type (P = 0.006), disc height index (DUI) (P = 0.04), facet orientation (FO) (P = 0.04), facet tropism (FT) (P = 0.04), and sagittal range of motion (from) (P = 0.04). By putting these differences in logistic regression analysis, it showed that being male, young age, current smoking, higher BMI, herniation type (transligamentous extrusion), surgical procedures (bilateral laminectomy or total laminectomy), heavy works, undergoing a traumatic event, a large from, a high DUI, a large FT, and a small FO significantly related with rLDH.

CONCLUSION

Based on our data, sex, age, current smoking, BMI, occupational lifting, trauma, surgical procedures, herniation type, DUI, FO, FT, and from showed a significant correlation with the incidence of rLDH. Patients with these risk factors should be paid more attention for prevention of recurrence after primary surgery.

LEVEL OF EVIDENCE

3.

Risk factors for recurrent lumbar disc herniation after discectomy

PURPOSE

There are many reports about the risk factors for recurrence after lumbar disc surgery. However, there are none about whether lumbosacral transitional vertebrae (LSTV) are associated with recurrent lumbar disc herniation (LDH). We investigated various risk factors for recurrent LDH after discectomy including LSTV.

METHODS

A total of 119 patients who had undergone a discectomy for L4-5 disc herniation were evaluated with a minimum follow-up of two years. Clinical parameters including age, gender, body mass index (BMI), and smoking status, and radiological parameters including type of herniated disc, degree of disc degeneration, LSTV, and sagittal range of motion (SROM) in flexion-extension radiography were evaluated. SROM was measured by the difference of the lordotic angle between the flexion and extension view.

RESULTS

Recurrent disc herniation at L4-5 developed in 21 (17.6%) of the 119 patients. The mean period between primary surgery and recurrence was 17.6 ± 21.1 months. LSTV was found in 11 (52.4%) of the 21 patients who had recurrence and seven (7.1%) of the 98 patients in the non-recurrent group. SROM at L4-5 was 11.68 ± 4.24° in the recurrent group and 9.04 ± 3.65° in the non-recurrent group with a significant difference (p = 0.004). Multiple logistic regression analyses confirmed that LSTV and a larger SROM were significant risk factors for recurrent disc herniation at L4-5.

CONCLUSIONS

Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography were found to be risk factors for recurrent lumbar disc herniation.

Comparison of unilateral pedicle screw fixation and interbody fusion with PEEK cage vs. standalone expandable fusion cage for the treatment of unilateral lumbar disc herniation

INTRODUCTION

This study was conducted to compare the clinical effects of unilateral pedicle screw fixation and interbody fusion with PEEK cage (UPSFC) and standalone expandable fusion cage (SAEFC) on unilateral lumbar disc herniation.

MATERIAL AND METHODS

From September 2011 to July 2014, a respective investigation was performed on 130 lumbar disc herniation patients treated with SAEFC or UPSFC. The hospital stay, operating time, blood loss, Japanese orthopaedic association scores (JOA), and visual analogue score (VAS) in the two groups were compared using Student's t-test.

RESULTS

The average of follow-up time was 25.6 ±6.4 and 25.2 ±5.8 months, respectively. No significant difference in the postoperative hospitalizsation, intraoperative blood loss, operative time, and postoperative fusion rate was detected between the two groups. VAS score in the UPSFC group was significantly lower than in the SAEFC group at 6 and 12 months after operation (p = 0.014, p = 0.004). X-ray images indicated that the subsidence rate was 8.1% (5/62) in the SAEFC group, while no subsidence was detected in UPSFC group 12 month after operation.

CONCLUSIONS

Both SAEFC and UPSFC are effective techniques. UPSFC may be a better choice for patients with lumbar disc herniation and unilateral limb symptoms of nerve root in view of the advantages of better low back pain relief and low subsidence rate.

OUTCOMES OF SURGICAL TREATMENT OF LUMBAR DISK HERNIATION USING AN ANNULAR CLOSURE DEVICE

ABSTRACT Objective: The aim of the study was to investigate the clinical and radiological results of using the annular closure device in patients with lumbar disc herniation (LDH). Methods: The study involved 120 patients with LDH operated on by limited discectomy and annular closure using the Barricaid device. A literature review was conducted to evaluate the effectiveness of the annuloplasty. Results: All patients showed postoperative regression of the radicular pain syndrome and were mobilized on the day of surgery. The correlation between the removed nucleus pulposus and changes in DHI was studied by linear regression. The results revealed that disc height loss is directly correlated with the volume of removed nucleus pulposus (p <0.05). Modic changes were present in 22 (22%) patients. Endplate changes (resorption and erosion) were present in 25 patients (20.7%). We found that these changes in MR and CT images have no effect on the clinical presentation of the disease. No intraoperative complications, such as severe hemorrhage requiring blood transfusion, or injury to the dura mater or nerve roots, were observed in our case series. Postoperative complications occurred in 3 (2.5%) patients. The reoperation rate was 4.2%. Conclusions: The use of the Barricaid annular closure device in 120 patients with lumbar disc herniation and high risk of recurrent herniation showed good clinical and radiographic outcomes. The reoperation rate in our study was 2.5%; disc reherniation at the operated level was observed in 1.7% of patients. This is a good outcome compared to the data reported for patients having a high risk of disc reherniation. Level of Evidence IV; Case series.

Surgical Treatment of Recurrent Lumbar Disk Herniation: A Systematic Review and Meta-analysis

Consensus is lacking regarding optimal surgical treatment of recurrent lumbar disk herniation. A systematic search of multiple databases was conducted for studies evaluating outcomes after treatment for recurrent lumbar disk herniation. Treatment options included decompression surgeries and fusion surgeries. Although fusion surgeries eliminated re-recurrence of disk herniation, this coincided with higher incidences of complications and reoperation. Decompression surgeries and fusion surgeries both resulted in improvements in Japanese Orthopaedic Association, Oswestry Disability Index, and visual analog scale back and leg scores postoperatively (P<.05). The complication risk profiles of decompression surgeries and fusion surgeries must be balanced with the risk of disk herniation re-recurrence, as both procedures lead to improvements in functional outcomes. [Orthopedics. 2018; 41(4):e457-e469.].

Thermoresponsive, redox-polymerized cellulosic hydrogels undergo in situ gelation and restore intervertebral disc biomechanics post discectomy

Back and neck pain are commonly associated with intervertebral disc (IVD) degeneration. Structural augmentation of diseased nucleus pulposus (NP) tissue with biomaterials could restore degeneration-related IVD height loss and degraded biomechanical behaviors; however, effective NP replacement biomaterials are not commercially available. This study developed a novel, crosslinked, dual-polymer network (DPN) hydrogel comprised of methacrylated carboxymethylcellulose (CMC) and methylcellulose (MC), and used in vitro, in situ and in vivo testing to assess its efficacy as an injectable, in situ gelling, biocompatible material that matches native NP properties and restores IVD biomechanical behaviors. Thermogelling MC was required to enable consistent and timely gelation of CMC in situ within whole IVDs. The CMC-MC hydrogel was tuned to match compressive and swelling NP tissue properties. When injected into whole IVDs after discectomy injury, CMC-MC restored IVD height and compressive biomechanical behaviors, including range of motion and neutral zone stiffness, to intact levels. Subcutaneous implantation of the hydrogels in rats further demonstrated good biocompatibility of CMC-MC with a relatively thin fibrous capsule, similar to comparable biomaterials. In conclusion, CMC-MC is an injectable, tunable and biocompatible hydrogel with strong potential to be used as an NP replacement biomaterial since it can gel in situ, match NP properties, and restore IVD height and biomechanical function. Future investigations will evaluate herniation risk under severe loading conditions and assess long-term in vivo performance.

Lumbar Disc Herniation

PURPOSE OF REVIEW

Substantial advancements have been made in the cause, diagnosis, imaging, and treatment options available for patients with lumbar disc herniation (LDH). We examined the current evidence and highlight the concepts on the frontline of discovery in LDH.

RECENT FINDINGS

There are a myriad of novel etiologies of LDH detailed in recent literature including inflammatory factors and infectious microbes. In the clinical setting, recent data focuses on improvements in computer tomography as a diagnostic tool and non-traditional injection options including tumor necrosis alpha inhibitors and platelet-rich plasma. Operative treatment outcomes have focused on minimally invasive endoscopic approaches and demonstrated robust 5-year post-operative outcomes. Advances in the molecular etiology of LDH will continue to drive novel treatment options. The role of endoscopic treatment for LDH will continue to evolve. Further research into10-year outcomes will be necessary as this surgical approach continues to gain widespread popularity.

Treatment for Recurrent Lumbar Disc Herniation

PURPOSE OF REVIEW

Recurrent lumbar disc herniation (RLDH) is the most common indication for reoperation after a lumbar discectomy. The purpose of this manuscript is to review the incidence, risk factors, and treatment for RLDH.

RECENT FINDINGS

Patients who require revision surgery for RLDH improved significantly compared to baseline; however, the magnitude of improvement is less than in primary discectomy patients. Treatment with either repeat discectomy or instrumented fusion has comparable clinical outcomes. Repeat discectomy patients, however, have shorter operative times and length of stay. Hospital charges are dramatically lower for repeat discectomy compared to instrumented fusion. The incidence of RLDH is somewhere between 5 and 18%. Risk factors include younger age, lack of a sensory or motor deficit, and a higher baseline Oswestry Disability Index (ODI) score. Available evidence suggests that some patients may respond to nonoperative interventions and avoid the need for reoperation. For those that fail a trial of conservative management or present with neurologic deficit, both repeat lumbar discectomy and instrumented fusion appear to effectively treat patients with similar complication rates and clinical outcomes.

Factors associated with lumbar disc hernia recurrence after microdiscectomy

INTRODUCTION

Lumbar disc hernias are a common cause of spinal surgery. Hernia recurrence is a prevalent complication.

OBJECTIVE

To analyse the risk factors associated with hernia recurrence in patients undergoing surgery in our institution.

MATERIALS AND METHODS

Lumbar microdiscectomies between 2010 and 2014 were analysed, patients with previous surgeries, extraforaminales and foraminal hernias were excluded. Patients with recurrent hernia were the case group and those who showed no recurrence were the control group.

RESULTS

177 patients with lumbar microdiscectomy, of whom 30 experienced recurrence (16%), and of these 27 were reoperated. Among the risk factors associated with recurrence, we observed a higher rate of disc height, higher percentage of spinal canal occupied by the hernia and presence of degenerative facet joint changes; we observed no differences in sex, body mass index or age.

DISCUSSION

Previous studies show increased disc height and young patients as possible factors associated with recurrence.

CONCLUSION

In our series we found that the higher rate of disc height, the percentage of spinal canal occupied by the hernia and degenerative facet joint changes were associated with hernia recurrence.

Comparison of Adjacent Segment Degeneration After Nonrigid Fixation System and Posterior Lumbar Interbody Fusion for Single-Level Lumbar Disc Herniation: A New Method of MRI Analysis of Lumbar Nucleus Pulposus Volume

PURPOSE

To evaluate the influence of a nonrigid fixation system and posterior lumbar interbody fusion on adjacent intervertebral disc degeneration by using MRI analysis of lumbar nucleus pulposus volume for single-level lumbar disc herniation.

MATERIALS AND METHODS

We selected 112 patients who underwent nonrigid fixation (17 men and 44 women) or posterior lumbar interbody fusion (13 men and 38 women) for this retrospective study. Based on the T2-weighted magnetic resonance imaging (MRI) scans taken preoperatively, and 6, 12, and 24 months after surgery, the nucleus pulposus in the upper segments of the operated level was considered an ellipsoid, and their volumes were measured respectively and then compared between the two groups.

RESULTS

The posterior lumbar interbody fusion group had significantly lower lumbar nucleus pulposus volume than the nonrigid fixation group at 12 (4.04 ± 1.42 vs. 5.25 ± 1.47 mm³) and 24 months (4.16 ± 0.89 vs. 5.06 ± 1.23 mm³), and had the highest nucleus pulposus. Meanwhile, the h value in the posterior lumbar interbody fusion group was notably smaller than the preoperative level at 12 (0.46 ± 0.03 vs. 0.55 ± 0.05 mm) and 24 months (0.44 ± 0.03 vs. 0.55 ± 0.05 mm).

CONCLUSIONS

MRI analysis of lumbar nucleus pulposus volume is a new and quantitative method of analysis, which is a considerable method and contributes to the detection of severe intervertebral disc degeneration. Based on this new method, nonrigid fixation demonstrates excellent outcomes on the adjacent segment in comparison with posterior lumbar interbody fusion.

Preoperative estimation of disc herniation recurrence after microdiscectomy: predictive value of a multivariate model based on radiographic parameters

BACKGROUND CONTEXT

Recurrence of lumbar disc herniation (rLDH) is one of the unfavorable outcomes after microdiscectomy. Prediction of the patient population with increased risk of rLDH is important because patients may benefit from preventive measures or other surgical options.

PURPOSE

The study assessed preoperative factors associated with rLDH after microdiscectomy and created a mathematical model for estimation of chances for rLDH.

STUDY DESIGN/SETTING

This is a retrospective case-control study.

PATIENT SAMPLE

The study includes patients who underwent microdiscectomy for LDH.

OUTCOME MEASURES

Lumbar disc herniation recurrence was determined using magnetic resonance imaging.

METHODS

The study included 350 patients with LDH and a minimum of 3 years of follow-up. Patients underwent microdiscectomy for LDH at the L4-L5 and L5-S1 levels from 2008 to 2012. Patients were divided into two groups to identify predictors of recurrence: those who developed rLDH (n=50) within 3 years and those who did not develop rLDH (n=300) within the same follow-up period. Multivariate analysis was performed using patient baseline clinical and radiography data. Non-linear, multivariate, logistic regression analysis was used to build a predictive model.

RESULTS

Recurrence of LDH occurred within 1 to 48 months after microdiscectomy. Preoperatively, patients who developed rLDH were smokers (70% vs. 27%, p<.01; odds ratio [OR]=6.31, 95% confidence interval [CI]: 3.27-12.16) and had higher body mass index (29.0±6.1 vs. 27.0±4.3, p=.03; OR=1.09 per 0.01 unit change). Radiological parameters that were associated with rLDH were higher disc height index (0.35±0.007 vs. 0.26±0.002, p<.001), higher segmental range of motion (9.8±0.28° vs. 7.6±0.11°, p<.001; OR=0.53 per 0.01 unit change), and lower central angle of lumbar lordosis (33.4±0.81° vs. 47.1±0.47°, p<.001; OR=0.53 per 0.01 unit change). Additionally, Pfirrmann grade 3 (OR=16.62, 95% CI: 8.10-34.11), protrusion type of LDH (OR=5.90, 95% CI: 3.06-11.36), and Grogan sclerosis grades 3 and 4 (OR=4.81, 95% CI: 2.50-9.22) were also associated with rLDH. Multivariate non-linear modeling allowed for more accurate prediction of rLDH (90% correct prediction of rLDH; 99% correct prediction of no rLDH) than other univariate logit models.

CONCLUSIONS

Preoperative radiographic parameters in patients with LDH can be used to assess the risk of recurrence after microdiscectomy. The multifactorial non-linear model provided more accurate rLDH probability estimation than the univariate analyses. The software developed from this model may be implemented during patient counseling or decision making when choosing the type of primary surgery for LDH.

Comparing clinical outcomes of repeat discectomy versus fusion for recurrent disc herniation utilizing the N2QOD

OBJECTIVE

Recurrent lumbar disc herniation (RLDH) is a significant cause of morbidity in patients undergoing lumbar discectomy and has been reported to occur in up to 18% of cases. While repeat discectomy is often successful in treating these patients, concern over repeat RLDH may lead surgeons to advocate instrumented fusion even in the absence of instability. The authors' goal was to compare clinical outcomes for patients undergoing repeat discectomy versus instrumented fusion for RLDH.

METHODS

The authors used the National Neurosurgery Quality and Outcomes Database (N2QOD) to assess outcomes of patients who underwent repeat discectomy versus instrumented fusion at a single institution from 2012 to 2015. Primary outcomes included Oswestry Disability Index (ODI) score, visual analog scale (VAS) score, and quality-adjusted life year (QALY) measures. Secondary outcomes included hospital length of stay, discharge status, and hospital charges.

RESULTS

The authors identified 25 repeat discectomy and 12 instrumented fusion patients with 3- and 12-month follow-up records. The groups had similar ODI and VAS scores and QALY measurements at 3 and 12 months. Patients in the instrumented fusion group had significantly longer hospitalizations (3.7 days vs 1.0 days, p < 0.001) and operative times (229.6 minutes vs 82.7 minutes, p < 0.001). They were also more likely to be female (p = 0.020) and to be discharged to inpatient rehabilitation instead of home (p = 0.036). Hospital charges for the instrumented fusion group were also significantly higher ($54,458.29 vs $11,567.05, p < 0.001). Rates of reoperation were higher in the repeat discectomy group (12% vs 0%), but the difference was not statistically significant (p = 0.211).

CONCLUSIONS

Repeat discectomy and instrumented fusion result in similar clinical outcomes at short-term follow-up. Patients undergoing repeat discectomy had significantly shorter operative times and length of stay, and they incurred dramatically lower hospital charges. They were also less likely to require acute rehabilitation postoperatively. Further research is needed to compare these two management strategies.

The impact of generalized joint laxity (GJL) on the posterior neck pain, cervical disc herniation, and cervical disc degeneration in the cervical spine

BACKGROUND CONTEXT

Generalized joint laxity (GJL) can have a negative impact on lumbar spine pathology, including low back pain, disc degeneration, and disc herniation, but the relationship between GJL and cervical spine conditions remains unknown.

PURPOSE

To investigate the relationship between GJL and cervical spine conditions, including the prevalence of posterior neck pain (PNP), cervical disc herniation (CDH), and cervical disc degeneration (CDD), in a young, active population.

STUDY DESIGN

Retrospective 1:2 matched cohort (case-control) study from prospectively collected data PATIENT SAMPLE: Of a total of 1853 individuals reviewed, 73 individuals with GJL (study group, gruop A) and 146 without GJL (control group, Group B) were included in the study according to a 1:2 case-control matched design for age, sex, and body mass index.

OUTCOME MEASURE

The primary outcome measure was the prevalence and intensity of PNP at enrollment based on a visual analogue scale score for pain. The secondary outcome measures were (1) clinical outcomes as measured with the neck disability index (NDI) and 12-item short form health survey (SF-12) at enrollment, and (2) radiological outcomes of CDH and CDD at enrollment.

METHODS

We compared baseline data between groups. Descriptive statistical analyses were performed to compare the 2 groups in terms of the outcome measures.

RESULTS

The prevalence and intensity of PNP were significantly greater in group A (patients with GJL) than in group B (patients without GJL) (prevalence: p=.02; intensity: p=.001). Clinical outcomes as measured with NDI and SF-12 did not differ significantly between groups. For radiologic outcomes, the prevalence of CDD was significantly greater in group A than in group B (p=.04), whereas the prevalence of CDH did not differ significantly between groups (p=.91).

CONCLUSIONS

The current study revealed that GJL was closely related to the prevalence and intensity of PNP, suggesting that GJL may be a causative factor for PNP. In addition, GJL may contribute to the occurrence of CDD, but not CDH. Spine surgeons should screen for GJL in patientswith PNP and inform patients of its potential negative impact on disc degeneration of the cervical spine.

Treatment of Recurrent Disc Herniation: A Systematic Review

Intervertebral disc herniation is one of the most common causes of back and extremity pain. The most commonly used surgical treatment is lumbar discectomy. About 0.5-25% go on to develop recurrent disc herniation (rDH) after a successful first discectomy. Currently, there aren't any guidelines to assist surgeons in determining which approach is most appropriate to treat rDH. A recent survey showed significant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, as there are no comparative studies with a sufficient level of evidence. In this study, we aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion. We applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of our study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, our study shows that further and more in-depth investigation is needed on the of treatment of rDH.

Expression levels of IL-17 and TNF-α in degenerated lumbar intervertebral discs and their correlation

The present study aimed to investigate the expression and roles of interleukin (IL)-17 and tumor necrosis factor (TNF)-α in intervertebral disc degeneration (IDD) and to identify the association between the effects of IL-17 and TNF-α in IDD. This may increase understanding of the pathogenic mechanism underlying IDD, and aid the development of alternative therapies. The experimental group consisted of 40 samples of nucleus pulposus tissue obtained from the intervertebral discs (IVDs) of patients with IDD by surgical intervention, and was further divided into an annulus fibrosus disrupted group, comprising 18 patients in which the external annulus was ruptured, and an annulus fibrosus intact group comprising 22 patients. The control group consisted of 20 samples of nucleus pulposus tissue from the IVDs of patients with traumatic lumbar disc fractures. The mRNA and protein expression levels of IL-17 and TNF-α in the 50 tissue samples were detected by semi-quantitative reverse transcription polymerase chain reaction and immunohistochemical staining, respectively, and the results were statistically analyzed. The IL-17 and TNF-α protein and mRNA expression levels in the annulus fibrosus disrupted and annulus fibrosus intact groups were both higher compared with those in the control group. In addition, the expression levels of IL-17 and TNF-α in the annulus fibrosus disrupted group were significantly higher compared with those in the annulus fibrosus intact group (P<0.01). A positive correlation was identified between the mRNA and protein expression levels of IL-17 and TNF-α in the experimental group (r=0.957, P<0.01). IL-17 and TNF-α may therefore be involved in the progression of human IDD, and may have synergistic effects in the development of IDD.

Revision Surgery for "Real" Recurrent Lumbar Disk Herniation: A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

To systematically review the previous literature regarding revision surgery for real recurrent lumbar disk herniation.

SUMMARY OF BACKGROUND DATA

"Real" recurrent lumbar disk herniation means the presence of herniated disk material at the same level and side as the primary disk herniation. If conservative treatment fails, revision surgery, a major concern, is indicated. It is important for both patients and spine surgeons to understand epidemiology trends and outcomes of revision surgery for real recurrent lumbar disk herniation (real-RLDH).

METHODS

The electronic databases PubMed, the Cochrane library, and EMBASE were queried for English articles regarding revision surgery for real-RLDH, published between January 1980 and May 2014. The incidence, interval between primary and revision surgery, risk factors, surgery type, complications, and clinical outcomes of revision surgery for real-RLDH were summarized.

RESULTS

The reported incidence of revision surgery, specifically for real-RLDH, lies between 1.4% and 11.4%. The complication rate is reported between 0% and 34.6%, with dural tear being the most common complication. Previous studies revealed that satisfactory or successful clinical outcome was achieved in 60%-100% of patients after revision surgery for real-RLDH. Several studies reported similar clinical outcomes between primary and revision surgery.

CONCLUSIONS

The incidence of revision surgery for real-RLDH is relatively low. It is essential to pay careful attention to prevent a dural tear. Patients may expect clinical outcomes similar to those following primary discectomy.

Non-fusion procedure using PEEK rod systems for lumbar degenerative diseases: clinical experience with a 2-year follow-up

Background

Polyetheretherketone (PEEK) rod system is a novel pedicle-based dynamic stabilization system. This study evaluated clinical and radiographic outcomes of non-fusion surgery by PEEK rod systems for treatment of degenerative lumbar diseases with a 2-year follow-up.

Methods

From February 2012 to October 2012, 38 patients who underwent non-fusion surgery using PEEK rod systems were included in the study. Data on Oswestry Disability Index (ODI) score and Japanese Orthopaedics Association (JOA) score were collected and radiographs were obtained to evaluate disc height index (DHI) and range of motion (ROM) at each interval.

Results

Both JOA and ODI scores significantly improved postoperatively. DHI showed a slight increase immediately after the surgery but gradually dropped below preoperative levels. Mean ROM values changed from 8.8° preoperatively to 1.8° at the 2-year follow-up point. Screw loosening occurred in one case at the 2-year follow-up.

Conclusions

The preliminary results indicated a significant improvement in clinical outcomes and advantageous implant safety. The non-fusion procedure using PEEK rod systems might be a viable alternative for treatment of lumbar degenerative diseases. The distraction technique needs to be improved for better postoperative DHI.

Risk Factors for Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

Recurrent lumbar disc herniation (rLDH) is a common complication following primary discectomy. This systematic review aimed to investigate the current evidence on risk factors for rLDH.Cohort or case-control studies addressing risk factors for rLDH were identified by search in Pubmed (Medline), Embase, Web of Science, and Cochrane library from inception to June 2015. Relevant results were pooled to give overall estimates if possible. Heterogeneity among studies was examined and publication bias was also assessed.A total of 17 studies were included in this systematic review. Risk factors that had significant relation with rLDH were smoking (OR 1.99, 95% CI 1.53-2.58), disc protrusion (OR 1.79, 95% CI 1.15-2.79), and diabetes (OR 1.19, 95% CI 1.06-1.32). Gender, BMI, occupational work, level, and side of herniation did not correlate with rLDH significantly.Based on current evidence, smoking, disc protrusion, and diabetes were predictors for rLDH. Patients with these risk factors should be paid more attention for prevention of recurrence after primary surgery. More evidence provided by high-quality observational studies is still needed to further investigate risk factors for rLDH.

The Effect of Smoking on the Risk of Sciatica: A Meta-analysis

BACKGROUND

The role of smoking in sciatica is unknown. This study aimed to estimate the effect of smoking on lumbar radicular pain and clinically verified sciatica.

METHODS

Comprehensive literature searches were conducted in PubMed, Embase, Web of Science, Scopus, Google Scholar, and ResearchGate databases from 1964 through March 2015. We used a random-effects meta-analysis, assessed heterogeneity and publication bias, and performed sensitivity analyses with regard to study design, methodological quality of included studies, and publication bias.

RESULTS

Twenty-eight (7 cross-sectional [n = 20,111 participants], 8 case control [n = 10,815], and 13 cohort [n = 443,199]) studies qualified for a meta-analysis. Current smokers had an increased risk of lumbar radicular pain or clinically verified sciatica (pooled adjusted odds ratio [OR] 1.46; 95% confidence interval [CI], 1.30-1.64, n = 459,023). Former smokers had only slightly elevated risk compared with never smokers (pooled adjusted OR 1.15; 95% CI, 1.02-1.30, n = 387,196). For current smoking the pooled adjusted OR was 1.64 (95% CI, 1.24-2.16, n = 10,853) for lumbar radicular pain, 1.35 (95% CI, 1.09-1.68, n = 110,374) for clinically verified sciatica, and 1.45 (95% CI, 1.16-1.80, n = 337,796) for hospitalization or surgery due to a herniated lumbar disc or sciatica. The corresponding estimates for past smoking were 1.57 (95% CI, 0.98-2.52), 1.09 (95% CI, 1.00-1.19), and 1.10 (95% CI, 0.96-1.26). The associations did not differ between men and women, and they were independent of study design. Moreover, there was no evidence of publication bias, and the observed associations were not due to selection or detection bias, or confounding factors.

CONCLUSIONS

Smoking is a modest risk factor for lumbar radicular pain and clinically verified sciatica. Smoking cessation appears to reduce, but not entirely eliminate, the excess risk.

Interspinous process stabilization with Rocker via unilateral approach versus X-Stop via bilateral approach for lumbar spinal stenosis: a comparative study

BACKGROUND

Rocker is a novel interspinous process stabilization (IPS) that can be installed via unilateral approach by virtue of its unique design. This controlled study compared the clinical outcome of Rocker versus X-Stop to access the feasibility and validity of the novel IPS.

METHODS

From March 2011 to September 2012, 32 patients treated with Rocker and 30 patients treated with X-Stop were enrolled in this study. The primary clinical outcome measure was Oswestry Disability Index (ODI) score. The secondary clinical outcome measure was Japanese orthopaedics association (JOA) score. Disc height index (DHI) and foraminal height index (FHI) were measured for postoperative radiographic evaluation. Implant failures were also recorded.

RESULTS

There were 55 patients with complete data during 24 months follow-up. Among the 55 patients, 38 patients underwent IPS in combination with microdecompression. At the final follow-up, 49 patients achieved a minimal clinical important difference (≥ 8 points ODI improvement). The mean operative time was 53.6 min (range, 30 to 90 min) in Rocker group and 63.1 min (range, 30 to 100 min) in X-Stop group. The average blood loss was 111 ml (range, 50 to 400 ml) in Rocker group and 138 ml (range, 50 to 350 ml) in X-Stop group. ODI score were significantly improved from preoperative 46.8 ± 9.2 to 12.2 ± 2.6 at 24 months follow-up in the Rocker group and from preoperative 45.8 ± 9.8 to 11.8 ± 2.4 at 24 months follow-up in the X-Stop group. JOA score also improved significantly in both groups. The radiographic parameters of DHI and FHI in both groups increased immediately postoperatively, however, the improvements seemed to revert toward initial value during follow-up. Two patients in Rocker group demonstrated implant dislocation within one week postoperatively and one patient in X-Stop group demonstrated implant migration at two months postoperatively.

CONCLUSIONS

Preliminary clinical and radiographic outcome was similar between Rocker and X-Stop group. For patients of lumbar spinal stenosis with unilateral nerve root involved or mild-to-moderate central canal stenosis, Rocker offers a new alternative with less damage.

Risk factors for the need of surgical treatment of a first recurrent lumbar disc herniation

PURPOSE

A recurrent lumbar disc herniation (RLDH) is the most prevalent cause for new radicular pain after surgery for disc herniation-induced sciatica. Reported risk factors include age, gender and smoking, while its surgical treatment is associated to a higher rate of complications and costs. The purpose of this study is to identify factors that increase the risk of requiring surgical treatment for a first RLDH in workers' compensation patients.

METHODS

Nested case-control: 109 patients operated for an RLDH (cases) between June 1st 1994 and May 31st 2011 (minimum follow-up 1 year) and 109 randomly selected patients operated for a first disc herniation with no recurrence during the study period (controls). Age, gender, smoking status, type of work and MRI characteristics of the index herniation were statistically evaluated as potential risk factors.

RESULTS

Patient's age of less than 35 years (p = 0.001) and a subligamentous herniation (p < 0.05) at the time of the index surgery were identified as risk factors for requiring surgical treatment of a first RLDH. No statistical differences were observed between both groups regarding the other evaluated variables.

CONCLUSION

A subligamentous disc herniation and patient's age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers' compensation patients.

Does daily tobacco smoking affect outcomes after microdecompression for degenerative central lumbar spinal stenosis? - A multicenter observational registry-based study

BACKGROUND

There are limited scientific data on the impact of smoking on patient-reported outcomes following minimally invasive spine surgery. The aim of this multicenter observational study was to examine the relationship between daily smoking and patient-reported outcome at 1 year using the Oswestry Disability Index (ODI) after microdecompression for single- and two-level central lumbar spinal stenosis (LSS). Secondary outcomes were the length of hospital stays, perioperative and postoperative complications.

METHOD

Data were collected through the Norwegian Registry for Spine Surgery (NORspine).

RESULTS

A total of 825 patients were included (619 nonsmokers and 206 smokers). For the whole patient population there was a significant difference between preoperative ODI and ODI at 1 year (17.3 points, 95% CI 15.93-18.67, p < 0.001). There was a significant difference in ODI change at 1 year between nonsmokers and smokers (4.2 points, 95% CI 0.98-7.34, p = 0.010). At 1 year 69.6% of nonsmokers had achieved a minimal clinically important difference (≥10 points ODI improvement) compared to 60.8% of smokers (p = 0.008). There was no difference between nonsmokers and smokers in the overall complication rate (11.6% vs. 9.2%, p = 0.34). There was no difference between nonsmokers and smokers in length of hospital stays for either single-level (2.3 vs. 2.2 days, p = 0.99) or two-level (3.1 vs. 2.3 days, p = 0.175) microdecompression. Smoking was identified as a negative predictor for ODI change in a multiple regression analysis (p = 0.001) CONCLUSIONS: Nonsmokers experienced a significantly larger improvement at 1 year following microdecompression for LSS compared to smokers. Smokers were less likely to achieve a minimal clinically important difference. However, it should be emphasized that considerable improvement also was found among smokers.

L5-S1 disc degeneration and the anatomic parameters of the iliac crest: imaging study

PURPOSE

To evaluate the relationship between height ratio of the iliac crest to L4 (HR), width ratio of the iliac crest to L4 (WR) and L5-S1 disc degeneration.

METHODS

On T2-weighted sagittal images of the 50 randomly selected patients, two observers graded L5-S1 discs and some other parameters were measured. Then, relative signal intensity (RSI) of the L5-S1 nucleus pulposus was calculated. On anteroposterior and lateral radiographs of the same 50 patients' lumbar spine, the parameters such as the height of the iliac crest were measured and then HR and WR were calculated. Finally, HR, WR and the percentage of the sROM of L5-S1 in L1-S1 segments of the other 51 randomly selected patients were calculated.

RESULTS

Positive correlations were found between HR, WR and RSI of the L5-S1 disc. Negative correlations were found between HR, WR and modified Pfirrmann scores of L5-S1 nucleus pulposus. A statistically significant negative correlation was found between HR and the percentage of sROM of L5-S1 in L1-S1 segments.

CONCLUSIONS

Low HR and (or) WR were the risk factors for L5-S1 disc degeneration. High HR could reduce the percentage of sROM of L5-S1 in L1-S1 segments and high HR and (or) WR could reduce the incidence of L5-S1 disc degeneration.

Comparison of clinical and radiographic results between isobar posterior dynamic stabilization and posterior lumbar inter-body fusion for lumbar degenerative disease: A four-year retrospective study

PURPOSE

A retrospective study was conducted to compare clinical outcome with radiographic data and clinical complications between isobar posterior dynamic stabilization (IPDS, Scient'x, France) and posterior lumbar inter-body fusion (PLIF) for lumbar degenerative disease.

METHODS

113 consecutive patients (IPDS group, N=62; PLIF group, N=51) with lumbar degenerative disease were operated on between March 2009 and November 2011. Patient charts, radiographic films and medical records were reviewed. Clinical outcomes including the visual analog scale (VAS), Oswestry disability index (ODI) scores, and radiographic outcomes, including disk height index (DHI) and range of motion (ROM) were retrospectively analyzed.

RESULTS

The ODI and VAS leg and back pain scores in two groups were significantly improved at 6 and, 24 months and at the final follow-up (all, P<0.05). The degree of improvements in the ODI and VAS back pain scores, the incidence of complications and the rate of adjacent segment degeneration were similar in both groups (P>0.05). However, operation times and blood loss were significantly reduced in the IPDS group (P<0.05).

CONCLUSION

In summary, with similar symptoms improvement and complication rates, the results of this study demonstrate that IPDS is an effective and safe treatment for lumbar degenerative disease. There is currently insufficient evidence to indicate that the IPDS can avoid adjacent segment degeneration therefore, it is essential to conduct prospective, randomized, controlled multicenter studies with larger sample size and longer follow-up.

Generalized Joint Laxity is Associated with Primary Occurrence and Treatment Outcome of Lumbar Disc Herniation

BACKGROUND

We investigated relationships between generalized joint laxity and primary lumbar disc herniation occurrence and compared clinical outcomes after conservative treatment in lumbar disc herniation patients with and without generalized joint laxity.

METHODS

The study group included 128 men, and the control group included 276 men matched for age and body mass index with the study group. The primary outcome measure was the presence or absence of generalized joint laxity using the Beighton scale. Clinical outcomes measured by the visual analog scale and the Oswestry disability index 2 years after conservative treatment were the secondary outcome measure.

RESULTS

Generalized joint laxity prevalence was 13.2% in the study group and 5.1% in the control group, a significant difference (P=0.01). Spearman correlation analysis revealed that weight (r=0.162, P=0.03), body mass index (r=0.131, P=0.03), and generalized joint laxity (r=0.372, P<0.01) significantly correlated with lumbar disc herniation occurrence. In multivariate regression analysis, generalized joint laxity was the only significant lumbar disc herniation predictor (P=0.002; 95% confidence interval, 1.08 to 5.26). Generalized joint laxity in lumbar disc herniation patients was associated with worse clinical outcomes after conservative treatment measured by visual analog scale scores for lower extremity pain (P=0.02), lower back pain (P=0.03), and Oswestry disability index scores (P=0.03).

CONCLUSION

Generalized joint laxity might be associated with lumbar disc herniation occurrence and might also be a negative predictor of worse clinical outcomes after conservative treatment.

The impact of generalized joint laxity on the clinical and radiological outcomes of single-level posterior lumbar interbody fusion

BACKGROUND CONTEXT

Recent reports have suggested that excessive motion of the lumbar spine might be associated with low back pain and accelerated disc degeneration and may negatively influence the outcome of posterior lumbar interbody fusion (PLIF) surgery. These findings suggest that generalized joint laxity (GJL) might be a negative factor affecting PLIF outcome, although this relationship has not been well studied. In addition, the impact of GJL on adjacent segment pathology (ASP) after PLIF has not been reported.

PURPOSE

To explore the relationship between GJL and the outcome of single-level PLIF, we compared fusion rates, clinical outcomes, and ASP in PLIF patients with and without GJL.

STUDY DESIGN

Retrospective comparative study.

PATIENT SAMPLE

A total of 256 patients who underwent PLIF and were followed for at least 2 years after surgery were classified into two groups: Group A (37 patients with GJL) and Group B (219 patients without GJL).

OUTCOME MEASURES

The primary outcome measure was the fusion rate on dynamic radiographs and computed tomography scans. The secondary outcome measures were pain intensity in the low back based on a visual analog scale, functional outcome based on the Oswestry Disability Index, and prevalence and severity of ASP on lumbar spine magnetic resonance imaging 2 years postoperatively compared with preoperative images.

METHODS

We compared baseline data for the two groups studied. To evaluate the effects of GJL on the outcome of PLIF, we also compared outcome measures between the two groups. No funds were received in support of this work.

RESULTS

Successful fusion 2 years after surgery was achieved in 91.9% of patients in Group A and 91.8% of patients in Group B according to dynamic radiographs (p=.85) and in 86.5% of patients in Group A and 90% of patients in Group B according to computed tomography scans (p=.14). Secondary endpoints including pain intensity (visual analog scale) and Oswestry Disability Index scores were not significantly different between the two groups (p=.71 and .86, respectively). Adjacent segment pathology was present in both the superior and inferior adjacent segments in both groups and was not significantly different (p=.07 and .06, respectively), although severe degeneration that was greater than Grade III on modified Pfirrmann classification was more frequently observed in Group A (15 of 37, 40.5%, at the superior segment and 11 of 20, 55%, at the inferior segment) than in Group B (60 of 219, 27.4%, at the superior segment and 30 of 111, 27%, at the inferior segment), which was statistically significant (p=.02 and .01, respectively). Moreover, ASP was more prominent at the superior adjacent segment compared with the inferior adjacent segment and was most commonly observed at the inferior adjacent segment (L5-S1) after L4-L5 PLIF and the superior adjacent segment (L4-L5) after L5-S1 PLIF (p=.02 and .03, respectively).

CONCLUSIONS

Generalized joint laxity at baseline does not impact fusion rate or clinical outcome with respect to pain intensity or functional status but could negatively impact ASP compared with that in patients without GJL. Consequently, GJL should be evaluated preoperatively, and patients with GJL undergoing PLIF should be informed of the potential risks of surgery.

The impact of generalized joint laxity on the occurrence and disease course of primary lumbar disc herniation

BACKGROUND CONTEXT

Generalized joint laxity (GJL) has been associated with spine-related disorders such as low back pain, accelerated disc degeneration, and recurrence after discectomy surgery for primary lumbar disc herniation (p-LDH). Generalized joint laxity might be a causative factor of p-LDH, but this relationship is poorly understood. In addition, the impact of GJL on outcomes after the treatment for p-LDH has not been reported.

PURPOSE

To explore relationship between GJL and p-LDH and to compare clinical and radiological outcomes post-therapy in p-LDH patients with or without GJL.

STUDY DESIGN

A retrospective comparative study.

PATIENT SAMPLE

The study group included 203 males, and the control group included 362 males who were matched for age, race, and body mass index with the study group.

OUTCOME MEASURES

The primary outcome was the presence or absence of GJL according to the Beighton scale. The secondary outcome measures included the clinical outcome according to a visual analog scale and the Oswestry disability index and the radiological outcome.

METHODS

We compared baseline data between groups, and we evaluated the impact of GJL on outcomes after different types of several treatment for LDH.

RESULTS

The prevalence of GJL was significantly higher in the study group (10.8%) than in the matched control group (4.4%) (p=.003). In multivariate logistic regression analysis, GJL was the only significant predictor (p=.012). For all treatment methods, patients with GJL had worse clinical outcomes than did patients without GJL. In the patients treated with lumbar discectomy surgery, the differential Cobb value at the last follow-up was higher in the GJL patients than in the non-GJL patients (p=.001).

CONCLUSIONS

Generalized joint laxity was closely related to p-LDH and may be a causative factor. In addition, patients with GJL had worse clinical and radiological outcomes than patients without GJL. Consequently, GJL should be evaluated preoperatively, and this information should be communicated to p-LDH patients with GJL.

Four-year follow-up results of transforaminal lumbar interbody fusion as revision surgery for recurrent lumbar disc herniation after conventional discectomy

This study investigated the safety, effectiveness, and clinical and radiological outcomes of transforaminal lumbar interbody fusion (TLIF) for recurrent lumbar disc herniation (rLDH) following previous lumbar spine surgery. Seventy-three consecutive patients treated for rLDH between June 2005 and May 2012 were included in the study. The previous surgical procedures included percutaneous discectomy, discectomy with laminotomy, discectomy with unilateral laminectomy, and discectomy with bilateral laminectomy. The level of rLDH was L4-L5 in 51 patients, L5-S1 in 19 patients, and L3-L4 in three patients. All patients underwent reoperation using the TLIF technique. Outcomes were evaluated using the Oswestry disability index (ODI), visual analogue scale (VAS) scores for low back pain and leg pain, and the Japanese Orthopaedic Association (JOA) score, based on the results of physical examinations and questionnaires. The range of motion and disc height index of the operative segment were compared between preoperative and postoperative radiographs. The mean follow-up period was 4.1 years. The VAS scores for low back pain and leg pain, ODI, and JOA score improved significantly between the preoperative and final follow-up evaluations. The mean recovery rate of the JOA score was 89.0%. The disc space height and stability at the fused level were significantly improved after surgery. The fusion rate at the final follow-up was 93.2%. There were no major complications. These results indicate that TLIF can be considered an effective, reliable, and safe alternative procedure for the treatment of rLDH.

Intraoperative systemic infusion of lidocaine reduces postoperative pain after lumbar surgery: a double-blinded, randomized, placebo-controlled clinical trial

BACKGROUND CONTEXT

Analgesic effect of lidocaine infusion on postoperative pain.

PURPOSE

The aim of this study was to evaluate the analgesic effect of lidocaine infusion on postoperative pain after lumbar microdiscectomy.

STUDY DESIGN

This study used a prospective, randomized, double-blinded, and placebo-controlled clinical trial.

PATIENT SAMPLE

Fifty-one patients participated in this randomized, double-blinded study.

OUTCOME MEASURES

The primary outcome was the visual analog scale (VAS) (0-100 mm) pain score at 4 hours after surgery. The secondary outcomes were the VAS pain score at 2, 8, 12, 24, and 48 hours after surgery, the frequency with which patients pushed the button (FPB) of the patient-controlled analgesia system, and the fentanyl consumption at 2, 4, 8, 12, 24, and 48 hours after surgery. Other outcomes were satisfaction scores regarding pain control and the overall recovery process, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (HS).

METHODS

Preoperatively and throughout the surgery, Group L received intravenous lidocaine infusion (a 1.5-mg/kg bolus followed by a 2-mg/kg/h infusion until the end of the surgical procedure) and Group C received normal saline infusion as a placebo.

RESULTS

The VAS scores and fentanyl consumption were significantly lower in Group L compared with Group C except at 48 h after surgery (p<.05). Total fentanyl consumption, total FPB, length of HS, and satisfaction scores were also significantly lower in Group L compared with Group C (p<.05).

CONCLUSIONS

Intraoperative systemic infusion of lidocaine decreases pain perception during microdiscectomy, thus reducing the consumption of opioid and the severity of postoperative pain. This effect contributes to reduce the length of HS.

The effect of gamma irradiation on the biological properties of intervertebral disc allografts: in vitro and in vivo studies in a beagle model

Study Design

An animal experiment about intervertebral disc allograft.

Objective

To explore the feasibility to decellularize disc allografts treated by ⁶°Co Gamma Irradiation, and simultaneously, to assess the possibility to make use of the decellularized natural disc scaffold for disc degeneration biotherapy.

Summary of Background Data

Studies of both animal and human disc allograft transplantation indicated that the disc allograft may serve as a scaffold to undertake the physiological responsibility of the segment.

Methods

Experiment in vitro: 48 discs of beagles were harvested and divided randomly into four groups including a control group and three irradiated groups. Immediate cell viability and biomechanical properties of the discs were checked and comparisons were made among these groups. Experiment in vivo: 24 beagles accepted single-level allografted disc treated with different doses of gamma irradiation. Plain X-rays and MRIs were taken before and after surgery. Then, the spinal columns were harvested en bloc from the sacrificed beagles and were examined morphologically.

Results

There were significant differences of both the annulus fibrosus and nucleus pulposus immediate cell viabilities among the various groups. There were no obvious differences of the biomechanical properties among the four groups. The disc height and range of motion decreased significantly in all groups as time went on. The observed indexes in irradiated groups were much smaller than those in the control group, but the indexes in 18-kGy group were larger than those in 25-kGy and 50-kGy groups. Both MRI and macroscopic findings showed that the segmental degeneration in the control and 18-kGy group was less severe than that in 25-kGy and 50-kGy groups.

Conclusion

Gamma Irradiation can decellularize disc allograft successfully to provide natural scaffold for the study of degenerative disc disease therapy, and also can be used as an effective method to produce adjustable animal models.

Obesity and low back pain: relationships and treatment

SUMMARY Low back pain (LBP) and obesity (defined as BMI ≥30 kg/m(2)) are common problems in the general population. The treatment of LBP is not clearly defined and has variable success in different populations and time-frames. When a person presents with LBP who also meets the criteria for obesity, many questions are raised as to the value of weight-loss treatments and the success and/or safety of usual treatments of LBP, especially exercise. Based on the current medical literature for the treatment of LBP in patients who are obese: there should be attempts at weight loss (nonsurgical or surgical), especially if the person is in the morbidly obese (BMI >40 kg/m(2)) range; all usual forms of exercise and physical therapy treatments are possible and can be beneficial without increased concerns for injury; and, if necessary, invasive treatments such as spinal injections or surgery are potentially beneficial and have similar complication rates to the nonobese population. These options should be offered when medically necessary and appropriate.

Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures

Context:

The optimal surgical treatment of recurrent lumbar disc herniation is controversial.

Aim:

To compare prospectively the clinical outcomes of surgical treatment of recurrent lumbar disc herniation by three different methods; discectomy alone, discectomy with transforaminal lumbar interbody fusion (TLIF), and diecectomy with posterolateral fusion (PLF), regardless of the postoperative radiological findings.

Study Design:

This is a prospective, randomized, comparative study.

Materials and Methods:

This is a prospective, randomized, comparative study on 45 patients with first time recurrent lumbar disc herniation. Patients were evaluated clinically by using the criteria of the Japanese Orthopedic Association's evaluation system for low back pain syndrome (JOA score). The patients were classified into three groups: Group A; patients who had revision discectomy alone, group B; patients who had revision discectomy with TLIF, and group C; patients who had revision discectomy with PLF. The mean follow-up period was 37 (±7.85 STD) months.

Results:

The mean overall recovery rate was 87.2% (±19.26 STD) and the satisfactory rate was 88.9%. Comparison between the three groups showed no significant difference with regard to the mean total postoperative JOA score, recovery rate, and satisfactory rate. However, the postoperative low back pain was significantly higher in group A than that of group B and C. Two patients in group A required further revision surgery. The incidences of dural tear and postoperative neurological deficit were higher in group A. The intraoperative blood loss and length of operation were significantly less in group A. The total cost of the procedure was significantly different between the three groups, being least in group A and highest in group B. There was no significant difference between the three groups with regard to the length of postoperative hospital stay.

Conclusion:

Revision discectomy is effective in patients with recurrent lumbar disc herniation. Fusion with revision discectomy improves the postoperative low back pain, decreases the intraoperative risk of dural tear or neural damage and decreases the postoperative incidence of mechanical instability or re-recurrence. TLIF and PLF have comparable results when used with revision discectomy, but PLF has significantly less total cost than TLIF.

Surgical Tips to Preserve the Facet Joint during Microdiscectomy

Lumbar microdiscectomy (MD) is the gold standard for treatment of lumbar disc herniation. Generally, the surgeon attempts to protect the facet joint in hopes of avoiding postoperative pain/instability and secondary degenerative arthropathy. We believe that preserving the facet joint is especially important in young patients, owing to their life expectancy and activity. However, preserving the facet joint is not easy during lumbar MD. We propose several technical tips (superolateral extension of conventional laminotomy, oblique drilling for laminotomy, and additional foraminotomy) for facet joint preservation during lumbar MD.