Surgical interventions for lumbar disc prolapse

Reassessing the minimum 2-year follow-up standard after lumbar decompression surgery: a 2-month follow-up seems to be an acceptable minimum

BACKGROUND CONTEXT

Academic orthopedic journals and specialty societies emphasize the importance of two-year follow-up for patient-reported outcome measures (PROMS) after spine surgery, but there are limited data evaluating the appropriate length of follow-up.

PURPOSE

To determine whether PROMs, as measured by the Oswestry Disability Index (ODI), would change significantly after 2-months postoperatively after lumbar decompression surgery for disc herniation or spinal stenosis.

STUDY DESIGN

Retrospective analysis of prospectively and consecutively enrolled patients undergoing lumbar decompression surgery between 2020 and 2021 from a single surgeon spine registry.

PATIENT SAMPLE

One hundred sixty-nine patients.

OUTCOME MEASURES

ODI, achievement of minimum clinically important difference (MCID), revisions.

METHODS

Patients without a preoperative baseline score were excluded. Completion of the ODI questionnaire was assessed at the follow-up points. The median ODI was compared at time baseline, 2-month, 1-year and 2-year follow-up. Risk of reoperation was assessed with receiver operating characteristic (ROC) analysis to identify at-risk ODI thresholds of requiring reoperation.

RESULTS

Median ODI significantly improved at all time points compared to baseline (median baseline ODI: 40; 2-month ODI: 16, p=.001; 1-year ODI: 11.1, p=.001; 2-year ODI: 8, p=.001). Posthoc analysis demonstrated no difference between 2-months, 1-year and 2-year postoperative ODI (p=.9, p=.468, p=.606). The MCID was met in 87.9% of patients at 2 months, 80.7% at 1 year, and 87.3% at 2 years postoperatively. Twelve patients (7.7%) underwent revision surgery between 2 months and 2 years after the index surgery (median time to revision: 5.6 months). ROC curve analysis demonstrated that an ODI score ≥24 points at 2-months yielded a sensitivity of 85.7% and a specificity of 71.8% for predicting revision after lumbar decompression (AUC=0.758; 95% CI: 0.613-0.903). The Youden optimal threshold value of ≥24 points at 2-month postop ODI yielded an odd ratio (OR) for revision of 15.3 (CI: 1.8-131.8; p=.004). The positive predictive value (PPV) and negative predictive value (NPV) were 15.4% and 98.8%, respectively.

CONCLUSION

Two-year clinical follow-up may not be necessary for future peer-reviewed lumbar decompression surgery studies given that ODI plateaus at 8 weeks. Patients with a score ≥24 points at 2-months postoperatively have a higher risk of requiring a second surgery within the first 2 years and warrant continued follow-up.

Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis

Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation

STUDY DESIGN

Systematic review.

OBJECTIVES

Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions.

METHODS

A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001).

CONCLUSION

Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Comparison of full-endoscopic foraminoplasty and lumbar discectomy (FEFLD), unilateral biportal endoscopic (UBE) discectomy, and microdiscectomy (MD) for symptomatic lumbar disc herniation

PURPOSE

This study aimed to evaluate the clinical outcomes of full-endoscopic foraminoplasty and lumbar discectomy (FEFLD), unilateral biportal endoscopic (UBE) discectomy, and microdiscectomy (MD) in the treatment of symptomatic lumbar disc herniation (LDH).

METHODS

From January 2020 and May 2021, 128 patients with single-level LDH at L4-5 or L5-S1 received FEFLD, UBE discectomy or MD. Patients were divided into three groups according to surgical method: the FEFLD group (n = 43), the UBE group (n = 42), and the MD group (n = 43). Operative time, fluoroscopy frequency, in-bed time, length of hospital stays, total expenses, complications, visual analogue scale (VAS, 0-10), and Oswestry Disability Index (ODI, 0-100%) were assessed and compared among three groups.

RESULTS

There were no significant differences in VAS or ODI scores at 12 months after surgery among three groups. In comparison with the MD group, the FEFLD and UBE group yield better VAS scores for back pain on the first day following surgery (P < 0.05). The FEFLD group was superior to the UBE group or MD group with less time in bed and shorter hospital stay (P < 0.05). The operation time and total expenses in the UBE group were significantly longer and higher than those in the FEFLD group or MD group (P < 0.05).

CONCLUSIONS

FEFLD and UBE discectomy yield comparable results to conventional MD concerning pain relief and functional outcomes. In addition, FEFLD and UBE discectomy enable less back pain in the immediate postoperative period. FEFLD offers advantages in rapid recovery. Conventional MD is still an efficient and cost-effective surgical procedure.

Effect of Intravenous Paracetamol on Opioid Consumption in Multimodal Analgesia After Lumbar Disc Surgery: A Meta-Analysis of Randomized Controlled Trials

Background: Intravenous paracetamol, as an adjunct to multimodal analgesia, has been shown to successfully reduce opioid consumption after joint arthroplasty, abdominal surgery, and caesarean delivery. However, there are limited data on the opioid-sparing effect of intravenous paracetamol on lumbar disc surgery.

Objectives: The aim of this study was to investigate the effectiveness and safety of intravenous paracetamol for reducing opioid consumption in lumbar disc surgery. The primary outcome was cumulative opioid consumption within 24 h postoperatively.

Method: We followed the PRISMA-P guidelines and used GRADE to assess the quality of evidence. The review was registered in PROSPERO under the registration number CRD42021288168. Two reviewers conducted electronic searches in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Clarivate Analytics). Randomized controlled trials (RCTs) that compared the postoperative opioid consumption of intravenous paracetamol with placebo in lumbar discectomy were included.

Results: Five trials comprising a total of 271 patients were included. The overall opioid consumption within 24 h postoperatively was reduced [mean difference (MD), −10.61 (95% CI, −16.00 to −5.22) mg, p = 0.0001, I² = 90%] in patients with intravenous paracetamol. Intravenous paracetamol significantly reduced the postoperative pain scores at 1 h [MD, −2.37 (95%CI, −3.81 to −0.94), p = 0.001, I² = 82%], 2 h [MD, −3.17 (95%CI, −3.85 to −2.48), p < 0.00001, I² = 38%], 6 h [MD, −1.75 (95%CI, −3.10 to −0.40), p = 0.01], 12 h [MD, −0.96 (95%CI, −1.77 to −0.15), p = 0.02], and 24 h [MD, −0.97 (95%CI, −1.67 to −0.27), p = 0.006] compared with the placebo. There were no differences in postoperative adverse effects.

Conclusion: Intravenous paracetamol reduced postoperative opioid consumption and decreased postoperative pain scores without increasing adverse effects. The overall GRADE quality of the evidence was rated as low to moderate. Intravenous paracetamol appears to be an applicable option as an important part of multimodal analgesia for postoperative analgesia after lumbar disc surgery.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, CRD42021288168.

Microendoscopic lumbar discectomy with general versus local anesthesia: A systematic review and meta-analysis

Background

While general anesthesia (GA) is the most commonly used anesthetic method during lumbar microendoscopic discectomy (MED), local ± epidural anesthesia (LA) has been gaining popularity as an alternate method. Theoretical advantages of LA include reduced morbidity of anesthesia and improved surgeon-patient communication facilitating less nerve root manipulation and yielding improved surgical outcomes. The objective of this systematic review is to examine the impact of anesthesia type on patient reported outcomes (PROs) and complications with MED.

Methods

A systematic review and meta-analysis of the available literature examining MED performed under GA or LA was performed. The PubMed, EMBASE and SCOPUS databases were searched from inception to August 16, 2021, utilizing strict inclusion and exclusion criteria with all studies reporting greater than 6 months of follow-up and PRO data. PROs including Visual Analog Scale (VAS)-leg/back, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) and/or 36-Item Short Form (SF-36) physical component scores were collected. Complication, recurrent disc herniation, durotomy and reoperation rates as well as surgical factors were collected. All outcomes were compared between pooled studies examining GA or LA. Risk of bias was assessed with the Newcastle-Ottawa Scale.

Results

A total of 23 studies consisting of 2,868 patients (1,335 GA, 1,533 LA) were included in the meta-analysis. There were no significant differences between GA and LA groups in regard to overall complication rate, durotomy rate, recurrent disc herniation rate, reoperation rate, blood loss, or surgical time (p > 0.05). Both groups demonstrated significant improvements in ODI and JOA (p<0.0004), however leg and back VAS was only improved in GA (p<0.0025) and not in LA (p>0.058), and SF-36 only in LA (p=0.003).

Conclusions

Patients undergoing MED under both anesthetic techniques demonstrated significant improvements in ODI and JOA, with no significant differences in complication or reoperation rates. However, patients undergoing GA demonstrated significant improvement in VAS leg and back pain at last follow-up while LA did not. LA may be offered to carefully selected patients and prior studies have demonstrated reduced costs and risks with LA. Conclusions are limited by a high level of study bias and heterogeneity. Further investigation is needed to assess the true effects of GA and LA on outcomes after MED.

Radiation exposure and clinical outcome in patients undergoing percutaneous intradiscal ozone therapy for disc herniation: Fluoroscopic versus conventional CT guidance

Purpose

To compare technical success, clinical success, complications and radiation dose for percutaneous intradiscal ozone therapy in patients with lumbar disc herniation using fluoroscopic guidance versus conventional computed tomography (CT) guidance.

Materials and methods

Between March 2018and March 2021, 124consecutive percutaneous intradiscal ozone therapies wereperformedon111 patients with low back pain (LBP) and/or sciatic pain due to lumbar disc herniation, using fluoroscopic or conventional CT guidance, respectively in 53 and 58 herniated lumbar discs, with at least 1-month follow up. Dose area product (DAP) and dose length product (DLP) were recorded respectively for fluoroscopy and CT, and converted to effective dose (ED).

Results

Fluoroscopic and CT groups were similar in terms of patient age (p-value 0.39), patient weight (p-value 0.49) and pre-procedure Oswestry Disability Index (ODI, p-value 0.94). Technical success was achieved in all cases. Clinical success was obtained in 83.02% (44/53) patients in fluoroscopic group and 79.31% (46/58) in CT group. Mean DAP was 11.63Gy*cm² (range 5.42–21.61). Mean DLP was 632.49mGy-cm (range 151.51–1699). ED was significantly lower in the fluoroscopic group compared toCT group (0.34 vs. 5.53mSv, p = 0.0119). No major complication was registered. Minor complications were observed in 4 cases (2 in fluoroscopic group; 2 in CT group).

Conclusions

Compared to conventional CT guidance, fluoroscopic guidance for percutaneous intradiscal ozone therapy in patients with lumbar disc herniation shows similar technical and clinical success rates, with lower radiation dose. This technique helps sparing dose exposure to patients.

Integrative traditional Chinese medicine for lumbar disc herniation after surgery: A protocol for systematic review and meta-analysis

BACKGROUND

Patients with lumbar disc herniation, who undergo spine surgery, occasionally complain of pain and functional disability. Fortunately, the concept of enhanced recovery after surgery has emerged recently. As a result, patients seek traditional Chinese medicine after spine surgery. This systematic review will thoroughly analyze and synthesize evidence on integrative traditional Chinese medicine therapy for lumbar disc herniation after surgery.

METHODS

The following databases will be utilized to search for pertinent studies: the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, Chinese National Knowledge Infrastructure, Japan Medical Abstracts Society, and 7 Korean databases (the Korean Studies Information Service System, Korean Association of Medical Journal Editors, National Digital Science Library, Database Periodical Information Academic Korean Traditional Knowledge Portal, Oriental Medicine Advanced Searching Integrated System, and Korean National Assembly Digital Library). The risk of bias of the selected studies will be assessed according to the Cochrane assessment tool for risk of bias. For articles that used the same measurements, a meta-analysis will be conducted to synthesize the results of each trial. Pain severity will be the primary outcome, while the results of functional questionnaires and range of motion, etc, will be the secondary outcomes.

RESULTS AND CONCLUSION

Since this protocol does not include any data from patients, ethics approval is not required. The results of this review will be disseminated through a peer-reviewed journal.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/KP47A (https://osf.io/kp47a).

Clinical evaluation of percutaneous transforaminal endoscopic discectomy (PTED) and paraspinal minitubular microdiscectomy (PMTM) for lumbar disc herniation: study protocol for a randomised controlled trial

INTRODUCTION

For sciatica caused by lumbar disc herniation (LDH), the standard surgical technique is conventional microdiscectomy. In recent years, minimally invasive techniques (eg, percutaneous transforaminal endoscopic discectomy (PTED), paraspinal minitubular microdiscectomy (PMTM)) have gained increasing interest. PTED and PMTM are considered alternative minimally invasive techniques for the treatment of LDH. Due to insufficient evidence, the differences in efficacy between PTED and PMTM have been debated. A pragmatic, multicentre, non-inferiority, randomised controlled trial has been designed to determine the efficacy and cost-effectiveness of PTED versus PMTM for the treatment of LDH.

METHODS AND ANALYSIS

A total of 280 patients (18-70 years) presenting with significant symptoms of sciatica and failure after 3 months of conservative treatment will be recruited. Patients must have an indication for surgery based on MRI demonstrating LDH with nerve root compression. Patients will be randomised to PTED or PMTM treatment. The primary outcome is Oswestry Disability Index scores. Secondary outcomes include Visual Analogue Scale scores, Short Form 36 health survey scores, physical examination, length of hospital stay, costs and complications. Outcomes will be measured the day following surgery, at 1 week, and at 1, 3, 6, 12 and 24 months after surgical treatment. Physical examination will be conducted at 1 week, 1 month and 12 months after surgery. The non-inferiority margin for the primary outcome is 5.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Ethics Committee of Fujian Medical University Union Hospital, Fuzhou, China (2018YF010-02). Results of the research will be published in an international peer-reviewed scientific journal and disseminated through presentation at scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR1800015727; Pre-results.

Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial

BACKGROUND

Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level.

METHOD

In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed.

RESULTS

Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association.

CONCLUSION

Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery.

TRIAL REGISTRATION

NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.

Functional Outcome after Endoscopic Lumbar Discectomy by Destandau's Technique: A Prospective Study of 614 Patients

Study Design

Prospective study.

Purpose

To investigate the efficacy of the lumbar discectomy procedure using the Destandau Endospine System by assessing the functional outcome and complication rate in 614 patients.

Overview of Literature

Endoscopic Spine Surgery (Endospine) using Destandau's technique is an established treatment method of lumbar disk herniation; it was introduced in 1993 and is gaining prominence for its small skin incision and minimal tissue dissection with excellent visualization.

Methods

Of 840 patients, we selected 614 patients, based on the strict inclusion criteria, who underwent endoscopic lumbar discectomy (ELD) between August 2008 and November 2015. The technique comprised localization of the symptomatic level followed by insertion of an endospine system device through a 15-20-mm skin and fascial incision to perform a discectomy. We evaluated results by Macnab's criteria, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) score after a minimum follow-up of 12 months and maximum up to 54 months.

Results

Based on the modified Macnab's criteria, 479 patients (78.01%) exhibited excellent, 110 (17.9%) good, 19 (3.09%) fair, and 6 (0.97%) poor results. The average ODI score was improved from 64 (range, 44-86; standard deviation [SD]=9.2) to 14 (range, 2-31; SD=4.4), and the average VAS score from 7.8 (range, 6-10; SD=0.9) to 2 (range, 0-7; SD=1.2) in a year. On 1-year follow-up, 589 patients (95.9%) were completely pain-free and satisfied with the procedure.

Conclusions

ELD provides a safe, effective, and minimal access corridor for lumbar discectomy. The technique also allows early postoperative mobilization and faster return-to-work.

Patient journey following lumbar discectomy surgery: protocol for a single-centre qualitative analysis of the patient rehabilitation experience (DiscJourn)

INTRODUCTION

Lumbar discectomy is a widely used surgical procedure internationally with the majority of patients experiencing significant benefit. However, approximately 20% of patients report suboptimal functional recovery and quality of life. The impact and meaning of the surgical experience from the patients' perspective are not fully understood. Furthermore, there is limited evidence guiding postoperative management with significant clinical practice variation and it is unclear if current postoperative support is valued, beneficial or meets patients' needs and expectations. This study aims to address the evidence gap by moving beyond current knowledge to gain insight into the lived experiences relating to patients' lumbar discectomy surgery journey. Results will inform more meaningful and specific care, thus, enhance rehabilitation and outcomes.

METHODS AND ANALYSIS

A qualitative investigation using interpretative phenomenology analysis (IPA) will provide a flexible inductive research approach. A purposive sample (n=20) of patients undergoing primary discectomy will be recruited from one UK NHS secondary care centre. Semi-structured interviews will be conducted postsurgery discharge. A topic guide, developed from the literature and our previous work with input from two patient co-investigators, will guide interviews with the flexibility to explore interesting or patient-specific points raised. Providing longitudinal data, patients will keep weekly diaries capturing experiences and change over time throughout 12 months following surgery. A second interview will be completed 1 year postsurgery with its topic guide informed by initial findings. This combination of patient interviews and diaries will capture patients' attitudes and beliefs regarding surgery and recovery, facilitators and barriers to progress, experiences regarding return to activities/function and interactions with healthcare professionals. The rich density of data will be thematically analysed in accordance with IPA, supported by NVivo software.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the London-Bloomsbury Research Ethics Committee (18/LO/0459; IRAS 241345). Conclusions will be disseminated through conferences and peer-reviewed journals.

Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain

STUDY DESIGN

A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted.

OBJECTIVE

The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures.

MATERIALS AND METHODS

English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included.

RESULTS

Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients.

CONCLUSIONS

These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.

Awareness of disc herniation among general population in Aseer province, Saudi Arabia

Background:

Herniated lumbar disc is a depositions of discs material (nucleus pulposus and annulus fibrosus) behind the intervertebral disk. Intervertebral disc connected the vertebral bodies together by pad of fibrocartilage. The major functions of intervertebral disc are mechanical, transferring load coming from the body weight and muscle contractions by spinal columns and letting the curving, flexion, and contortion.

Aim:

To assess the awareness of general population in Aseer region, southern of Saudi Arabia, regarding disc herniation and to identify the predictors for their awareness.

Methodology:

A descriptive cross-sectional approach was conducted through a questionnaire designed to examine the public herniated disc awareness and knowledge. The questionnaire given to individuals from general population visiting general public places in Aseer region. Content validity for the questionnaire was done as it was reviewed by three experts for any modification of corrections.

Results:

The study included 1,044 participants aged between 15 and 70 years with mean age of 36.3 ± 11.2 years old. The majority of respondents were males (62.4%) and Saudi (98.9%). About 71% of the participants were university graduated. Generally, only 9% of the study participants recorded good awareness level regarding all aspects of disc herniation.

Conclusion:

This study showed that awareness regarding disc herniation among the general population was very poor for all domains.

Deep learning-based preoperative predictive analytics for patient-reported outcomes following lumbar discectomy: feasibility of center-specific modeling

BACKGROUND CONTEXT

There is considerable variability in patient-reported outcome measures following surgery for lumbar disc herniation. Individualized prediction tools that are derived from center- or even surgeon-specific data could provide valuable insights for shared decision-making.

PURPOSE

To evaluate the feasibility of deriving robust deep learning-based predictive analytics from single-center, single-surgeon data.

STUDY DESIGN

Derivation of predictive models from a prospective registry.

PATIENT SAMPLE

Patients who underwent single-level tubular microdiscectomy for lumbar disc herniation.

OUTCOME MEASURES

Numeric rating scales for leg and back pain severity and Oswestry Disability Index scores at 12 months postoperatively.

METHODS

Data were derived from a prospective registry. We trained deep neural network-based and logistic regression-based prediction models for patient-reported outcome measures. The primary endpoint was achievement of the minimum clinically important difference (MCID) in numeric rating scales and Oswestry Disability Index, defined as a 30% or greater improvement from baseline. Univariate predictors of MCID were also identified using conventional statistics.

RESULTS

A total of 422 patients were included (mean [SD] age: 48.5 [11.5] years; 207 [49%] female). After 1 year, 337 (80%), 219 (52%), and 337 (80%) patients reported a clinically relevant improvement in leg pain, back pain, and functional disability, respectively. The deep learning models predicted MCID with high area-under-the-curve of 0.87, 0.90, and 0.84, as well as accuracy of 85%, 87%, and 75%. The regression models provided inferior performance measures for each of the outcomes.

CONCLUSIONS

Our study demonstrates that generating personalized and robust deep learning-based analytics for outcome prediction is feasible even with limited amounts of center-specific data. With prospective validation, the ability to preoperatively and reliably inform patients about the likelihood of symptom improvement could prove useful in patient counselling and shared decision-making.

Therapeutic Effect of Medical Ozone on Lumbar Disc Herniation

BACKGROUND This study aimed to investigate the therapeutic effect of low, medium, and high concentrations of medical ozone on trauma-induced lumbar disc herniation. MATERIAL AND METHODS A total of 80 patients were included and were grouped into a control group, a low medical ozone (20 μg/ml) group, a medium medical ozone (40 μg/ml) group, and a high medical ozone (60 μg/ml) group. The CT scan and enzyme-linked immunosorbent assay (ELISA) were used to detect IL-6 level, SOD activity, IgM, and IgG levels upon admission and at 6 and 12 months after follow-up. The area under the ROC curve (AUC) was calculated for visual analogue scale (VAS) and efficiency rate. RESULTS All patients showed disc retraction at 6- and 12-month follow-up; while patients in the medium medical ozone (40 μg/ml) group showed the greatest disc retraction rate. The IL-6, IgM, IgG, and VAS levels significantly decreased while SOD activity increased among all groups over time (p<0.05). The AUCIL-6, AUCIgG, AUCIgM, and AUCSOD was closest to 1 in the medium medical ozone (40 μg/ml) group compared with other groups (p<0.01), with the highest efficacy at 6 (35%) and 12 (85%) months during follow-up. CONCLUSIONS Low concentrations of medical ozone (20 μg/ml and 40 μg/ml) reduced the serum IL-6, IgG, and IgM expression, presenting as analgesic and anti-inflammatory effects, while high concentrations of medical ozone (60 μg/ml) increased the serum IL-6, IgG, IgM expression, presenting as pain and pro-inflammatory effects. The medical ozone concentration of 40 μg/ml showed the optimal treatment efficacy.

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.

METHODS

This was a retrospective observational study of patients undergoing elective lumbar microdiscectomy between August 2012 and December 2014. Age, gender, day of surgery, distance to hospital, ASA grade, regular opiate use, smoking status, order on the operating list, and side and level of surgery were examined by logistic regression to assess their influence on same-day discharge.

RESULTS

28/95 (29.5%) patients were discharged on the day of surgery. Age (p = 0.041), ASA grade (p = 0.016), distance to hospital (p = 0.011), and position on the list (p = 0.004) were associated with day-case discharge by univariate analysis. ASA grade (p = 0.032; OR 0.176), distance to hospital (p = 0.003; OR 0.965), and position on the operating list (morning case; p = 0.011; OR 8.901) remained significant in multivariate analysis. Thirteen (13.7%) patients were identified who could have been managed as day cases had they been listed for morning operations.

CONCLUSIONS

Day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimise bed space and improve spinal services.

Lumbar herniated disc: spontaneous regression

BACKGROUND

Low back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy.

METHODS

This retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3-L4, L4-L5 or L5-S1 were enrolled.

RESULTS

The average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3-L4, L4-L5, and L5-S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5-22).

CONCLUSIONS

It should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery.

Neurogenic muscle hypertrophy: a case report

Muscular hypertrophy is caused mainly due to myopathic disorder. But, it is also rarely produced by neurogenic disorder. A 74-year-old woman complained of right calf pain with hypertrophy for several years. Recent lumbar spine magnetic resonance imaging (MRI) showed central and lateral canal narrowing at the L4-L5 intervertebral space. Lower extremity MRI revealed fatty change of right medial head of the gastrocnemius and soleus, causing right calf hypertrophy. Electrodiagnostic examinations including electromyography and nerve conduction velocity testing demonstrated 5th lumbar and 1st sacral polyradiculopathy. Integrating all the results, the diagnosis was neurogenic muscle hypertrophy. Neurogenic muscle hypertrophy is very rare, but we recommend that clinicians consider this problem when a patient complains of lower limb hypertrophy and pain.

PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol

BACKGROUND

Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes.

METHODS

This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index.

DISCUSSION

The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery.

TRIAL REGISTRATION

ClinicalTrials.gov reference: NCT02454400 (Trial registration date: August 31st 2015) and has been registered on ClinicalTrials.gov, identifier: NCT02454400 .

Diagnostic accuracy of the Self-administered, Self-reported History Questionnaire for lumbar spinal stenosis patients in Japanese primary care settings: a multicenter cross-sectional study (DISTO-project)

BACKGROUND

Diagnostic support tools for lumbar spinal stenosis such as the Self-administered, Self-reported History Questionnaire have been developed in Japan, but no report has demonstrated the diagnostic accuracy of this questionnaire in Japanese primary care settings. This multicenter, cross-sectional survey was performed to evaluate and improve the diagnostic accuracy of this questionnaire for lumbar spinal stenosis patients in Japanese primary care settings.

METHODS

The lumbar spinal stenosis diagnosis support tool project was conducted in 1657 hospitals to evaluate the diagnostic accuracy of the Self-administered, Self-reported History Questionnaire in Japan from 2011 to 2012. Consecutive adults (≥50 years old) from physicians, including non-orthopedic general practitioners and orthopedic general practitioners, were considered for enrollment. Consecutive adults (≥50 years old) with low back pain from hospital-based orthopedic surgeons were also considered for enrollment. The diagnostic accuracy of the Self-administered, Self-reported History Questionnaire with initial and several new cutoff points in classifying patients according to the presence of lumbar spinal stenosis was assessed in terms of sensitivity, specificity and negative predictive values.

RESULTS

Among the 33,545 patients, 10,199 (30.4 %) were diagnosed with lumbar spinal stenosis by the physicians. The Self-administered, Self-reported History Questionnaire version 1.1 with a new cutoff point was more sensitive than the Self-administered, Self-reported History Questionnaire version 1.0 with the initial cutoff point (79.8 vs. 68.3 %) and less specific (68.8 vs. 75.1 %) for lumbar spinal stenosis diagnosis. The respective negative predictive values were 88.5 and 84.3 %.

CONCLUSIONS

The Self-administered, Self-reported History Questionnaire version 1.1 with the new cutoff was more sensitive and had higher negative predictive value than version 1.0 with the initial cutoff. Therefore, the improved Self-administered, Self-reported History Questionnaire version 1.1 can be used for lumbar spinal stenosis screening, and its use may improve the quality of lumbar spinal stenosis diagnostic practice in Japanese primary care settings.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Preliminary Report on the CO2 Laser for Lumbar Fusion: Safety, Efficacy and Technical Considerations

The purpose of this study was to evaluate potential technical advantages of the CO2 laser technology in mini-open transforaminal lumbar interbody fusion (TLIF) surgeries and report our preliminary clinical data on the safety and clinical outcomes. There is currently no literature discussing the recently redeveloped CO2 laser technology application for lumbar fusion. Safety and clinical outcomes were compared between two groups: 24 patients that underwent CO2 laser-assisted one-level TLIF surgeries and 30 patients that underwent standard one-level TLIF surgeries without the laser. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. At a mean follow-up of 17.4 months, significantly reduced lower back pain scores (P=0.013) were reported in the laser-assisted patient group compared to a standard fusion patient group. Lower extremity radicular pain intensity scores were similar in both groups. Laser-assisted TLIF surgeries showed a tendency (P = 0.07) of shorter operative times that was not statistically significant. Based on this preliminary clinical report, the safety of the CO2 laser device for lumbar fusion surgeries was assessed. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. Further investigation of CO2 laser-assisted lumbar fusion procedures is warranted in order to evaluate its effect on clinical outcomes.

Transarticular laser discal fragmentectomy. A new minimally invasive surgical approach for challenging disc herniations in the elderly

This report describes two elderly patients with large disc fragments extruded into lumbar radicular recesses not treatable by any conventional conservative, minimally invasive or surgical approach. Direct access to the disc fragments was obtained crossing the articular zygapophyseal cavity instead of the interlaminar space and spinal canal, using a small needle through which a laser fibre was inserted to deliver energy for tissue ablation. The procedures obtained regression of both symptoms and the bulk of the fragments at early and late clinical and MR follow-ups.

Is NICE guidance for identifying lumbar nerve root compression misguided?

PURPOSE

To determine the extent to which the clinical manifestations of a cohort of people undergoing surgery for lumbosacral nerve root compression satisfy those described in The National Institute for Health and Care Excellence (NICE) guidance.

METHOD

We studied consecutive admissions for lumbar nerve root decompression surgery at two neurosurgical units. Pre-operatively, each person's clinical manifestations were documented and compared with NICE's description. Post-operatively, at three time points (within 48 h, 3 months, 12 months), each person rated their symptoms as either better, the same, or worse.

RESULTS

Pre-operatively, one person (0.8%), from 123 admissions, under 20 different consultant neurosurgeons, had manifestations consistent with NICE's clinical description of lumbar nerve root compression. Post-operatively, self-reported benefit associated with surgery appeared high, at all three time points (78-91%), supporting the diagnosis of symptomatic nerve root compression and the value of surgery.

CONCLUSIONS

In this small sample, from two units, NICE's description of the clinical manifestations of lumbar nerve root compression did not describe 99% of people having surgery for it. Using NICE's definition to triage people with low back pain could result in prolonged symptoms and delayed treatment. Diagnosing lumbar nerve root compression is complex. NICE's guidance requires examination.

Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis

PURPOSE

Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation.

METHODS

A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD).

OUTCOMES

Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis.

RESULTS

Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD.

CONCLUSIONS

There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis

PURPOSE

Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation.

METHODS

A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD).

OUTCOMES

Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis.

RESULTS

Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD.

CONCLUSIONS

There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

Evidence for surgery in degenerative lumbar spine disorders

We aimed to evaluate the available evidence on the effectiveness of surgical interventions for a number of conditions resulting in low back pain (LBP) or spine-related irradiating leg pain. We searched the Cochrane databases and PubMed up to June 2013. We included systematic reviews and randomised controlled trials (RCTs) on degenerative disc disease (DDD), herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons between surgery and conservative care and between different techniques. The quality of the systematic reviews was evaluated using assessment of multiple systematic reviews (AMSTAR). Twenty systematic reviews were included which covered the following diagnoses: disc herniation (n = 9), spondylolisthesis (n = 2), spinal stenosis (n = 3), DDD (n = 4) and combinations (n = 2). For most of the comparisons, no significant and/or clinically relevant differences between interventions were identified. In general, surgery is only indicated for relief of leg pain in clear indications such as disc herniation, spondylolisthesis or spinal stenosis.

Barriers and facilitators to implement shared decision making in multidisciplinary sciatica care: a qualitative study

BACKGROUND

The Dutch multidisciplinary sciatica guideline recommends that the team of professionals involved in sciatica care and the patient together decide on surgical or prolonged conservative treatment (shared decision making [SDM]). Despite this recommendation, SDM is not yet integrated in sciatica care. Existing literature concerning barriers and facilitators to SDM implementation mainly focuses on one discipline only, whereas multidisciplinary care may involve other barriers and facilitators, or make these more complex for both professionals and patients. Therefore, this qualitative study aims to identify barriers and facilitators perceived by patients and professionals for SDM implementation in multidisciplinary sciatica care.

METHODS

We conducted 40 semi-structured interviews with professionals involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons) and three focus groups among patients (six to eight per group). The interviews and focus groups were audiotaped and transcribed in full. Reported barriers and facilitators were classified according to the framework of Grol and Wensing. The software package Atlas.ti 7.0 was used for analysis.

RESULTS

Professionals reported 53 barriers and 5 facilitators, and patients 35 barriers and 18 facilitators for SDM in sciatica care. Professionals perceived most barriers at the level of the organizational context, and facilitators at the level of the individual professional. Patients reported most barriers and facilitators at the level of the individual professional. Several barriers and facilitators correspond with barriers and facilitators found in the literature (e.g., lack of time, motivation) but also new barriers and facilitators were identified. Many of these new barriers mentioned by both professionals and patients were related to the multidisciplinary setting, such as lack of visibility, lack of trust in expertise of other disciplines, and lack of communication between disciplines.

CONCLUSIONS

This study identified barriers and facilitators for SDM in the multidisciplinary sciatica setting, by both professionals and patients. It is clear that more barriers than facilitators are perceived for implementation of SDM in sciatica care. Newly identified barriers and facilitators are related to the multidisciplinary care setting. Therefore, an effective implementation strategy of SDM in a multidisciplinary setting such as in sciatica care should focus on these barriers and facilitators.

Nucleoplasty as a therapeutic option for lumbar disc degeneration related pain: a retrospective study of 396 cases

OBJECTIVES

To make a retrospective analysis and evaluate a clinical response to the control of disc degeneration related pain of 396 patients submitted to percutaneous lumbar nucleoplasty; and to make a record of visual analogical scale (VAS) up to a three-year follow-up after the surgical procedure.

METHODS

Analysis of VAS score in 396 patients with lumbar disc degeneration related pain, according to anamnesis, clinical examination and magnetic resonance imaging (MRI), without improvement of previous clinical treatment, submitted to percutaneous nucleoplasty.

RESULTS

A total of 26% of the patients presented 100% remission of pain or paresthesia, of whom 75% showed at least 50% of pain improvement. The median VAS pain improvement was about 67%.

CONCLUSIONS

The median VAS improvement in inferior disc levels was higher than four points. The VAS showed improvement of the pain and paresthesia up to a three-year follow up after the surgical procedure.

Spine surgery outcomes in a workers' compensation cohort

INTRODUCTION

Lumbar spine surgery (fusion, disc replacement or decompression) is common, yet indications are unclear and outcomes, particularly in a workers' compensation setting, are not consistently favourable. This study aimed to determine the outcomes of spine surgery in an Australian workers' compensation cohort.

METHODS

A retrospective review of prospectively collected data from WorkCover NSW and insurer agents was performed. Subjects were included if they had lumbar spine decompression, fusion or disc replacement procedures performed between 1 January 2004 and 31 December 2006 (inclusive). Main outcome measures were as follows: need for further lumbar spine surgery, return to work (RTW), return to pre-injury duties (PID) and need for ongoing physical treatment or prescription opioids. All outcomes were measured at 24 months post-surgery.

RESULTS

A total of 476 patients had undergone lumbar spine surgery within the workers' compensation system. The revision surgery rate was 9.2%. The RTW rate and return to PID rate were 50.3% and 14.2%, respectively. The proportion of patients still undergoing treatment was 77.7%. The rates of RTW (or PID) and need for ongoing treatment were significantly worse in patients undergoing fusion and disc replacement, compared with patients undergoing decompressive procedures (laminectomy, discectomy).

DISCUSSION

The findings do not support the use of lumbar spine fusion or disc replacement surgery as a method of achieving RTW and relief of pain in patients treated under workers' compensation.

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

Introduction

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

Materials and methods

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

Results

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

Conclusions

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

Cytokine inhibition and time-related influence of inflammatory stimuli on the hyperalgesia induced by the nucleus pulposus

INTRODUCTION

The symptoms of lumbar disc herniation, such as low back pain and sciatica, have been associated with local release of cytokines following the inflammatory process induced by the contact of the nucleus pulposus (NP) with the spinal nerve.

MATERIAL AND METHODS

Using an animal experimental model of intervertebral disc herniation and behavioral tests to evaluate mechanical (electronic von Frey test) and thermal (Hargreaves Plantar test) hyperalgesia in the hind paw of rats submitted to the surgical model, this study aimed to detect in normal intervertebral disc the cytokines known to be involved in the mechanisms of inflammatory hyperalgesia, to observe if previous exposure of the intervertebral disc tissue to specific antibodies could affect the pain behavior (mechanical and thermal hyperalgesia) induced by the NP, and to observe the influence of the time of contact of the NP with the fifth lumbar dorsal root ganglion (L5-DRG) in the mechanical and thermal hyperalgesia.

RESULTS

The cytokines present at highest concentrations in the rat NP were TNF-α, IL-1β and CINC-1. Rats submitted to the disc herniation experimental model, in which a NP from the sacrococcygeal region is deposited over the right L5-DRG, showed increased mechanical and thermal hyperalgesia that lasted at least 7 weeks. When the autologous NP was treated with antibodies against the three cytokines found at highest concentrations in the NP (TNF-α, IL-1β and CINC-1), there was decrease in both mechanical and thermal hyperalgesia in different time points, suggesting that each cytokine may be important for the hyperalgesia in different steps of the inflammatory process. The surgical remotion of the NP from herniated rats 1 week after the implantation reduced the hyperalgesia to the level similar to the control group. This reduction in the hyperalgesia was also observed in the group that had the NP removed 3 weeks after the implantation, although the intensity of the hyperalgesia did not decreased totally. The removal of the NP after 5 weeks did not changed the hyperalgesia observed in the hind paw, which suggests that the longer the contact of the NP with the DRG, the greater is the possibility of development of chronic pain.

CONCLUSION

Together our results indicate that specific cytokines released during the inflammatory process induced by the herniated intervertebral disc play fundamental role in the development of the two modalities of hyperalgesia (mechanical and thermal) and that the maintenance of this inflammation may be the most important point for the chronification of the pain.

Posterior endoscopic discectomy: Results in 300 patients

BACKGROUND

Posterior endoscopic discectomy is an established method for treatment of lumbar disc herniation. Many studies have not been reported in literature for lumbar discectomy by Destandau Endospine System. We report a series of 300 patients operated for lumbar dissectomy by Destandau Endospine system.

MATERIALS AND METHODS

A total of 300 patients suffering from lumbar disc herniations were operated between January 2002 and December 2008. All patients were operated as day care procedure. Technique comprised localization of symptomatic level followed by insertion of an endospine system devise through a 15 mm skin and fascial incision. Endoscopic discectomy is then carried out by conventional micro disc surgery instruments by minimal invasive route. The results were evaluated by Macnab's criteria after a minimum followup of 12 months and maximum up to 24 months.

RESULTS

Based on modified Macnab's criteria, 90% patients had excellent to good, 8% had fair, and 2% had poor results. The complications observed were discitis and dural tear in five patients each and nerve root injury in two patients. 90% patients were able to return to light and sedentary work with an average delay of 3 weeks and normal physical activities after 2 months.

CONCLUSION

Edoscopic discectomy provides a safe and minimal access corridor for lumbar discectomy. The technique also allows early postoperative mobilization and faster return to work.

Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review

The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6-12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.

Spontaneous regression of a large lumbar disc extrusion

Although the spontaneous disappearance or decrease in size of a herniated disc is well known, that of a large extruded disc has rarely been reported. This paper reports a case of a spontaneous regression of a large lumbar disc extrusion. The disc regressed spontaneously with clinical improvement and was documented on a follow up MRI study 6 months later. The literature is reviewed and the possible mechanisms of spontaneous disc regression are discussed.

Sciatica

Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. Sciatica is mainly diagnosed by history taking and physical examination. In general, the clinical course of acute sciatica is considered to be favourable. In the first 6-8 weeks, there is consensus that treatment of sciatica should be conservative. We review and comment on the levels of evidence of the efficacy of patient information, advice to stay active, physical therapy analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), epidural corticosteroid injections and transforaminal peri-radicular injections of corticosteroid. There is good evidence that discectomy is effective in the short term. but, in the long term, it is not more effective than prolonged conservative care. Shared decision making with regard to surgery is necessary in the absence of severe progressive neurological symptoms. Although the term sciatica is simple and easy to use, it is, in fact, an archaic and confusing term. For most researchers and clinicians, it refers to a radiculopathy, involving one of the lower extremities, and related to disc herniation (DH). As such, the term 'sciatica' is too restrictive as nerve roots from L1 to L4 may also be involved in the same process. However, even more confusing is the fact that patients, and many clinicians alike, use sciatica to describe any pain arising from the lower back and radiating down to the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to DH nor does it result from nerve-root compression. Although differentiating the radicular pain from the referred pain may be challenging for the clinician, it is of primary importance. This is because the epidemiology, clinical course and, most importantly, therapeutic interventions are different for these two conditions. It should, however, be emphasised that the quality of the available evidence is rather limited due to a considerable heterogeneity in the study populations included in the trials. This makes generalisation of findings across studies, and to routine clinical practice, a challenge. Prevalence estimates of radicular pain related to DH also vary considerably between studies, which is, in part, due to differences in the definitions used. A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programs are available for individuals after lumbar disc surgery.

OBJECTIVES

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL and PsycINFO to May 2007.

SELECTION CRITERIA

We only included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

MAIN RESULTS

Fourteen studies were included, seven of which had a low risk of bias. Most programs were only assessed in one study. Statistical pooling was only completed for three comparisons in which exercises were started four to six weeks post-surgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises.There is low quality evidence (three RCTS, N = 156) that exercises are more effective than no treatment for pain at short-term follow-up (WMD -11.13; 95% CI -18.44 to -3.82) and moderate evidence (two RCTs, N = 136) that they are more effective for functional status on short-term follow-up (WMD -6.50; 95% CI -9.26 to -3.74). None of the studies reported that exercises increased the re-operation rate.There is low quality evidence (two RCTs, N =103) that high intensity are slightly more effective than low intensity exercise programs for pain in the short term (WMD -10.67; 95% CI -17.04 to -4.30) and moderate evidence (two RCTs, N = 103) that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36).There is low quality evidence (three RCTS, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD -1.12; 95% CI -2.77 to 0.53) or functional status (three RCTs, N = 88; SMD -1.18; 95% CI -2.63 to 0.26).

AUTHORS' CONCLUSIONS

Exercise programs starting four to six weeks post-surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.

Spontaneously disappearing lumbar disc protrusion

Spontaneous disappearance of a herniated lumbar disc is known to occur. This case study describes a 45-year-old patient whose symptoms of lumbar radiculopathy resolved and follow-up imaging showed complete disappearance of the disc prolapse. This phenomenon strengthens the role of conservative treatment in the management of lumbar disc protrusions.

Safety of carboxymethylcellulose/polyethylene oxide for the prevention of adhesions in lumbar disc herniation--consecutive case series review

BACKGROUND

Epidural fibrosis is regarded as a cause of failed back surgery syndrome (FBSS) when excessive adhesional/fibrotic scar tissue causes compression, pain or discomfort by tethering of nerve tissue to the surrounding muscle or bone. Fibrosis inhibitors could therefore increase the success rate of spinal surgery and decrease the need for reoperations. In recent years, bio-resorbable gels or films for the prevention of peridural fibrosis and post-operative adhesions have been developed that look clinically promising. This included a 100% synthetic, sterile, absorbable gel combinations of carboxymethylcellulose (CMC) and polyethylene oxide (PEO) used to coat the dura to reduce scarring after discectomy which became available in Europe in 2002. However, given the burden of the problem and unfavorable experience with other types of adhesion-reduction agents, our unit decided to evaluate the safety of CMC/PEO in a large population of patients undergoing spinal microdiscectomy for herniation.

METHODS

To determine the safety and assess efficacy of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel as an anti-adhesion gel, a consecutive series of 396 patients undergoing lumbar discectomy performed by one surgeon had CMC/PEO gel administered at the end of surgery. The patients were followed up in accordance with standard clinical practice and records reviewed for side effects, such as skin reactions, general reactions or local fluid collections. Reoperations for recurrent herniation included an evaluation of fibrosis reduction.

RESULTS

No product related complications were observed. Five patients needed reoperations for recurrent herniation. Significant but subjective reduction in fibrosis was observed in these patients.

CONCLUSION

The findings provide confidence that CMC/PEO gel is well tolerated as an agent to achieve reduction of fibrosis in lumbar disc surgery. Further formal prospective study is recommended in this area of unmet need.

Minimally invasive spine surgery: a historical perspective

Minimally invasive spine surgery has gained considerable momentum and increased acceptance among spine surgeons throughout the years. An understanding and awareness of the development of minimally invasive spine surgery and its role in the operative treatment of various spine conditions is imperative. This article provides a succinct historical perspective of the development of spine surgery from the more traditional, open procedures to the use of more "minimal access" or minimally invasive spine surgery procedures.

Surgical interventions for lumbar disc prolapse

BACKGROUND

Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.

OBJECTIVES

The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 January 2007 are included.

SELECTION CRITERIA

Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

MAIN RESULTS

Forty RCTs and two QRCTs were identified, including 17 new trials since the first edition of this review in 1999. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy, There are no published RCTs of coblation therapy or trans-foraminal endoscopic discectomy.

AUTHORS' CONCLUSIONS

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).