Long-term outcomes of the revision open lumbar discectomy by fenestration: A follow-up study of more than 10 years

Annulus Fibrosus Repair for Lumbar Disc Herniation: A Meta-Analysis of Clinical Outcomes From Controlled Studies

STUDY DESIGN

Meta-analysis.

OBJECTIVES

This study aimed to summarize the clinical efficacy and safety of the various annular defect repair methods that have emerged in recent years.

METHODS

A meta-analysis of randomized and non-randomized controlled trials was conducted. Articles from PubMed, Embase, and the Cochrane Library (CENTRAL) on Lumbar disc herniation treatment with annular repair published from inception to April 2, 2022 were included. We summarized the clinical efficacy and safety of annular repair techniques based on a random-effects model meta-analysis.

RESULTS

7 randomized controlled studies and 8 observational studies with a total of 2161 participants met the inclusion criteria. The pooled data analysis showed that adding the annular repair technique reduced postoperative recurrence rate, reoperation rate, and loss of intervertebral height compared with lumbar discectomy alone. Subgroup analysis based on different annular repair techniques showed that the Barricaid Annular Closure Device (ACD) was effective in preventing re-protrusion and reducing reoperation rates, while there was no significant difference between the other subgroups. The annulus fibrosus suture (AFS) did not improve the postoperative Oswestry Disability Index (ODI). No statistically significant difference was observed in the incidence of adverse events between the annular repair and control groups.

CONCLUSIONS

Lumbar discectomy combined with ACD can effectively reduce postoperative recurrence and reoperation rates in patients with LDH. AFS alone was less effective in reducing recurrence and reoperation rates and did not improve postoperative pain and function.

Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review

OBJECTIVE

Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation.

METHODS

A systematic literature search was conducted using Pubmed and Embase databases on 18^thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates).

RESULTS

Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques.

CONCLUSION

There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.

Lumbar disc herniation: long-term outcomes after mini-open discectomy

PURPOSE

The outcomes of mini open discectomy in lumbar disc herniation are usually satisfying. Our study aims at finding if its results are still good at long-term follow-up.

METHODS

We reviewed 552 patients operated between 1993 and 2013 by mini open discectomy procedure. Our main evaluation criterion is a modified Stauffer and Coventry classification applied during follow-up visits at three months, one year, five years, and every five years. The secondary criterion was the Oswestry Disability Index.

RESULTS

The outcomes are considered good to very good in 87.3% of the cases at one year follow-up. These results deteriorate after an average follow-up of 14.7 years but remain satisfactory with 63.7%. The global decrease is 23.6%. The Oswestry Score decreases by 35 points at the same follow-up. In addition, 6.52% of patients required fusion at first revision and 1.08% at second revision. We also noticed 51 (9.2%) post-operative recurrences at the same level. In 23 (4.16%) of them, we proceeded to a new discectomy in an average interval of 41.4 months. At an adjacent level, 29 patients (5.2%) presented a new symptomatic disc herniation; among them, eight cases (1.44%) needed discectomy. The re-operative rate (including recurrent disc herniation and fusion for degenerative indications) is 10.68% at the last follow-up.

CONCLUSIONS

Nearly 2/3 of our patient series keep satisfactory outcomes after about 15-year follow-up. The mini open discectomy remains a reliable surgical technique provided we respect the indications and surgical requirements. This procedure also avoids excessive instrumentation and its possible iatrogenic complications. Powerful randomized and controlled trials are needed to strengthen these deductions.

The evidence-based approach for surgical complications in the treatment of lumbar disc herniation

PURPOSE

The purpose of this article is to review the evidence-based approach for surgical complications following disc herniation.

METHODS

A search of the primary English literature was conducted for research examining the outcomes and complications of surgical discectomy. Special regard was given to high-quality prospective randomized studies.

RESULTS

The most commonly reported complications of surgical treatment of disc herniation are included in this review. Medical complications, and surgical complications including infection, durotomy, neurological injury, symptomatic re-herniation, and revision surgery are defined and systematically reviewed in detail for incidence, evaluation, and management.

CONCLUSION

This article provides the clinician and surgeon with a review of the evidence-based evaluation and management of surgical complications following disc herniation, offering best practice guidelines for informed discussions with patients in shared decision-making.

Clinical Outcomes after Microdiscectomy for Recurrent Lumbar Disk Herniation: A Single-Center Study

BACKGROUND

Revision discectomy is the principal procedure for recurrent lumbar disk herniation (RLDH). The clinical outcomes after this procedure are as good as or slightly poorer than those produced by primary discectomy. In this study, the clinical outcomes of patients treated with microsurgical discectomy for RLDH were analyzed.

METHODS

We examined 179 patients undergoing lumbar microdiscectomy surgery for RLDH. The visual analogue scale (VAS), Prolo scoring system, and Oswestry Disability Index (ODI) were used for evaluating the improvement of symptoms and functional outcomes.

RESULTS

Among 179 patients, 101 (56%) obtained good and excellent Prolo scores (group 1), while 78 (44%) obtained fair or poor results (group 2). There was no significant difference between the groups regarding age (P=0.515), gender (P=0.545), body mass index (P=0.523), diabetes mellitus (P=0.074), smoking (P=0.100), interval between primary and revision surgeries (P=0.749), and surgical outcomes (P=0. 749). However, significant improvements were achieved in VAS scores for back (P=0.197) and radicular pain (P=0.606), as well as ODI scores (P= 0.000). Based on the findings, only ODI scores showed a significant inter-group difference in the 12-month follow-up (P=0.038).

CONCLUSION

Limited microsurgical discectomy could be considered as the main surgical method in patients with RLDH without overt instabilities.

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.].

Treatment of Recurrent Lumbar Disc Herniation With or Without Fusion in Workers' Compensation Subjects

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine outcomes after reoperation discectomy with or without fusion surgery for recurrent lumbar disc herniation (RLDH) in the workers' compensation (WC) population.

SUMMARY OF BACKGROUND DATA

RLDH is estimated to occur in 7% to 24% of patients after discectomy. There are two main surgical options after reherniation: a revision discectomy (RD), or an RD combined with fusion (RDF).

METHODS

A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with lumbar spine comorbidities, a smoking history, or multilevel surgery were excluded. One hundred two patients had RD alone for RLDH and 196 had RDF procedures. The primary outcome was whether subjects returned to work (RTW).

RESULTS

A total of 298 WC patients met our study criteria, including 230 (77.2%) men and 68 (22.8%) women with an average age of 39.4 years (range 19-66). The RDF group had lower rates of RTW than the RD group (27.0% vs 40.2%; P = 0.03). Multivariate regression analysis showed that reoperation with discectomy and fusion (P = 0.04; odds ratio [OR] = 0.56), psychiatric illness (P < 0.01; OR = 0.19), and opioid analgesic use within 1 month of reoperation (P < 0.01; OR = 0.44) were independent negative predictors of RTW. RDF patients were supplied with opioids for 252.3 days longer (P < 0.01) and incurred $34,914 (31.8%) higher medical costs (P < 0.01) than the RD alone group.

CONCLUSION

We analyzed outcomes after operative management of RLDH in the WC population. WC patients receiving RDF had lower RTW rates, higher costs, and a longer duration of postoperative opioid use than those receiving RD alone. This information allows for informed patient management decisions and suggests that fusion should be reserved for patients with clear indications for its use. We are unable to conclude what treatment method is best, but rather we provide a baseline for future studies.

LEVEL OF EVIDENCE

3.

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.

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.

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.

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.

Recurrent Lumbar Disc Herniation: Results of Revision Surgery and Assessment of Factors that May Affect the Outcome. A Non-Concurrent Prospective Study

STUDY DESIGN

Non-concurrent prospective study.

PURPOSE

To determine the functional outcome after open 'fragment' discectomy for recurrent lumbar disc herniation, and to analyze the factors that may affect the outcome.

OVERVIEW OF LITERATURE

Literature search revealed only four studies where the factors affecting the outcome of a revision surgery for recurrent disc herniation have been evaluated. None of these studies analyzed for diabetes, disc degeneration and facet arthropathy. We have analyzed these features, in addition to the demographic and clinical factors.

METHODS

Thirty-four patients who underwent the procedure were followed up for an average period of 27.1 months. The Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) were used to assess the functional outcome. Age, gender, smoking, diabetic status, duration of recurrent symptoms, the side of leg pain, level and type of disc herniation, degree of disc degeneration on magnetic resonance imaging, and facet joint arthritis before first and second surgeries, were analyzed as factors affecting the outcome.

RESULTS

The average Hirabayashi improvement in JOA was 56.4%. The mean preoperative ODI was 74.5% and the mean ODI at final follow-up was 32.2%, the difference being statistically significant (p<0.01). Patients with diabetes, all of whom had poor long term glycemic control, were found to have a poor outcome in terms of ODI improvement (p=0.03).

CONCLUSIONS

Open fragment discectomy is a safe and effective surgical technique for the treatment of recurrent disc herniation. However, patients with uncontrolled diabetes may have a less favorable outcome.

CT-guided nucleoplasty with radiofrequency energy for the treatment of lumbar disk herniation

STUDY DESIGN

A clinical randomized controlled trial.

OBJECTIVE

This study sought to compare the clinical effectiveness of CT-guided nucleoplasty, CT-guided nucleoplasty combined with nerve root injection, and CT-guided transforaminal lumbar epidural injections in treating patients with contained lumbar disk herniation and leg pain, which are caused by radicular encroachment.

SUMMARY OF BACKGROUND DATA

Lumbar disk herniation is the most common cause of nerve root pain. The conservative treatment is proved to be effective for the majority of these patients, and the remaining patients are not ideal surgical candidates. Studies have found that minimally invasive percutaneous disk procedures may be preferable to open surgery in certain clinical situations. However, nucleoplasty in treating contained lumbar disk herniation and leg pain caused by radicular encroachment is still a controversy.

DESIGN

A total of 97 patients with leg pain and MRI evidence of small-sized or medium-sized herniated disks correlating with the symptoms participated in the study. The patients were randomly allocated into 3 groups: the CT-guided nucleoplasty group (N=33), the CT-guided nucleoplasty with nerve root injection group (N=35), and CT-guided transforaminal lumbar epidural injections group (N=29). Numeric Rating Scale (NRS) pain score and Oswestry Disability Index (ODI) values were applied at pretreatment and 1 week, 1 month, 3 months, and 12 months at posttreatment.

RESULTS

There were statistically significant decreases (P=0.000) in the NRS and ODI scores for all posttreatment time points when compared with the pretreatment values in all the 3 groups. The average NRS and ODI results for the transforaminal lumbar epidural injections group were significantly higher than those for the other 2 groups at 3 and 12 months posttreatment (P<0.05). The combination of nucleoplasty with nerve root injection produced a significantly greater reduction in the NRS and ODI scores when compared with nucleoplasty at 1 week (P=0.000 for NRS and P=0.004 for ODI) and 1 month (P=0.000 for NRS and P=0.007 for ODI) after the treatment.

CONCLUSIONS

The results of this study suggest that CT-guided nucleoplasty with radiofrequency energy is a relative effective and safe technique for treating leg pain caused by radicular encroachment. Furthermore, nucleoplasty combined with nerve root injection had achieved a significant greater improvement in pain management and functional level in short term (within 1 mo) after treatment than nucleoplasty alone.

A comparative study of the outcomes of primary and revision lumbar discectomy surgery

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side.

A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI).

There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05).

Revision discectomy can give results that are as good as those seen after primary surgery.

Cite this article: Bone Joint J 2013;95-B:90–4.

The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-up

PURPOSE

The purpose of this study was to evaluate longer-term efficacy over a two-year follow-up of coblation nucleoplasty treatment for protruded lumbar intervertebral disc.

METHODS

Forty-two cases of protruded lumbar intervertebral disc treated by coblation nucleoplasty followed-up for two years were analysed. Relief of low back pain, leg pain and numbness after the operation were assessed by visual analogue pain scale (VAS). Function of lower limb and daily living of patients were evaluated by the Oswestry Disability Index (ODI).

RESULTS

Operations were performed successfully in all cases. Three patients had recurrence within a week of the procedure. Evaluation of the 42 patients demonstrated significant improvement rate of VAS: defined as 66.2% in back pain, 68.1% in leg pain, and 85.7% in numbness at one-week after the operation; 53.2%, 58.4%, 81.0% at one-year; and 45.5%, 50.7%, 75.0% at two-year follow-up. One week after the operation, obvious amelioration occurred in all the patients, but the tendency decreased. Before operation, the mean value of ODI was 68.2 ± 10.9%. The value at one week was 28.6 ± 8.2%; one-year at 35.8 ± 6.5%; and two-years at 39.4 ± 5.8%.

CONCLUSION

Coblation nucleoplasty may have satisfactory clinical outcomes for treatment of protruded lumbar intervertebral disc for as long as two-year follow-up, but longer-term benefit still needs verification.