Clinical factors of importance for outcome after lumbar disc herniation surgery: long-term follow-up

Lumbar Disc Herniation

BACKGROUND

Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines.

RESULTS

Symptoms resolve in 60% to 80% of patients with herniated discs in 6-12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6-12 weeks of conservative treatment are recommended in the absence of significant neu - rologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis).

CONCLUSION

Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score.

Changes in Disc Height as a Prognostic Factor in Patients Undergoing Microscopic Discectomy

OBJECTIVE

Some patients with disc herniation who underwent discectomy complain of back pain after surgery and are unsatisfied with the surgical results. This study aimed to evaluate the relationship between preoperative disc height (DH), postoperative DH, and pain score 12 months after surgery in patients who underwent microdiscectomy for herniated lumbar disc.

METHODS

This study enrolled patients who underwent microdiscectomy at a medical center between January 2012 and December 2020. Patients with X-ray or computed tomography and pain score assessment (visual analog scale score) prior to surgery, immediately post-op, and at 1, 6, and 12 months after surgery were included. The DH index was defined as DH/overlying vertebral width. The DH ratio was defined as the postoperative DH/preoperative DH. Simple linear regression and multivariate linear regression analyses were applied to assess the correlation between DHs and leg pain scores 12 months after surgery.

RESULTS

A total of 118 patients who underwent microdiscectomy were included. DH decreased up to 12 months after surgery. The DH ratio at 1, 6, and 12 months after discectomy showed a significant positive correlation with the pain scores at 12 months after discectomy (1 month : p=0.045, B=0.52; 6 months : p=0.008, B=0.78; 12 months : p=0.005, B=0.69). Multivariate linear regression analysis revealed that the level of surgery, sex, age, and body mass index had no significant relationship with back pain scores after 12 months.

CONCLUSION

In patients who underwent microdiscectomy, the DH ratios at 1, 6, and 12 months after surgery were prognostic factors for back pain scores at 12 months after surgery. Aggressive discectomy is recommended for lower postoperative DH ratios and Visual analog scale scores, leading to improved patient satisfaction.

Altered central pain processing in patients with degenerative lumbar diseases and its association with low physical activity levels after lumbar spinal surgeries: a retrospective cohort analysis

PURPOSE

To investigate the occurrence of altered central pain modulation in patients with degenerative lumbar diseases (DLDs) and to analyze its association with physical activity (PA) 3 years after lumbar decompression and fusion.

METHODS

Preoperative assessments of pressure pain thresholds (PPTs), temporal summation (TS), conditioned pain modulation (CPM) and pain were, respectively, recorded in 304 patients. These patients further underwent International Physical Activity Questionnaire (IPAQ) and both pain-related and psychological assessments 3 years post-operation.

RESULTS

Preoperatively, the patients had lower PPTs in both local pain and pain-free areas and lower CPM and higher TS in pain-free areas than healthy subjects (P < 0.05). Postoperatively, 53.9% (164/304) patients showed PA below healthy-related thresholds (< 600 MET min/w). Low PA group showed a greater postoperative weight gain and bone loss and a higher postoperative prevalence of both moderate anxiety and marginal depression than high PA group (P < 0.05). All covariates with differences between the high and low PA groups were subjected to multivariate logistic regression, and long preoperative disease duration, low preoperative PPT in pain-free area, high preoperative TS, revision surgery, severe postoperative low back pain and significant postoperative pain catastrophizing thought were independently associated with low postoperative PA (P < 0.05).

CONCLUSIONS

This study supports the existence of central sensitization (CS) caused by abnormal central pain modulation in DLDs. Pre-existing CS in these patients may be associated with low PA after lumbar surgeries, and this low-activity lifestyle may predispose patients to multiple adverse health outcomes. Preoperative dynamic quantitative sensory testing may provide information for the identification of at-risk patients.

Magnetic Resonance Imaging Evaluation of Multifidus Muscle in Patients with Low Back Pain after Microlumbar Discectomy Surgery

Cross-sectional area (CSA) and signal intensity ratio (SIR) of the multifidus muscle (MFM) on magnetic resonance imaging (MRI) was used to evaluate the extent of injury and atrophy of the MFM in patients with negative treatment outcomes following microlumbar discectomy (MLD). Negative treatment outcome was determined by pain score improvement of <50% compared to baseline. Patients in groups 1, 2, and 3 were evaluated at <4 weeks, 4-24 weeks, and >24 weeks postoperatively, respectively. The associations between the follow-up, surgery time and the changes in the MFM were evaluated. A total of 79 patients were included, with 22, 27, and 30 subjects in groups 1, 2, and 3, respectively. The MFM SIR of the ipsilateral side had significantly decreased in groups 2 (p = 0.001) and 3 (p < 0.001). The ipsilateral MFM CSA significantly decreased postoperatively in groups 2 (p = 0.04) and 3 (p = 0.006). The postoperative MRI scans found significant MFM changes on the ipsilateral side in patients with negative treatment outcomes regarding pain intensity following MLD. As the interval to the postoperative MRI scan increased, the changes in CSA of the MFM and change in T2 SIR of the MFM showed a tendency to increase.

Prevalence of Chronic Pain After Spinal Surgery: A Systematic Review and Meta-Analysis

Degenerative disc disease and low back pain are common challenges that persist even after a discectomy. However, characterizations and quantifications of these illnesses from the patients' perspective are insufficient. We aimed to perform a systematic review of the literature and meta-analysis to determine the frequency of chronic pain after spinal surgery. We searched MEDLINE (PubMed), Google Scholar, and the Saudi Digital Library to retrieve research articles describing the frequency of persistent back pain, reoccurring disc herniation, and undergoing another operation following primary lumbar discectomy. We excluded articles that did not disclose the proportion of patients who experienced ongoing back or leg pain for over six months after the operation. We included 16 studies evaluating 85,643 patients. The pooled prevalence of persistent pain was 14.97% (95% confidence interval: 12.38-17.76). With all advancements in technology and operation techniques, many patients (14.97%) still have failed back surgery syndrome. Appropriate preoperative communication and multidisciplinary and coordinated treatment strategies yielded the best results.

Does Central Sensitization Influence Outcomes of Lumbar Discectomy Surgery in Patients With Lumbar Disc Herniation? A Multicenter Prospective Study

STUDY DESIGN

Multicenter prospective study.

OBJECTIVE

Patients with central sensitization (CS) are reported to be at high risk of poor outcomes after spinal surgery. However, the influence of CS on surgical outcomes for lumbar disc herniation (LDH) remains unknown. This study aimed to examine the association between preoperative CS and surgical outcomes in LDH patients.

METHODS

A total of 100 consecutive patients with LDH (mean age 51.2) who underwent lumbar surgery were included in this study. The extent of CS was evaluated using the central sensitization inventory (CSI), a screening tool for CS-related symptoms. The patients completed the following CSI and clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire (JOABPEQ), and Oswestry Disability Index (ODI). The association between preoperative CSI scores, and preoperative and postoperative COAs was analyzed, and the postoperative changes were statistically evaluated.

RESULTS

The preoperative CSI score significantly decreased 12 months postoperatively. Preoperative CSI scores showed a significant correlation with most COAs; however, a significant correlation was only identified in the social function and mental health domains of JOABPEC postoperatively. Higher preoperative CSI showed worse preoperative COAs; however, all COAs significantly improved regardless of CSI severity. There were no significant differences in any COAs among the CSI severity groups 12 months postoperatively.

CONCLUSIONS

The results of this study showed that lumbar surgeries significantly improved the COAs regardless of preoperative severity of CS in patients with LDH.

Favorable long-term health-related quality of life after surgery for lumbar disc herniation in young adult patients

BACKGROUND

Lumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them.

METHODS

A total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients' baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome.

RESULTS

The mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender-matched general population sample (difference 0.02, 95% CI - 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013).

CONCLUSION

Patients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender-matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.

Preoperative ODI and Intake of Analgesics Predict Outcome after Lumbar Microdiskectomy: Results from a Prospective Register

BACKGROUND

 Lumbar disk herniation (LDH) typically causes leg pain and neurologic deficits, but can also be a source of low back pain (LBP). Lumbar microdiskectomy (LMD) is among the most common neurosurgical procedures to relieve radicular symptoms. It is important for both surgeon and patient to understand potential predictors of outcome after LMD. The aim of this study was to investigate if the presence and intensity of preoperative LBP, the ODI score, and analgesic intake can predict the outcome of patients undergoing LMD.

METHODS

 This is a single-center retrospective study based on the analysis of prospectively acquired data of patients in the SwissDisc Registry. A total of 685 surgeries on 640 patients who underwent standardized LMD at our institution to treat LDH were included in this study. We performed multivariable linear regression analysis to determine preoperative predictors for patient outcomes based on the Oswestry Disability Index (ODI) scores, recorded on average 39.77 (±33.77) days after surgery.

RESULTS

 Our study confirmed that surgery overall improves patient degree of disability as measured by ODI score. Following model selection using Aikake Information Criterion (AIC), we observed that higher preoperative ODI scores (β: 0.020 [95% CI: 0.008 to 0.031]) and higher number of analgesic medication usage by patients prior to surgery (β: 0.236 [95% CI: 0.057 to 0.415]) were both associated with an increased postoperative ODI score.

CONCLUSION

 LDH surgery generally improves patient degree of disability. The analysis of patients with a high preoperative ODI score and increased intake of analgesics before surgery predicted a worsening of patients' disability after LMD in this subgroup.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Effect of Preoperative Parameters on Outcomes of Lumbar Microdiscectomy: A Retrospective Analysis

Objective  The objective of this study was to characterize the effect of preoperative variables on outcomes after minimally invasive lumbar microdiscectomy.

Materials and Methods  This study was done from January 2019 to May 2020. This included medical records of all patients who were diagnosed with lumbar disc herniation and treated surgically by microdiscectomy. The medical records of such patients from January 2016 to January 2018 were included in this study. Postoperative outcomes were analyzed by Oswestry Disability Index (ODI), visual analog scale (VAS) leg, and VAS back scores, that were noted at preoperative, immediate postoperative, 6 months postoperative, and 1 year after operation. Difference in each outcomes score was calculated postoperatively with respect to the preoperative readings. Minimal clinically important difference was further calculated for each outcome score.

Results  On analyzing the ODI, VAS leg, and VAS back scores across various age groups, genders, body mass indexes, addictions, comorbidities, preoperative epidural steroid injection and physiotherapy, and levels of disc herniation, and it was found that there was no statistically significant difference across these categories. However, the ODI scores (∼ ODI) at all time points showed greater difference in the younger age group, that is, 18 to 30 years, males, nonsmokers, those with symptom duration of less than 6 weeks, and with disc herniation at L3 to L4.

Conclusion  The findings of this study will help to properly counsel patients with regard to the factors mentioned above so as to set realistic expectations, to help improve the outcomes, and for appropriate surgical decision making, that is, at which point should a surgical intervention be made.

Predictive Factors of Successful Return to Work Following Discectomy

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To identify modifiable factors associated with successful return to work 12 weeks following discectomy. Lumbar disc herniation is a common cause of sciatica and sick leave. This presents an economic burden to the individual and the society.

METHODS

Data from DaneSpine on a consecutive cohort of patients operated due to lumbar disc herniation during a 3-year period was identified and merged with data from the Ministry of Employment's register on public welfare payments. Data on welfare payments 2 years prior to the date of operation and 1 year postoperative was included. Patients were considered to be on sick leave if they received welfare payments for the week. Patients are considered to have returned to work if they did not receive public welfare payments for a 4-week period.

RESULTS

Of 1134 patients meeting inclusion criteria, 98.5% had complete preoperative surgical data available. Postoperatively, 79.1% of the patients returned to the work within 12 weeks. Physically demanding jobs, low preoperative EQ5D score, and long duration of sick leave prior to surgery were associated negatively with return to work at 12 weeks.

CONCLUSION

The results of this study indicate that patients who have a longer duration of sick leave have a physically demanding job and are in a poor health are more likely not to return to work by 12 weeks after surgery for lumbar disc herniation. Future studies are needed to determine if earlier referral to a surgeon leads to an earlier return to work.

The association between changes in multifidus muscle morphology and back pain scores following discectomy surgery for lumbar disc herniation: a systematic review and meta-analysis

PURPOSE

To evaluate the impact of discectomy on back muscles (e.g. multifidus muscle (MM)) morphology in patients with lumbar disc herniation (LDH) following discectomy surgery, address the association of back muscles morphology with pain score preoperatively and post-operatively, and investigate the relationships between the changes from pre- to post-operative back muscles measurements and pain score (primary outcome) and disability score (secondary outcome) change following discectomy if any.

METHODS

We searched three online databases for randomized controlled trials (RCTs) and observational studies. In LDH patients, eligible for discectomy surgery, pre- and post-operative and the changes from pre- to post-operative of back and/or leg pain with Visual Analogue Scale (VAS) and multifidus muscle morphology, were considered as primary outcomes. Cochrane Risk-of-Bias 2 tool and Newcastle-Ottawa Scale (NOS) were used to assess the methodological quality of RCTs and observational studies, respectively. Standardize mean difference (SMD) with 95% confidence intervals (CI) was evaluated. A meta-regression analysis was conducted. GRADE approach was used to summarize the strength of evidence.

RESULTS

One RCT and five observational studies were included in the analysis of 489 patients with LDH undergoing discectomy surgery. The mean overall follow-up was 64.9 weeks (6 to 148.7 weeks). There was a significant negative relationship between the change from pre- to post-operative cross-sectional area (CSA) in MM and change in VAS back pain [regression coefficient = -0.01, (95% CI = -0.02, -0.01), p = 0.044] after discectomy surgery. No significant relationship between preoperative CSA in MM and preoperative/post-operative clinical (any of the follow-up periods) scores could be established.

CONCLUSION

The results of this study found very low-quality grade evidence for an association between higher reduction of CSA in MM and less reductions of back pain scores following discectomy surgery for patients with LDH. Due to the heterogeneity and methodological limitations, further studies will improve understanding and aid preoperative counselling.

Low-Dose Collagenase Chemonucleolysis Combined with Radiofrequency in the Treatment of Lumbar Disc Herniation: A 10-Year Retrospective Study

Objective

This study explored the 10-year efficacy, safety, and prognostic factors of low-dose collagenase chemonucleolysis (CCNL) combined with radiofrequency (RF) in the treatment of lumbar disc herniation (LDH).

Methods

The data of 167 LDH patients were collected. Modified MacNab criteria, Numerical Rating Scale (NRS), and Japanese Orthopedic Association (JOA) scores were, respectively, used to evaluate patients' excellent and good rates, pain degree, and nerve function. The preoperative and 10-year postoperative patients' pain, numbness, and muscle weakness were compared. Patients' complications in perioperative period, recurrent/reappeared LDH, and reoperations were recorded. Finally, the independent risk factors affecting the long-time efficacy were assessed.

Results

A total of 126 patients were included. The patients' excellent and good rates were 86.51%–92.86% with no significant difference (P > 0.05). Postoperative NRS and JOA scores significantly improved (P < 0.01), most obvious within 6 months postoperatively. At 10 years postoperatively, 65.08%, 83.95%, and 93.02% of patients' pain, numbness, and muscle weakness were completely relieved (P < 0.05). Perioperative complications occurred in three patients with the rate of 2.38%. Recurrent/reappeared LDH patients were 11 with the ratio of 8.73%; nine of them underwent reoperations with the rate of 7.14%. And patients' probability of fair and poor efficacy at 10 years postoperatively with the course of disease >12 months and the responsibility disc ≥2 were, respectively, 6.005 and 4.227 times that of patients with the course of disease ≤12 months and the responsibility disc = 1 (P < 0.05).

Conclusion

The combined treatment is effective and safe in the long term. A course of disease >12 months and responsibility disc ≥2 independently reduce efficacy, and a course of disease >12 months has a more significant impact.

Return to work after lumbar disc herniation surgery: an occupational cohort study

Background and purpose - Lumbar disc herniation is a common surgically treated condition in the working-age population. We assessed health-related risk factors for return to work (RTW) after excision of lumbar disc herniation. Previous studies on the subject have had partly contradictory findings.Patients and methods - RTW of 389 (n = 111 male, n = 278 female; mean age 46 years, SD 8.9) employees who underwent excision of lumbar disc herniation was assessed based on the Finnish Public Sector Study (FPS). Baseline information on occupation, preceding health, and health-risk behaviors was derived from linkage to national health registers and FPS surveys before the operation. The likelihood of RTW was analyzed using Cox proportional hazard univariable and multivariable modelling.Results - 95% of the patients had returned to work at 12 months after surgery, after on average 78 days of sickness absence. Faster RTW in the univariable Cox model was associated with a small number of sick leave days (< 30 days) before operation (HR 1.3, 95% CI 1.1-1.6); high occupational position (HR 1.6, CI 1.2-2.1); and age under 40 years (HR 1.5, CI 1.1-1.9). RTW was not associated with sex or the health-related risk factors obesity, physical inactivity, smoking, heavy alcohol consumption, poor self-rated health, psychological distress, comorbid conditions, or purchases of pain or antidepressant medications in either the univariable or multivariable model.Interpretation - Almost all employees returned to work after excision of lumbar disc herniation. Older age, manual job, and prolonged sick leave before the excision of lumbar disc herniation were risk factors for delayed return to work after the surgery.

The association between pain scores and disc height change following discectomy surgery in lumbar disc herniation patients: a systematic review and meta-analysis

PURPOSE

To evaluate the impact of discectomy on disc height (DH) in lumbar disc herniation (LDH) patients following discectomy surgery and address the association of DH change with pain score change.

METHODS

We searched three online databases for randomized controlled trials (RCTs) and observational studies. In LDH patients, eligible for discectomy surgery, the changes in pre- and post-operative back and/or leg pain score and DH and/or disc height index (DHI) were considered as primary outcomes. Standardize mean difference (SMD) and their 95% confidence intervals (CI) were evaluated. The GRADE approach was used to summarize the strength of evidence.

RESULTS

Two RCTs and sixteen observational studies were included in the analysis of 893 LDH patients undergoing discectomy surgery. The mean overall follow-up was 211 weeks. There was a statistically significant reduction in DH (14.4% reduction: SMD =  -0.74 (95% CI =  -0.86 to -0.61)) and DHI (11.5% reduction: SMD =  -0.81 (95% CI =  -0.97 to -0.65)) following discectomy surgery. There was a significant relationship between the reduction in DH and decrease in back pain score (r = 0.68, (95% CI = 0.07-1.30), p = 0.034) after discectomy surgery. No significant relationship between DHI change and decrease in clinical pain scores (back and leg pain) could be established.

CONCLUSION

Discectomy surgery produces significant and quantifiable reductions in DH and DHI. Additionally, the reduction in DH is responsible for the decrease in back pain scores post discectomy, but further studies will improve understanding and aid preoperative counselling.

Do Markers of Inflammation and/or Muscle Regeneration in Lumbar Multifidus Muscle and Fat Differ Between Individuals with Good or Poor Outcome Following Microdiscectomy for Lumbar Disc Herniation?

STUDY DESIGN

Observational study.

OBJECTIVE

The aim of this study was to evaluate whether inflammatory and/or muscle regeneration markers in paraspinal tissues (multifidus muscle/fat) during microdiscectomy surgery in patients with lumbar disc herniation (LDH) with radiculopathy, differ between individuals with good or poor outcome.

SUMMARY OF BACKGROUND DATA

Structural back muscle changes, including fat infiltration, muscle atrophy, and fiber changes, are ubiquitous with LBP and are thought to be regulated by inflammatory and regeneration processes. Muscle changes might be relevant for recovery after microdiscectomy, but a link between expression of inflammatory and muscle regeneration genes in paraspinal tissues and clinical outcome has not been tested.

METHOD

Paraspinal tissues from deep multifidus muscles and fat (intramuscular, sub-cutaneous, epidural) were harvested from twenty-one patients with LDH undergoing microdiscectomy surgery. Quantitative polymerase chain reaction (qPCR) measured expression of 10 genes. Outcome was defined as good (visual analogue scale (VAS) low back pain (LBP)+) or poor (VAS LBP-) by an improvement of >33% or ≤33% on the pain VAS, respectively. Good functional improvement was defined as 25% improvement on the physical functioning scale (PFS).

RESULTS

Brain-derived neurotrophic factor expression in deep multifidus was 91% lower (P = 0.014) in the VAS LBP- than VAS LBP+ group. Expression of interleukin-1β in subcutaneous fat was 48% higher (P = 0.026) in the VAS LBP- than VAS LBP+ group. No markers differed based on PFS.

CONCLUSION

Results show a relationship between impaired muscle regeneration profile in multifidus muscle and poor outcome following microdiscectomy for LDH. Inflammatory dysregulation in subcutaneous fat overlying the back region might predict poor surgical outcome.Level of Evidence: 4.

A Prospective Observational Study of Return to Work after Single Level Lumbar Discectomy

OBJECTIVE

Lumbar disc herniation (LDH) is a common disease, and lumbar discectomy (LD) is a common neurosurgical procedure. However, there is little previous data on return to work (RTW) after LD. This study investigated the period until the RTW after LD prospectively. Clinically, the pain state at the time of RTW also checked. RTW failure rate 6 months after surgery also investigated.

METHODS

Patients with daily/regular jobs undergoing LD between September 2014 and December 2018 were enrolled. Pain was assessed by the Oswestri Disability Index (ODI) and the Numeric Rate Scale (NRS). Employment type was divided into self-employed, regular and contracted. Monthly telephone interviews were conducted to check RTW status and self-estimated work capability after surgery.

RESULTS

Sixty-seven patients enrolled in this study. Three patients failed to RTW, and three others resigned within 6 months after surgery. The preoperative NRS and ODI were 7.2±1.2 and 22.1±7.9, respectively. The average time to RTW was 5.1±6.0 weeks. At RTW, NRS was 1.5±1.8 and ODI was 6.3±3.9. Amongst patients that successfully returned to work were 16 self-employed workers, 42 regular employees, and three contracted workers. The time to RTW of self-employed, regular, and contracted workers were 5.9±8.8, 4.2±4.3 and 13.3±2.3 weeks, respectively (p=0.011). Thirty-six of the patients that returned to work self-reported a 22.8±15.6% reduction in work capability at 6 months.

CONCLUSION

RTW may vary depending on the employment status. In this study, we found that while employment type may affect the length to RTW, most patients were able to RTW and >40% of patients reported no loss of work capabilities 6 months postoperatively, hopefully alleviating some patient hesitation towards LD.

Surgical outcomes of full endoscopic spinal surgery for lumbar disc herniation over a 10-year period: A retrospective study

Objective

Full endoscopic lumbar discectomy (FELD) for lumbar disc herniation (LDH) has become popular in recent years. Previous studies have proven the efficacy, but few have discussed the possible risk factors of poor outcome. In this study, we reviewed patients who underwent FELD at Changhua Christian Hospital in the past 10 years and sought to identify factors associated with poor surgical outcomes and re-operations.

Methods

We retrospectively reviewed records from mid-2009 to mid-2018. Patients had undergone FELD and follow-up for ≥1 year were included. Factors included in the outcome evaluations were age, sex, surgical time, body mass index, surgical methods, disc herniation type, extension of herniation, degree of canal compromised, disc degenerative grade, smoking and alcohol use, surgical lumbar level, symptom duration, Oswestry low back disability index, and visual analog scale score. We had evolved from inside-out methods to outside-in methods after 2016, thus, we included this factor in the analysis. The primary outcomes of interest were poor/fair MacNab score and re-operation.

Results

From mid-2009 to mid-2018, 521 patients met our criteria and were analyzed. The median follow-up was 1685 days (range, 523–3923 days). Thirty-one (6.0%) patients had poor surgical outcomes (fair/poor MacNab score) and 45 (8.6%) patients required re-operation. Prolapsed herniated disc (P < 0.001), higher disc degenerative grade (P = 0.047), higher lumbar level (P = 0.026), longer preoperative symptoms (P < 0.001), and surgery before 2017 (outside-in technique, P = 0.020) were significant factors associated with poor outcomes in univariate analyses. In multivariate analyses, prolapsed herniated disc (P < 0.001), higher disc degenerative grade (P = 0.030), and higher lumbar level (P = 0.046) were statistically significant. The most common adverse symptom was numbness. Factors possibly associated with higher re-operation rate were older age (P = 0.045), alcohol use (P = 0.073) and higher lumbar level (P = 0.069). Only alcohol use showed statistically significant re-operation rates in multivariate analyses (P = 0.035).

Conclusions

For treating LDH by FELD, we concluded that prolapsed disc, higher disc degenerative grade, higher lumbar level, and longer preoperative symptom duration were possibly associated with unsatisfactory surgical outcomes (poor/fair MacNab score). The outside-in technique might be superior to the inside-out technique. Older age and alcohol use might be associated with a higher re-operation rate.

Predictors of Treatment Success Following Limited Discectomy With Annular Closure for Lumbar Disc Herniation

Background

Previous studies have demonstrated bone-anchored annular closure to significantly reduce reherniation and reoperation rates after lumbar discectomy in patients with large annular defects. It is important to identify the prognostic factors that may be associated with successful treatment. This study aimed to identify predictors of treatment success in patients with lumbar disc herniation treated with limited microdiscectomy supplemented by a bone-anchored annular closure device (ACD).

Methods

This study was a retrospective analysis of 133 consecutive patients with lumbar disc herniation treated with the ACD. Treatment success was defined as ≥24% improvement in visual analog scale (VAS) for back pain, ≥39% improvement in VAS leg pain, and ≥33% in the Oswestry Disability Index (ODI), with the raw ODI score ≤48. Success was calculated at 3, 6, and 12 months after surgery. Potentially predictive outcomes included patient characteristics, operative data, and imaging outcomes, such as disc, facet, and end plate morphology. Logistic regression was used to determine the significant predictive factors for treatment success.

Results

After 3, 6, and 12 months, 97 of 131 (74%), 104 of 129 (81%), and 112 of 126 (89%) patients, respectively, achieved the success criteria. At 3 months follow-up, a higher proportion of younger (17-40 years) versus older (41-65 years) patients met the success criteria (P = .025). On the basis of logistic regression, the following factors were significantly associated with treatment success at 1 or more of the follow-up time points: sex (male), lower body mass index, higher baseline pain and ODI scores, lower grade preoperative disc degeneration, and the absence of a postoperative complication. The rates of index-level recurrent herniation and reoperation were 1.5% and 3.0%, respectively.

Conclusions

This real-world evidence supports a promising benefit-risk profile for augmenting limited microdiscectomy with a bone-anchored ACD and provides some insights into the patient populations that may have a greater chance of realizing significant improvements in pain and function.

Level of Evidence

2 (Cohort study).

Return to work after surgery for lumbar disc herniation, secondary analyses from a randomized controlled trial comparing supervised rehabilitation versus home exercises

BACKGROUND CONTEXT

Patients undergoing lumbar discectomy are typically referred for postoperative rehabilitation. However, evidence regarding effectiveness of postoperative rehabilitation to improve surgical outcome and hasten return to work is scarce with conflicting results in the published literature.

PURPOSE

This study investigates the effect of postoperative rehabilitation on return to work, duration of sick leave and working ability after surgery for lumbar disc herniation.

STUDY DESIGN/SETTING

Single center randomized controlled trial.

PATIENT SAMPLE

Patients scheduled for primary discectomy due to lumbar disc herniation were included in the study.

OUTCOME MEASURES

Self-reported measures included working ability, work status, and job type defined by the International Standard Classification of Occupations. All outcomes including duration of sick leave were obtained from follow-up questionnaires at 1 and 2 years after surgery.

METHODS

This is a secondary analysis from a randomized controlled trial comparing patients who were referred to rehabilitation at the municipal facility starting 4-6 weeks postoperative (REHAB) and patients sent home after surgery without any planned rehabilitation course (HOME). Linear regression was performed to identify baseline characteristics associated with duration of sick leave.

RESULTS

One hundred forty-six patients were included and equally distributed between the groups. Follow-up rate was 78% after 1 and 2 years. Both groups had a similar postoperative sick leave period of approximately 9 weeks. After 1 year 79% had returned to work in the HOME-group versus 74% in the REHAB-group, which was not statistically significant. Working ability improved from baseline to 1 year in both groups and this improvement was sustained at 2-year follow-up. Stepwise linear regression showed that preoperative duration of leg pain and working ability was associated with duration of postoperative sick leave.

CONCLUSIONS

Referral for unstandardized municipal rehabilitation does not affect duration of postoperative sick leave, return to work or working ability in patients recovering after surgery for lumbar disc herniation. Duration of preoperative leg pain and preoperative working ability was significantly associated with the duration of postoperative sick leave.

Predictors of satisfaction after lumbar disc herniation surgery in elderly

Background

The aim of this study was to evaluate satisfaction and factors associated with satisfaction in elderly undergoing lumbar disc herniation surgery.

Methods

In the national Swedish register for spinal surgery (SweSpine) we identified 2095 patients aged > 65 years (WHO definition of elderly) whom during 2000–2016 had undergone LDH surgery and had pre- and one-year postoperative data (age, gender, preoperative duration and degree of back- and leg pain, quality of life (SF-36) and one-year satisfaction (dissatisfied, uncertain, satisfied). We utilized a logistic regression model to examine preoperative factors that were independently associated with low and high satisfaction and after LDH surgery.

Results

One year after surgery, 71% of the patients were satisfied, 18% uncertain and 11% dissatisfied. Patients who were satisfied were in comparison to others, younger, had shorter preoperative duration of leg pain, higher SF-36 mental component summary and more leg than back pain (all p < 0.01). Patients who were dissatisfied were compared to others older, had longer preoperative duration of leg pain and lower SF-36 scores (all p < 0.01). 81% of patients with leg pain up to 3 months were satisfied in comparison with 57% of patients with leg pain > 2 years (p < 0.001).

Conclusion

Only one out of ten elderly, is dissatisfied with the outcome of LDH surgery. Age, preoperative duration of leg pain, preoperative SF 36 score, and for satisfaction also dominance of back over leg pain, are in elderly factors associated to good and poor subjective outcome after LDH surgery.

Preoperative Patient Reported Outcomes Measurement Information System Scores Assist in Predicting Early Postoperative Success in Lumbar Discectomy

STUDY DESIGN

Retrospective review of prospective data.

OBJECTIVE

Determine whether patient reported outcome (PRO) data collected prior to lumbar discectomy predicts achievement of a minimal important difference (MID) after surgery. Compare ability of PRO and clinical information to predict achievement of MID in short term follow-up after discectomy.

SUMMARY OF BACKGROUND DATA

We investigated the ability of patient reported outcomes measurement information system (PROMIS) and clinical factors at the preoperative time point to determine patients achieving MID after surgery.

METHODS

PROMIS physical function (PF), pain interference (PI), and depression (D) scores were assessed at evaluation and follow-up for consecutive visits between February, 2015 and September, 2017. Patients with preoperative scores within 30 days prior to surgery and with scores 40 days or more after surgery who completed all PROMIS domains were included yielding 78 patients. MIDs were calculated using a distribution-based method. A multivariate logistic regression model was created, and the ability to predict achieving MID for each of the PROMIS domains was assessed. Cut-off values and prognostic probabilities were determined for this model and models combining preoperative PROMIS with clinical data.

RESULTS

Preoperative PROMIS scores modestly predict reaching MID after discectomy (areas under the curve [AUC] of 0.62, 0.68, and 0.76 for PF, PI, and D, respectively). Preoperative cut-off scores show patients who have PF and PI scores more than 2 standard deviations, and D more than 1.5 standard deviations worse-off than population mean are likely to achieve MID. The combination of PROMIS with clinical data was the most powerful predictor of reaching MID with AUCs of 0.87, 0.84, and 0.83 for PF, PI, and D.

CONCLUSION

PROMIS scores before discectomy modestly predict improvement after surgery. Preoperative PROMIS combined with clinical factors was more predictive of achieving MID than either clinical factors or PROMIS alone.

LEVEL OF EVIDENCE

3.

Postural instability after lumbar spinal surgery: are there any predictive factors? A case control study

Background

The surgical spinal degenerative pathology mainly concerns the herniated intervertebral disks. Surgery is indicated when the pain becomes chronic and intense, and when motor signs appear. The results are positive in about 90% of cases, leading to the solution of the problem. However, an estimated percentage of 4% to 20% reported residual pain and postural instability after the surgical treatment of discectomy.

Method

We have examined a sample of patients, retrospectively registered, undergoing surgical treatment for degenerative lumbar disease. Some of them developed postural instability. They were subjected to cycles of postural gymnastics. Postural gymnastics has proved to be a tool capable of solving unstable post-surgical posture. It included an exercise of breathing, one or two of muscular distension, one of muscular reinforcement, and one of postural correction. We used an evaluation form we created in agreement with the physiatrist for postural exercises that was based on some basic parameters such as muscle and respiratory function. At each cycle, a score was attributed to the performance of muscular and respiratory exercise to evaluate the function and therefore the degree of instability (1–3 = mild, 4–7 = medium, 8–10 = severe).

Results

Results were satisfactory, with return to normal posture. The improvement of postural instability has been demonstrated both by the score of the evaluation forms that have highlighted the transition from a state of severe intensity to one of normality and by a clinical aspect, concerning the static and dynamic posture.

Conclusions

The postural instability has a multifactorial genesis, and different mechanisms are involved: the vertebral bone structures and the pelvis, the paraspinal muscular structures, and the nerve structures. These structures are altered after surgery due to predisposing factors, and for the action of conditions acquired as obesity.

Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis

BACKGROUND

Success rates for lumbar discectomy are estimated as 78-95% patients at 1-2 years post-surgery, supporting its effectiveness. However, ongoing pain and disability is an issue for some patients, and recurrence contributing to reoperation is reported. It is important to identify prognostic factors predicting outcome to inform decision-making for surgery and rehabilitation following surgery. The objective was to determine whether pre-operative physical factors are associated with post-operative outcomes in adult patients [≥16 years old] undergoing lumbar discectomy or microdiscectomy.

METHODS

A systematic review was conducted according to a registered protocol [PROSPERO CRD42015024168]. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. radicular pain] to 31/3/2017; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥1-year follow-up, evaluating candidate physical prognostic factors [e.g. leg pain intensity and straight leg raise test], in adult patients undergoing lumbar discectomy/microdiscectomy were included. Two reviewers independently searched information sources, evaluated studies for inclusion, extracted data, and assessed risk of bias [QUIPS]. GRADE determined the overall quality of evidence.

RESULTS

1189 title and abstracts and 45 full texts were assessed, to include 6 studies; 1 low and 5 high risk of bias. Meta-analysis was not possible [risk of bias, clinical heterogeneity]. A narrative synthesis was performed. There is low level evidence that higher severity of pre-operative leg pain predicts better Core Outcome Measures Index at 12 months and better post-operative leg pain at 2 and 7 years. There is very low level evidence that a lower pre-operative EQ-5D predicts better EQ-5D at 2 years. Low level evidence supports duration of leg pain pre-operatively not being associated with outcome, and very low-quality evidence supports other factors [pre-operative ODI, duration back pain, severity back pain, ipsilateral SLR and forward bend] not being associated with outcome [range of outcome measures used].

CONCLUSION

An adequately powered low risk of bias prospective observational study is required to further investigate candidate physical prognostic factors owing to existing low/very-low level of evidence.

Return to work following surgery for lumbar radiculopathy: a systematic review

BACKGROUND CONTEXT

Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.

PURPOSE

We aimed to give an overview of the duration of sick leave and RTW rates after surgery for lumbar radiculopathy and to list predictors of and factors related to RTW.

STUDY DESIGN

A systematic review was carried out.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and SCOPUS. Full-text articles on RTW following surgery for lumbar radiculopathy were included through double-blind screening. Risk of bias was assessed using a modified version of the Downs and Black checklist.

RESULTS

Sixty-three full-text articles (total sample size: 7,100 patients) were included. Risk of bias was scored low to high. Mean duration of sick leave ranged from 0.8 to 20 weeks. Within 0.1-240 months post surgery, 3%-100% of patients resumed work. Most important predictors for work resumption were preoperative work status, presence of comorbidities, age, sex and duration of preoperative symptoms. Duration of sick leave can be predicted by the preoperative level of pain or disability and presence of symptoms of depression, occupational mental stress, and lateral disc prolapse. Furthermore, less invasive surgical techniques were found to result in better RTW outcomes compared with more invasive techniques.

CONCLUSIONS

Diverse results were found for RTW rates and duration of sick leave. Preoperative work status, presence of comorbidities, and several demographic factors were retrieved as predictors of RTW and duration of sick leave.

The Fear Avoidance Model predicts short-term pain and disability following lumbar disc surgery

Objective

To examine the prognostic value of the Fear Avoidance Model (FAM) variables when predicting pain intensity and disability 10-weeks postoperative following lumbar disc surgery.

Methods

We recruited patients scheduled for first-time, single level lumbar disc surgery. The following aspects of the FAM were assessed at preoperative baseline and after 10 postoperative weeks: numeric pain rating scale (0–10) for leg and back pain intensity separately, Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), Beck Depression Inventory (BDI), Oswestry Disability Questionnaire (ODI), and the International Physical Activity Questionnaire (IPAQ). Multivariate regression models were used to examine the best combination of baseline FAM variables to predict the 10-week leg pain, back pain, and disability. All multivariate models were adjusted for age and sex.

Results

60 patients (30 females, mean [SD] age = 40.4 [9.5]) were enrolled. All FAM measures correlated with disability at baseline. Adding FAM variables to each of the stepwise multiple linear regression model explained a significant amount of the variance in disability (Adj. R² = .38, p < .001), leg pain intensity (Adj. R² = .25, p = .001), and back pain intensity Adj. R² = .32, p < .001 at 10-weeks). After adjusting for age and gender, BDI and FABQ-work subscale were the only significant predictors added to each of the prediction models for the 10-week clinical outcome (leg pain, back pain, and ODI).

Conclusion

BDI and FABQ-work subscale variables are associated with baseline pain intensity and disability and predict short-term pain and disability following lumbar disc surgery. Measuring these variables in patients being considered for lumbar disc surgery may improve patient outcome.

Predictive value of Modic type II changes in the choice of surgical treatment of lumbar disc herniation

OBJECTIVE

To evaluate the predictive value of Modic typeII changes on nuclear magnetic resonance (NMR) prior to intervention by discectomy for lumbar disc herniation in patients with radicular symptoms.

MATERIAL AND METHOD

Retrospective descriptive study of 190 patients (58.2% men and 41.8% women) with a mean age of 43.5 years, treated between December 2005 and January 2013. They were divided into group 1, single disc herniation (n=85), and group 2, with disc herniation and changes Modic typeII (n=80). Variables studied: weight, height, handedness, level of injury, previous neurological deficit, postoperative complications, persistent pain and need for posterior lumbar fusion, with a mean of 67 months (group 1: 68.1; group 2: 66.8).

RESULTS

In group 1 there were four hernia recurrences requiring revision surgery and six patients needed lumbar fusion. In group 2, four recurrences were also revised and eight cases requiring arthrodesis were observed. No statistically significant differences were found when comparing the occurrence of relapse (P=.903), the need for subsequent fusion (P=.572) or in the remaining variables.

DISCUSSION

The data obtained and the characteristics of our study, we cannot say that Modic typeII changes were a predictive sign of the result of lumbar discectomy in our study population.

Multidimensional long-term outcome analysis after single-level lumbar microdiscectomy: a retrospective single-centre study

OBJECTIVE

To present multidimensional long-term results after mono-segmental microdiscectomy for lumbar disc herniation (LDH) in a large adult cohort treated at a tertiary care centre.

METHODS

Retrospective study design with Oswestry Disability Index (ODI) questionnaire employed at follow-up. All patients undergoing surgical treatment for single-level LDH between 2003 and 2009 were identified. Electronic patient records and imaging data were analysed.

RESULTS

A total of 939 patients underwent single-level lumbar MD at our institution. Three hundred and seven complete ODI forms (32.7%) were returned at a median follow-up of 48 months. Mean ODI score was 24.04, and mean age was 58 years. Females reported slightly higher ODI scores (25.52 vs. 22.68). Age and ODI score showed statistically significant correlation. Early surgery yielded lower ODI scores with patients faring significantly worse if symptoms persisted for a year or longer (one-way ANOVA, p < 0.001). ODI scores increased sharply even among those operated later than 1 week after symptom onset. Sequestered herniations were associated with significantly lower ODI scores than contained discs on MRI (21.96 vs. 39.89). Surgical complications occurred in 17 cases (5.6%), 82 patients (26.7%) required additional surgery, 58 (18.9%) of those for recurrent disc herniations.

CONCLUSION

Our findings suggest better outcomes with early surgical treatments. Time limits for conservative treatments should be set to avoid the chronification of pain and the worse overall outcomes that go along with belated surgery. Particularly in those with acute onset of pain, sequestered herniations and only mild degrees of immobilization good outcomes are common and surgical treatment appears best if indicated early.

Spinal canal dimensions affect outcome of adolescent disc herniation

PURPOSE

Small spinal canal dimensions play a role in symptomatic adult disc herniation, but its role in adolescent disc herniation has not been investigated with MRI. The goal of this study was to examine retrospectively if there is a correlation with dimensions of osseous spinal canal and need of discectomy in an adolescent population suffering from disc herniation.

METHODS

A retrospective review of child and adolescent patients who were treated in our institution for back or back--related leg pain was conducted. Patients were divided in three groups; group 1: lumbar disc herniation requiring operative treatment; group 2: lumbar disc herniation treated with observation; and group 3: back pain and no disc herniation on MRI. MRI images and radiographs were studied for spinal canal dimensions and compared between groups.

RESULTS

The discectomy group presented considerably smaller spinal canal dimensions measured from the MRI images than the two other groups.

CONCLUSION

Adolescent patients requiring operative treatment for symptomatic disc herniation have smaller osseous spinal canals than patients who are managed non-operatively.

Prolonged Physiotherapy versus Early Surgical Intervention in Patients with Lumbar Disk Herniation: Short-term Outcomes of Clinical Randomized Trial

Study Design

Randomized controlled trial.

Purpose

We compared the disability and functional outcome after conservative treatment with prolonged physiotherapy versus early surgical intervention in patients with lumbar disk herniation.

Overview of Literature

Lumbar disk herniation is one of the most common causes of job-related disability in individuals less than 45 years old. Conservative treatment is the initial pathway for the majority of patients but the duration of conservative treatment remains debatable and the adverse effects of prolonged conservative treatment are still unclear. Prolonged duration of symptoms before surgical intervention is associated with worse outcomes than a short period of symptoms.

Methods

From June 2011 to July 2013, 60 patients with lumbar disk herniation at our institute were randomized into two groups. Group I was treated with prolonged physiotherapy and rehabilitation for 6 months, while group II was treated with early surgical discectomy. Oswestry disability index was used to assess disability, while the Prolo economic outcome rating scale was used to assess the work status.

Results

Most patients were males between 21 and 45 years old (mean age, 35.88±7.15). There was significant improvement in the disability and work status in both groups without statistically significant differences in the disability score at the second or third assessment. However, the Prolo scale became significantly better in group I than in group II patients during the second and third assessments.

Conclusions

A prolonged physiotherapy and rehabilitation program is a beneficial and successful treatment in patients with recently diagnosed lumbar disk herniation.

Vertebral End-Plate Perforation for Intervertebral Disc Height Preservation After Single-level Lumbar Discectomy: A Randomized-controlled Trial

STUDY DESIGN

Pilot single-centre, stratified, prospective, randomized, double-blinded, parallel-group, controlled study.

OBJECTIVE

To determine whether vertebral end-plate perforation after lumbar discectomy causes annulus reparation and intervertebral disc volume restoration. To determine that after 6 months there would be no clinical differences between the control and study group.

SUMMARY OF BACKGROUND DATA

Low back pain is the most common long-term complication after lumbar discectomy. It is mainly caused by intervertebral disc space loss, which promotes progressive degeneration. This is the first study to test the efficiency of a previously described method (vertebral end-plate perforation) that should advocate for annulus fibrosus reparation and disc space restoration.

METHODS

We selected 30 eligible patients according to inclusion and exclusion criteria and randomly assigned them to the control (no end-plate perforation) or study (end-plate perforation) group. Each patient was evaluated in 5 different periods, where data were collected [preoperative and 6-mo follow-up magnetic resonance imaging and functional outcome data: visual analogue scale (VAS) back, VAS legs, Oswestry disability index (ODI)]. Intervertebral space volume (ISV) and height (ISH) were measured form the magnetic resonance images. Statistical analysis was performed using paired t test and linear regression. P<0.05 was considered statistically significant.

RESULTS

We found no statistically significant difference between the control group and the study group concerning ISV (P=0.6808) and ISH (P=0.8981) 6 months after surgery. No statistically significant differences were found between ODI, VAS back, and VAS legs after 6 months between the 2 groups, however, there were statistically significant differences between these parameters in different time periods. Correlation between the volume of disc tissue removed and preoperative versus postoperative difference in ISV was statistically significant (P=0.0020).

CONCLUSIONS

The present study showed positive correlation between the volume of removed disc tissue and decrease in postoperative ISV and ISH. There were no statistically significant differences in ISV and ISH between the group with end-plate perforation and the control group 6 months after lumbar discectomy. Clinical outcome and disability were significantly improved in both groups 3 and 6 months after surgery.

The Timing of Surgery and Symptom Resolution in Patients Undergoing Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disk Disease and Radiculopathy

OBJECTIVE

Success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms. It is not clear whether there is a "cutoff" time when decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. The main objective of this study was to analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF).

METHODS

The prospective observational study was performed. Eighty-four patients with radicular symptoms due to degenerative disk disease and stenosis with spondylolisthesis with no previous fusion surgeries and undergoing 1- to 3-level TLIF surgery were enrolled. Fifteen patients (18%) were lost to follow-up and were excluded from this analysis leaving a total of 69 patients. Standardized questionnaires were used to analyze clinical outcomes and were administered preoperatively within 3 months of scheduled surgery, and postoperatively at 3, 6, 12, and 24 months. To emphasize the change in clinical outcome scores, the relevant scores were calculated as the ratio of minimal clinically important difference values and change scores. The change scores were calculated by subtracting the postoperative scores from the baseline scores. Multiple regression analyses were conducted to examine the relationship of the duration of symptoms and relevant minimal clinically important difference ratio values while controlling for independent variables. Further, a comparison between 2 groups of patients was performed to analyze the changes of clinical outcomes for the patients who underwent fusion within <24 months versus ≥24 months.

RESULTS

It was determined that the duration of symptoms was a significant predictor of better leg pain resolution (P=0.018), but not back pain resolution (P=0.27), or improvement in ODI (P=0.10) and SF-36 PCS scores (P=0.19). The patients with shorter duration of symptoms had significantly better radicular symptom resolution (P=0.032) compared with patients who waited at least 24 months or longer to undergo fusion.

CONCLUSIONS

A shorter duration of symptoms was found to be a statistically significant predictor for better resolution of radicular symptoms in patients undergoing TLIF for painful degenerative disk disease and stenosis with spondylolisthesis.

Healthy Physical Activity Levels Below Recommended Thresholds Two Years After Lumbar Spine Surgery

STUDY DESIGN

Prospective analysis.

OBJECTIVE

To quantify physical activity after lumbar surgery and identify spine-related variables associated with not meeting recommended activity thresholds.

SUMMARY OF BACKGROUND DATA

National guidelines recommend ≥150 minutes/week of moderate-intensity activity; however, only 52% of the general population meets this threshold. For patients not participating in exercise/sports, ≥1400 kcal/week of energy expenditure, including from walking, is another threshold. Potential spine-related variables associated with not meeting these thresholds after lumbar surgery have not been described.

METHODS

Clinical data were collected pre- and intraoperatively for 422 patients. Patients were contacted 2.2 years postoperatively to measure several patient-reported outcomes, including physical activity with the Paffenbarger Physical Activity and Exercise Index. The Paffenbarger Physical Activity and Exercise Index encompasses blocks walked, stairs climbed, and exercise/sports. Minutes/week of activity and total kcal/week were calculated and compared to recommended thresholds. Spine-related variables associated with not meeting thresholds were assessed in multivariable analyses.

RESULTS

Mean age was 57 years, 55% were men, 80% had degenerative diagnoses, and 63% had multilevel surgery. Only 35% met ≥1400 kcal/week; in multivariable analysis, not meeting this threshold was associated with revision surgery (OR 0.53, CI 0.30-0.95), surgery at ≥3 levels (OR 0.51, CI 0.31-0.84), and more postoperative back pain (OR 0.38, CI 0.24-0.59) (P <0.05 for all variables). Only 26% met ≥150 minutes/week; in multivariable analysis, not meeting this threshold was associated with degenerative diagnoses (OR 0.53, CI 0.31-0.92), subsequent spine surgery (OR 0.17, CI 0.05-0.58), and more postoperative back pain (OR 0.41, CI 0.25-0.67) (P <0.05 for all variables). All multivariable associations persisted after controlling for demographic characteristics.

CONCLUSION

Physical activity is below population norms after lumbar surgery and is associated with spine-related variables. Patients with stable spine conditions should be encouraged to engage in prudent physical activity to decrease their risk of long-term adverse health outcomes due to inactivity.

LEVEL OF EVIDENCE

3.

Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review

OBJECTIVES

Pain relief has been shown to be the most frequently reported goal by patients undergoing lumbar disc surgery. There is a lack of systematic research investigating the course of postsurgical pain intensity and factors associated with postsurgical pain. This systematic review focuses on pain, the most prevalent symptom of a herniated disc as the primary outcome parameter. The aims of this review were (1) to examine how pain intensity changes over time in patients undergoing surgery for a lumbar herniated disc and (2) to identify socio-demographic, medical, occupational and psychological factors associated with pain intensity.

METHODS

Selection criteria were developed and search terms defined. The initial literature search was conducted in April 2015 and involved the following databases: Web of Science, Pubmed, PsycInfo and Pubpsych. The course of pain intensity and associated factors were analysed over the short-term (≤ 3 months after surgery), medium-term (> 3 months and < 12 months after surgery) and long-term (≥ 12 months after surgery).

RESULTS

From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being.

CONCLUSIONS

Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support.

Assessment and Determinants of Spinal Pain in the Course of Disc Disorders Treated Surgically

Background

Intervertebral disc disease is defined as a complex of structural changes in the aftermath of disorders of mutual elements, the structure of which form the discus intervertebralis and the spinal canal. The present work assessed pain in patients who were surgically treated due to spinal discopathy and analyzed factors that determine the condition.

Material/Methods

The research was carried on a group of 187 patients diagnosed with discopathy of the lumbosacral and cervical segment. The data are discussed in the context of medical records and the Visual Analogue Scale used for pain assessment. We used a prospective study plan with a 3-time assessment.

Results

The pain level observed among patients prior to the procedure (M=6.52) was higher than after 7 days (M=3.15) and 6 months from the operation (M= 3.45). The highest level of pain (M=6.88), with a relatively high consistency among the patients (SD=2.25), was observed in the case of left-side hernia (H=7.31; p=0.023). The influence of the analyzed factors on pain experience markedly increased by the third assessment (R2=0.14), and was strongly associated with the type of work performed by the patient.

Conclusions

Surgical operation significantly reduces pain in patients with disc disorders. The level of pain is predominantly affected by the location of the hernia and the type of work performed by the patient.

A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy

BACKGROUND CONTEXT

Sciatica is often caused by a herniated lumbar intervertebral disc. When conservative treatment fails, a lumbar discectomy can be performed. Surgical treatment via lumbar discectomy is not always successful and may depend on a variety of preoperative factors. It remains unclear which, if any, preoperative factors can predict postsurgical clinical outcomes.

PURPOSE

This review aimed to determine preoperative predictors that are associated with postsurgical clinical outcomes in patients undergoing lumbar discectomy.

STUDY DESIGN

This is a systematic review.

METHODS

This systematic review of the scientific literature followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE and PubMed were systematically searched through June 2014. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. No financial support was provided for this study. No potential conflict of interest-associated biases were present from any of the authors.

RESULTS

The search strategy yielded 1,147 studies, of which a total of 40 high-quality studies were included. There were 17 positive predictors, 20 negative predictors, 43 non-significant predictors, and 15 conflicting predictors determined. Preoperative predictors associated with positive postoperative outcomes included more severe leg pain, better mental health status, shorter duration of symptoms, and younger age. Preoperative predictors associated with negative postoperative outcomes included intact annulus fibrosus, longer duration of sick leave, worker's compensation, and greater severity of baseline symptoms. Several preoperative factors including motor deficit, side and level of herniation, presence of type 1 Modic changes and degeneration, age, and gender had non-significant associations with postoperative clinical outcomes.

CONCLUSIONS

It may be possible for certain preoperative factors to be targeted for clinical evaluation by spine surgeons to assess the suitability of patients for lumbar discectomy surgery, the hope being to thereby improve postoperative clinical outcomes. Prospective cohort studies are required to increase the level of evidence with regard to significant predictive factors.

Cut-Off Value for Pain Sensitivity Questionnaire in Predicting Surgical Success in Patients with Lumbar Disc Herniation

Various factors related to predict surgical success were studied; however, a standard cut-off point for the Pain Sensitivity Questionnaire (PSQ) measure has not yet been established for a favorable surgical outcome for lumbar disc herniation (LDH). This study was to find the optimal cut-off point on the PSQ to distinguish surgical success in patients with LDH. A total of 154 patients with LDH consecutively referred to our clinic were enrolled into this prospective study between February 2011 and January 2014. All participants completed the PSQ. Patients completed the Oswestry Disability Index (ODI) score before surgery, and at 2 years after surgery. Surgical success was defined as a 13-point improvement from the baseline ODI scores. The cut-off value for PSQ was determined by the receiver-operating characteristic curve (ROC). The mean age of patients was 49.3±9.6 years, and there were 80 women. The mean time for follow-up assessment was 31±5 months (range 24–35). Post-surgical success was 79.9% (n = 123) at 2 years follow up. The mean score for the total PSQ, PSQ-minor, and PSQ-moderate were 6.0 (SD = 1.6), 5.4 (SD = 1.9) and 6.5 (SD = 1.7), respectively. Total PSQ score was also significantly correlated with the total scores of the ODI. The optimal total PSQ cut-off point was determined as > 5.2 to predict surgical success in LDH patients, with 80.0% sensitivity and 75.6% specificity (AUC-0.814, 95% CI 0.703–0.926). This study showed that the PSQ could be considered a parameter for predicting surgical success in patients with LDH, and can be useful in clinical practice.

How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry

OBJECTIVE

To date, the factors that predict whether a patient returns to work after lumbar discectomy are poorly understood. Information on postoperative work status is important in analyzing the cost-effectiveness of the procedure.

METHODS

An observational prospective cohort study was completed at 13 academic and community sites (NeuroPoint–Spinal Disorders [NeuroPoint-SD] registry). Patients undergoing single-level lumbar discectomy were included. Variables assessed included age, sex, body mass index (BMI), SF-36 physical function score, Oswestry Disability Index (ODI) score, presence of diabetes, smoking status, systemic illness, workers' compensation status, and preoperative work status. The primary outcome was working status within 3 months after surgery. Stepwise logistic regression analysis was performed to determine which factors were predictive of return to work at 3 months following discectomy.

RESULTS

There were 127 patients (of 148 total) with data collected 3 months postoperatively. The patients' average age at the time of surgery was 46 ± 1 years, and 66.9% of patients were working 3 months postoperatively. Statistical analyses demonstrated that the patients more likely to return to work were those of younger age (44.5 years vs 50.5 years, p = 0.008), males (55.3% vs 28.6%, p = 0.005), those with higher preoperative SF-36 physical function scores (44.0 vs 30.3, p = 0.002), those with lower preoperative ODI scores (43.8 vs 52.6, p = 0.01), nonsmokers (83.5% vs 66.7%, p = 0.03), and those who were working preoperatively (91.8% vs 26.2%, p < 0.0001). When controlling for patients who were working preoperatively (105 patients), only age was a statistically significant predictor of postoperative return to work (44.1 years vs 51.1 years, p = 0.049).

CONCLUSIONS

In this cohort of lumbar discectomy patients, preoperative working status was the strongest predictor of postoperative working status 3 months after surgery. Younger age was also a predictor. Factors not influencing return to work in the logistic regression analysis included sex, BMI, SF-36 physical function score, ODI score, presence of diabetes, smoking status, and systemic illness.

Clinical trial registration no.: 01220921 (clinicaltrials.gov)

Clinical values of control over pain and pain coping strategies in surgical treatment for patients with lumbar spinal stenosis

BACKGROUND

Control over pain and pain coping strategies are associated with pain intensity as well as psychological status and subjective disability in patients experiencing pain. The present study assessed the clinical values of control over pain and pain coping strategies in surgical treatment for patients with lumbar spinal stenosis using mediation analysis.

METHODS

Sixty-two patients with lumbar spinal stenosis (median age, 70 years; 34 men, 28 women) were evaluated before surgery. The pain intensity and area, psychological status/subjective disability (Japanese Orthopaedic Association Back Pain Evaluation Questionnaire), and control over pain/pain coping strategies (Coping Strategies Questionnaire) were assessed. Mediation analysis, which consisted of serial regression analyses, mainly tested whether (1) control over pain/pain coping strategies were predicted by pain characteristics and (2) control over pain/pain coping strategies predicted psychological status/subjective disability after controlling for pain characteristics.

RESULTS

Control over pain was predicted by pain intensity (regression coefficient, -0.33; p = 0.01); moreover, it predicted walking ability (standardized partial regression coefficient, 0.31; p = 0.01) and social function (0.38; p = 0.00) after controlling for pain intensity. Although increasing activity level, one pain coping strategy, was predicted by pain intensity (regression coefficient, -0.30; p = 0.02), it did not predict walking ability (standardized partial regression coefficient, 0.07; p = 0.53) or social function (0.13; p = 0.33) when considering pain intensity.

CONCLUSIONS

In this cohort, mediation analysis demonstrated that pain intensity did not directly affect perceived walking ability or social function, but did affect control over pain; moreover, control over pain affected walking ability and social function.

CLINICAL RELEVANCE

These findings are useful for a deep understanding of the relationships between pain and subjective disability in preoperative patients with lumbar spinal stenosis. More attention should be given to patients' thoughts about pain such as control over pain.

Predictors of an unfavorable outcome 1.5 and 12 years after a first, uncomplicated lumbar disc surgery

PURPOSE

To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.

METHODS

Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5-8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.

RESULTS

Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.

CONCLUSIONS

Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.

The Course of Pain Intensity in Patients Undergoing Herniated Disc Surgery: A 5-Year Longitudinal Observational Study

Objectives

The aims of this study are to answer the following questions (1) How does the pain intensity of lumbar and cervical disc surgery patients change within a postoperative time frame of 5 years? (2) Which sociodemographic, medical, work-related, and psychological factors are associated with postoperative pain in lumbar and cervical disc surgery patients?

Methods

The baseline survey (T0; n = 534) was conducted 3.6 days (SD 2.48) post-surgery in the form of face-to-face interviews. The follow-up interviews were conducted 3 months (T1; n = 486 patients), 9 months (T2; n = 457), 15 months (T3; n = 438), and 5 years (T4; n = 404) post-surgery. Pain intensity was measured on a numeric rating-scale (NRS 0–100). Estimated changes to and influences on postoperative pain by random effects were accounted by regression models.

Results

Average pain decreased continuously over time in patients with lumbar herniated disc (Wald Chi² = 25.97, p<0.001). In patients with cervical herniated disc a reduction of pain was observed, albeit not significant (Chi² = 7.02, p = 0.135). Two predictors were associated with postoperative pain in lumbar and cervical disc surgery patients: the subjective prognosis of gainful employment (p<0.001) and depression (p<0.001).

Conclusion

In the majority of disc surgery patients, a long-term reduction of pain was observed. Cervical surgery patients seemed to benefit less from surgery than the lumbar surgery patients. A negative subjective prognosis of gainful employment and stronger depressive symptoms were associated with postoperative pain. The findings may promote multimodal rehabilitation concepts including psychological and work-related support.

Scope of practice review: providers for triage and assessment of spine-related disorders

Purpose

This study explored which health care providers could be involved in centralized intake for patients with nonspecific low back pain to enhance access, continuity, and appropriateness of care.

Methods

We reviewed the scope of practice regulations for a range of health care providers. We also conducted telephone interviews with 17 individuals representing ten provincial colleges and regulatory bodies to further understand providers’ legislated scopes of practice. Activities relevant to triaging and assessing patients with low back pain were mapped against professionals’ scope of practice.

Results

Family physicians and nurse practitioners have the most comprehensive scopes and can complete all restricted activities for spine assessment and triage, while the scope of registered nurses and licensed practical nurses are progressively narrower. Chiropractors, occupational therapists, physiotherapists, and athletic therapists are considered experts in musculoskeletal assessments and appear best suited for musculoskeletal specific assessment and triage. Other providers may play a complementary role depending on the individual patient needs.

Conclusion

These findings indicate that an interprofessional assessment and triage team that includes allied health professionals would be a feasible option to create a centralized intake model. Implementation of such teams would require removing barriers that currently prevent providers from delivering on their full scope of practice.

Does the duration of symptoms influence outcome in patients with sciatica undergoing micro-discectomy and decompressions?

BACKGROUND

Early surgical treatment for back and leg pain secondary to disc herniation has been associated with very good outcomes. However, there are conflicting data on the role of surgical treatment in case of prolonged radicular symptomatology.

PURPOSE

We aimed to evaluate whether the duration of symptoms at presentation affects the subjective outcome.

STUDY DESIGN/SETTING

This is a retrospective review of prospectively collected data from a single surgeon including micro-discectomies and lateral recess decompressions in patients younger than 60 years old using patient medical notes, radiology imaging, operation notes, and Patient Reported Outcome Measures (PROMS) including Oswestry Disability Index (ODI), visual analogue scale for back pain and leg pain (VAS-BP and VAS-LP). The final follow-up was carried out through postal questionnaire or telephone consultation.

METHODS

Demographic information, duration of symptoms, type and incidence of complications, length of hospital stay, and follow-up were analyzed. Data were categorized into four subgroups: symptoms 0≥6 months, 6 months≥1 year, 1 year≥2 years, and >2 years. A clinically significant result was an average improvement of 2 or more points in the VAS and of 20% and over in the ODI. The level of statistical significance was <0.05%.

RESULTS

A total number of 107 patients who underwent 109 operations were included. The level of surgery was L5/S1 (50), L4/L5 (43), L3/L4 (3), L2/L3 (2), and two levels (11). The mean improvement was from 0 to ≤6 months (VAS-LP 5.21±2.81, VAS-BP 3.04±3.15, ODI 35.26±19.25), 6 months to ≤1 year (VAS-LP 4.73±2.61, VAS-BP 3.30±3.05, ODI 26.92±19.49), 1 year to ≤2 years (VAS-LP 3.78±3.68, VAS-BP 3.00±2.78, ODI 19.03±20.24), and >2 years (VAS-LP 4.77±3.61, VAS-BP 3.54±3.43, ODI 28.36±20.93). The length of hospital stay and complication rate was comparable between groups. Average follow-up was 15.69 months.

CONCLUSIONS

Our study showed significant improvement in patients with symptoms beyond 1 as well as 2 years since onset, and surgery is a viable option in selected patients.

Clinical evaluation of the post-laminectomy syndrome in public hospitals in the city of São Luís, Brazil

Background and objectives

Although not well known, post-laminectomy syndrome (PLS) is an important cause of chronic back pain, which may lead to decreased quality of life, disability and psychological disorders. This study aimed to evaluate the clinical characteristics and prevalence of PLS, to estimate its impact on the quality of life and to determine its association with anxiety, depression and disability in patients at public hospitals in São Luís, MA.

Methods

Cross-sectional, descriptive and analytical study. Eighteen patients characterized as having PLS were selected, and their clinical, epidemiological and psychological characteristics, their quality of life and their levels of physical fitness were evaluated through clinical evaluations, Beck questionnaires, the Short Form-36 (SF-36), the Rolland-Morris questionnaire and the Douleur Neurophatique 4 questions. The multidimensional pain evaluation was performed using the McGill Pain Questionnaire.

Results

The prevalence of post-laminectomy pain was 60 %. Most of the patients assessed in this study were male and received a family income of up to minimum wage; their mean age was 45 years. All of the patients presented with chronic, intense pain that had lasted an average of 7.22 years. The prevalence of neuropathic pain was 89.9 %. The physical appearance and functional capacity domains of the SF-36 were classified as unsatisfactory in 94.4 and 83.3 % of the patients, respectively. None of the patients exhibited high levels of physical fitness. The average score was 21.33 for anxiety and 18.88 for depression. There was a strongly positive and significant relationship between the anxiety and depression scores. Additionally, there was a moderately positive and significant relationship between the disability and anxiety scores. Regarding the correlation between the pain intensity and the quality of life, there was a moderately significant relationship between the patients’ mental health and their vitality.

Conclusion

PLS exhibits a high prevalence and significance, and it causes high levels of morbidity in patients. Furthermore, PLS features intense levels of pain, reduced quality of life and greater physical and occupational disability.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1400-9) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS SYSTEMATIC REVIEW

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

PROSPECTIVE STUDY

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

CONCLUSIONS

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