Overweight and smoking promote recurrent lumbar disk herniation after discectomy

Posterior Cartilage Endplate Disruption on T1-weighted Magnetic Resonance Imaging as a Predictor for Postoperative Recurrence of Lumbar Disk Herniation

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aimed to investigate the relationship between disruption of cartilage endplates and postoperative recurrence of lumber disk herniation (LDH) using preoperative T1-weighted magnetic resonance imaging (MRI-T1WI).

SUMMARY OF BACKGROUND DATA

Recurrence of LDH is a relatively common complication after discectomy. Although several risk factors have been identified, their predictive capability remains limited. Previous histologic studies reported that cartilage endplates were present in 85% of patients with recurrent LDH.

METHODS

Patients with a single level of LDH who underwent open or microendoscopic discectomy were retrospectively reviewed. On the basis of preoperative sagittal MRI-T1WI, cartilage endplates were divided into anterior and posterior portions at the center of the disk and evaluated for discontinuity. Patient background characteristics, spinopelvic sagittal parameters, degrees of disk degeneration, and recurrence level were also evaluated.

RESULTS

A total of 100 patients were included in this study (mean age, 50.5 years old; 41% female). Symptomatic recurrence of LDH occurred in 15 patients (15%). There were no significant differences in patient background characteristics (age, 46.9 vs. 51.2 years old; %female, 60% vs. 38%; smoking, 33% vs. 41%; diabetes mellitus, 27% vs. 29%) or spinopelvic parameters (PI, 44.1 vs. 47.0 degrees; PT, 16.8 vs. 19.4 degrees; SS, 27.3 vs. 27.6 degrees; LL, 37.7 vs. 33.7 degrees). In the recurrence group, MRI-T1WI showed a higher rate of cartilage endplate disruption in the posterior portion than in the no-recurrence group (73% vs. 34%, P=0.01). A multivariate analysis demonstrated that the disruption of the posterior cartilage endplate remained an independent predictor of recurrence.

CONCLUSIONS

Disruption in the posterior cartilage endplate on preoperative MRI-T1WI was closely associated with recurrence after LDH surgery. These results suggest that this MRI finding is a practical and useful predictor of LDH recurrence.

LEVEL OF EVIDENCE

Level III.

Obesity Does Not Negatively Affect Patient-perceived Outcomes After Cervical Disc Replacement for Disc Herniation

STUDY DESIGN

Retrospective review.

OBJECTIVE

To assess the impact of Body Mass Index (BMI) on patient-reported outcome measures (PROMs) after cervical disc replacement (CDR).

BACKGROUND

BMI may affect PROMs after spine surgery.

METHODS

Primary CDR recipients for herniated disc(s) with BMI <40 were retrospectively selected from a single-surgeon registry. Cohorts were divided into non-obese (BMI <30) and obese (BMI ≥30). Intercohort in-hospital complication rates were compared through independent samples t tests. Pre/postoperative PROMs were compared between cohorts through multivariable regression accounting for demographic differences. Final follow-up dates between patients averaged 11.8 ± 9.3 months. PROMs assessed included Patient-reported Outcomes Measurement Information System-Physical Function, Neck Disability Index, Visual Analog Scale-Neck, Visual Analog Scale-Arm, and the 9-item Patient Health Questionnaire. Improvements in PROMs were evaluated and compared at each follow-up within cohorts through paired t tests. The magnitude of improvement in PROMs from preoperative baseline at 6-week follow-up (∆PROM-6W) and final follow-up (∆PROM-FF) along with achievement rates of minimum clinically important differences were compared between cohorts through multivariable regression accounting for demographic differences.

RESULTS

Of 153 patients, 53 patients were noted as obese. Demographic differences included age, prevalence of hypertension and diabetes, and comorbidity burden scores ( P ≤ 0.011, all). No significant variations in in-hospital complications were found. The non-obese cohort demonstrated improvements in all PROMs at 6 weeks and final follow-up periods ( P ≤ 0.005, all). The obese cohort demonstrated improvements in all postoperative PROMs besides 9-item Patient Health Questionnaire at 6 weeks ( P ≤ 0.015, all). After accounting for age and comorbidity variations, there were no significant intercohort differences in raw PROM scores, ∆PROM-6W, ∆PROM-FF, or minimum clinically important difference achievement rates.

CONCLUSIONS

Regardless of BMI, patients experience significant improvements in physical function, disability, pain, and mental health after CDR for disc herniation. Patients with obesity do not suffer inferior patient-perceived outcomes after CDR. These findings may help surgeons counsel patients in the preoperative period.

Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review

Amid the worldwide increase in spinal surgery rates, a significant proportion of patients continue to experience refractory chronic pain, resulting in reduced quality of life and escalated healthcare demands. Failed back surgery syndrome (FBSS) is a clinical condition characterized by persistent or recurrent pain after one or more spinal surgeries. The diverse characteristics and stigmatizing descriptions of FBSS necessitate a reevaluation of its nomenclature to reflect its complexity more accurately. Accurate identification of the cause of FBSS is hampered by the complex nature of the syndrome and limitations of current diagnostic labels. Management requires a multidisciplinary approach that may include pharmacological treatment, physical therapy, psychological support, and interventional procedures, emphasizing realistic goal-setting and patient education. Further research is needed to increase our understanding, improve diagnostic accuracy, and develop more effective management strategies.

Association of spinal-pelvic parameters with recurrence of lumbar disc herniation after endoscopic surgery: a retrospective case-control study

PURPOSE

This study aimed to investigate the relationship between spinal-pelvic parameters and recurrence of lumbar disc herniation (rLDH) after percutaneous endoscopic lumbar discectomy (PELD) through a retrospective case-control study.

METHODS

Patients who underwent PELD for single-segment LDH at our hospital were included in this study. The relationship between sagittal balance parameters of the spine and recurrence was analysed through correlation analysis, and ROC curves were plotted. The baseline characteristics, sagittal balance parameters of the spine and radiological parameters of the case and control groups were compared, and the relationship between sagittal balance parameters of the spine and recurrence of rLDH after PELD was determined through univariate and multivariate logistic regression analysis.

RESULTS

Correlation analysis showed that PI and ∆PI-LL were negatively correlated with grouping (r = -0.090 and -0.120, respectively, P = 0.001 and 0.038). ROC curve analysis showed that the area under the curve (ROC-AUC) for predicting rLDH based on PI was 0.65 (CI95% = 0.598, 0.720), with a cut-off of 50.26°. The ROC-AUC for predicting rLDH based on ∆PI-LL was 0.56 (CI95% = 0.503, 0.634), with a cut-off of 28.21°. Multivariate logistic regression analysis showed that smoking status (OR = 2.667, P = 0.008), PI ≤ 50.26 (OR = 2.161, P = 0.009), ∆PI-LL ≤ 28.21 (OR = 3.185, P = 0.001) and presence of Modic changes (OR = 4.218, P = 0.001) were independent risk factors, while high DH (OR = 0.788, P = 0.001) was a protective factor.

CONCLUSION

PI < 50.26 and ∆PI-LL < 28.21 were risk factors for recurrence of lumbar disc herniation after spinal endoscopic surgery and had some predictive value for post-operative recurrence.

Return to sports following discectomy: does a consensus exist?

INTRODUCTION

In the USA, lumbar discectomy is one of the most commonly performed spinal procedures. As certain sports are considered to be major risk factors for disc herniation, the question remains as to when highly active patients should return to their previous level of activity. This study aimed to analyze spine surgeons' opinions on when patients may return to activities following discectomy as well as their underlying rationale for their decision.

METHODS

A questionnaire was designed by five different fellowship-trained spine surgeons for the 168 members of the Spine Society of Australia. Questions on the surgeons experience, decision making, preferred surgical technique, the postoperative rehabilitation and the response to patient expectations were included.

RESULTS

In total, 83.9% of surgeons discuss the postoperative level of activity with their patients. Sport is considered as an important contributor for good functional outcome by 71.0% of surgeons. Surgeons recommend avoiding, often permanently, weightlifting (35.7%) of the time, rugby (21.4%), horseback riding (17.9%) as well as martial arts (14.3%) postoperatively even with previous training. The return to high levels of activity is considered as a major risk factor for disc herniation recurrence by 25.8% of surgeons. Return to high level of activity is typically recommended after 3 months by 48.4% of surgeons.

CONCLUSION

So far no consensus on the rehabilitation protocol and return to level of activity exists. Recommendations depend on personal experience as well as the individuals' training, and typically, a period of avoidance of sport for up to 3 months is recommended.

LEVEL OF EVIDENCE

Level III, therapeutic and prognostic study.

[Surgical treatment of recurrent herniated discs of the lumbar spine depending on risk factors]

According to the literature, recurrent disc herniation of the lumbar spine occurs in 5-10% of cases. Objective. To develop an algorithm for surgical treatment of recurrent lumbar spine disc herniation based on analysis of risk factors of relapse and assessment of intra- and postoperative period.

MATERIAL AND METHODS

The study included 61 patients with recurrent intervertebral disc herniation. Thirty patients underwent repeated microdiscectomy without transpedicular fixation, 31 patients - resection of recurrent disc herniation with transpedicular fixation (PLIF technique). The control group included 63 patients without recurrent disc herniation. Mean follow-up period was 3.5 years.

RESULTS

Discectomy with transpedicular fixation is characterized by larger extent, prolonged surgery time and rehabilitation period. However, there is lower risk of recurrent disc herniation and CSF leakage. Repeated microdisectomy without transpedicular fixation is characterized by smaller extent and shorter surgery time, as well as faster recovery period. Nevertheless, we have higher risk of recurrent disc herniation and CSF leakage. We developed a method for assessing the probability of recurrent intervertebral disc herniation. This algorithm allows us to predict the probability of recurrent disc herniation in a particular patient with 86.7% accuracy.

CONCLUSION

We proposed an algorithm for choosing surgical treatment of recurrent disc herniation. Microdiscectomy without fixation is advisable for the risk of recurrent disc herniation <30%, discectomy with transpedicular fixation - for risk of disc herniation >30%.

Clinical Effects of the End-Love Technique in the Treatment of Recurrent Lumbar Disc Herniation 1 Year After Surgery

Background

The number of patients with lumbar disc herniation in China is increasing year by year. Percutaneous endoscopic lumbar discectomy (PELD) is currently the main surgical method for treating lumbar disc herniation (LDH). However, with the increase in the number of surgical cases, the number of patients with recurrent lumbar disc herniation (RLDH) is also increasing. Currently, the common method in China is lumbar fusion surgery, but this surgery would cause the loss of fusion segment mobility and considerable postoperative complications. In order to solve the problem above the following technique will be studied: the technique of posterior lumbar laminectomy and nucleus pulposus removal under fully visualized spinal endoscopy (ENDO-LOVE) to treat RLDH. Its clinical effects will be observed in this paper, too.

Methods

This series includes RLDH patients treated with ENDO-LOVE technology between January 2017 and January 2021. All patients will undergo at least three follow-up visits one year after surgery. The modified MacNab standard, VAS, JOA, and ODI scores will be used to evaluate clinical efficacy, observe for cerebrospinal fluid leak, nerve root injury, and surgical site infection, and evaluate clinical safety.

Results

All 29 patients completed the surgery successfully. Three patients had postoperative pain and numbness in the area of nerve root innervation, and all patients had no serious complications. The VAS, JOA scores and ODI indices of back pain and leg pain 1-day, 3-months, and 1-year postoperatively differed statistically significantly from the preoperative scores (p < 0.05). Efficacy evaluated at 1-year postoperatively using the modified MacNab criteria showed an excellent rate of 89.7%.

Conclusion

ENDO-LOVE technology has demonstrated good clinical efficacy and safety in the treatment of patients with RLDH. It should be considered for all patients with this condition.

Chronic pain after spine surgery: Insights into pathogenesis, new treatment, and preventive therapy

Chronic pain after spine surgery (CPSS) is often characterized by intractable low back pain and/or radiating leg pain, and has been reported in 8-40% of patients that received lumbar spine surgery. We conducted a literature search of PubMed, MEDLINE/OVID with a focus on studies about the etiology and treatments of CPSS and low back pain. Our aim was to provide a narrative review that would help us better understand the pathogenesis and current treatment options for CPSS. This knowledge will aid in the development of optimal strategies for managing postoperative pain symptoms and potentially curing the underlying etiologies. Firstly, we reviewed recent advances in the mechanistic study of CPSS, illustrated both structural (e.g., fibrosis and scaring) and non-structural factors (e.g., inflammation, neuronal sensitization, glial activation, psychological factor) causing CPSS, and highlighted those having not been given sufficient attention as the etiology of CPSS. Secondly, we summarized clinical evidence and therapeutic perspectives of CPSS. We also presented new insights about the treatments and etiology of CPSS, in order to raise awareness of medical staff in the identification and management of this complex painful disease. Finally, we discussed potential new targets for clinical interventions of CPSS and future perspectives of mechanistic and translational research. CPSS patients often have a mixed etiology. By reviewing recent findings, the authors advocate that clinicians shall comprehensively evaluate each case to formulate a patient-specific and multi-modal pain treatment, and importantly, consider an early intraoperative intervention that may decrease the risk or even prevent the onset of CPSS.

Translational potential statement

CPSS remains difficult to treat. This review broadens our understanding of clinical therapies and underlying mechanisms of CPSS, and provides new insights which will aid in the development of novel mechanism-based therapies for not only managing the established pain symptoms but also preventing the development of CPSS.

Recurrent or junctional lumbar foraminal herniated disc in patients operated with trans pars microscopic approach

This is a retrospective monocentric study. The aim of this study is to analyze the incidence of recurrent or junctional lumbar foraminal herniated disc, in patients treated with trans pars microsurgical approach. Foraminal lumbar disc herniation represents a challenging pathology for the spinal surgeon. The appropriate surgical approach still represents a matter of debate. Several open and minimally-invasive techniques have been developed, in order to allow a proper tissue exposure and preserving the vertebral stability. The trans pars approach has already been described as a possible alternative, allowing excellent exposure of the herniated fragment with minimum bone removal. While few studies have analyzed the very low rate of post-operative instability, no articles deal with the incidence of post-operative herniated disc recurrence or junctional disc herniation in patients treated with this technique. We enrolled 160 patients operated at our institution. A univariate and multivariate analysis of possible factors influencing outcome (age, sex, level and BMI) was performed. Outcome variables were recurrent or junctional herniated disc. At the end, 135 patients were analyzed. Of the 135 patients, six presented recurrent herniated disc (4.4%) and other three developed a junctional herniation (2.2%). The occurrence of junctional herniated disc or recurrent herniated disc was not influenced by the analyzed variables, both at univariate and at multivariate analyses. The trans pars approach presents a low rate of recurrence and junctional herniation. Age, sex, level, and BMI do not influence the recurrence rate, both at same level and at junctional level.

Moderate to Severe Multifidus Fatty Atrophy is the Risk Factor for Recurrence After Microdiscectomy of Lumbar Disc Herniation

OBJECTIVE

We attempted to investigate the potential risk factors of recurrent lumbar disc herniation (rLDH) after tubular microdiscectomy.

METHODS

We retrospectively analyzed the data of patients who underwent tubular microdiscectomy. The clinical and radiological factors were compared between the patients with and without rLDH.

RESULTS

This study included 350 patients with lumbar disc herniation (LDH) who underwent tubular microdiscectomy. The overall recurrence rate was 5.7% (20 of 350). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) at the final follow-up significantly improved compared with those preoperatively. There was no significant difference in the preoperative VAS score and ODI between the rLDH and non-rLDH groups, while the leg pain VAS score and ODI of the rLDH group were significantly higher than those of the non-rLDH group at final follow-up. This suggested that rLDH patients had a worse prognosis than non-rLDH patients even after reoperation. There were no significant differences in sex, age, body mass index, diabetes, current smoking and drinking, disc height index, sagittal range of motion, facet orientation, facet tropism, Pfirrmann grade, Modic changes, interdisc kyphosis, and large LDH between the 2 groups. Univariate logistic regression analysis revealed that rLDH was associated with hypertension, multilevel microdiscectomy, and moderate-severe multifidus fatty atrophy (MFA). A multivariate logistic regression analysis indicated that MFA was the sole and strongest risk factor for rLDH after tubular microdiscectomy.

CONCLUSION

Moderate-severe MFA was a risk factor for rLDH after tubular microdiscectomy, which can serve as an important reference for surgeons in formulating surgical strategies and the assessment of prognosis.

Machine Learning Prediction Model and Risk Factor Analysis of Reoperation in Recurrent Lumbar Disc Herniation Patients After Percutaneous Endoscopic Lumbar Discectomy

OBJECTIVE

To investigate the risk factors of reoperation after percutaneous endoscopic lumbar discectomy (PELD) due to recurrent lumbar disc herniation (rLDH) and to establish a set of individualized prediction models.

METHODS

Patients who underwent PELD successfully from January 2016 to February 2022 in a single institution were enrolled in this study. Six methods of machine learning (ML) were used to establish an individualized prediction model for reoperation in rLDH patients after PELD, and these models were compared with logistics regression model to select optimal model.

RESULTS

A total of 2603 patients were enrolled in this study. 57 patients had repeated operation due to rLDH and 114 patients were selected from the remaining 2546 nonrecurrent patients as matched controls. Multivariate logistic regression analysis showed that disc herniation type (P < .001), Modic changes (type II) (P = .003), sagittal range of motion (sROM) (P = .022), facet orientation (FO) (P = .028) and fat infiltration (FI) (P = .001) were independent risk factors for reoperation in rLDH patients after PELD. The XGBoost AUC was of 90.71%, accuracy was approximately 88.87%, sensitivity was 70.81%, specificity was 97.19%. The traditional logistic regression AUC was 77.4%, accuracy was about 77.73%, sensitivity was 47.15%, specificity was 92.12%.

CONCLUSION

This study showed that disc herniation type (extrusion, sequestration), Modic changes (type II), a large sROM, a large FO and high FI were independent risk factors for reoperation in LDH patients after PELD. The prediction efficiency of XGBoost model was higher than traditional Logistic regression analysis model.

Effect of Obesity on Surgical Outcomes of Lumbar Microdiscectomy: A Retrospective Analysis of 525 Patients

INTRODUCTION

Obesity has been implicated in higher rates of intra-operative complications, as well as increased risk for recurrent herniation and re-operation following lumbar microdiscectomy (LMD). However, the current literature is still controversial about whether obesity adversely affects surgical outcomes, especially a higher re-operation rate. In this study, we have compared surgical outcomes such as recurrence of symptoms, recurrence of disc herniation, and re-operation rates in obese and non-obese patients undergoing one segment LMD.

METHODS

A retrospective review was conducted on patients undergoing single-level LMD between 2010-2020 at an academic institution. Exclusion criteria included prior lumbar surgery. Outcomes assessed included the presence of persistent radicular pain, imaging evidence of recurrent herniation, and the need for re-operation due to recurrent herniation.

RESULTS

A total of 525 patients were included in the study. The mean±SD body mass index (BMI) was 31.2±6.6 (range 16.2-70.0). The mean follow-up was 273.8±445.2 days (range 14-2494). Reherniation occurred in 84 patients (16.0%), and 69 (13.1%) underwent re-operation due to persistent recurrent symptoms. Neither reherniation nor re-operation was significantly associated with BMI (p = 0.47 and 0.95, respectively). Probit analysis did not show any significant association between BMI and the need for re-operation following LMD.

CONCLUSION

Obese and non-obese patients experienced similar surgical outcomes. Our results showed that BMI did not adversely affect reherniation or re-operation rate following LMD. If clinically indicated, LMD can be performed in obese patients with disc herniation without a significantly higher re-operation rate.

Risk Factors for Recurrence After Percutaneous Endoscopic Lumbar Discectomy: A Meta-Analysis

OBJECTIVE

Postoperative recurrence of percutaneous endoscopic lumbar disc increases the physical damage and financial burden on patients and negatively affects physicians' treatment decisions. We conducted this meta-analysis to explore the risk factors for postoperative recurrence of percutaneous endoscopic lumbar disc for lumbar disc herniation.

METHODS

We conducted article search in the PubMed, EMBASE and Cochrane Library databases. PRISMA guidelines were followed in this review. The data are statistically analyzed by the Roundup Manager (version 3.6.1). The results of the meta-analysis are presented in the form of forest-like plots.

RESULTS

We included 13 articles and identified 7524 cases. Patients with older age (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 1.18-1.40), higher body mass index (OR = 1.16, 95% CI: 1.05-1.28), smoker (OR = 1.73, 95% CI: 0.95-3.15), degenerative grades ≥3 (OR = 6.07, 95% CI: 2.81-13.11), and postoperative sagittal motion ≥10° (OR = 2.42, 95% CI: 1.63-3.58) have a higher recurrence rate.

CONCLUSIONS

A thorough preoperative evaluation is essential to prevent postoperative recurrence of percutaneous endoscopic lumbar discectomy. The study addresses several factors of preoperative evaluation, which is hopeful to provide a reference for neurosurgeons.

A 9-year retrospective cohort of patients with lumbar disc herniation: Comparison of patient characteristics and recurrence frequency by smoking status

To evaluate the association between smoking status and patient characteristics and to identify risk factors associated with recurrence in patients who underwent surgery for lumbar disc herniation (LDH). This retrospective study was carried out at Lokman Hekim University, Ankara, Turkey between January 1, 2021 and January 1, 2022. The medical data of patients who underwent microsurgical discectomy for LDH were retrospectively recorded. Patients with any reemergence of LDH within a 6-month period after surgery were defined as having recurrent LDH. A total of 1109 patients were included in the study and mean age was 50.7 ± 14.3 years. The frequency of hernia at L2-L3 and L3-L4 levels was higher in the nonsmoker group (P < .001). The frequency of cases with Pfirrmann Grade 4 degeneration was higher in the nonsmoker group than in smokers and ex-smokers (P < .001). Protrusion-type hernias were more common in nonsmokers (P = .014), whereas paracentral hernias were more common in smokers (P < .001). The overall frequency of recurrence was 20.4%, and was higher in smokers than in non-smokers and ex-smokers (P < .001). Multivariable logistic regression revealed that current smoking (OR: 2.778, 95% CI [confidence interval]: 1.939-3.980, P < .001), presence of Pfirrmann Grade 4&5 disc degeneration (OR: 4.217, 95% CI: 2.966-5.996, P < .001), and paracentral herniation (OR: 5.040, 95% CI: 2.266-11,207, P < .001) were associated with higher risk of recurrence, whereas presence of sequestrated disc was associated with lower risk of recurrence (OR: 2.262, 95% CI:0.272-0.717, P = .001). Taken together, our data show that smoking, increased degree of degeneration and paracentral hernia increase the risk of LDH recurrence, while sequestrated disc appears to decrease risk. Taking steps to combat smoking in individuals followed for LDH may reduce the risk of recurrence in LDH patients.