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

Analysis of the clinical efficacy of visualization of percutaneous endoscopic lumbar discectomy combined with annulus fibrosus suture in lumbar disc herniation

The objective of this study is to compare the clinical effectiveness of visualization of percutaneous endoscopic lumbar discectomy (VPELD) combined with annulus fibrosus suture technique and simple percutaneous endoscopic lumbar discectomy (PELD) technique in the treatment of lumbar disc herniation. A retrospective analysis was conducted on 106 cases of lumbar disc herniation treated with foraminoscopic technique at our hospital from January 2020 to February 2022. Among them, 33 cases were treated with VPELD combined with annulus fibrosus suture in group A, and 73 cases were treated with PELD in group B. The preoperative and postoperative visual analogue scale (VAS), functional index (Oswestry Disability Index, ODI), healing of the annulus fibrosus, intervertebral space height, and postoperative recurrence were recorded and compared between the two groups. All patients underwent preoperative and postoperative MRI examinations, and the average follow-up period was 12 ± 2 months. Both groups showed significant improvements in postoperative VAS and ODI scores compared to the preoperative scores (P < 0.05), with no statistically significant difference between the groups during the same period (P > 0.05). There was no significant decrease in intervertebral space between the two groups after surgery (P > 0.05). Group A showed significantly lower postoperative recurrence rate and better annulus fibrosus healing compared to group B (P < 0.05). The VPELD combined with annulus fibrosus suture technique is a safe, feasible, and effective procedure for the treatment of lumbar disc herniation. When the indications are strictly adhered to, this technique can effectively reduce the postoperative recurrence rate and reoperation rate. It offers satisfactory clinical efficacy and can be considered as an alternative treatment option for eligible patients.

Analysis of risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy in patients with lumbar disc herniation: a meta-analysis

BACKGROUND

This study aimed to systematically evaluate risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH).

METHODS

The eligible studies were retrieved from PubMed, Embase, and Web of Science databases. Quality assessment was performed. The effects of binary variables (sex, Modic change (MC), type 2 diabetes (T2DM), and smoking) on post-operative recurrence were evaluated as odds ratio (OR) and 95% confidence interval (CI). The effects of continuous variables (sagittal range of motion (SROM), body mass index (BMI), and age) were assessed as weighted mean difference (WMD) and 95% CI. Sensitivity analysis and publication bias were conducted to evaluate the reliability of pooled results.

RESULTS

Eight studies were included, and their methodological quality was medium. MC (OR (95% CI) = 3.88 (2.24-6.74), P < 0.001), smoking (OR (95% CI) = 1.87 (1.45, 2.42), P < 0.001), T2DM (OR (95% CI) = 1.61 (1.12, 2.31), P = 0.010), SROM (WMD (95% CI) = 2.33 (0.95, 3.70), P = 0.001), BMI (WMD (95% CI) = 1.68 (1.37, 1.99) kg/m2, P < 0.001), and age (WMD (95% CI) = 9.95 (5.05, 14.86) years, P < 0.001) were significantly related to post-operative recurrence in patients with LDH after PELD. Significant publication bias was not observed among studies in all outcome indicators.

CONCLUSION

Our findings reveal that high levels of age, BMI, and SROM, history of T2DM or smoking, or more MC may be correlated with post-operative recurrence after PELD.

Combining adhesive and nonadhesive injectable hydrogels for intervertebral disc repair in an ovine discectomy model

Background

Intervertebral disc (IVD) disorders (e.g., herniation) directly contribute to back pain, which is a leading cause of global disability. Next-generation treatments for IVD herniation need advanced preclinical testing to evaluate their ability to repair large defects, prevent reherniation, and limit progressive degeneration. This study tested whether experimental, injectable, and nonbioactive biomaterials could slow IVD degeneration in an ovine discectomy model.

Methods

Ten skeletally mature sheep (4-5.5 years) experienced partial discectomy injury with cruciate-style annulus fibrosus (AF) defects and 0.1 g nucleus pulposus (NP) removal in the L1-L2, L2-L3, and L3-L4 lumbar IVDs. L4-L5 IVDs were Intact controls. IVD injury levels received: (1) no treatment (Injury), (2) poly (ethylene glycol) diacrylate (PEGDA), (3) genipin-crosslinked fibrin (FibGen), (4) carboxymethylcellulose-methylcellulose (C-MC), or (5) C-MC and FibGen (FibGen + C-MC). Animals healed for 12 weeks, then IVDs were assessed using computed tomography (CT), magnetic resonance (MR) imaging, and histopathology.

Results

All repaired IVDs retained ~90% of their preoperative disc height and showed minor degenerative changes by Pfirrmann grading. All repairs had similar disc height loss and Pfirrmann grade as Injury IVDs. Adhesive AF sealants (i.e., PEGDA and FibGen) did not herniate, although repair caused local endplate (EP) changes and inflammation. NP repair biomaterials (i.e., C-MC) and combination repair (i.e., FibGen + C-MC) exhibited lower levels of degeneration, less EP damage, and less severe inflammation; however, C-MC showed signs of herniation via biomaterial expulsion.

Conclusions

All repair IVDs were noninferior to Injury IVDs by IVD height loss and Pfirrmann grade. C-MC and FibGen + C-MC IVDs had the best outcomes, and may be appropriate for enhancement with bioactive factors (e.g., cells, growth factors, and miRNAs). Such bioactive factors appear to be necessary to prevent injury-induced IVD degeneration. Application of AF sealants alone (i.e., PEGDA and FibGen) resulted in EP damage and inflammation, particularly for PEGDA IVDs, suggesting further material refinements are needed.

The effectiveness and safety of annulus closure device implantation in lumbar discectomy for patients with lumbar disc herniation: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to systematically estimate the effectiveness and safety of annulus closure device (ACD) implantation in discectomy for patients with lumbar disc herniation (LDH).

METHODS

A systematic search was performed on PubMed, EMBASE and the Cochrane Library for randomized controlled trial (RCT) from inception until April 16, 2022. Trials which investigated comparisons between with and without ACD implantation in discectomy for LDH patients were identified.

RESULTS

In total, five RCTs involving 2380 patients with LDH underwent discectomy were included. The included patients were divided into ACD group and control group (CTL). Significant differences were found in the rate of re-herniation (ACD: 7.40%, CTL: 17.58%), reoperation (ACD: 5.39%, CTL: 13.58%) and serious adverse event (ACD: 10.79%, CTL: 17.14%) between ACD group and CTL group. No significant difference was found in VAS-BACK, VAS-LEG, ODI and SF-12 PCS between ACD and CTL. The surgical time of ACD was longer than CTL with statistical significance. In subgroup analyses based on discectomy type, significant differences were found in the rate of re-herniation (ACD: 10.73%, CTL: 21.27%), reoperation (ACD: 4.96%, CTL: 13.82%) and serious adverse event (ACD: 7.59%, CTL: 16.89%) between ACD and CTL in limited lumbar discectomy (LLD).

CONCLUSION

Discectomy either with or without ACD implantation is considered to achieve similar clinical outcomes. Whereas, the ACD implantation in LLD is associated with lower re-herniation and reoperation rate but prolonged surgical time for LDH patients. Researches on cost-effectiveness and effect of ACD implantation in different discectomy are needed in the future.

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.

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.

Factors associated with the recurrence of lumbar disk herniation: non-biomechanical-radiological and intraoperative factors

BACKGROUND

Recurrent lumbar disk herniation (RLDH) is one of the most undesirable complications following lumbar discectomy (LD). This study aimed to prospectively investigate the non-biomechanical-radiological and intraoperative factors affecting the recurrence after discectomy.

PATIENTS AND METHODS

Data of 988 consecutive patients with Lumbar disk herniation (LDH) who underwent LD at our department for over 2 years (2014-2015) were prospectively collected. Patients who met our study criteria were included (n = 816). Patients were divided into the following groups; group 1 included patients with symptomatic RLDH within the first postoperative 2 years (PO24M), group 2 included patients with symptomatic RLDH after PO24M, and group 3 included patients without symptomatic RLDH/LDH. The preoperative non-biomechanical-radiological, surgical, and intraoperative characteristics were compared among the groups.

RESULTS

A total of 842 LDHs in 816 (386 men and 430 women) patients received LD. The mean age was 46.9 years. The mean follow-up period was 72.8 months. The first recurrence rates within the first PO24M and after PO24M were 7.1% and 3.2%, respectively. Disks with Modic changes type-II and contained disks without fragments were associated with the short- and long-term RLDH [(p = 0.004; HR = 0.6); (p < 0.0001; HR = 0.14)] and [(p = 0.041; HR = 0.6); (p < 0.0001; HR = 0.16)], respectively.

CONCLUSIONS

Several radiological, surgical, and intraoperative factors can play a critical role in RLDH; therefore, the selection criteria of patients with LDH should be carefully considered for surgical treatment to obtain acceptable outcomes.

ABBREVIATIONS

ANOVA: A one-way analysis of variance, CIs: 95% confidence intervals, HR: Hazard ratio, LD: Lumbar discectomy, LDH: Lumbar disc herniation, LF: ligamentum flavum, MRI: Magnetic resonance imaging, MC-I: Modic changes type I, MC-II: Modic changes type II, MC-III: Modic changes type III, n: Number, ODI: Oswestry Disability Index, OR: Odds ratio, p-value: Probability value, PO: Postoperative, Pre: Preoperative, Pts: Patients, RLDH: Recurrent lumbar disc herniation, RR: Relative/risk ratio, SPSS: Statistical package for the social science, T1WIs: T1-weighted images, T2WIs: T2-weighted images, VAS: Visual analog scale.

Genipin-crosslinked fibrin seeded with oxidized alginate microbeads as a novel composite biomaterial strategy for intervertebral disc cell therapy

Discectomy procedures alleviate disability caused by intervertebral disc (IVD) herniation, but do not repair herniation-induced annulus fibrosus (AF) defects. Cell therapy shows promise for IVD repair, yet cell delivery biomaterials capable of sealing AF defects and restoring biomechanical function have poor biological performance. To balance the biomechanical and biological demands of IVD cell delivery biomaterials, we engineered an injectable composite biomaterial using cell-laden, degradable oxidized alginate (OxAlg) microbeads (MBs) to deliver AF cells within high-modulus genipin-crosslinked fibrin (FibGen) hydrogels (FibGen + MB composites). Conceptually, the high-modulus FibGen would immediately stabilize injured IVDs, while OxAlg MBs would protect and release cells required for long-term healing. We first showed that AF cells microencapsulated in OxAlg MBs maintained high viability and, upon release, displayed phenotypic AF cell morphology and gene expression. Next, we created cell-laden FibGen + MB composites and demonstrated that OxAlg MBs functionalized with RGD peptides (MB-RGD) minimized AF cell apoptosis and retained phenotypic gene expression. Further, we showed that cell-laden FibGen + MB composites are biomechanically stable and promote extracellular matrix (ECM) synthesis in long-term in vitro culture. Lastly, we evaluated cell-laden FibGen + MB-RGD composites in a long-term bovine caudal IVD organ culture bioreactor and found that composites had low herniation risk, provided superior biomechanical and biological repair to discectomy controls, and retained anabolic cells within the IVD injury space. This novel injectable composite hydrogel strategy shows promise as an IVD cell delivery sealant with potentially broad applications for its capacity to balance biomechanical and biological performance.

Effects of Enhanced Recovery Rehabilitation Surgery Concepts on the Surgical Process, Postoperative Pain, Complications, and Prognosis of Discectomy in Patients with Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

Objective

The purpose of this study was to investigate the effect of lumbar disc herniation (LDH) disease degree on lumbar discectomy and to explore the relationship between the degree of intervertebral disc disease and postoperative pain score changes.

Methods

We conducted a comprehensive search in China National Knowledge Infrastructure (CNKI), Wanfang Data, PubMed, MEDLINE, Embase, Cochrane database, and other databases, obtained all relevant studies as of April 2017, and then followed strict inclusion and exclusion criteria. Standard screening was performed on the retrieved literature. We extract and analyze key data using Review Manager 5.3 software. Pooled effects were calculated by mean difference or odds ratio and 95% confidence interval analysis, depending on data attributes.

Results

Various databases were searched for the results of papers from lumbar discectomy since April 2017 to April 2022. Nine papers from 2502 patients were selected. The average overall follow-up was 52 weeks. There were statistically significant reductions in postoperative pain scores and degree of disc disease. There was a significant correlation between the reduction in pain score after discectomy and the degree of disc disease (r = 0.73, 95%CI = 0.01-1.20, p = 0.005).

Conclusions

Decreased disc disease grade is one of the reasons for the lower back pain score after discectomy. Furthermore, region-dependent economic factors must be considered before developing a treatment strategy. Larger, well-defined randomized controlled trials are needed to further confirm these results.

Factors associated with the recurrence of lumbar disk herniation: biomechanical-radiological and demographic factors

Many risk factors associated with recurrent lumbar disk herniation (RLDH) following lumbar discectomy (LD) have been reported. This study aimed to elucidate the biomechanical-radiological, clinical, and demographic factors that affect symptomatic RLDH prospectively.We collected prospective data of 988 consecutive patients with LDH who underwent LD at our department from January 2014 to December 2015. Patients who met the study criteria and were followed up postoperatively for more than 5 years were included (n = 816). Patients were divided into 3 groups; group 1 included patients who experienced symptomatic RLDH within the first postoperative 24 months (PO24M), group 2 included patients with symptomatic RLDH after PO24M, and group 3 included the patients who hadn't experienced symptomatic RLDH/LDH. The preoperative biomechanical-radiological, clinical, and the patients' demographic characteristics were compared among the groups.A total of 816 patients with 842 LDH met our study criteria. The mean age at the first LD was 46.9 years. The mean follow-up period was 72.8 months. The preoperative trauma history, postoperative trauma history, and BMI > 24.5 kg/m² were independent risk factors for RLDH. Large sROM at the L4-5 level and a higher intervertebral disk height index (IDH) were significantly higher in groups 1 and 2.Biomechanical-radiological and demographic factors can affect the incidence of symptomatic RLDH. To reduce the risk of RLDH, patients with these risk factors should receive more attention during surgical interventions. The patients should avoid gaining weight and potential traumatic accidents.

Lumbar discectomy with annulus fibrosus closure: a retrospective series of 53 consecutive patients

INTRODUCTION

Lumbar disc herniation is most common degenerative alteration of the spine. Whenever surgical therapy proves to be necessary, recurrent disc herniation is most frequent concern. Here, primary aim was to determine the percentage of patients eligible for insertion of an annular closure device (ACD). Secondary aim to evaluate 12-month incidence of recurrent disc herniation at the operated level. Our hypothesis was that ACD might help in preventing recurrent disc herniation.

METHODS

Patients in a single XXX neurosurgical center underwent limited discectomy alone (n=41, group 1) versus limited discectomy plus ACD (n=12, group 2). Mean postoperative follow-up period was 12 months.

RESULTS

Twelve out of 53 patients (22.6 %) were eligible for ACD implantation. Patients of group 2 were significantly taller (mean 176 cm, p= 0.007) as compared with group 1 (mean 170). The only statistically significant difference of intraoperative parameters between group 1 and 2 was amount of nucleus materiel removed (p= 0.01), being greater in group 2 (mean 0.9) as compared with group 1 (mean 0.3). In group 1 six patients (6/41, 14.6%) presented with symptomatic reherniation at same level of surgery, while in group 2 only one patient experienced recurrence (1/12, 8.3%). No adverse events were reported.

DISCUSSION

In the current study one out of five patients with lumbar disc herniation was considered suitable for ACD placement. In vast majority of these patients reherniation was precluded on the short-term basis. Patients with ACD were taller and had intraoperatively a higher volume of the nucleus pulposus materiel removed.