Magnetic resonance image changes and clinical outcome after microdiscectomy or nucleotomy for ruptured disc

Magnetic Resonance Imaging Findings and Clinical Outcomes in the Early Postoperative Period after Full Endoscopic Diskectomy for Lumbar Disk Herniation

INTRODUCTION

 This prospective case-control study aimed to establish the normal spectrum of early magnetic resonance imaging (MRI) findings in patients whose symptoms resolve after full endoscopic diskectomy (FED). We examined the changes in postoperative MRI findings and their relation to early clinical symptoms.

METHODS

 In total, 33 patients underwent FED under local anesthesia. Clinical assessments and MRI examinations were performed preoperatively and immediately (within 1 week) and late (at 3 and 12 months) postoperatively. Residual disk bulging after surgery was classified into four grades compared with preoperative MRI findings: none (grade A), <25% (grade B), 25-75% (grade C), and >75% (grade D).

RESULTS

 MRI at postoperative week 1 showed grade B residual disk bulging in 9 patients, grade C residual disk bulging in 8 patients, and grade D residual disk bulging in 16 patients. Improvement was seen at postoperative month 3 (grade A in 18 patients, grade B in 10 patients, and grade C in 5 patients) and at postoperative month 12 (grade A in 29 patients, grade B in 3 patients, and grade C in 1 patient). Visual analog scale scores and the Japanese Orthopaedic Association scores showed significant differences at 1 week, 3 months, and 12 months after surgery.

CONCLUSION

 Postoperative MRI findings within 1 week of FED showed grade C or D residual disk material in 24 of 33 patients (73%). Clinical symptoms improved in the early postoperative period, even though residual disk bulging was present. Persisting residual bulging in the early stage following surgery may not correlate with clinical symptoms.

Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review

The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.

Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis

BACKGROUND

Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment.

METHODS

A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points).

RESULTS

The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I(2)=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33).

CONCLUSIONS

Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined.

Spontaneous resolution of tetraparesis because of postoperative cervical epidural hematoma

BACKGROUND CONTEXT

Symptomatic postoperative spinal epidural hematoma (PSEH) is a rare but potentially devastating postoperative complication, accounting for 0.1% to 0.2% of cases.

PURPOSE

To describe a patient with a PSEH that completely resolved, clinically and radiographically, without surgical treatment.

STUDY DESIGN

Case report and review of the literature.

METHODS

A 47-year-old man with no history of a bleeding disorder underwent anterior cervical interbody fusion for C5-C6 disc herniation. The dura was exposed through removal of the posterior longitudinal ligament, and extensive decompression of posterior osteophytes of C5 and C6 vertebral bodies was performed. The patient developed tetraparesis and respiratory distress rapidly in the postanesthesia care unit and was reintubated for assisted ventilation. The computed tomography (CT) scan revealed a very large ventral epidural hematoma compressing the dural sac from C1 to C6.

RESULTS

The patient was prepared for hematoma evacuation. However, the neurological symptoms and respiration problems began to resolve spontaneously before the surgery was started. The hematoma was markedly improved on the follow-up CT scan, and the patient was discharged 2 weeks after surgery without neurological deficit.

CONCLUSIONS

This case illustrates that an unpredictable extensive hematoma can occur after uneventful surgery of the cervical spine in low-risk patients. In case of the dural exposure with a creation of hidden and large epidural space, the spine surgeon must pay particular attention to the possibility of a PSEH during the early postoperative period.

Are Drains Useful for Lumbar Disc Surgery?

OBJECTIVE

In this prospective, observer-masked clinical study, we evaluated if insertion of a drain had a significant role in decreasing the existence and the size of postoperative epidural hematoma, which is believed to be a factor causing epidural fibrosis in patients undergoing lumbar discectomy.

METHOD

Fifty patients undergoing lumbar disc surgery were randomly assigned to two groups: with or without insertion of a drain in the epidural space. A drain was inserted in 22 patients, whereas 28 were left without a drain. All patients were evaluated, by means of magnetic resonance imaging (MRI) on the first postoperative day, specifically looking for the existence and the size of epidural hematoma. The size of epidural hematoma was graded as none, minimal, moderate, or prominent. The patients were clinically examined preoperatively and at the follow-up of 6 months by Oswestry Disability Index and recurrence of pain. A follow-up MRI was repeated at 6 months, and the subsequent development of epidural fibrosis was evaluated.

RESULTS

Epidural hematoma was detected in 36% of patients with a drain and in 89% of patients without a drain (P=0.000). There were significant less number of minimum, moderate, and prominent sized hematomas in the group with a drain (P=0.000). On the 6-month follow-up, epidural fibrosis was found in 58.3% of patients without a drain and in 31.6% of patients with a drain (P=0.08). Late clinical outcome (improvement in Oswestry Index and no recurrent pain) was better in the group with drain, but not statistically significant (P=0.4).

CONCLUSIONS

Occurrence of hematoma in the epidural space is common after lumbar disc surgery even if meticulous hemostasis has been achieved. Insertion of a drain decreases both the incidence and the size of hematoma on the first postoperative day as detected by MRI. This may have practical implications for the prevention of significant postoperative fibrosis and obtaining better surgical outcome.

Long-term vertebral changes attributable to postoperative lumbar discitis: a retrospective study of six cases

A clinical, plain radiographic, and magnetic resonance imaging retrospective followup study was done on six patients with postoperative septic L4-L5 lumbar spondylodiscitis to identify the characteristic long-term radiographic findings predicting the clinical outcome. The mean followup was 12 years (range, 9-13 years). Three patients had moderate low-back pain and two were handicapped. One patient had slight peroneal weakness. Flexibility of the lumbar spine was restricted to some extent in all patients. Laminectomy for spinal stenosis (L4-L5) had been done in one patient and reoperation because of recurring disc herniation was done in two patients. Partial or total bone marrow depletion and corresponding enhancement of fat signals in relation to adjacent vertebral bodies, narrowing of the intervertebral disc space, and irregularity or cavitations affecting one or both end plates were long-term findings of magnetic resonance imaging. Plain radiographs and magnetic resonance imaging scans revealed a complete bony fusion in one patient and partial fusion in one patient. In two patients, residual disc protrusion or herniation in relation to the surgically treated disc was evident; three affecting L3-L4 and two affecting L5-S1 disc levels. Septic postoperative lumbar discitis severely hampers clinical recovery after disc operations and results in long-term changes as seen on magnetic resonance imaging scans.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The Oswestry Disability Index

STUDY DESIGN

The Oswestry Disability Index (ODI) has become one of the principal condition-specific outcome measures used in the management of spinal disorders. This review is based on publications using the ODI identified from the authors' personal databases, the Science Citation Index, and hand searches of Spine and current textbooks of spinal disorders.

OBJECTIVES

To review the versions of this instrument, document methods by which it has been validated, collate data from scores found in normal and back pain populations, provide curves for power calculations in studies using the ODI, and maintain the ODI as a gold standard outcome measure.

SUMMARY OF BACKGROUND DATA

It has now been 20 years since its original publication. More than 200 citations exist in the Science Citation Index. The authors have a large correspondence file relating to the ODI, that is cited in most of the large textbooks related to spinal disorders.

METHODS

All the published versions of the questionnaire were identified. A systematic review of this literature was made. The various reports of validation were collated and related to a version.

RESULTS

Four versions of the ODI are available in English and nine in other languages. Some published versions contain misprints, and many omit the scoring system. At least 114 studies contain usable data. These data provide both validation and standards for other users and indicate the power of the instrument for detecting change in sample populations.

CONCLUSIONS

The ODI remains a valid and vigorous measure and has been a worthwhile outcome measure. The process of using the ODI is reviewed and should be the subject of further research. The receiver operating characteristics should be explored in a population with higher self-report disabilities. The behavior of the instrument is incompletely understood, particularly in sensitivity to real change.

Early postoperative MRI findings following surgery for herniated lumbar disc. Part II: A gadolinium-enhanced study

The aim of our study was to evaluate the contrast-enhanced MR imaging (MRI) findings, in the early postoperative period, in unselected patients undergoing lumbar microdiscectomy (15/16 had total resolution of their symptoms). Contrast-enhanced imaging studies were performed, in all 16 patients of our series, before surgery, and at the third postoperative day and, two months after surgery. Postoperative paraspinal muscles enhancement was present in all patients. In the postoperative period, nerve root enhancement was present in 5/16 patients at the early survey and persisted in one after two months. A pseudohernia depicted as epidural intermediate signal intensity tissue, was seen in 13 patients at the third day MRI, and only in eight after two months. This pseudohernia enhanced peripherally in 8/13 patients and enhanced homogeneously in the remaining five at the first postsurgical examination; in the late MRI the peripheral enhancement was appreciable in only two patients while a homogeneous enhancement was observed in six. Clinical symptoms resolved completely in 14/16 patients on clinical evaluation at the third postoperative day, while the remaining two patients showed residual symptoms and signs of radicular compression. At the early MRI these two patients showed intradural nerve root enhancement. Two months later, one patient did not show the previously described nerve root enhancement and improved clinically, while the other had a positive Straight Leg Raising Sign with persistent intradural nerve root enhancement. In conclusion, no correlation between clinical course and contrast-enhancement of pseudohernia and extradural nerve root was appreciable, although intradural nerve root enhancement seems to represent a clinically relevant finding.

Early postoperative MRI findings following surgery for herniated lumbar disc

MRI is routinely used in the evaluation and management of patients with failed back surgery syndrome (FBSS). However, its value is unclear in the early detection of signs that can negatively affect that later course of surgical cases. The purpose of the present study is to describe the MR images of early postoperative MRI at 3 days in 30 unselected patients who underwent lumbar microdiscectomy, and to correlate the findings with follow up MRI at 8 weeks and with final outcome. The findings are correlated with literature data. Early postoperative MRI findings were consisting of pseudohernia in 24 patients (80%), annular rent in 23 patients (80%), and other non-specific postoperative findings. On the late MRI the pseudohernia persisted in 12 patients (50%), the annular rent in 4 patients (15%) and asymptomatic pseudo-spondylodiscitis was apparent in 3 patients (10%) as was a case of true spondylodiscitis. Therefore, early postoperative findings have limited value in the management of patients after surgery for lumbar disc herniation, since the images were not correlated with the immediate clinical course after surgery nor with the late radiological and clinical outcome. The evident imaging changes in the early postoperative period after lumbar disc surgery limit the accuracy of the interpretation of MRI examinations.

Cross-sectional areas of lumbar muscles after surgical treatment of lumbar disc herniation. A study with magnetic resonance imaging after microdiscectomy or percutaneous nucleotomy

We assessed in this study the potential development of postoperative muscle atrophy in the operation area in 39 patients treated by either microdiscectomy or percutaneous nucleotomy for lumbar disc herniation. The cross-sectional areas of the lumbar muscles were measured on magnetic resonance images created on the day preceding the operation and 6 months postoperatively. The cross-sections of the lumbar muscles remained unchanged during the observation period in all treated patients indicating that no muscle atrophy had developed in the operation area. Since peroperative tissue trauma may correlate with subsequent muscle denervation and atrophy, this finding may be due to the tissue sparing nature of microdiscectomy and percutaneous nucleotomy, thus encouraging the use of these techniques in the treatment of lumbar disc herniation.

Percutaneous nucleotomy in the treatment of lumbar disc herniation results after a mean follow-up of 2 years

We have evaluated the clinical outcome of 45 consecutive patients who underwent percutaneous nucleotomy for a single-level disc herniation. Included were 28 (62%) woman and 17 (38%) men, with a mean age of 46 years. The mean postoperative follow-up time was 2 years. Intra-operatively, disc herniation was graded as a protrusion in 23 (51%) patients and as a prolapse in 22 (49%) patients. During the follow-up, sciatic pain completely recovered or markedly diminished in 38 (84%) patients and 35 (78%) patients returned to work. The occupational outcome of the patients operated on for a protrusion was inferior to that of the patients operated on for a prolapse: only 22% of the patients who underwent surgery for a protrusion reported to manage their work well, while as many as 41% of those with a prolapse managed well (p = 0.04). Pre-operatively, clinical examination revealed segmental instability of the lumbar spine in 11 (24%) patients. There was a significant association between instability and unsatisfactory long-term outcome: of the patients with pre-operative instability, 45% were postoperatively retired or on sick leave because of the back, as compared to 15% of the 34 patients without instability (p = 0.03). Furthermore, patients with instability suffered from sciatica and low back pain significantly (p = 0.02) more often than those without instability. Surgical complications were infrequent. There were no nerve root lesions and no vascular injuries. Postoperative discitis developed in 2 (4%) patients. Of all patients, only 1 (2%) has been re-operated on for a recurrent disc.