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

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation

STUDY DESIGN

Systematic review.

OBJECTIVES

Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions.

METHODS

A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001).

CONCLUSION

Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Return to Play, Performance, and Earnings Analysis After Lumbar Disc Herniation in National Hockey League Players

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Professional hockey players have a high incidence of lumbar disc herniations (LDH). The purpose of this study was to determine the impact of LDH on the performance and financial earnings of National Hockey League (NHL) players.

METHODS

NHL players who sustained a LDH were retrospectively reviewed utilizing an online database and a 2:1 matched control cohort. Player performance and game usage was compared at one- and three-season(s) pre- and post-injury season within the cohorts. Injured and matched players were divided into 3 groups based on the player's adjusted index season salary.

RESULTS

A total of 181 players were included, with 62 LDH players matched to 119 healthy controls. Return to play after LDH was 79%. The LDH cohort had fewer seasons played throughout their career compared to the matched group (12.5 ± 4.3 vs 14.2 ± 3.8; P = .031). At 1 season post-index, the LDH cohort had significantly fewer goals per 60 and points per 60 when compared to pre-index. At 3 seasons post-index, the LDH cohort exhibited a significant decline in time-on-ice per game played, goals per 60, and points per 60 compared to pre-index.

CONCLUSION

The majority of NHL players who sustained a LDH returned to play (79%) but had shorter careers overall and decreased performance outcomes when compared to matched cohorts at both 1 and 3 seasons post-injury.

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.

Evaluation of outcomes of discectomy with a dynamic neutralization system in treatment of lumbar disk herniation

OBJECTIVE

The study aimed to explore the clinical outcomes of discectomy with dynamic neutralization system (Dynesys) for single-segmental lumbar disk herniation (LDH) versus simple discectomy.

METHODS

The eligible patients with single-segmental LDH were randomly divided into the discectomy with Dynesys group (group A) and the simple discectomy group (group B). The Oswestry disability index (ODI), visual analog score (VAS), radiological results of intervertebral height and range of motion (ROM) of the treated segment were evaluated pre- and post-operatively in both groups. Operation duration and blood loss were recorded. Complications, reoperation, and mortality were also assessed. All patients received a 2-year follow-up.

RESULTS

123 (96.1%) participants completed the follow-up. The operation duration and blood loss of group B were significantly lower than those of group A (p<0.05). After operation, ODI and VAS were improved significantly in both groups, and there was no significant difference between the two groups immediately after surgery. But a rising trend was found in ODI and VAS of group B, especially after the 1-year follow-up (p<0.05). X-rays showed a continuing loss of intervertebral height of the treated segment in group B, while it was preserved in group A (p<0.05). ROM of the treated segment was also maintained stable in group A.

CONCLUSION

Discectomy with Dynesys is safe and effective for LDH treatment.

Implementing the 27 PRISMA 2020 Statement items for systematic reviews in the sport and exercise medicine, musculoskeletal rehabilitation and sports science fields: the PERSiST (implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science) guidance

Poor reporting of medical and healthcare systematic reviews is a problem from which the sports and exercise medicine, musculoskeletal rehabilitation, and sports science fields are not immune. Transparent, accurate and comprehensive systematic review reporting helps researchers replicate methods, readers understand what was done and why, and clinicians and policy-makers implement results in practice. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and its accompanying Explanation and Elaboration document provide general reporting examples for systematic reviews of healthcare interventions. However, implementation guidance for sport and exercise medicine, musculoskeletal rehabilitation, and sports science does not exist. The Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science (PERSiST) guidance attempts to address this problem. Nineteen content experts collaborated with three methods experts to identify examples of exemplary reporting in systematic reviews in sport and exercise medicine (including physical activity), musculoskeletal rehabilitation (including physiotherapy), and sports science, for each of the PRISMA 2020 Statement items. PERSiST aims to help: (1) systematic reviewers improve the transparency and reporting of systematic reviews and (2) journal editors and peer reviewers make informed decisions about systematic review reporting quality.

Technical Tips for Percutaneous Transforaminal Endoscopic Discectomy: A Three-step Maneuver for Puncture and Early Clinical Experience

OBJECTIVE

To investigate the feasibility and efficacy of percutaneous transforaminal endoscopic discectomy (PTED) with three-step maneuver for puncture (TSMP) for lumbar herniated disc (LDH).

METHODS

We performed a retrospective review of 30 patients who underwent PTED using TSMP for LDH and met inclusion criteria from January 2018 to September 2018. The primary outcome, leg or back pain, was assessed using Visual Analogue Scale (VAS). Patient surgical satisfaction was measured at 12 months post surgery using a five-point Likert scale. Potential prognostic factors measured were demographic characteristics, duration of symptom (DOS), and involved levels. Statistical analysis was performed using Fisher exact test and t-test. TSMP is a three-step maneuver that builds on the concept of needle puncture site and trajectory determination based on the principles of Kambin's triangle. First, accurate direction of the puncture is confirmed by inserting the needle horizontally. Then by gradually raising the needle tail in the manner described, the superior articular facet and the intervertebral foramen are sequentially located. Finally, the needle tip slides into the intervertebral foramen to reach the target superior articular facet.

RESULTS

Preoperative mean VAS was 7.6 ± 1.19, which decreased to 1.4 ± 0.97 at 12 months following treatment (P < 0.0001). Rates of surgical satisfaction per Likert scale were as follows: very satisfied and satisfied in 26 patients (86.7%). Three recurrent disc herniations of adjacent segmental levels were observed in the L5-S1 group at eight and 12 months after surgery. VAS scores at 12 months varied significantly between L4-L5 level surgery and L5-S1 level surgery groups (P < 0.01).

CONCLUSION

TSMP is a reliable technique for puncture into the intervertebral foramen.

Return to Play for Cervical and Lumbar Spine Conditions

Although the safety of contact sports has improved over the years, participation in any sport always carries a risk of injury. When cervical or lumbar spine injuries do occur, prompt diagnosis is essential, and athletes must be held out of the sport if indicated to prevent further harm and allow for recovery. This article highlights some of the most common cervical spine pathologies (stinger/burners, strain, stenosis/cord neuropraxia, disc herniation, and fracture/instability) and lumbar spine pathologies (strain, disc degeneration, disc herniation, fracture, spondylolysis/spondylolisthesis, and scoliosis) encountered in sports and reviews the associated return to play guidelines and expectations for each condition.

The Efficacy and Treatment Fidelity of Kinesiology Taping in Conjunction With Conservative Treatment Interventions Among Individuals With Shoulder Pain: A Systematic Review with Meta-Analysis

PURPOSE

Kinesiology taping is a common intervention used to treat individuals with shoulder pain. While there have been several studies published to date evaluating the effectiveness of this intervention, a systematic review with meta-analysis synthesizing the collective effectiveness of kinesiology taping is not available. Therefore, the purpose of this study was to perform a systematic review with meta-analysis investigating the efficacy and treatment fidelity of kinesiology taping (KT) in combination with conservative interventions for shoulder pain.

METHODS

Databases (PubMed, EMBASE, SportDiscus, CINAHL) of studies published in English meeting criteria were searched to October 2019. Methodologic quality was assessed utilizing the Modified Downs and Black checklist. Treatment fidelity was evaluated using a modified fidelity tool. Random effects meta-analyses were performed when an outcome (disability, pain, range of motion (ROM)) was reported by two or more studies. Overall effect size (pooled random effects) was estimated for studies with acceptable clinical homogeneity.

RESULTS

When KT was used with conservative treatments, meta-analysis revealed large effect sizes for improvements in disability (standard mean difference (SMD) = -1.35; 95% CI, -2.09 to -0.60) and ROM (SMD = 0.96; 95% CI, 0.60-1.33) with no significant effects for pain. The average Modified Downs & Black score for bias was 11.5 ± 3.9. Of 10 retained studies, only two had good treatment fidelity.

CONCLUSIONS

Adding KT to interventions performed in clinical settings appears to demonstrate efficacy regarding disability and ROM when compared to conservative interventions alone. However, despite reasonably good methodologic quality, fidelity was lacking in a majority of studies. Because of its impact on the implementation of evidence-based practice, lower fidelity should be considered when interpreting results.

Guidelines for Rehabilitation and Return to Play After Cervical Surgery in a General Athletic Population: A Delphi Analysis

OBJECTIVE

Decisions concerning the rehabilitation process and return to play (RTP) after cervical spine surgery in a general sporting population can be difficult and may be influenced by several factors. Moreover, no clear guidelines for this are currently available. The aim of this study was to create tentative guidelines for rehabilitation and RTP after cervical surgery in a general sporting population.

DESIGN

Five-step Delphi analysis.

SETTINGS

Primary, secondary, and tertiary medical practitioners.

PARTICIPANTS

Panel of Belgian neurosurgeons, orthopedic surgeons, physiotherapists, and physical and rehabilitation medicine practitioners.

ASSESSMENT

Round 1 (R1) was a brainstorm phase. A comprehensive list of answers from R1 was validated in round 2 (R2). In round 3 (R3), experts ranked these items in a chronological order. Contraindications and criteria to start each rehabilitation step were linked in round 4 (R4). In round 5 (R5), panelists ranked theses about contraindications and criteria on a 5-point Likert scale.

MAIN OUTCOME MEASURES

Theses scoring ≥10% "oppose" or "strongly oppose" were rejected.

RESULTS

The response rate was 100% (n = 15) for R1, 93% (n = 14) for R2, 73% (n = 11) for R3, 53% (n = 8) for R4, and 67% (n = 10) for R5. In R5, 25 theses on absolute and relative contraindications and criteria were endorsed.

CONCLUSIONS

This Delphi analysis resulted in contraindications and criteria for the rehabilitation process and RTP after cervical surgery in a general athletic population. Tentative guidelines and timetable are proposed. Key messages from these guidelines are (1) Rehabilitation should start before surgery with education; (2) Rehabilitation should be patient-tailored; and (3) An unstable arthrodesis is an absolute contraindication for RTP.

Return to Play After Symptomatic Lumbar Disc Herniation in Elite Athletes: A Systematic Review and Meta-analysis of Operative Versus Nonoperative Treatment

Context:

The prevalence of symptomatic lumbar disc herniation (LDH) in athletes can be as high as 75%. For elite athletes diagnosed with LDH, return to play (RTP) is a major concern, and thus comparing surgical with nonoperative care is essential to guide practitioners and athletes, not just in terms of recovery rates but also speed of recovery.

Objective:

The purpose of this systematic review is to provide an update on RTP outcomes for elite athletes after lumbar discectomy versus nonoperative treatment of LDHs.

Data Sources:

A search of the literature was conducted using 3 online databases (MEDLINE, EMBASE, and PubMed) to identify pertinent studies.

Study Selection:

Yielded studies were screened according to the inclusion criteria.

Study Design:

Systematic review with meta-analysis.

Level of Evidence:

Level 4.

Data Extraction:

Relevant data were extracted. A meta-analysis was performed comparing RTP rate for all comparative studies.

Results:

Twenty studies met the inclusion criteria and were included in this review. Overall, 663 out of 799 patients (83.0%) returned to play in the surgical group and 251 out of 308 patients (81.5%) returned to play in the nonoperative group. No statistically significant difference for RTP rate was found (odds ratio, 1.39; 95% CI, 0.58-3.34; P = 0.46; I2, 71%). The mean time to RTP for patients undergoing lumbar discectomy was 5.19 months (range 1.00-8.70 months), and 4.11 months (range 3.60-5.70 months) for those treated conservatively.

Conclusion:

There was no significant difference in RTP rate between athletes treated with operative or nonoperative management of LDHs, nor did operative management have a faster time to RTP. Athletes should consider the lack of difference in RTP rate in addition to the potential risks associated with spinal surgery when choosing a treatment option. Future randomized controlled trials are needed on this topic to allow for high-powered conclusions.

Treating low back pain in athletes: a systematic review with meta-analysis

OBJECTIVE

To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement.

DATA SOURCES

Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS).

RESULTS

Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments.

CONCLUSIONS

While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

Biopsychosocial variations in quality of life outcome following microdiscectomy

Background

Lumbar microdiscectomy is one of the most frequently performed neurosurgical procedures. In this review, we ask why patients' outcomes vary so widely even within the same unit, with the same surgeon performing the procedure and utilizing the technique?

Methods

In a cohort of 87 patients, we investigated how/whether multiple patient variables impacted outcomes following single-level lumbar microdiscectomy. We studied whether early surgical intervention improved the patients' quality of life (QOL) versus late intervention. Furthermore, we assessed other variables that could influence patient-perceived improvement. Preoperatively and postoperatively, we additionally utilized the following internationally standardized questionnaires (EQ-5D, Oswestry, and Core Outcome Measures Index [COMI]).

Results

A generalized substantial improvement in QOL was identified throughout the cohort population (<0.05). There was no difference in health measurement scores for those undergoing early versus late surgery. However, there was a statistically significant improvement in all QOL scores for privately insured patients versus publicly insured patients (e.g., on COMI, EQ-5D, and ODI Scores).

Conclusion

There was no objective statistically significant difference in QOL health scores between patients undergoing early versus late surgical lumbar microdiscectomy. This would suggest that the length of time patients is symptomatic before surgery did not significantly impact postoperative outcome. Of interest, however, was the difference in QOL health scores for private versus public patients suggesting that there are more subjective, complex, and psychosocial issues that influence outcome.

Are Modic Changes Associated With Health-related Quality of Life After Discectomy: A Study on 620 Patients With Two-year Follow-up

STUDY DESIGN

A registry-based comparative cohort study with 2-year follow-up.

OBJECTIVE

To assess whether Modic changes (MCs) are associated with health-related quality of life, long-term physical disability, back- or leg pain after discectomy.

SUMMARY OF BACKGROUND DATA

Previous studies have failed to show a clinically significant association between MCs and patient-reported outcomes (PROs) after discectomy.

METHODS

Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014 to 2017 with an accessible preoperative lumbar magnetic resonance imaging, complete preoperative, and 2-year follow-up questionnaires were obtained. PROs including Oswestry disability index (ODI), European Quality of Life-Five Dimensions (EQ-5D), visual analogue scale (VAS) back and leg pain, and patient satisfaction were collected. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI.

RESULTS

Of 620 patients included, MCs were present in 290 patients (47%). Of these, MC type 1 (MC-1) was present in 73 (25%) and MC type 2 (MC-2) in 217 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PROs from baseline compared with 2-year follow-up (P < 0.001). At 2-year follow-up, both groups had improved with no significant difference between them in regards to ODI (15.5 vs. 17.2, P = 0.208); EQ-5D (0.75 vs. 0.72, P = 0.167); VAS-BP (27.1 vs. 28.3, P = 0.617); VAS-LP (26.8 vs. 25.0, P = 0.446); and patient satisfaction (74% vs. 76%, P = 0.878).

CONCLUSION

MCs were not found to be associated with health-related quality of life, disability, back- or leg pain, or patient satisfaction 2 years after discectomy.

LEVEL OF EVIDENCE

2.

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance.

Hypothesis/Purpose

Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures.

Study Design

Systematic Review & Meta-Analysis.

Methods

A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale.

Results

Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity.

Conclusions

Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination.

Level of Evidence

Level 1a.

Endoscopic Spine Surgery in Athletes: Case Series and Review of Literature

BACKGROUND

Degenerative spine disease is common in athletes and can progress to requiring surgical intervention. Traditional open surgical techniques necessitate prolonged recovery time and time away from play. Newly developed endoscopic surgical techniques may promote faster healing and recovery, and increased return to play. The goal of this paper is to summarize the current evidence in return to play after spine surgery and to present our series of 3 athletes who underwent endoscopic spine surgery.

METHODS

A complete search of all PubMed indexed articles pertaining to spine surgery in athletes was conducted. This was supplemented by a 3-patient case series of our own endoscopic spine experience in athletes.

RESULTS

There are no current widely accepted guidelines for return to play after spinal surgery. The best evidence available cites a return to play of 81% at 5.2-8.7 months after traditional open and minimally invasive surgery, and endoscopic surgery produces an average 88% return to play rate at 3 months.

CONCLUSIONS

Although return to play can vary widely, case-based evidence as well as biomechanical principles support endoscopic spine surgery as a viable surgical modality for the treatment of spinal pathologies in athletes.

Injuries and associated risk factors of the shoulder and elbow among adolescent baseball pitchers: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to perform a systematic review and meta-analysis of the current literature surrounding risk factors associated with shoulder and elbow injuries among adolescent baseball pitchers.

METHODS

Relevant studies were assessed for inclusion and retained from PubMed, EMBASE, SportDiscus, and CINAHL databases. Data was extracted from the retained studies and underwent methodological quality assessment and meta-analysis.

RESULTS

The search resulted in 1238 studies identified with 10 ultimately retained for systematic review. Five studies including one case-control, two prospective cohort, and two cross-sectional studies met inclusion criteria for meta-analysis. This meta-analysis revealed that playing with arm fatigue was a significant risk factor (pooled odds ratio = 13.32, 95% confidence interval: 3.22-55.09). The other three risk factors (long competitive season, pitching for more than one team or league, and playing catcher as a secondary position) were not statistically significant.

CONCLUSION

Pitching with arm fatigue is a significant risk factor for shoulder and elbow injuries among adolescent baseball pitchers. Future efforts in assessment and mitigation of pitching with arm fatigue among this population may help to reduce the risk of arm injuries. Furthermore, investigations of additional risk factors in a more homogeneous population of adolescent pitchers may be warranted.

Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations

Low back pain is one of the most prevalent complaints of athletes at all levels of competition. The purpose of this literature review is to provide an overview of sport-specific injuries and treatment outcomes that can be used by healthcare providers to better recognize injury patterns and treatment options for different groups of athletes. To our knowledge, no prior comprehensive review of lumbar spine injuries in sports is currently available in the literature, and it is essential that healthcare providers understand the sport-specific injury patterns and treatment guidelines for athletes presenting with low back pain following an athletic injury. Injury mechanisms were found to vary significantly by sport, although some broad recommendations can be made with regards to optimal treatment for these injuries and return to play. Additionally, it was found that certain treatments were more beneficial and resulted in higher rates of return to play depending on the specific sport of the injured athlete. Healthcare providers need to be aware of the different injury patterns seen in specific sports in order to properly evaluate and treat these injuries. Furthermore, an individualized treatment plan needs to be selected in a sport-specific context in order to meet the needs of the athlete in the short and long term.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Prospective Detailed Time Analysis Study of 18 Patients Undergoing Elective Single-Level Open Lumbar Microdiscectomy Spinal Surgery Compared with Centers for Medicare and Medicaid Services Reimbursement Guidelines

BACKGROUND

Single-level open lumbar microdiscectomy surgery is one of the most straightforward and effective spinal surgeries performed by spinal surgeons today to treat disk herniation. Although a common operation, little in the literature is reported on the exact overall time, cost, and effort associated with the performance of this surgery. The consistency of this operation across institutions and disciplines makes it a good starting point to accurately track the total time and effort of all phases of the surgical intervention.

METHODS

Eighteen patients undergoing elective single-level open lumbar microdiscectomy surgery were prospectively enrolled in this study. The time spent interacting with each patient by every member of the surgical team was tracked and recorded along will every phone call and e-mail. All perioperative times associated with the surgery were tracked and analyzed. Each patient was followed from their first interaction through surgery and for the first 3 months postoperatively.

RESULTS

The advanced practice providers spent the most time with the patient both pre- and postoperatively followed by the surgeon and resident. A total of 2.98 hours was spent with the patient preoperatively in clinic and 1.69 hours postoperatively. The total time commitment of an institution treating this condition was 12.56 hours.

CONCLUSIONS

Comparing our results with the Centers for Medicare and Medicaid Services data, a significant discrepancy and underestimation was observed. As such, we hope our results enable health care providers to more accurately allocate resources for the provision of high-quality medical care to patients with this increasingly common condition.

Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of surgical versus non-operative treatment on the physical function and safety of patients with lumbar disc herniation.

DATA SOURCES

PubMed, Cochrane Library, Embase, EBSCO, Web of Science, China National Knowledge Infrastructure and Chinese Biomedical Literature Database were searched from initiation to 15 May 2017.

METHODS

Randomized controlled trials that evaluated surgical versus non-operative treatment for patients with lumbar disc herniation were selected. The primary outcomes were pain and side-effects. Secondary outcomes were function and health-related quality of life. A random effects model was used to calculate the pooled mean difference with 95% confidence interval.

RESULTS

A total of 19 articles that involved 2272 participants met the inclusion criteria. Compared with non-operative treatment, surgical treatment was more effective in lowering pain (short term: mean difference = -0.94, 95% confidence interval = -1.87 to -0.00; midterm: mean difference = -1.59, 95% confidence interval = -2.24 to -9.94), improving function (midterm: mean difference = -7.84, 95% confidence interval = -14.00 to -1.68; long term: mean difference = -12.21, 95% confidence interval = -23.90 to -0.52) and quality of life. The 36-item Short-Form Health Survey for physical functions (short term: mean difference = 6.25, 95% confidence interval = 0.43 to 12.08) and bodily pain (short term: mean difference = 5.42, 95% confidence interval = 0.40 to 10.45) was also utilized. No significant difference was observed in adverse events (mean difference = 0.82, 95% confidence interval = 0.28 to 2.38).

CONCLUSION

Low-quality evidence suggested that surgical treatment is more effective than non-operative treatment in improving physical functions; no significant difference was observed in adverse events. No firm recommendation can be made due to instability of the summarized data.