Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes

Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain

Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.

The Duration of Symptoms Influences Outcomes After Lumbar Microdiscectomies: A Michigan Spine Surgery Improvement Collaborative

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

We investigate whether duration of symptoms a patient experiences prior to lumbar microdiscectomy affects pain, lifestyle, and return to work metrics after surgery.

METHODS

A retrospective review of patients with a diagnosis of lumbar radiculopathy undergoing microdiscectomy was conducted using a statewide registry. Patients were grouped based on self-reported duration of symptoms prior to surgical intervention (Group 1: symptoms less than 3 months; Group 2: symptoms between 3 months and 1 year; and Group 3: symptoms greater than 1 year). Radicular pain scores, PROMIS PF Physical Function measure (PROMIS PF), EQ-5D scores, and return to work rates at 90 days, 1 year, and 2 years after surgery were compared using univariate and multivariate analysis.

RESULTS

There were 2408 patients who underwent microdiscectomy for lumbar disc herniation for radiculopathy with 532, 910, and 955 in Groups 1, 2, and 3, respectively. Postoperative leg pain was lower for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05). Postoperative PROMIS PF and EQ-5D scores were higher for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05).

CONCLUSION

Patients with prolonged symptoms prior to surgical intervention experience smaller improvements in postoperative leg pain, PROMIS PF, and EQ-5D than those who undergo surgery earlier. Patients undergoing surgery within 3 months of symptom onset have the highest rates of return to work at 1 year after surgery.

Impact of Preoperative Duration of Symptoms on Patient Satisfaction, Outcomes and Complications After Lumbar Discectomy: A Propensity-matched Comparison

STUDY DESIGN

Observational study.

OBJECTIVE

To identify associations between preoperative symptom duration and postoperative patient satisfaction.

SUMMARY OF BACKGROUND DATA

Sciatica due to lumbar disk herniation (LDH) is a cause of disability and reduced quality life. Patients with severe pain and disability or were recovery is unacceptably slow, surgical intervention can be advised. For these patients, evidence-based recommendations on the timing of the surgical intervention needs to be established.

METHODS

All patients who underwent discectomy at a Spine Centre, due to radicular pain from June 2010 to May 2019 were included. Pre- and postoperative data including demographic data, smoking, consumption of pain medication, comorbidity, back and leg-pain, health-related quality of life as measured by EQ-5D, ODI, previous spine surgery, sick leave, and duration of back and leg-pain before surgery were utilized. The patients were divided into four groups based on their self-reported duration of leg-pain before surgery. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on all reported preoperative factors.

RESULTS

Of 1607 patients undergoing lumbar discectomy, four matched cohorts based on their self-reported duration of leg-pain before surgery were created. Each cohort consisted of 150 patients well balanced on preoperative factors. Overall 62.7% of the patients were satisfied with the surgical result ranging from 74.0% in the <3 months group to 48.7% in the >24 months group ( P <0.000). The portion of patients achieving a minimum clinically important difference for EQ-5D decreased from 77.4% with early intervention to 55.6% in the late group ( P <0.000). The number of surgical complications were not affected by the duration of preoperative leg-pain.

CONCLUSION

We found significant difference in patient satisfaction and health-related quality of life in patients related to the duration of preoperative leg-pain due to symptomatic LDH.

LEVEL OF EVIDENCE

3.

Comparison of Surgical Outcomes of Microdiskectomy Procedures by Patient Admission Status

OBJECTIVE

We sought to compare the cost and in-hospital outcomes following lumbar microdiskectomy procedures by admission type.

METHODS

Patients undergoing lumbar microdiskectomy at a single institution from 2008 to 2016 following an elective admission (EL) were compared against those who were admitted from the emergency department (ED) or from elsewhere within or outside the hospital system (TR) for their perioperative outcomes and cost. Multivariable modeling controlled for age, sex, self-reported race, Elixhauser comorbidity score, payer type, number of segments, and procedure length.

RESULTS

Of the 1249 patients included in this study, 1116 (89.4%) were admitted electively while 123 (9.8%) were admitted from the ED and 10 (0.8%) were transferred from other hospitals. EL patients had significantly lower comorbidity burdens (P < 0.0001). Univariate and multivariable analyses revealed that transfer admission patients experienced significantly longer hospitalizations (ED: +1.7 days; P < 0.0001; TR: +5.3 days; P < 0.0001) and higher direct costs (ED: $1889; P < 0.0001; TR: $7001; P < 0.0001) compared with EL patients. Despite these risks, ED and TR patients only had increased odds of nonhome discharge compared with EL patients (ED: 3.4; P = 0.002; TR: 7.9; P = 0.02).

CONCLUSIONS

Patients admitted as transfers and from the ED had significantly increased hospitalization lengths of stay and direct costs compared with electively admitted patients.

Utilization of the American Society of Anesthesiologists (ASA) classification system in evaluating outcomes and costs following deformity spine procedures

PURPOSE

Adult spinal deformity (ASD) has increased prevalence in aging populations. Due to the high cost of surgery, studies have evaluated risk factors that predict readmissions and poor outcomes. The American Society of Anesthesiologists (ASA) classification system has been applied to patients with ASD to assess preoperative health and assess the correlation between ASA class and postoperative complications. This study evaluates the relationship between ASA and complications, length of stay (LOS), and direct costs following spine deformity surgery.

METHODS

Patients undergoing spine deformity surgery at a single institution from 2008-2016 were included and stratified based upon ASA status. Primary outcomes included patient demographics, adjusted LOS, and cost of care. Secondary measures compared between cohorts included adverse events, non-home discharge, and readmission rates.

RESULTS

442 patients with ASD were included in this study. Higher ASA class was correlated with greater Elixhauser Comorbidity Index (ECI) scores (p < 0.0001) and older age (p < 0.0001). Univariate analysis showed longer LOS (p < 0.0001) and greater direct costs in patients with higher ASA class (p < 0.0001). Patients in ASA Class III or IV had the greatest incidence of ICU stay when compared to patients without systemic disease (p < 0.0001). Upon multivariable regression analysis, high ASA class was associated with higher rates of non-home discharge (OR 5.0, 95% CI 3.1-8.1). Direct costs were greater for higher ASA class (regression estimate =  + $9,666, p = 0.002).

CONCLUSION

This study demonstrates that ASA class is correlated with a more complicated postoperative hospital course, greater rates of non-home discharge, total direct costs in spine deformity patients.

Association of age with incidence and timing of recurrence after microdiscectomy for lumbar disc herniation

OBJECTIVE

Recurrent lumbar disc herniation (LDH) is the most frequent reason for reoperation after lumbar microdiscectomy. While several risk factors for recurrent LDH have been well-described, the effect of age on recurrence remains unclear, especially concerning the timing of recurrent LDH.

METHODS

From a prospective registry, we identified all patients who underwent tubular microdiscectomy for LDH. Recurrent LDH was defined as reoperation for LDH at the same index level and side. The associations among age and incidence of recurrent LDH as well as on time to recurrent LDH were statistically evaluated using multivariable analysis of covariance, linear regression, and Cox proportional hazards modelling.

RESULTS

Of the 3013 patients who underwent surgery for LDH, 166 (5.5%) had to undergo reoperation due to LDH recurrence. Uni- and multivariable analysis revealed no influence of age on the incidence of recurrent LDH (both p > 0.05). Linear regression indicated earlier reoperation in older patients, both with (β = -0.248) and without (β = -0.374) correction for confounders (both p < 0.05). An additional survival analysis found that patients aged over 35 years had recurrent LDH significantly earlier (hazard ratio 0.617, p = 0.013).

CONCLUSION

In an analysis of a large prospective database of patients undergoing microdiscectomy for lumbar disc herniation, we found that younger patients do not have a higher reoperation probability than their older counterparts, even after correcting for multiple confounders. However, older patients tend to experience recurrent LDH significantly earlier after the index surgery compared to younger patients.