Minimum two-year follow-up of cases with recurrent disc herniation treated with microdiscectomy and posterior dynamic transpedicular stabilisation

Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair

OBJECTIVE

There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion.

METHODS

Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36.

RESULTS

Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution.

CONCLUSIONS

Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

Relationship between herniated intervertebral disc fragment weight and pain in lumbar microdiscectomy patients

OBJECTIVE

The relationship between lumbar disc herniation (LDH) size and the severity of preoperative pain and its impact on postoperative recovery is incompletely understood. This study was conducted to investigate the association between herniated disc fragment weight and pain before and after microdiscectomy.

METHODS

A consecutive series of patients from an ongoing randomised controlled trial (ACTRN12616001360404) were included in this study. Included patients were aged between 18 and 75, had a clinical diagnosis of radiculopathy, and MRI evidence of a concordant single-level lumbar disc herniation. All patients underwent standard microdiscectomy without aggressive discectomy or curettage of the endplates. Disc fragment weight was measured intraoperatively.

RESULTS

A total of 122 patients with a mean age of 49.5 ± 12.8 years, were included. The median weight of disc fragment was 0.545 g (95% CI 0.364 - 0.654 g). There was no relationship between disc weight and the duration of symptoms (p = 0.409) severity of preoperative leg pain (p = 0.070) or preoperative back pain (p = 0.884). Disc fragment weight was demonstrated to have no correlation with clinically significant postoperative leg pain improvement (p = 0.535) or back pain (p = 0.991). Additional LDH factors, including radiological percentage of canal compromise (p = 0.714), herniation classification (p = 0.462), and vertebral level (p = 0.788) were also shown to have no effect on leg pain outcomes.

CONCLUSIONS

Disc fragment weight had no effect on the severity of pain at presentation or after microdiscectomy. Patients benefit from surgery equally, regardless of the size of LDH.

Lumbar Dynamic Stabilization With 2-Stage Surgery: Early Results

BACKGROUND

Screw loosening, which is a major problem in dynamic systems, can be easily overcome with 2-stage surgery. In this article, the clinical and radiological results of patients undergoing dynamic stabilization with a Dynesys device in 2 stages are discussed.

METHODS

A total of 10 male and 13 female adult patients were included in this single-center retrospective study conducted between 2018 and 2021. The mean age of the patients was 65.6 years. All of the patients had pain complaints that affected their daily lives. Bone density T scores were determined with the dual-energy x-ray absorptiometry method before patients were admitted for surgery. In the first surgery, Dynesys system pedicle screws were inserted. After 6 months of osteointegration, Dynesys system spacers and elastic bandages were placed. Preoperative, early postoperative, and late postoperative visual analog pain scale (VAS) scores and Oswestry Disability Index (ODI) scores were determined and statistically compared.

RESULTS

Patients were followed for an average of 30 months. Complications and recurrence were not observed. Neurological deficits were not observed after patients recovered from anesthesia. Significant improvement was observed in the ODI and VAS parameters in the preoperative (ODI: 66.2%, VAS: 7.8), early postoperative (ODI: 20.3%, VAS: 2.4), and late postoperative (ODI: 6.8% and VAS: 1.1) periods. Symptomatic improvement was seen in all patients. No screw breakage or loosening was detected by radiological evaluation in any of the patients during the 2-year follow-up period.

CONCLUSIONS

In our experience, the insufficiency of the proximal and distal end screws is eliminated when 2 stages of dynamic system stabilizations are completed after osteointegration of the screws.

LEVEL OF EVIDENCE: 4

Should Iliac Wing Screws Be Included in Long Segment Dynamic Stabilization?

Background

In this article, clinical satisfaction and radiological results are discussed in a series of patients where the iliac wings participate in dynamic stabilization. Dynamic stabilization is an effective alternative surgical treatment method, especially in clinical pictures that go with pain due to minor instabilities. Practically the unique surgical instrument used in multilevel instabilities is the Dynesys system. The most important drawback of the Dynesys system is that the S1 screws become loose in time. In this article, our aim is to find solution to S1 insufficiency by extension of the system to the iliac wings.

Methods

Nineteen patients (eight females, 11 males) with a mean age of 54.16 were included in the study. Patients had multilevel (level 2 and above) instability, iliac wings were included in the stabilized segments, and Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for patient follow-up.

Results

First year results showed a significant improvement in VAS and ODI. Regarding the complications, infection developed in one patient, loosening in the proximal iliac wing in one patient, and both S1 and iliac proximals in one patient, but no clinical findings were encountered.

Conclusion

When more than two levels of dynamic systems are used in chronic instability, especially in the elderly patients, S1 screws are loosened. In these patients, if the iliac bones are also included in stabilization, this problem is solved successfully. However unfortunately, Dynesys system does not have a screw suitable for the iliac bones.

Comparison of the Pull-Out Strength between a Novel Micro-Dynamic Pedicle Screw and a Traditional Pedicle Screw in Lumbar Spine

OBJECTIVE

This study aimed to investigate the strength of a novel micro-dynamic pedicle screw by comparing it to the traditional pedicle screw.

METHODS

Forty-five lumbar vertebrae received a traditional pedicle screw on one side and a micro-dynamic pedicle screw on the other side as follows (traditional group vs micro-dynamic group): 15 vertebrae underwent instant pull-out testing; 15 vertebrae underwent 5000-cyclic fatigue loading testing; and 15 vertebrae underwent 10,000-cyclic fatigue loading testing and micro-computed tomography (micro-CT) scanning. The peek pull-out force and normalized peek pull-out force after instant pull-out testing, 5000-cyclic and 10,000-cyclic fatigue loading testing were recorded to estimate the resistance of two types of screws. Bone mineral density was recorded to investigate the strength of the different screws in osteoporotic patients. And the semidiameter of the screw insertion area on micro-CT images after fatigue were compared to describe the performance between screw and bone surface.

RESULTS

The bone mineral density showed a weak correlation with peek pull-out force (r = 0.252, P = 0.024). The peek pull-out force of traditional pedicle screw after 10,000-cyclic fatigue loading were smaller than that of instant pull-out test in both osteoporotic (P = 0.017) and healthy group (P = 0.029), the peek pull-out force of micro-dynamic pedicle screw after 10,000-cyclic fatigue loading was smaller than that in instant pull-out test in osteoporotic group (P = 0.033), but no significant difference in healthy group (P = 0.853). The peek pull-out force in traditional group and micro-dynamic group underwent instant pull-out testing (P = 0.485), and pull-out testing after 5000-cyclic fatigue loading testing (P = 0.184) did not show significant difference. However, the peek pull-out force in micro-dynamic group underwent pull-test after 10,000-cyclic fatigue loading testing was significantly greater than that measured in traditional group (P = 0.005). The normalized peek pull-out force of traditional groups underwent instant pull-out testing, pull-out test after 5000-cyclic and 10,000-cyclic fatigue loading testing significantly decreased as the number of cycles increased (P < 0.001); meanwhile, the normalized peek pull-out force of micro-dynamic groups remained consistent regardless of the number of cycles (P = 0.133). The semidiameter after the fatigue loading test of the traditional screw insertion area was significantly larger than that of the micro-dynamic screw insertion area (P = 0.013).

CONCLUSION

The novel micro-dynamic pedicle screw provides stronger fixation stability in high-cyclic fatigue loading and non-osteoporotic patients versus the traditional pedicle screw, but similar resistance in low-cycle fatigue testing and osteoporotic group vs the traditional pedicle screw.

Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review

OBJECTIVE

Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation.

METHODS

A systematic literature search was conducted using Pubmed and Embase databases on 18^thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates).

RESULTS

Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques.

CONCLUSION

There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.

Risk Factors and Surgical Treatment for Recurrent Lumbar Disc Prolapse: A Review of the Literature

We aim to present the current evidence on various risk factors and surgical treatment modalities for recurrent lumbar disc herniation (rLDH). Using PubMed, a literature search was performed using the Mesh terms "recurrent disc prolapse," "herniated lumbar disc," "risk factors," and "treatment." Articles that were published between January 2010 and May 2017 were selected for further screening. A search conducted through PubMed identified 213 articles that met the initial screening criteria. Detailed analyses showed that 34 articles were eligible for inclusion in this review. Sixteen articles reported the risk factors associated with rLDH. Decompression alone as a treatment option was studied in seven articles, while 11 articles focused on different types of fusion surgery (anterior lumbar interbody fusion, posterior lumbar interbody fusion, open transforaminal lumbar interbody fusion [TLIF], and minimally invasive surgery-TLIF). Management of the rLDH requires consideration of the possible risk factors present in individual patients before primary and at the time of second surgery. Both, minimally invasive and conventional open procedures are comparably effective in relieving leg pain, and minimally invasive techniques offer advantage over the other technique in terms of tissue sparing. Non-fusion surgeries involve the risk of lumbar disc herniation re-recurrence, and the patient may require a third (fusion) surgery.

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis

OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

Treatment of Recurrent Disc Herniation: A Systematic Review

Intervertebral disc herniation is one of the most common causes of back and extremity pain. The most commonly used surgical treatment is lumbar discectomy. About 0.5-25% go on to develop recurrent disc herniation (rDH) after a successful first discectomy. Currently, there aren't any guidelines to assist surgeons in determining which approach is most appropriate to treat rDH. A recent survey showed significant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, as there are no comparative studies with a sufficient level of evidence. In this study, we aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion. We applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of our study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, our study shows that further and more in-depth investigation is needed on the of treatment of rDH.

Revision Surgery for "Real" Recurrent Lumbar Disk Herniation: A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

To systematically review the previous literature regarding revision surgery for real recurrent lumbar disk herniation.

SUMMARY OF BACKGROUND DATA

"Real" recurrent lumbar disk herniation means the presence of herniated disk material at the same level and side as the primary disk herniation. If conservative treatment fails, revision surgery, a major concern, is indicated. It is important for both patients and spine surgeons to understand epidemiology trends and outcomes of revision surgery for real recurrent lumbar disk herniation (real-RLDH).

METHODS

The electronic databases PubMed, the Cochrane library, and EMBASE were queried for English articles regarding revision surgery for real-RLDH, published between January 1980 and May 2014. The incidence, interval between primary and revision surgery, risk factors, surgery type, complications, and clinical outcomes of revision surgery for real-RLDH were summarized.

RESULTS

The reported incidence of revision surgery, specifically for real-RLDH, lies between 1.4% and 11.4%. The complication rate is reported between 0% and 34.6%, with dural tear being the most common complication. Previous studies revealed that satisfactory or successful clinical outcome was achieved in 60%-100% of patients after revision surgery for real-RLDH. Several studies reported similar clinical outcomes between primary and revision surgery.

CONCLUSIONS

The incidence of revision surgery for real-RLDH is relatively low. It is essential to pay careful attention to prevent a dural tear. Patients may expect clinical outcomes similar to those following primary discectomy.

Failed back (surgery) syndrome: time for a paradigm shift

1. The group of patients with so-called 'failed back surgery syndrome' (FBSS) is very diverse. Published studies evaluating the outcome of surgical treatment vary widely in terms of surgical interventions that were performed. Results from these papers cannot be generally applied to all people who have persisting complaints after low back surgery. 2. The literature search that was performed demonstrated that the articles that scored as acceptable on assessment bias demonstrated a low to moderate patient-perceived recovery percentage. The only randomized controlled trial on this topic did not demonstrate a difference between instrumented fusion and cognitive intervention and exercise. 3. Current research does not show repeat surgery to be successful in 'FBSS patients', but clinical practice indicates that, in a small, carefully selected group, repeat surgery can yield rewarding results. However, parameters that make a patient prone to recover from a subsequent surgical intervention cannot be found in the literature. 4. The term 'failed back surgery syndrome' implies a causative role of surgery in a problem situation; failed back surgery syndrome is frequently regarded as failed back surgery. The literature does not, however, provide evidence for this. 5. It is important to inform the patient adequately to shape realistic expectations. Preoperative evaluation of parameters evaluating the psychological condition could help to better predict the outcome of surgery. 6. The term 'failed back surgery syndrome' has been demonstrated to be an ill-defined term, serving as a container for all kinds of back and leg problems, and wrongly implying a definite role for the surgical intervention in the aetiology. We suggest shifting the paradigm to 'failed back syndrome'. With this term we suggest defining those patients with back and radicular leg pain without a structural deficit, or with a structural deficit that has a low a priori chance of benefiting from a surgical intervention.

Dynamic stabilization for challenging lumbar degenerative diseases of the spine: a review of the literature

Fusion and rigid instrumentation have been currently the mainstay for the surgical treatment of degenerative diseases of the spine over the last 4 decades. In all over the world the common experience was formed about fusion surgery. Satisfactory results of lumbar spinal fusion appeared completely incompatible and unfavorable within years. Rigid spinal implants along with fusion cause increased stresses of the adjacent segments and have some important disadvantages such as donor site morbidity including pain, wound problems, infections because of longer operating time, pseudarthrosis, and fatigue failure of implants. Alternative spinal implants were developed with time on unsatisfactory outcomes of rigid internal fixation along with fusion. Motion preservation devices which include both anterior and posterior dynamic stabilization are designed and used especially in the last two decades. This paper evaluates the dynamic stabilization of the lumbar spine and talks about chronologically some novel dynamic stabilization devices and thier efficacies.

Posterior Transpedicular Dynamic Stabilization versus Total Disc Replacement in the Treatment of Lumbar Painful Degenerative Disc Disease: A Comparison of Clinical Results

Study Design. Prospective clinical study. Objective. This study compares the clinical results of anterior lumbar total disc replacement and posterior transpedicular dynamic stabilization in the treatment of degenerative disc disease. Summary and Background Data. Over the last two decades, both techniques have emerged as alternative treatment options to fusion surgery. Methods. This study was conducted between 2004 and 2010 with a total of 50 patients (25 in each group). The mean age of the patients in total disc prosthesis group was 37,32 years. The mean age of the patients in posterior dynamic transpedicular stabilization was 43,08. Clinical (VAS and Oswestry) and radiological evaluations (lumbar lordosis and segmental lordosis angles) of the patients were carried out prior to the operation and 3, 12, and 24 months after the operation. We compared the average duration of surgery, blood loss during the surgery and the length of hospital stay of both groups. Results. Both techniques offered significant improvements in clinical parameters. There was no significant change in radiologic evaluations after the surgery for both techniques. Conclusion. Both dynamic systems provided spine stability. However, the posterior dynamic system had a slight advantage over anterior disc prosthesis because of its convenient application and fewer possible complications.

A short history of posterior dynamic stabilization

Interspinous spacers were developed to treat local deformities such as degenerative spondylolisthesis. To treat patients with chronic instability, posterior pedicle fixation and rod-based dynamic stabilization systems were developed as alternatives to fusion surgeries. Dynamic stabilization is the future of spinal surgery, and in the near future, we will be able to see the development of new devices and surgical techniques to stabilize the spine. It is important to follow the development of these technologies and to gain experience using them. In this paper, we review the literature and discuss the dynamic systems, both past and present, used in the market to treat lumbar degeneration.

Pedicle screw-based posterior dynamic stabilization: literature review

Posterior dynamic stabilization (PDS) indicates motion preservation devices that are aimed for surgical treatment of activity related mechanical low back pain. A large number of such devices have been introduced during the last 2 decades, without biomechanical design rationale, or clinical evidence of efficacy to address back pain. Implant failure is the commonest complication, which has resulted in withdrawal of some of the PDS devices from the market. In this paper the authors presented the current understanding of clinical instability of lumbar motions segment, proposed a classification, and described the clinical experience of the pedicle screw-based posterior dynamic stabilization devices.