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

Is Minimally Invasive Spinal Surgery Superior to Endoscopic Spine Surgery in Postoperative Radiologic Outcomes of Lumbar Spine Degenerative Disease? A Systematic Review

BACKGROUND

 Minimally invasive spinal surgery (ESS) are both well-established surgical techniques for lumbar spinal stenosis; however, there is limited literature comparing the efficacy of the two techniques with respect to radiologic decompression data.

METHODS

 In this review, PubMed, Google Scholar, and Scopus databases were systematically searched from inception until July 2022 for studies that reported the radiologic outcomes of endoscopic and minimally invasive approaches for decompressive spinal surgery, namely, the spinal canal area, neural foraminal area, and neural foraminal heights.

RESULTS

 Of the 378 articles initially retrieved using MeSH and keyword search, 9 studies reporting preoperative and postoperative spinal areas and foraminal areas and heights were finally included in our review. Of the total 581 patients, 391 (67.30%) underwent MISS and 190 (32.70%) underwent ESS. The weighted mean difference between the spinal canal diameter in pre- and postoperative conditions was 56.64 ± 7.11 and 79.52 ± 21.31 mm2 in the MISS and ESS groups, respectively. ESS was also associated with a higher mean difference in the foraminal area postoperatively (72 ± 1 vs. 35.81 ± 11.3 mm2 in the MISS and ESS groups, respectively), but it was comparable to MISS in terms of the foraminal height (0.32 ± 0.037 vs. 0.29 ± 0.03 cm in the MISS and endoscopic groups, respectively).

CONCLUSIONS

 Compared with MISS, ESS was associated with improved radiologic parameters, including spinal canal area and neural foraminal area in the lumbar spinal segments. Both techniques led to the same endpoint of neural decompression when starting with a more severe compression. However, the present data do not allow the correlation of the radiographic results with the related clinical outcomes.

Minimally Invasive Transforaminal Interbody Fusion Versus Microdiscectomy Without Fusion for Recurrent Lumbar Disk Herniation: A Prospective Comparative Study

OBJECTIVE

The objective of this study was to compare the clinical outcome of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) versus standard revision diskectomy for recurrent lumbar disk herniation (RLDH).

BACKGROUND

RLDH is the most common cause of redo surgery after a microdiscectomy. Commonly, in patients without evidence of spinal instability, many surgeons would simply redo microdiscectomy, while others proceed to a redo microdiscectomy with arthrodesis. According to the literature, there is no evidence of what the best management of an RLDH would be.

METHODS

This study involved 90 patients who underwent lumbar microdiscectomy in the past and were now experiencing a new lumbar disk herniation for the first time. The patients were divided into two groups, each with 45 patients: group A received standard revision microdiscectomy, whereas group B received revision microdiscectomy with MIS TLIF.The Japanese Orthopaedic Association score, operating time, blood loss, duration of hospital stay, costs, and complications were all prospectively recorded in a database and examined. Back and leg discomfort were measured using the visual analog scale.

RESULTS

The mean total postoperative Japanese Orthopaedic Association score across the groups exhibited no statistically significant difference, nor did the preoperative clinical and epidemiological data. Although postoperative leg pain was comparable in both groups, postoperative lower back pain in group A was much worse than that in group B. Additional revision surgery was necessary for six individuals in group A. Group A had higher rates of dural rupture and postoperative neurological impairment. Group A experienced much less intraoperative blood loss, longer operation times, and postoperative hospital stays.

CONCLUSION

In patients with RLDH, revision microdiscectomy is effective. In comparison with conventional microdiscectomy, MIS TLIF reduces intraoperative risk of dural rupture or neural injury, postoperative incidence of mechanical instability or recurrence, and postoperative lower back pain.

STUDY DESIGN

Prospective, randomized, multicenter, comparative study.

Recurrence of lumbar disk herniation after microdiscectomy: a two-center retrospective analysis of 1214 cases and identification of risk factors

Background/aim

To present the incidence of recurrent lumbar disc herniation (RLDH) and to identify radiological and patient-related risk factors that lead to recurrence after lumbar disc herniation (LDH) treatment with microdiscectomy.

Materials and methods

Between January 2013 and December 2021, 1214 patients who had undergone microdiscectomy for LDH were included in this retrospective study. Patients were divided into two groups, the recurrent group and the non-recurrent group, and their demographic, clinical and radiologic characteristics were recorded. The association between the variables and RLDH was assessed by univariate and multivariable logistic regression analyses.

Results

Mean ages were similar in the recurrent (51.48 ± 13.63) and non-recurrent(50.38 ± 14.53) groups (p=0.232). Males represented 59.6% of the recurrent group and 49.8% of the non-recurrent group (p=0.002). Multivariable logistic regression revealed that being a male (p=0.009), diabetes mellitus (p=0.038), smoking (p<0.001), grade 4&5 disc degeneration (p<0.001), and having protruded (p=0.002), extruded LDH (p<0.001), paracentral (p=0.008) and foraminal LDH (p=0.008) were independently associated with recurrence.

Conclusion

To reduce RLDH frequency and need for revision surgery, modifiable risk factors should be minimized before and after the initial surgery. Also, in patients with unmodifiable risk factors, patients should be clearly informed about the risk for recurrence and possible alternative treatment methods should be considered.

How I do it: biportal endoscopic paraspinal approach for recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy

BACKGROUND

Although percutaneous endoscopic lumbar discectomy (PELD) has been popularized as an alternative to microscopic lumbar discectomy, it has been reported to be associated with a re-herniation rate of 5-11%. Recurrent lumbar disc herniation (RLDH) might occur not only at the same level previously operated upon but also at the annular penetration site created during PELD procedures.

METHOD

Biportal endoscopic paraspinal approach (BE-Para) was used for revisional foraminal lumbar discectomy. Procedures and some discussions regarding indications, advantages, potential complications, and ways to avoid complications were described.

CONCLUSION

BE-Para may be an effective modality for RLDH after PELD.

Risk of reoperation and infection after percutaneous endoscopic lumbar discectomy and open lumbar discectomy : a nationwide population-based study

AIMS

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

METHODS

In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated.

RESULTS

Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325).

CONCLUSION

Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392-1399.

Surgical outcomes of decompression alone versus transpedicular screw fixation for upper lumbar disc herniation

Background

Surgical outcomes of upper lumbar disc herniations (ULDHs) including T12-L1, L1-L2, and L2-L3 levels are characteristically less favorable and more unpredictable.

Objectives

This study was conducted to compare the surgical outcomes of decompression alone versus decompression combined with transpedicular screw fixation in treating upper lumbar disc herniation.

Methods

This retrospective cohort study was carried out at Neurosurgery Departments, Tanta University. The study included 46 patients with a symptomatic high lumbar herniated disc at T12-L1, L1-L2, and L2-L3 levels. The enrolled patients were divided into two groups depending on whether they were operated on via decompression and partial medial facetectomy (group 1, 22 patients) or via the previous maneuver plus transpedicular screw fixation (group 2, 24 patients). All patients were medically evaluated immediately after the operation; then, they were followed up at the 3rd and the 6th months following surgery. Patients’ outcomes were assessed by visual analogue score (VAS) and Oswestry Disability Index (ODI) scores.

Results

Median VAS scores in each group revealed significant reduction immediately following surgery and at each of 7 days, 3 months, and 6 months in comparison with the preoperative VAS score (p<0.001). Furthermore, each group showed significant stepwise reduction in the median ODI score at the 3rd and the 6th months postoperative compared to the preoperative ODI score (group 1 = 68.0, 19.0, 15.0; p< 0.001 and group 2 = 66.5, 20.0, 15.0; p< 0.001), with no significant differences between both groups (p> 0.05).

Conclusions

Both standalone decompression and decompression combined with transpedicular screw fixation revealed comparable favorable outcomes in patients with ULDH.

Comparison of endoscopic spine surgery and minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar disease: A meta-analysis

This study aimed to compare the clinical outcomes of endoscopic spinal surgery (ESS) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative lumbar disease (DLD) through meta-analysis. The Medline (via PubMed), Cochrane, Scopus, and Embase databases were searched for studies that evaluated the outcomes of ESS and MIS-TLIF in DLD, including visual analog scale (VAS) score for low back pain, VAS score for leg pain, Oswestry Disability Index (ODI), and complications published between January 2000 and August 2020. Two authors extracted the data independently. Any discrepancies were resolved by a consensus. Four comparative studies were identified. No significant differences were found between the ESS and MIS-TLIF groups in terms of VAS score for back pain, VAS score for leg pain, and ODI, except for complication rate. The complication rate was higher in the ESS than in the MIS-TLIF group. A literature review identified four comparative studies reporting the clinical outcomes of ESS and MIS-TLIF for DLD. Despite the heterogeneity, a limited number of meta-analyses showed that the clinical outcomes between the two groups were not significantly different except for complication rate. Hence, further large-scale multicenter studies are required to validate our results.

Fusion versus nonfusion treatment for recurrent lumbar disc herniation

Background:

Recurrent lumbar disc herniation (RLDH) is one of the major causes for failure of primary surgery. The optimal surgical treatment of RLDH remains controversial.

Aim:

Retrospectively, we evaluate 135 patients and compare the clinical outcomes between fusion and nonfusion treatment of RLDH.

Methods:

Records of 75 men and 35 women aged 28–60 years for conventional revision discectomy alone (nonfusion) and 15 men and 10 women aged 30–65 years for revision discectomy with transforaminal lumbar interbody fusion (TLIF) and transpedicular screw fixation (fusion) were reviewed. Demographics, surgical data, and complications were collected and pre- and postoperative assessment were done by the Visual Analogue Scale (VAS) scale and Japanese Orthopaedic Association (JOA) score. The results after surgery were assessed according to the recovery rate as excellent, good, fair, and poor.

Results:

The mean follow-up period was 28.8 and 24.6 months in Group A (nonfusion) and Group B (fusion group), respectively. The preoperative data between both the groups showed no statistically significant difference. The postoperative mean VAS and JAO scores, recovery rate, and satisfaction rate showed no statistically significant difference except postoperative low back pain and occasional radicular pain and neurological deficit in nonfusion group which was significantly higher than that of fusion group. In comparison to fusion group, nonfusion group required significantly less operative time, less intraoperative blood loss, less postoperative hospital stay, no blood transfusion, and less total cost of the procedure. Satisfaction rate was 80% and 88% in nonfusion and fusion groups, respectively.

Conclusions:

Both convention revision discectomy (nonfusion) and discectomy with instrumented fusion (TLIF) surgery are effective in patients with RLDH.

A systematic review and meta-analysis for Chinese herbal medicine Duhuo Jisheng decoction in treatment of lumbar disc herniation: A protocol for a systematic review

BACKGROUND

Lumbar disc herniation (LDH) is 1 of the most common diseases in orthopedics, which seriously affects people's daily life and brings a heavy burden on society and families. Chinese herbal medicine has been used in clinical practice for a long time and Duhuo Jisheng Decoction (DHJSD) is believed to help alleviate the symptoms of LDH. This systematic review aims to collect evidences from randomized clinical trials and evaluate the efficacy of DHJSD on LDH in order to provide a reference for clinicians and researchers.

METHODS

We will comprehensively search the 8 electronic databases until December 2019 to identify related randomized controlled trials, including 4 foreign databases (PubMed, MEDLINE, EMBASE, Cochrane Library) and 4 Chinese databases (China National Knowledge Infrastructure Database, VIP Database, Wanfang Database and China Biology Medicine disc). The data of the World Health Organization International Clinical Trial Registry Platform and the Chinese Clinical Trial Registry also will be searched. The primary outcomes are Japanese Orthopaedic Association scores and visual analog scale scores. The risk of bias will be assessed using the Cochrane Collaboration tool. RevMan (V.5.3) software will be used for meta-analysis.

RESULTS

This study will report the results of DHJSD for the treatment of LDH from the literature screening, the basic information of the included studies, the risk of bias of the included studies, treatment effects, safety, and so on.

CONCLUSION

This systematic review will evaluate the effectiveness and safety of DHJSD for the treatment of LDH and provide the latest evidence for its clinical application.

ETHICS AND DISSEMINATION

This is a literature-based study, therefore it does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42019147302.