Minimally invasive lumbar microdiscectomy in pediatric patients: a series of 6 patients

Age and Sex Differences in Pediatric Neuropathic Pain and Complex Regional Pain Syndrome: A Scoping Review

BACKGROUND

Age and sex differences may exist in the frequency (incidence, prevalence) or symptoms of neuropathic pain (NP) and complex regional pain syndrome (CRPS) due to biopsychosocial factors (eg, neurodevelopment, physiological and hormonal changes, psychosocial differences) that evolve through childhood and adolescence. Age and sex differences may have implications for evaluating screening and diagnostic tools and treatment interventions.

OBJECTIVE

To map the existing literature on pediatric NP and CRPS with respect to age and sex distributions, and age and sex differences in symptomology and frequency.

METHODS

A scoping literature review was conducted. Databases were searched from inception to January 2023. Data were collected on study design, setting, demographics, and age and sex differences in frequency and symptoms.

RESULTS

Eighty-seven studies were included. Distribution of participants with CRPS (n=37 studies) was predominantly early adolescence (10 to 14 y) and female sex, while NP (n=42 studies) was most commonly reported throughout adolescence (10 to 19 y) in both sexes. Forty-one studies examined age and sex differences in frequency; 6 studies reported higher frequency in adolescence. Very few studies (n=11) examined differences in symptomology.

DISCUSSION

Large epidemiological studies are required to further understand age and sex differences in frequency of pediatric NP and CRPS. Age and sex differences must be considered when evaluating screening and diagnostic tools and treatment interventions to ensure relevance and validity to both sexes and across ages. Validated tools will improve understanding of age-dependent and sex-dependent differences in symptoms, pathophysiology, and psychosocial impact of pediatric NP and CRPS.

Adolescent Disc Disease: Risk Factors and Treatment Success-Related Factors

OBJECTIVE

A paucity of literature is available discussing the associated risk factors, treatment options (including the use of minimally invasive surgery), and outcomes related to lumbar disc herniation (LDH) in children. We have discussed the risk factors for disc disease among pediatric patients and evaluated the efficacy of the minimally invasive approach.

METHODS

A retrospective review of pediatric patients with lumbar disc disease who had undergone microdiscectomy at our institution from 2005 to 2016 was conducted. The preoperative presentation, hospital course, postoperative course, and follow-up data (≥3 years) were reviewed. We evaluated the risk factors for LDH and the surgical outcomes for both groups.

RESULTS

A total of 52 pediatric patients had undergone 61 lumbar disc surgeries for LDH in our department from 2005 to 2016. Their average age at surgery was 16.65 years. Of the 61 procedures, 48 (78.7%) had been performed via the minimally invasive spine microdiscectomy approach and 13 (21.3%) via the open microdiscectomy approach. The average body mass index for all cases was 29.3 kg/m². The average interval to diagnosis was 7.9 months. Of the 61 cases, 21 (34.4%) had been required for patients who were competitive athletes. In addition, 15 had been for LDH related to trauma (24.6%). In 46 of the 61 cases, complete resolution of the symptoms had occurred at the 1-year follow-up visit (79.2% of minimally invasive spine microdiscectomy vs 61.5% of open microdiscectomy).

CONCLUSION

Risk factors similar to those for adult LDH, such as an elevated body mass index, can be seen in the pediatric population. However, some unique risk factors such as post-traumatic LDH were found in the pediatric age group. Minimally invasive techniques are demonstrably safe and useful in this patient population.

Pediatric herniated lumbar disc: a population-based risk factor analysis

OBJECTIVE

Surgical treatment of herniated lumbar disc (HLD) remains rare in children. The purpose of this study was to evaluate for potential disease risk factors leading to surgery based on a large single-center experience.

METHODS

Data for all patients who had undergone surgical treatment for HLD between December 2008 and December 2016 at a single pediatric tertiary care referral center were collected and compared to data for a healthy control population obtained through a Youth Risk Behavior Surveillance System (YRBSS) survey in order to determine relevant disease risk factors. Univariate and multivariate logistic regression were used to determine the effect of potential risk factors.

RESULTS

Twenty-seven patients in the disease cohort and 5212 healthy controls from the general population were included in the risk factor analysis. The mean body mass index was significantly higher in the disease population (30.2 vs 24.0 kg/m2, p < 0.0001). Children who had undergone microdiscectomy were more likely to be obese (OR 7.4, 95% CI 3.46-15.8, p < 0.001). No association was found between lumbar microdiscectomy and sports participation (OR 1.0, 95% CI -0.002 to 0.005, p = 0.37).

CONCLUSIONS

Microdiscectomy remains a viable and safe option in the setting of failed conservative management for pediatric HLD. Childhood obesity is a risk factor for HLD and many other diseases, which increases its importance as a public health priority.

Percutaneous endoscopic discectomy in adolescent lumbar disc herniation: a 3- to 5-year study

OBJECTIVEThe authors sought to investigate the efficiency of percutaneous endoscopic discectomy (PED) in adolescent patients with lumbar disc herniation (LDH), compare PED outcomes in adolescent patients with those in young adult LDH patients as controls, and discuss relevant technical notes.METHODSThis was a retrospective study involving 19 adolescent LDH patients (age > 13 and < 18 years, 20 discectomies) and 38 young adults (age < 40 years, 38 discectomies) who also had LDH and were matched to the adolescent group for sex and body mass index. The combined cohort included 51 male patients (89.5%) and 6 female patients (10.5%), with an average age of 26.7 years (range 14-39 years). The operated levels included L3-4 in 1 patient (1.7%), L4-5 in 22 patients (37.9%), and L5-S1 in 35 patients (60.4%). Two adolescents (10.5%) exhibited apophyseal ring separation and one (5.3%) had had previous PED. All patients underwent PED under local anesthesia. Outcomes were evaluated through a visual analog scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the modified MacNab grading system.RESULTSThe mean duration of follow-up was 41.7 months (range 36-65 months). The outcomes in adolescents were satisfactory and comparable with previously reported outcomes of microsurgical discectomy (MD) and conventional open discectomy (COD). The adolescent patients had a faster and better recovery course than the adult patients (p < 0.01). One adolescent patient (5.3%) exhibited recurrence and 2 adults (5.3%) experienced transient dysesthesia; the complication rates were comparable in the 2 age groups (p = 0.47). Prolonged duration of symptoms (p < 0.01) and disc degeneration (p = 0.01) were correlated with lower postoperative JOA values; patients with extrusions had higher postoperative JOA values than those with protrusions (p = 0.01).CONCLUSIONSPED may yield favorable results in the treatment of adolescent LDH in terms of short- to medium-term follow-up; restricted discectomy and a conservative rehabilitation program might be advisable. Further long-term studies are warranted to address this rare disease entity.

Minimally invasive spine surgery in the pediatric and adolescent population: A case series

Background:

There is scant literature evaluating the indications, techniques, and outcomes of minimally invasive spine (MIS) surgery undertaken for pediatric and adolescent spine pathology. Our study attempts to evaluate the safe and effective use of MIS techniques in pediatric and adolescent patients and to appreciate the technical nuances of MIS surgery for this age group.

Methods:

Consecutive pediatric and adolescent patients undergoing elective MIS lumbar procedures, from 2008 to 2016, were retrospectively analyzed from the practice of a single fellowship-trained academic spinal neurosurgeon. Information was retrieved regarding procedure and disease pathology. Descriptive data was obtained including age, sex, body mass index (BMI), insurance coverage, smoking status, and co-morbidities. Outcome measures were recorded including intraoperative complications, revision surgery, and return-to-function.

Results:

Sixteen patients underwent 17 surgeries. The median BMI was 29.2 (range, 20.8–41.5). Age ranged from 12 to 19 years. Nearly 20% of the patients in our series were smokers. Most patients underwent discectomy, with L5-S1 being the most common level. One patient underwent direct pars defect repair and another underwent recurrent discectomy. More than 90% of the patients were complication-free at follow-up period of 6 months. One patient had a recurrent disc herniation and another had a superficial wound infection. Overall, 82.4% patients enjoyed full return to sports such as weight lifting, gymnastics, and contact sports. One patient required pain management to help alleviate ongoing pain. Another patient required a course of outpatient rehabilitation to help with a “foot drop.”

Conclusion:

Our series illustrates the effective application of MIS techniques among carefully selected pediatric patients. Emphasis is on using a smaller (16 mm) tubular retractor and causing minimal disruption of paraspinal osseo-tendinous structures. MIS techniques can be successfully applied to the pediatric and adolescent age group.

Tubular approach to minimally invasive microdiscectomy for pediatric lumbar disc herniation

OBJECTIVE Lumbar disc herniation (LDH) in the pediatric population is rare and exhibits unique characteristics compared with adult LDH. There are limited data regarding the safety and efficacy of minimally invasive surgery (MIS) using tubular retractors in pediatric patients with LDH. Here, the outcomes of MIS tubular microdiscectomy for the treatment of pediatric LDH are evaluated. METHODS Twelve consecutive pediatric patients with LDH were treated with MIS tubular microdiscectomy at the authors' institution between July 2011 and October 2015. Data were gathered from retrospective chart review and from mail or electronic questionnaires. The Macnab criteria and the Oswestry Disability Index (ODI) were used for outcome measurements. RESULTS The mean age at surgery was 17 ± 1.6 years (range 13-19 years). Seven patients were female (58%). Prior to surgical intervention, 100% of patients underwent conservative treatment, and 50% had epidural steroid injections. Preoperative low-back and leg pain, positive straight leg raise, and myotomal leg weakness were noted in 100%, 83%, and 67% of patients, respectively. The median duration of symptoms prior to surgery was 9 months (range 1-36 months). The LDH level was L5-S1 in 75% of patients and L4-5 in 25%. The mean ± SD operative time was 90 ± 21 minutes, the estimated blood loss was ≤ 25 ml in 92% of patients (maximum 50 ml), and no intraoperative or postoperative complications were noted at 30 days. The median hospital length of stay was 1 day (range 0-3 days). The median follow-up duration was 2.2 years (range 0-5.8 years). One patient experienced reherniation at 18 months after the initial operation and required a second same-level MIS tubular microdiscectomy to achieve resolution of symptoms. Of the 11 patients seen for follow-up, 10 patients (91%) reported excellent or good satisfaction according to the Macnab criteria at the last follow-up. Only 1 patient reported a fair level of satisfaction by using the same criteria. Seven patients completed an ODI evaluation at the last follow-up. For these 7 patients, the mean ODI low-back pain score was 19.7% (SEM 2.8%). CONCLUSIONS To the authors' knowledge, this is the longest outcomes study and the largest series of pediatric patients with LDH who were treated with MIS microdiscectomy using tubular retractors. These data suggest that MIS tubular microdiscectomy is safe and efficacious for pediatric LDH. Larger prospective cohort studies with longer follow-up are needed to better evaluate the long-term efficacy of MIS tubular microdiscectomy versus other open and MIS techniques for the treatment of pediatric LDH.

Pediatric spondylolysis/spinal stenosis and disc herniation: national trends in decompression and discectomy surgery evaluated through the Kids' Inpatient Database

PURPOSE

The purpose of this study is to describe national trends in spinal decompression without fusion and discectomy procedures in the US pediatric inpatient population.

METHODS

The Kids' Inpatient Database (KID) was queried for pediatric patients with primary diagnoses of spinal spondylolysis/stenosis or disc herniation and having undergone spinal decompression without fusion or discectomy over more than a decade (2000 to 2012). The primary (indirect) outcomes of interest were in-hospital complication rates, length of stay (LOS), total costs, and discharge dispositions.

RESULTS

A total of 7315 patients, comprised of pediatric spinal spondylolysis/stenosis (n = 287, 3.92%) and pediatric disc herniation (n = 7028, 96.1%) patients, were included in the study. During the years 2000 to 2012, diagnoses of pediatric spondylolysis/spinal stenosis increased from 61 to 90 diagnoses per 3-year period, while diagnoses of pediatric disc herniation decreased from 2133 to 1335 diagnoses per 3-year period. Spinal decompression was associated with higher in-hospital complication rates (18.1 vs 5.3%, p < 0.0001), longer hospital stays (5 vs 1.69 days, p < 0.0001), higher mean total charges ($49,186 vs $19,057, p < 0.0001), and higher non-routine discharge rates (12.3 vs 2.5%, p < 0.0001) versus discectomy.

CONCLUSIONS

Spinal decompression is associated with longer hospital stays, more complications, higher costs, and more non-routine discharges when compared to discectomy. The data supports the disparate nature of these disease processes and elucidates basic clinical trends in uncommon spinal disorders affecting children.