Clinical and radiological instability following standard fenestration discectomy

Influence of microsurgical decompression on segmental stability of the lumbar spine - One-year results in a prospective, consecutive case series using upright, kinetic-positional MRI

Background

Standard procedure in patients with lumbar spinal canal stenosis is decompression to relieve the neural structures. Clinical results generally show superiority compared to nonoperative therapy after an observation period of several years. However, there is still a question of postsurgical segmental stability and correlation to clinical findings. Therefore, the aim of this prospective study was to evaluate the clinical outcome in patients who underwent microsurgical decompression in lumbar spine and particularly to analyze intervertebral movement by use of upright, kinetic-positional magnetic resonance imaging (MRI) over a period of 12 months and then to correlate the clinical and imaging data with each other.

Methods

Complete clinical data of 24 consecutive participants with microsurgical decompression of the lumbar spine were obtained by questionnaires including visual analogue scale (VAS) for back and leg, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), Short-Form-36 (SF-36), walking distance and use of analgesics with assessment preoperatively and after 6 weeks and 12 months. At the same points of time all patients underwent upright, kinetic-positional MRI to measure intersegmental motion of the operated levels with determination of intervertebral angles and translation and to correlate the clinical and imaging data with each other.

Results

VAS for leg, ODI, RMDQ and physical component scale of SF-36 improved statistically significantly without statistically significant differences regarding intersegmental motion and horizontal displacement 6 weeks and 12 months after operation. Regression analysis did not find any linear dependencies between the clinical scores and imaging parameters.

Conclusions

In awareness of some limitations of the study, our results demonstrate no increase of intersegmental movement or even instability after microsurgical decompression of the lumbar spine over a follow-up period of 12 months, which is equivalent to preservation of intervertebral stability. Furthermore, the magnitude of intervertebral range of motion showed no correlation to the clinical score parameters at all three examination points of time.

Evaluation of the effectiveness of surgical methods for the treatment of recurrent lumbar disc herniation: a cohort retrospective study

Objective. To compare the effectiveness of surgical methods for treating patients with recurrent lumbar disc herniation.

Material and Methods. The sample consisted of 160 patients operated on in 2014–2019 for recurrent lumbar disc herniation by percutaneous endoscopic discectomy (Group 1), microsurgical discectomy (Group 2), single-level transforaminal interbody fusion (Group 3) and single-level total intervertebral disc replacement (Group 4). The effectiveness of surgical treatment was evaluated using the NRS-11, ODI, and MacNab questionnaires.

Results. Assessment of the pain syndrome severity and the vital activity level of patients revealed significant (p < 0.05) differences in favor of total intervertebral disc replacement. Excellent and good outcomes after arthroplasty according to MacNab criteria were noted in all patients in this group. Similar outcomes were reported in 77.5 % (31/40) of patients in the TLIF group, in 75.1 % (24/32) of patients in the percutaneous endoscopic discectomy group and in 72.6 % (45/62) of patients in the microdiscectomy group. The operation time and length of hospital stay were shorter in the endoscopic and microsurgical discectomy groups (p < 0.001). However, the lower incidence of complications and reoperations was observed in groups of posterior interbody fusion and arthroplasty (p > 0.05).

Conclusion. Arthroplasty with the M6-L implant expands the possibilities of surgery for recurrent lumbar disc herniation. Total intervertebral disc replacement and posterior interbody fusion for recurrent lumbar disc herniation are more effective in comparison with decompressive operations, which is reflected in the improvement of clinical treatment outcomes, reduction of perioperative complications and frequency of repeated interventions.

Endoscopic and Microscopic Interlaminar Discectomy for the Treatment of Far-Migrated Lumbar Disc Herniation: A Retrospective Study with a 24-Month Follow-Up

Purpose

Percutaneous endoscopic lumbar discectomy for the treatment of far-migrated lumbar disc herniation (LDH) is clinically challenging. The aim of this study was to compare the efficacy and safety of interlaminar endoscopic lumbar discectomy (IELD) and interlaminar microscopic lumbar discectomy (IMLD) for the treatment of far-migrated LDH.

Materials and Methods

We retrospectively analyzed 50 consecutive cases of far-migrated LDH treated by IELD or IMLD. Clinical data and outcomes were assessed before the operation and 1 day and 3, 12, and 24 months after the surgery using the visual analog scale (VAS) and Oswestry disability index (ODI). Modified MacNab criteria were used to evaluate patient satisfaction at the 24-month follow-up.

Results

A significant reduction in leg pain and improvement in ODI (P<0.01) were observed in both groups after surgery. Lower back pain (LBP) was reduced at 24 months postsurgery in the IELD group (P<0.05) but not in the IMLD group (P>0.05). There were significant intergroup differences in VAS LBP score at 1 day and 24 months postsurgery (p=0.01 and 0.02, respectively) and in ODI at 24 months (p=0.03). The rate of excellent or good outcome was 90.32% with IELD and 78.95% with IMLD (p=0.55). Hospital stay and time to ambulation were shorter in the IELD group than in the IMLD group, but the former had a longer operative time (p<0.01). Low and comparable complication rates were reported in the IELD (16.13%) and IMLD (10.53%) groups (p=0.70).

Conclusion

Both IELD and IMLD achieve favorable clinical results in the treatment of far-migrated LDH, with only minor complications. Compared to IMLD, LBP was significantly reduced with IELD presumably because it involved less trauma.

Endoscopic removal of nucleus pulposus of intervertebral disc on lumbar intervertebral disc protrusion and the influence on inflammatory factors and immune function

Endoscopic removal of nucleus pulposus (NP) of intervertebral disc (IVD) on lumbar intervertebral disc protrusion (LIDP) and its influence on inflammatory factors and immune function were explored. A total of 145 patients with LIDP admitted to The First Affiliated Hospital of Bengbu Medical College from June 2017 to December 2018 were selected and electively treated, in which 87 patients were treated with fenestration discectomy (fenestration group) and 58 patients were treated with endoscopic removal of NP of IVD (minimally invasive group). Effects on patients in the two groups within 6 months after surgery were evaluated by modified MacNab score; differences in surgical related indexes and incidence rates of complications between the two groups were compared; the Oswestry dysfunction score and VAS pain score before treatment, and 1, 3 and 6 months after treatment, and changes of cellular levels of TNF-α, IL-4, IL-6, CD3⁺, CD4⁺, and CD8⁺ before treatment, and 24 and 48 h after surgery were evaluated. Length of surgical incision, intraoperative blood loss, time of operation, time in bed, and hospital stays of patients in minimally invasive group were lower than those in the fenestration group (P<0.05). The Oswestry score and VAS score of patients in minimally invasive group 1, 3 and 6 months after surgery were lower than those in fenestration group (P<0.05). The incidence rate of spinal instability and overall incidence of complications of patients in minimally invasive group were significantly lower than those in fenestration group (P<0.05). Levels of TNF-α and IL-6 of patients in the minimally invasive group 24 and 48 h after surgery were lower than those in the fenestration group (P<0.05) and cellular levels of IL-4, CD3⁺, CD4⁺, and CD8⁺ were higher (P<0.05). In conclusion, endoscopic removal of NP of IVD has good therapeutic effects in patients with LIDP. It reduces inflammation and suppresses immune function with higher safety, worthwhile for clinical use.

Degeneration and Instability and the Relation to Patients' Function Late After Lumbar Disc Surgery: Data from a 12-Year Follow-Up

OBJECTIVE

To investigate the excess risk of degeneration and segmental instability in operated segments late after lumbar disc surgery in patients with presurgically stable segments, and whether local pathological findings relate to patients' back health.

DESIGN

This retrospective analysis reports on 69 patients 12 years after first-time, uncomplicated lumbar disc surgery. Two independent radiologists evaluated the patients' lumbar functional x-rays; the Back Pain Rating Score (LBP-RS) assessed back-specific function.

RESULTS

At 12 years after lumbar disc surgery, degenerative changes as well as segmental instability occurred significantly more frequently in the operated than nonoperated lumbar segments, but there was no association between increased degeneration and segmental instability rates. The risk for acquiring segmental instability was significantly associated with surgery (odds ratio, 6.5; 95% confidence interval, 1.5-28.8). Prevalence of segmental instabilities was associated with better LBP-RS scores. Analyses of LBP-RS subscores revealed a clear association of segmental instability with physical function, but not with pain or activities of daily living.

CONCLUSIONS

Lumbar disc surgery seems to be associated with an increased risk of degeneration and segmental instability in the long term. This structural impairment, however, seems functionally well compensated and does not seem to be a relevant causal factor for a chronic back pain syndrome.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES:: Upon completion of this article, the reader should be able to: (1) Describe the impact of lumbar disc surgery on segmental instability and degenerative changes; (2) Recognize the lack of association between degenerative changes and segmental instability after lumbar disc surgery; and (3) State the value of lumbar spinal functional tests in the evaluation of patients after lumbar disc surgery.

LEVEL

Advanced ACCREDITATION:: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Prolo Scale: history, evolution and psychometric properties

BACKGROUND

The Prolo Scale (PS) is a widely accepted assessment tool for lumbar spinal surgery results. Nevertheless, in the literature there is a dearth of consensus about its application, interpretation and accuracy. The purpose of this review is to investigate the evolution of the PS from its introduction in 1986 to the present, including an analysis of different versions of the scale and research on the existing studies investigating its psychometric properties.

MATERIALS AND METHODS

PubMed, Cochrane Library and PEDro databases were searched. Studies in English, Italian, French, Spanish and German published from 1986 to December 2012 were analyzed.

RESULTS

The original lumbar surgery outcome scale consisted of two Likert-type scales (economic and functional). There are three more versions of the scale: Schnee proposed one consisting of 10 items, Brantigan made one with 20 items and introduced 2 more subscales (pain and medication), and Davis adapted the scale for the cervical spine. PS is often mentioned without any specific reference to the version used; therefore, a homogeneous comparison of studies is difficult to achieve. Several authors agree on the need to embrace a multidimensional measuring system to evaluate low back pain (LBP), but there is still no consensus regarding the most reliable tool. To date, PS has been mostly used as secondary outcome measure in association with validated primary measures for LBP.

CONCLUSIONS

The Prolo Scale has been adopted for clinical examination for 20 years because it is easy to administer and useful to compare significant amounts of data from surgical studies carried out at different times. Although several authors demonstrated the scale sensitivity among a battery of tests, no thorough validation study was found in the current literature.