Pain improvement and reoperation rate after full-endoscopic decompression for lateral recess stenosis: a 10-year follow-up

PURPOSE

To share long-term clinical outcomes and our experience with full-endoscopic interlaminar decompression (FEI) for lateral recess stenosis (LRS).

METHODS

We included all patients who underwent FEI for LRS from 2009 to 2013. VAS for leg pain, ODI, neurological findings, radiographic findings, and complications were analyzed at one week, one month, three months, and one year postoperation. The telephone interview for local patients with simple questions was done approximately ten years after the operation. International patients receive an email with the same questionnaire as local patients during the same follow-up period.

RESULTS

One hundred and twenty-nine patients underwent FEI for LRS with complete data during 2009-2013. Most of the patients (70.54%) had LRS radiculopathy for less than one year, mainly L4-5 (89.92%), followed by L5-S1 (17.83%). Early outcomes three months after surgery showed that most patients (93.02%) reported significant pain relief, and 70.54% reported no pain at their ODI scores were significantly reduced from 34.35 to 20.32% (p = 0.0052). In contrast, the mean VAS for leg pain decreased substantially by 3.77 points (p < 0.0001). There were no severe complications. At ten years of follow-up, 62 patients responded to the phone call or email. 69.35% of the patients reported having little or no back or leg pain, did not receive any further lumbar surgery, and were still satisfied with the result of the surgery. There were six patients (8.06%) who underwent reoperation.

CONCLUSION

FEI for LRS was satisfactory at 93.02%, with a low complication rate during the early follow-up period. Its effect seems to decline slightly in the long term at a 10-year follow-up. 8.06% of the patients subsequently underwent reoperation.

Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case

INTRODUCTION

Posterior epidural sequestrated disc is a fairly uncommon condition. We report a case of an unusual presentation of posterior epidural migration with contralateral symptoms. We emphasize a high index of suspicion for early recognition and treatment to promote a good neurological recovery.

CASE PRESENTATION

A 58-year-old man with a history of severe back pain for 1 week developed sudden right leg weakness while walking. Neurological examination revealed motor and sensory impairments of the right lower extremities (positive right straight leg raising test, right tibialis anterior grade 2/5, right extensor hallucis longus grade 1/5, decreased pinprick sensation of L4-5 dermatome right side) according to the Standards for Neurological Classification of Spinal Cord Injury as Asia Impairment Scale D. Magnetic resonance images showed an acute disc herniation at L4-5 on the left side, cranially migrated and sequestrated to the posterior epidural area, causing severe compression to the cauda equina in the thecal sac. The patient was successfully treated with surgery (transforaminal lumbar interbody fusion) on an urgent basis. We saw significant neurological recovery on the first day after surgery. Motor power recovery was achieved with a minor deficit at 4 weeks. At the follow-up examination at 3 months, the patient had no residual neurological deficits as Asia Impairment Scale E.

DISCUSSION

Posterior epidural sequestrated disc with contralateral radiculopathy is very rare. This case brings a new presentation of posterior epidural sequestrated disc. To our knowledge, this is the first report of a case with an unusual presentation of contralateral radiculopathy.

A Cost-Effectiveness Analysis of Intradiscal Electrothermal Therapy Compared with Circumferential Lumbar Fusion

STUDY DESIGN

Cost-effectiveness analysis.

OBJECTIVE

To evaluate the cost-effectiveness of intradiscal electrothermal therapy (IDET) relative to circumferential lumbar fusion with femoral ring allograft (FRA) in the United Kingdom.

SUMMARY OF BACKGROUND DATA

Circumferential lumbar fusion is an established treatment for discogenic low back pain. However, IDET could be a cost-effective treatment alternative as it can be carried out as a day case.

METHODS

Patient-level data were available for patients with discogenic low back pain treated with FRA (n = 37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n = 85). Both studies were carried out at a single institution in the United Kingdom. Patients were followed-up for 24 months, with data collected on low back disability (Oswestry Disability Index), back and leg pain (visual analog scale), quality of life (Short Form 36), radiographic evaluations, and U.K. National Health Service (NHS) resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

Both treatments produced statistically significant improvements in outcome at 24-month follow-up. NHS costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). At a threshold of £20,000 per QALY, the probability that IDET is cost effective is high.

CONCLUSIONS

Both treatments led to significant improvements in patient outcomes that were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.

Full endoscopic lumbar discectomy via interlaminar approach: 2-year results in Ramathibodi Hospital

OBJECTIVE

To present the surgical outcome of the full-endoscopic lumbar discectomy via interlaminar approach.

MATERIAL AND METHOD

Analysis of the prospectively collected data. The indication for full endoscopic discectomy is the same as for microscopic discectomy. Sixty consecutive patients with lumbar disc herniation were included. Full-endoscopic discectomy via interlaminar approach were done in all cases. The Visual analog scale (VAS), Thai version of modified Oswestry Disability Index (ODI), Macnab score, neurological symptoms, and complications were collected and followed for two years.

RESULTS

Mean follow-up period was 26 months. Excellent outcomes as defined by Macnab criteria were found in fifty-five of sixty patients (91.6%). The authors found two cases of recurrent disc herniation, which were re-operated by the same method and the symptoms were completely resolved later in the follow up period. There were two cases of persistent radicular pain after the operation, which were completely resolved after selective epidural nerve root injection. There was no serious neurological deficit, dura tear, or cauda equina syndrome in the present study series.

CONCLUSION

Full-endoscopic lumbar discectomy is a safe and effective procedure for lumbar disc herniation. Patients can expect less postoperative pain, early recovery, and a short period of work absence. However, the learning curve is steep. Proper surgical training and careful patient selection in the early cases are the keys to success.

Result of full endoscopic uniportal lumbar discectomy: preliminary report

OBJECTIVE

Several techniques of minimal invasive spinal surgery are now becoming common roles in the treatment of spinal diseases in many spinal centers. In the present report, the authors present a retrospective, cohort evaluation of 46 consecutive patients who underwent full endoscopic lumbar discectomy. The purpose of the present report was to present outcomes in this initial series of patients and to present outlines of the operative technique; the full endoscopic uniportal lumbar discectomy. The present research is the first preliminary report in Thailand to analyze and evaluate this new surgical technique.

MATERIAL AND METHOD

Forty-six lumbar disc herniation operations were performed in two spinal centers between February and June 2008, using the full endoscopic uniportal with Vertebris instrumentation system. The operations were carried out by interlaminar and transforaminal approach using an 8 mm-diameter uniportal endoscopy of Vertebris instrumentation. The outcome was clinically assessed, on immediate post-operation and one month after surgery, by using Visual Analogue Scale (VAS), the Thai Version of the modified Oswestry disability index (ODI) questionnaire (version 1.0), and modified McNab criteria.

RESULTS

Excellent and good outcome was achieved in 87.4% of patients from Modified McNab criteria. Forty-three patients (93.5%) had significant improvement of sciatic pain immediately after the operation. Eight postoperative complications were demonstrated and discussed.

CONCLUSION

Full endoscopic uniportal lumbar discectomy is a novel and effective minimally invasive spinal surgical technique. However, the technique requires surgical skill training and experience.