Lumbar disc herniation: long-term outcomes after mini-open discectomy

Influence of spine biomechanics and sagittal balance on the outcome of lumbar discectomy

Purpose

Spine biomechanics, particularly sagittal balance and spino-pelvic angulation are determinant factors in the understanding of lumbar degenerative disease. These concepts translated into objective measurements are progressively being integrated into clinical practice. The present study explores them as prognostic factors in patients undergoing lumbar microdiscectomy, which could help identify those at higher risk of surgical failure.

Methods

Prospective analysis of patients treated with lumbar microdiscectomy (n = 52) and healthy control subjects (n = 45) in a single tertiary centre. Follow up of 12 and 24 months after surgery, with radicular and lumbar pain evaluation according to the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). Comparison of several objective spinal biomechanic factors, measured by a single experienced radiologist. Assessment of spinal sagittal balance as a prognostic factor after lumbar discectomy.

Results

Compared to healthy individuals, patients with symptomatic lumbar disc herniation showed lower thoracic kyphosis (39.03 vs. 34.42° p = 0.034), lower thoraco-lumbar transition T10-L2 angulation (6.79 vs. 2.08° p = 0.005), lower lumbar lordosis (59.54 vs. 48.36° p < 0.001) and lumbo-sacral angulation L4-S1 (40.20 vs. 29.16° p < 0.001), lower pelvic incidence (54.71vs 49.86° p = 0.014) and lower sacral slope (42.07 vs. 33.34° p < 0.001). Sagittal balance (SVA) was negative in healthy subjects -3.09 mm and positive lumbar-disc patients 15.04 (p = 0.013). Noteworthy, the radicular and lumbar pain and disability outcomes 12 and 24 months after surgery were significantly better in the group with normal sagittal balance (ODI 14.52 vs. 40.06 p < 0.001; radicular VAS 2.74 vs. 5.58 p < 0.001; lumbar VAS 3.61 vs. 4.06 p < 0.001).

Conclusion

Lumbar degenerative disc disease represents a major burden for healthcare systems; thus, its management is determinant. Lumbar discectomy shows overall positive results, with a significant reduction of pain and disability in the majority of cases. However, a subgroup of patients, still not well defined, may experience persistent pain after the intervention. The use of objective measurements of sagittal balance may help identify these patients for which simple discectomy may not suffice and contribute to treatment planification.

Differential diagnosis between recurrent disc herniation and granulation tissue after lumbar disc herniation Surgery: Qualitative analysis on MRI scans

BACKGROUND

Recurrence of disc herniation is a prevalent late-term complication among patients surgically treated for lumbar disc herniation. Differential diagnosis between recurrent disc herniation and granulation tissue can be achieved through signal intensity measurements on T2-weighted MRI examinations. This study aims to examine cases operated on for recurrence of lumbar disc herniation, assessing those presenting with either disc recurrence or granulation tissue. The objective is to demonstrate that differential diagnosis can be facilitated through signal intensity value measurements and radiological findings in MRI examinations of patients with disc herniation recurrence and granulation tissue.

METHODS

Analysis involved reviewing lumbar MRI T2 sequences of patients operated on with a presumptive diagnosis of lumbar disc herniation recurrence. Mean T2 signal intensity values in preoperative MRI images of cases with disc herniation recurrence and granulation tissue were examined and recorded on the Picture Archiving and Communication System. Mean T2 signal intensity values of recurrent disc herniation and granulation tissue were then compared.

RESULTS

Among the patients who underwent surgery, disc herniation recurrence was observed in 135 cases, while granulation tissue was found in 12 patients (8.89 %). The preopreative mean T2 signal intensity value for disc herniation was recorded as 54.82 ± 2.42, whereas the mean T2 signal intensity value for granulation tissue was 205.96 ± 5.62.

CONCLUSIONS

T2 sequences in MRI examinations offer the clearest evaluation of disc herniations. Mean T2 signal intensity value measurements conducted on the PACS system can aid in differentiating between recurrent disc herniation and granulation tissue. These findings serve to inform surgical protocols during the preoperative phase.

Management of recurrent lumbar disc herniation: a comparative analysis of posterior lumbar interbody fusion and repeat discectomy

Background

For recurrent lumbar disc herniation, many experts suggest a repeat discectomy without stabilization due to its minimal tissue manipulation, lower blood loss, shorter hospital stay, and lower cost, recent research on the role of instability in disc herniation has made fusion techniques popular among spinal surgeons. The authors compare the postoperative outcomes of posterior lumbar interbody fusion (PLIF) and repeat discectomy for same-level recurrent disc herniation.

Methods

The patients included had previously undergone discectomy and presented with a same-level recurrent lumbar disc herniation. The patients were placed into two groups: 1) discectomy only, 2) PLIF based on the absence or presence of segmental instability. Preoperative and postoperative Oswestry disability index scores, duration of surgery, blood loss, duration of hospitalization, and complications were analyzed.

Results

The repeat discectomy and fusion groups had 40 and 34 patients, respectively. The patients were followed up for 2.68 (1-4) years. There was no difference in the duration of hospitalization (3.73 vs. 3.29 days P=0.581) and operative time (101.25 vs. 108.82 mins, P=0.48). Repeat discectomy had lower intraoperative blood loss, 88.75 ml (50-150) versus 111.47 ml (30-250) in PLIF (P=0.289). PLIF had better ODI pain score 4.21 (0-10) versus 9.27 (0-20) (P-value of 0.018). Recurrence was 22.5% in repeat discectomy versus 0 in PLIF.

Conclusion

PLIF and repeat discectomy for recurrent lumbar disc herniation have comparable intraoperative blood loss, duration of surgery, and hospital stay. PLIF is associated with lower durotomy rates and better long-term pain control than discectomy. This is due to recurrence and progression of degenerative process in discectomy patients, which are eliminated and slowed, respectively, by PLIF.

Repeat Discectomy for the Management of Same-Level Recurrent Disc Herniation: A Study of 50 Patients

Background Same-level recurrent disc herniation remains a challenge in spine surgery. Although most surgeons agree on discectomy as the treatment of choice for primary lumbar disc herniation, the management of recurrent disc herniation remains ambiguous and largely depends on the operating surgeon. Many surgeons recommend repeat discectomy over fusion because it is cheaper and less invasive. In this study, we analyzed 50 patients who underwent a repeat discectomy. Materials and methods The patients in the study had previously been managed for lumbar disc herniation and then presented with either recurrent same-level herniation or symptoms attributed to the same level. The patients were then managed with a repeat discectomy without fusion. We analyzed the preoperative and postoperative Oswestry Disability Index (ODI), duration of surgery, blood loss, duration of hospitalization, and complications. Results Fifty patients were included: 27 females (54%), and 23 males (46%). They were followed up for an average of 2.81 years (range: 1-4). The mean duration of hospitalization was 4.06 ± 1.5 days (range: 2-8). The operative time was 104.60 minutes (range: 50-195), with an intraoperative blood loss of 85.40 mL (range: 50-150 mL). Durotomy occurred as a complication in eight (16%) patients. The recurrence rate was 26%, with 36% progressing to fusion. The change in preoperative ODI and postoperative ODI was 20.94 ± 7.24 (6-37), with a p-value of 0.04. There were no long-term complications recorded. Conclusion Repeat discectomy is a good management option for same-level recurrent disc herniation. The procedure is associated with low intraoperative blood loss and a short operating time, but there is a significant risk of durotomy. The risk of recurrence remains a concern due to the progression of degenerative changes, especially in the presence of Modic-2 changes. These advantages and disadvantages should be discussed with patients.

Short-Term Postoperative Pain and Function of Unilateral Biportal Endoscopic Discectomy versus Percutaneous Endoscopic Lumbar Discectomy for Single-Segment Lumbar Disc Herniation: A Systematic Review and Meta-analysis

Objective

Spinal surgery is gradually moving toward minimally invasive surgery, but there is still some lack of knowledge about the Unilateral Biportal Endoscopic (UBE) technique that has been hotly debated in recent years. We performed this systematic review and meta-analysis to clarify whether UBE is superior to percutaneous endoscopic lumbar discectomy (PELD) for relieving short-term postoperative pain and promoting functional recovery.

Methods

Computer searches of PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang databases were performed to search for studies on UBE versus PELD for single-segment lumbar disc herniation (ssLDH) from the time of database construction to Mar. 2022, and two investigators independently performed literature screening and data extraction, and evaluation of the quality of the included studies was observed as operation time, complications, and visual analogue scale (VAS) at each preoperative and postoperative stage as well as Oswestry Disability Index (ODI), and meta-analysis was performed by applying the Review Manager 5.4 software.

Results

Meta-analysis showed that PELD had shorter operation time (MD = 35.36, 95% CI (4.67, 66.04), P = 0.02) and had lower VAS of back pain at 3 days postoperatively (MD = 0.62, 95% CI (0.04, 1.19), P = 0.04) compared to the UBE. However, there was no statistical significance between the two groups in terms of complications (MD = 2.53, 95% CI (0.40, 16.11), P = 0.33), VAS of back pain at 30 days postoperatively (MD = 0.05, 95% CI (-0.19, 0.28), P = 0.70), VAS of leg pain at 3 days postoperatively (MD = 0.21, 95% CI (-0.20, 0.61), P = 0.33), VAS of leg pain at 30 days postoperatively (MD = 0.09, 95% CI (-0.29, 0.46), P = 0.65), and ODI at 30 days postoperatively (MD = -0.81, 95% CI (-3.03, 1.41), P = 0.47).

Conclusions

Current evidence suggests that both UBE and PELD are effective in relieving short-term postoperative pain and promoting functional recovery, and there is no difference in complications between them; UBE requires longer operation time, and PELD may be superior in relieving immediate postoperative pain. This trial is registered with PROSPERO ID: CRD42021287810.

Finite Element Analysis of a Bionate Ring-Shaped Customized Lumbar Disc Nucleus Prosthesis

Study design: Biomechanical study of a nucleus replacement with a finite element model. Objective: To validate a Bionate 80A ring-shaped nucleus replacement. Methods: The ANSYS lumbar spine model made from lumbar spine X-rays and magnetic resonance images obtained from cadaveric spine specimens were used. All materials were assumed homogeneous, isotropic, and linearly elastic. We studied three options: intact spine, nucleotomy, and nucleus implant. Two loading conditions were evaluated at L₃-L₄, L₄-L₅, and L₅-S₁ discs: a 1000 N axial compression load and this load after the addition of 8 Nm flexion moment in the sagittal plane plus 8 Nm axial rotation torque. Results: Maximum nucleus implant axial compression stresses in the range of 16–34 MPa and tensile stress in the range of 5–16 MPa, below Bionate 80A resistance were obtained. Therefore, there is little risk of permanent implant deformation or severe damage under normal loading conditions. Nucleotomy increased segment mobility, zygapophyseal joint and end plate pressures, and annulus stresses and strains. All these parameters were restored satisfactorily by nucleus replacement but never reached the intact status. In addition, annulus stresses and strains were lower with the nucleus implant than in the intact spine under axial compression and higher under complex loading conditions. Conclusions: Under normal loading conditions, there is a negligible risk of nucleus replacement, permanent deformation or severe damage. Nucleotomy increased segmental mobility, zygapophyseal joint pressures, and annulus stresses and strains. Nucleus replacement restored segmental mobility and zygapophyseal joint pressures close to the intact spine. End plate pressures were similar for the intact and nucleus implant conditions under both loading modes. Manufacturing customized nucleus implants is considered feasible, as satisfactory biomechanical performance is confirmed.

Incidence of recurrent lumbar disc herniation: A narrative review

Background:

Recurrent disc herniation is a common condition that often results in months of disabling symptoms and additional costs.

Objective:

The objective of this study was to investigate the incidence of recurrent disc herniation in patients treated surgically.

Materials and Methods:

Clinical trials and prospective studies involving patients treated with different techniques, such as open, percutaneous, or microendoscopic discectomy, were included. The incidence of recurrence as well as the level and the time until the recurrent disc herniation was collected.

Results:

Thirteen studies were included. Recurrence of disc herniation ranged from 0% to 14% of patients. Most recurrences occurred at the same level of herniation and on the same side. The time to recurrence of disc herniation ranged from 1 to 5 years.

Conclusion:

This study answers the question of how much, when, and where in lumbar recurrent disc herniation.

Clinical Outcomes and Postoperative Radiographic Assessment of Osteoplastic Hemilaminectomy in the Treatment of Lumbar Foraminal Nerve Root Compression

Introduction

Osteoplastic hemilaminectomy for the treatment of lumbar foraminal nerve root compression is a safe technique as the exiting nerve root can be directly observed during neuroforaminal decompression without spinal fusion. Moreover, this procedure allows anatomical reconstruction of the posterior elements. However, there might be a potential risk for the progression of lumbar segmental instability after performing this procedure. This study aimed to review the radiographic and clinical outcomes of osteoplastic hemilaminectomy for the treatment of lumbar foraminal nerve root compression.

Methods

We retrospectively reviewed 51 patients who underwent osteoplastic hemilaminectomy with a minimum follow-up of 2 years. The clinical outcomes were evaluated using the visual analog scale (VAS) for low back pain, leg pain, and numbness and the Japanese Orthopaedic Association (JOA) score. Lumbar segmental instability was evaluated as a radiographic assessment using functional radiography. The mean follow-up period was 65 months.

Results

The preoperative VASs for low back pain, leg pain, and numbness were 46±31, 72±26, and 43±34, respectively, which were improved to 24±23, 19±23, and 19±23, respectively. The JOA score was also improved from 14±5 to 22±4. Three patients (5.9%) were reoperated due to recurrent disc herniation within 2 years following surgery. In addition, three patients (5.9%) developed postoperative lumbar segmental instability but did not require additional surgery.

Conclusions

The current study revealed that 94.1% of the patients who underwent osteoplastic hemilaminectomy achieved a significant improvement in the clinical outcomes and did not require additional surgery within 2 years following the procedure. Over a 5-year follow-up on average, 5.9% of the subjects developed postoperative lumbar segmental instability; however, they have maintained acceptable clinical conditions.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy

Objective

The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients.

Methods

A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong.

Results

A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients.

Conclusion

We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

Minimum Seven-Year Follow-Up Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Lumbar Degenerative Disease

Purpose

To investigate the long-term (> 7 years) clinical outcomes of percutaneous endoscopic lumbar discectomy for lumbar degenerative disease to address postoperative problems including postoperative dysesthesia (POD), residual back pain and segmental instability.

Methods

Inclusion and exclusion criteria were established. All patients who met the above criteria were treated by PELD using the transforaminal approach. Limited discectomy was performed to preserve the disc material in the intervertebral space as much as possible. The Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back pain (VAS-B) and leg pain (VAS-L) and Modified MacNab’s criterion were used for clinical evaluation. Radiographic parameters including height of intervertebral disc and segmental instability were also evaluated.

Results

Forty-two patients (24 men and 18 women) who met our inclusion and exclusion criteria were included in our study. The average follow-up period was 95.71±5.63 months (ranging from 87 to 105 months). There were no neurological complications associated with the operation. POD was found in 14.29% of patients, while only 2 patients (4.76%) complained of mild dysesthesia at final follow-up. Two patients (4.76%) required revision surgery during the follow-up period. The final follow-up ODI, JOA score, VAS-B and VAS-L were significantly better than preoperative values. The average disc-height ratio was 84.52±5.66% of the preoperative disc height. No instability at the operation level was noted at final follow-up.

Conclusion

Our study showed that PELD using the transforaminal approach can provide favorable results after a long-term follow-up period. POD is a common complication at initial prognosis. Limited discectomy can preserve the disc height well and minimize the risk of residual back pain.

Systematically characterized mechanism of treatment for lumbar disc herniation based on Yaobitong capsule ingredient analysis in rat plasma and its network pharmacology strategy by UPLC-MS/MS

ETHNOPHARMACOLOGICAL RELEVANCE

Yaobitong capsule (YBTC) was a traditional Chinese medicine (TCM) and it had clinically used to treat lumbar disc degeneration (LDH) for a long time. However, the active ingredients of YBTC absorption into the plasma and its pharmacological mechanism of treatment for LDH still remained unclear.

AIM OF THE STUDY

In this study, our research committed to identify the absorbed active ingredients of YBTC in rat plasma, and it may be a potential mechanism of action on LDH by the biological targets regulating related pathways.

MATERIALS AND METHODS

An ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method was established to identify the absorption components and metabolites of YBTC in rat plasma, and the network pharmacology was further investigated to illuminate its potential mechanism of treatment for LDH by the biological targets regulating related pathways.

RESULTS

The network analysis found that 56 components were identified as its main active ingredients including ginsenoside Rg1, ginsenoside Rb1, senkyunolide H, and tetrahydropalmatine, etc. Combining with biological process, cellular component and molecular functions of GO, and kyotoencyclopedia of genes and genomes pathway enrichment analysis to perform network topology analysis on core targets. These active ingredients regulated 29 mainly pathways by 87 direct target genes including MAPK, Ras, PI3K-Akt, and NF-kappa B signaling pathway, etc. CONCLUSION: In this study, the absorption active ingredients of YBTC in rat plasma were firstly combined with the network pharmacology investigation to elucidate its biological mechanism of treatment for LDH in vivo. It inhibited excessive inflammatory reactions, thereby reducing the sensitivity of the nerves to reduce pain and relieve LDH, and potential medicine targets could be identified to clarify the molecular mechanism of YBTCs' regulation of LDH.

Extraction optimization of accelerated solvent extraction for eight active compounds from Yaobitong capsule using response surface methodology: Comparison with ultrasonic and reflux extraction

This work described the development of a novel method for simultaneous extraction of eight active compounds (including catechin, albiflorin, paeoniflorin, ferulic acid, ginsenoside Rg1, tetrahydropalmatine, ginsenoside Rb1 and osthole) from Yaobitong capsule by accelerated solvent extraction (ASE). Response surface methodology (RSM) with desirability functions was employed to optimize the extraction conditions yielding the optimal conditions of ASE (extraction time 8 min, extraction temperature 80 °C, extraction solvent 70% methanol and flushing volume 100%). A high-performance liquid chromatography coupled with a diode array detector (HPLC-DAD) method was developed and validated for simultaneous quantification of the eight compounds in Yaobitong capsule. The values of correlation coefficient (R) were satisfactory between 0.9992 and 0.9999 over the linear concentration range of 0.5-1000 μg mL^-1. It was found that the limits of detection (LODs) and the limits of quantification (LOQs) for the eight active compounds were 0.10-2.90 μg•mL^-1 and 0.30-9.40 μg•mL^-1, respectively. The recoveries of the eight main active compounds in Yaobitong capsule were in the range of 93.31%-106.22%. And the contents of the analytes extracted by ASE under the optimal conditions were compared to traditional solvent extraction methods, such as ultrasonic and reflux extraction. The results indicated that the ASE method proved to be more suitable for the extract of active compounds in Yaobitong capsule, which could obtain higher extraction efficiency. At last, the proposed method was applied to analyze ten batches of actual samples, which provided high extraction efficiency and had wide potential application in the analysis of traditional Chinese medicines.