Microdiscectomy compared with standard discectomy: an old problem revisited with new outcome measures within the framework of a spine surgical registry

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study

STUDY DESIGN

Prospective Study.

OBJECTIVES

There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons.

METHODS

This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group.

RESULTS

Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches.

CONCLUSION

Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair

OBJECTIVE

There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion.

METHODS

Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36.

RESULTS

Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution.

CONCLUSIONS

Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

S SV, Soundararajan DCR, Shetty T AP, Kanna P RM, Pushpa B. Lumbar Disc Herniation and Preoperative Modic Changes: A Prospective Analysis of the Clinical Outcomes After Microdiscectomy

STUDY DESIGN

Prospective comparative cohort study.

OBJECTIVES

The study aims to elucidate the relationship between Modic endplate changes and clinical outcomes after a lumbar microdiscectomy.

METHODS

Consecutive patients undergoing microdiscectomy for lumbar disc herniation (LDH) were prospectively studied. Pre-operative clinical and radiological parameters were recorded. The pain was assessed by Numeric pain rating scale (NPRS), and functional assessment by Oswestry Disability Index (ODI). Minimal clinically important difference (MCID) in outcome was calculated for both the groups. Complications related to surgery were studied. Follow-up was done at 6 weeks, 3 months, 6 months and 1 year. Mac Nab criteria were used to assess patient satisfaction at 1 year.

RESULTS

Out of 309 patients, 86 had Modic changes, and 223 had no Modic changes. Both groups had similar back pain (p-value: 0.07) and functional scores (p-value: 0.85) pre-operatively. Postoperatively patients with Modic changes had poorer back pain and ODI scores in the third month, sixth month and 1 year (p-value: 0.001). However, MCID between the groups were not significant (p-value: 0.18 for back pain and 0.58 for ODI scores). Mac Nab criteria at 1 year were worse in Modic patients (p-value: 0.001). No difference was noted among Modic types in the pre-operative and postoperative pain and functional outcomes. Four patients in Modic group (4.7%) and one patient in the non-Modic group (0.5%) developed postoperative discitis (p-value: 0.009).

CONCLUSIONS

Preoperative Modic changes in lumbar disc herniation is associated with less favorable back pain, functional scores and patient satisfaction in patients undergoing microdiscectomy.

Retrospective Analysis of Reoperation Rate After Standard Lumbar Discectomy and Microdiscectomy - Single Center Experience

Discectomy is a surgical procedure in the treatment of lumbar disc herniation (LDH) if sciatica or neurological deficits occur and still persist after a course of conservative therapy. Standard discectomy (SD) and microdiscectomy (MD) are still equal in curent clinical practice. Many retrospective and prospective studies have shown that there is no clinically significant difference in the functional outcome after two treatment modalities.

The aim of our study was to determine whether there are differences in the incidence of reoperation after performing SD and MD.

The research included 545 patients with average period of postoperative follow-up of approximately 5.75 years. Standard discectomy was performed in 393 patients (72.11%), and micro-discectomy in 152 (27.8%) patients. The total number of reoperated patients was 37/545, or 6.78%. In the SD group, the number of reoperated patients was 33/393 (8.39%) and in the MD group 4/152 or 2.63%. Statistically significant difference (p <0.05) was recorded in favor of the MD group.

Although it has been proven that both SD and MD give good endpoints of treatment and similar functional recovery, the advantage is given to microdiscectomy due to statistically significantly lower rates of recurrent herniation. This result is attributed to better visualization of neural structures and pathological substrates, as well as their mutual relationship.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Retrospective Study

OBJECTIVES

Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the perioperative factors, outcomes, and complications of each procedure and compare among them with 946 patients contributed by 10 centers and operated by experienced surgeons.

METHODS

This was a retrospective study of patients operated using open discectomy, microdiscectomy, microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques with a follow-up of minimum 2 years. The inclusion criteria were age >18 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level.

RESULTS

There was a significant improvement in the visual analog scale score of back, leg, and Oswestry Disability Index scores postoperatively across the board, with no significant difference between them. Minimally invasive procedures (microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) had shorter operation time, hospital stay, better cosmesis, and decreased blood loss compared with open procedures (open discectomy and microdiscectomy). The overall complication rate was 10.1%. The most common complication was recurrence (6.86%), followed by reoperation (4.3%), cerebrospinal fluid leak (2.24%), wrong level surgery (0.74%), superficial infection (0.62%), and deep infection (0.37%). There were minor differences in incidence of complications between techniques.

CONCLUSION

Although minimally invasive techniques have some advantages over the open techniques in the perioperative factors, all the techniques are effective and provide similar pain relief and functional outcomes at the end of 2 years. The various rates of individual complications provide a reference value for future studies.

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes

STUDY DESIGN

Retrospective analysis of clinical data from a single institution.

OBJECTIVE

The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy.

SUMMARY OF BACKGROUND DATA

The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy.

METHODS

Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates.

RESULTS

Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts.

CONCLUSION

The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.

Pain During Sex Before and After Surgery for Lumbar Disc Herniation: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar disc herniation (LDH).

SUMMARY OF BACKGROUND DATA

There are limited data available on sexual function in patients undergoing surgery for LDH.

METHODS

Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at one year, assessed by item number eight of the Oswestry disability index (ODI) questionnaire. Secondary outcome measures included ODI, EuroQol-5D (EQ-5D), and numeric rating scale (NRS) scores for back and leg pain.

RESULTS

Among the 18,529 patients included, 12,103 (64.8%) completed 1-year follow-up. At baseline, 16,729 patients (90.3%) provided information about pain during sexual activity, whereas 11,130 (92.0%) among those with complete follow-up completed this item. Preoperatively 2586 of 16,729 patients (15.5%) reported that pain did not affect sexual activity and at 1 year, 7251 of 11,130 patients (65.1%) reported a normal sex-life without pain. Preoperatively, 2483 (14.8%) patients reported that pain prevented any sex-life, compared to 190 patients (1.7%) at 1 year. At baseline, 14,143 of 16,729 patients (84.5%) reported that sexual activity caused pain, and among these 7232 of 10,509 responders (68.8%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, working until time of surgery, undergoing emergency surgery, and increasing ODI score were predictors of improvement in pain during sexual activity. Increasing age, tobacco smoking, increasing body mass index, comorbidity, back pain >12 months, previous spine surgery, surgery in two or more lumbar levels, and complications occurring within 3 months were negative predictors.

CONCLUSION

This study clearly demonstrates that a large proportion of patients undergoing surgery for LDH experienced an improvement in pain during sexual activity at 1 year.

LEVEL OF EVIDENCE

2.

Evaluation of Percutaneous Transforaminal Endoscopic Discectomy in the Treatment of Lumbar Disc Herniation: A Retrospective Study

OBJECTIVE

The objective of the present study was to evaluate the safety and efficacy of percutaneous transforaminal endoscopic discectomy (PTED) and open fenestration discectomy (OFD) in the treatment of lumbar disc herniation (LDH).

METHODS

Patients in our hospital with LDH who received PTED (n = 71) and OFD (n = 39) from 2013 to 2014 were retrospectively studied. Patient information, including age, gender, visual analogue scale (VAS) score for low back pain and leg pain, body weight, height, Oswestry disability index (ODI), Japanese Orthopedic Association (JOA), and recurrence, was collected. The patients in the two groups were followed up for an average of 63 months after surgery.

RESULTS

A total of 136 patients completed the operation and 110 patients were followed up completely. There was no significant difference in baseline data between the two groups (P > 0.05). The postoperative low back pain, leg pain, ODI, and JOA of the two groups were better than those preoperatively (P < 0.05). One week after surgery, the recovery of PTED patients was better than that of OFD. The ODI score of the PTED group was lower than that of the OFD group (10 [8, 12] vs 14 [11, 16]; P < 0.05), the waist VAS score of the PTED group was lower than that of the OFD group (2 [2, 3] vs 3 [2, 4]; P < 0.05), the leg VAS score of the PTED group was lower than that of the OFD group (1 [0,1] vs 1 [1, 2]; P < 0.05), while the JOA score of the PTED group was higher than that of OFD group [19(16, 20) vs 12(10, 17); P < 0.05]. There were no significant differences in ODI, JOA, waist and leg VAS scores between the two groups at 1 month after surgery and at subsequent follow-up (P > 0.05). At the end of the follow up, 89.7% (35/39) of patients in the OFD group had excellent improvement in the JOA score, and 88.7% (63/71) of patients in the PTED group had an excellent improvement. There was no significant difference between the two (P > 0.05). There was also no significant difference in the recurrence rate between the two groups [(5/71) vs (3/39); P > 0.05]. [Correction added on 05 March 2021, after first online publication: "3/29" was amended to "3/39" in the preceding sentence.] CONCLUSION: Both PTED and OFD can achieve good mid-term efficacy in the treatment of LDH but PTED has certain advantages, including the small incision, a shorter hospital stay, and quicker, earlier recovery. However, prospective randomized controlled studies with a larger sample size are needed.

Functional Evolution after Percutaneous Endoscopic Lumbar Discectomy, an Earlier Evaluation of 32 Cases

Objective  To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD).

Methods  Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks.

Results  All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks.

Conclusion  All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3 ^rd month.

Review of response rates over time in registry-based studies using patient-reported outcome measures

OBJECTIVES

Gain an overview of expected response rates (RRs) to patient-reported outcome measures (PROMs) in clinical quality registry-based studies and long-term cohorts in order to better evaluate the validity of registries and registry-based studies. Examine the trends of RRs over time and how they vary with study type, questionnaire format, and the use of reminders.

DESIGN

Literature review with systematic search.

DATA SOURCES

PubMed, MEDLINE, EMBASE, kvalitetsregistre.no, kvalitetsregister.se and sundhed.dk.

ELIGIBILITY CRITERIA

Articles in all areas of medical research using registry-based data or cohort design with at least two follow-up time points collecting PROMs and reporting RRs. Annual reports of registries including PROMs that report RRs for at least two time points.

PRIMARY OUTCOME MEASURE

RRs to PROMs.

RESULTS

A total of 10 articles, 12 registry reports and 6 registry articles were included in the review. The overall RR at baseline was 75%±22.1 but decreased over time. Cohort studies had a markedly better RR (baseline 97%±4.7) compared with registry-based data at all time points (baseline 72%±21.8). For questionnaire formats, paper had the highest RR at 86%±19.4, a mix of electronic and paper had the second highest at 71%±15.1 and the electronic-only format had a substantially lower RR at 42%±8.7. Sending one reminder (82%±16.5) or more than one reminder (76%±20.9) to non-responders resulted in a higher RR than sending no reminders (39%±6.7).

CONCLUSIONS

The large variation and downward trend of RRs to PROMs in cohort and registry-based studies are of concern and should be assessed and addressed when using registry data in both research and clinical practice.

Open fenestration discectomy versus microscopic fenestration discectomy for lumbar disc herniation: a randomized controlled trial

Background

Fenestration discectomy, for symptomatic lumbar disc herniation, is the most common surgical procedure in spine surgery. It can be done by open or microscopic procedures. This study compared the results of fenestration microdiscectomy with open fenestration discectomy in the treatment of symptomatic lumbar disc herniation as a relation to the functional outcome, leg pain, back pain, hospital stay, returns to daily activity, cost, recurrence, reoperation and type of surgery for recurrent disc herniation.

Methods

60 patients age (29 - 50 years), with L4-L5 disc herniation, are divided randomly into group A- 30 patients underwent an open fenestration discectomy- and group B- 30 patients underwent fenestration microdiscectomy. All patients are assessed at 1 week, 3 months, 6 months, 12 months after surgery for Oswestry disability index and Visual analogue scale for back pain and leg pain and followed up for 4 years.

Results

In both groups, all patients have minimal disability by Oswestry Disability Index after surgery.

There were significant differences between means of post-operative Visual Analogue Scale for back pain between these two groups after 1 week (3.7 in group A versus 2.2 in group B) (t = 13.28, P = < 0.001*) and after 3 months (1.73 in group A versus 0.43 in group B) (t = 10.54, P = < 0.001*).

There were no significant differences between two groups regarding post-operative VAS for leg pain, recurrence (5 patients in group A versus 4 patients in group B) and reoperation rate (2 patients in each group).

There were significant differences between means of length of hospital stay (2.10 in group A versus 1.06 in group B) (P < 0.001), time of returning to daily activities (7.33 in group A versus 4.03 in group B) (P < 0.001) and cost of surgery (1996.66 in group A versus 3003.3 in group B) (P < 0.001).

Conclusion

Use of microscope in fenestration discectomy for treatment of symptomatic lumbar disc herniation can achieve the same goals of open fenestration regarding nerve root decompression and relief of leg pain with advantage of less back pain, less hospital staying and early return to daily activities with disadvantage of more cost with the use of microscope. With 4 years follow up, there was no significant deference in rate of recurrence and reoperation with the use of microscope but we found that type of surgery for recurrent cases may be less invasive if microscope was used in primary surgery.

Trial registration

NCT, NCT04112485. Registered 30 September 2019 - Retrospectively registered, https://clinicaltrials.gov/NCT04112485

Devices for minimally-invasive microdiscectomy: current status and future prospects

Introduction: The current gold standard technique for lumbar disc herniation (LDH) is open lumbar microdiscectomy. The use of a tubular retractor system in the microdiscectomy technique can minimize tissue trauma by muscle-splitting sequential dilation during the surgical approach. This review aimed to describe the devices and surgical procedure of this minimally invasive microdiscectomy (MI-MD) and to discuss the pros and cons of the use of tubular retractors.Areas covered: Published medical literatures were extensively reviewed to summarize the practical devices and techniques related to the MI-MD for LDH. The placement of the tubular retractor by gradual muscle-splitting dilation technique may reduce muscle damage and postoperative wound pain. The use of flexible arm may easily change the tube direction and create a wide surgical field.Expert opinion: With reference to published literature, the MI-MD provides comparable clinical outcomes with less tissue trauma and early recovery. Development of devices for MI-MD is still ongoing. Extensive studies, including high-quality randomized trials, are required to establish a more practical and relevant MI-MD technique.

Propensity-matched Comparison of Outcomes and Costs After Macroscopic and Microscopic Anterior Cervical Corpectomy Using a National Longitudinal Database

STUDY DESIGN

A retrospective analysis of national longitudinal database.

OBJECTIVE

The aim of this study was to examine the outcomes and cost-effectiveness of operating microscope utilization in anterior cervical corpectomy (ACC).

SUMMARY OF BACKGROUND DATA

The operating microscope allows for superior visualization and facilitates ACC with less manipulation of tissue and improved decompression of neural elements. However, many groups report no difference in outcomes with increased cost associated with microscope utilization.

METHODS

A longitudinal database (MarketScan) was utilized to identify patients undergoing ACC with or without microscope between 2007 and 2016. Propensity matching was performed to normalize differences between the two cohorts. Outcomes and costs were subsequently compared.

RESULTS

A total of 11,590 patients were identified for the "macroscopic" group, while 4299 patients were identified for the "microscopic" group. For the propensity-matched analysis, 4298 patients in either cohort were successfully matched according to preoperative characteristics. Hospital length of stay was found to be significantly longer in the macroscopic group than the microscopic group (1.86 nights vs. 1.56 nights, P < 0.0001). Macroscopic ACC patients had an overall higher rate of readmissions [30-day: 4.2% vs. 3.2%, odds ratio (OR) = 0.76 (0.61-0.96), P = 0.0223; 90-day: 7.0% vs. 5.9%, OR = 0.82 (0.69-0.98), P = 0.0223]. Microscopic ACC patients had a higher rate of discharge to home [86.6% vs. 92.5%, OR = 1.91 (1.65-2.21), P < 0.0001] and lower rates of new referrals to pain management [1.0% vs. 0.4%, OR = 0.42 (0.23-0.74), P = 0.0018] compared with macroscopic ACC. Postoperative complication rate was not found to be significantly different between the groups. Finally, total initial admission charges were not significantly different between the macroscopic and microscopic groups ($30,175 vs. $29,827, P = 0.9880).

CONCLUSION

The present study suggests that the use of the operating microscope for ACC is associated with decreased length of stay, readmissions, and new referrals to pain management, as well as higher rate of discharge to home.

LEVEL OF EVIDENCE

3.

Comparison between Results of Microdiscectomy and Open Discectomy in Management of High-Level Lumbar Disc Prolapse

AIM

This work aims to compare between results of microdiscectomy and open discectomy in management of high-level lumbar disc prolapse.

METHODS

This is a controlled randomised study, where patients having upper lumbar disc herniations were evaluated preoperatively both clinically and radiologically, randomisation was planned to perform open discectomy in odd number patients and to perform microdiscectomy in even number patients, patients were evaluated and followed up for deficits and outcomes.

RESULTS

We operated ten patients in this study, five cases were operated upon with microdiscectomy, and five cases were operated upon with open discectomy, the median age of presentation in this study was 44 years, there were five males and five females, postoperative pain improvement was better in microdiscectomy. Hospital stay, blood loss, bone loss and postoperative complications were less in microdiscectomy.

CONCLUSION

Microdiscectomy allows good surgical visualisation and is less traumatic to the involved tissues. The results of this study indicated that microsurgery reduces hospitalisation time, improves the overall surgery-related outcome. The main differences between the two procedures were the length of the incision and blood loss. We found that lumbar microdiscectomy allows patients earlier return to work and normal life with less reliance on postoperative narcotic analgesic agents.

Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database

OBJECTIVE

There has been considerable debate about the utility of the operating microscope in lumbar discectomy and its effect on outcomes and cost.

METHODS

A commercially available longitudinal database was used to identify patients undergoing discectomy with or without use of a microscope between 2007 and 2015. Propensity matching was performed to normalize differences between demographics and comorbidities in the 2 cohorts. Outcomes, complications, and cost were subsequently analyzed using bivariate analysis.

RESULTS

A total of 42,025 patients were identified for the “macroscopic” group, while 11,172 patients were identified for the “microscopic” group. For the propensity-matched analysis, the 11,172 patients in the microscopic discectomy group were compared with a group of 22,340 matched patients who underwent macroscopic discectomy. There were no significant differences in postoperative complications between the groups other than a higher proportion of deep vein thrombosis (DVT) in the macroscopic discectomy cohort versus the microscopic discectomy group (0.4% vs 0.2%, matched OR 0.48 [95% CI 0.26–0.82], p = 0.0045). Length of stay was significantly longer in the macroscopic group compared to the microscopic group (mean 2.13 vs 1.83 days, p < 0.0001). Macroscopic discectomy patients had a higher rate of revision surgery when compared to microscopic discectomy patients (OR 0.92 [95% CI 0.84–1.00], p = 0.0366). Hospital charges were higher in the macroscopic discectomy group (mean $19,490 vs $14,921, p < 0.0001).

CONCLUSIONS

The present study suggests that the use of the operating microscope in lumbar discectomy is associated with decreased length of stay, lower DVT rate, lower reoperation rate, and decreased overall hospital costs.

[Rehabilitation of the patients presenting with the operated spine syndrome during the complicated postoperative period after discectomy]

This article presents an analytical review of the literature concerning the problem of rehabilitation of the patients following the surgical treatment of hernias of intervertebral disks. The relevance of this problem and the importance of the related research activities in the context of neurorehabilitation are beyond any doubt. Despite the obvious progress in the modernization of the methods and technologies for medical rehabilitation, the number of re-operations in connection with the recurrences of herniated discs remains too high and the overall success thus far achieved in this field falls short of expectations. The authors discuss in detail the need for and the contemporary approaches to the rehabilitative treatment of the patients undergoing vertebral microdiscectomy including medication therapy, physiotherapy an therapeutic physical exercises. The variants of the application of magnetic stimulation during the early period of the rehabilitative treatment of the patients following the minimally invasive interventions for discogenic radiculopathy are considered.

The Influence of Single-level Versus Multilevel Decompression on the Outcome in Multisegmental Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data

STUDY DESIGN

This is prospective multicenter cohort study.

OBJECTIVE

To assess whether patients with confirmed multisegmental lumbar spinal stenosis benefit more from a single-level or a multilevel decompression.

SUMMARY OF BACKGROUND DATA

In multisegmental lumbar spinal stenotic cases, the decision as to how many levels of stenosis need to be operated to achieve the best possible clinical outcome is still unknown and remains a controversy between spine surgeons.

MATERIALS AND METHODS

Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed multisegmental LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcomes of this study were Spinal Stenosis Measure (SSM) symptoms and function over time, measured at baseline, 6, 12, and 24 months follow-up. Further outcomes of interest were changes in SSM, numeric rating scale, feeling thermometer, the EQ-5D-EL, and the Roland and Morris disability questionnaire from baseline to 6, 12, and 24 months.

RESULTS

After 12 months, a total of 141 patients met the inclusion criteria; of these, 33 (23%) underwent a single-level and 108 (77%) a multilevel decompression. Multilevel decompression was associated with a significantly less favorable SSM symptoms and function score, respectively, as compared with single-level decompression. In all further outcomes of interest single-level as well as multilevel patients improved over time.

CONCLUSIONS

Our study showed that in multisegmental stenotic cases a single-level decompression was associated with a significantly more favorable SSM symptoms and function score, respectively, as compared with multilevel decompression. This study provides evidence that in multisegmental stenotic cases a single-level decompression might be sufficient to improve patient's symptoms and function.

Criteria for failure and worsening after surgery for lumbar disc herniation: a multicenter observational study based on data from the Norwegian Registry for Spine Surgery

PURPOSE

In clinical decision-making, it is crucial to discuss the probability of adverse outcomes with the patient. A large proportion of the outcomes are difficult to classify as either failure or success. Consequently, cutoff values in patient-reported outcome measures (PROMs) for "failure" and "worsening" are likely to be different from those of "non-success". The aim of this study was to identify dichotomous cutoffs for failure and worsening, 12 months after surgical treatment for lumbar disc herniation, in a large registry cohort.

METHODS

A total of 6840 patients with lumbar disc herniation were operated and followed for 12 months, according to the standard protocol of the Norwegian Registry for Spine Surgery (NORspine). Patients reporting to be unchanged or worse on the Global Perceived Effectiveness (GPE) scale at 12-month follow-up were classified as "failure", and those considering themselves "worse" or "worse than ever" after surgery were classified as "worsening". These two dichotomous outcomes were used as anchors in analyses of receiver operating characteristics (ROC) to define cutoffs for failure and worsening on commonly used PROMs, namely, the Oswestry Disability Index (ODI), the EuroQuol 5D (EQ-5D), and Numerical Rating Scales (NRS) for back pain and leg pain.

RESULTS

"Failure" after 12 months for each PROM, as an insufficient improvement from baseline, was (sensitivity and specificity): ODI change <13 (0.82, 0.82), ODI% change <33% (0.86, 0.86), ODI final raw score >25 (0.89, 0.81), NRS back-pain change <1.5 (0.74, 0.86), NRS back-pain % change <24 (0.85, 0.81), NRS back-pain final raw score >5.5 (0.81, 0.87), NRS leg-pain change <1.5 (0.81, 0.76), NRS leg-pain % change <39 (0.86, 0.81), NRS leg-pain final raw score >4.5 (0.91, 0.85), EQ-5D change <0.10 (0.76, 0.83), and EQ-5D final raw score >0.63 (0.81, 0.85). Both a final raw score >48 for the ODI and an NRS >7.5 were indicators for "worsening" after 12 months, with acceptable accuracy.

CONCLUSION

The criteria with the highest accuracy for defining failure and worsening after surgery for lumbar disc herniation were an ODI percentage change score <33% for failure and a 12-month ODI raw score >48. These cutoffs can facilitate shared decision-making among doctors and patients, and improve quality assessment and comparison of clinical outcomes across surgical units. In addition to clinically relevant improvements, we propose that rates of failure and worsening should be included in reporting from clinical trials.

Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse

Objectives:

Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy.

Materials and Methods:

Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates.

Results:

The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1^st year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group.

Conclusion:

This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study

Introduction: 

Since the introduction of lumbar microdiscectomy in the 1970’s, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice.

Methods and analysis:  

This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

Microdiscectomy for the treatment of lumbar disc herniation: an evaluation of reoperations and long-term outcomes

Design Retrospective case series. Objective The objective of this study was to assess the reoperation rate after microdiscectomy for the treatment of lumbar disc herniation (LDH) in patients with ≥ 5-year follow-up and identify demographic, perioperative, and outcome-related differences between patients with and without a reoperation. Methods The medical records, operative reports, and office notes of patients who had undergone microdiscectomy at a single institution between March 1994 and December 2007 were reviewed and long-term follow-up was assessed via a telephone questionnaire. Results Forty patients (M:24, F:16) with an average age at surgery of 39.9 ± 12.5 years (range: 18-80) underwent microdiscectomy at the levels L5-S1 (n = 28, 70%), L4-L5 (n = 9, 22.5%), L3-L4 (n = 2, 5.0%), and L1-L2 (n = 1, 2.5%). After an average of 40.4 ± 40.1 months (range: 1-128), 25% of patients (10/40) required further spine surgery related to the initial microdiscectomy. At an average postoperative follow-up of 11.1 ± 4.0 years (range: 5-19), additional symptoms apart from back and leg pain were reported more frequently by patients who underwent a reoperation (p = 0.005). Patient satisfaction was significantly higher in patients who did not undergo a reoperation (p = 0.041). For the Oswestry disability index, pain intensity (p = 0.036), and pain-related sleep disturbances (p = 0.006) were reported to be more severe in the reoperation group. Conclusions Microdiscectomy for the treatment of LDH results in a favorable long-term outcome in the majority of cases. The reoperation rate was higher in our series than reported in previous investigations with shorter follow-up. Although there were no statistically significant pre-/perioperative differences between patients with and without reoperation, our findings suggest a difference in self-reported long-term outcome measures.

Incidental durotomy in lumbar spine surgery--a three-nation survey to evaluate its management

BACKGROUND

Although it is generally accepted that incidental durotomies (ID) should be primarily repaired, the current literature shows no consensus regarding the peri- and postoperative management in case of ID during lumbar spine surgery. Because ID is a rather frequent complication and may be associated with significant disability, we were interested to analyze the current handling of ID in three European countries.

METHODS

In March 2014, members of the Swiss, German, and Austrian neurosurgical and spine societies were asked to complete an online questionnaire regarding the management of ID during and after lumbar spine surgery. Two, respectively 4 weeks after the first invitation, reminder requests were sent to all invitees, who had not already responded at that time.

RESULTS

There were 175 responses from 397 requests (44.1 %). Responders were predominantly neurosurgeons (89.7 %; 10.3 % were orthopedic surgeons), of which 45.7, 40.0, and 17.8 % work in a non-university hospital, university hospital, and private clinic, respectively. As for the perioperative management of ID, 19.4 % of the responders suggest only bed rest, while, depending on the extent of the ID, 84.0 % suggest additional actions, TachoSil/Spongostan with fibrin glue or a similar product and single suture repair being the most mentioned. Concerning epidural wound drainage in case of ID, 37.2 % desist from placing an epidural wound drainage with or without aspiration, 30.9 % place it sometimes, and 33.7 % place it regularly, but only without aspiration. Most responders prescribe bed rest for 24 (34.9 %) or 48 h (28.0 %), with much fewer prescribing bed rest for 72 h (6.3 %) and none more than 72 h, and 14.9 % of participants never prescribe bed rest. The vast majority of physicians (82.9 %, n = 145) always inform their patients after the operation in case of ID.

CONCLUSIONS

There is substantial heterogeneity in the management of incidental durotomies. The majority of spine surgeons today aim at complete/sufficient primary repair of the ID with varying recommendations concerning postoperative bed rest. Still, there is a trend towards early mobilization if the incidental durotomy has been closed completely/sufficiently with no participant favoring bed rest for more than 72 h.

The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials

OBJECT

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID.

METHODS

The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes.

RESULTS

Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33).

CONCLUSIONS

The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.

Recovery of muscle strength after microdiscectomy for lumbar disc herniation: a prospective cohort study with 1-year follow-up

BACKGROUND

Surgery has not been proven to be a better treatment option than non-operative management for limb paresis due to lumbar disc herniation. For the patients it will still be a concern, whether they will regain full strength after the operation or not.

METHODS

A prospective cohort study of 91 patients with preoperative paresis due to disc herniation with 1-year follow up was carried out. The primary outcome was muscle strength in affected limb, and the secondary outcome was self-reported symptoms on back and leg pain, disability, health related quality of life, general health and working capability.

RESULTS

Seventy-five percent of patients had no paresis 1 year after the operation. The severity of the paresis was the only predictor for persistent paresis. Preoperative duration of the paresis did not influence the rate of full recovery. Non-recovery was associated with inferior outcomes and higher risk for reduced working capability.

CONCLUSIONS

The majority of patients with paresis were fully recovered 1 year after microdiscectomy for lumbar disc herniation. If the paresis was severe at baseline, there was a four times higher risk for non-recovery. Patients who did not recover had significantly worse outcomes.

Minimally invasive compared to open microdiscectomy for lumbar disc herniation

Before the advent of minimally invasive surgery for microdiscectomy, an open microdiscectomy had been the standard surgical intervention. Minimally invasive techniques have recently become more popular based upon the premise that smaller, less traumatic incisions should afford better recovery times and outcomes. From 2005 to 2008 we analyzed the outcomes of 25 patients who received an open microdiscectomy compared to 20 patients who received a minimally invasive microdiscectomy by the senior author (DC) in the lumbar region for disc herniation. A retrospective analysis was performed by carefully reviewing medical records for perioperative and immediate postoperative outcomes, and clinical follow-up was obtained either in the clinic or by telephone. There were no statistically significant differences between the minimally invasive and open groups in terms of operative time, length of stay, neurological outcome, complication rate, or change in pain score (pain improvement).

Development of a documentation instrument for the conservative treatment of spinal disorders in the International Spine Registry, Spine Tango

Spine Tango is the first and only International Spine Registry in operation to date. So far, only surgical spinal interventions have been recorded and no comparable structured and comprehensive documentation instrument for conservative treatments of spinal disorders is available. This study reports on the development of a documentation instrument for the conservative treatment of spinal disorders by using the Delphi consensus method. It was conducted with a group of international experts in the field. We also assessed the usability of this new assessment tool with a prospective feasibility study on 97 outpatients and inpatients with low back or neck pain undergoing conservative treatment. The new 'Spine Tango conservative' questionnaire proved useful and suitable for the documentation of pathologies, conservative treatments and outcomes of patients with low back or neck problems. A follow-up questionnaire seemed less important in the predominantly outpatient setting. In the feasibility study, between 43 and 63% of patients reached the minimal clinically important difference in pain relief and Core Outcome Measures Index at 3 months after therapy; 87% of patients with back pain and 85% with neck pain were satisfied with the received treatment. With 'Spine Tango conservative' a first step has been taken to develop and implement a complementary system for documentation and evaluation of non-surgical spinal interventions and outcomes within the framework of the International Spine Registry. It proved useful and feasible in a first pilot study, but it will take the experience of many more cases and therapists to develop a version similarly mature as the surgical instruments of Spine Tango.