Recurrence after Successful Percutaneous Endoscopic Lumbar Discectomy

Radiologic Analysis of Causes of Early Recurrence After Percutaneous Endoscopic Transforaminal Discectomy

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the causes of and factors influencing early recurrence after TELD performed in the treatment of lumbar disc herniation.

METHODS

We included 285 patients with single-segment lumbar disc herniation treated using transforaminal endoscopy lumbar discectomy TELD from January 2017 to December 2019 at the First Affiliated Hospital of the University of South China. Patients were classified into early recurrence and non-early recurrence groups based on clinical symptoms and MRI reexamination. Imaging data (eg, disc height index (DHI), Pfirrman grades, base width, postoperative annulus-fibrosus tear size, cross-sectional area of the foramen (CSAF), etc.)were analyzed, and multivariate, binomial logistic regression was utilized to determine which factors were associated with early recurrence after TELD.

RESULTS

A total of 285 patients completed surgery and clinical follow-up, during which 19 patients relapsed within 6 months postsurgery, for an early recurrence rate of 6.7%. There were statistically significant differences between DHI, Pfirrman grades, base width, postoperative annulus-fibrosus tear size, herniation sites, CSAF and Modic changes between the early recurrence and non-early recurrence groups (P < .05). On multivariate logistic regression,the degree of disc degeneration (OR = .747, P = .037), CSAF (OR = 5.255, P = .006), degree of Modic change (OR = 1.831, P = .018) and base width of the herniation (OR = 4.942, P = .003) were significantly correlated with early recurrence after TELD.

CONCLUSIONS

Postoperative annulus-fibrosus tear size, DHI, and location of the disc herniation were associated with early recurrence after TELD. Increased base width of the herniation, severe disc degeneration, decreased CSAF and Modic change were risk factors for early recurrence after TELD.

Machine Learning Predicts Recurrent Lumbar Disc Herniation Following Percutaneous Endoscopic Lumbar Discectomy

STUDY DESIGN

Retrospective study.

OBJECTIVES

To develop machine learning (ML) models to predict recurrent lumbar disc herniation (rLDH) following percutaneous endoscopic lumbar discectomy (PELD).

METHODS

We retrospectively analyzed 1159 patients who had undergone single-level PELD for lumbar disc herniation (LDH) between July 2014 to December 2019 at our institution. Various preoperative imaging variables and demographic metrics were brought in analysis. Student's t test and Chi-squared test were applied for univariate analysis, which were feature selection for ML models. We established ML models to predict rLDH: Artificial neural networks (ANN), Extreme Gradient Boost classifier (XGBoost), KNeighborsClassifier (KNN), Decision tree classifier (Decision Tree), Random forest classifier (Random Forest), and support vector classifier (SVC).

RESULTS

A total 130 patients (11.22%) were diagnosed as rLDH in 1159 patients. Recurrence occurred within 10.25 ± 11.05 months. Body mass index (BMI) (P = .027), facet orientation (FO) (P < .001), herniation type (P = .012), Modic changes (P = .004), and disc calcification (P = .013) are significant factors in univariate analysis (P < .05). Extreme Gradient Boost classifier, Random Forest, ANN showed fine area under the curve, .9315, .9220, and .8814 respectively.

CONCLUSION

We developed a deep learning and 2 ensemble models with fine performance in prediction of rLDH following PELD. Predicting re-herniation before surgery has the potential to optimize decision-making and meaningfully decrease the rates of rLDH following PELD. Our ML model identified higher BMI, lower FO, Modic changes, disc calcification in a non-protrusive region, and herniation type (noncontained herniation) as significant features for predicting rLDH.

Analysis of risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy in patients with lumbar disc herniation: a meta-analysis

BACKGROUND

This study aimed to systematically evaluate risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH).

METHODS

The eligible studies were retrieved from PubMed, Embase, and Web of Science databases. Quality assessment was performed. The effects of binary variables (sex, Modic change (MC), type 2 diabetes (T2DM), and smoking) on post-operative recurrence were evaluated as odds ratio (OR) and 95% confidence interval (CI). The effects of continuous variables (sagittal range of motion (SROM), body mass index (BMI), and age) were assessed as weighted mean difference (WMD) and 95% CI. Sensitivity analysis and publication bias were conducted to evaluate the reliability of pooled results.

RESULTS

Eight studies were included, and their methodological quality was medium. MC (OR (95% CI) = 3.88 (2.24-6.74), P < 0.001), smoking (OR (95% CI) = 1.87 (1.45, 2.42), P < 0.001), T2DM (OR (95% CI) = 1.61 (1.12, 2.31), P = 0.010), SROM (WMD (95% CI) = 2.33 (0.95, 3.70), P = 0.001), BMI (WMD (95% CI) = 1.68 (1.37, 1.99) kg/m2, P < 0.001), and age (WMD (95% CI) = 9.95 (5.05, 14.86) years, P < 0.001) were significantly related to post-operative recurrence in patients with LDH after PELD. Significant publication bias was not observed among studies in all outcome indicators.

CONCLUSION

Our findings reveal that high levels of age, BMI, and SROM, history of T2DM or smoking, or more MC may be correlated with post-operative recurrence after PELD.

Factors affecting return to work following endoscopic lumbar foraminal stenosis surgery: A single-center series

Background

This study evaluates the factors affecting the return to work of endoscopic surgery for lumbar foraminal stenosis (LFS), including symptoms, functional status, complications, and reoperation rates.

Methods

The authors' retrospective cohort study included 100 consecutive patients (50 males and 50 females) diagnosed with LFS who underwent endoscopic surgery at Trotsky National Research Center of Surgery between January 2018 and December 2021.

Results

There were no significant differences in age and preoperative visual analog scale and Oswestry disability index scores between the male and female groups, time to return to work for different patient groups after undergoing endoscopic lumbar foraminotomy (ELF). However, patients with more severe stenosis and comorbidities may take longer to recover. Confounding factors were patient age, preoperative physical function, and job requirements.

Conclusion

This study confirms that study ELF can effectively improve symptoms associated with lumbar radiculopathy, as well as back pain, and improve patients' quality of life. Comorbidity, smoking status, and complications prolong the time to return to work following ELF surgery compared to healthy subjects.

Functional Outcomes After Discectomy for Recurrent Lumbar Herniation Using the Destandau Endospine System: A Retrospective Study of 44 Patients

Background Recurrent disc herniation is a major cause of morbidity and surgical failure after disc surgery. This study aimed to investigate the feasibility, safety, and effectiveness of the Destandau endospine system (DES) for treating recurrent lumbar disc herniation (LDH). Methodology A total of 44 patients who underwent minimally invasive Destandau endoscopic lumbar discectomy (DELD) for recurrent LDH were included in this study. All data were collected retrospectively. The preoperative and postoperative visual analog scale (VAS) score was used for the evaluation and gradation of pain. The clinical outcome was analyzed according to modified MacNab criteria. The minimum follow-up was two years. Preoperative and postoperative VAS scores were compared using the paired Student's t-test. Statistical significance was set at a p-value <0.05. Results The mean surgical time was 30 ± 20 minutes. The VAS score for leg pain was improved in all cases from 5.9 ± 2.1 to 1.7 ± 1.3 (p< 0.001). In 98% of cases, a successful outcome was noted (excellent or good outcome according to MacNab criteria). In three (7%) patients, incidental durotomy occurred, but there was no neurological worsening, cerebrospinal fluid fistula, or negative influence on the clinical outcome. No recurrence or instability occurred in our series. Conclusions The clinical outcomes of minimally invasive DES for LDH were found to be comparable with the reported success rates of other minimally invasive techniques reported in the existing literature. The dural tear rate was independent of postoperative morbidity and functional outcome. The technique is a safe and effective treatment option for recurrent LDH.

Risk factors for lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: a meta-analysis of 58 cohort studies

Recurrent lumbar disc herniation (rLDH) is one of the most serious complications and major causes of surgical failure and paralysis following percutaneous endoscopic lumbar discectomy (PELD). There are reports in the literature on the identification of risk factors associated with rLDH; however, the results are controversial. Therefore, we conducted a meta-analysis to identify risk factors for rLDH among patients following spinal surgery. PubMed, EMBASE, and the Cochrane Library were searched without language restrictions from inception to April 2018 for studies reporting risk factors for LDH recurrence after PELD. MOOSE guidelines were followed in this meta-analysis. We used a random effects model to aggregate odds ratios (ORs) with 95% confidence intervals (CIs). The evidence of observational studies was classified into high quality (class I), medium quality (class II/III), and low quality (class IV) based on the P value of the total sample size and heterogeneity between studies. Fifty-eight studies were identified with a mean follow-up of 38.8 months. Studies with high-quality (class I) evidence showed that postoperative LDH recurrence after PELD was significantly correlated with diabetes (OR, 1.64; 95% CI, 1.14 to 2.31), the protrusion type LDH (OR, 1.62; 95% CI, 1.02 to 2.61), and less experienced surgeons (OR, 1.54; 95% CI, 1.10 to 2.16). Studies with medium-quality (class II or III) evidence showed that postoperative LDH recurrence was significantly correlated with advanced age (OR, 1.11; 95% CI, 1.05 to 1.19), Modic changes (OR, 2.23; 95% CI, 1.53 to 2.29), smoking (OR, 1.31; 95% CI, 1.00 to 1.71), no college education (OR, 1.56; 95% CI, 1.05 to 2.31), obesity (BMI ≥ 25 kg/m²) (OR, 1.66; 95% CI, 1.11 to 2.47), and inappropriate manual labor (OR, 2.18; 95% CI, 1.33 to 3.59). Based on the current literature, eight patient-related and one surgery-related risk factor are predictors of postoperative LDH recurrence after PELD. These findings may help clinicians raise awareness of early intervention for patients at high risk of LDH recurrence after PELD.

Machine Learning Prediction Model and Risk Factor Analysis of Reoperation in Recurrent Lumbar Disc Herniation Patients After Percutaneous Endoscopic Lumbar Discectomy

OBJECTIVE

To investigate the risk factors of reoperation after percutaneous endoscopic lumbar discectomy (PELD) due to recurrent lumbar disc herniation (rLDH) and to establish a set of individualized prediction models.

METHODS

Patients who underwent PELD successfully from January 2016 to February 2022 in a single institution were enrolled in this study. Six methods of machine learning (ML) were used to establish an individualized prediction model for reoperation in rLDH patients after PELD, and these models were compared with logistics regression model to select optimal model.

RESULTS

A total of 2603 patients were enrolled in this study. 57 patients had repeated operation due to rLDH and 114 patients were selected from the remaining 2546 nonrecurrent patients as matched controls. Multivariate logistic regression analysis showed that disc herniation type (P < .001), Modic changes (type II) (P = .003), sagittal range of motion (sROM) (P = .022), facet orientation (FO) (P = .028) and fat infiltration (FI) (P = .001) were independent risk factors for reoperation in rLDH patients after PELD. The XGBoost AUC was of 90.71%, accuracy was approximately 88.87%, sensitivity was 70.81%, specificity was 97.19%. The traditional logistic regression AUC was 77.4%, accuracy was about 77.73%, sensitivity was 47.15%, specificity was 92.12%.

CONCLUSION

This study showed that disc herniation type (extrusion, sequestration), Modic changes (type II), a large sROM, a large FO and high FI were independent risk factors for reoperation in LDH patients after PELD. The prediction efficiency of XGBoost model was higher than traditional Logistic regression analysis model.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation

PURPOSE OF REVIEW

Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population.

RECENT FINDINGS

Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Factors associated with incomplete clinical improvement in patients undergoing transforaminal endoscopic lumbar discectomy for lumbar disc herniation

PURPOSES

To analyze the clinical and radiographic risk factors that might predict incomplete clinical improvement after transforaminal endoscopic lumbar discectomy (TELD).

METHODS

A retrospective analysis was conducted from 194 consecutive patients who underwent TELD due to lumbar disc herniation (LDH). Patients with incomplete clinical improvement were defined from patient-reported outcomes of poor improvement in pain or disability after surgery and patient dissatisfaction. Clinical and radiographic characteristics were evaluated to identify predicting factors of poor outcomes.

RESULTS

Of 194 patients who underwent TELD procedures, 32 patients (16.5%) had incomplete clinical improvement and 12 patients (6.1%) required revision surgery. The mean ages were 46.4 years and most of the patients suffered from predominant leg pain (48.9%). The most common surgical level was L4-5 (63.9%). Overall, the Oswestry Disability Index (44.3-15), visual analog scores of back pain (4.9-1.8) and leg pain (7.3-1.6) were significantly improved after surgery. Multivariate logistic regression analysis demonstrated that high body mass index, history of previous surgery, preoperative disability, weakness, and disc degeneration were related to incomplete clinical improvement. There were 15 recurrent LDH (7.7%) with a total of 12 revision surgeries (6.2%).

CONCLUSIONS

We identified independent risk factors associated with incomplete clinical improvement following TELD, including overweight, significant preoperative disability or weakness and history of previous surgery. Advanced age, disc degeneration, vacuum phenomenon, and spondylolisthesis were also possible risk factors. Recognizing these risk factors would help decide whether patients are good candidates for TELD, and optimize the surgical planning preoperatively to achieve good surgical results.

Factors related to the postoperative recurrence of lumbar disc herniation treated by percutaneous transforaminal endoscopy: A meta-analysis

Objective

To explore factors related to the postoperative recurrence of lumbar disc herniation treated by percutaneous transforaminal endoscopy.

Methods

PubMed, EMBASE, Cochrane Library, CNKI, Wanfang database and VIP database were systematically searched from the time of each library's construction to October 20, 2022. The studies that compared the influencing factors of recurrent lumbar disc herniation were included based on the PICO search structure. The Newcastle-Ottawa Scale was used to evaluate the quality of observational studies. The effects of the patient's age, gender, BMI, smoking, drinking, hypertension, diabetes, course of the disease, Pfirrmann grade, and the surgical segment on recurrent lumbar disc herniation were systematically evaluated using Revman 5.3. The odds ratio (OR) and 95% confidence interval (CI) were calculated.

Results

Thirteen studies involving 3,393 patients (323 patients with recurrent lumbar disc herniation) treated with percutaneous transforaminal endoscopy were included in this study. The results of the systematic evaluation showed that the effects of gender, smoking, drinking, hypertension, type of lumbar disc herniation and the surgical segment on recurrent lumbar disc herniation were not statistically significant. However, age ≥60 years (OR = 2.23; 95% CI: 1.13, 4.41), BMI ≥25 (OR = 2.89; 95% CI: 1.23, 6.80), diabetes (OR = 1.73; 95% CI: 1.18, 2.55), course of disease ≥4 years (OR = 2.93; 95% CI: 1.58, 5.43), Pfirrmann grades 3-4 (OR = 3.10; 95% CI: 2.18, 4.40), incomplete removal of nucleus pulposus (OR = 3.26; 95% CI: 1.69, 6.27) and intraoperative fibre breakage (OR = 3.18; 95% CI: 1.56, 6.50) increased the risk of recurrence after treatment.

Conclusion

The recurrence of lumbar disc herniation after percutaneous transforaminal endoscopic treatment is related to demographic characteristics, disease history and surgical conditions. In the future, more high-quality studies are needed to explore the influencing factors of recurrent lumbar disc herniation.

Early Readmission and Reoperation After Percutaneous Transforaminal Endoscopic Decompression for Degenerative Lumbar Spinal Stenosis: Incidence and Risk Factors

PURPOSE

To identify the incidence rates and risk factors for early readmission and reoperation after percutaneous transforaminal endoscopic decompression (PTED) for degenerative lumbar spinal stenosis (DLSS).

PATIENTS AND METHODS

A total of 1011 DLSS patients who underwent PTED were retrospectively evaluated. Of them, 58 were readmitted, and 31 underwent reoperation. The patients were matched with 174 control patients to perform case-control analyses. The clinical and preoperative imaging data of each patient were recorded. Univariate analyses were performed using independent sample t-tests and Fisher's exact tests. Furthermore, the risk factors for early readmission and reoperation were analyzed using multivariate logistic regression analyses.

RESULTS

The incidence rates of readmission and reoperation within 90 days after PTED were 5.7% and 3.1%, respectively. Age (odds ratio [OR]=1.054, p=0.001), BMI (OR=1.104, p=0.041), a history of lumbar surgery (OR=3.260, p=0.014), and the number of levels with radiological lumbar foraminal stenosis (LFS, OR=2.533, p<0.001) were independent risk factors for early readmission. The number of levels with radiological LFS (OR=5.049, p<0.001), the grade of surgical-level facet joint degeneration (OR=2.010, p=0.023), and a history of lumbar surgery (OR=10.091, p<0.001) were independent risk factors for early reoperation.

CONCLUSION

This study confirmed that aging, a higher BMI, a history of lumbar surgery, and more levels with radiological LFS were associated with a higher risk of early readmission. More levels with radiological LFS, a higher grade of surgical-level facet joint degeneration, and a history of lumbar surgery were predictors of early reoperation. These results are helpful in patient counseling and perioperative evaluation of PTED.

Risk Factors Involved in the Early and Medium-Term Poor Outcomes of Percutaneous Endoscopic Transforaminal Discectomy: A Single-Center Experience

Objective

To investigate the risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic transforaminal discectomy (PETD) treatment of lumbar disc herniation (LDH) at the L4-5 level.

Methods

Between January 2015 and May 2020, we recruited 148 LDH patients at the L4-5 level who underwent PETD surgery. The patients were divided into Groups A and B, according to the surgical outcomes. Good and excellent outcomes were categorized into Group A, and generally good and poor outcomes were categorized into Group B. Clinical parameters (age, gender, symptom duration, hospital stay, operation time, blood loss, straight-leg raising (SLR), visual analog scale (VAS), Oswestry Disability Index (ODI) score and modified MacNab criteria) and radiologic parameters (foraminal height (FH), intervertebral height index (IHI), intervertebral angle (IVA), sagittal range of motion (sROM), and lumbar lordosis (LL)) were collected and analyzed using univariate and multiple logistic regression analyses.

Results

At the 6-month follow-up post operation, univariate analysis revealed that the symptom duration, SLR, IHI, and sROM were strongly associated with poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes. At the 2-year follow-up post operation, univariate analysis suggested that advanced age, prolonged symptom duration, large preoperative VAS score, small FH, small IHI, and large sROM were potential risk factors for poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes.

Conclusion

Our study demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes immediately following PETD at the L4-5 level. However, prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes at medium-term post PETD at the L4-5 level.

Revision surgery for symptomatic postoperative pseudocyst following full-endoscopic lumbar discectomy: clinical characteristics and surgical strategies

BACKGROUND

A symptomatic postoperative pseudocyst (PP) is a cystic lesion that is formed in the operation area of the intervertebral disc, leading to worse symptoms. Some minority patients who developed PP experienced rapidly aggravating symptoms and could not be treated by any kind of conservative treatment. However, no clinical studies have evaluated the clinical characteristics and surgical strategies of symptomatic PP requiring a revision surgery after full-endoscopic lumbar discectomy (FELD). This study aimed to demonstrate the clinical characteristics and surgical strategies of symptomatic PP requiring a revision surgery after FELD.

METHODS

We retrospectively analyzed the data of patients who received FELD revision surgeries due to symptomatic PP formation between January 2016 and December 2021. Common characteristics, time intervals of symptom recurrence and revision surgery, strategies for conservative treatment and revision surgery, operative time, imaging characteristics, numeric rating scale (NRS) score, Oswestry disability index (ODI) and overall outcome rating based on modified MacNab criteria were analyzed.

RESULTS

Fourteen patients (males = 10, females = 4), with a mean age of 24.4 years, were enrolled. The mean time intervals of symptom recurrence and revision surgery were 43.5 and 18.9 days respectively. While the patients were conservatively managed with analgesics and physical therapy, pain persisted or progressively worsened. In comparison to the initial herniated disc, the PP was larger in 11 cases, and up- or down-migrated in four cases. The PP location included the lateral recess (n = 12), foraminal (n = 1), and centrolateral (n = 1) zones. One of the two cases treated by percutaneous aspiration (PA) was eventually treated by FELD as pain was not relieved. Follow-ups revealed an improved mean NRS score from 7.1 to 1.4, mean ODI from 68.6 to 7.9% and promising overall surgical outcomes.

CONCLUSIONS

The progressively severe pain experienced due to PP might be a result of its enlargement or migration to the lateral recess and foraminal zones. As complete removal of capsule is the goal, we recommend FELD instead of PA.

Earlier or heavier spinal loading is more likely to lead to recurrent lumbar disc herniation after percutaneous endoscopic lumbar discectomy

PURPOSE

To evaluate the clinical features of and risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous endoscopic lumbar discectomy (PELD) in our clinical practice.

METHODS

A total of 942 consecutive patients who underwent single-level PELD from January 2013 to August 2019 were included. Patients were divided into the recurrence group and the nonrecurrence group. Patient characteristics, radiographic parameters and surgical variables were compared between the two groups. Univariate analysis and multiple logistic regression analysis were adopted to determine the risk factors for recurrence after PELD.

RESULTS

The prevalence of rLDH was 6.05%. Age, sex, tobacco use, duration of low back pain, body mass index (BMI), occupational lifting, herniated disc type, facet joint degeneration, operation time and time to ambulation were significantly different between the two groups. Univariate analysis showed that age (P < 0.001), sex (P = 0.019), BMI (P = 0.001), current smoking (P < 0.001), occupational lifting (P < 0.001), facet joint degeneration (P = 0.001), operation time (P = 0.002), and time to ambulation (P < 0.001) could be significantly associated with the incidence of rLDH after PELD. Multivariate analysis suggested that an older age (P < 0.001), the male sex (P = 0.017), a high BMI (P < 0.001), heavy work (P = 0.003), grade II facet joint degeneration (P < 0.001) and early ambulation (P < 0.001) were significantly related to rLDH after PELD.

CONCLUSIONS

An older age, the male sex, a higher BMI, heavy work, grade II facet joint degeneration, and early ambulation are independent significant risk factors for rLDH after PELD. Great importance should be attached to these risk factors to prevent rLDH. We suggest that patients control their weight, avoid heavy work, ambulate at an appropriate time, and perform strengthening rehabilitation exercises to reduce the incidence of rLDH.

Psoas muscle measurement as a predictor of recurrent lumbar disc herniation: A retrospective blind study

AbstractParaspinal (erector spinae and multifidus) and psoas muscles contribute to spinal stability, but no study has yet examined the relationship between muscle mass and recurrent lumbar disc herniation (rLDH). The purpose of this study was to investigate the effect of psoas and paraspinal muscle mass on recurrent Lumbar disc herniation (LDH). This retrospective study included 49 patients with LDH (22 men, 27 women; mean age: 59.9 years; range 32-80) who underwent discectomy and partial laminectomy without fusion and underwent both pre- and postoperative magnetic resonance imaging. The presence of rLDH was determined using medical records and postoperative magnetic resonance imagings. Patients were divided into an rLDH group (26 patients) and a without-rLDH group (23 patients). Clinical characteristics, segmental motion, and paraspinal and psoas muscle mass were compared between the groups. Using ImageJ software, the cross-sectional area (CSA), lean muscle mass (LMM), and skeletal muscle index (SMI) were measured on T2 axial preoperative magnetic resonance images at L2-L3, L3-L4, and L4-L5 disc levels to represent muscle mass. Univariate and multivariate logistic regression analyses were performed. In the rLDH group, patients were younger (52.6 years vs 68.2 years; P = .001), segmental instability was more common (50.0% vs 4.3%; P = .001), and the CSA, LMM, CSASMI, and LMMSMI of psoas muscles were larger (5851.59 mm2 vs 4264.93 mm2, 5456.59 mm2 vs 4044.77 mm2, 18.77 cm2/m2 vs 13.86 cm2/m2, and 17.52 cm2/m2 vs 12.98 cm2/m2; P < .01 for all 4 variables). On multivariate logistic regression, age and segmental instability were independent risk factors for rLDH (odds ratio 0.886 and 18.527; P = .01 and P = .02, respectively). In middle-aged and elderly patients with lumbar disc herniation, relatively younger age, segmental instability, and greater psoas muscle mass may be risk factors for recurrence.

Whether Out-of-Bed Activity Restriction in the Early Postoperative Period of PELD Is Beneficial to Therapeutic Efficacy or Reduce Recurrence

Objective

To detect the influences of postoperative out-of-bed activity restriction on recurrence rate, low back and leg pain, functional rehabilitation after percutaneous endoscopic lumbar discectomy (PELD).

Methods

In this research, 213 patients with lumbar intervertebral disc herniation (LDH) who underwent PELD were divided into the out-of-bed activity restriction group and out-of-bed activity non-restriction group. The visual analog scale (VAS) and Oswestry disability index (ODI) scores were used to evaluate postoperative clinical efficacy at 1 and 3 months after the operation, and to count the recurrence rates. All of these operations were performed between August 2017 and July 2020, and they were followed in the outpatient department for 12 months at least.

Results

Both of the groups showed significantly lower VAS and higher ODI scores at 1 month and 3 months post-operation, respectively, when compared with pre-operation. At 1 month after the operation, the restriction group performed lower VAS scores of low back pain compared with the non-restriction group, but this advantage disappeared at 3months post-operation. However, there was no statistical difference in the VAS scores of leg pain and ODI scores between the two groups, neither at 1 nor 3 months after the surgery. The recurrence rate is significantly lower in the restriction group than in the non-restriction group at a 12-month follow-up after the surgery.

Conclusion

Out-of-bed activity restriction in the early postoperative period of PELD could reduce LDH recurrence effectively, and it may relieve the low back pain to some extent. It has no benefit in the recovery of leg pain and functional rehabilitation.

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation With Type II Modic Changes

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has become a favorable surgical approach for lumbar radiculopathy caused by intervertebral disc herniation. Studies have revealed patients with type II Modic change may suffer from unrelieved low back pain and higher lumbar disc herniation (LDH) recurrence after herniated nucleus pulposus removal. Therefore, in this study, we aim to evaluate how PELD performed in management of LDH patients with type II Modic change.

METHODS

We collected 267 single-level LDH cases aged 20-50 yearswho underwent PELD from December 2016 to December 2019. The mean follow-up time was 26.3 months (range: 12-48 months). The visual analog scale (VAS), Oswestry Disability Index (ODI), and MacNab scores, as well as the recurrence rate, were analyzed pre- and post-surgery, as well as at the time points of 3 months, 12 months, and the final follow-up time after surgery. The clinical outcomes in LDH patients with or without type II Modic change who underwent PELD were thoroughly analyzed.

RESULTS

Within the 267 LDH patients enrolled, 145 cases present Modic signals, among which 3 are type I and 142 are type II. The VAS and ODI scores of the patients in the 2 groups at different follow-up times were significantly lower than those before surgery. The excellent and good MacNab scores in the control group and Modic type II change group were 87.0% and 82.1%, respectively. However, with the extension of follow-up time, the VAS and ODI scores, as well as the recurrence rate, were found to be higher in the type II Modic change group when compared with those in the non-Modic change group.

CONCLUSIONS

PELD performed well in management of LDH patients. However, we need to pay more attention to the continuous low back pain and the recurrence possibility in the cases with type II Modic change. In these cases, longer brace support or other interventions could be applied.

Overweight and smoking promote recurrent lumbar disk herniation after discectomy

PURPOSE

Recurrent lumbar disk herniation (rLDH) following lumbar microdiscectomy is common. While several risk factors for primary LDH have been described, risk factors for rLDH have only sparsely been investigated. We evaluate the effect of Body mass index (BMI) and smoking on the incidence and timing of rLDH.

METHODS

From a prospective registry, we identified all patients undergoing primary tubular microdiscectomy (tMD), with complete BMI and smoking data, and a minimum 12-month follow-up. We defined rLDH as reherniation at the same level and side requiring surgery. Overweight was defined as BMI > 25, and obesity as BMI > 30. Intergroup comparisons and age- and gender-adjusted multivariable regression were carried out. We conducted a survival analysis to assess the influence of BMI and smoking on time to reoperation.

RESULTS

Of 3012 patients, 166 (5.5%) underwent re-microdiscectomy for rLDH. Smokers were reoperated more frequently (6.4% vs. 4.0%, p = 0.007). Similarly, rLDH was more frequent in obese (7.5%) and overweight (5.9%) than in normal-weight patients (3.3%, p = 0.017). Overweight smokers had the highest rLDH rate (7.6%). This effect of smoking (Odds ratio: 1.63, 96% CI: 1.12-2.36, p = 0.010) and BMI (Odds ratio: 1.09, 95% CI: 1.02-1.17, p = 0.010) persisted after controlling for age and gender. Survival analysis demonstrated that rLDH did not occur earlier in overweight patients and/or smokers.

CONCLUSIONS

BMI and smoking may directly contribute to a higher risk of rLDH, but do not accelerate rLDH development. Smoking cessation and weight loss in overweight or obese patients ought to be recommended with discectomy to reduce the risk for rLDH.

Risk Factors and Surgical Management of Recurrent Herniation after Full-Endoscopic Lumbar Discectomy Using Interlaminar Approach

Full-endoscopic lumbar discectomy (FED) is one of the least invasive procedures for lumbar disc herniation. Patients who receive FED for lumbar disc herniation may develop recurrent herniation at a frequency similar to conventional procedures. Reoperation and risk factors of recurrent lumbar disc herniation were investigated among 909 patients who received FED using an interlaminar approach (FED-IL). Sixty-five of the 909 patients received reoperation for recurrent herniation. Disc height, smoking, diabetes mellitus (DM), subligamentous extrusion (SE) type, and Modic change were identified as the risk factors for recurrence. Other indicators such as LL, Cobb angle, disc migration, age, sex, and body mass index (BMI) did not reach significance. Among 65 patients, reoperation was performed within 14 days following FED-IL (very early) in 7 patients, from 15 days to 3 months (early) in 14 patients, from 3 months to 1 year (midterm) in 17 patients, and after more than 1 year (late) in 27 patients. The very early group included a greater number of males, and the mean age was significantly lower in comparison to other groups. All patients in the very early group received FED-IL for reoperation. Reoperation within 2 weeks allows FED-IL to be performed without adhesion. Fusion surgery was performed on three cases in the early and midterm groups and on 10 cases in the late group, which increased over time as degenerative change and adhesion progressed. The procedure selected to treat recurrent herniation mostly depends on the surgeon’s preference. Revision FED-IL is the first choice for recurrent herniation in terms of minimizing surgical burden, whereas fusion surgery offers the advantage that discectomy can be performed through unscarred tissues. FED-IL is recommended for recurrent herniation within 2 weeks before adhesion progresses.

Better Functional Outcome and Pain Relief in the Far-Lateral-Outside-in Percutaneous Endoscopic Transforaminal Discectomy

Background

Even though percutaneous endoscopic transforaminal discectomy (PETD) has been widely used for the surgical treatment of lumbar herniated disc, there are only a few studies directly comparing the clinical outcomes between microdiscectomy (MD) and PETD. Therefore, further studies are needed in order to compare the clinical outcomes between PETD and MD on a single level more thoroughly.

Methods

We proposed a far-lateral-outside-in technique for PETD to get an entry point without complex planning and facet violation. From September 2017 to September 2019, a total of 155 patients (69 with PETD and 86 with MD) were enrolled for this retrospective study, with the inclusion criteria: single level between L2 and S1, clinical sciatica for at least 6 weeks, and failed attempts with non-surgical treatments. Patients were excluded due to cauda equina syndrome, progressive neurologic deficits, history of lumbar spinal surgery, endplate modic changes, severe disc degeneration and less than 24 months of follow-up.

Results

PETD showed significantly shorter surgery time and less intraoperative blood loss compared to MD. The difference between PETD and MD in VAS back pain (but not VAS leg pain) at follow-up time was significant. The ODI improvement in the follow-up time of 6 months between the 2 groups showed a significant difference (PETD: 31.23±6.59, MD: 39.85±7.81, p < 0.001). MD had a significantly higher chance of postoperative wound infection and poor healing, while PETD was more likely to have recurrence of the herniated disc.

Conclusion

MD has been the gold standard procedure for LDH. However, with the advanced endoscopic technology and surgical technique, PETD has emerged as an alternative method due to higher functional outcome and less wound problems.

RISK FACTORS FOR RECURRENT LUMBAR DISK HERNIATION

ABSTRACT Objective: to investigate the frequency of recurrent lumbar disk herniation (rLDH) and evaluated risk factors of rLDH in Russian population. Methods: this was a retrospective clinical study. From January 2015 to March 2022, 218 patients having single-level LDH at three institutes were included in this clinical study and who were then observed for a minimum of 5 years postoperatively. All the patients or relatives gave informed consent to participate in this study. The levels of disk herniation were L4-L5 in 132 cases (60.5 %), and L5-S1 in 86 cases (39.4 %). Results: The rLDH group was composed of 31 male and 12 female, whose ages ranged from 18 to 57 years (34.8±9.5 years). The non-rLDH group was composed of 97 male and 78 female, whose ages ranged from 19 to 73 years (47.5±9.8 years). According to the constructed binary logistic model, body mass index (p=0.021), current smoking (p=0.017), stage of disk degeneration (p=0.043), facet tropism (p=0.037), disk height index (p=0.018) and apparent diffusion coefficient (p=0.009) are significantly associated with incidence of rLDH. Conclusions: patients with these risk factors should be paid more attention for prevention of rLDH. Level of Evidence III; Retrospective Study.

PREVALENCE AND CHARACTERISTICS OF UPPER LUMBAR DISC HERNIATIONS IN OUR PRACTICE: A RETROSPECTIVE ANALYSIS

ABSTRACT Introduction: Upper lumbar disc herniations (ULDH) are considered infrequent injuries (1-11%). They present, most often in older adults, with special clinical features that make diagnosis and therapeutic decision-making difficult. The prevalence, location, and management of these herniations and the medical history of our patients were analyzed. Methods: Sex, age, injury level, previous surgery, and patient treatment data from July 2018 to May 2021 were collected retrospectively. During this period, 179 patients underwent surgery, 33 of whom patients presented ULDH. Results: Thirty-three patients were included in the study (18 male and 15 female). Ages ranged from 39 to 85 years, with a predominance of elderly patients. The levels operated were L1-L2 in seven patients, L2-L3 in ten patients, L3-L4 in fourteen patients, and surgery in two levels (L2-L3, L3-L4) in two patients. In our practice, microdiscectomy is the preferred approach and was performed in all cases, with the addition of fusion in four of the 33 patients. Finally, a history of low lumbar disc herniation (LLDH) surgery was found in 16 patients. Conclusions: In our population, ULDHs are a rare entity with lower prevalence at the higher lumbar levels. They occur more frequently in elderly patients and clinical presentation can vary, which is a challenge for surgeons. In older adults, the development of lumbar kyphosis due to vertebral wedging is considered a risk factor for the development of ULDH. Surgical management by microdiscectomy is considered a technique with good results for this pathology. Level of Evidence III; Retrospective, longitudinal, descriptive, observational study.

Adjuvant surgical decision-making system for lumbar intervertebral disc herniation after percutaneous endoscopic lumber discectomy: a retrospective nonlinear multiple logistic regression prediction model based on a large sample

BACKGROUND CONTEXT

Lumbar disc herniation (LDH) is a common condition that can affects an individual' quality of life. In patients for whom conservative treatment is ineffective after 3 months, surgical treatment, such as percutaneous endoscopic lumbar discectomy (PELD), is recommended. Because PELD is minimally invasive and produces thorough nerve root decompression, both surgeons and patients often prefer it to other techniques.

PURPOSE

Surgeons find it challenging to prevent postoperative recurrent LDH (rLDH) when they use PELD. We created and verified a model for evaluating patients' recurrence risk factors before surgery so that surgeons can choose other surgical techniques when necessary.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

One thousand eight hundred seven patients who underwent PELD at our hospital between 2012 and 2015 were enrolled.

OUTCOME MEASURE

The main outcome measure was rLDH at any follow-up time point.

METHODS

Data were retrospectively analyzed for 1807 patients who underwent PELD at our hospital at some point between 2012 and 2015; all patients had been monitored for at least 5 years after surgery. They were divided into a recurrence group and a nonrecurrence group. Clinical and radiological risk factors were assessed over time to determine their correlations with recurrence and to exclude less important factors. A nonlinear multivariate logistic regression model was established to predict the recurrence rate before surgery.

RESULTS

A total of 1706 patients were monitored after PELD; data were missing for 101 additional patients. The total recurrence rate was 10.38%, and the most common time from surgery to recurrence was 1 year. Ten risk factors were assessed and included in the analysis. Regarding clinical risk factors, patients with hypertension (p < .001; correlation coefficient R [R] = 0.235; odds ratio [OR] = 4.749), diabetes (p < .001; R = 0.381; OR = 16.797), a history of smoking (p < .001; R = 0.347; OR = 9.012), and a history of performing intense physical labor (p < .001; R = 0.409; OR = 19.592) had a higher recurrence rate. Regarding radiological risk factors, patients with disc degeneration (Pfirrmann grade III) (p < .001; R = 0.228; OR = 4.919), Modic changes (level 2) (p < .001; R = 0.309; OR = 7.934), herniation in the form of extrusion (p < .001; R = 0.365; OR = 12.228), a higher disc height index (DHI) (p < .001; R = 0.336), and a larger segmental range of motion (p < .001; R = 0.243) had a higher recurrence rate. When the lumbar motion angle was negative (p < .001; R = 0.318; OR = 13.680), the recurrence rate was high. The overall accuracy of the final model was 97.6% (1665 of 1706). The recognition rate for non-rLDH cases was 99.0% (1514 of 1529), and the rate for rLDH cases was 85.3% (151 of 177); the AUC was 0.9315. A simple model was used. For those patients with postoperative trauma (p < .001; R = 0.382; OR = 13.680), a comparison model was established, and the corresponding recurrence rate was 23.0% ± 25.0% (0-76%).

CONCLUSIONS

A large cohort of patients underwent long-term monitoring, and 11 risk factors were verified for assessing each patient's risks before surgery to predict the postoperative recurrence of LDH following PELD. The risk of recurrence may be effectively reduced with the use of alternative surgical techniques in high risk cases.

Nomograms for Predicting Recurrent Herniation in PETD with Preoperative Radiological Factors

Purpose

To investigate the preoperative radiological risk factors for recurrent lumbar disc herniation (rLDH) within 1 year after percutaneous endoscopic transforaminal discectomy (PETD).

Patients and Methods

A retrospective case–control study was conducted. Between January 2013 and November 2019, a total of 1210 patients with single-level L4/5 LDH who underwent PETD were enrolled in the present study. In total, 62 rLDH patients were diagnosed and collected based on the clinical and radiological manifestations, and 224 non-rLDH controls were selected from the remaining 1148 patients. Preoperative radiological parameters were collected and measured. An age threshold to distinguish patients into subgroups was established using the Youden index. The relationships between the risk factors and rLDH were evaluated by univariate and multivariate analyses in two subgroups. Predictive models were established based on logistic analysis. The area under the curve (AUC) of receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) were used to assess the predictive models.

Results

In the present study, logistic analysis identified six significant predictors associated with rLDH in the young group: superior endplate concave angle (ECA), sacral slope, Modic changes, sagittal range of motion (sROM), extension intervertebral angle (IVA), and lumbar lordosis. Four significant predictors were identified in the elderly group: disc height index (DHI), retrolisthesis (posterior spondylolisthesis), sROM, and extension IVA. Validation of both models demonstrated excellent model discrimination (AUC= 0.940 and 0.946, respectively). DCA also showed excellent clinical utility and benefits.

Conclusion

The nomograms that we constructed could accurately predict individual patient recurrence risk. Individualized measures should be taken for patients of different ages with the above risk factors, and tailored postoperative surveillance of patients who underwent PETD can be planned.

Artificial intelligence predicts disk re-herniation following lumbar microdiscectomy: development of the "RAD" risk profile

PURPOSE

Surgical treatment of herniated lumbar intervertebral disks is a common procedure worldwide. However, recurrent herniated nucleus pulposus (re-HNP) may develop, complicating outcomes and patient management. The purpose of this study was to utilize machine-learning (ML) analytics to predict lumbar re-HNP, whereby a personalized risk prediction can be developed as a clinical tool.

METHODS

A retrospective, single center study was conducted of 2630 consecutive patients that underwent lumbar microdiscectomy (mean follow-up: 22-months). Various preoperative patient pain/disability/functional profiles, imaging parameters, and anthropomorphic/demographic metrics were noted. An Extreme Gradient Boost (XGBoost) classifier was implemented to develop a predictive model identifying patients at risk for re-HNP. The model was exported to a web application software for clinical utility.

RESULTS

There were 1608 males and 1022 females, 114 of whom experienced re-HNP. Primary herniations were central (65.8%), paracentral (17.6%), and far lateral (17.1%). The XGBoost algorithm identified multiple re-HNP predictors and was incorporated into an open-access web application software, identifying patients at low or high risk for re-HNP. Preoperative VAS leg, disability, alignment parameters, elevated body mass index, symptom duration, and age were the strongest predictors.

CONCLUSIONS

Our predictive modeling via an ML approach of our large-scale cohort is the first study, to our knowledge, that has identified significant risk factors for the development of re-HNP after initial lumbar decompression. We developed the re-herniation after decompression (RAD) profile index that has been translated into an online screening tool to identify low-high risk patients for re-HNP. Additional validation is needed for potential global implementation.

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for Highly Migrated Lumbar Disc Herniation

Objective

To describe minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for highly migrated lumbar disc herniation (LDH) and assess its clinical outcomes.

Patients and Methods

This research retrospectively assessed 25 patients who were diagnosed with one-segmental highly migrated LDH and underwent MIS-TLIF in Peking University First Hospital from June 2015 to September 2019. Demographic data, perioperative parameters, complications, recurrence, and surgical outcomes were assessed.

Results

Twelve males and 13 females, with a mean age of 56.68 years old, were involved and the follow-up period was at least one year. The mean operation time was 222.16 minutes, the mean intraoperative hemorrhage was 250.00 mL, and the mean post-operative hospitalization was 5.76 days. The improvements in visual analog scale (VAS) and Oswestry disability index (ODI) were statistically significant. In addition, based on the MacNab criteria, 22 patients (88.0%) acquired satisfactory (good or excellent) results. One patient underwent post-operative epidural hematoma and recovered after evacuation of the hematoma. No recurrence was found.

Conclusion

MIS-TLIF is safe and effective and it can provide satisfactory clinical outcomes for highly migrated LDH.

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation Using an Endoscopic Staining: A Technical Note

Symptomatic lumbar disc herniation (LDH) is widely treated using percutaneous endoscopic lumbar discectomy (PELD). In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over-invasion of the undegenerated annulus fibrosus. A wide range of intraoperative exploration also induces an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe case. Hence, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression. However, the classical disc staining technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered, even induces unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is accomplished more effectively by designing procedures that perform fully visible disc staining under spinal endoscope. There is no specific research to discuss the technique note of endoscopic staining in PELD surgery. We have come up with a new original technology of endoscopic staining with methylene blue injection in PELD for treatment of LDH.

Percutaneous endoscopic lumbar discectomy compared with other surgeries for lumbar disc herniation: A meta-analysis

OBJECTIVE

This meta-analysis was performed to investigate whether percutaneous endoscopic lumbar discectomy (PELD) had a superior effect than other surgeries in the treatment of patients with lumbar disc herniation (LDH).

METHOD

We searched PubMed, Embase, and Web of Science through February 2018 to identify eligible studies that compared the effects and complications between PELD and other surgical interventions in LDH. The outcomes included success rate, recurrence rate, complication rate, operation time, hospital stay, blood loss, visual analog scale (VAS) score for back pain and leg pain, 12-item Short Form Health Survey (SF12) physical component score, mental component score, Japanese Orthopaedic Association Score, Oswestry Disability Index. A random-effects or fixed-effects model was used to pool the estimate, according to the heterogeneity among the included studies.

RESULTS

Fourteen studies (involving 2,528 patients) were included in this meta-analysis. Compared with other surgeries, PELD had favorable clinical outcomes for LDH, including shorter operation time (weight mean difference, WMD=-18.14 minutes, 95%CI: -25.24, -11.05; P < .001) and hospital stay (WMD = -2.59 days, 95%CI: -3.87, -1.31; P < .001), less blood loss (WMD = -30.14 ml, 95%CI: -43.16, -17.13; P < .001), and improved SF12- mental component score (WMD = 2.28, 95%CI: 0.50, 4.06; P = .012)) and SF12- physical component score (WMD = 1.04, 95%CI: 0.37, 1.71; P = .02). However, it also was associated with a significantly higher rate of recurrent disc herniation (relative risk [RR] = 1.65, 95%CI: 1.08, 2.52; P = .021). There were no significant differences between the PELD group and other surgical group in terms of success rate (RR = 1.01, 95%CI: 0.97, 1.04; P = .733), complication rate (RR = 0.86, 95%CI: 0.63, 1.18; P = .361), Japanese Orthopaedic Association Score score (WMD = 0.19, 95%CI: -1.90, 2.27; P = .861), visual analog scale score for back pain (WMD = -0.17, 95%CI: -0.55, 0.21; P = .384) and leg pain (WMD = 0.00, 95%CI: -0.10, 0.10; P = .991), and Oswestry Disability Index score (WMD = -0.29, 95%CI: -1.00, 0.43; P = .434).

CONCLUSION

PELD was associated with better effects and similar complications with other surgeries in LDH. However, it also resulted in a higher recurrence rate. Considering the potential limitations in the present study, further large-scale, well-performed randomized trials are needed to verify our findings.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Radiological risk factors for recurrent lumbar disc herniation after percutaneous transforaminal endoscopic discectomy: a retrospective matched case-control study

PURPOSE

To investigate radiological risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous transforaminal endoscopic discectomy (PTED).

METHODS

Patients who underwent PTED due to a single-level L4-L5 or L5-S1 disc herniation from January 2013 to May 2019 were enrolled in this study. A matched case-control design was carried out in a single institution. Cases were defined as those who developed rLDH, and controls were matched from those patients without rLDH according to corresponding clinical characteristics. The radiological parameters were compared between two groups. The radiological risk factors for rLDH after PTED were identified by univariate and multivariate logistic regression analysis.

RESULTS

A total of 2186 patients who underwent PTED at L4-L5 or L5-S1 level were enrolled in this study. Sixty-eight patients were diagnosed with rLDH, and 136 patients were selected from the remaining 2118 nonrecurrent patients as matched controls. Univariate analysis demonstrated that herniation type (P = 0.009), surgical-level disc degeneration (P < 0.001), adjacent-level disc degeneration (P = 0.017), disc height index (DHI) (P = 0.003), and sagittal range of motion (sROM) (P < 0.001) were significantly related to rLDH. Multiple logistic regression analysis showed that low grade of surgical-level disc degeneration (P < 0.001), senior grade of adjacent-level disc degeneration (P < 0.001), a high DHI (P = 0.012), and a large sROM (P < 0.001) were the radiological independent risk factors.

CONCLUSION

This study showed that low grade of surgical-level disc degeneration, senior grade of adjacent-level disc degeneration, a high DHI, and a large sROM were the radiological independent risk factors for rLDH after PTED.

Risk factors for early reherniation after lumbar discectomy with or without annular closure: results of a multicenter randomized controlled study

BACKGROUND

Reherniation after lumbar discectomy is classified as a failure and occurs in 3 to 18% of cases. Various risk factors for reherniation such as age, sex, body mass index, smoking, and size of annular defect have been reported. The aim of this study was to identify risk factors for early reherniation after one-level lumbar discectomy with or without annular closure within 3 months after surgery.

METHODS

This study is based on data analysis of a prospective, multicenter randomized controlled trial in Europe. Patients included underwent standard lumbar discectomy-with or without implantation of an annular closure device (ACD). Enrollment of 554 patients in 21 centers in Europe (Germany, Switzerland, Austria, Belgium, The Netherlands, and France) started in 2010 and was completed in October 2014. A total of 276 patients were randomized to the ACD group (ACG) and 278 patients to the control group (CG).

RESULTS

Four (1.5%) symptomatic reherniations occurred in the ACG and 18 (6.5%) in the CG. In the overall population, a significant correlation was found with recurrent herniation for disc degeneration (Pfirrmann p = 0.009) and a trend for current smoker status (p = 0.07). In CG, age ≥ 50 years (p = 0.05) and disc degeneration (Pfirrmann p = 0.026, Kellgren and Lawrence p = 0.013) were predictive factors for reherniation.

CONCLUSION

In the current study, risk factors for early recurrent disc herniation after lumbar discectomy were age ≥ 50 years and moderate disc degeneration. The annular closure device reduced the risk of early reherniation.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01283438.

Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases

Background

Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.

Purpose

This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).

Methods

A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.

Results

The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle-disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.

Conclusion

Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.

Association of age with incidence and timing of recurrence after microdiscectomy for lumbar disc herniation

OBJECTIVE

Recurrent lumbar disc herniation (LDH) is the most frequent reason for reoperation after lumbar microdiscectomy. While several risk factors for recurrent LDH have been well-described, the effect of age on recurrence remains unclear, especially concerning the timing of recurrent LDH.

METHODS

From a prospective registry, we identified all patients who underwent tubular microdiscectomy for LDH. Recurrent LDH was defined as reoperation for LDH at the same index level and side. The associations among age and incidence of recurrent LDH as well as on time to recurrent LDH were statistically evaluated using multivariable analysis of covariance, linear regression, and Cox proportional hazards modelling.

RESULTS

Of the 3013 patients who underwent surgery for LDH, 166 (5.5%) had to undergo reoperation due to LDH recurrence. Uni- and multivariable analysis revealed no influence of age on the incidence of recurrent LDH (both p > 0.05). Linear regression indicated earlier reoperation in older patients, both with (β = -0.248) and without (β = -0.374) correction for confounders (both p < 0.05). An additional survival analysis found that patients aged over 35 years had recurrent LDH significantly earlier (hazard ratio 0.617, p = 0.013).

CONCLUSION

In an analysis of a large prospective database of patients undergoing microdiscectomy for lumbar disc herniation, we found that younger patients do not have a higher reoperation probability than their older counterparts, even after correcting for multiple confounders. However, older patients tend to experience recurrent LDH significantly earlier after the index surgery compared to younger patients.

Comparison of Percutaneous Endoscopic Lumbar Discectomy with Minimally Invasive Transforaminal Lumbar Interbody Fusion as a Revision Surgery for Recurrent Lumbar Disc Herniation after Percutaneous Endoscopic Lumbar Discectomy

Objective

The purpose of this study was to compare the outcomes between percutaneous endoscopic lumbar discectomy (PELD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the revision surgery for recurrent lumbar disc herniation (rLDH) after PELD surgery.

Patients and Methods

A total of 46 patients with rLDH were retrospectively assessed in this study. All the patients had received a PELD in Peking University First Hospital between January 2015 and June 2019, before they underwent a revision surgery by either PELD (n=24) or MIS-TLIF (n=22). The preoperative data, perioperative conditions, complications, recurrence condition, and clinical outcomes of the patients were compared between the two groups.

Results

Compared to the MIS-TLIF group, the PELD group had significantly shorter operative time, less intraoperative hemorrhage, and shorter postoperative hospitalization, but higher recurrence rate (P<0.05). Complication rates were comparable between the two groups. Both groups had satisfactory clinical outcomes at a 12-month follow-up after the revision surgery. The PELD group also showed significantly lower visual analog scale (VAS) scores of back pain and Oswestry disability index (ODI) in one month after the revision surgery, whereas the difference was not detectable at six- and 12-month follow-ups.

Conclusion

Both PELD and MIS-TLIF are effective as a revision surgery for rLDH after primary PELD. PELD is superior to MIS-TLIF in terms of operative time amount of intraoperative hemorrhage and postoperative hospitalization. However, its higher postoperative recurrence rate must be considered and patients should be well informed, when making a decision between the two surgical approaches.

Radiological predictors of recurrent lumbar disc herniation: a systematic review and meta-analysis

OBJECTIVE

Lumbar discectomy for the management of lumbar radiculopathy is a commonly performed procedure with generally excellent patient outcomes. However, recurrent lumbar disc herniation (rLDH) remains one of the most common complications of the procedure, often necessitating repeat surgery. rLDH is known to be influenced by a variety of factors, and in this systematic review the authors aimed to explore the radiological predictors of recurrence.

METHODS

A systematic review and meta-analysis was conducted to identify studies analyzing radiological predictors of recurrent herniation, both ipsilateral and contralateral. A search was conducted on Medline and EMBASE. Both retrospective and prospective comparative studies were included, measuring radiological parameters of lumbar discectomy patients. All factors were considered irrespective of imaging modality, and a meta-analysis of the data was performed in which 5 or more studies were identified analyzing the same parameter.

RESULTS

In total, 1626 reported studies were screened, with 23 being included in this review, of which 13 were appropriate for meta-analysis. Three factors, namely disc height index, Modic changes, and sagittal range of motion, were determined to be significantly correlated with an increased rate of rLDH. Some variables were considered in only 1 or 2 different studies, and the authors have included a narrative review of these novel findings.

CONCLUSIONS

The findings of associations between the radiological parameters and rLDH implicates the role of instability in the development of recurrence. Understanding the physiological factors associated with instability is important, because although early degenerative disc changes may predispose patients to herniation recurrence, more advanced degeneration likely reduces segmental motion and concurrently risk of recurrence.

Effect of continuous nursing based on wechat platform on postoperative rehabilitation of patients with lumbar disc herniation

OBJECTIVE

The present randomized controlled trial was conducted to investigate the effect of continuous nursing based on wechat platform on postoperative rehabilitation of patients with lumbar disc herniation (LDH).

METHODS

A total of 95 patients with LDH who underwent surgery in Suzhou BenQ Medical Center from March 2, 2016 to June 23, 2018 were enrolled and randomly divided into the control group (routine continuous nursing) and the study group (continuous nursing based on wechat platform). During the follow-up, the patients' compliance and the effectiveness were recorded. The 36-Item Short-Form Health Survey scale (SF-36 score) was used to evaluate quality of life. The spinal nerve function was evaluated with Japanese Orthopedics Association (JOA) score while the lumbar function was determined with Oswestry dysfunction index (ODI).

RESULTS

There were 48 patients in the control group and 47 patients in the study group. The results showed that the compliance rate of the study group was 89.36%, significantly higher than that of the control group (60.42%). The effective rate of the study group was 95.74%, significantly higher than that of the control group (81.25%). Further, continuous nursing based on wechat platform brought more obvious improvement in the SF-36 scores as well as the JOA score and ODI.

CONCLUSION

The compliance rate and the effectiveness rate of patients received continuous nursing based on wechat platform were higher than those of patients who received routine continuous nursing, which further brought more obvious improvement in the quality of life as well as the JOA scores and ODI.

Recurrent disc herniation following percutaneous endoscopic lumbar discectomy preferentially occurs when Modic changes are present

Objective

To investigate the relationship between Modic changes (MCs) and recurrent lumbar disc herniation (rLDH) and that between the herniated disc component and rLDH following percutaneous endoscopic lumbar discectomy (PELD).

Methods

We included 102 (65 males, 37 females, aged 20–66 years) inpatients who underwent PELD from August 2013 to August 2016. All patients underwent CT and MRI preoperatively. The presence and type of Modic changes were assessed. During surgery, the herniated disc component of each patient was classified into two groups: nucleus pulposus group and hyaline cartilage group. The association of herniated disc component with Modic changes was investigated. The incidence of rLDH was assessed based on a more than 2-year follow-up.

Results

In total, 11 patients were lost to follow-up; the other 91 were followed up during 24–60 months. Of the 91 patients, 99 discs underwent PELD; 28/99 (28.3%) had MCs. Type I and II MCs were seen in 9 (9.1%) and 19 (19.2%), respectively; no type III MCs were found. Among 28 endplates with MCs, according to the herniated disc component, 18/28 (64.3%) showed evidence of hyaline cartilage in the intraoperative specimens, including 6/9 and 12/19 endplates with type I and II MCs, respectively. Among 71 endplates without MCs, 14/71 (19.7%) showed evidence of hyaline cartilage in the intraoperative specimens. Hyaline cartilage was more common in patients with MCs (P < 0.05). We found 2 cases of rLDH in the non-MC group (n = 71); 6 cases of rLDH were found in the MC group (n = 28), including 2 and 4 cases for types I and II, respectively. There was no significant difference between types I and II (P > 0.05). rLDH was more common in patients with MCs (P < 0.05). We found 5 rLDH cases in the hyaline cartilage group (n = 32); 3 rLDH cases were found in the nucleus pulposus group (n = 67). rLDH was more common in the hyaline cartilage group (P < 0.05).

Conclusions

rLDH following PELD preferentially occurs when MCs or herniated cartilage are present.

Risk Factors for Recurrent L5-S1 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Study

Background

This retrospective study aimed to investigate the risk factors associated with the recurrence of L5–S1 disc herniation after percutaneous endoscopic transforaminal discectomy (PETD).

Material/Methods

There were 484 patients L5–S1 disc herniation who underwent PETD who were divided into the recurrence group (n=46) and the non-recurrence group (n=438). Transforaminal endoscopic approaches included modifications of the Yeung endoscopy spine system (YESS) (the intraforaminal intradiscal approach) and the transforaminal endoscopic spine system (TESSYS) (intraforaminal extradiscal approach). Demographic and clinical characteristics and imaging data were analyzed. The two study groups were compared to determine the factors associated with the recurrence of L5–S1 disc herniation. The patients underwent postoperative follow-up for between one and four years.

Results

At follow-up, 9.504% of patients (46/484) with the recurrence of L5–S1 disc herniation following PETD when compared with the non-recurrence group showed no significant difference for time to return to work, gender, history of diabetes mellitus, trauma, duration of symptoms, smoking and alcohol history, hypertension, location of disc herniation, transverse process length, intervertebral space height, and pelvic incidence angle (P>0.05). However, age, body mass index (BMI), the degree of disc degeneration, sagittal range of motion, lumbar lordosis angle, and sacral slope were significantly associated with the recurrence of L5–S1 disc herniation following PETD (P<0.05). Logistic regression analysis supported these main associations.

Conclusions

The recurrence of L5–S1 disc herniation following PETD was significantly associated with increased age and BMI, more severe disc degeneration, increased sagittal range of motion, increased lumbar lordosis, and sacral slope.

Predictive Scoring and Risk Factors of Early Recurrence after Percutaneous Endoscopic Lumbar Discectomy

Purpose

To predict the early recurrence after full endoscopic lumbar discectomy, we analyzed factors related to demographic factor anatomical factors, operative method, and postoperative management, and predicted the possibility of recurrence according to the scoring system.

Materials and Methods

In this prospective study, we enrolled 300 patients who underwent 1 out of 3 surgical procedures. The patients were randomized into one of the following groups: group A (n = 100), transforaminal inside-out approach; group B (n = 100), transforaminal outside-in approach; and group C (n = 100), interlaminar approach. The clinical results were evaluated by a visual analogue scale (VAS). Related factors evaluated with points of (A) demographic factors: (1) age, (2) gender, (3) BMI, (B) anatomical factors: (4) disc degeneration scale, (5) modic change, (6) number of involved disc herniation, (7) history of discectomy (first, recurred), (8) herniated disc level, (9) disc height, (10) segmental dynamic motion, (11) disc location, (C) operation factors: (12) annulus preservation along the disc protrusion, (13) approach method (transforaminal inside-out, transforaminal outside-in, interlaminar); (D) postoperative care factors: (14) early ambulation, (15) spinal orthosis (corset) application. Among these, we analyzed statistically significant recurrence risk factors after PELD in all patients and early recurrence predicting score ratio was obtained.

Results

The overall recurrence rate was 9.33%. The recurrence rate was 11%, 10%, and 7% for groups A, B, and C, respectively. Average early recurrence time was 3.26 months. The change in preoperative and postoperative VAS score was from 8.07 to 1.39, 8.34 to 1.34, and 8.14 to 1.86 in groups A, B, and C, respectively. The recurrence rate based on the (1) age was <40 years: 5.22% (6/115), 41–60 years: 16.1% (20/124), and >61 years: 3.07% (2/65); (2) gender was male: 13/139 (9.35%), female: 15/161 (9.32%); (3) BMI was obese: 17.57% (13/74), overweight: 11.6% (9/77), underweight: 6.35% (4/63), and normal weight: 2.33% (2/86); (4) degeneration scale was grades 1–2: 2% (1/50), grade 3: 7.4% (10/135), and grades 4–5: 14.8% (17/115); (5) modic change was type I: 25% (3/12), type II: 14.3% (1/7), type III: 33% (1/3), and no modic change: 8.27% (23/278); (6) number of involved disc herniation was 1 level: 3.9% (5/128), 2 level: 10.4% (13/125), 3 levels: 18.9% (7/37), and 4 levels: 30% (3/10); (7) history of discectomy was first: 8.83% (25/283) and repeated: 17.65% (3/17); (8) herniated disc level was L1–L2/L2–L3/L3–L4: 3.95% (3/76) and L4–L5: 14.6% (18/123); (9) disc height was <80%: 17.14% (6/35), 81%–100%: 8.16% (12/147), and >101%: 8.5% (10/118); (10) segmental dynamic motion was 1–10°: 8.58% (20/233) and 11–20° : 11.9% (8/67); (11) disc location was central: 7.41% (2/27), foraminal: 3.03% (2/66), and inferior/superior/paracentral: 11.59% (24/207); (12) radical annulotomy was 8.05% (7/87) vs. 9.86% (21/213); (13) approach method was transforaminal (inside-out): 11% (11/100), transforaminal (outside-in): 10% (10/100), and interlaminar: 7% (7/100); (14) early ambulation was 16.42% (23/140) vs. 3.13% (5/160); and (15) spinal orthosis application was 7.35% (10/136) vs. 10.98% (18/164). According to the above results, after summation of all scores, the early recurrence predicting score: recurrence rate ratio was 1–4: 0% (0/23), 5–8: 7.1% (13/183), 9–12: 8% (6/75) and 13–16 100% (10/10).

Conclusions

Early recurrence after PELD is associated with several risk factors such as BMI, degeneration scale, combined HNP, and early ambulation. If we use the predicting score, we can postulate the occurrence of early recurrence after PELD. Knowing the predictive factors prior to surgical intervention will allow us to decrease the early recurrence rate after PELD.

Comparison of Anterior Cervical Foraminotomy and Posterior Cervical Foraminotomy for Treating Single Level Unilateral Cervical Radiculopathy

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare clinical and radiological outcomes after two surgical procedures.

SUMMARY OF BACKGROUND DATA

Anterior cervical discectomy and fusion is the gold standard treatment for cervical radiculopathy. Cervical foraminotomy is an alternative decompressive treatment option to preserve segmental motion and avoid fusion-related complications. Anterior cervical foraminotomy (ACF) and posterior cervical foraminotmy (PCF) has been introduced to achieve foraminal decompression. The objective of this study was to compare long-term clinical and radiological outcomes after two surgical procedures for the treatment of single-level cervical radiculopathy.

METHODS

A retrospective review of patients undergoing ACF or PCF for the treatment of single-level unilateral cervical radiculopathy from 2010 to 2012 was performed. Demographic, perioperative, and clinical outcomes of 40 patients for each group were collected from the electronic medical records. Clinical outcomes were assessed by visual analog scores, while disc height (DH), cervical lordosis (CL), and C2-7 sagittal vertical axis (C2-7 SVA) data were obtained from pre- and postoperative radiography data.

RESULTS

Both groups showed similar clinical improvements after surgery. Radiographically, the ACF groups showed profound decrease in DH only at the first month after surgery, and there was no significant change in DH after 1 year. The PCF group showed no significant changes in DH at follow-up. With respect to CL, ACF showed a significant decrease. There was no statistically significant change in C2-7 SVA before or after surgery in both groups.

CONCLUSION

Both ACF and PCF showed significant clinical improvement of radiculopathy. In the ACF group, the DH decreased, and CL decreased during the early postoperative period. Radiological parameters were preserved in the PCF group after surgery. However, this group showed greater intraoperative bleeding and revision rates. Care should be taken to manage complications according to the specific surgical treatment.

LEVEL OF EVIDENCE

3.

Could the Splitting of the Annulus During Percutaneous Endoscopic Lumbar Diskectomy (PELD) Be a Culprit for Recurrent Disk Herniation?: An Analysis of the Reherniation Pattern After PELD

OBJECTIVE

To explore which preoperative radiologic variables have propensity for reherniation and to evaluate whether the inherent annulus splitting procedure during percutaneous endoscopic lumbar diskectomy (PELD) could prompt reherniation, we assessed the correlation between the anatomic location of annular penetration and reherniation.

METHODS

Three hundred and fifty patients who underwent PELD for central or subarticular disk herniation through a transforaminal approach were followed-up for at least 24 months. Fifty-four subjects that were reoperated for recurrent herniation were allocated as the reherniation group and the other 296 subjects were allocated as the non-reherniation group. The numerical rating scale score, another lumbosacral disk herniation (LDH) lesion in addition to the PELD level (another LDH), location (central or subarticular) and severity of LDH (protrusion or extrusion), and tear of the posterior longitudinal ligament (PLL) were compared between the 2 groups to identify which variables could be predictive factors for reherniation. To assess the influences of PELD on reherniation, location and severity of reherniation were compared with those of initial herniation.

RESULTS

The location at the subarticular region and the existence of a concomitant PLL tear during initial LDH were significantly related to subsequent reherniation. The location and severity of these reherniations were significantly retained when compared with those of primary herniation.

CONCLUSIONS

PLL tear and subarticular herniation were significantly related to recurrent disk herniation. Reherniation patterns after PELD generally matched those of primary herniation. The annulus penetrating step during PELD did not increase the risk of reherniation.

Trends in Incidence and Treatment of Herniated Lumbar Disc in Republic of Korea : A Nationwide Database Study

OBJECTIVE

This study aimed to determine the incidence and analyze trends of the herniated lumbar disc (HLD) based on a national database in the Republic of Korea (ROK) from January 2008 to December 2016.

METHODS

This study was a retrospective analysis of data obtained from the national health-claim database provided by the National Health Insurance Service for 2008-2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of HLD were calculated, and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and some treatments were analyzed using the Korean Classification of Diseases procedure codes.

RESULTS

The number of patients diagnosed with HLD was 472245 in 2008 and increased to 537577 in 2012; however, it decreased to 478697 in 2016. The pattern of crude incidence and the standardized incidence were also similar. Overall, the incidence of HLD increased annually for the 30s, 40s, 50s, and 70s until 2012 and then decreased. However, the incidence of HLD for the 80s continued to increase. The crude incidence of HLD in female patients exceeded that of male patients in their middle age (30s or 40s) and was 1.5-1.6 times higher than in male patients in their 60s. The total number of open discectomy (OD) increased from 71598 in 2008 to 93942 in 2012 and then decreased to 85846 in 2016. The rate of younger patients (the 20s, 30s, and 40s) who underwent OD was decreased, and the rate of younger patients who underwent percutaneous endoscopic lumbar discectomy was increased. However, the rate of older patients (the 70s and 80s) who underwent OD was continuously increased.

CONCLUSION

This nationwide data on HLD from 2008 to 2016 in the ROK demonstrated that the crude incidence and the standardized incidence increased until 2012 and then decreased. The annual crude incidence was different according to age and sex. These findings may be considered when deciding future health policy, especially in countries with a similar national health insurance system (or with plans to adopt).

Revision Surgery after Percutaneous Endoscopic Transforaminal Discectomy Compared with Primary Open Surgery for Symptomatic Lumbar Degenerative Disease

Objective

To evaluate the clinical outcome of reoperation after percutaneous endoscopic lumbar discectomy (PELD) as compared with primary spinal decompression and fusion.

Methods

A retrospective study from December 2014 to December 2017 was conducted at Peking Union Medical College Hospital and comprised 39 patients with symptomatic lumbar degenerative disease (LDD): 13 post‐PELD who underwent reoperation (revision surgery group) and 26 who received primary spinal decompression and fusion (primary open surgery group). The two groups were compared regarding: operative time, blood loss, transfusion, hospitalization, postoperative visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, Japanese Orthopedic Association (JOA) improvement rate, and postoperative complications. The Mann–Whitney U‐test was applied to analyze continuous parameters, and the χ²‐test for categorical parameters. Fisher's exact test was used for small data subsets.

Results

There was no statistically significant difference between the two groups in mean age (52.7 years vs 52.9 years), gender ratio (6 men‐to‐7 women vs 12 men‐to‐14 women), body mass index, medical history, preoperative diagnosis, or surgical spine level (P > 0.05). The mean operative time of the revision surgery group was significantly longer than that of the primary open surgery group (160.0 min vs 130.2 min, P < 0.05). The revision surgery group also had a significantly higher mean estimated blood loss, postoperative drainage, and length of hospital stay (P < 0.05). However, no significant differences were found between the two groups in terms of hemoglobin and hematocrit values, preoperatively and postoperatively. The rate of transitional neurological irritation was higher in the revision surgery group (61.5% vs 3.8%; P < 0.05), as was intraoperative durotomy and cerebrospinal fluid leakage (30.8% vs 3.8%, P < 0.05). At 1 month, the VAS and ODI scores of the primary open surgery group were significantly better than those of the revision surgery group, while the improvement in JOA scores was similar. After 6 and 12 months’ follow‐up, the VAS and ODI scores and the rates of JOA improvement were comparable.

Conclusion

Patients with LDD who received primary spinal decompression and fusion experienced lower rates of perioperative complications and shorter hospitalization compared with patients who underwent revision surgery after PELD, but the clinical outcomes at the last follow‐up of both groups were satisfactory.

Revision for Endoscopic Diskectomy: Is Lateral Lumbar Interbody Fusion an Option?

OBJECTIVE

This study aims to report the clinical outcome of stand-alone lateral lumbar interbody fusion (LLIF) on recurrent disk herniation and to compare the outcome of stand-alone LLIF to that of conventional transforaminal lumbar interbody fusion (TLIF).

METHODS

A retrospective study of 47 patients with recurrent disk herniation was included from January 2008 to October 2016. The inclusion criteria were 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous percutaneous endoscopic lumbar diskectomy surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, and 4) with follow-up more than 1 year. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey.

RESULTS

Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Radiographic analysis revealed a similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups. Two weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups. The TLIF group showed significantly larger postoperative VAS back pain after surgery (P = 0.03). For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups.

CONCLUSIONS

Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with recurrent disk herniation after a previous percutaneous endoscopic lumbar diskectomy surgery. Compared with the TLIF procedure, LLIF could achieve a similar improvement of patient-reported outcome with a better VAS back pain score.

A Pilot Study of Percutaneous Interlaminar Endoscopic Lumbar Sequestrectomy: A Modern Strategy to Tackle Medically-Refractory Radiculopathies and Restore Spinal Function

Objective

Angled scopes allow 360° visualization, which makes percutaneous endoscopic techniques (percutaneous endoscopic lumbar discectomy, PELD) particularly attractive for sequestrectomies, which entail the removal of extruded lumbar disc fragments that have migrated caudally or cranially between the ligaments, foramina, and neural structures, while preserving the disc. Although many different PELD techniques are currently available, not all of them are suitable for sequestrectomies; furthermore, long-term follow-up data are unfortunately lacking.

Methods

A pilot study was conducted on a cohort of 270 patients with lumbar radiculopathy undergoing minimally invasive spine surgery (PELD or microdiscectomy), of whom only 7 were eligible for endoscopic interlaminar sequestrectomy with disc preservation. The patients’ baseline conditions and clinical outcomes were measured with the Oswestry Disability Index and a visual analogue scale. Long-term follow-up was conducted using satisfaction questionnaires that were based on the MacNab criteria and administered by medical/nursing personnel not involved in their primary surgical management.

Results

EasyGo system was eventually used in 5 PELD cases. No dural tears, infections, or nerve root injuries were recorded in patients undergoing sequestrectomy. Surgical events, including blood loss and overall length of hospital stay, did not differ significantly among the 270 patients. In the group treated with endoscopic sequestrectomy, no recurrences or complications were noted during a follow-up of 3 years, and an excellent degree of satisfaction was reported.

Conclusion

We provide OCEBM (Oxford Centre for Evidence-Based Medicine) level 3 evidence that interlaminar endoscopic sequestrectomy is a tailored and well-tolerated surgical option; nonetheless, a cost-effectiveness analysis assessing the interval until return to working activities and long-term benefits is warranted.

Recurrent Lumbar Disc Herniation: A Review

STUDY DESIGN

Narrative review.

OBJECTIVES

To identify the risk factors and surgical management for recurrent lumbar disc herniation using a systematic review of available evidence.

METHODS

We conducted a review of PubMed, MEDLINE, OVID, and Cochrane Library databases using search terms identifying recurrent lumbar disc herniation and risk factors or surgical management. Abstracts of all identified articles were reviewed. Detailed information from articles with levels I to IV evidence was extracted and synthesized.

RESULTS

There is intermediate levels III to IV evidence detailing perioperative risk factors and the optimal surgical technique for recurrent lumbar disc herniations.

CONCLUSIONS

Multiple risk factors including smoking, diabetes mellitus, obesity, intraoperative technique, and biomechanical factors may contribute to the development of recurrent disc disease. There is widespread variation regarding optimal surgical management for recurrent herniation, which often include revision discectomies with or without fusion via open and minimally invasive techniques.

Predictors for Poor Outcomes After Percutaneous Endoscopic Lumbar Discectomy: A Retrospective Study of 241 Patients

OBJECTIVE

Percutaneous endoscopic lumbar discectomy (PELD) is a popular surgical procedure for the treatment of lumbar disc herniation (LDH). However, a small proportion of patients will have poor surgical outcomes. We sought to identify the predictors for poor outcomes after PELD.

METHODS

A total of 241 patients who had undergone PELD were followed up. Their numerical rating scale (NRS) for pain and Oswestry Disability Index scores were analyzed. They were divided by outcome (excellent, good, fair, poor) using the MacNab criteria. Their clinical history, physical examination, imaging, and surgical findings were compared among the groups. Ordinal logistic regression analysis was used to identify independent predictors for poor outcomes.

RESULTS

The preoperative mean total NRS for back pain, NRS for leg pain, and Oswestry Disability Index scores were 4.3 ± 2.6, 5.6 ± 2.5, and 52.1% ± 23.0%. At 2 years after PELD, the corresponding scores had decreased to 1.2 ± 1.7, 0.9 ± 1.5, and 8.4% ± 11.2% (P < 0.001). The excellent, good, fair, and poor outcome rates were 44.4%, 31.5%, 17.4%, and 6.6%, respectively. Ordinal logistic regression analysis revealed that 2-level PELD (P = 0.001), a history of lumbar fusion (P = 0.007), and Modic changes (P = 0.011) were independent predictors for poor outcomes. Numbness was an independent predictor for excellent outcomes (P = 0.014).

CONCLUSIONS

PELD appears to be an effective surgery for LDH. Two-level PELD, a history of lumbar fusion, and Modic changes at the same level were independent predictors for poor outcomes after PELD. Patients with LDH with numbness were more likely to have excellent outcomes.

Recurrent lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: A case report

RATIONALE

Lumbar disc herniation (LDH) is a degenerative disease and affects human health. Although percutaneous endoscopic lumbar discectomy (PELD) can redeem the living quality of patient with LDH rapidly, it appears weak to limit the recurrence rate of LDH.

PATIENT CONCERNS

A 52-year-old male suffered lower back pain and lower limb paralysis for 20 years. However, conservative treatment could not relieve above-mentioned symptoms after doing heavy labor.

DIAGNOSES

Computed tomography (CT) revealed a disc fragment had migrated to the inferior edge of the L5 pedicle. Magnetic resonance imaging (MRI) demonstrated a type 2 Modic change (MC) at L5 and spinal canal stenosis at L4-L5. Based on these findings, the patient was diagnosed with L4-L5 disc herniation and secondary lumbar stenosis.

INTERVENTIONS

The patient underwent surgery twice for PELD at L4-L5 in 1 month. Symptoms were not improved effectively until the conventional posterior discectomy with fusion was performed.

OUTCOMES

No signs of recurrence have been detected in 6 months of follow-up, except for mild lower back pain meeting the temperature change.

LESSONS

Rapid decompression and instant therapeutic effect do not mean extending the indications of PELD. It is unreasonable to revise the recurrent LDH or treat the primary LDH with PELD under inadequate preoperative assessment.