Development and clinical application of grading and classification criteria of lumbar disc herniation

Comparison of Clinical and Radiographic Outcomes Between Transforaminal Endoscopic Lumbar Discectomy and Microdiscectomy: A Follow-up Exceeding 5 Years

OBJECTIVE

To compare the long-term clinical and radiographic outcomes of transforaminal endoscopic lumbar discectomy (TELD) versus microdiscectomy (MD).

METHODS

The data of 154 patients with lumbar disc herniation (LDH) who underwent TELD (n = 89) or MD (n = 65) were retrospectively analyzed. The patients' clinical outcomes were evaluated using visual analogue scales for leg and low back pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI). The evolution of radiographic manifestations was observed during follow-up. Potential risk factors for a poor clinical outcome were investigated.

RESULTS

During a mean follow-up of 5.5 years (range, 5-7 years), the recurrence rate was 4.49% in the TELD group and 1.54% in the MD group. All scores significantly improved from preoperatively to postoperatively in both groups (p < 0.01). The improvement in the ODI and JOA scores was significantly greater in the TELD than MD group (p < 0.05). Forty-seven patients (52.8%) in the TELD group and 32 (49.2%) in the MD group had Modic changes before surgery, most of which showed no changes at the last follow-up. The degeneration grades of 292 discs (71.0%) were unchanged at the last follow-up, while 86 (20.9%) showed improvement, mostly at the upper adjacent segment. No significant difference was observed in the intervertebral height index or paraspinal muscle-disc ratio.

CONCLUSION

Both TELD and MD provide generally satisfactory long-term clinical outcomes for patients with LDH. TELD can be used as a reliable alternative to MD with less surgical trauma. Modic type II changes, decreased preoperative intervertebral height, and a high body mass index are predictors of a poor prognosis.

Comparison of Analgesic Efficacy between Epidural and Perineural Administration of Autologous Conditioned Serum in the Conservative Treatment of Low Back Pain Due to Lumbar Degenerative Disc Disease: A Randomized, Open-Label, Controlled Clinical Trial

Lumbar degenerative disc disease (LDDD) is widely acknowledged as a significant contributor to low back pain (LBP), which is a prevalent and debilitating health condition affecting millions of individuals worldwide. The pathogenesis of LDDD and associated pain mechanisms are thought to be mediated by inflammatory mediators. Autologous conditioned serum (ACS, Orthokine) may be used for symptomatic treatment of LBP due to LDDD. This study aimed to compare the analgesic efficacy and safety of two routes of ACS administration, perineural (periarticular) and epidural (interlaminar), in the conservative treatment of LBP. This study used an open-label, randomized, controlled trial protocol. A group of 100 patients were enrolled in the study and randomly allocated into two comparative groups. Group A (n = 50) received the epidural (interlaminar) approach-2 ultrasound-guided injections as control intervention (each containing two doses of ACS-8 mL). Group B (n = 50) received the perineural (periarticular) approach-2 ultrasound-guided injections as experimental intervention at 7-day intervals (the same volume of ACS). Assessments consisted of an initial assessment (IA) and control assessments at 4 (T1), 12 (T2), and 24 (T3) weeks after the last intervention. Primary outcomes comprised Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Questionnaire (RMQ), and Euro Quality of Life-5 Dimensions-5 Levels (EQ-5D-5L): Index, Visual Analogue Scale (VAS), and Level Sum Score (LSS). Secondary outcomes included differences between groups in specific endpoints for the above-mentioned questionnaires. In conclusion, this study revealed that both perineural (periarticular) and epidural ACS injections tended to perform in a very similar way. Both routes of Orthokine application show significant improvement in the primary clinical parameters, such as pain and disability, and therefore, both methods can be considered equally effective in managing LBP due to LDDD.

A novel classification based on magnetic resonance imaging for individualized surgical strategies of lumbar disc herniation

INTRODUCTION

Although the anatomy and pathology of lumbar disc herniation (LDH) have been clearly defined and classified in many studies, its imaging definition and classification still needs further clarification. This study intends to propose a novel classification and individualized surgical strategy for LDH based on preoperative magnetic resonance imaging (MRI).

MATERIALS AND METHODS

According to MRI features, LDH types were identified, and the corresponding surgical strategies were formulated to accurately remove the herniated discs while minimizing the disturbance to the normal disc. We retrospectively analyzed prospectively collected data of LDH patients who underwent surgery guided by this classification system.

RESULTS

This study included 357 patients with LDH who underwent tubular microdiscectomy. LDH was classified into four types based on MRI features. The inter- and intra-observer agreement using this classification was good. The follow-up results showed that surgery improved visual analog scale scores for low-back and leg pain and the Oswestry disability index in patients with different LDH types. The average recurrence rate at 1-5 years postoperatively was 5.62%. There was no significant difference in recurrence rates among the four LDH types (3.7-6.2%). MRI showed no significant differences in the Pfirrmann grade and disc height index of the operated segment between before surgery and 1-3 years after surgery. The operated segments did not show faster disc degeneration rates compared to adjacent proximal segments.

CONCLUSIONS

We proposed a novel classification system and an individualized surgical strategy for LDH based on preoperative MRI. Further, the surgical suitable interventions guided by this system achieved good clinical outcomes and mild recurrence rates.

Evaluation of outcomes of discectomy with a dynamic neutralization system in treatment of lumbar disk herniation

OBJECTIVE

The study aimed to explore the clinical outcomes of discectomy with dynamic neutralization system (Dynesys) for single-segmental lumbar disk herniation (LDH) versus simple discectomy.

METHODS

The eligible patients with single-segmental LDH were randomly divided into the discectomy with Dynesys group (group A) and the simple discectomy group (group B). The Oswestry disability index (ODI), visual analog score (VAS), radiological results of intervertebral height and range of motion (ROM) of the treated segment were evaluated pre- and post-operatively in both groups. Operation duration and blood loss were recorded. Complications, reoperation, and mortality were also assessed. All patients received a 2-year follow-up.

RESULTS

123 (96.1%) participants completed the follow-up. The operation duration and blood loss of group B were significantly lower than those of group A (p<0.05). After operation, ODI and VAS were improved significantly in both groups, and there was no significant difference between the two groups immediately after surgery. But a rising trend was found in ODI and VAS of group B, especially after the 1-year follow-up (p<0.05). X-rays showed a continuing loss of intervertebral height of the treated segment in group B, while it was preserved in group A (p<0.05). ROM of the treated segment was also maintained stable in group A.

CONCLUSION

Discectomy with Dynesys is safe and effective for LDH treatment.

Does the Size or Location of Lumbar Disc Herniation Predict the Need for Operative Treatment?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The goal of this study was to determine whether the absolute size (mm²), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention.

METHODS

MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics-including size of disc herniation (mm²), size of spinal canal (mm²), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)-were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses.

RESULTS

The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P = .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P = .002) or disc extrusion (OR 11.5 [1.63, 81.2], P = .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P = .017, and OR = 5.46 [1.77, 16.8], P = .003, respectively).

CONCLUSIONS

Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

Predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus: A prospective study in Indonesia

BACKGROUND

The objective of this study was to identify the predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus (HNP).

METHODS

A prospective study was conducted between June 2010 and April 2012 in Banda Aceh, Indonesia. Clinical and baseline neurologic examinations such as passive straight leg raising test (SLRT), cross SLRT, and patellar and Achilles reflexes were assessed prior to the conservative management. The patients were evaluated at 2nd, 4th, 8th, 12th and 24th week following commencement of the conservative management.

RESULTS

We recruited and followed 171 HNP patients of which 35.7% of them had good outcome. At univariate analysis, patients with more than 12 months duration of complaint, those with dominant radicular pain, severe pain intensity (visual analogue scale 7-10), positive SLRT, positive cross SLRT, and reduced motor power of knee extensors (muscle strength grade 1-4), were associated with poor outcome. Multivariate analysis suggested that patients with dominant radicular type of pain were likely to had poor outcome compared to those with dominant back pain (odd ratio (OR) 10.57 with 95% confidence interval (CI) 1.15-96.93). Patients with reduced motor power of knee extensors also had a higher chance to have poor outcome compared to those who were normal (OR: 10.57; 95% CI: 1.15-96.93).

CONCLUSION

Type of pain and the strength of lower extremities could be able to predict the failure of conservative management in patients with lumbar disc herniation. However, further studies with the bigger sample size are warrant to validate our results.

Comparison of lumbar degenerative disc disease using conventional fast spin echo T2W MRI and T2 fast spin echo dixon sequences

OBJECTIVES

To compare the grading of lumbar degenerative disc disease (DDD), Modic end-plate changes (MEPC) and identification of high intensity zones (HIZ) on a combination of sagittal T₁weighted turbo spin echo (T₁W TSE), T₂weighted fast spin echo (T₂W FSE) and short tau inversion recovery (STIR) sequences (routine protocol) with a single sagittal T₂W FSE Dixon MRI sequence which provides in-phase, opposed-phase, water only and fat only images in a single acquisition (Dixon protocol).

METHODS

50 patients underwent lumbar spine MRI using the routine protocol with the addition of a T₂W FSE Dixon sequence. DDD grade, MEPC and HIZ for each disc level were assessed on the routine and Dixon protocols. Each protocol was reviewed independently by three readers (consultant musculoskeletal radiologists with 26-, 8- and 4 years' experience), allowing assessment of inter-reader agreement and inter protocol agreement for each assessed variable.

RESULTS

The study included 17 males and 33 females (mean age 51 years; range 8-82 years). Inter-reader agreement for DDD grade on the routine protocol was 0.57 and for the Dixon protocol was 0.63 (p = 0.08). Inter-reader agreement for MEPC on the routine protocol was 0.45 and for the Dixon protocol was 0.53 (p = 0.02), and inter-reader agreement for identification of the HIZ on the routine protocol was 0.52 and for the Dixon protocol was 0.46 (p = 0.27). Intersequence agreement for DDD grade ranged from 0.61 to 0.97, for MEPC 0.46-0.62 and for HIZ 0.39-0.5.

CONCLUSION

A single sagittal T₂W FSE Dixon MRI sequence could potentially replace the routine three sagittal sequence protocol for assessment of lumbar DDD, MEPC and HIZ resulting in ~60% time saving.

ADVANCES IN KNOWLEDGE

Grading of lumbar DDD, presence of Modic changes and high intensity zones were compared on sagittal T₁W TSE, T₂W FSE and STIR sequences with a T₂W FSE Dixon sequence, with fair-to-good correlation suggesting that three conventional sequences could be replaced by a single Dixon sequence.

Effects of type 1 diabetes mellitus on lumbar disc degeneration: a retrospective study of 118 patients

BACKGROUND

The study aimed to investigate the correlation between type 1 diabetes (T1D) and lumbar disc degeneration (LDD).

METHODS

A retrospective analysis of 118 patients with T1D recruited from January 2014 to March 2019 was performed, and multivariate logistic regression was used to analyse the incidence of T1D; the age, sex, and body mass index (BMI) of the patients; the disease duration and the glycosylated haemoglobin and venous blood glucose levels. All patients who suffered low back pain were assessed by MRI using the Pfirrmann grading system.

RESULTS

A total of 118 patients with an average age of 36.99 ± 17.01 (8-85 years) were reviewed. The mean hospitalization duration, venous glucose fluctuation range, glycated haemoglobin level, highest venous glucose level, venous glucose level, and disease course duration were 13.98 ± 10.16 days, 14.99 ± 5.87 mmol/L, 9.85 ± 2.52 mmol/L, 25.29 ± 7.92 mmol/L, 13.03 ± 5.75 mmol/L and 7.30 ± 8.41 years. The average Pfirrmann scores of the different discs were 2.20 ± 0.62 (L1-2), 2.35 ± 0.67 (L2-3), 2.90 ± 0.45 (L3-4), 4.20 ± 0.52 (L4-5) and 4.10 ± 0.72 (L5-S1). The patients with T1D showed severe disc degeneration. The male sex, glycosylated haemoglobin, venous glucose and venous glucose fluctuations were significantly associated with LDD (P < 0.05).

CONCLUSIONS

Glycosylated haemoglobin, the male, venous glucose and the venous glucose fluctuation range were risk factors for LDD.

Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review

OBJECTIVE

Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation.

METHODS

A systematic literature search was conducted using Pubmed and Embase databases on 18^thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates).

RESULTS

Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques.

CONCLUSION

There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.