Risk Factors for Reoperation in Patients Treated Surgically for Intervertebral Disc Herniation: A Subanalysis of Eight-Year SPORT Data

The Relationship Between Disc Herniation Morphology and Patient-Reported Outcomes after Microdiscectomy

OBJECTIVE

Determine if herniation morphology based on the Michigan State University Classification is associated with differences in (1) patient-reported outcome measures (or (2) surgical outcomes after a microdiscectomy.

METHODS

Adult patients undergoing single-level microdiscectomy between 2014 and 2021 were identified. Demographics and surgical characteristics were collected through a query search and manual chart review. The Michigan State University classification, which assesses disc herniation laterality (zone A was central, zone B/C was lateral) and degree of extrusion into the central canal (grade 1 was up to 50% of the distance to the intra-facet line, grade >1 was beyond this line), was identified on preoperative MRIs. patient-reported outcome measures were collected at preoperative, 3-month, and 1-year postoperative time points.

RESULTS

Of 233 patients, 84 had zone A versus 149 zone B/C herniations while 76 had grade 1 disc extrusion and 157 had >1 grade. There was no difference in surgical outcomes between groups (P > 0.05). Patients with extrusion grade >1 were found to have lower Physical Component Score at baseline. On bivariate and multivariable logistic regression analysis, extrusion grade >1 was a significant independent predictor of greater improvement in Physical Component Score at three months (estimate = 7.957; CI: 4.443-11.471, P < 0.001), but not at 1 year.

CONCLUSIONS

Although all patients were found to improve after microdiscectomy, patients with disc herniations extending further posteriorly reported lower preoperative physical function but experienced significantly greater improvement three months after surgery. However, improvement in Visual Analog Scale Leg and back, ODI, and MCS at three and twelve months was unrelated to laterality or depth of disc herniation.

Inferior long-term outcomes after surgery for lumbar disc herniation in patients with prior lumbar spine surgery

BACKGROUND

Previous lumbar spine surgery is a frequent exclusion criterion for studies evaluating lumbar surgery outcomes. In real-life clinical settings, this patient population is important, as a notable proportion of patients evaluated for lumbar spine surgery have undergone prior lumbar surgery already previously. Knowledge about the long-term outcomes after microdiscectomy on patients with previous lumbar surgery and how they compare to those of first-time surgery is lacking.

METHODS

The original patient cohort for screening included 615 consecutive patients who underwent surgery for lumbar disc herniation, with a median follow-up time of 18.1 years. Of these patients, 89 (19%) had undergone lumbar spine surgery prior to the index surgery. Propensity score matching (based on age, sex, and follow-up time) was utilized to match two patients without prior surgery with each patient with a previous surgery. The primary outcome measure was the need for further lumbar spine surgery during the follow-up period, and the secondary outcome measures consisted of present-time patient-reported outcome measures (Oswestry Disability Index, EuroQol-5D) and present-time ability to carry out employment.

RESULTS

Patients who received previous lumbar surgeries had a higher need for further surgery (44% vs. 28%, p = 0.009) and had a shorter time to further surgery than the propensity score-matched cohort (mean Kaplan-Meier estimate, 15.7 years vs. 19.8 years, p = 0.008). Patients with prior surgery reported inferior Oswestry Disability Index scores (13.7 vs. 8.0, p = 0.036). and EQ-5D scores (0.77 vs. 0.86, p = 0.01). In addition, they had a higher frequency of receiving lumbar spine-related disability pensions than the other patients (12% vs. 1.9%, p = 0.01).

CONCLUSIONS

Patients with previous lumbar surgery had inferior long-term outcomes compared to patients without prior surgery. However, the vast majority of these patients improved quickly after the index surgery. Furthermore, the difference in the patients' reported outcomes was small at the long-term follow-up, and they reported high satisfaction with the results of the study surgery. Hence, surgery for these patients should be considered if surgical indications are met, but special care needs must be accounted for when deliberating upon their indications for surgery.

Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study

BACKGROUND

Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up.

METHODS

We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits.

RESULTS

Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6).

CONCLUSIONS

This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture.

REGISTRATION

Open Science Framework ( https://osf.io/vgrwz ).

Condoliase therapy for lumbar disc herniation -2 year clinical outcome

BACKGROUND

Condoliase-induced chemonucleolysis is a less invasive treatment for lumbar disc herniation (LDH); however, its long-term clinical outcomes remain unclear. We investigated 2-year clinical outcomes and assess radiographs after chemonucleolysis with condoliase.

METHODS

We enrolled patients with LDH who received condoliase therapy, with a minimum follow-up period of two years. Sixty-seven patients (44 men, 23 women; mean age, 46.7 ± 18.0 years) were analyzed. Time-course changes in disc height, disc degeneration, and herniation size were assessed. For clinical outcomes assessment, visual analog scale (VAS) scores for leg and back pain and the Oswestry disability index (ODI) were obtained at baseline and the 3-month, 1-year, and 2-year follow-ups. We obtained a questionnaire from these patients at two years to assess satisfaction and recommendation. Condoliase therapy was considered to be effective in patients whose VAS score for leg pain improved by ≥ 50% at 2 years from baseline and who did not require surgery.

RESULTS

Condoliase therapy was effective in 51 patients (76.1%). Eight patients (11.9%) required surgery due to ineffectiveness of the therapy. Condoliase therapy was ineffective in five out of six patients with a history of discectomy. The ODI and VAS scores for leg and back pain significantly improved from three months to two years. Of the patients, 80% satisfied with their outcomes, and 85% recommended this therapy. Progression of disc degeneration was observed in 57.1% of patients at three months; however, 30% recovered to baseline at two years. The mean disc height decreased at three months, but recovered slightly at one year and remained stable until two years. No recurrent disc herniation was observed.

CONCLUSIONS

Chemonucleolysis with condoliase was effective in 78% of patients with LDH for 2 years. Chemonucleolysis-induced disc degeneration was slightly recovered and maintained for two years post-injection. This treatment resulted in high patient satisfaction and recommendations.

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.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD).

METHODS

Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12 months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2 days and at 3, 6, and 12 months. Postoperative complications were noted.

RESULTS

Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1).

CONCLUSION

BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

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.

Predictors of reoperation in hispanic-americans with recurrent lumbosacral disc herniation following primary hemilaminectomy and discectomy surgery

Background

Multiple risk factors for recurrent lumbosacral disc herniation (rLDH) have been evaluated. However, it has been difficult to establish a consensus due to conflicting results. Therefore, the aim of our study was to evaluate the predictors of reoperation in Hispanic-Americans with rLDH following primary hemilaminectomy and discectomy surgery.

Methods

A retrospective case-control study of 451 Hispanic-Americans with lumbosacral disc herniation (LDH) was conducted. The sample was divided into two groups: reoperated (cases) and non-reoperated (controls). Preoperative, operative, and postoperative variables of initial surgery were compared between the two groups.

Results

The reoperation rate was 11.5%, with a mean interval between primary surgery and reoperation of 3.32 years ± 2.07. Analysis of preoperative variables identified a higher rate of reoperation in patients who were unemployed (cases: 48.1%, controls: 17.1%, p=0.001). A significant difference was also seen regarding the presence of gastrointestinal disease (cases: 11.5%, controls: 4.3%, p=0.038). However, there were no differences in the sociodemographic factors, preoperative physical exam, preoperative management, radiological parameters, or operative data. Those patients with persistent postoperative lower extremity pain, radiculopathy, low back pain, and buttock pain demonstrated a higher correlation with rLDH. Multivariable logistic regression analysis identified a significant difference only in work status (employed; OR and 95% CI [0.60 (0.55, 0.67)], p=0.002) and presence of postoperative low back pain (OR and 95% CI [2.17 (1.13, 4.29)], p=0.014).

Conclusions

Patients who required reoperation due to rLDH were more frequently unemployed and/or suffered postoperative low back pain after primary hemilaminectomy and discectomy surgery.

Favorable long-term health-related quality of life after surgery for lumbar disc herniation in young adult patients

BACKGROUND

Lumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them.

METHODS

A total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients' baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome.

RESULTS

The mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender-matched general population sample (difference 0.02, 95% CI - 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013).

CONCLUSION

Patients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender-matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.

Prevalence of Long-Term Low Back Pain After Symptomatic Lumbar Disc Herniation

OBJECTIVE

Lumbar disc herniation (LDH) is a global issue associated with potentially debilitating long-term consequences, including chronic low back pain (LBP). Short-term outcomes (<2 years) of patients with LDH have been extensively studied and demonstrate improvements in back and leg pain for both operative and conservative management. However, these improvements may not be sustained long-term (>2 years); patients with LDH may develop recurrent disc herniations, progressive degenerative disc disease, and LBP regardless of management strategy. Therefore, our objective is to determine the prevalence of chronic LBP after LDH, understand the relationship between LDH and chronic LBP, and investigate the relationship between radiological findings and postoperative pain outcomes.

METHODS

We performed a literature review on the PubMed database via a combination medical subject heading and keyword-based approach for long-term LBP outcomes in patients with LDH.

RESULTS

Fifteen studies (2019 patients) evaluated surgical and/or nonoperative outcomes of patients with LDH . Regardless of surgical or nonoperative management, 46.2% of patients with LDH experienced some degree of LBP long-term (range 2-27 years) as compared to a point prevalence of LBP in the general population of only 11.9%.

CONCLUSIONS

Patients with LDH are more likely to experience long-term LBP compared to the general population (46.2% vs. 11.9%). Additionally, understanding the relationship between radiological findings and pain outcomes remains a major challenge as the presence of radiological changes and the degree of LBP do not always correlate. Therefore, higher quality studies are needed to better understand the relationship between radiological findings and pain outcomes.

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.

Percutaneous Transforaminal Endoscopic Discectomy Versus Microendoscopic Discectomy for Lumbar Disk Herniation: Five-year Results of a Randomized Controlled Trial

STUDY DESIGN

A prospective randomized controlled study.

OBJECTIVE

To compare the efficacy and safety between percutaneous transforaminal endoscopic discectomy (PTED) and microendoscopic discectomy (MED).

SUMMARY OF BACKGROUND DATA

Two kinds of minimally invasive discectomy, PTED and MED, are now widely used for treating lumbar disk herniation (LDH). The long-term comparative results of these two techniques still remained uncertain.

MATERIALS AND METHODS

In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed LDH and were randomly allocated to PTED or MED groups. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (SF36-BP) and physical function (SF36-PF), European Quality of Life-Five Dimensions (EQ-5D), Visual Analog Scales for back pain (VAS-back) and leg pain (VAS-leg).

RESULTS

A total of 241 patients were accepted to enroll in our randomized controlled trial, of which 119 were randomly assigned to the PTED group, and the rest 122 were assigned to the MED group. A total of 194 out of 241 patients (80.5%) completed the five-year follow-up. PTED group was associated with shorter postoperative in-bed time and length of hospital stay. Both primary and secondary outcomes did not differ significantly between the two treatment groups at each follow-up time point. During the five-year follow-up, seven recurrent cases occurred in PTED and MED groups, respectively.

CONCLUSION

Over the five-year follow-up period, PTED and MED were both efficacious in the treatment of LDH. The long-term clinical outcomes and recurrent rates were comparable between the treatment groups. PTED represents a more minimally invasive technique with the advantages of rapid recovery.

Development and Validation of a Nomogram to Predict the Risk of Lumbar Disk Reherniation within 2 Years After Percutaneous Endoscopic Lumbar Discectomy

OBJECTIVE

To develop and validate a nomogram for predicting recurrent lumbar disk herniation (LDH) within 2 years after percutaneous endoscopic lumbar discectomy.

METHODS

Information on patients' LDH was collected from 1 medical center between January 2015 and September 2020. The LASSO (least absolute shrinkage and selection operator) method was applied to select the most significant risk factors. A multivariate logistic regression analysis was used to develop a predictive model incorporating the possible factors selected by the LASSO regression model. The discriminant, corrected, and clinically useful prediction models were evaluated using consistency index (C-index), receiver operating characteristic curve, calibration curves, and decision curve analysis. Internal validation of clinical predictive power was also assessed by bootstrap validation.

RESULTS

A total of 690 patients with LDH were included in this study. Sixty-three patients experienced recurrence within 2 years whereas 627 experienced no recurrence. The nomogram predictors included age, body mass index, Modic change, Pfirrmann grade, and sagittal range of motion. The model had good discrimination power, with a reliable C-index of 0.868 (95% confidence interval, 0.822-0.913) and interval validation confirmed a higher C-index value of 0.846. The area under the receiver operating characteristic curve was 0.868, indicating a good predictive value. The decision curve analysis indicated that it was clinically feasible to use the predictive recurrence nomogram model.

CONCLUSIONS

We developed and validated a new accurate and effective nomogram for predicting recurrent LDH within 2 years after percutaneous endoscopic lumbar discectomy. Age, body mass index, Modic change, Pfirrmann grade, and sagittal range of motion were significant features for predicting rLDH.

Reoperation Rates of Microendoscopic Discectomy Compared With Conventional Open Lumbar Discectomy: A Large-database Study

BACKGROUND

Microendoscopic discectomy for lumbar disc herniation has been shown to be as effective as traditional microdiscectomy or open discectomy in terms of clinical outcomes such as pain relief, and it is less invasive. Nevertheless, the reoperation rate for microendoscopic discectomy compared with microdiscectomy or open discectomy remains unclear, possibly due to difficulties in conducting follow-up of sufficient duration and in obtaining information about reoperation in other facilities.

QUESTIONS/PURPOSES

(1) What is the rate of reoperation after microendoscopic discectomy for primary lumbar disc herniation on a large scale at a median of 4 years postoperatively? (2) Is there any difference in revision rate at a median of 4 years and within 90 days postoperatively based on surgical method?

METHODS

We conducted a retrospective, comparative study of adult patients who underwent microendoscopic discectomy or microdiscectomy or open discectomy for lumbar disc herniation from April 2008 to October 2017 and who were followed until October 2020 using a commercially available administrative claims database from JMDC Inc. This claims-based database provided information on individual patients collected across multiple hospitals, which improved the accuracy of postoperative reoperation rates. We included 3961 patients who received microendoscopic discectomy or microdiscectomy or open discectomy between April 2008 and October 2017 in the JMDC claims database. After applying exclusion criteria, 50% (1968 of 3961) of patients were eligible for this study. Propensity score-weighted analyses were conducted in 646 patients in the microendoscopic discectomy group and in 1322 in the microdiscectomy or open discectomy group, with a median (IQR) of 4 years (3 to 6) of follow-up in both groups. Mean patient age was 42 ± 12 years in the microendoscopic discectomy group and 43 ± 12 years in the microdiscectomy or open discectomy group. Males accounted for 78% (505 of 646) of patients in the microendoscopic discectomy group and 79% (1050 of 1322) of patients in microdiscectomy or open discectomy group. The proportion of patients with diabetes mellitus in the microendoscopic discectomy group (10% [64 of 646]) was less than in the microdiscectomy or open discectomy group (15% [195 of 1322]). The primary outcome was Kaplan-Meier survivorship free from any type of additional lumbar spine surgery at a median of 4 years after the index surgery. The secondary outcome was survival probability using the Kaplan-Meier method with endpoints of any type of reoperation within 90 days after the index surgery. To determine which procedure had the higher revision rate, we conducted propensity score overlap weighting analysis, which controlled for potential confounding variables such as age, sex, comorbidities, and type of hospital as well as Cox proportional hazard models to estimate HRs and 95% confidence intervals (CIs).

RESULTS

The 5-year cumulative reoperation rate was 12% (95% CI 9% to 15%) in the microendoscopic discectomy group and 7% (95% CI 6% to 9%) in the microdiscectomy or open discectomy group. After controlling for potentially confounding variables like age, sex, and diabetes mellitus, the microendoscopic discectomy group had a higher reoperation risk than the microdiscectomy or open discectomy group (weighted HR 1.57 [95% CI 1.14 to 2.16]; p = 0.004). Within 90 days of the index surgery, after controlling for potentially confounding variables like age, sex, and diabetes mellitus, we found no difference between the microendoscopic discectomy group and microdiscectomy or open discectomy group in terms of risk of reoperation (weighted HR 1.38 [95% CI 0.68 to 2.79]; p = 0.38).

CONCLUSION

Given the higher reoperation risk with microendoscopic discectomy compared with microdiscectomy or open discectomy at a median of 4 years of follow-up, surgeons should select microdiscectomy or open discectomy, despite the current popularity of microendoscopic discectomy. The revision risk of microendoscopic discectomy compared with microdiscectomy or open discectomy in the long term remains unclear. Future large, prospective, multicenter cohort studies with long-term follow-up are needed to confirm the association between microendoscopic discectomy and risk of reoperation.

LEVEL OF EVIDENCE

Level Ⅲ, therapeutic study.

A 9-year retrospective cohort of patients with lumbar disc herniation: Comparison of patient characteristics and recurrence frequency by smoking status

To evaluate the association between smoking status and patient characteristics and to identify risk factors associated with recurrence in patients who underwent surgery for lumbar disc herniation (LDH). This retrospective study was carried out at Lokman Hekim University, Ankara, Turkey between January 1, 2021 and January 1, 2022. The medical data of patients who underwent microsurgical discectomy for LDH were retrospectively recorded. Patients with any reemergence of LDH within a 6-month period after surgery were defined as having recurrent LDH. A total of 1109 patients were included in the study and mean age was 50.7 ± 14.3 years. The frequency of hernia at L2-L3 and L3-L4 levels was higher in the nonsmoker group (P < .001). The frequency of cases with Pfirrmann Grade 4 degeneration was higher in the nonsmoker group than in smokers and ex-smokers (P < .001). Protrusion-type hernias were more common in nonsmokers (P = .014), whereas paracentral hernias were more common in smokers (P < .001). The overall frequency of recurrence was 20.4%, and was higher in smokers than in non-smokers and ex-smokers (P < .001). Multivariable logistic regression revealed that current smoking (OR: 2.778, 95% CI [confidence interval]: 1.939-3.980, P < .001), presence of Pfirrmann Grade 4&5 disc degeneration (OR: 4.217, 95% CI: 2.966-5.996, P < .001), and paracentral herniation (OR: 5.040, 95% CI: 2.266-11,207, P < .001) were associated with higher risk of recurrence, whereas presence of sequestrated disc was associated with lower risk of recurrence (OR: 2.262, 95% CI:0.272-0.717, P = .001). Taken together, our data show that smoking, increased degree of degeneration and paracentral hernia increase the risk of LDH recurrence, while sequestrated disc appears to decrease risk. Taking steps to combat smoking in individuals followed for LDH may reduce the risk of recurrence in LDH patients.

Variability in recovery following microdiscectomy and postoperative physiotherapy for lumbar radiculopathy: A latent class trajectory analysis

OBJECTIVES

The clinical course of lumbar radiculopathy following microdiscectomy and post-operative physiotherapy varies substantially. No prior studies assessed this variability by deriving outcome trajectories. The primary aims of this study were to evaluate the variability in long-term recovery after lumbar microdiscectomy followed by post-operative physiotherapy and to identify outcome trajectories. The secondary aim was to assess whether demographic, clinical characteristics and patient-reported outcome measures routinely collected at baseline could predict poor outcome trajectories.

METHODS

We conducted a prospective cohort study with a 24-month follow-up. We included 479 patients with clinical signs and symptoms of lumbar radiculopathy confirmed by Magnetic Resonance Imaging findings, who underwent microdiscectomy and post-operative physiotherapy. Outcomes were leg pain and back pain measured with Visual Analogue Scales, and disability measured with the Roland-Morris Disability Questionnaire. Descriptive statistics were performed to present the average and the individual clinical course. A latent class trajectory analysis was conducted to identify leg pain, back pain, and disability outcome trajectories. The best number of clusters was determined using the Bayesian Information Criterion, Akaike's information criteria, entropy, and overall interpretability. Prediction models for poor outcome trajectories were assessed using multivariable logistic regression analyses.

RESULTS

Several outcome trajectories were identified. Most patients were assigned to the 'large improvement' trajectory (leg pain: 79.3%; back pain: 70.2%; disability: 59.5% of patients). Smaller proportions of patients were assigned to the 'moderate improvement' trajectory (leg pain: 7.9%; back pain: 10.6%; disability: 20.7% of patients), the 'minimal improvement' trajectory (leg pain: 4.9%, back pain: 6.7%, disability: 16.3% of patients) and the 'relapse' trajectory (leg pain: 7.9%; back pain: 12.5%; disability: 3.5%). Approximately one-third of patients (32.6%) belonged to one or more than one poor outcome trajectory. Patients with previous treatment (prior back surgery, injection therapy, and medication use) and those who had higher baseline pain and disability scores were more likely to belong to the poor outcome trajectories in comparison to the large improvement trajectories in back pain, leg pain and disability, and the moderate improvement trajectory in disability. The explained variance (Nagelkerke R2) of the prediction models ranged from 0.06 to 0.13 and the discriminative ability (Area Under the Curve) from 0.66 to 0.73.

CONCLUSION

The clinical course of lumbar radiculopathy varied following microdiscectomy and post-operative physiotherapy, and several outcome trajectories could be identified. Although most patients were allocated to favorable trajectories, one in three patients was assigned to one or more poor outcome trajectories following microdiscectomy and post-operative physiotherapy for lumbar radiculopathy. Routinely gathered data were unable to predict the poor outcome trajectories accurately. Prior to surgery, clinicians should discuss the high variability and the distinctive subgroups that are present in the clinical course with their patients.

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.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) Compared with Open TLIF for Acute Cauda Equina Syndrome: A Retrospective Single-Center Study with Long-Term Follow-Up

OBJECTIVES

In a retrospective study, we sought to compare the clinical efficacy and postoperative magnetic resonance imaging (MRI) scans of minimally invasive (MI) and open (O) transforaminal lumbar interbody fusion (TLIF) in the treatment of cauda equina syndrome (CES) caused by lumbar disc herniation.

METHODS

In total, 116 patients with CES associated with disc herniation underwent decompression and stabilization surgery from January 2005 to January 2020 in a single-center study, and data were collected and retrospectively analyzed. The patients were divided into the O-TLIF and the MI-TLIF group. The perioperative clinical data and MRI assessment were used to assess the efficacy of the respective surgical methods preoperatively and with a minimum follow-up of 30 months.

RESULTS

As expected, the O-TLIF group had statistically significantly longer surgery times and hospital stay, more bleeding, and perioperative surgical complications than the MI-TLIF group. At a minimum follow-up period of 30 months, the MI-TLIF group had significantly better Oswestry Disability Index, visual analog scale, and Short-Form-36, and neurologic CES symptoms than the O-TLIF group. The postoperative MRIs revealed a statistically significant difference in the multifidus muscle area in MI group compared with the O group.

CONCLUSIONS

In patients with acute CES caused by disc herniation, MI-TLIF, with decreased disruption of paravertebral tissues and postoperative pain syndrome, results in earlier mobilization and rehabilitation with better long-term clinical outcomes compared with O-TLIF.

Percutaneous Endoscopic Lumbar Discectomy for the Treatment of Recurrent Lumbar Disc Herniation: A Meta-analysis

Objective. To evaluate the incidence and safety of clinical complications associated with percutaneous endoscopic lumbar discectomy (PELD) for the treatment of recurrent lumbar disc herniation (RLDH) by meta-analysis. Methods. PubMed, Embase, The Cochrane Library, and Web of Science electronic databases were searched for clinical studies on complications related to the treatment of RLDH with PELD. The search time extended from the databases’ inception until May 2021. RevMan5.4 software was used for meta-analysis after two researchers independently scanned the literature, gathered data, and assessed the bias risk of the included studies. Results. A total of 8 clinical studies, including 1 randomized controlled trial and 7 cohort studies including 906 individuals, were included. According to the results of the meta-analysis, the overall complications ( $\text{OR}=0.18$ , 95% CI: 0.04-0.83, $p=0.03$ ) and dural tear rates ( $\text{OR}=0.11$ , 95% CI: 0.01-0.92, $p=0.04$ ) of PELD were lower than those of traditional fenestration nucleus pulposus removal. Moreover, the PELD group had a greater recurrence rate compared to the MIS-TLIF group ( $\text{OR}=19.71$ , 95% CI: 3.68-105.62, $p=0.0005$ ), and the difference was statistically significant. However, compared with MED and MIS-TLIF, there were no significant differences in the incidence of overall complications, dural tear, nerve root injury, and incomplete nucleus pulposus removal ( $P>0.05$ ). Conclusion. PELD is an effective and safe method for the treatment of recurrent lumbar disc herniation, with a lower incidence of complications and higher safety profile than traditional fenestration nucleus pulposus removal.

Is annular repair technique useful for reducing reherniation and reoperation after limited discectomy?

The annular defect because of the primary lumbar disc herniation (LDH) or surgical procedure is considered a primary reason for recurrent herniation and eventually reoperation. Efforts to close the defect with annular repair devices have been attempted several times, but the results were controversial. The present aims to detect whether the annular repair techniques were useful for reducing the re-herniation and re- operation rate. The Pubmed, Cochrane library, and Embase databases were searched to retrieve relevant studies published before January 1, 2021. Continuous variables were compared by calculating the standard difference of the means (SDM), whereas categorical dichotomous variables were assessed using relative risks (RRs). A random-effects model was used if the heterogeneity statistic was significant; otherwise, a fixed-effects model was used. A total of 10 researches were suitable for the meta-analysis, including four different repair techniques and 1907 participates. Compared with the control group, there was no statistical difference with the ODI, VAS-leg, and VAS-back scales for patients treated with the annular repair. However, using an annular repair device was associated with a significant reduction in the re- herniation (p=0.004) and re-operation (0.004) rates. There was no difference between the groups with perioperative complications. However, much more device-related long-term complications happened in the annual repair group (p=0.031) though it still decreased the overall re-operation rate significantly (p=0.006).Our results demonstrated that using an annular repair device was safe and beneficial for reducing re-herniation and re-operation rates.

Early Reoperation Rates and Its Risk Factors after Instrumented Spinal Fusion Surgery for Degenerative Spinal Disease: A Nationwide Cohort Study of 65,355 Patients

Reoperation is a major concern in spinal fusion surgery for degenerative spinal disease. Earlier reported reoperation rates were confined to a specific spinal region without comprehensive analysis, and their prediction models for reoperation were not statistically validated. Our study aimed to present reasonable base rates for reoperation according to all possible risk factors and build a validated prediction model for early reoperation. In our nationwide population-based cohort study, data between 2014 and 2016 were obtained from the Korean National Health Insurance claims database. Patients older than 19 years who underwent instrumented spinal fusion surgery for degenerative spinal diseases were included. The patients were divided into cases (patients who underwent reoperation) and controls (patients who did not undergo reoperation), and risk factors for reoperation were determined by multivariable analysis. The estimates of all statistical models were internally validated using bootstrap samples, and sensitivity analyses were additionally performed to validate the estimates by comparing the two prediction models (models for 1st-year and 3rd-year reoperation). The study included 65,355 patients: 2939 (4.5%) who underwent reoperation within 3 years after the index surgery and 62,146 controls. Reoperation rates were significantly different according to the type of surgical approach and the spinal region. The third-year reoperation rates were 5.3% in the combined lumbar approach, 5.2% in the posterior lumbar approach, 5.0% in the anterior lumbar approach, 3.0% in the posterior thoracic approach, 2.8% in the posterior cervical approach, 2.6% in the anterior cervical approach, and 1.6% in the combined cervical approach. Multivariable analysis identified older age, male sex, hospital type, comorbidities, allogeneic transfusion, longer use of steroids, cages, and types of surgical approaches as risk factors for reoperation. Clinicians can conduct comprehensive risk assessment of early reoperation in patients who will undergo instrumented spinal fusion surgery for degenerative spinal disease using this model.

The involvement of immune system in intervertebral disc herniation and degeneration

Intervertebral disc (IVD) herniation and degeneration contributes significantly to low back pain (LBP), of which the molecular pathogenesis is not fully understood. Disc herniation may cause LBP and radicular pain, but not all LBP patients have disc herniation. Degenerated discs could be the source of pain, but not all degenerated discs are symptomatic. We previously found that disc degeneration and herniation accompanied by inflammation. We further found that anti‐inflammatory molecules blocked immune responses, alleviated IVD degeneration and pain. Based on our recent findings and the work of others, we hypothesize that immune system may play a prominent role in the production of disc herniation or disc degeneration associated pain. While the nucleus pulposus (NP) is an immune‐privileged organ, the damage of the physical barrier between NP and systemic circulation, or the innervation and vascularization of the degenerated NP, on one hand exposes NP as a foreign antigen to immune system, and on the other hand presents compression on the nerve root or dorsal root ganglion (DRG), which both elicit immune responses induced by immune cells and their mediators. The inflammation can remain for a long time at remote distance, with various types of cytokines and immune cells involved in this pain‐inducing process. In this review, we aim to revisit the autoimmunity of the NP, immune cell infiltration after break of physical barrier, the inflammatory activities in the DRG and the generation of pain. We also summarize the involvement of immune system, including immune cells and cytokines, in degenerated or herniated IVDs and affected DRG.

Microdiscectomy for sciatica: reality check study of long-term surgical treatment effects of a Lumbosacral radicular syndrome (LSRS)

PURPOSE

It remains unclear whether the long-term results of RCTs regarding the outcome of microdiscectomy for lumbosacral radicular syndrome (LSRS) are generalizable. The purpose of this study was to determine the external validity of the outcome preseneted in RCTs after microdicectomy for LSRS in a patient cohort from a high-volume spine center.

METHODS

Between 2007 and 2010, 539 patients had a single level microdiscectomy for MRI disk-related LSRS of whom 246 agreed to participate. Questionnaires included visual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36 and Likert scores for recovery, leg and back pain. Lumbar re-operation(s) were registered.

RESULTS

Mean age was 51.3, and median time of follow-up was 8.0 years. Re-operation occurred in 64 (26%) patients. Unfavorable perceived recovery was noted in 85 (35%) patients, and they had worse leg and back pain than the 161 (65%) patients with a favorable recovery: median VAS for leg pain 28/100 mm versus 2/100 mm and median VAS for back pain 9/100 mm versus 3/100 mm, respectively. In addition, the median RDQ and OLBD scores differed significantly: 9 vs 3 for RDQ and 26 vs 4 for OLBD, respectively (p < 0.001).

CONCLUSION

In this cohort study, the long-term results after microdiscectomy for LSRS were less favorable than those obtained in RCTs, possibly caused by less strict patient selection than in RCTs. Our findings emphasize that patients, who do not meet the same inclusion criteria for surgery as in RCTs, should be informed about the chances of a less favorable result.

Laser Reconstruction of Spinal Discs Experiments and Clinic

Degenerative disease of the intervertebral discs (DDD) is currently a serious problem facing the world community. The surgical methods and conservative therapy used today, unfortunately, do not stop the pathological process, but serve as a palliative method that temporarily relieves pain and improves the patient’s quality of life. Therefore, at present, there is an active search for new methods of treating DDD. Among new techniques of treatment, biological methods, and minimally invasive surgery, including the use of laser radiation, which, depending on the laser parameters, can cause ablative or modifying effects on the disc tissue, have acquired considerable interest. Here, we analyze a new approach to solving the DDD problem: laser tissue modification. This review of publications is focused on the studies of the physicochemical foundations and clinical applications of a new method of laser reconstruction of intervertebral discs. Thermomechanical action of laser radiation modifies tissue and leads to its regeneration as well as to a long-term restoration of disc functions, elimination of pain and the return of patients to normal life.

Endoscopic Transforaminal Lumbar Foraminotomy: A Systematic Review and Meta-Analysis

INTRODUCTION

Spinal endoscopic techniques have recently been applied to complex degenerative conditions or failed back surgery syndrome. We performed a systematic review and meta-analysis to assess transforaminal endoscopic lumbar foraminotomy (TELF) outcomes and adverse event rates. We also analyzed the effectiveness of the technique for chronic pain after arthrodesis or previous spinal surgery.

METHODS

Multiple databases were searched for studies published in the English language, involving patients > 18 years old who underwent endoscopic foraminotomy. Outcomes included the rate of patients who showed "excellent" and "good" postoperative improvement, decreased leg pain, and improved Oswestry Disability Index (ODI) scores. Adverse events considered in the analysis included nerve root damage and intraoperative dural tear, the proportion of patients requiring revision surgery or recurrences, and infections.

RESULTS

A total of 14 studies, encompassing 600 patients, were identified. Approximately 85% of patients improved significantly after TELF, without significant differences among different groups (85% vs. 78%, respectively). Mean leg pain decreased an average of 5.2 points, and ODI scores improved by 41.2%. Patients with previous spine surgery or failed back surgery syndrome had higher postoperative leg dysesthesia rates after TELF (14% vs. 1%, respectively).

CONCLUSION

TELF is a useful and safe method to achieve decompression in foraminal stenosis. This technique is indicated in the elderly or patients with comorbidities. Preoperative planning is paramount in determining the foraminal size and endoscope trajectory. A diamond burr is recommended because it has an advantage over the regular endoscopic shaver in bleeding control and complication avoidance.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Surgical Risk Assessment

BACKGROUND

Patient factors (increased body mass index [BMI], smoking, and diabetes) may impact outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for and potentially modified preoperatively to optimize outcome.

OBJECTIVE

The purpose of this evidence-based clinical practice guideline is to determine if preoperative patient factors of diabetes, smoking, and increased BMI impact surgical outcomes.

METHODS

A systematic review of the literature for studies relevant to spine surgery was performed using the National Library of Medicine PubMed database and the Cochrane Library. Clinical studies evaluating the impact of diabetes or increased BMI with reoperation and/or surgical site infection (SSI) were selected for review. In addition, the impact of preoperative smoking on patients undergoing spinal fusion was reviewed.

RESULTS

A total of 699 articles met inclusion criteria and 64 were included in the systematic review. In patients with diabetes, a preoperative hemoglobin A1c (HbA1c) >7.5 mg/dL is associated with an increased risk of reoperation or infection after spine surgery. The review noted conflicting studies regarding the relationship between increased BMI and SSI or reoperation. Preoperative smoking is associated with increased risk of reoperation (Grade B). There is insufficient evidence that cessation of smoking before spine surgery decreases the risk of reoperation.

CONCLUSION

This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative HbA1c test before surgery and should be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. There is conflicting evidence that BMI correlates with greater SSI rate or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/2-preoperative-surgical-risk-assessement.

Disproportionate Vertebral Bodies and Their Impact on Lumbar Disc Herniation

BACKGROUND

The aim of this study was to determine whether the presence of disproportionate vertebral bodies is a risk factor for disc herniation (DH).

METHODS

Sixty-seven consecutive patients (m: 31 f: 36) who underwent lumbar discectomy for symptomatic DH at one level between L3 and S1 were retrospectively included. The last three motion segments (3 × 67 = 201) were assessed on sagittal MRI scans. A disproportionate motion segment was defined as the difference of more than 10% of the antero-posterior diameter of two adjacent endplates.

RESULTS

DH was present in 6/67 (9%), 26/67 (38.8%), and 35/67 (52.2%) patients at L3/4, L4/5, and L5/S1, respectively. A total of 14 of 67 patients demonstrated a disproportionate motion segment at the discectomy level (20.9%). A total of 23 of the 201 (11.4%) investigated motion segments met our criteria for a disproportionate motion segment. In our study population, when one of the 201 segments was disproportionate, the positive predictive value (PPV) for DH increased toward the lower segments: the PPV at the L5/S1 level was 83.0%. The odds ratio of disproportion for DH was the highest at the L5/S1 level, with 6.0 ± 0.82 (p = 0.017).

CONCLUSIONS

The presence of a disproportionate motion segment in the lower spine may lead to a significant higher risk for DH in patients undergoing discectomy.

Evaluation of the effectiveness of surgical methods for the treatment of recurrent lumbar disc herniation: a cohort retrospective study

Objective. To compare the effectiveness of surgical methods for treating patients with recurrent lumbar disc herniation.

Material and Methods. The sample consisted of 160 patients operated on in 2014–2019 for recurrent lumbar disc herniation by percutaneous endoscopic discectomy (Group 1), microsurgical discectomy (Group 2), single-level transforaminal interbody fusion (Group 3) and single-level total intervertebral disc replacement (Group 4). The effectiveness of surgical treatment was evaluated using the NRS-11, ODI, and MacNab questionnaires.

Results. Assessment of the pain syndrome severity and the vital activity level of patients revealed significant (p < 0.05) differences in favor of total intervertebral disc replacement. Excellent and good outcomes after arthroplasty according to MacNab criteria were noted in all patients in this group. Similar outcomes were reported in 77.5 % (31/40) of patients in the TLIF group, in 75.1 % (24/32) of patients in the percutaneous endoscopic discectomy group and in 72.6 % (45/62) of patients in the microdiscectomy group. The operation time and length of hospital stay were shorter in the endoscopic and microsurgical discectomy groups (p < 0.001). However, the lower incidence of complications and reoperations was observed in groups of posterior interbody fusion and arthroplasty (p > 0.05).

Conclusion. Arthroplasty with the M6-L implant expands the possibilities of surgery for recurrent lumbar disc herniation. Total intervertebral disc replacement and posterior interbody fusion for recurrent lumbar disc herniation are more effective in comparison with decompressive operations, which is reflected in the improvement of clinical treatment outcomes, reduction of perioperative complications and frequency of repeated interventions.

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.

A matched comparison of outcomes between percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for the treatment of lumbar disc herniation: a 2-year retrospective cohort study

BACKGROUND CONTEXT

Although open lumbar microdiscectomy (OLMD) is considered to be the gold standard method for discectomy, recent progress in endoscopic spinal surgery has increased the popularity of percutaneous endoscopic lumbar discectomy (PELD) for this indication. However, one of the main drawbacks of PELD is incomplete decompression, especially at the start of the surgeon's learning curve. The functional outcomes of PELD and OLMD in patients matched for age, hernia level, and hernia location have not previously been compared.

PURPOSE

To compare OLMD with PELD in terms of the clinical outcome and the time to recovery.

STUDY DESIGN

Retrospective, matched cohort study.

PATIENT SAMPLE

Data of all patients who underwent elective spinal surgery between January 2015 and June 2017 were extracted from the local database.

OUTCOME MEASURES

Clinical outcomes were assessed using a 0-to-10 visual analogue scale (VAS) for lower back pain (LBP) and leg pain were scored before surgery and at postoperative day 1 and at each follow-up visit (3, 12, and 24 months), the Oswestry Disability Index (ODI: 0%-100%), the length of hospital stay, time to resumption of work, recurrence of Lumbar disc herniation, procedure failures, and complications.

METHODS

The participants were matched for age, disc level, and location of the herniated disk (central and paracentral vs. far-lateral). The participants' mean±standard deviation age was 47.09±12.55 (range: 28-70). We compared the various clinical outcomes between the two groups to identify which procedure had better immediate and long-term functional outcomes. The differences in mortality and occurrence of postoperative complications were also compared in patients with PELD versus controls.

RESULTS

Fifty-eight patients were enrolled (29 with PELD and 29 with OLMD). Both groups reported significant reductions in LBP and leg pain (p<0.01) postoperatively and an improvement in the ODI at 24 months postsurgery. The intergroup difference in the VAS for LBP at 1 day and 3 months was statistically significant (1.48 vs. 3.5, and 1.62 vs. 2.72, respectively; p=0.01 and 0.026, respectively) but the intergroup difference in the ODI was not. The mean length of hospital stay and the time to resumption of work were significantly shorter in the PELD group than in the OLMD group (2.55 vs. 3.21 days, and 4.45 vs. 6.62 weeks, respectively; p=0.037 and 0.01, respectively. There were no significant intergroup differences in terms of complications, recurrence, or procedure failures.

CONCLUSIONS

Both PELD and OLMD can provide equivalent, satisfactory outcomes. However, PELD demonstrated several potential advantages, including more rapid recovery and lower LBP early on. Further large-scale, randomized studies with long-term follow-up are now warranted.

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.

Disk Area Is a More Reliable Measurement Than Anteroposterior Length in the Assessment of Lumbar Disk Herniations: A Validation Study

STUDY DESIGN

Retrospective study.

OBJECTIVE

The goal of this study is to identify and validate the reliability and accuracy of 2 methods used to assess lumbar disk herniations (LDHs): anteroposterior length and cross-sectional area.

BACKGROUND

Many clinicians characterize LDHs through the measurement of the anteroposterior length in the axial plane. Radiologists, on the other hand, have utilized software to measure the disk and canal areas to define the injury. In this study, the authors consider the reliability and accuracy of anteroposterior length in comparison with the area.

METHODS

Using International Classification of Diseases, 10th Revision (ICD-10) code M51.26, patients at a single academic medical center who received a diagnosis of primary lumbar radicular pain with subsequent magnetic resonance imaging documentation of a single-level disk herniation in 2015 and 2016 were identified. AGFA-IMPACS software was utilized to make the following measurements: anterior-posterior canal length; anterior-posterior disk length; mid-canal width; mid-disk width; total canal area; total disk area. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach alpha as a measure of reliability was obtained.

RESULTS

A total of 408 patients met the inclusion and exclusion criteria for this study. Sixteen (3.9%) had L3-L4 herniation, 208 had L4-L5 herniation (51.0%), and 184 had L5-S1 herniation (47.5%). The least reliable interobserver metrics, with respective Cronbach alpha values of 0.381 and 0.659, were the linear measurements of mid-disk width and anterior-posterior canal length. Area measurements of the disk and canal areas generated Cronbach alpha values of 0.707 and 0.863. Intraobserver Cronbach alpha values for all measurements, including all areas and lengths, met or exceeded 0.982.

CONCLUSIONS

The cross-sectional area provides a more reliable measurement modality for diskLDHs in comparison to linear measurements. Unlike anteroposterior length, cross-sectional area incorporates the shape of a herniation or canal in its measurement. Thus, it is superior in its characterization LDH particularly in light of its stronger reproducibility.

LEVEL OF EVIDENCE

Level III-retrospective study.

Effect of Nicotine Dependence and Smoking on Revision Diskectomy After Single-Level Lumbar Diskectomy

Removal of a herniated disk that is causing neural compression is among the most common indications for spinal surgery. Previous population database studies of risk factors for reoperation after this procedure analyzed small to medium numbers of patients. To date, no study has concurrently assessed the effect of modifiable risk factors, such as smoking and nicotine dependence, with a large number of patients. Data were obtained with commercially available software that houses de-identified data for several major US health care systems. A database search was conducted to find all patients who had undergone lumbar diskectomy. Obesity, scoliosis, spondylolisthesis, and depression were excluded as possible confounding variables. The remaining patients were divided into smoking and nonsmoking groups. Those who had undergone revision lumbar diskectomy within 2 years were counted. Pearson's chi-square statistical test was used to determine significance at P<.05. Of the 50 million patient records in the software platform, 53,360 patients were identified who had undergone single-level lumbar diskectomy. Of these, 26,980 fulfilled the inclusion criteria. A total of 890 of those patients had undergone revision lumbar diskectomy within 2 years of their original procedure. Those who smoked were found to have a relative risk of 2.47 compared with nonsmokers (95% confidence interval, 2.17-2.82; P<.0001). Nicotine dependence and smoking had a significant effect on the rate of reoperation. These findings support the importance of preoperative assessment of modifiable risk factors and their effects on surgical complications. [Orthopedics. 2020;43(5):e438-e441.].

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial for Intervertebral Disc Herniation

MINI: We summarized the 10-year outcomes of Spine Patient Outcomes Research Trial for intervertebral disc herniation through a systematic review. The observational cohort 2-year analysis and the as-treated analysis of the randomized control trial at 4 and 8 years showed statistically greater improvements in those patients who were treated surgically.

STUDY DESIGN

We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

OBJECTIVE

We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation.

SUMMARY OF BACKGROUND DATA

The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies.

METHODS

Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes.

RESULTS

The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video.

CONCLUSION

Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of IDH. Results showed significantly greater improvements in patients treated surgically.

LEVEL OF EVIDENCE

3.

Comparison of Reoperation after Fusion and after Decompression for Degenerative Lumbar Spinal Stenosis: A Single-Center Experience of 987 Cases

BACKGROUND AND STUDY AIM

 Reoperation for lumbar spinal stenosis (LSS) is technically challenging. Studies comparing preoperative risk factors and reoperation outcomes between spinal fusion and spinal decompression are limited. Thus this study compared fusion and decompression with respect to reoperation rates, preoperative factors related to re-surgery, and clinical outcomes.

PATIENTS AND METHODS

 This retrospective cohort study included prospectively collected data from patients who underwent revision surgeries for degenerative LSS between May 2001 and March 2015. The reoperation rate, risk factors (proportional hazards analysis of index surgery), surgery type, main reason for revision, and final clinical outcomes (pain, quality-of-life modification, patient satisfaction, and complication rate) were analyzed and compared between the fusion and decompression surgeries.

RESULTS

 Among 987 cases during 13 years, 25 cases of reoperation after fusion and 23 cases of reoperation after decompression were identified, accounting for reoperation rates of 5.88% and 4.00%, respectively. Combined comorbidities (hazard ratio [HR]: 1.98 for fusion; multilevel involvement [with fusion, HR: 2.92; decompression, HR: 1.95]) were strongly correlated with preoperative demographic risk factor for each procedure. The main reason for reoperation in fusion cases was proximal junctional kyphosis (40%) and implant failure (20%), and in decompression cases, recurrent lesions (48.8%) and incomplete surgery (17.4%) An additional fusion after initial fusion and re-decompression without fusion after initial decompression were the most common surgical procedure. Back pain and patient satisfaction after fusion were better compared with those after decompression.

CONCLUSION

 The reoperation rate, preoperative risk factors, reason for revision, reoperation type, clinical outcomes, patient satisfaction, and time interval between index and re-surgery were different between the primary fusion and primary decompression. A better understanding of disease pathophysiology and surgical procedure characteristics will facilitate improvement in disease management and the development of treatment strategies.

Predictors of Treatment Success Following Limited Discectomy With Annular Closure for Lumbar Disc Herniation

Background

Previous studies have demonstrated bone-anchored annular closure to significantly reduce reherniation and reoperation rates after lumbar discectomy in patients with large annular defects. It is important to identify the prognostic factors that may be associated with successful treatment. This study aimed to identify predictors of treatment success in patients with lumbar disc herniation treated with limited microdiscectomy supplemented by a bone-anchored annular closure device (ACD).

Methods

This study was a retrospective analysis of 133 consecutive patients with lumbar disc herniation treated with the ACD. Treatment success was defined as ≥24% improvement in visual analog scale (VAS) for back pain, ≥39% improvement in VAS leg pain, and ≥33% in the Oswestry Disability Index (ODI), with the raw ODI score ≤48. Success was calculated at 3, 6, and 12 months after surgery. Potentially predictive outcomes included patient characteristics, operative data, and imaging outcomes, such as disc, facet, and end plate morphology. Logistic regression was used to determine the significant predictive factors for treatment success.

Results

After 3, 6, and 12 months, 97 of 131 (74%), 104 of 129 (81%), and 112 of 126 (89%) patients, respectively, achieved the success criteria. At 3 months follow-up, a higher proportion of younger (17-40 years) versus older (41-65 years) patients met the success criteria (P = .025). On the basis of logistic regression, the following factors were significantly associated with treatment success at 1 or more of the follow-up time points: sex (male), lower body mass index, higher baseline pain and ODI scores, lower grade preoperative disc degeneration, and the absence of a postoperative complication. The rates of index-level recurrent herniation and reoperation were 1.5% and 3.0%, respectively.

Conclusions

This real-world evidence supports a promising benefit-risk profile for augmenting limited microdiscectomy with a bone-anchored ACD and provides some insights into the patient populations that may have a greater chance of realizing significant improvements in pain and function.

Level of Evidence

2 (Cohort study).

International Society for the Advancement of Spine Surgery Policy 2019-Surgical Treatment of Lumbar Disc Herniation with Radiculopathy

Lumbar disc herniation (LDH) is a frequent cause of low back pain and radiculopathy, disability, and diminution in quality of life. While nonsurgical care remains the mainstay of initial treatment, symptoms that persist for prolonged periods of time are well treated with discectomy surgery. A large body of evidence shows that, in patients with unremitting symptoms despite a reasonable period of nonsurgical treatment, discectomy surgery is safe and efficacious. In patients with symptoms lasting greater than 6 weeks, various forms of discectomy (open, microtubular, and endoscopic) are superior to continued nonsurgical treatment. The small but significant proportion of patients with recurrent disc herniation experience less improvement overall than patients who do not experience reherniation after primary discectomy. Lumbar discectomy patients with large annular defects (≥6 mm wide) are at a higher risk for recurrent herniation and revision surgery. Annular closure via a bone-anchored device has been shown to decrease the rate of recurrent disc herniation and associated reoperation in these high-risk patients. After a detailed review of the literature, current clinical evidence supports discectomy (open, microtubular, or endoscopic discectomy) as a medically necessary procedure for the treatment of LDH with radiculopathy in indicated patients. Furthermore, there is new scientific evidence that supports the use of bone-anchored annular closure in patients with large annular defects, who are at greater risk for recurrent disc herniation.

Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases

BACKGROUND

Spinal percutaneous biportal endoscopic surgery (PBES) is a minimally invasive surgery; however, it is associated with several poor outcomes. This study aimed to analyze unsuccessful PBES outcomes and verify their relationships with patient satisfaction.

METHODS

From May 2015 to June 2018, PBES was performed at several institutions. Unsuccessful outcomes (reoperation and prolonged hospital stay) due to various reasons (hematoma, lesion recurrence, incomplete decompression, dural tear, instability, ascites, and infection) were analyzed. To verify the relationships between surgical experience and unsuccessful outcomes, the first 50 cases and the later cases were compared. Logistic regression was used to assess the relationships between unsuccessful outcomes and patient dissatisfaction.

RESULTS

Among 866 patients, 797 cases with 1-year follow-up and complete data were analyzed. In total, 82 patients with unsuccessful outcomes were identified (10.29%). The incidences of hematoma (p < 0.04), incomplete operation (p < 0.01), and dural tear (p < 0.01) were significantly higher in the first 50 cases than in the later cases. Analyses of the relationship between unsuccessful outcomes and patient dissatisfaction showed that incomplete decompression (odds ratio (OR) 4.06), postoperative instability (OR 3.64), hematoma (OR 3.25), ascite (OR 3.25), dural tear (OR 3.02), and local recurrence (OR 2.45, 95%) contributed significantly.

CONCLUSIONS

Unsuccessful PBES outcomes were mostly associated with hematomas, incomplete decompression, and dural tears; instability, ascites, and infection contributed to a lesser extent. Incomplete decompression, instability, hematoma, ascite, dural tear, and local recurrence were significantly related to patient dissatisfaction. The potential for poor outcomes should be described to the patient and considered prior to surgery.

Endoscopic removal of nucleus pulposus of intervertebral disc on lumbar intervertebral disc protrusion and the influence on inflammatory factors and immune function

Endoscopic removal of nucleus pulposus (NP) of intervertebral disc (IVD) on lumbar intervertebral disc protrusion (LIDP) and its influence on inflammatory factors and immune function were explored. A total of 145 patients with LIDP admitted to The First Affiliated Hospital of Bengbu Medical College from June 2017 to December 2018 were selected and electively treated, in which 87 patients were treated with fenestration discectomy (fenestration group) and 58 patients were treated with endoscopic removal of NP of IVD (minimally invasive group). Effects on patients in the two groups within 6 months after surgery were evaluated by modified MacNab score; differences in surgical related indexes and incidence rates of complications between the two groups were compared; the Oswestry dysfunction score and VAS pain score before treatment, and 1, 3 and 6 months after treatment, and changes of cellular levels of TNF-α, IL-4, IL-6, CD3⁺, CD4⁺, and CD8⁺ before treatment, and 24 and 48 h after surgery were evaluated. Length of surgical incision, intraoperative blood loss, time of operation, time in bed, and hospital stays of patients in minimally invasive group were lower than those in the fenestration group (P<0.05). The Oswestry score and VAS score of patients in minimally invasive group 1, 3 and 6 months after surgery were lower than those in fenestration group (P<0.05). The incidence rate of spinal instability and overall incidence of complications of patients in minimally invasive group were significantly lower than those in fenestration group (P<0.05). Levels of TNF-α and IL-6 of patients in the minimally invasive group 24 and 48 h after surgery were lower than those in the fenestration group (P<0.05) and cellular levels of IL-4, CD3⁺, CD4⁺, and CD8⁺ were higher (P<0.05). In conclusion, endoscopic removal of NP of IVD has good therapeutic effects in patients with LIDP. It reduces inflammation and suppresses immune function with higher safety, worthwhile for clinical use.

A systematic review of event-level measures of risk-taking behaviors and harms during alcohol intoxication

Alcohol intoxication is associated with transient increases in risk-taking behaviors which can lead to harm. Certain assessment and intervention evaluation approaches require measurement of risk behaviors and associated harms at the event-level (i.e., within a single drinking session). This systematic review aimed to identify measures solely assessing risk-taking behaviors and harms while intoxicated and identify evidence of their reliability and validity. EMBASE, Medline, PsycINFO, and PsycTESTs were searched for articles published between 1997 and 2019. Articles were selected based on use of a scale with one or more items measuring risk-taking behaviors and harms (to the individual or others around them) occurring while intoxicated. Additional searches were run to identify studies reporting estimates of reliability and validity for identified measures. Nineteen measures were identified containing at least one relevant item. Most measures indexed both acute and chronic risk behaviors and consequences, mainly with the intent of screening for established patterns of problematic use. No individual measure was identified exclusively quantifying risk-taking behavior and harms which had occurred within a drinking session (with the exception of one scale measuring tendency to engage in risk behaviors), yet three measures had a subscale meeting this criterion. These measures demonstrated good validity and reliability. This gap represents an opportunity for scale development, designed for use in ecological momentary assessment and evaluation of structural interventions targeting risk behaviors and harms whilst intoxicated.

Annular closure device lowers reoperation risk 4 years after lumbar discectomy

Objective

To determine whether implanting an annular closure device (ACD) following a lumbar discectomy procedure in patients with large defects in the annulus fibrosus lowers the risk of reoperation after 4 years.

Methods

In a multicenter randomized trial, patients with large annular defects following single-level lumbar discectomy were intraoperatively randomized to additionally receive an ACD or no treatment (Controls). Clinical and imaging follow-up were performed at routine intervals over 4 years of follow-up. Main outcomes included reoperations at the treated lumbar level, leg pain scores on a visual analog scale, Oswestry Disability Index (ODI), and Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36 questionnaire.

Results

Among 550 patients (ACD 272, Control 278), the risk of reoperation over 4 years was 14.4% with ACD and 21.1% with Controls (P=0.03). The reduction in reoperation risk with ACD was not significantly influenced by patient age (P=0.51), sex (P=0.34), body mass index (P=0.21), smoking status (P=0.85), level of herniation (P=0.26), leg pain severity at baseline (P=0.90), or ODI at baseline (P=0.54). All patient-reported outcomes improved in each group from baseline to 4 years (all P<0.001). The percentage of patients who achieved the minimal clinically important difference without a reoperation was proportionally higher in the ACD group compared to Controls for leg pain (P=0.07), ODI (P=0.10), PCS (P=0.02), and MCS (P=0.06).

Conclusion

The addition of a bone-anchored ACD following lumbar discectomy in patients with large post-surgical annular defects reduces the risk of reoperation and provides better long-term pain and disability relief over 4 years compared to lumbar discectomy only.

Closing the Treatment Gap for Lumbar Disc Herniation Patients with Large Annular Defects: A Systematic Review of Techniques and Outcomes in this High-risk Population

Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.

Endoscopic spinal surgery using a new tubular retractor with 15 mm outer diameter

Purpose: To assess whether the instrument handling and image quality of endoscopic spinal decompression procedures is adequate and effects the treatment of degenerative spinal disorders. Material and Methods: Forty-six patients underwent endoscopic procedures for radicular pain or sensorimotor deficit due to a degenerative disorder using a 15mm tubular retractor. Endoscopic video recordings were reviewed with focus on instrument handling and intraoperative complication. At final follow-up the clinical outcome was assessed via a standardized questionnaire including the Oswestry Disability Index (ODI) Neck Disability Index (NDI), Odoms criteria and a personal examination focusing on pain, and sensorimotor deficits. Results: Forty out of 46 patients attended a final follow-up (86.9%). The mean follow-up time was 51.8 month (range 15-84 month). At final follow-up, of patients who were operate at the lumbar spine 93.9% and at the cervical spine 85.7% were free of radicular pain, no weakness was documented in 84.9% of cases after lumbar and 85.7% after cervical spine procedure, and according to Odoms criteria clinical success was noted in 84.5% and 100%, respectively. The mean ODI was 9.0% and mean NDI was 11.7%. The dural tear rate was 4.3%, all dural tear were closed endoscopically. The recurrent disc herniation rate was 6.1%. Conclusions: Endoscopic decompression using a 15m tubular retractor offers a good view onto the surgical field and a high clinical success rate. The decompression of degenerative pathologies in bimanual technique is not limited by a 15mm tubular retractor.

Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure

Purpose

Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy.

Patients and methods

This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period.

Results

Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (P=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD.

Conclusion

Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.

Impact of Comorbidities on Outcome Following Revision of Recurrent Single-Level Lumbar Disc Prolapse between Revision Microdiscectomy and Posterior Lumbar Interbody Fusion: A Single-Institutional Analysis

Objectives

Reports exist in the literature on the relationship between comorbid conditions and recurrence of lumbar disc herniation. Meanwhile, documented evidence abound on microdiscectomy and posterior lumbar interbody fusion (PLIF) as techniques of managing recurrent disc prolapse. Some surgeons would choose to perform PLIF instead of microdiscectomy for a first time re-herniation, because of the possibility of higher chances of further recurrence as well as increased likelihood of spinal instability following treatment with microdiscectomy. In this study, the authors sought to determine whether PLIF is better than microdiscectomy for first-time recurrent single-level lumbar disc prolapse and to compare the impact of comorbidities on outcome following revision.

Patients and Methods

This was retrospective review of surgical treatment of patients with recurrent single-level disc prolapse with either microdiscectomy or PLIF at a tertiary health institution in India.

Results

A total of 26 patients were evaluated. There was no statistically significant correlation between the presence of comorbidity and outcome in terms of improvement of pain (P > 0.05 at 95% degree of confidence; Spearman's ρ =0.239). Patients who had PLIF were neither more nor less likely to have a better outcome compared to those who had microdiscectomy, though this finding was not statistically significant (odds ratio = 0.263; P = 0.284).

Conclusion

There was no significant relationship between the presence of comorbidity and outcome following revision. Microdiscectomy did not prove to be a better option than PLIF for surgical management of recurrent single-level disc prolapse. A quality randomized controlled study would help to validate these findings.

Primary Versus Revision Discectomy for Adults With Herniated Nucleus Pulposus: A Propensity Score-Matched Multicenter Study

STUDY DESIGN

Retrospective propensity score matched analysis.

OBJECTIVE

To compare the incidence of any 30-day perioperative complication following primary and revision discectomy for lumbar disc herniation.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to identify patients undergoing primary or revision lumbar discectomy from 2005 to 2012. Propensity score matching was performed to create matched pairs of primary and revision discectomy cases for analysis. Univariate analysis was then performed to compare 30-day morbidity and mortality between propensity score-matched pairs.

RESULTS

We identified 4730 cases of primary discectomy performed through a minimally invasive or open approach and 649 revision discectomy cases. Baseline patient characteristics and comorbidities were compared and then propensity score-matched adjustments were made to create 649 matched pairs of primary and revision cases. On univariate analysis, there were no significant differences in 30-day perioperative outcomes between the 2 groups.

CONCLUSION

While there were no significant differences in 30-day perioperative complications between patients undergoing primary lumbar discectomy and those undergoing revision lumbar discectomy, this finding should be interpreted with caution since the ACS-NSQIP database lacks functional and pain outcomes, and also does not include dural tear or durotomy as a complication. Future large-scale and long-term prospective studies including these variables are needed to better understand the outcomes and complications following primary versus revision discectomy for lumbar disc herniation.

Updated imaging does not affect revision rates in adults undergoing spine surgery for lumbar degenerative disease

OBJECTIVEDiagnostic workup for lumbar degenerative disc disease (DDD) includes imaging such as radiography, MRI, and/or CT myelography. If a patient has unsuccessful nonoperative treatment, the surgeon must then decide if obtaining updated images prior to surgery is warranted. The purpose of this study was to investigate whether the timing of preoperative neuroimaging altered clinical outcome, as reflected by the subsequent rate of revision surgery, in patients with degenerative lumbar spinal pathology.METHODSFrom the Health Care Service Corporation administrative claims database, adult patients (minimum age 55 years old) with lumbar DDD who underwent surgery including posterior lumbar decompression with and without fusion (1-2 levels) and at least 5 years of continuous coverage after the index surgery were identified. The chi-square test was used to determine differences in revision rates stratified by timing of each imaging procedure relative to the index procedure (< 6 months, 6-12 months, 12-24 months, or > 24 months).RESULTSOf 28,676 cases identified, 5128 (18%) had revision surgery within 5 years. The timing of preoperative MRI or plain radiography was not associated with revision surgery. Among the entire cohort, there was a lower incidence of revision surgery in patients who had a CT myelogram within 1 year prior to the index surgery (p = 0.017). This observation was strongest in patients undergoing decompression only (p = 0.002), but not significant in patients undergoing fusion (p = 0.845).CONCLUSIONSRoutine reimaging prior to surgery, simply because the existing MRI is 6-12 months old, may not be beneficial, at least as reflected in subsequent revision rates. The study also suggests that there may be a subset of patients for whom preoperative CT myelography reduces revision rates. This topic has important financial implications and deserves further study in a more granular data set.