Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy

OBJECTIVE

This study aimed to evaluate the influence of herniation of cartilaginous endplates on postoperative pain and functional recovery in patients undergoing percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH).

METHODS

A retrospective analysis was conducted on 126 patients with LDH treated with PELD at the Third Hospital of Hebei Medical University from January 2021 to January 2022. Whether cartilaginous endplates had herniated was identified by analyzing these specific findings from MRI scans: posterior marginal nodes, posterior osteophytes, mid endplate irregularities, heterogeneous low signal intensity of extruded material, and Modic changes in posterior corners and mid endplates. Patients were assessed for postoperative pain using the Visual Analogue Scale (VAS) and functional recovery using the Oswestry Disability Index (ODI) and Modified MacNab criteria. Statistical analyses compared outcomes based on the presence of herniation of cartilaginous endplates.

RESULTS

Patients with herniation of cartilaginous endplates experienced higher pain scores early postoperatively but showed significant improvement in pain and functional status over the long term. The back pain VAS scores showed significant differences between the groups with and without herniation of cartilaginous endplates on postoperative day 1 and 1 month (P < 0.05). Leg pain VAS scores showed significant differences on postoperative day 1 (P < 0.05). Modic changes were significantly associated with variations in postoperative recovery, highlighting their importance in predicting patient outcomes. In patients with herniation of cartilaginous endplates, there were statistically significant differences in the back pain VAS scores at 1 month postoperatively and the ODI functional scores on postoperative day 1 between the groups with and without Modic changes (P < 0.05). There were no significant differences in the surgical outcomes between patients with and without these conditions regarding the Modified MacNab criteria (P > 0.05).

CONCLUSION

Herniation of cartilaginous endplates significantly affect early postoperative pain and functional recovery in LDH patients undergoing PELD. These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction.

Prevalence, distribution characteristic and risk factors of lumbar vertebral axial rotation in patients with lumbar disc herniation: a retrospective study

This retrospective study aimed to investigate the impact of lumbar disc herniation (LDH) on vertebral axial rotation (VAR) in the lumbar spine, focusing on both close and distant neighboring vertebrae. A total of 516 patients with LDH and an equal number of healthy individuals were included in the study, matched for age and gender. The degree of axial rotation for each lumbar spine vertebra was assessed using the Nash-Moe index. The results revealed that the prevalence of VAR in the lumbar spine was significantly higher in the LDH group compared to the Control group (65.7% vs 46.7%, P < 0.001). Among the LDH group, the L2 vertebra had the highest frequency of VAR (49.5%), followed by L1 (45.1%), and then L3 to L5 (33.6%, 8.9%, 3.1%, respectively). A similar pattern was observed in the Control group (L2, 39.8%; L1, 34.6%; L3, 23.2%; L4, 3.1%; L5, 0.8%). Furthermore, the study found that disc herniation was associated with a higher incidence of VAR not only in close neighboring vertebrae but also in distant neighboring vertebrae. This indicates that the biomechanical influence of LDH extends beyond just the immediate adjacent vertebrae. To identify potential risk factors for VAR in LDH patients, multivariate analysis was performed. The results revealed that age was an independent risk factor for VAR (OR 1.022, 95% CI [1.011, 1.034], P < 0.001). However, the duration of symptoms and presence of back pain were not found to be significant risk factors for VAR.

Evaluation of the effect of cervical and lumbar disc herniations on female sexual function: a comparative prospective study

PURPOSE

We aimed to evaluate the effect of cervical disc herniation (CDH) and lumbar disc herniation (LDH) on female sexual functioning before and after surgical intervention.

METHODS

The current study was conducted from February 2022 to February 2023. A total of 100 sexually active female patients in their reproductive phase who were diagnosed with CDH and LDH based on physical examination and previous magnetic resonance imaging (MRI) results, as well as 50 healthy females, were enrolled. The female subjects were evaluated using the validated Arabic version of the female sexual function index (ArFSFI), a 0 to 10 visual analogue scale (VAS), the Oswestry disability index (ODI) and Beck's depression index (BDI).

RESULTS

The baseline ArFSFI domains and total scores were greatest in the controls, followed by the CDH group. The ArFSFI domains and total scores were greatest in the control group, followed by the postoperative ArFSFI domains and total scores in the cervical group. The variations in satisfaction, pain, and overall ArFSFI ratings were significant across research groups. The difference in desire, arousal, lubrication, and orgasm was substantial in the lumbosacral group, but there were no significant changes between the cervical and control groups. Postoperatively, ArFSFI domains and overall scores improved in both of the cervical and lumbar groups. Both research groups' ODI score and grade improved after surgery. Finally, both groups' BDI score and grade improved after surgery.

CONCLUSION

Female sexual dysfunctions caused by CDH and LDH improved considerably after surgery.

Correlation between Disc Imaging Observations and Clinical Efficacy after Percutaneous Endoscopic Lumbar Discectomy: A 1-Year Follow-up Study

OBJECTIVE

The connection between alterations in the disc structure following percutaneous endoscopic lumbar discectomy (PELD) and symptoms in patients postsurgery has not been reported yet. The purpose of the present study was to discuss the potential correlation between the changes in the morphological characteristics of various reference surfaces of the intervertebral disc after percutaneous endoscopic lumbar discectomy (PELD) and clinical outcomes, to identify the morphological parameters that affect efficacy and provide an evidence-based foundation for assessing postoperative efficacy.

METHODS

From October 2019 to October 2021, after percutaneous endoscopic lumbar discectomy (PELD), 98 individuals were enrolled. MRI DICOM data of the lumbar spine were obtained before and after surgery, specifically around 3 months. The morphological parameters of the operated and adjacent segments of the discs were measured using T2-weighted images from three reference planes. Outcomes were assessed using the Oswestry disability index (ODI), visual analogue pain scores for the back and leg (VAS-back/VAS-leg), Japanese Orthopaedic Association (JOA) scores, and recovery rates. Postoperative changes in disc parameters and outcomes were compared between patients with different severity and types of LDH based on the MSU staging. Patients completed the questionnaire during outpatient follow-up appointments 3, 6, and 12 months after the surgery. The follow-up period was 14.69 ± 4.21 months, ranging from 12 to 24 months.

RESULTS

Parameters such as area and circumference of intervertebral discs in the cross-section were not associated with the change in the efficacy index. Postoperatively, a negative correlation between the variation of the disc height, disc height index, and protrusion distance and the difference in VAS scores for low back pain at 3 and 6 months was observed among the two sagittal change parameters. Differences between changes in disc imaging parameters and postoperative efficacy were not statistically significant between various types of lumbar disc herniation.

CONCLUSION

For the patients after percutaneous endoscopic lumbar discectomy, the changes in parameters such as disc area and circumference in the cross-sectional plane are not associated with efficacy, and the changes in disc height and herniation distance in the sagittal plane provide a morphologic basis for the assessment of short-term postoperative efficacy. In addition, the changes in disc morphologic parameters and postoperative efficacy do not differ between various types of lumbar disc herniation.

Analysis of the therapeutic effect and postoperative complications associated with 3-dimensional computed tomography navigation-assisted intervertebral foraminoscopic surgery in lumbar disc herniation in the elderly: a retrospective cohort study

Background

With the increasing aging of the population, the incidence of lumbar disc herniation (LDH) is gradually increasing. The 3-dimensional (3D) computed tomography (CT) navigation-assisted intervertebral foraminoscopic surgery for LDH is minimally invasive, and due to its localization and guidance features, it can precisely reach the target location. This study sought to investigate the treatment effect and the incidence of postoperative complications of 3D CT navigation-assisted intervertebral foraminoscopic surgery in elderly patients with LDH to provide a reference basis for improving patient prognosis.

Methods

We retrospectively included 213 elderly patients with LDH admitted to our hospital from October 2017 to October 2021 in this study and followed them up for 1 year. Among them, 103 patients (Group A) underwent conventional C-arm fluoroscopy-assisted system alone intervertebral foraminoscopic surgery, and 110 patients (Group B) underwent 3D CT navigation-assisted intervertebral foraminoscopic surgery. The general characteristics of the participants were compiled using a general information questionnaire designed by the investigator. The t-test and chi-square test were used to analyze the relationship between the treatment outcomes and surgical modalities. Binary logistics regression was used to analyze the independent risk factors affecting patient outcomes.

Results

The patients who underwent 3D CT navigation-assisted intervertebral foraminoscopic surgery had significantly better outcomes than those who underwent conventional C-arm fluoroscopy-assisted system alone intervertebral foraminoscopic surgery. The binary logistic regression analysis results showed that in addition to the surgical method [odds ratio (OR) =0.258, P=0.042], the history of lumbar trauma (OR =11.001, P=0.005), usual work intensity (OR =4.589, P=0.002), disease duration (OR =3.587, P=0.017), the presence of diabetes (OR =3.315, P=0.026), the presence of a ruptured annulus fibrosus (OR =3.485, P=0.012), the degree of disc degeneration (OR =3.899, P=0.009), and the number of punctures (OR =0.412, P=0.034) were independent risk factors affecting patient outcomes.

Conclusions

3D CT navigation-assisted intervertebral foraminoscopic surgery for LDH effectively reduced the number of punctures, decreased intraoperative bleeding and postoperative drainage volumes, shortened the length of hospitalization, bed rest time and operative time, reduced stress reactions, decreased the degree of low-back pain, and the risk of complications, had better overall efficacy, and significantly improved patient prognosis.

Minimally invasive versus open transforaminal lumbar interbody fusion for single segmental lumbar disc herniation: A meta-analysis

BACKGROUND

Numerous studies on the comparison of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open-transforaminal lumbar interbody fusion (O-TLIF) for the treatment of lumbar disc herniation (LDH) have been published, but there is no clear conclusion.

OBJECTIVE

The aim of this study was to evaluate the efficacy of MIS-TLIF compared with O-TLIF in the treatment of LDH in the Chinese population by meta-analysis.

METHODS

Studies on the treatment of LDH by MIS-TLIF versus O-TLIF were searched in Pubmed, Web of Science, Medline, Embase, CNKI, VIP and China Wanfang databases from the establishment of the databases to January 2020. The meta-analysis was used to analyze the pooled operation time, intraoperative blood loss, postoperative drainage, postoperative ground movement time, Waist and leg Visual Analogue Scale (VAS) score, Oswestry Disability Index (ODI) score and Japanese orthopaedic association (JOA) score. Mean difference (MD) and standard mean difference (SMD) were used as the effect size.

RESULTS

Eleven studies with 1132 patients were included. The results showed that MIS-TLIF compared with O-TLIF, MD =-133.82 (95% CI: -167.10 ∼-100.53, P< 0.05) in intraoperative blood loss, MD =-114.43 (95% CI: -141.12 ∼-87.84, P< 0.05) in postoperative drainage, MD =-3.30 (95% CI: -4.31 ∼-2.28, P< 0.05) in postoperative ground movement time, SMD =-1.44 (95% CI: -2.63 ∼-0.34, P< 0.05) in postoperative low back pain VAS score, SMD = 0.41 (95% CI: 0.15 ∼ 0.66, P< 0.05) in postoperative JOA score, MD = 4.12 (95% CI: -11.64 ∼ 19.87, P> 0.05) in the average operation time, SMD =-0.00 (95% CI: -0.36 ∼ 0.36, P> 0.05) in leg pain VAS score, and SMD =-0.59 (95% CI: -1.22 ∼ 0.03, P> 0.05) in ODI score.

CONCLUSION

MIS-TLIF was superior to O-TLIF in the treatment of LDH, especially in the intraoperative blood loss, postoperative drainage, postoperative ground movement time and low back pain in the Chinese population.

Two-dimensional fluoroscopy-guided robot-assisted percutaneous endoscopic transforaminal discectomy: a retrospective cohort study

Percutaneous Endoscopic Transforaminal Discectomy (PETD) has been widely used for minimally invasive treatment of lumbar disc herniation (LDH), and percutaneous disc target puncture has a steep learning curve and high radiation exposure. Proper technology grafting can improve the surgical procedure and clinical outcomes. The changes brought by grafting surgical robots into PETD are worth investigating. A retrospective analysis was performed on the information of patients who received PETD in our hospital from March 2019 to July 2020. A total of 102 of patients who received 2D-guided robot-assisted PETD were included in Group A, and 102 of patients who received C-arm fluoroscopy-guided bare-handed PETD were included in Group B. The number of punctures, number of fluoroscopies, operation duration, intraoperative anxiety score, complications, and visual analogue scale (VAS) score and Oswestry disability index (ODI) before operation, on Day 1 after operation and at the last follow-up visit of the two groups were compared. All 204 patients received successful operations. Group A received 1.20±0.42 punctures, 10.49±2.16 fluoroscopies and 60.69±5.63 minutes of operation, significantly fewer than the 4.84±1.94 punctures, 17.41±3.23 fluoroscopies and 71.19±5.11 minutes of operation of Group B (all P<0.05), and Group A had significantly lower intraoperative anxiety scores and incidence of complications than Group B (both P<0.05). Both groups had comparable VAS and ODI scores on Day 1 after operation and at the last follow-up visit, which were both significantly higher than those before operation (P<0.05). 2D-guided robot-assisted PETD can enable precise planning of the puncture path, make it easier for operators to complete targeted punctures at pathogenic targets, reduce the number of punctures and fluoroscopies, shorten the operation duration to optimize the operation process, and reduce complications and alleviate intraoperative anxiety for better clinical results. Therefore it mayb be a better choice to assist PETD.

Enhanced recovery after surgery pathway reduces the length of hospital stay without additional complications in lumbar disc herniation treated by percutaneous endoscopic transforaminal discectomy

Background

Enhanced recovery after surgery (ERAS) pathway in spine surgery is increasingly popular which can reduce the length of hospital stay (LOS). However, there are few studies on the safety and effectiveness of ERAS pathway in the treatment of single-level lumbar disc herniation (LDH) by percutaneous endoscopic transforaminal discectomy (PETD). The aim of this study was to investigate whether ERAS can reduce LOS of patients with single segment LDH treated by PETD.

Methods

We reviewed the outcomes of all LDH patients (L4/5) who had been treated with PETD at our institution. Quasi-experimental study was adopted between patients treated in an ERAS after PETD with those rehabilitated on a traditional pathway. The two groups were analyzed for LOS, operation time, complications, visual analog scale (VAS), Oswestry Dysfunction Index (ODI), hospitalization expenses (HE), and improved MacNab efficacy assessment criteria (MacNab).

Results

A total of 120 single segment LDH patients (ERAS pathway 60 cases, traditional care pathway 60 cases) who were selected from January 2019 to January 2021 met the inclusion criteria. There was a significant difference in mean LOS postoperative VAS scores and ODI on the 3rd day after surgery between the two groups (P < 0.05). The incidence of complications and HE were similar in the two groups (P > 0.05). The mean LOS decreased from 3.47 ± 1.14 days to 5.65 ± 1.39 days after application of ERAS pathway (P < 0.05).

Conclusions

The ERAS pathway reduced LOS without resulting in additional complications after PETD. These findings support the application of the perioperative ERAS pathway in the treatment of single-level LDH with PETD.

Level of evidence

Level IV, therapeutic

IL-1β promotes disc degeneration and inflammation through direct injection of intervertebral disc in a rat lumbar disc herniation model

BACKGROUND CONTEXT

Lumbar intervertebral disc herniation (LDH) is a common disease that causes low back pain, radiating leg pain, and sensory impairment. Preclinical studies rely heavily upon standardized animal models of human diseases to predict clinical treatment efficacy and to identify and investigate potential adverse events in human subjects. The current method for making the LDH model involves harvesting the nucleus pulposus (NP) from autologous coccygeal discs and applying to the lumbar nerve roots just proximal to the corresponding dorsal root ganglion. However, this surgical method generates a model that exhibits very different characteristics of disc herniation than that observed in human.

PURPOSE

To produce a rat LDH model that better resembles disc herniation in humans and a standardized and uniform LDH model using Interleukin-1 beta (IL-1β).

STUDY DESIGN

Experimental rat LDH model.

METHODS

We exposed the L5-6 disc dorsolaterally on the right side through hemi-laminectomy without nerve compression. Herniation was initiated by puncturing the exposed disc with a 30-gauge needle at a depth of 4 mm. Interleukin-1 beta (IL-1β) was injected simultaneously to heighten the pathological processes of disc degeneration, including inflammatory responses, matrix destruction, and herniation of the NP. We performed histological staining to assess morphological changes, immunohistochemistry to analyze inflammation- and pain-related expression within and around the puncture site of the L5-6 disc, and real-time polymerase chain reaction to examine expression of markers for degenerative processes. In addition, we performed locomotor tests on the rats.

RESULTS

We found that the IL-1β groups showed that the border between the annulus fibrosis and nucleus pulposus was severely interrupted compared to that of the control (puncture only) group. And, the injection of IL-1β leads to accelerated disc degeneration and inflammation in a more consistent manner in LDH model. Functional deficit was consistently induced by puncturing and injection of IL-1β in the exposed disc.

CONCLUSIONS

The method proposed here can be used as an index to control the severity of disc degeneration and inflammation through the injected IL-1β concentration concurrent with surgically induced herniation.

CLINICAL SIGNIFICANCE

Our proposed model may facilitate research in drug development to evaluate the efficacy of potential therapeutic agents for disc herniation and neuropathic pain and may also be used for nonclinical studies to more accurately assess the effectiveness of various treatment strategies according to the severity of disc degeneration.

MRI based analysis of grade of spinal canal stenosis and grade of compression of nerve root by lumbar disc herniation as tools to predict probability to need surgical treatment

Background

Patients with a lumbar disc herniation (LDH) without high-grade neurological deficit (PWN) are usually treated non-operatively. If non-operative treatment is not successful, a postponed surgical treatment is performed. Postponed surgery is reported to show later improvement of pain and health-related quality of life and later return to work than early surgery. There are presently no objective parameters to predict if non-operative treatment may be successful in PWN, or if an early surgical treatment could be performed.

Methods

To analyze if high-grade spinal canal stenosis lead to a higher rate of surgical treatment in PWN, we conducted a retrospective single-center cohort study and included PWN with acute onset of severe radicular pain (VAS ≥8). We excluded patients with workers' compensation involvement, chronic pain syndrome, motor deficit <3/5, malignancy and history of prior spinal surgery. All patients were initially treated by the same standardized non-operative treatment. It was monitored if patients eventually choose an operative treatment or not. After a power analysis (aiming at >0.8), 1,053 consecutive patients (02.2008 to 12.2017) were identified by diagnostic code. One hundred and eight patients were enrolled in our investigation. Thirty-nine patients were treated non-operatively (Group 1), 69 were treated by operation (Group 2).

Results

Percent (%) spinal canal compromise based on cross-sectional area of LDH was 26.3% in Group 1, 33.7% in Group 2. The difference was significant (P<0.025).

Conclusions

The investigated group of PWN had a significantly higher probability to need surgical treatment if they had a high-grade stenosis of the spinal canal. However, these results do not constitute a general indication for surgical treatment of PWN. The results of this study merely provide information for patients, and spine specialists, to be implemented in an individual decision-process that leads to a recommendation for type of treatment.

Correlation of EYS polymorphisms with lumbar disc herniation risk among Han Chinese population

BACKGROUND

Lumbar disc herniation (LDH) is a common spinal disease in clinical practice. Once lumbar disc herniation occurs, it seriously reduces patient's quality of life. The EYS (eyes shut homolog) was discovered in recent years and it may be related to lumbar disc herniation. So we conducted a case-control study to explore the relationship between EYS polymorphism and lumbar disc herniation risk.

METHODS

We selected 5 single-nucleotide polymorphisms (SNPs) of EYS gene in a case-control study with 508 cases and 508 healthy controls to evaluate the relatedness by using genetic model, haplotype, and stratification analysis.

RESULTS

We found that the minor alleles of rs62413038 (OR = 1.21, 95%CI: 1.01-1.43, p = .036) and rs9450607 (OR = 1.26, 95% CI: 1.05-1.53, p = .016) were associated with an increased risk of lumbar disc herniation in the allelic model analysis. In the genotypic model analysis, rs62413038 displayed a significantly increased risk of lumbar disc herniation in log-additive models (OR = 1.20, 95% CI: 1.01-1.43, p = .039). While the rs9450607 was also obviously associated with an increased lumbar disc herniation risk in recessive (OR = 1.98, 95% CI: 1.24-3.13, p = .004) and log-additive models (OR = 1.27, 95% CI: 1.05-1.55, p = .014). In addition, in the haplotype analyses of the SNPs, we found that the "CGGA" haplotype of rs1482456, rs9342097, rs9450607, and rs7757884 was associated with lumbar disc herniation. (OR = 0.52, 95% CI: 0.30-0.89, p = .017).

CONCLUSION

These results suggest that EYS polymorphism may be associated with lumbar disc herniation among Han Chinese population. It also opens up a new exploration direction for the etiology of lumbar disc herniation.

Analysis of the depression and anxiety status and related risk factors in patients with lumbar disc herniation

Objectives:

To evaluate the depression and anxiety status and related risk factors in patients with lumbar disc herniation, and help spine surgeons better identify those patients who need psychological care.

Methods:

A cross-sectional study was performed on patients with lumbar disc herniation treated in our hospital between October 2015 and August 2018. Visual analog scale and Oswestry disability index were used to assess pain intensity and lumbar function, and Zung self-rating depression and anxiety scale were employed to evaluate the depression and anxiety status of the patients, and the demographic and clinical data including age, gender, marital status, occupation type, employment status, education level, surgery history, herniation type, disease duration, and insurance status were collected for analysis.

Results:

In the current study, 165 patients were enrolled based on the inclusion and exclusion criteria. In multivariate logistic regression analysis, gender (p=0.03), pain intensity (p=0.01), self-rating anxiety scale (SAS) (p=0.00), and disease duration (p=0.001) were identified as independent risk factors for depression status, and pain intensity (p=0.02), disease duration (p=0.002) and SDS (Zung self-rating depression scale) (p=0.003) were independent risk factors for anxiety status in patients with lumbar disc herniation. There was a significant correlation between Zung self-rating depression and anxiety scale in patients with lumbar disc herniation (p<0.05).

Conclusion:

Psychological intervention is critical for patients with lumbar disc herniation, especially for those female patients with severe pain and longer disease duration.

Characterization of neuroinflammation and periphery-to-CNS inflammatory cross-talk in patients with disc herniation and degenerative disc disease

The aim of the study was to identify inflammatory cytokines/chemokines associated with neuroinflammation and periphery-to-CNS inflammatory cross-talk in degenerative disc disease (DDD) and lumbar disc herniation (LDH), common causes of low back pain (LBP). A secondary aim was to investigate the associations between cytokines and symptom severity.

METHODS

In total, 40 DDD and 40 LDH patients were recruited from a surgical waiting list, as well as 39 healthy controls (HC) and 40 cerebrospinal fluid (CSF) controls. The subjects completed questionnaires and pressure algometry was performed at the lumbar spine and forearm. The CSF, serum and disc tissues were collected during surgery. Inflammatory mediators TNF, INFg, IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13 and MCP1 were analysed by immunoassay (Meso Scale Discovery) and quantitative real-time polymerase chain reaction (qPCR) was used for analysis of IL-6, IL-8, MCP1 and TSPO expression in intervertebral discs (IVDs).

RESULTS

In the LDH group, we found elevated IL-8 concentrations in CSF indicating neuroinflammation, while IL-8 and MCP1 concentrations in serum were lower compared to HC. The IVD expression of IL-6, IL-8 and TSPO was lower in LDH patients compared to DDD. LDH patients had a positive correlation between IL-8 concentrations in CSF and serum and IL-8 in CSF was associated with higher pain intensity and increased spinal pressure pain sensitivity. The MCP1 concentration in serum was associated with higher global pain ratings and increased spinal pressure pain sensitivity, while IL-6 serum concentration correlated with the intensity of the neuropathic pain component (leg pain) in LDH patients. IVD expression of TSPO in LDH patients was associated with increased intensity of back pain. No differences were found in cytokine CSF concentrations between DDD patients and CSF controls, but DDD patients had lower IL-8 and MCP1 serum concentrations than HC. In female DDD patients, IL-8 and MCP1 concentrations in serum were associated with increased intensity of back pain.

CONCLUSION

Our results suggest that neuroinflammation mediated by elevated IL-8 concentrations in CSF and IL-8 mediated periphery-to-CNS inflammatory cross-talk contributes to pain in LDH patients and suggest a link between TSPO expression in discs and low back pain.

An observation of massive lumbar disc prolapse

Background

The aim of this study was to investigate whether massive lumbar disc herniations (LDH) can be managed safely with non-operative treatment. Whilst most LDH are treated successfully with analgesia and physiotherapy, there is little literature regarding the treatment of massive LDH. Their impressive size raises the suspicion that they may cause cauda equina syndrome and are therefore often treated surgically.

Methods

Patients were referred to our tertiary unit by either their general practitioner or the musculoskeletal service. To be included in the study, patients had to have a diagnosis of massive LDH on their initial magnetic resonance imaging (MRI) and opt for non-operative treatment. Seventeen patients with a diagnosis of massive LDH with an average follow-up of 209 days (0 to 1,005 days) were reviewed.

Results

One patient was listed for surgery due to persisting radicular pain only. However, they were deemed unfit for surgery and this was therefore cancelled. One patient developed impending cauda equina syndrome and underwent urgent discectomy with no complications. All remaining patients were managed safely non-operatively with no complications.

Conclusions

We conclude that the massive LDH can be safely managed non-operatively, providing patients are examined for cauda equina syndrome and are fully educated on the need to represent urgently should red-flag symptoms develop.

Determination of minimally clinically important differences for JOABPEQ measure after discectomy in patients with lumbar disc herniation

Background

It is crucial to define if changes in patient-reported outcome (PRO) measure correspond to relevant clinical improvements. Aim of this study was to determine minimally clinically important differences (MCID) of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with lumbar disc herniation (LDH) to assess surgical success.

Methods

A total of 127 patients with LDH consecutively referred to our clinic were enrolled into this prospective study between March 2012 and August 2015. All participants completed the JOABPEQ and the Oswestry Disability Index (ODI) score before surgery, and at 1 year after surgery. Surgical success was defined based on clinical consensus of the team and be used as anchor. The MCID value of the JOABPEQ subscales were estimated using two anchor-based methods: (I) average change procedure (responsiveness); and (II) receiver operating characteristic (ROC) curve analysis.

Results

The mean age of patients was 51.2±9.4 years, and there were 68 (53.5%) male. A total of 83.5% (106 cases) showed improvement based on the clinical consensus of the spine surgeon team at last follow-up. To assess surgical success, the two MCID calculation methods generated two optimal prediction thresholds on the JOABPEQ subscales (low back pain: 19.1, 22.4; lumbar function: 21.3, 24.2; walking ability: 24.5, 27.9; social life function: 14.3, 17.1; and mental health: 12.8, 14.8) for ROC analysis and average change procedure, respectively (P<0.002 for all of subscales in two methods). For all five subscales, the sensitivity and specificity were between 61.2 and 81.1 with AUC greater than 0.70.

Conclusions

These findings support the value of the MCID to assess surgical success for the JOABPEQ subscales in patients with LDH. This estimate may be a useful tool in clinical practice.