Return to sport after lumbar microdiscectomy in high school and college age athletes

BACKGROUND

Previous studies have reported return to play (RTP) rates for athletes after lumbar discectomy, but not specifically younger athletes. The purpose of this study was to evaluate RTP rate of young athletes after lumbar microdiscectomy.

METHODS

Medical records for a single spine surgeon were reviewed to identify lumbar microdiscectomy patients. Patients were included if they were 21 years old or younger at the time of surgery and were athletes. 38 patients (25 male, 13 female) were identified, with mean age at surgery of 19 years. Level of herniated nucleus pulposus, variant anatomy, degenerative change, gender, preoperative blocks, ring apophyseal fractures, and duration of symptoms from onset until surgery were recorded. Patients were contacted to determine when and if they RTP.

RESULTS

Most patients had degenerative changes at the time of surgery, with a mean Pfirrmann score of 2.2. The average time from onset of symptoms until surgery was 11 months. All patients were reached for follow-up at an average 51 months post-op. 71% returned to play at an average of 4.5 months. There were no statistical differences in Pfirrmann Grade and RTP rates between high school and collegiate athletes, between males and females, nor between patients with two-level and one-level discectomies. Pfirrmann Grade was not significantly different between patients who RTP and those who did not RTP.

CONCLUSIONS

The prognosis for returning to competitive sports after lumbar microdiscectomy in young athletes is good. RTP rate and Pfirrmann Grade were not related to gender, sport level, or discectomy level.

Preoperative MRI predictors of health-related quality of life improvement after microscopic lumbar discectomy

BACKGROUND

Lumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD.

PURPOSE

To analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD.

STUDY DESIGN/SETTING

Retrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period.

PATIENT SAMPLE

Eighty-eight patients receiving MLD treatment for HNP.

OUTCOME MEASURES

Cephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores.

METHODS

Patients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID-). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID- groups.

RESULTS

There were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=-0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm²), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID- patients had in five out of six HRQoL score comparisons (116.6 mm²±46.4 vs 90.0 mm²±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID- patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05).

CONCLUSIONS

Patients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.

Fat quantification of multifidus muscle using T2-weighted Dixon: which measurement methods are best suited for revealing the relationship between fat infiltration and herniated nucleus pulposus

OBJECTIVE

To reveal the best-suited method for fat quantification of lumbar multifidus to demonstrate its relationship to herniated nucleus pulposus (HNP) using T2-weighted Dixon.

MATERIALS AND METHODS

One hundred eight patients who underwent MRI for low back pain were enrolled. Two readers independently analyzed the fat fraction (Ff) using axial two-dimensional (D), coronal 2-D, and coronal 3-D measurement. Pearson's correlation coefficient was calculated between age, body mass index (BMI), and the Ff, and age, sex, BMI, and Ff were compared between 'HNP group' and 'no HNP group'. Multivariate logistic regression analysis was performed to identify factors associated with HNP.

RESULTS

Coronal 2-D Ff showed the highest correlation with age (r = 0.536, P < 0.001). Coronal 2-D Ff, and coronal 3-D Ff were significantly higher in those with HNP (coronal 2-D: 18.9 ± 2.9, coronal 3-D: 19.7 ± 2.6, respectively) than those without HNP (coronal 2-D: 17.2 ± 3.2, coronal 3-D: 17.4 ± 3.2, respectively). Ff of all three measurements were significantly higher in those with HNP ≥ 3 levels (axial 2-D: 20.7 ± 3.0, coronal 2-D: 21.1 ± 2.7, coronal 3-D: 21.6 ± 2.5, respectively) than those with HNP <3 levels (axial 2-D: 17.5 ± 4.3, coronal 2-D: 18.5 ± 2.7, coronal 3-D: 19.3 ± 2.5). The BMI was an independent predisposing factor to HNP (P = 0.011). Age and coronal 2-D Ff were significant predictors for multilevel HNP (P = 0.028 and 0.040, respectively).

CONCLUSIONS

The Ff of the multifidus muscle on T2-weighted Dixon was associated with age, sex, and HNP. The coronal 2-D measurement was the best suited for fat quantification in multifidus muscle among three measurement methods.

Transforaminal full-endoscopic lumbar discectomy under local anesthesia in awake and aware conditions: the inside-out and outside-in techniques

PURPOSE OF THE REVIEW

Transforaminal full-endoscopic lumbar discectomy (TELD) under local anesthesia was first introduced in Japan in 2003. Initially referred to as percutaneous endoscopic discectomy, in 2018, a consensus was reached worldwide and the preferred term is now TELD. The procedure requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles. Thus, it is the least invasive disc surgery. In this review, we introduce two types of the TELD surgery.

RECENT FINDINGS

Initially, TELD was performed as the "inside-out" technique but was associated with reports of postoperative dysesthesia due to exiting nerve injury. Recently, the "outside-in" technique after foraminoplasty was proposed for safer insertion of the cannula into the disc. Foraminoplasty can widen the narrow foramen, thereby allowing the 8-mm cannula to pass through easily and safely, and thus injury to the exiting nerve root can be theoretically avoided. We described two types of the TELD in this review. Surgeons should be familiar with the inside-out and outside-in techniques for TELD; therefore, we can select appropriate technique for each case.

Retrolisthesis and lumbar disc herniation: a postoperative assessment of outcomes at 8-year follow-up

BACKGROUND CONTEXT

Lumbar disc herniation and retrolisthesis have been shown to be significant degenerative changes that can be associated with back pain. Current literature has shown evidence that retrolisthesis is associated with similar baseline function in patients with L5-S1 disc herniation, but worse postoperative outcomes 2 years after lumbar discectomy. However, literature comparing long-term postoperative outcomes at 8-year follow-up in patients with L5-S1 disc herniation with retrolisthesis is lacking.

PURPOSE

The purpose of the present study is to compare long-term postoperative outcomes at 8-year follow-up in patients with retrolisthesis and L5-S1 disc herniations to patients with L5-S1 disc herniations without retrolisthesis.

STUDY DESIGN

Retrospective review of prospectively collected data from the Spine Patients Outcomes Research Trial (SPORT) database.

PATIENT SAMPLE

Sixty-five patients who underwent lumbar discectomy for L5-S1 disc herniations with 8-year follow-up from the SPORT.

OUTCOME MEASURES

Short Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index, Sciatica Bothersomeness Index, and reoperation rate.

METHODS

Baseline surgical parameters, length of stay, complication rates, reoperation rates, and outcome measures were recorded in the SPORT database. Follow-up data were collected at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. Retrolisthesis was defined as posterior subluxation ≥8%. Patients with and without retrolisthesis were compared using a mixed-effects model of longitudinal regression. Outcomes were calculated as time-weighted averages over 8 years. Reoperation rates were compared using the log-rank test based on time to first reoperation.

RESULTS

One hundred-twenty five patients met inclusion criteria for the present study, including 29 patients with retrolisthesis (23.3%) and 96 patients who did not have retrolisthesis (76.7%). The greatest difference in clinical outcome measures was found at 2 years postoperatively. This was the only point at which both the Short Form-36 Bodily Pain scale (SF-36 BP) and PF showed significant differences between the retrolisthesis and nonretrolisthesis group. At 3 years, SF-36 BP was significantly lower in patients with retrolisthesis (39.9 vs. 52, p=.046). At 8-year follow-up, the presence of retrolisthesis in patients undergoing L5-S1 discectomy was not associated with worse outcome measure scores based on the area under the curve analysis for any metric investigated (SF-36 BP 41.4 vs. 47.1, p=.18; SF-36 Physical Function scale 38.9 vs. 45.4, p=.12; Oswestry Disability Index -39.4 vs. -34.8, p=.23; -11.6 vs. -10.4, p=.25) or a difference in reoperation rate (retrolisthesis group 10%, nonretrolisthesis group 17%, p=.41).

CONCLUSIONS

While retrolisthesis can contribute to low back pain and dysfunction in patients undergoing lumbar discectomy for L5-S1 herniated nucleus pulposus in early follow-up, no significant difference was found in postoperative outcomes after 3 years. Additionally, retrolisthesis was not found to be associated with different reoperation rates at 8 years postoperatively.

Postoperative discal cyst: An unusual complication after microendoscopic discectomy in teenagers

Various complications after microendoscopic discectomy (MED) are well known, but postoperative discal cyst is a unique and relatively unknown complication. Here, we report on two teenage patients who presented with postoperative discal cyst after MED for herniated nucleus pulposus (HNP), which resolved after conservative treatment. The patients were diagnosed with HNP at L4-5 and L5-S1 based on MRI and then treated by MED. Postoperative discal cyst was diagnosed on MRI after recurrence of symptoms. Both patients were managed conservatively. T2-weighted MRI demonstrated hyperintense collections adjacent to the operated intervertebral disc level, which were communicating with the corresponding disc annulus. Because the clinical symptoms were relatively mild, the patients were managed conservatively; both made a complete clinical recovery with radiological evidence of improvement. Postoperative discal cyst is a relatively unknown complication after MED for HNP. Surgeons should be aware of this postoperative complication when operating on young individuals with HNP.

A study on dispersion and rate of fat infiltration in the lumbar spine of patients with herniated nucleus polpusus

[Purpose] This study investigated the relationship between herniated nucleus pulposus (HNP) and fat infiltration of muscles around the spine by measuring body mass index (BMI) and fat infiltration of the muscles around the spine. [Subjects and Methods] Subjects were 82 people, both men and women they were divided into two groups, a normal group and a patient group who were suffering from serious HNP between L4 and L5. Of the anthropometric measurement, and fat infiltration muscles by measuring the cross-sectional area from the center of the disc to the muscle around the spine and the cross-sectional area of fat infiltration. [Results] Fat infiltration rate of each lumbar layer in the normal group was different L34–L45 and L45–L5S1, but not between L23–L34. Fat infiltration in the muscle between the normal group and patients with HNP was different in the layers and the difference was greatest in the L5–S1 layer. [Conclusion] We performed correlation analysis of BMI and the total fat infiltration rate in each group to find the relationship between obesity and fat infiltration in the lumbar spine. Fat infiltration increased, and normal people or patients with chronic back pain are considered to be exposed to other diseases as fat infiltration in the lumbar spine increases.

A review of utilization of diagnostic imaging in the evaluation of patients with back pain: The when and what of back pain imaging

PURPOSE

To review the indications for imaging in patients with back pain.

METHODS

The author's experience as a clinical neuroradiologist in dealing with both referring physicians and their patients with back pain form the basis of this manuscript. Several texts and recent peer reviewed papers dealing with imaging of the spine were consulted.

RESULTS

There are controversies over when to image and the appropriate imaging modality to be used. The author presents his views on the sources of these controversies and his philosophy on imaging patients with back pain. A brief review of the major imaging findings in degenerative and non-degenerative causes of back pain is presented. To fully appreciate and see examples of these imaging findings, the reader should read texts devoted to spinal imaging.

CONCLUSION

Controversy over the decision of when to perform imaging of patients with back pain persist. From the perspective of the radiologist there is little controversy over the choice of imaging studies to be performed. MRI is superior to all other tests in the identification of degenerative and non-degenerative causes of back pain. CT without intrathecal contrast is an excellent test for degenerative disease but will often fail to detect non-degenerative (e.g. neoplastic) causes of back pain.