Chemonucleolysis and disk surgery for lumbar disk herniation

Prospective, case series. To identify and characterize any differences in specific patient factors, MRI findings, features of spontaneous disc resorption, and outcomes between patients with single-level and multilevel LDH. Lumbar disc herniation (LDH) is one of the most common spinal pathologies worldwide. Though many cases of LDH resolve by spontaneous resorption, the mechanism underlying this "self-healing" phenomenon remains poorly understood, particularly in the context of multilevel herniations. A one-year prospective study was conducted of patients presenting with acute symptomatic LDH between 2017 and 2019. Baseline demographics, herniation characteristics, and MRI phenotypes were recorded before treatment, which consisted of gabapentin, acupuncture, and the avoidance of inflammatory-modulating medications. MRIs were performed approximately every three months after the initial evaluation to determine any differences between patients with single-level and multilevel LDH. Ninety patients were included, 17 demonstrated multilevel LDH. Body mass index was higher among patients with multilevel LDH ( P <0.001). Patients with multilevel LDH were more likely to exhibit L3/L4 inferior endplate defects ( P =0.001), L4/L5 superior endplate defects ( P =0.012), and L4/L5 inferior endplate defects ( P =0.020) on MRI. No other differences in MRI phenotypes ( e.g. Modic changes, osteophytes, etc .) existed between groups. Resorption rate and time to resolution did not differ between those with single-level and multilevel LDH. Resorption rates were similar between single-level and multilevel LDH at various time points throughout one prospective assessment, providing insights that disc healing may have unique programmed signatures. Compared with those with single-level LDH, patients with multilevel herniations were more likely to have a higher BMI, lesser initial axial and sagittal disc measurements, and endplate defects at specific lumbar levels. In addition, our findings support the use of conservative management in patients with LDH, regardless of the number of levels affected. Level 3.

Background:Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation.Materials and Methods:Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification.Results:The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%).Conclusions:TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.

Background: Lumbar disc herniation is frequently-occurring and the most common spine-related disease in orthopedic surgery. However, nearly more than 50% of affected persons usually respond to conservative treatment. Furthermore, there is another group of patients who are suffering from incapacitating low back pain and sciatica although they have been treated for more than 6 weeks or who are suffering from early or progressive neurological impairment that required another approach far from the conservative treatments. Aim of the Study: The present study is designed to unveil the most reliable procedure which should be most adopted for single level lumbar disc herniation in Iraqi patients. Patients and Methods: A total of 40 patients who were suffering from back pain radiated to the lower limb were included in the present investigation. Out of them, 20 patients underwent open discectomy and the other 20 patients underwent tubular discectomy. Results: 1- At the 10th day of postoperatively assessment, an obvious statistically significant decrease in the mean total Oswestry low back pain disability score was recorded in micro-tubular discectomy compared with the open discectomy ( P&lt;0.001). 2- At the 6th month of postoperatively, the mean total Oswestry low back pain disability score was increased in both groups; nonetheless, there has still been a decrease in the micro-tubular discectomy group in comparison with that of open discectomy group (P&lt;0.001).

Prospective cohort study. To describe the naturally occurring magnetic resonance imaging (MRI) findings after successful microsurgical removal of lumbar disc herniation with repeated MRI examinations. The interpretation of MRI after spinal surgery may be particularly challenging and image findings do not always correlate to clinical findings. Early postoperative MRI has limited value in the evaluation of patients after surgery for lumbar disc herniation. Prospective study of 30 successfully operated patients, which underwent 3.0 T MRI within 24 h after surgery for lumbar disc herniation and repeated at 6 weeks and 3 months postoperatively. Postoperative image findings (nerve root enhancement, nerve root thickening, displacement or compression of the nerve root, and residual mass size and signal) were assessed quantitatively. Inter-rater reliability was tested. Inter-rater reliability between neuroradiologists was moderate for assessed MRI variables. In the immediate postoperative phase, compression or dislocation of the nerve root at the operated level was common. A residual mass at the operated level was seen in 80%, 47%, and 33% after 24 h, 6 weeks, and 3 months, respectively. Postoperative dislocation or compression of the nerve root from residual masses was seen in 67%, 24%, and 14% after 24 h, 6 weeks, and 3 months, respectively. A residual mass with a higher signal than muscle on T2-weighted images was seen in 80%, 30%, and 17% after 24 h, 6 weeks, and 3 months, respectively. A residual mass with compression or dislocation of the nerve root at the operated level, that disappears over 3 months, is a common MRI finding in patients successfully operated for symptomatic lumbar disc herniation. An expectant approach instead of early reoperations may perhaps be preferred in patients with residual pain and root compression due to residual masses with high T2-signal since these often seem to resolve spontaneously. 3.

IntroductionThe effectiveness of post-surgical rehabilitation following lumbar disc herniation (LDH) surgery is unclear.Research questionTo investigate the effectiveness and safety of rehabilitation interventions initiated within three months post-surgery for adults treated surgically for LDH.Material and methodsThis systematic review searched seven databases from inception to November 2023. Independent reviewers screened studies, assessed and extracted data, and rated the certainty of the evidence using the GRADE approach.ResultsThis systematic review retrieved 20,531 citations and included 25 randomized controlled trials. The high certainty evidence suggests that adding Pilates exercise to routine care and cognitive behavioral therapy may improve function immediately post-intervention (1 RCT), and that adding whole-body magnetic therapy to exercise, pharmacological and aquatic therapy may reduce low back pain intensity (1 RCT) immediately post-intervention. Compared to placebo, pregabalin did not reduce low back pain or leg pain intensity (1 RCT) (moderate to high certainty evidence). We found no differences between: 1) behavioral graded activity vs. physiotherapy (1 RCT); 2) exercise and education vs. neck massage or watchful waiting (1 RCT); 3) exercise, education, and in-hospital usual care vs. in-hospital usual care (1 RCT); 4) functional or staged exercise vs. usual post-surgical care including exercise (2 RCTs); and 5) supervised exercise with education vs. education (1 RCT). No studies assessed adverse events.Discussion and conclusionEvidence on effective and safe post-surgical rehabilitation interventions is sparse. This review identified two interventions with potential short-term benefits (Pilates exercises, whole-body magnetic therapy) but safety is unclear, and one with an iatrogenic effect (pregabalin).

Surgery for lumbar disc herniation: Analysis of 500 consecutive patients treated in an interdisciplinary spine centre

Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work (with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry unto itself. Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed surgically and to compare the results of different surgeries performed. Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or impending cauda equina syndrome. Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 % patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic discectomy. L4-L5 level was the most common level to get involved. Mean Pre operative VAS score for male patients was 6.64 and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean Pre operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95 and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed. Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures. We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient satisfaction was high, and a cost savings was realized. Keywords: Degenerative, Lumbar Spine, Disc Surgeries, Microscopic Discectomy, Laminectomy, Decompression

In order to explore the effective nursing methods and clinical therapeutic effects for patients with lumbar disc herniation after receiving minimally invasive surgery. In this study, a total of 50 patients receiving minimally invasive surgery for lumbar disc herniation in our hospital over the past year were selected and randomly divided into trial group and control group, with 25 patients in each group. Patients in control group were given routine nursing, and those in trial group were given postoperative comprehensive nursing including postoperative rehabilitation exercise, psychological nursing, diet nursing and other aspects. Visual analogue scale (VAS) was used to score the pain of patients in both groups before and after surgery; The final result shown that patients in trial group had better postoperative recovery time and hospital stays than patients in control group after nursing, with statistically significant difference (P < 0.05); the score of visual analogue scale (VAS) in trial group was better than that in control group, and with statistically significant difference (P < 0.05); the effective rate of trial group was 92.5%, compared with the 75% of control group with statistically significant difference (P < 0.05); the score of Barthel index of trial group was obviously better than that of control group, with statistically significant difference (P < 0.05). Therefore, the postoperative comprehensive nursing can not only help to improve the postoperative therapeutic effect, but also reduce the pain, accelerate the postoperative recovery and shorten the hospital stays of patients. Therefore, it shall be paid attention to and widely used in clinical practice.

The aim of this study is to explore the occurrence and the risk factors of back-related loss of working time in patients undergoing surgery for lumbar disc herniation. One hundred and fifty-two gainfully employed patients underwent surgery for lumbar disc herniation. Two months postoperatively, those patients completed a self-report questionnaire including queries on back and leg pain (VAS), functional capacity (Oswestry disability index--ODI, version 1.0), and motivation to work. After 5 years, lost working time was evaluated by means of a postal questionnaire about sick leave and disability pensions. The cumulative number of back pain-related days-off work was calculated for each patient. All 152 patients, 86 men and 66 women, were prescribed sick leave for the first 2 months. Thereafter, 80 (53%) of them reported back pain-related sick leave or early retirement. A permanent work disability pension due to back problems was awarded to 15 (10%) patients, 5 men (6%) and 10 women (15%). Median number of all work disability days per year was 11 (interquartile range [IQR] 9-37); it was 9 days (IQR 9-22) in patients with minimal disability (ODI score 0-20) at 2 months postoperatively and 67 days (IQR 9-352) in those with moderate or severe disability (ODI > 20; P < 0.001). The respective means were 61, 29, and 140 days/year. Multivariate analysis showed ODI > 20, leg pain, and poor motivation to work to be the risk factors for extension of work disability. Results of the present study show that after the lumbar disc surgery, poor outcome in questionnaire measures the physical functioning (ODI) and leg pain at 2 months postoperatively, as well as poor motivation to work, are associated with the loss of working time. Patients with unfavourable prognosis should be directed to rehabilitation before the loss of employment.

PurposeThe purpose of the study was to evaluate the long-term outcome after surgery for lumbar disc herniation in a young adult population.MethodsA total of 526 consecutive patients between 18 and 40 years of age who underwent surgery for lumbar disc between 1990 and 2005 were included in the study. The primary outcomes were the need for new lumbar spine surgery during the follow-up and secondary outcomes were short-term subjective outcome, the Oswestry Disability Index (ODI) score, and the ability to carry out employment at the end of the long-term follow-up.ResultsA total of 96% of the patients had a reduction in their symptoms at the clinical follow-up (median of 50 days post-surgery). Twenty-one patients (4.0%) had a reoperation within 28 days. Excluding these early reoperations, 136 patients (26%) had additional lumbar spine surgery and 18 patients (3.4%) underwent lumbar fusion during the follow-up of median 18 years. The annual risk for new surgery was 1.4%. In total, 316 patients (60%) returned the ODI questionnaire, and their mean score was 8.1. Patients with a higher number of additional lumbar spine surgeries (p < 0.001) reported deteriorating ODI scores.ConclusionPatients showed excellent short-term recovery from their symptoms. In the long term, the mean ODI score for the patients was comparable to the normative population. However, a notable proportion of the patients required additional lumbar surgery during the follow-up period, and a higher number of lumbar surgeries was associated with poor ODI scores.

An abnormal serum uric acid (SUA) level is associated with many diseases. To our knowledge, there is no research on the association between SUA and intervertebral disc degeneration (IDD). The purpose of this study was to determine the relationship between SUA and IDD. From June 2011 to July 2020, 691 patients undergoing surgery for lumbar disc herniation (LDH) were included in the LDH group, and 684 patients who underwent endoscopic surgery for knee trauma were included in the non-LDH group. We examined the baseline characteristics of all these patients and divided the SUA level into 10 groups according to the percentiles in males, females, and the total population. Subsequently, the relationship between the SUA level and IDD was further analyzed. There was no statistically significant difference in the baseline characteristics of the two groups (p > 0.05). Among the 10 groups, the LDH rate was higher at both lower and higher SUA levels. In multiple logistic regression analysis, after adjustment for age, sex, body mass index, smoking, and drinking, when the SUA level was <20% or >80%, compared with 60–80%, the odds ratio (OR) and 95% confidence interval (CI) of LDH of the total population were 1.821 (1.125–2.946) and 1.701 (1.186–2.438), respectively, and in the males, they were 1.922 (1.169–3.161) and 2.800 (1.766, 4.439), respectively. In females, when the SUA was <20%, there was a higher LDH rate (OR = 1.951, 95% CI 1.091-3.486). The present study suggests that there is a U-shaped relationship between SUA and IDD, being particularly prominent among male. Lower and higher SUA level may be risk factors for IDD.

These two studies address the use of surgery for different types of degenerative lumbar spine disease. Peul and colleagues randomized 283 patients with lumbosacral radicular pain to either microdiskectomy or conservative treatment; incapacitating lumbosacral radicular pain had lasted 6 to 12 weeks and was due to lumbar disc herniation. In the conservative-treatment group, surgery was offered after 6 months to patients with persistent sciatica and before 6 months to patients with nonresponsive leg pain or progressive neurologic deficits. Of the 141 patients randomized to early surgery, 16 recovered before surgery could be performed; the remainder underwent surgery with a median …

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 214. Application of gelatin sponge impregnated with a mixture of three drugs to intraoperative nerve root block to promote early postoperative recovery of lumbar disc herniation

BackgroundSymptomatic lumbar disc herniation (LDH) and lumbar isthmic spondylolisthesis (LIS) present significant challenges for military pilots, which may result in grounding if not effectively managed. Surgical treatment for LDH and LIS may offer a pathway to return to flight duty (RTFD), but recent data on this crucial topic is lacking. This study seeks to address this gap by investigating the RTFD outcomes among Chinese military pilots who have undergone lumbar spine surgery for symptomatic LDH and LIS.MethodsA retrospective review was conducted on active-duty military pilots who underwent isolated decompressive or fusion procedures at an authorized military medical center from March 1, 2007, to March 1, 2023. The analysis utilized descriptive statistics to examine demographic, occupational, surgical, and outcome data, with a particular focus on preoperative flight status, recommended clearance by spine surgeons, and actual RTFD outcomes and time.ResultsAmong the identified cases of active-duty military pilots with LDH or LIS treated by lumbar surgery (n = 24), 70.8% (17 of 24) consistently maintained RTFD status without encountering surgical complications or medical issues during the follow-up period. Of the seven pilots who did not RTFD, one retired within a year of surgery, two had anterior cruciate ligament injuries, three had residual radicular symptoms, and one had chronic low back pain. Excluding pilots who retired and did not RTFD for reasons unrelated to their lumbar conditions, the RTFD rate stood at 81.0% (17 of 21). The median time for recommended clearance by spine surgeons was 143.0 days (inter-quartile range, 116.5–196.0), while the median duration for actual RTFD attainment was 221.0 days (inter-quartile range, 182.0–300.0). The median follow-up post-lumbar surgery was 1.7 years (inter-quartile range, 0.4–2.9).ConclusionMost military pilots diagnosed with symptomatic LDH and LIS can continue their careers and regain active-duty flight status following lumbar spine surgery, as reflected by the high RTFD rate. Lumbar spine surgery can successfully alleviate the physical constraints associated with spinal conditions, facilitating the return of military pilots to their demanding profession.

Background: Surgery for lumbar disc herniation is one of the most commonly performed procedures in spine surgery. Questions remain if lumbar discectomy is the optimal treatment for patients with lumbar disc herniation who exhibit a substantial amount of preoperative back pain.&#x0D; Objective: To evaluate the outcome of improvement of back pain and radiculopathy between male and female patients with single-level discectomy and in relation to different indications for the surgery. &#x0D; Patients and Methods: In this retrospective follow-up study, 80 patients (40males and 40 females) with symptoms of radiculopathy and back pain who underwent single-level open discectomy (small incision of 2-3 cm) were followed-up by discharge from the hospital between 2017 and 2019 in Erbil, Iraqi Kurdistan. The patients were included after having the symptoms of radiculopathy as confirmed on magnetic resonance imaging. In addition, patients who had undergone discectomy due to radiculopathy without response after 6 weeks of conservative treatment were included in this investigation.&#x0D; Results: The mean age of the patients was 45.1 (19-70 years old). The study showed that the level of back pain and radicular pain was significantly decreased from the initial step to 3, 6, and 12 months. The levels of back and radicular were not changed significantly from three to six months. The study showed that the prevalence of different levels of back and radicular pain was similar between male and female patients at different periods. The study did not find a significant difference in levels of back and radicular pains among patients with different indications in male and male patients.&#x0D; Conclusion: This study showed that single-level lumbar discectomy improved back and radicular pain by 12 months postoperatively in males and females, regardless of the indication for surgery.