Evaluation of Degenerative Lumbar Disc Surgeries

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.

Spontaneous regression of herniated lumbar discs was reported occasionally. The mechanisms proposed for regression of disc herniation are still incomplete. This paper describes and discusses a case of spontaneous regression of herniated lumbar discs with a new disc protrusion in the adjacent level. A 41-year-old man was admitted with radiating pain and numbness in the left lower extremity with a left posterolateral disc extrusion at L5-S1 level. He was admitted to hospital with low back pain due to disc herniation caudally immigrating at L4-5 level three years ago. He refused the surgical intervention that was offered and was treated conservatively at that time. He had no neurological deficit and a history of spontaneous regression of the extruded lumbar disc; so, a conservative therapy, including bed rest, physical therapy, nonsteroidal anti-inflammatory drugs, and analgesics, was advised. In conclusion, herniated lumbar disc fragments may regress spontaneously. Reports are prone to advise conservative treatment for extruded or sequestrated lumbar disc herniations. However, these patients should be followed up closely; new herniation at adjacent/different level may occur. Furthermore, it is important to know which herniated disk should be removed and which should be treated conservatively, because disc herniation may cause serious complications as muscle weakness and cauda equine syndrome.

Background: Full-endoscopic interlaminar discectomy (FEID) is widely applied for the treatment of lumbar disc herniation (LDH) and satisfactory short-term outcomes have been achieved. However, the long-term evaluation for this technique is still lacking, especially the comparison between FEID and microendoscopic discectomy (MED). Objective: To evaluate the clinical outcome of FEID technique in comparison with MED for singlelevel LDH with a minimum of 5-year follow-up. Study Design: Retrospective study. Setting: Inpatient surgery center. Methods: A total of 152 patients with single-level LDH located at either L4-L5 or L5-S1 who underwent either FEID or MED from August 2008 to April 2011 at our hospital were enrolled in this study. General parameters including operative time, length of hospital stay, mean time to return to work, complications, and recurrences were recorded. Clinical outcomes were evaluated using visual analog scale (VAS) for low back and leg pain, Oswestry Disability Index (ODI) for functional assessment, and modified MacNab criteria for patient satisfaction. Results: At the final follow-up, the VAS of leg and back pain decreased from 7.6 ± 1.6 and 3.1 ± 2.2 points preoperatively to 1.6 ± 1.2 and 1.7 ± 0.9 at the final follow-up, respectively (P &lt; 0.05). The ODI score was 69.5% ± 10.5% preoperatively, and declined to 21.8% ± 7.0% at the final follow-up (P &lt; 0.05). VAS, ODI, and modified MacNab criteria of the FEID group were improved compared to the control group though there were no statistically significant differences between the 2 groups. Limitations: This was a retrospective study with a relatively small sample size. Additionally, this study contained only clinical outcomes, without long-term radiological outcomes. Conclusions: The application of FEID achieved similar satisfactory long-term clinical outcomes for the surgical treatment of LDH as MED. However, compared with MED, FEID exhibits advantages including less operation time, shorter hospital stay, and faster postoperative recovery. Key words: Lumbar disc herniation, full-endoscopic interlaminar discectomy, microendoscopic disectomy, long-term Pain Physician 2017

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

The Japan Orthopedic Association has led the way with endoscopic surgery for the spine and has developed its own training course and technical authorization system. Endoscopic surgery can be classified roughly as an anterior procedure from the pleural or peritoneal cavity or as a posterior procedure from the posterior interlaminar space in spine endoscopic surgeries. A representative technique of the endoscopic posterior spine surgery, which uses the posterior method, is microendoscopic discectomy (MED). While MED was initially utilized for lumbar herniotomy, it has recently been used for lumbar spinal canal stenosis and cervical spine disease. Therefore, all the posterior operative procedures are generally used with an MED system and they are referred to as MED. Thus, MED accounts for 98.7% of spine endoscopic operations performed in Japan (2006). There is little soft tissue damage with this approach and the lamina can be reached between the muscles for lumbar disc herniation. In the MED, radiographic control is indispensable for localization of the tube retractor, and it is necessary to resect the yellow ligament little by little to divide the superficial layer and the deep layer. MED is superior in visual safety for retraction of the nerve root to herniotomy. As for issues with MED, there is a substantial learning curve, the operation requires a long time, expensive instrumentation, there is the lack of haploscopic vision, the visual field to operate is limited, there is a tendency to become disoriented, and the lack of sensation of palpating an organ. Additional approaches include video-assisted thoracoscopic spine surgery (VATS) and endoscopic anterior lumbar spine surgery via the peritoneal or retroperitoneal cavity, but they do not lead to global operations.

Objective To explore the clinical outcomes of posterior lumbar interbody fusion using BTwin expandable spinal spacer with microendoscopic discectomy (MED) for lumbar disc herniation accompanying degenerative instability.Methods From March 2006 to May 2010,87 patients with lumbar disc heniation (only one level) accompanying degenerative instability were managed with posterior lumbar interbody fusion using B-Twin with MED,includeing 49 males and 38 females with an average of 47.6 years (range,37-65).Objective level located in L3,4 in 2 cases,L4,5 in 43,and L5S1 in 41.The patients were treated with single BTwin (Single group,n=51) and double B-Twin (Double group,n=36).Clinical outcomes were evaluated with surgical time,blood loss,visual analogue scale (VAS) scores,Oswestry disability questionnaire (ODI),and the pre- and post-operative disk space heights.Results The patients were followed up for an average of 35.8months (range,12-46).All the patients felt the low back pain and radiation pain disappeared or relieved apparently.The mean preoperative ODI and VAS scores decreased from 78％±3％ to 18％±3％,and (8.70±11.3)to (0.65±10.48) at the final follow-up respectively.Disc space increased from a pre-operative height of (8.76±1.3) mm to a post-operative of (11.8±0.6) mm.ODI,VAS and the disk space heights in all patient showed statistical significance,which revealed no statistical significance between the two groups.However,the operation time,blood loss were statistical difference between the two groups.All the patients achieved solid union or probable union at a mean time of 5.6 months (range,3.9-8.6).Conclusion Posterior lumbar interbody fusion using B-Twin with MED can obtain satisfactory outcomes in the treatment of lumbar disc herniation accompanying degenerative instability.Single B-Twin can get similar clinical outcomes,but shorter surgical time,less blood loss,and less medical costs. Key words: Lumbar vertebrae; Intervertebral disk displacement; Spinal fusion; Surgical procedures,minimally invasive

Introduction: Though there are various modalities of conservative and minimally invasive management they do not resolve or regress the fibrotic process of the tendon sheath in deQuervain’s disease hence surgical release of the tendons from the sheath improves the patients symptoms by correcting the underlying pathology. Aim: Analysis of functional outcome of surgical release for deQuervain’s disease.Materials and Methods: Prospective evaluation of 20 cases with at least 3 months of unsuccessful conservative therapy undergone open surgical release through longitudinal incision of tendon sheath along with removal of thin strip of extensor retinacilam.Results: Follow up analysis of the patients were made using DASH scoring and VAS scale and clinical evaluation by negative finkelstein test and range of movements of thumb and wrist. The mean pre operative DASH score is 78.25 where as mean post operative DASH score is 8.03 which is statistically significant. The mean pre operative VAS score is 8.65 where as post operative VAS score is 0.35 also statistically significant.Conclusion: Surgery is the only treatment for resistant cases after 6 months of conservative measures, and should be carried out as soon as possible. In our study group follow up is short term even though it shows significant outcome.

Chiropractic Treatment of a Patient with Progressive Lumbar Disk Injury, Spondylolisthesis, and Spondyloptosis

Lumbar disc prolapse (LDP) is a significant cause of low back pain and radiculopathy. While both Microlumbar Discectomy (MLD) and Microendoscopic Discectomy (MED) are established minimally invasive treatments, comparative data for double-level LDP is limited. This study aimed to compare the efficacy and safety of MED versus MLD for patients with double-level lumbar disc prolapse. This randomized controlled trial included 50 patients with double-level LDP who failed 8 weeks of conservative treatment, randomized equally into two groups: MED group (n = 25) who underwent tubular microendoscopic interlaminar discectomy and MLD group (n = 25) who underwent standard microlumbar discectomy. Patients were followed for one year postoperatively. Primary outcomes included Visual Analogue Scale (VAS) scores for back and leg pain. Secondary outcomes encompassed Oswestry Disability Index (ODI), operative time, blood loss, wound length, hospital stay, return to work, and postoperative complications. Both MED and MLD significantly improved pain and disability. The MED group demonstrated statistically lower VAS scores for back pain at one month (2.1 ± 0.73 vs. 2.7 ± 0.84, p = 0.012), and consistently lower VAS scores for both back and leg pain at 6 and 12 months postoperatively. Operative time was significantly longer for MED (103 ± 15.6 mins vs. 73 ± 14.9 mins, p < 0.001). However, MED was associated with significantly less blood loss (49.9 ± 10.1 mL vs. 87.2 ± 26.2 mL, p < 0.001), smaller wound length (2.3 ± 0.4 cm vs. 4.7 ± 0.5 cm, p < 0.001), shorter hospital stay (1.1 ± 0.61 days vs. 1.7 ± 0.58 days, p = 0.007), and earlier return to work (39.4 ± 7.24 days vs. 43.1 ± 3.6 days, p = 0.029). Both microendoscopic and microlumbar discectomy are effective and safe for double-level lumbar disc prolapse. Microendoscopic discectomy offers superior short-term pain relief, reduced invasiveness, shorter hospital stays, and earlier returns to work, despite a longer operative time. These benefits suggest MED as a favorable option for patients with double-level LDP

The microendoscopic discectomy (MED) system for lumbar disc herniation has been developed in recent years. We applied the MED system to the treatment of extraforaminal lumbar disc herniation. The purpose of this Chapter is to present the clinical results of the MED system for cases of extraforaminal lumbar disc herniation. We performed operations using the MED system on eight patients suffering from extraforaminal lumbar disc herniation. The mean age was 57.4 years. Herniation affected discs at the L2-3 (one patient), L3-4 (one patient), L4-5 (two patients), and L5-S1 (four patients) levels. We recorded the operation time, blood loss, and time until the resumption of walking, and used the Japanese Orthopaedic Association (JOA) score for low back pain in evaluating the clinical results. The mean operation time was 90.1 min. The mean blood loss was 12.3g. All patients began to walk within 6 h postoperatively. The mean JOA score improved from a preoperative 8.2 to a postoperative 25.8. There were no complications. The MED system allows treatment of extraforaminal lumbar disc herniation with good visualization, less pain, and early return to daily activity. Our results showed that the MED system is beneficial in the treatment of extraforaminal lumbar disc herniation.

To compare the clinical efficacy of microendoscopic discectomy + fibrous ring suture versus microendoscopic discectomy alone in the treatment of lumbar disc herniation (LDH) in young and middle-aged patients. A retrospective analysis was performed on the clinical data of 66 young and middle-aged patients with single-segment LDH diagnosed in Orthopedic Hospital of Henan Province from October 2019 to October 2022. All patients were divided into two groups: the microendoscopic discectomy + fibrous ring suture group and the microendoscopic discectomy alone group, with 33 cases in each group. The Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) scores of the two groups were recorded before surgery and six and twelve months after surgery. Both groups completed the surgery and postoperative follow-up successfully and showed no statistically significant differences in terms of incision length, duration of surgery, intraoperative blood loss and length of hospital stay (all P>0.05). VAS, ODI and JOA scores were significantly improved in both groups at 6 and 12 months after surgery compared with those before surgery (all P<0.05). The two groups were similar in terms of excellent and good rates of postoperative modified MacNab Evaluation Criteria, with no statistically significant differences. No serious complications were observed in the two groups during and after surgery. Both of the two surgical methods are effective in the treatment of LDH in young and middle-aged patients, and microendoscopic discectomy + fibrous ring suture in particular may be preferred because it results in significant improvement in patients' VAS and ODI scores.

OBJECTIVE This study aimed to evaluate the clinical outcomes of percutaneous endoscopic transforaminal discectomy (PETD), microendoscopic discectomy (MED), and microdiscectomy (MD) for treatment of symptomatic lumbar disc herniation (LDH). METHODS One hundred ninety-two patients with symptomatic LDH at L3-4 and L4-5 were included in this study. The mean (± SD) age of patients was 34.2 ± 2.6 years (range 18-62 years). The patients were divided into groups as follows: group A was treated with PETD and included 60 patients (31 men and 29 women) with a mean age of 36.2 years; group B was treated with MED and included 63 patients (32 men and 31 women) with a mean age of 33.1 years; and group C was treated with MD and included 69 patients (36 men and 33 women) with a mean age of 34.0 years. The Japanese Orthopaedic Association (JOA) scale for low-back pain (LBP), Oswestry Disability Index (ODI), creatine phosphokinase activity 3 days after surgery, and visual analog scale (VAS) scores for LBP and leg pain were used for evaluation of clinical results. RESULTS There were no significant differences in mean preoperative JOA score, ODI score, and VAS scores for LBP and leg pain among groups A, B, and C. Incision length, duration of the operation, blood loss, creatine phosphokinase, length of hospital stay, and postoperative incision pain according to the VAS were best in the PETD group (p < 0.05). The number of seconds of intraoperative fluoroscopy was highest in the PETD group (p < 0.05), whereas there was no difference between the MED and MD groups. Three cases from the MED group and 2 cases from the MD group had an intraoperative durotomy. No CSF leakage was observed after surgery. One case from the MED group and 3 cases from the MD group had incision infections. There were no neurological deficits related to the surgeries in any of the groups. Fifty-five (91.6%), 59 (93.7%), and 62 patients (89.9%) had at least 2 years of follow-up in groups A, B, and C, respectively. At the last follow-up, JOA scores, VAS scores of LBP and leg pain, and ODI scores were significantly better than preoperative correlates in all groups. There were no differences among the 3 groups in JOA scores, JOA recovery rate, ODI scores, and VAS scores for leg pain. The VAS score for LBP was best in the PETD group (p < 0.05). No lumbar instability was observed in any group. Three cases (5.5%) in the PETD group had recurrent LDH, and 2 recurrent cases (3.4%) were confirmed in the MED group. CONCLUSIONS PETD, MED, and MD were all reliable techniques for the treatment of symptomatic LDH. With a restricted indication, PETD can result in rapid recovery and better clinical results after at least 2 years of follow-up.

We assessed the long-term outcomes of patients with lumbar disc herniation treated with percutaneous lumbar discectomy (PLD) or microendoscopic discectomy (MED). A retrospective study was performed in consecutive patients with lumbar disc herniation treated with PLD (n = 129) or MED (n = 101) in a single hospital from January 2000 to March 2002. All patients were followed up with MacNab criteria and self-evaluation questionnaires comprising the Oswestry Disability Index and Medical Outcomes Study 36-Item Short-Form Health Survey. Several statistical methods were used for analyses of the data, and a p value of <0.05 was considered to be statistically significant. A total of 104 patients (80.62%) with PLD and 82 patients (81.19%) with MED were eligible for analyses, with a mean follow-up period of 6.64 +/- 0.67 years and 6.42 +/- 0.51 years, respectively. There were no significant differences between the two groups in age, number of lesions, major symptoms and physical signs, and radiological findings. According to the MacNab criteria, 75.96% in the PLD group and 84.15% in the MED group achieved excellent or good results, respectively, this was statistically significant (p = 0.0402). With the Oswestry Disability Index questionnaires, the average scores and minimal disability, respectively, were 6.97 and 71.15% in the PLD group and 4.89 and 79.27% in the MED group. Total average scores of Medical Outcomes Study 36-Item Short-Form Health Survey were 75.88 vs. 81.86 in PLD group vs. MED group (p = 0.0582). The cost and length of hospitalization were higher or longer in MED group, a statistically significant difference (both p < 0.0001). Long-term complications were observed in two patients (2.44%) in the MED group, no such complications were observed in the PLD group. Both PLD and MED show an acceptable long-term efficacy for treatment of lumbar disc herniation. Compared with MED patients, long-term satisfaction is slightly lower in the PLD patients; complications, hospitalization duration, and costs in PLD group are also lower.

Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.

Introduction: Herniated nucleus pulposus (HNP) is infrequent among children and adolescents. The first case of surgical intervention for disc herniation was reported in a 12-year-old child. Since then, very few cases or series of cases have been published. The reactive scoliosis is frequently associated with lumbar HNPs, a compensatory effort to relieve nerve compression. Moreover, reactive scoliosis secondary to lumbar HNP is typically associated with children and usually resolves with effective management of lumbar HNP. Although the surgical intervention is frequently employed among adults, only 0.5% of discectomies are carried out in children &lt;16 years old. The current case report is of a 15-year-old girl, with no history of spinal ailment, who presented with a large disc herniation at L4–L5 region, associated with a reactive secondary scoliosis, which was resolved following a successful surgical intervention. Case Report: A 15-year-old female with known case of scoliosis and a history of lower back pain for nine months following a fall while playing football presented at outpatient clinic. She sought medical opinion after two months of persistent pain with radiculopathy to the right side toward big toe. Similarly, there was normal plantar reflex and no clonus or Hoffman sign. There was positive straight leg raise test as well as positive contralateral straight leg raise test. Scoliosis is idiopathic in majority of young patients. However, it might also arise as a part or complication of a triggering health state. Although scoliosis has been frequently associated with lumbar HNP among adolescents, most patients with lumbar disc ailment in this age group might be underdiagnosed initially. Similarly, in our case study the patient was not diagnosed when medical opinion was sought after two months of persistent pain with radiculopathy to the right side toward big toe. The clinical characteristics of pediatric lumbar HNP are usually comparable to those seen in adults; however, one distinguishing feature is that up to 90% have a positive straight-leg raising test. The most common symptom is lumbar pain; limitation of lumbar motility and lassegue are the most common signs. The etiology, pathophysiology, and patterns of the scoliotic posture in cases secondary to HNP remain debated. It is highly recommended to do CT scan in cases of adolescent lumbar HNP to rule out apophyseal ring fracture; accurate diagnosis helps surgeon in planning the appropriate surgical intervention needed. Scoliosis secondary to lumbar disc herniation is observed occasionally, therefore, its clinical significance and pathophysiology are not well-established. However, it is well-recognized that children’s spines have superior adaptive capacity, which shields nervous tissue. An example of this could be scoliosis in patients with root compression, when they bend to the side contrary to the compression, causing an enlargement of the affected foramen and root release. It has been reported that 80% of the patients with disc herniation and scoliosis had the convexity on the side of the root compression. The MRI findings revealed that the scoliosis widened the foramen. Similarly, in our case report the X-ray depicted scoliotic deformity with convexity toward the right side. MRI is the best imaging technique to indicate disc herniation and eliminate other likelihoods in both children and adolescents. Surgical interventions, such as micro-endoscopy discectomy and percutaneous endoscopic lumbar discectomy, could achieve considerable pain relief and function improvement. Our case finding revealed that microscopic discectomy relieved the pain and improved the scoliosis. Conclusion: Lumbar disc herniation is a rare entity among both children and adolescent and may also result in scoliosis and lumbar pain with or without sciatica. Therefore, lumbar disc herniation in association with scoliosis need vigilant evaluation of signs and symptoms in addition to appropriate diagnostic imaging. Imaging has a vital role in the diagnosis of underlying disease state and helps in clinical management along with surgical planning. The appropriate treatment is discectomy.