Operative Management of Lumbar Disc Herniation with End Plate Modic Changes Necessitates More Definite Procedures

Abstract

Introduction Nucleotomy through interlaminar fenestration has been the standard operation for lumbar disc herniation, but it does not always work well in clinical practice. End plate Modic changes are strongly linked with lower back pain, and Modic changes in the end plates of the herniation level may be one reason for the unpredictable result of nucleotomy alone. Studies on more definite surgical procedures for lumbar disc herniation with end plate Modic changes are still rare. To compare the clinical outcomes between two surgical options, nucleotomy alone and nucleotomy with additional posterolateral lumbar interbody fusion (PLIF), for lumbar disc herniation patients with end plate Modic changes, and to testify the hypothesis that end plate Modic change is an indication of interbody fusion for operative management of lumbar disc herniation. Materials and Methods A total of 91 patients who complained about both lower extremity radicular pain and lower back pain (lower back pain more severe than leg pain) were included, and all of them were of single segment disc herniation with Modic changes in the corresponding lumbar degenerative end plates. Of the 91 patients, 47 were treated with nucleotomy alone and 44 were treated with posterolateral lumbar interbody fusion (PLIF) in addition to nucleotomy. They were followed up for at least 2 years. Clinical outcomes were evaluated according to the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) for lower back pain and VAS for lower extremity radicular pain before operation and at each follow-up, and the results before surgery and at 18 months after operation were statistically compared. Results In both the groups, the JOA scores, as well as VAS, for lower back pain significantly improved 18 months after surgery. The improvement rate of JOA score and power of improvement of VAS for lower back pain also showed significant difference between the two groups, being better in nucleotomy with PLIF procedure than in nucleotomy alone procedure. On the contrary, the mean VAS of lower extremity radicular pain showed a significant reduction in both groups at the follow-up of 18 months after operation. However, a significant difference of the power of this improvement between both the groups was not found. Conclusion Operative management of lumbar disc herniation with end plate Modic changes necessitates more definite procedures in addition to nucleotomy. PLIF is a good and reliable option. Disclosure of Interest None declared