Surgical treatment of herniated lumbar inter-vertebral discs: Follow-up study of 130 patients without spinal fusion

Abstract

An attempt has been made to demonstrate the end results in an unselected number of patients who had surgical treatment tor herniated or ruptured intervertebral disc. One hundred thirty cases were studied. The study revealed a ratio of male to female of almost two and one-half to one. The age incidence was about the same and averaged thirty-eight to thirty-nine years of age. There was an incidence of trauma in 48.5 per cent of patients. The diagnosis followed a definite pattern in all patients. The signs and symptoms in physical examination were back and radiating leg pain with muscle spasm of the lumbar spine, limitation of motion of the back, limitation of straight leg raising and neurologic changes. Sensory changes in the form of paresthesias were present in most cases, but the reflex changes were the best guide to localization. There was an absence of reflex changes in 75 per cent of fourth space lesions whereas the ankle jerk was absent in 65 per cent of fifth space lesions. Lesions of the fourth and fifth spaces comprised 95.7 per cent of the total number of lesions proven by surgery. Plain x-ray views of the lumbar spine were negative in the majority of patients, but a list of the lumbar spine and narrowing of the inter-vertebral space, especially the fourth space, were suggestive of disc lesions. The width of the lumbosacral space was not considered to be of diagnostic value. Myelograms were performed in fifty-nine cases and revealed this procedure to be about 90 per cent efficient. The spinal fluid total protein determination was performed in eighty patients and revealed an elevation in 69 per cent. The surgical procedure consisted of a laminotomy or laminectomy with removal of as much of the degenerated nucleus pulposus as possible. There were ninety-three herniated discs, twenty-three ruptured discs and fourteen negative explorations. The incidence of double lesions was 2.6 per cent in proven cases. Twelve patients required a second operation, the highest incidence being recurrence of herniated or ruptured disc at the same space in six patients. There were two interesting complications of spinal fluid cyst which developed postoperatively. The postoperative period in the follow-up of these patients averaged three years and three months. All patients except one had returned to productive work and 90 per cent had returned to the same kind of work performed prior to the onset of their disability. Of the 130 patients interviewed 87 per cent reported 100 per cent improvement and none reported no improvement following surgery. Examination of these patients revealed only five to have any limitation of back motion or spasm. There was an area of numbness and hypesthesia in about 45 per cent of the cases. The return of reflexes following surgery was the exception and there were definite reflex alterations due to the surgical procedure itself. Follow-up x-ray examination of the lumbar spine in all patients revealed degrees of narrowing in 73.8 per cent of patients and arthritic changes characterized by sclerosis in 30 per cent. However, there was no correlation between these x-ray results and the clinical results and even patients with severe collapse of the intervertebral space were asymptomatic. There was only one patient who may possibly have had a better result if a spinal fusion had been performed.