Limited Discectomy Research Articles

Limited discectomy versus aggressive discectomy by spinal endoscopy with the transforaminal approach for lumbar disc herniation: a retrospective study

ObjectiveTo compare the clinical and radiological outcomes of limited discectomy (LD) and aggressive discectomy (AD) performed via spinal endoscopy using the transforaminal approach in patients with lumbar disc herniation(LDH)MethodsWe conducted a retrospective review of patients who underwent percutaneous endoscopic transforaminal discectomy (PETD) at the L4-L5 lumbar spine segments in our department from January 2017 to December 2020. The follow-up period extended to 24 months postoperatively. Patients were categorized into the LD and AD groups based on the extent of intraoperative disc removal. We retrospectively collected and analyzed clinical and radiological data.ResultsThe study followed 65 patients, with 36 in the LD group and 29 in the AD group. No statistically significant differences were noted in recurrence rates, the excellent and good Macnab rates, preoperative Disc Height Index (DHI), and preoperative Modic changes between the groups (P >0.05). However, significant differences were observed in operation duration, postoperative DHI and postoperative Modic change (P<0.05). No significant differences in Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores were detected between the groups preoperatively, or one and two years postoperatively (P>0.05). Nevertheless, notable differences in VAS and ODI scores were present one month postoperatively (P<0.05).ConclusionAs a conventional surgical method for treating LDH, PETD can achieve satisfactory clinical results in both LD and AD, with no significant variance in recurrence rates. However, AD is associated with longer operation times, and greater postoperative reductions in DHI and greater postoperative Modic changes compared to LD.

Is annular repair technique useful for reducing reherniation and reoperation after limited discectomy?

The annular defect because of the primary lumbar disc herniation (LDH) or surgical procedure is considered a primary reason for recurrent herniation and eventually reoperation. Efforts to close the defect with annular repair devices have been attempted several times, but the results were controversial. The present aims to detect whether the annular repair techniques were useful for reducing the re-herniation and re- operation rate. The Pubmed, Cochrane library, and Embase databases were searched to retrieve relevant studies published before January 1, 2021. Continuous variables were compared by calculating the standard difference of the means (SDM), whereas categorical dichotomous variables were assessed using relative risks (RRs). A random-effects model was used if the heterogeneity statistic was significant; otherwise, a fixed-effects model was used. A total of 10 researches were suitable for the meta-analysis, including four different repair techniques and 1907 participates. Compared with the control group, there was no statistical difference with the ODI, VAS-leg, and VAS-back scales for patients treated with the annular repair. However, using an annular repair device was associated with a significant reduction in the re- herniation (p=0.004) and re-operation (0.004) rates. There was no difference between the groups with perioperative complications. However, much more device-related long-term complications happened in the annual repair group (p=0.031) though it still decreased the overall re-operation rate significantly (p=0.006).Our results demonstrated that using an annular repair device was safe and beneficial for reducing re-herniation and re-operation rates.

Lumbar discectomy with annulus fibrosus closure: A retrospective series of 53 consecutive patients

IntroductionLumbar disc herniation is most common degenerative alteration of the spine. Whenever surgical therapy proves to be necessary, recurrent disc herniation is most frequent concern. Here, primary aim was to determine the percentage of patients eligible for insertion of an annular closure device (ACD). Secondary aim to evaluate 12-month incidence of recurrent disc herniation at the operated level. Our hypothesis was that ACD might help in preventing recurrent disc herniation. MethodsPatients in a single Swiss neurosurgical center underwent limited discectomy alone (n=41, group 1) versus limited discectomy plus ACD (n=12, group 2). Mean postoperative follow-up period was 12months. ResultsTwelve out of 53 patients (22.6%) were eligible for ACD implantation. Patients of group 2 were significantly taller (mean 176cm, P=0.007) as compared with group 1 (mean 170). The only statistically significant difference of intraoperative parameters between group 1 and 2 was amount of nucleus materiel removed (P=0.01), being greater in group 2 (mean 0.9) as compared with group 1 (mean 0.3). In group 1 six patients (6/41, 14.6%) presented with symptomatic reherniation at same level of surgery, while in group 2 only one patient experienced recurrence (1/12, 8.3%). No adverse events were reported. DiscussionIn the current study one out of five patients with lumbar disc herniation was considered suitable for ACD placement. In vast majority of these patients reherniation was precluded on the short-term basis. Patients with ACD were taller and had intraoperatively a higher volume of the nucleus pulposus materiel removed.

Limited Discectomy for single level lumbar disc herniation: a retrospective study in a tertiary level hospital

Objective: To perform retrospective analysis of 1000 patients who underwent open limited discectomy (OLD) for single level lumbar disc herniation (LDH) and to assess the long- term clinical outcomes. Methods: 745 men and 255 women, with mean age of 38.03 ± 9.14 years (range 19- 55 years) who had primary LDH at L4-5 (n=640), L5-S1 (n=352), and L3-4 (n=8); underwent OLD were reviewed. Records were obtained regarding their demographic data, the side and level of disc herniation, operating time period, intraoperative blood loss, hospital stay, and perioperative complications. VAS score was measured before and after operation, for the assessment of low back pain (LBP) and radicular pain. Comprehensive outcome outcomes were measured postoperatively with the modified Macnab criteria and the Oswestry Disability Index (ODI) score. Results: The mean follows up was 24.5 (range 24-70) months. Significant improvement of mean VAS score for back and leg pain was achieved. At the two years follow-up, results were excellent in 525 (52.50%), good in 325 (32.50%), fair in 140 (14.00%) and poor in 10 (1.00%). Complications found were reherniation (n=52), discitis (n=19), superficial wound infection (n=7), dural tear (n=7) and foot drop (n=2). Conclusion: Open limited discectomy following fenestration or laminotomy is a safe and effective procedure and achieved favorable long-term outcome (e.g., low rate of recurrent LBP) and excellent patients’ satisfaction. Bangladesh Journal of Medical Science Vol. 21(1) 2022 Page : 37-44

Minimum Seven-Year Follow-Up Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Lumbar Degenerative Disease.

PurposeTo investigate the long-term (> 7 years) clinical outcomes of percutaneous endoscopic lumbar discectomy for lumbar degenerative disease to address postoperative problems including postoperative dysesthesia (POD), residual back pain and segmental instability.MethodsInclusion and exclusion criteria were established. All patients who met the above criteria were treated by PELD using the transforaminal approach. Limited discectomy was performed to preserve the disc material in the intervertebral space as much as possible. The Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back pain (VAS-B) and leg pain (VAS-L) and Modified MacNab’s criterion were used for clinical evaluation. Radiographic parameters including height of intervertebral disc and segmental instability were also evaluated.ResultsForty-two patients (24 men and 18 women) who met our inclusion and exclusion criteria were included in our study. The average follow-up period was 95.71±5.63 months (ranging from 87 to 105 months). There were no neurological complications associated with the operation. POD was found in 14.29% of patients, while only 2 patients (4.76%) complained of mild dysesthesia at final follow-up. Two patients (4.76%) required revision surgery during the follow-up period. The final follow-up ODI, JOA score, VAS-B and VAS-L were significantly better than preoperative values. The average disc-height ratio was 84.52±5.66% of the preoperative disc height. No instability at the operation level was noted at final follow-up.ConclusionOur study showed that PELD using the transforaminal approach can provide favorable results after a long-term follow-up period. POD is a common complication at initial prognosis. Limited discectomy can preserve the disc height well and minimize the risk of residual back pain.

113. Lumbar discectomy patients who undergo reoperation experience worse clinical outcomes and greater socioeconomic burden four years after the primary procedure

BACKGROUND CONTEXT Multiple studies have observed that the clinical outcomes of patients who have undergone revision surgery after lumbar discectomy are less positive than outcomes in patients who did not require revision. Lumbar disc herniation patients with large annular defects undergoing discectomy are at significantly greater risk for symptom recurrence and revision, indicating that this population is also at significantly greater risk for worse clinical outcomes. The goal of this analysis was to assess the clinical and socioeconomic outcomes associated with post-discectomy reoperations and the utility of a bone-anchored annular closure device (ACD) for avoiding reoperations in patients with large annular defects. PURPOSE Not applicable. STUDY DESIGN/SETTING Not applicable. PATIENT SAMPLE Not applicable. OUTCOME MEASURES Not applicable. METHODS This was a retrospective analysis of a prospective randomized controlled trial (RCT). Lumbar discectomy patients with large (≥6 mm) annular defects were randomized to treatment with limited discectomy alone (Control; n=278) or limited discectomy augmented by an annular closure device (ACD; n=272). Clinical outcomes included visual analog scale (VAS) for ipsilateral leg and back pain, Oswestry Disability Index (ODI), reoperations at the index-level, serious adverse events (SAE), and working status. Comparisons of clinical and socioeconomic outcomes were made between reoperated and nonreoperated patients, regardless of ACD or Control treatment, at 4 years following the primary surgery. RESULTS At 4 years, clinical outcomes data were available for 73% of the patients. Among patients with data at 4 years, 64 experienced at least one index-level reoperation (Reoperated group) and 340 were not reoperated (Non-reoperated group). The Kaplan-Meier estimate of subjects experiencing at least one index-level reoperation within 48 months was 14.4% in the ACD group and 21.1% in the Control group (p=0.03 log-rank). In all, 49 procedures were performed in ACD subjects and 77 procedures performed in Control subjects. The reoperated patients had significantly worse scores than non-reoperated patients for ODI (22 ± 16 vs 11 ± 13; p CONCLUSIONS Index-level reoperations following lumbar discectomy in patients with large annular defects are associated with worse clinical outcomes and greater socioeconomic burden. These findings are consistent with reports on outcomes from large registry analyses including the Spine Patient Outcomes Research Trial (SPORT) and the Swedish National Spine Registry (Swespine). The ACD was effective in minimizing the number of patients subject to revision, primarily through prevention of repeat discectomy, with 33% fewer patients undergoing at least one index-level reoperation. FDA DEVICE/DRUG STATUS Barricaid Annular Closure Device (ACD) - (Approved for this indication).

Predictors of Treatment Success Following Limited Discectomy With Annular Closure for Lumbar Disc Herniation.

Previous studies have demonstrated bone-anchored annular closure to significantly reduce reherniation and reoperation rates after lumbar discectomy in patients with large annular defects. It is important to identify the prognostic factors that may be associated with successful treatment. This study aimed to identify predictors of treatment success in patients with lumbar disc herniation treated with limited microdiscectomy supplemented by a bone-anchored annular closure device (ACD). This study was a retrospective analysis of 133 consecutive patients with lumbar disc herniation treated with the ACD. Treatment success was defined as ≥24% improvement in visual analog scale (VAS) for back pain, ≥39% improvement in VAS leg pain, and ≥33% in the Oswestry Disability Index (ODI), with the raw ODI score ≤48. Success was calculated at 3, 6, and 12 months after surgery. Potentially predictive outcomes included patient characteristics, operative data, and imaging outcomes, such as disc, facet, and end plate morphology. Logistic regression was used to determine the significant predictive factors for treatment success. After 3, 6, and 12 months, 97 of 131 (74%), 104 of 129 (81%), and 112 of 126 (89%) patients, respectively, achieved the success criteria. At 3 months follow-up, a higher proportion of younger (17-40 years) versus older (41-65 years) patients met the success criteria (P = .025). On the basis of logistic regression, the following factors were significantly associated with treatment success at 1 or more of the follow-up time points: sex (male), lower body mass index, higher baseline pain and ODI scores, lower grade preoperative disc degeneration, and the absence of a postoperative complication. The rates of index-level recurrent herniation and reoperation were 1.5% and 3.0%, respectively. This real-world evidence supports a promising benefit-risk profile for augmenting limited microdiscectomy with a bone-anchored ACD and provides some insights into the patient populations that may have a greater chance of realizing significant improvements in pain and function. 2 (Cohort study).

Surgical Experience and Complications in 50 Patients Treated with an Anular Closure Device Following Lumbar Discectomy

ObjectiveTo examine the results of an anular closure device for prevention of lumbar disc reherniation in daily routine practice.MethodsFifty patients with large anular defects were treated with limited discectomy and a bone‐anchored anular closure device. The device physically occludes the defect in the anulus fibrosus and is intended for prevention of lumbar disc reherniation. Pain scores on a visual analogue scale, back function on the Oswestry Disability Index, and neurological status were noted. Symptomatic reherniation and reoperation rates were assessed at each follow‐up. Surgical findings and complications, device‐related and/or procedure‐related, were recorded. Follow‐up was 6, 12, 26, and 52 weeks.ResultsMean anular defect height/width was 4.6 mm/10.1 mm. The overall symptomatic reherniation and reoperation rate was 2%. During the 1‐year follow‐up period, mean back pain decreased from 43 to 8 (P < 0.001), leg pain decreased from 71 to 4 (P < 0.001), and the Oswestry Disability Index decreased from 46 to 5 (P < 0.001). Among 15 patients with preoperative neurological deficits, improvements in neurological function were noted in 14 (93%). There were no serious device‐related complications.ConclusionsThe presented study shows promising early results in using the anular closure device. The procedure is safe with significantly fewer reherniations than for patients with large anular defects without anular closure. Further studies with longer follow‐up periods are warranted to prove these findings for long‐term outcomes.

Three-year results from a randomized trial of lumbar discectomy with annulus fibrosus occlusion in patients at high risk for reherniation

BackgroundA larger defect in the annulus fibrosus following lumbar discectomy is a well-known risk factor for reherniation. Procedures intended to prevent reherniation by sealing or occluding the annular defect warrant study in high-risk patients. This study sought to determine 3-year results of lumbar discectomy with a bone-anchored annular closure device (ACD) or lumbar discectomy only (controls) in patients at high risk for reherniation.MethodsThis multicenter randomized trial enrolled patients with sciatica due to lumbar intervertebral disc herniation who failed conservative treatment. Patients with large annular defects after lumbar limited microdiscectomy were intraoperatively randomly assigned to receive ACD or control. Clinical and imaging follow-up was performed at routine intervals over 3 years. Main outcomes included rate of reherniations, reoperations, and endplate changes; leg and back pain scores on a visual analogue scale; Oswestry Disability Index (ODI); Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36; and adverse events adjudicated by a data safety monitoring board.ResultsAmong 554 randomized patients, the modified intent-to-treat population consisted of 272 patients in which ACD implantation was attempted and 278 receiving control; device implantation was not attempted in 4 patients assigned to ACD. Outcomes at 3 years favored ACD for symptomatic reherniation (14.8% vs. 29.5%; P < 0.001), reoperation (11.0% vs. 19.3%; P = 0.007), leg pain (21 vs. 30; P < 0.01), back pain (23 vs. 30; P = 0.01), ODI (18 vs. 23; P = 0.02), PCS (47 vs. 44; P < 0.01), and MCS (52 vs. 49; P < 0.01). The frequency of all-cause serious adverse events was comparable between groups (42.3% vs. 44.5%; P = 0.61).ConclusionsThe addition of a bone-anchored ACD in patients with large annular defects following lumbar discectomy reduces the risk of reherniation and reoperation, and has a similar safety profile over 3-year follow-up compared with lumbar limited discectomy only.Trial registrationClinicalTrials.gov NCT01283438

Closing the Treatment Gap for Lumbar Disc Herniation Patients with Large Annular Defects: A Systematic Review of Techniques and Outcomes in this High-risk Population.

Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.

New insights into the natural course and clinical relevance of Modic changes over 2\xa0years following lumbar limited discectomy: analysis of prospective collected data

PurposeFew retrospective studies have addressed Modic changes (MC) following lumbar spine surgery, though it is usually assumed that MC increase in grade and incidence. To test this conventional wisdom, we investigated the natural course of MC following primary lumbar limited discectomy with two-year follow-up. In addition, a possible clinical relevance to those changes was assessed.MethodsThe data of the control group (278 subjects) of a prospective randomized, controlled trial (RCT) were evaluated retrospectively.ResultsWe did not observe a simple increase in MC with regard to grade. There is variable activity observed in Type 2 (at 12 months) and in Type 1 (at 24 months). Conversion from one grade to another may occur and may be upward or downward. The incidence of MC increased slightly over time, as after surgery a decreasing percentage of the study group remained without MC over two years (1 year: 34% (85/250); 2 years: 30% (72/237)). Radiological parameters (rotation, translation, and spondylolisthesis) had no significant correlation to MC or MC subtypes. Lastly, we found that neither the different MC types nor their changes were correlated with clinical parameters (VAS back, VAS leg, ODI score) preoperatively or during follow-up.ConclusionThe pattern of Modic changes following lumbar limited discectomy is complex, not simply increasing. There is variable activity in MC Types 1 and 2 at the different time points of follow-up, and conversion from a higher grader to a lower one or vice versa is possible.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

OUTCOMES OF SURGICAL TREATMENT OF LUMBAR DISK HERNIATION USING AN ANNULAR CLOSURE DEVICE

ABSTRACT Objective: The aim of the study was to investigate the clinical and radiological results of using the annular closure device in patients with lumbar disc herniation (LDH). Methods: The study involved 120 patients with LDH operated on by limited discectomy and annular closure using the Barricaid device. A literature review was conducted to evaluate the effectiveness of the annuloplasty. Results: All patients showed postoperative regression of the radicular pain syndrome and were mobilized on the day of surgery. The correlation between the removed nucleus pulposus and changes in DHI was studied by linear regression. The results revealed that disc height loss is directly correlated with the volume of removed nucleus pulposus (p &lt;0.05). Modic changes were present in 22 (22%) patients. Endplate changes (resorption and erosion) were present in 25 patients (20.7%). We found that these changes in MR and CT images have no effect on the clinical presentation of the disease. No intraoperative complications, such as severe hemorrhage requiring blood transfusion, or injury to the dura mater or nerve roots, were observed in our case series. Postoperative complications occurred in 3 (2.5%) patients. The reoperation rate was 4.2%. Conclusions: The use of the Barricaid annular closure device in 120 patients with lumbar disc herniation and high risk of recurrent herniation showed good clinical and radiographic outcomes. The reoperation rate in our study was 2.5%; disc reherniation at the operated level was observed in 1.7% of patients. This is a good outcome compared to the data reported for patients having a high risk of disc reherniation. Level of Evidence IV; Case series.

Patients at the Highest Risk for Reherniation Following Lumbar Discectomy in a Multicenter Randomized Controlled Trial.

Background:The purposes of the present study were to (1) confirm the risk of recurrent lumbar disc herniation in patients with a large anular defect who had undergone limited discectomy and (2) assess potential risk factors within this population.Methods:The patient population was extracted from the control cohort of a prospective, randomized, multicenter controlled trial investigating the efficacy of an anular closure device following standard limited discectomy. All control patients underwent limited discectomy for the treatment of a single-level symptomatic posterior or posterolateral lumbar disc herniation. Only patients presenting with a large anular defect (6 to 10 mm wide by 4 to 6 mm long) were included in the study (n = 278). Baseline demographic, clinical, and surgical characteristics were recorded. Follow-up evaluations were performed at 6 weeks and at 3, 6, 12, and 24 months. Imaging modalities included magnetic resonance imaging, low-dose computed tomography, and radiographs. Symptomatic recurrent lumbar disc herniation was defined as any symptomatic postoperative herniation on either side of the index level. A multivariate logistic regression analysis of demographic and surgical variables associated with the incidence of recurrent lumbar disc herniation was performed.Results:The mean anular defect area (and standard deviation) was 39.3 ± 9.1 mm2, and the mean excised nuclear tissue volume was 1.3 ± 0.8 mL. At 2 years, the incidence of symptomatic recurrent lumbar disc herniation was 25.3% (64 of 253), with the herniation occurring at a mean of 264 days after the index procedure. Of the 64 patients with recurrent lumbar disc herniation, 36 underwent a subsequent surgical procedure. Logistic regression analysis identified an increased risk for recurrent lumbar disc herniation in females (odds ratio, 2.2) and in patients with greater anular defect widths (odds ratio, 1.3). Furthermore, multivariate logistic regression analyses revealed a significant interaction between age and sex (p = 0.005).Conclusions:The outcomes of the present study provide the most substantial evidence to date in confirming previous reports of a high risk of reherniation among patients with large anular defects. Among those with large anular defects (width, ≥6 mm), females ≤50 years of age had the highest risk (up to ∼10 times higher) of recurrent lumbar disc herniation. It is recommended that an anular repair or closure should be performed after limited discectomies in patients with large anular defects.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of an annular closure device in a &amp;ldquo;real-world&amp;rdquo; population: stratification of registry data using screening criteria from a randomized controlled trial

PurposeIncreased focus has been put on the use of “‘real-world” data to support randomized clinical trial (RCT) evidence for clinical decision-making. The objective of this study was to assess the performance of an annular closure device (ACD) after stratifying a consecutive series of “real-world” patients by the screening criteria of an ongoing RCT.Materials and methodsThis was a single-center registry analysis of 164 subjects who underwent limited discectomy combined with ACD for symptomatic lumbar disc herniation. Patients were stratified into two groups using the selection criteria of a pivotal RCT on the same device: Trial (met inclusion; n=44) or non-Trial (did not meet inclusion; n=120). Patient-reported outcomes, including Oswestry Disability Index (ODI) and visual analog scale (VAS) for leg and back pain, and adverse events were collected from baseline to last follow-up (mean: Trial – 15.6 months; non-Trial – 14.6 months). Statistical analyses were performed with significance set at p<0.05.ResultsPatient-reported outcomes were not significantly different between groups at last (p≥0.15) and clinical success (≥15-point improvement in ODI score; ≥20-point improvement in VAS scores) was achieved in both the groups. Three non-Trial (2.5%) and three Trial (6.8%) patients experienced symptomatic reherniation (p=0.34). Rates of reoperation, ACD mesh dislocation/separation, and other radiographic findings were similar between groups (p=1.00).ConclusionOutcomes with the ACD appeared advantageous in both the groups, particularly in comparison with historical reherniation rates reported in the same high-risk, large annular defect population. Stratification of this “real-world” series on the basis of RCT screening criteria did not result in significant between-group differences. These findings suggest that the efficacy of the ACD extends beyond the strictly defined patient population being studied in the RCT of this device. Furthermore, reducing the reherniation rate following lumbar discectomy has positive clinical and economic implications.

Performance of an Annular Closure Device in a 'Real-World', Heterogeneous, At-Risk, Lumbar Discectomy Population.

Study design/settingRetrospective analysis of single-center registry outcomes data.ObjectiveAssess the utility of an annular closure device (ACD) as an adjunct to limited discectomy for lumbar disc herniation (LDH).BackgroundRecurrent lumbar disc herniation (rLDH) following limited discectomy persists at clinically significant rates, especially in large annular defect (at least 6 mm width) patients. While the etiology of reherniation is often multifactorial, inadequate annular occlusion remains one of the foremost considerations. Accordingly, annular closure has emerged as a promising technique and is the focus of this analysis.MethodsThis was a retrospective analysis of 171 patients who underwent limited lumbar discectomy with an ACD for LDH. Standardized patient assessment was performed preoperatively, three months postoperatively, and 12 months postoperatively, in addition to self-presented visits. No minimum last follow-up was required for inclusion. Oswestry Disability Index (ODI) and Visual Analog Scale (VAS Leg/Back) pain scores were collected at all visits. Plain radiographs were obtained at all visits, with magnetic resonance imaging (MRI) scans performed annually and/or when patients presented as symptomatic. ACD-related complications due to partial or complete mesh detachment from the titanium anchor were reported. All secondary surgical interventions were also reported. The Wilcoxon Rank-sum test was used to compare outcomes and events between sub-groups (p < 0.05).ResultsMean last follow-up for all patients was 15 months. Large annular defects were present in 154 patients (90%). Symptomatic reherniations were observed in six patients (3.5%; five were present in the large annular defect subpopulation). All patients demonstrated clinically meaningful improvement in clinical outcome scores at both follow-up intervals. ACD mesh detachment was observed in 15 patients (8.8%; two underwent a subsequent surgical intervention). No symptomatic reherniations were observed in secondary herniation patients compared to six (4.1%) in the primary herniation group (p = 0.60).ConclusionsAnnular closure with the ACD results in clinically meaningful improvements in both primary and secondary LDH patients, with decreased rates of reherniation in high-risk patients compared to previous discectomy reports.

Occurrence of discal and non-discal changes after sequestrectomy alone versus sequestrectomy and implantation of an anulus closure device

Sequestrectomy alone represents a procedure for the treatment of lumbar disc herniation. For selected cases, an anulus closure device (ACD) can be implanted which may result in lower reoperation rates. However, comparative magnetic resonance imaging (MRI) changes and their clinical relevance of both procedures are unclear and have not been reported so far.Clinical and MRI data of patients after limited discectomy with ACD implantation (group ACD; N=45) and patients after sequestrectomy alone (group S; N=40) with primary lumbar disc herniation were compared retrospectively. Pain intensity on the visual analogue pain scale (VAS), oswestry disability index (ODI) or the patient satisfaction index (PSI) were collected. Disc signal intensity, Modic type changes, endplate reactions, anular tears and reherniations were investigated using MRI before and <18months postoperative. Morphologic changes were correlated with clinical outcome.There was no difference in VAS back, VAS leg or ODI/PSI after the operation although group S showed significantly more reherniations in MRI. The overall rate of repeated surgery at the same level was similar with a trend in favour of the ACD group (P=0.729). Significantly more patients of the ACD group experienced endplate erosions after surgery (P<0.001). Both groups experienced progression of disc signal intensity, Modic type changes, and anular tears with most MRI signs being without clinical relevance.ACD implantation is associated with a significantly lower reherniation rate in MRI but showed a significantly higher rate of endplate erosions. The structural changes do not appear to be clinically relevant.

A multicenter, prospective, randomized study protocol to demonstrate the superiority of a bone-anchored prosthesis for anular closure used in conjunction with limited discectomy to limited discectomy alone for primary lumbar disc herniation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Same-level reherniation and progressive degeneration with disc height loss are main causes of poor outcome after discectomy and may necessitate reoperation. A novel prosthesis for anular closure was developed to address these causes.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The design of a multicenter, prospective, randomized, post-market superiority trial comparing limited lumbar discectomy augmented with this device (intervention group) with limited lumbar discectomy alone (control group) is presented.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Patients with single-level (L1-S1) posterior or posterolateral disc herniation and radiologic confirmation of neural compression for whom at least six weeks of conservative treatment has failed are eligible. Patients must have posterior disc height ≥5 mm at index level and baseline Oswestry and VAS leg pain scores of ≥40/100. Intraoperatively, subjects meeting anular defect size criteria post-discectomy (4-6 mm tall and 6-10 mm wide) will be randomized to study groups in a 1:1 ratio using centralized, web-based software. A Bayesian statistical approach will be used to enroll 400 to 800 subjects who will be followed for at least 24 months. Two co-primary endpoints will be assessed at 24 months: 1) a composite of leg pain, clinical function, disc height maintenance, and absence of reherniation, reoperation, and device failure; and 2) absence of reherniation based upon independent radiologic analysis. &lt;/p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; This type of analysis is becoming increasingly important as governments and health insurers continue to be pressured to spend limited healthcare funding wisely.

Annulus Fibrosus Repair

Intervertebral disc (IVD) herniation is a common origin of disabled spine and low back pain (LBP) which cause enormous health care toll. The annulus fibrosus (AF), which constitutes the outer part ...

Limited Microdiscectomy for Lumbar Disk Herniation

Surgical treatment of lumbar disk herniation is traditionally accomplished by removal of the extruded fragment as well as an aggressive decompression of the disk space. This retrospective study evaluates the long-term results of limited discectomy, otherwise known as fragmentectomy, for lumbar disk herniation using a minimally invasive technique. Although there are ample studies in literature regarding short-term outcome after limited microdiscectomy, there is a paucity of literature for long-term outcomes after fragmentectomy. We present long-term outcomes averaging 7 years after limited discectomy. A total of 152 patients were operated on between January 1, 2001 and June 30, 2003 for single-level herniated lumbar disks. All patients had microsurgical fragmentectomy performed through a small skin incision off the midline using a tubeless retraction system. Fifty-four patients participated in the study, whereas 98 patients were lost to long-term follow-up. Long-term outcome was assessed by telephone survey or mail-in survey using the Oswestry Low Back Pain Disability Index and a patient outcome survey. After Institutional Review Board approval and patient consent, all 54 patients had a thorough chart review for evaluation of further lumbar surgeries. The mean long-term follow-up was 86.2 months (range, 72-104 mo) or about 7.2 years. Forty-eight of the 54 patients (88.9%) reported an excellent (26 patients) or good (22 patients) long-term outcome with surgery. Long-term back and leg pain improvement was seen in 44 of 49 (89.8%) and 44 of 50 (88.0%) patients reporting back or leg pain, respectively. The mean Oswestry Disability Index for long-term follow-up was 8.89, indicating minimal disability. Same-level recurrences requiring reoperation were seen in 6 of the 54 patients who participated (11.1%) within the average 86.2-month follow-up. Four of 34 (11.85%) known contained herniations and 2 of 20 (10.0%) known extruded herniations presented for same-level surgical recurrence. All recurrences were successfully treated with reexploration and fragmentectomy. Two patients from the recurrence group and 1 from the original 54 progressed to need an arthrodesis at the initial operated level (5.6%). One patient in the same-level recurrence group and 2 patients from the original 54 developed an operative herniated disk at an adjacent level (5.6%). Our long-term outcome study shows that a minimally invasive approach to microdiscectomy with removal of the fragment only is an effective way to treat lumbar disk herniation. The rate of recurrence in our long-term study seems slightly higher compared with previously published studies, which generally had shorter follow-up periods. Long-term patient outcomes for back and leg pain were also very low. No appreciable difference in operative reherniation could be found with patients who had contained verses extruded fragments. It is difficult to predict from this study whether a simple fragmentectomy was the cause of the progression to further surgeries or whether this was the natural progression of a degenerative spine. Further prospective trials are necessary to fully understand the factors associated with limited microdiscectomy.

Answer to the Letter to the Editor of Dr. Yusuf Izci entitled “Anular closure device: Is it necessary after discectomy?” concerning “The high-risk discectomy patient: prevention of reherniation in patients with large anular defects using an anular closure device” by G. J. Bouma, M. Barth, D. Ledic, M. Vilendecic (2013) Eur Spine J; 22(5):1030–1036

Dear Editor, We appreciate the thoughtful comments by Dr. Izci. Our conclusion that an anular closure device (ACD) may prevent reherniation after limited discectomy was based on our finding of an overall symptomatic reherniation rate of 1.4 % in our patients, which compares favorably to previous studies reporting much higher rates, especially with large anular defects. The relationship between the size of the anular defect and the risk of recurrence has been well documented previously [1]. In addition, the benefits and risks of limited vs. radical discectomy have been investigated in several clinical trials showing less back pain but higher reherniation risk with limited disc removal [2]. It was our assumption that the use of an ACD may overcome the disadvantage of limited discectomy without losing the benefits. The indication for surgery in our patients was according to generally accepted standards: Persistent radicular pain (VAS ≥ 40) from an MRI-proven lumbar disc herniation that did not respond to conservative treatment for at least 6 weeks. Patients with urgent indications, e.g., progressive paresis or cauda equina syndrome, were not included in our study. We agree with Dr. Izci that the lack of randomization and a control group represents a weakness of our study, that we also alluded to in our paper. Clearly, a randomized controlled trial (RCT) is warranted and we are happy to report that such a study is currently in progress, with over 400 patients enrolled to date (http://www.clinicaltrials.gov/ct2/show/NCT01283438). The ACD is meant to remain in place permanently and will only be removed in special circumstances. The ACD was removed in one patient in our series with the assistance of a tool provided by the implant manufacturer. Following careful adhesiolysis and mobilization of the dural sac, a small rim of bone posterior to the anchor was removed, where after the device could be extracted without much difficulty. Previous reports have documented the significant costs associated with recurrent herniation after discectomy [3], and any reduction in rehernation rate that can be achieved may contribute to healthcare savings. But again, the RCT will definitively identify any healthcare savings attributable to the ACD. In line with Dr. Izci’s notion, we also tend to believe that the benefit of an ACD may be greater in patients with large anular defects, but obviously the results of the RCT will have to be awaited to answer this question with more certainty.