Lumbar Discectomy Patients Research Articles

Surgical site infection following isolated lumbar discectomy increases odds of revision lumbar surgery within first 6 months, but not beyond

BACKGROUND CONTEXTLumbar discectomy is a commonly performed surgery following which surgical site infection (SSI) may occur. Prior literature has suggested that, following SSI related to lumbar fusion, the rate of subsequent lumbar surgeries is increased over prolonged periods of time. This has not been studied specifically for lumbar discectomy. PURPOSETo define factors associated with SSI following lumbar discectomy and determine if subsequently matched cohorts with and without SSI have differential rates of subsequent lumbar surgery beyond irrigation and debridement (I&Ds) over time. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLEAdult patients undergoing isolated primary lumbar laminotomy/discectomy were identified from the 2010-2021 M157 PearlDiver database. Exclusion criteria included: age<18 years, preoperative diagnosis of infection, neoplastic, or traumatic diagnoses within 90 days prior to index surgery, additional spinal surgeries on the same day as lumbar discectomy, and not being active in the database for at least 90 days postoperative.From this study population, those who developed SSI were identified based on undergoing I&D within 90 days after surgery. Those with versus without SSI were then matched 1:4 based on age, sex, Elixhauser Comorbidity Index (ECI), and obesity. OUTCOME MEASURESFollowing initial I&D, incidence of revision lumbar surgery (revision lumbar discectomy, lumbar laminectomy, lumbar fusion) out to 5 years after lumbar discectomy. METHODSFollowing index isolated lumbar discectomy, those with versus without SSI requiring I&D were matched and compared for incidence of secondary surgery in defined time intervals (0–6 months, 6–12 months, 1–2 years, 2–5 years) using multivariable logistic regression, controlling for patient age, sex, ECI, and obesity status. RESULTSOf 323,025 isolated lumbar discectomy patients, SSI requiring I&D was identified for 583 (0.18%). Multivariable analysis revealed several independent predictors of these SSIs: younger age (odds ratio [OR] 0.85 per decade increase), ECI (OR 1.22 per 2-point increase), and obesity (OR 1.30).Following matching of those with versus without SSI requiring I&D, rates of subsequent surgery beyond I&D were compared. Those with SSI had significantly increased odds of lumbar revision in the first six months (OR 5.26, p<.001), but not 6–12 months (p=.462), 1–2 years (p=.515), or 2–5 years (p=.677). CONCLUSIONSOverall, SSI requiring I&D is a rare postoperative complication following lumbar discectomy. If occurring, subsequent surgery beyond I&D was higher in the first 6 months, but then not increased at subsequent time points out to five years.

Analysis of risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy in patients with lumbar disc herniation: a meta-analysis

BackgroundThis study aimed to systematically evaluate risk factors for post-operative recurrence after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH).MethodsThe eligible studies were retrieved from PubMed, Embase, and Web of Science databases. Quality assessment was performed. The effects of binary variables (sex, Modic change (MC), type 2 diabetes (T2DM), and smoking) on post-operative recurrence were evaluated as odds ratio (OR) and 95% confidence interval (CI). The effects of continuous variables (sagittal range of motion (SROM), body mass index (BMI), and age) were assessed as weighted mean difference (WMD) and 95% CI. Sensitivity analysis and publication bias were conducted to evaluate the reliability of pooled results.ResultsEight studies were included, and their methodological quality was medium. MC (OR (95% CI) = 3.88 (2.24–6.74), P < 0.001), smoking (OR (95% CI) = 1.87 (1.45, 2.42), P < 0.001), T2DM (OR (95% CI) = 1.61 (1.12, 2.31), P = 0.010), SROM (WMD (95% CI) = 2.33 (0.95, 3.70), P = 0.001), BMI (WMD (95% CI) = 1.68 (1.37, 1.99) kg/m2, P < 0.001), and age (WMD (95% CI) = 9.95 (5.05, 14.86) years, P < 0.001) were significantly related to post-operative recurrence in patients with LDH after PELD. Significant publication bias was not observed among studies in all outcome indicators.ConclusionOur findings reveal that high levels of age, BMI, and SROM, history of T2DM or smoking, or more MC may be correlated with post-operative recurrence after PELD.

Predictive Factors for Residual Low Back Pain Following Percutaneous Endoscopic Lumbar Discectomy in Patients with Lumbar Disc Herniation.

BACKGROUND Percutaneous endoscopic lumbar discectomy (PELD) is a mature and popular surgery for treatment of lumbar disc herniation (LDH). The main objective of our study was to identify risk factors for residual low back pain after PELD and to improve postoperative management. MATERIAL AND METHODS We retrospectively analyzed the clinical and imaging data of 251 patients who underwent PELD for LDH. We defined residual LBP as visual analog scale (VAS) score for LBP ≥3 at 2 years postoperatively, and severe LBP was defined as VAS for LBP ≥7.5. The clinical and imaging data were analyzed by comparing patients with VAS scores ≥3 and <3, and univariate analysis and multivariable logistic regression analysis were applied to predict the risk factors for residual LBP. RESULTS There were 56 (22.3%) patients with LBP VAS ≥3 at 2 years postoperatively. Multivariable logistic regression analysis demonstrated that severe baseline VAS for LBP (P<0.001), MCs type I (P=0.006), and severe fatty infiltration of the paravertebral muscles (P<0.001) were independent risk factors for residual LBP after PELD. CONCLUSIONS In patients with LDH, MCs type I, severe baseline LBP, and fatty infiltration of the paravertebral muscles were predictive factors for residual LBP after PELD. Our study suggests that spine surgeons should pay more attention to these imaging parameters, which may be a helpful indicator for the choice of surgical modality.

Emergency department visits within 90 days of lumbar discectomy

BACKGROUND CONTEXTLumbar discectomy is a common procedure following which emergency department (ED) visits may occur. Although many quality improvement initiatives target reemissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to health-care resource utilization and costs. PURPOSETo analyze the timing and risk factors predicting ED utilization following lumbar discectomy and thereby facilitate better-targeted risk reduction. STUDY DESIGN/SETTINGRetrospective database review of the 2010 to April 30th, 2021, M157Ortho PearlDiver dataset. PATIENT SAMPLESingle-level lumbar laminotomy/discectomy between 2010 and April 30th, 2021, in the PearlDiver M157Ortho dataset. OUTCOME MEASURESFunctional measures—ED utilization in the 90 days following lumbar discectomy, patient-level predictors for ED utilization, and number and type of reoperations performed in the 90 days following lumbar discectomy. METHODSLumbar laminotomies/discectomies were identified. Patients were excluded if additional procedures were performed or if there was not 90-day follow-up in the dataset. Patient factors were extracted, including age, sex, Elixhauser comorbidity index (ECI), region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of lumbar discectomy were then determined. Cohort average weekly ED utilization at 1-year postoperatively was calculated as a baseline for reference. Patient factors predictive of postoperative ED utilization were then determined with univariate and multivariate analyses. Primary diagnoses for ED visits were also categorized. Patients who underwent reoperation for complications related to lumbar discectomy following ED visits were determined, and types of reoperation procedures were characterized. RESULTSOf 281,103 lumbar discectomy patients identified, ED visits within 90 days of surgery were identified for 28,632 (10.2%). Of note, 40.4% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following lumbar discectomy, including: younger age (odds ratio [OR] 1.21 per decade decrease), female sex (OR 1.12 relative to male), higher ECI (OR 1.42 per 2-point increase), having surgery performed in the Northeast, Midwest, or West United States (OR 1.05, 1.17, and 1.13, respectively, relative to South), and Medicaid coverage (OR 1.89 relative to Medicare). Forty-three percent of ED visits were surgical site related, of which surgical site pain predominated at 34.2% of overall reasons. Of patients who visited the ED, 943 (3.3%) underwent reoperation in the subsequent 2 weeks. Laminectomy with nerve root decompression was the most performed reoperation (30.9%), followed by incision and drainage (22.5%), posterior nonsegmental instrumentation (10.3%), laminectomy facetectomy and foraminotomy (9.97%), repair of dural/CSF leak or pseudomeningocele with laminectomy (9.3%), repair of dural/CSF leak not requiring laminectomy (8.9%), arthrodesis (4.3%), and posterior segmental instrumentation (3.9%). CONCLUSIONSFollowing lumbar discectomy, over 1 in 10 patients were found to visit the ED in the 90 days following their surgery, most commonly in the first 2 postoperative weeks. Specific patient characteristics were associated with such ED visits, with the most common primary diagnoses among ED visitors being surgical site pain. About 3.3% of patients who visited the ED underwent reoperation in the subsequent 2 weeks. Through identification of the timing, risk factors, primary reasons for, and risk of reoperation following ED utilization in the 90-day period after lumbar discectomy, care pathways can be modified to improve patient satisfaction, outcomes, and reduce excess health-care expenditures.

Rheumatoid arthritis patients are at increased risk for adverse events following lumbar discectomy

BACKGROUND CONTEXTLumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes. PURPOSETo assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset. STUDY DESIGN/SETTINGRetrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset. PATIENT SAMPLEAfter exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included. OUTCOME MEASURESIncidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy. METHODSPatients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken. RESULTSMatched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all).Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000). CONCLUSIONSLumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy.

Endoscopic lumbar discectomy vs microdiscectomy: Early results, complications and learning curve an Australian perspective

BackgroundEndoscopic spine surgery has been recently introduced in Australia. A comparison of endoscopic lumbar discectomy, open or microscopic approach with learning curve is presented. Patients and methodsA retrospective observational cohort study design of Uniportal endoscopic lumbar discectomy of a single surgeon series was conducted. All patients above 18 years of age with symptomatic disc herniation and who have failed non-surgical management were selected. This data is the initial 30 consecutive uniportal endoscopic lumbar discectomy patients (group E). These were compared to the immediately prior 30 lumbar microdiscectomy (Group M) cases of the same surgeon. Demography, operative data, complications and postoperative results were collected. Learning curve duration for endoscopic cases was also examined. ResultsThere were 39 males and 21 females with mean age of 53.6 yrs. In group E there were 23 Transforaminal cases and 7 interlaminar cases. Mean operative time was 125.5 min. The first 10 cases took 181 mins, next 111mins and last 10, 84 mins showing a vast improvement with learning curve. A significant difference in operative time between transforaminal endoscopic and interlaminar endoscopic discectomy (P < 0.001) was found. On comparison of endoscopic and microscopic cases a significant difference was found in blood loss (p < 0.001) and there was an expected non-significant difference in operation time. Complication rates at 6 weeks were comparable (dural tears – 1 E, 2 M) and recurrent discs (E = 1,M = 2). An additional recurrence occurred at 20 weeks postop in the endoscopic group that required a revision discectomy surgery. ConclusionWe present an Australian perspective of endoscopic vs microscopic lumbar discectomy. Early results reveal comparable outcomes of endoscopic lumbar discectomy compared to microscopic surgery with respect to operative time, blood loss and complications. In endoscopic cases, interlaminar approach had longer operative time and complications compared to transforaminal approach. With the learning curve the operative times improved. Further studies are required to evaluate long term outcomes and complications.

Physical therapy of patients undergoing first-time lumbar discectomy: a survey of current UK practice

BackgroundThe type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers.MethodPhysical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy.ResultsSeventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription.ConclusionsWhilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.

Comparison of clinical outcomes of Endoscopic vs Microscopic lumbar discectomy: A prospective randomized controlled study

To compare clinical and functional outcomes of Endoscopic and Microscopic lumbar discectomy in patients with L3-L4, L4-L5, L5-S1 intervertebral disc prolapse. 50 patients planned for surgical discectomy, were randomized by selecting every alternate case for either ED or MD, and their outcomes were compared on basis of Pain relief by VAS at pre op and at 6 months POD, difference in surgical time, complications, number of days of stay at the hospital, patient satisfaction assessment and time to return to work.On comparing the VAS scores of both the groups at preop and at 6-month post op period, the average VAS is reduced by 74% in the Endoscopic groups (Mean VAS (preop)= 8.76 +/- 1.12 to Mean VAS (at 6months) = 1.36 +/- 1.15) while it reduced by 72.4% (Mean VAS (preop)= 8.56+/- 1.12 to Mean VAS (at 6months) = 1.36 +/- 1.142) in the microscopic group. The mean time for ED is 81.4 minutes (SD=15.38) and for MD is 85.20 minutes (SD= 19.36). 80% patients iMD patients got discharged by POD3 compared to 64% in ED. Satisfaction rates by McNab criteria in ED is 72% and in MD 64%. 60% patients with ED went back to work within POD30 compared to 40% in MD group. Both the techniques are effective and safe for lumbar discectomy, but when it comes to patient satisfaction and return to work, endoscopic method has a slight advantage whereas in levels above L4/L5 and far lateral discs, microscopic technique is the technically better choice.

Lumbar Discectomy With Barricaid Device Implantation in Patients at High Risk of Reherniation: Initial Results From a Postmarket Study.

BackgroundPatients with large defects in the annulus fibrosus following lumbar discectomy have high rates of symptomatic reherniation and reoperation. An FDA randomized controlled trial (RCT) with a bone-anchored device (Barricaid, Intrinsic Therapeutics, Woburn, MA) that occludes the annular defect reported significantly lower risk of symptomatic reherniation and reoperation compared to patients receiving discectomy only. However, results of the Barricaid device in real-world use remain limited. MethodsThis was a post-market study to determine the real-world outcomes of the Barricaid device when used in addition to primary lumbar discectomy in patients with large annular defects. Main outcomes included leg pain severity, Oswestry Disability Index (ODI), adverse events, symptomatic reherniation, and reoperation. Imaging studies were read by an independent imaging core laboratory. This paper reports the initial three-month primary endpoint results from the trial; one-year patient follow-up is ongoing.ResultsAmong 55 patients (mean age 41±13 years, 60% male), the mean percent reduction in leg pain severity was 92%, and the mean percent reduction in ODI score was 79%. The three-month rate of symptomatic reherniation was 3.6% and the rate of reoperation was 1.8%. The serious adverse event rate was 5.5%; no device migrations or fractures were observed. ConclusionAmong patients with large annular defects following lumbar discectomy treated with the Barricaid device in real-world conditions, early results demonstrated clinically meaningful improvements in patient symptoms and low rates of symptomatic reherniation, reoperation, and complications, which were comparable to those observed with the device in an FDA-regulated trial.

Characteristics of postoperative opioid prescription use following lumbar discectomy.

The role of spine surgeons in precipitating and mediating sustained prescription opioid use remains controversial at this time. The purpose of this study was to identify prescription opioid use following lumbar discectomy and characterize the source of opioid prescriptions by clinician specialty (surgeon vs nonsurgeon). Using a retrospective review, the authors identified adult patients undergoing lumbar discectomy for a primary diagnosis of disc herniation between 2010 and 2017. The primary outcome was sustained prescription opioid use, defined as issue of an opioid prescription at a time point 90 days or longer after the surgical procedure. The primary predictor variable was prescriber specialty (surgeon vs nonsurgeon). The independent effect of provider specialty on the number of opioid prescriptions issued to patients was assessed using multivariable Poisson regression that accounted for confounding from all other clinical and sociodemographic variables. This study included 622 patients who underwent a lumbar discectomy. A total of 610 opioid prescriptions were dispensed for this population after surgery. In total, 126 patients (20.3%) had at least one opioid prescription in the period beyond 90 days following their surgery. The majority of opioid prescriptions, 494 of 610 (81%), were non-inpatient prescriptions. Among these, only a minority (26%) of outpatient opioid prescriptions were written by surgical providers. Following multivariable Poisson regression analysis, surgical providers were found to have a lower likelihood of issuing an opioid prescription compared to nonsurgical clinicians (incidence rate ratio [IRR] 0.78; 95% CI 0.68-0.89; p = 0.001). A minority of lumbar discectomy patients continue to receive opioid prescriptions up to 15 months after surgery. Many of these prescriptions are written by nonsurgical providers unaffiliated with the operative team.

Risk Factors for Recurrence of Disc Herniation After Single-Level Lumbar Discectomy

Objective: Herniated nucleus pulposus is a common disease of the lumbar spine. Recurrence of disc herniation and subsequent disc degeneration are the most common problems following discectomy. Many first-time lumbar discectomy patients experience favorable outcomes; however, same-level recurrent discectomy can occasionally induce unfavorable results. Therefore, in this study, we retrospectively analyzed the risk factors for recurrence of lumbar disc herniation after discectomy.Methods: From January 2013 to December 2015, 226 patients underwent one-level discectomy in our department. We excluded patients with less than two years of follow-up, a previous spine deformity with a compression fracture, foraminal or extraforaminal discs, or a history of previous lumbar operation history, leaving 71 selected patients. Patients were divided into recurrent and non-recurrent groups and various factors were retrospectively compared between the groups.Results: Patients with preoperative disc space narrowing experienced recurrence less commonly; however, this was not statistically significant (10.0% and 25.5%, respectively; p=0.150). A disc height decrease of more than 20% during the follow-up period was a statistically significant risk factor for recurrence (36.4% and 14.3%, respectively; p=0.035), and grades 3 and 4, compared to grades 1 and 2, facet joint degeneration were also statistically significant risk factors for recurrence of disc herniation (41.2% and 14.8%, respectively; p=0.020).Conclusion: Patients who underwent more than a moderate degree of preoperative facet joint degeneration on the operated side and for whom the progression of disc space height decreased during the follow-up period may require closer observation for recurrence of disc herniation.

Burden of preoperative opioid use and its impact on healthcare utilization after primary single level lumbar discectomy

Background ContextThe complication profile and higher cost of care associated with preoperative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models. PurposeTo study the burden of pre-operative opioid use and its effect on postoperative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy. Study DesignRetrospective cohort study. Patient SampleA 29,745 patients undergoing primary single level lumbar discectomy from the IBM MarketScan (2000-2018) database. Outcome MeasuresNinety-day and 1-year utilization of lumbar epidural steroid injections, emergency department (ED) services, lumbar magnetic resonance imaging, hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months postoperatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups. MethodsPatients were categorized in opioid use groups based on the duration and number of oral prescriptions before discectomy (opioid naïve, < 3-months opioid use, chronic preoperative use, chronic preoperative opioid use with 3-month gap before surgery, and other). The risk of association of preoperative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables. ResultsA total of 29,745 patients with mean age of 45.3±9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar epidural steroid injections, magnetic resonance imaging , ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared with patients with < 3-months use and opioid naïve patients (p<.001). Chronic post-operative opioid use was present in 62.6% of the preoperative chronic opioid users as compared with 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described. ConclusionChronic preoperative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year postoperatively. Two-third of chronic preoperative opioid users had continued long-term postoperative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term postoperative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.

OUTCOME OF ENDOSCOPIC LUMBAR DISCECTOMY FOR THE TREATMENT OF SCIATICA

Objective: To evaluate the outcome of endoscopic lumbar discectomy in patients having sciatica due to single level prolapsed disc. Methodology: This descriptive study was conducted in neurosurgery departments of Lady Reading Hospital and Hayatabad Medical Complex Peshawar from June 2017 to December 2019, after approval from the ethics com­mittee. All patients with straight leg raising (SLR) less than 60 degree, failed conservative treatment and with single level prolapsed disc were included while redo cases, cauda equine syndrome and traumatic disc prolapse asso­ciated with fractures were excluded. Per operative and post operative complications were documented. Patients were followed up for 3 months. Data was collected and analyzed with SPSS version 20. Results: One hundred and fifteen endoscopic lumbar discectomies were done. There were 75 (65.2%) male and 40 (34.8%) female patients. Age range was 17 to 63 years with mean age of 31.0±2.13 years. L5-S1 was involved in 67 (58.26%) cases, L4-5 in 42 (36.52%) cases and L3-4 in 6 (5.22%) cases. Procedure time ranged from 35 to 125 min with a mean of 62 minutes. Four cases were converted to open discectomies due to technical difficulties. Sciatica pain relief was achieved in 110 (95.65%) cases. Surgical site infection was observed in 2 (1.74%) cases. Conclusion: Endoscopic discectomy has acceptable rate of complications and good post-operative pain relief.

Hypoalbuminemia and Elevated CRP are Risk Factors for Deep Infections and Urinary Tract Infections After Lumbar Spine Surgery in a Large Retrospective Patient Population.

Retrospective cross-sectional study. To determine if pre-operative albumin and CRP can predict post-operative infections after lumbar surgery. Patients who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lumbar discectomy were identified using a patient record database (PearlDiver) and were included in this retrospective study. Patients were stratified by Charlson Comorbidity Index (CCI) scores and pre-operative albumin and CRP status. Post-operative complications included deep infections and urinary tract infections within 3 months of the surgery and revisions within 1 year of the surgery. 74,280 patients were included in this study. 21,903 had pre-operative albumin or CRP lab values. 7,191 (33%), 12,183 (56%), and 2,529 (12%) patients underwent an ALIF, PLIF, and a lumbar discectomy, respectively. 16,191 did not have any complication (74%). The most common complication was UTI (16%). Among all patients, hypoalbuminemia was a significant risk factor for deep infection and UTI after ALIF, deep infection, UTI, and surgical revision after PLIF, and deep infection after lumbar discectomy. Elevated CRP was a significant risk factor for deep infection after ALIF, UTI after PLIF, and deep infection after lumbar discectomy in patients with a CCI ≤ 3. Pre-operative hypoalbuminemia and elevated CRP were significant risk factors for deep infection, UTI, and/or revision, after ALIF, PLIT, and/or lumbar discectomy. Future studies with a larger population of patients with low albumin and high CRP values are needed to further elaborate on the current findings.

Radiological predictors of recurrent lumbar disc herniation: a systematic review and meta-analysis.

Lumbar discectomy for the management of lumbar radiculopathy is a commonly performed procedure with generally excellent patient outcomes. However, recurrent lumbar disc herniation (rLDH) remains one of the most common complications of the procedure, often necessitating repeat surgery. rLDH is known to be influenced by a variety of factors, and in this systematic review the authors aimed to explore the radiological predictors of recurrence. A systematic review and meta-analysis was conducted to identify studies analyzing radiological predictors of recurrent herniation, both ipsilateral and contralateral. A search was conducted on Medline and EMBASE. Both retrospective and prospective comparative studies were included, measuring radiological parameters of lumbar discectomy patients. All factors were considered irrespective of imaging modality, and a meta-analysis of the data was performed in which 5 or more studies were identified analyzing the same parameter. In total, 1626 reported studies were screened, with 23 being included in this review, of which 13 were appropriate for meta-analysis. Three factors, namely disc height index, Modic changes, and sagittal range of motion, were determined to be significantly correlated with an increased rate of rLDH. Some variables were considered in only 1 or 2 different studies, and the authors have included a narrative review of these novel findings. The findings of associations between the radiological parameters and rLDH implicates the role of instability in the development of recurrence. Understanding the physiological factors associated with instability is important, because although early degenerative disc changes may predispose patients to herniation recurrence, more advanced degeneration likely reduces segmental motion and concurrently risk of recurrence.

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).

International Society for the Advancement of Spine Surgery Policy 2019-Surgical Treatment of Lumbar Disc Herniation with Radiculopathy.

Lumbar disc herniation (LDH) is a frequent cause of low back pain and radiculopathy, disability, and diminution in quality of life. While nonsurgical care remains the mainstay of initial treatment, symptoms that persist for prolonged periods of time are well treated with discectomy surgery. A large body of evidence shows that, in patients with unremitting symptoms despite a reasonable period of nonsurgical treatment, discectomy surgery is safe and efficacious. In patients with symptoms lasting greater than 6 weeks, various forms of discectomy (open, microtubular, and endoscopic) are superior to continued nonsurgical treatment. The small but significant proportion of patients with recurrent disc herniation experience less improvement overall than patients who do not experience reherniation after primary discectomy. Lumbar discectomy patients with large annular defects (≥6 mm wide) are at a higher risk for recurrent herniation and revision surgery. Annular closure via a bone-anchored device has been shown to decrease the rate of recurrent disc herniation and associated reoperation in these high-risk patients. After a detailed review of the literature, current clinical evidence supports discectomy (open, microtubular, or endoscopic discectomy) as a medically necessary procedure for the treatment of LDH with radiculopathy in indicated patients. Furthermore, there is new scientific evidence that supports the use of bone-anchored annular closure in patients with large annular defects, who are at greater risk for recurrent disc herniation.

Frequency of Discitis in Lumbar Discectomy Patients: A Two Year Study

Objective: Aim of conducting the study was to evaluate the incidence of post op discitis in lumbo-sacral disc surgeries.Materials and Methods: This observational prospective study was carried out in Neurosurgery unit Hayatabad Medical Complex, Peshawar for 12 months (1st July 2017– 30thJune 2019).A total of 250 patients operated for lumbar disc surgeries were enrolled in the study, both genders and age range of 16-60 were in inclusion criteria.Patients with co-morbidities e.g., poorly controlled diabetics and immunosuppressed patients were excluded from the study. All patients were followed to calculate the frequency of discitis. Results: Among the 250 cases, 11 (4.4%) were diagnosed with discitis. 15% cases had slight sign and symptoms, pain and surgical scar tenderness not warranting the diagnosis of discitis. The mean age in this study was 37 years with Standard Deviation of 13.769. Male cases were 133 (53.2%) while females were 117 (46.8%). Discitis was more common at L4-5.Conclusion: From this data it was concluded that incidence of discitis is slightly higher in our setup than international discitis incidence/rates. The possible reason could be (to some extent) due to inefficient/poorly resourced infection prevention committee and partly due to less standardized OT system in comparison to international OT complex standards.

Analysis of Efficacy of Depo-Med Role Injection in Post-Operative Pain Relief for Lumbar Discectomy Patients

Objectives: The main objective of the study was to analyze the efficacy of Depo-medrole injection in post-operative pain relief after lumbar discectomy. Material and Methods: This study was conducted in the Neurosurgery department of Mayo Hospital KEMU, Lahore during March 2018 to September 2018. The data was collected from 50 patients of lumbar discectomy randomly into two groups. One was operated patients and in group 2 patients were injected with local Depo-med role after lumbar discectomy. We studied the efficacy of Depo-med role injection in the second group. Pain intensity was measured using VAS from the whole sample at two weeks, four weeks, three months and last at one year post operatively.&#x0D; Results: Data were collected from 50 patients. These patients were divided into two groups, 25 in group one and 25 in group two. The mean age of group one was 30.14 ± 8.15 and for group two was 29.82 ± 7.16. Both groups neither contrasted by age (p = 0.187) nor as indicated by term of side effects (p = 0.639) at the season of operation.&#x0D; Conclusion: The usage of low dose Depo-med role decreased an abrupt lumbago and pain leg after surgery effectively. But it needs more observations due to small nonrandomized sample.