Microscopic Lumbar Discectomy Research Articles

Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis.

Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis. Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English. Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13). It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.

Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A Preliminary Analysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials.

A preliminary report from a single institution, noninferiority, prospective randomized controlled trial is conducted to determine the effectiveness of interlaminar endoscopic lumbar discectomy (IELD) versus microscopic lumbar discectomy (MLD) for the treatment of L5-S1 lumbar disc herniation (LDH). This prospective, noncrossover, randomized controlled trials was conducted at a single neurosurgical center. Patients with symptomatic radiculopathy or intermittent neurogenic claudication caused by LDH were enrolled from July 2016 to July 2021. The study compared the effectiveness of microscopic and full-endoscopic discectomy procedures. Outcome measures included visual analogue scale (VAS) scores for back and leg pain, Oswestry Disability Index scores, radiologic measurements, endurance time of walking, and satisfaction rate. Of 37 assessed patients, both IELD and MLD groups demonstrated significant improvements in VAS scores for pain over time, with no significant difference between them. For secondary outcomes, the IELD group had a shorter hospital stay and reduced blood loss but a longer operation time than the MLD group. Radiographic evaluations showed no change compared to preoperative data. Patient satisfaction and recovery rates were slightly higher for the MLD group, but both groups were comparable in most evaluations, with complications being minimal. The IELD was noninferior in improving the intensity of back and leg pain and functional disability, compared to the MLD. Additionally, the IELD showed no difference in clinical outcomes for patients in terms of radiographic results and patient satisfaction rates. The results of this research preliminarily demonstrate that the IELD could be considered an effective alternative to MLD for L5-S1 central or paracentral LDH.

Minimally Invasive Microscopic Lumbar Discectomy for Treatment of Cauda Equina Syndrome, Is It Effective?

Minimally Invasive Microscopic Lumbar Discectomy for Treatment of Cauda Equina Syndrome, Is It Effective?

Comparison of Postoperative Bone Healing in Patients With Unilateral Biportal Endoscopic Lumbar Discectomy and Microscopic Lumbar Discectomy

Objective: Unilateral biportal endoscopic lumbar discectomy and microscopic lumbar discectomy are typical surgical treatments for spinal disease that are performed in different environment. This study investigated differences in bone healing at the postoperative laminecrtomy site between 2 surgical treatments performed in different environments.Methods: From January 2018 to June 2021, 66 patients who underwent laminectomy at Department of Neurosurgery, Gangnam Severance Hospital were retrospectively reviewed. All patients were matched for sex, age, body mass index, bone mineral density, and follow-up duration at a 1:2 matching ratio and were divided into the UBE group (22 patients) and the microscopic discectomy group (44 patients). We investigated the site of laminectomy shown on preoperative and postoperative x-ray images using ImageJ software. The factors related to bone healing were also investigated.Results: The average bone healing area was 69.59 mm<sup>2</sup> in the UBE group and 44.56 mm<sup>2</sup> in the microscopic discectomy group, constituting a significant difference (p = 0.022). The remaining laminectomy area was significantly lower in the UBE group than in the microscopic discectomy group (13.91 mm<sup>2</sup> vs. 53.84 mm<sup>2</sup>, p < 0.001). The bone recovery ratio in the UBE group was 85.42%, compared to 51.33% in the microscopic discectomy group, which was a significant difference (p < 0.001). The primary laminectomy area, bone healing during 6 months, and clinical outcomes were not significantly different between the 2 groups.Conclusion: Compared with the microscopic discectomy group, the UBE group had a larger bone healing area and a higher bone recovery ratio for patients with lumbar discectomy. These findings suggest that preserving normal structures is more feasible during UBE than during microscopic surgery.

MANAGEMENT OF DURAL TEARS IN ENDOSCOPIC LUMBAR SPINE SURGERY – A SYSTEMATIC REVIEW STUDY

Lumbar degenerative disorders are the most common cause of low back pain with or without radicular pain(1) .Lumbar decompression and discectomy are two major and commonly performed surgeries for patients not responding to conservative management. Microscopic lumbar discectomy and decompression are gold standard to treat these diseases(2). Endoscopic lumbar spine surgeries are being done at more and more centers since last decade(3). Dural tears are common but troublesome complication of Endoscopic Spine surgeries. Management of the same is well dened in Microscopic lumbar discectomy but not clearly dened for tears during endoscopic surgeries. Therefore, this study is an attempt to establish management principles after extensive reviewing of studies on management principles of iatrogenic dural tears during endoscopic spine surgeries till date. PRISMA (Preferred Methodology: reporting items for systematic reviews and meta-analyses) guideline was used. A search of articles in PubMed, MEDLINE, Embase published between were included in the screening process. For identication of studies included detailed computerized literature search strategies were carried out in these databases. Total of 1569 studies on 'Dural tear Study selection: s ' were identied from electronic database from year 1947 to 2023 searching. Out of those 1569 studies, 180 studies were regarding Dural tears in endoscopic spine surgeries. After exclusion, 7 studies qualied the inclusion criteria and were included as per eligibility criteria for further analysis. Objective of this study is to do a systematic review on present guid Objective: elines for management of dural tears in endoscopic spine surgery

Survey research of patient's preference on choosing microscopic or endoscopic spine surgery for lumbar discectomy.

There are several surgical methods of lumbar discectomy which provide the similar clinical outcomes. There is no clear evidence for how to select the procedures. To better understand the patient's opinion and decision process in the selection of surgical methods between microscopic lumbar discectomy (MLD) and endoscopic lumbar discectomy (ELD). A cross-sectional survey study. Summary information sheet was created by reviewing the comparative literatures, and tested for quality and bias. Participants read the summary information sheet then were asked to complete the anonymous questionnaire. Seventy-six patients (71%) of patients who had no experience in lumbar discectomy selected ELD while 31 patients (29%) selected MLD. There were significant differences of score between patients who selected MLD and ELD in this group for wound size, anesthetic method, operative time, blood loss and length of stay (P< 0.05). In patients who had experience in discectomy group, 22 patients (76%) who underwent MLD still selected MLD if they could select surgical methods again for themselves, while 24 patients (96%) who underwent ELD still selected ELD if they could select again. The most important factor in patients who selected MLD was outcomes of treatment. The most important factor in patients who selected ELD was wound size. There were significant differences of scores between patients who selected MLD and ELD in this group for wound size, anesthetic method, operative time, complication, cost and length of stay (P< 0.05). About two thirds of the participants preferred ELD after reading the summary evidence information. The most important factor in MLD group was outcomes of treatment while the most important factor in ELD group was wound size.

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.

How I do it: biportal endoscopic paraspinal approach for recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy.

Although percutaneous endoscopic lumbar discectomy (PELD) has been popularized as an alternative to microscopic lumbar discectomy, it has been reported to be associated with a re-herniation rate of 5-11%. Recurrent lumbar disc herniation (RLDH) might occur not only at the same level previously operated upon but also at the annular penetration site created during PELD procedures. Biportal endoscopic paraspinal approach (BE-Para) was used for revisional foraminal lumbar discectomy. Procedures and some discussions regarding indications, advantages, potential complications, and ways to avoid complications were described. BE-Para may be an effective modality for RLDH after PELD.

Minimally invasive surgical management of symptomatic lumbar disc herniation: can the endoscope replace the microscope?

BackgroundDegenerative lumbar spine pathologies such as spinal stenosis and disc herniation constitute the most common causes of back pain and radiculopathy. After the introduction of the operative microscope in the 1970s, microscopic discectomy has become the gold standard of treatment for herniated lumbar disc by many surgeons. A tubular endoscopic approach was first described in 1997 by Foley and Smith as a new minimally invasive technique alternative to open surgical techniques. The objective of this study is to evaluate the outcome and efficacy of microscopic discectomy and endoscopic discectomy for the management of herniated lumbar disc as regard the clinical results, operation time, intraoperative blood loss, and postoperative complications.ResultsThis is a retrospective study of 40 patients, with symptomatic lumbar disc herniation managed by the authors either by microscopic discectomy (MD) (n = 20) or by endoscopic discectomy (ED) (n = 20). Patients were followed up and postoperative data was recorded at 1, 6, 12 months after surgery. Clinical scoring systems included the Visual Analog Scale (VAS) for the preoperative and the postoperative low back ache (VAS-B) as well as preoperative and postoperative sciatic pain (VAS-S), in addition to the evaluation of the modified Japanese Orthopedic Association scale (mJOA) over the same time intervals. Significant postoperative improvement in clinical and functional outcome of the two groups was noted, including a statistically significant improvement in postoperative VAS-B and VAS-S as well as the mJOA scores in comparison to the preoperative data (p = 0.001). There was a statistically significant shorter operative time, less blood loss and less rate of operative complications recorded in the microscopic discectomy group as compared with endoscopic discectomy group in our study.ConclusionsOur study concluded that microscopic lumbar discectomy is as safe and effective as endoscopic lumbar discectomy for the management of symptomatic lumbar disc herniation with a low complication rate, less operative blood loss and operative time. Larger series and further studies would be yet considered with longer follow-up periods.

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.

Endoscopic and Microscopic Interlaminar Discectomy for the Treatment of Far-Migrated Lumbar Disc Herniation: A Retrospective Study with a 24-Month Follow-Up.

PurposePercutaneous endoscopic lumbar discectomy for the treatment of far-migrated lumbar disc herniation (LDH) is clinically challenging. The aim of this study was to compare the efficacy and safety of interlaminar endoscopic lumbar discectomy (IELD) and interlaminar microscopic lumbar discectomy (IMLD) for the treatment of far-migrated LDH.Materials and MethodsWe retrospectively analyzed 50 consecutive cases of far-migrated LDH treated by IELD or IMLD. Clinical data and outcomes were assessed before the operation and 1 day and 3, 12, and 24 months after the surgery using the visual analog scale (VAS) and Oswestry disability index (ODI). Modified MacNab criteria were used to evaluate patient satisfaction at the 24-month follow-up.ResultsA significant reduction in leg pain and improvement in ODI (P<0.01) were observed in both groups after surgery. Lower back pain (LBP) was reduced at 24 months postsurgery in the IELD group (P<0.05) but not in the IMLD group (P>0.05). There were significant intergroup differences in VAS LBP score at 1 day and 24 months postsurgery (p=0.01 and 0.02, respectively) and in ODI at 24 months (p=0.03). The rate of excellent or good outcome was 90.32% with IELD and 78.95% with IMLD (p=0.55). Hospital stay and time to ambulation were shorter in the IELD group than in the IMLD group, but the former had a longer operative time (p<0.01). Low and comparable complication rates were reported in the IELD (16.13%) and IMLD (10.53%) groups (p=0.70).ConclusionBoth IELD and IMLD achieve favorable clinical results in the treatment of far-migrated LDH, with only minor complications. Compared to IMLD, LBP was significantly reduced with IELD presumably because it involved less trauma.

Quality of life after lumbar microsciopic discectomy

Introduction&#x0D; Lumbar disc herniation also known as prolapsed intervertebral disc is one of the well-known causes of low back pain. Among various modalities of treatment, surgery is often kept as the last resort when conservative treatment fails. Conventional surgical methods have been replaced by minimally invasive surgeries like microscopic, endoscopic and percutaneous lumbar discectomy in the hopes of decreasing post-operative pain. However, it is not uncommon for patient to have residual pain even after discectomy. Patients also complains of reduced quality of life (QOL). SF-36 is a standardized questionnaire for measuring QOL. Few studies have used this questionnaire to look into QOL of these patients but no such study is available in Nepalese perspective.&#x0D; Materials and Methods&#x0D; A prospective cross-sectional study was conducted among all patients undergoing single level unilateral microscopic lumbar discectomy in Upendra Devkota Memorial National Institute of Neurological Sciences from February 1st 2017 to January 31 2018. After taking informed consent, subjects were asked to respond to the preformed questionnaire and SF-36 survey. Interviews were individually conducted by the same investigator at two different time points: i) before lumbar discectomy. ii) 3 months after lumbar discectomy. QOL scores before and after were compared.&#x0D; Results&#x0D; Total of 50 patients meeting the inclusion criteria were studied. The mean age of the study group was 38.7 ± 9.9 years with male preponderance of 76%. The median duration of exacerbation of symptoms was 4 weeks. Along with pain, 64% had sensory deficit whereas 52% had motor deficit. Surgery led to significant improvement in pain score as well as marked improvement of SF 36 quality of life score at 3 months of surgery. However, age, gender, duration of symptoms or presence of sensory or motor deficit before surgery did not predict improvement in overall QOL.&#x0D; Conclusion&#x0D; Patients undergoing microscopic lumbar discectomy for prolapsed intervertebral disc have significant improvement in pain score and QOL after 3 months of surgery.

Intraoperative findings, complications, and short-term results after lumbar microdiscectomy with or without implantation of annular closure device.

Standard microscopic lumbar discectomy (MLD) is a short operation with minimal blood loss, and a low rate of peri- and intraoperative complications. The objective of this study was to evaluate intraoperative findings, complications, and early postoperative neurological outcome (< 105days) in patients undergoing MLD with or without implantation of an annular closure device (ACD). This study is based on data analysis of a post-marketing, prospective, multicenter RCT in Europe including patients undergoing standard MLD with or without implantation of an ACD (Barricaid®, Intrinsic Therapeutics, Inc., Woburn, MA). Enrollment of 554 patients in 21 centers in Europe (Germany, Switzerland, Austria, Belgium, The Netherlands, and France) started in 2010 and was completed in October 2014, with 276 patients randomized to the ACD group and 278 to the control group. Mean operation time was 70min in the ACD group and 52min in the control group (p < 0.0001). Intraoperative fluoroscopy time was 24s in the ACD group and 7s in the control group (p < 0.0001). Average blood loss was 94.2ml in the ACD group and 64.7ml in the control group (p = 0.0001). Serious device- or procedure-related adverse events occurred in 3.7% (10/272) of the ACD group and 7.9% (22/278) of the control group. Dural injuries occurred in 13 (4.8%) patients in the ACD group and 7 (2.5%) in the control group. There was one device-related nerve root injury resulting in a nerve root amputation. Surgical complications included 3 hematomas in the ACD group and 4 in the control group; 3 infections occurred in both groups. Device migrations were documented in 3 patients in the ACD group. Patients in the ACD group (n = 7, 2.6%) underwent fewer reoperations compared with that in the control group (n = 16, 5.8%, OR = 2.3 (0.9-5.7)). Mean VAS leg pain at 3months was 11.9 in the ACD and 15.1 in the control group, respectively. Short-term outcome after MLD with or without implantation of ACD was similar in both groups. Patients included in the ACD group underwent fewer reoperations in the first 3months after surgery. Nevertheless, longer operation time, higher amount of blood loss, and risk of nerve root lesion during device implantation should be considered additional risks in patients undergoing ACD implantation after MLD.

Functional outcome of microscopic lumbar discectomy for the treatment of lumbar disc prolapse in tertiary care hospital in South India

Functional outcome of microscopic lumbar discectomy for the treatment of lumbar disc prolapse in tertiary care hospital in South India

Preoperative MRI predictors of health-related quality of life improvement after microscopic lumbar discectomy

BACKGROUNDLumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD. PURPOSETo analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD. STUDY DESIGN/SETTINGRetrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period. PATIENT SAMPLEEighty-eight patients receiving MLD treatment for HNP. OUTCOME MEASURESCephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores. METHODSPatients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID–). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID– groups. RESULTSThere were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=−0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm2), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID– patients had in five out of six HRQoL score comparisons (116.6 mm2±46.4 vs 90.0 mm2±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID– patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05). CONCLUSIONSPatients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.

54. Preoperative MRI predictors of health related quality of life improvement after microscopic lumbar discectomy

54. Preoperative MRI predictors of health related quality of life improvement after microscopic lumbar discectomy

219. Evaluation of health related quality of life improvement in patients undergoing spine vs adult reconstructive surgery

BACKGROUND CONTEXT The discussion regarding value based care has evolved in recent years, yet the ability to report Health Related Quality of Life (HRQoL) between different disease states has been limited by lack of validated standardized metrics to compare them. The recent advent of computer adaptive Patient Reported Outcome Information System (PROMIS), which allows for standardized assessment across health conditions, provides the ability to compare differing disease states and procedures. PURPOSE To compare baseline and postoperative PROMIS scores for patients undergoing common single-level spinal surgery procedures, total hip arthroplasty (THA) and total knee arthroplasty (TKA). STUDY DESIGN/SETTING Retrospective clinical cohort study of patients undergoing common single-level spine surgery procedures, THA and TKA at 6-month postoperative follow-up. PATIENT SAMPLE A total of 505 orthopedic surgical patients were included who underwent either: single level anterior cervical discectomy and fusion (ACDF, N=37), lumbar laminectomy (Lami, N=31), microscopic lumbar discectomy (MLD, N=58), transforaminal lumbar interbody fusion (TLIF, N=46), total hip arthroplasty (THA, N=131), or total knee arthroplasty (TKA, N=202) at a single institution. OUTCOME MEASURES Baseline (BL) and 6 month (6M) PROMIS metrics (Physical Function, Pain Interference, Pain Intensity). Patients were compared by T-values, which is age and gender adjusted to give a normal distribution of the general population, as the mean is scored at 50, and each 10 point deviation reflects 1SD of the population in improving or worsening function. METHODS Patients>18 years old who underwent spine surgery (ACDF, Lami, MLD, TLIF) or adult reconstruction surgery (THA or TKA) with BL & 6M PROMIS scores of physical function, pain interference and pain intensity were separately grouped based on surgery type. Paired t-tests compared differences in BL, 6M and the change in PROMIS scores for spine vs adult reconstruction procedures. RESULTS A total of 172 spine surgery patients (age=54.6±15.6; 42.9% female) and 333 adult reconstruction patients were compared (age=65.8±9.5; 59.8% female). Spine surgery patients were significantly younger (p CONCLUSIONS Patients undergoing single level spinal surgery had lower initial and 6 month postoperative PROMIS scores compared to those undergoing total hip and knee arthroplasty. All procedure cohorts demonstrated meaningful improvement after orthopaedic surgical treatment, but spinal surgery patients demonstrated more improvement in physical function and pain interference scores compared to arthroplasty patients. Future study is required to assess the value base of spinal and adult reconstruction surgery, including durability. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation.

Study Design:Retrospective cohort study.Objective:To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients.Methods:Patients with primary treatment for an HNP at a single academic institution between November 2012 to March 2017 were divided into MLD and nonoperative treatment groups. Using magnetic resonance imaging (MRI), axial HNP area; axial canal area; HNP canal compromise; HNP cephalad/caudal migration and HNP MRI signal (black, gray, or mixed) were measured. T test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors.Results:A total of 285 patients (78 MLD, 207 nonoperative) were included. Risk factors for MLD treatment included larger axial HNP area (P < .01, OR = 1.01), caudal migration, and migration magnitude (P < .05, OR = 1.90; P < .01, OR = 1.14), and gray HNP MRI signal (P < .01, OR = 5.42). Cutoff values for risks included axial HNP area (70.52 mm2, OR = 2.66, P < .01), HNP canal compromise (20.0%, OR = 3.29, P < .01), and cephalad/caudal migration (6.8 mm, OR = 2.43, P < .01). MLD risk for those with gray HNP MRI signal (67.6% alone) increased when combined with axial HNP area >70.52 mm2 (75.5%, P = .01) and HNP canal compromise >20.0% (71.1%, P = .05) cutoffs. MLD risk in patients with cephalad/caudal migration >6.8 mm (40.5% alone) increased when combined with axial HNP area and HNP canal compromise (52.4%, 50%; P < .01).Conclusion:Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

Feasibility and Safety of Outpatient Lumbar Microscopic Discectomy in a Developing Country.

Study DesignProspective study.PurposeTo verify the feasibility and safety of outpatient microscopic lumbar discectomy (MLD) in a developing country.Overview of LiteratureOutpatient MLD is advantageous in terms of cost effectiveness and avoidance of nosocomial infections. Safety of outpatient MLD has been well established in the developed nations of North America and Europe. There is no published study of outpatient MLD from the rest of the world, especially in developing countries.MethodsFifty-eight consecutive patients undergoing outpatient MLD with a median follow-up time of 12 months (range, 6–21 months) were included in this study. Simultaneous patient counseling was done by a surgical and anesthetic team preoperatively and pre-discharge. We collected and analyzed data pertaining to the demography, socioeconomic status, perioperative parameters, complications, and outcome assessment scores of the patients.ResultsThe average patient age was 37.8±9.6 years (39 males, 19 females). Unilateral discectomy was performed in 55 patients, and bilateral discectomy in three. The majority (80.3%) of the patients were classified to lower middle (III) or upper lower (IV) class on the Modified Kuppuswamy Scale. The average operative time was 41.0±8.4 minutes with an average blood loss of 42.6±14.9 mL. The average postoperative stay was 5.5±0.7 hours and the successful discharge rate was 100%. Complications noted were postoperative nausea (n=8), urinary retention (n=2), meralgia paresthetica (n=3), delayed wound healing (n=2), and recurrence (n=1). The successful outcome rates were Visual Analog Scale (VAS) score leg pain, 93.1%; VAS score back pain, 89.6%; Oswestry Disability Index score, 91.3%; return to activities of daily living, 94.8%; return to work, 79.3%; patient satisfaction rate, 82.7%; and overall success rate, 88.4%.ConclusionsOutpatient MLD can be safely performed with success, even in the setting of a developing country, if the prerequisites of appropriate patient selection, arduous adherence to outpatient surgery protocol, competent surgical/anesthetic team, and infrastructure needed for conduction of microsurgery are met.

Intraoperative epidural application of steroid and local anaesthetic agent following lumbar discectomy: A prospective double blinded randomized controlled trial

BackgroundPostoperative pain management following lumbar discectomy is a key part of the procedure and various postoperative pain protocols including a wide range of agents are being used in daily practice worldwide. The aim of this study is to investigate the effect of intraoperative epidural infiltration of local anaesthetic and steroid compared with placebo (normal saline) following microscopic lumbar discectomy. MethodsSixty patients undergoing lumbar discectomy were randomized to intraoperative infiltration of 3 mg betamethoasone acetate and 18 mg ropivacaine (Group A) or normal saline (Group B). Infiltration was performed after discectomy and decompression and immediately prior to incision closure. Postoperatively a standard protocol of intravenous acetaminophen administration and physiotherapy was followed. Additional analgesia with tramadol was given only in patients who required further pain management. Postoperative pain was evaluated using VAS score. Opioid consumption was recorded. Primary outcome measures included immediate postoperative back pain VAS score, opioid consumption and infection rate. Patients were reviewed in clinic at 6 weeks, 6 months and 1 year postoperatively. ResultsNone of the patients in Group A required further analgesia while 12 Group B patients required further treatment with tramadol (p = 0.01). At 3 h postoperatively the VAS score was significantly lower in Group A compared to Group B (p < 0.05). Fifty-seven patients completed the 1 year follow up (95%) and 2 patients (1 from each group) suffered a complication of postoperative radiculopathy. ConclusionIntraoperative application of steroid and local anaesthetic agent is effective on pain reduction for only a short period after surgery, while there is no effect on infection rate or any other long-term outcome compared with placebo. Hence although it is a safe technique, its benefits are limited from the duration of action.