Open Lumbar Discectomy Research Articles

Postoperative Trichosporon asahii Spondylodiscitis After Open Lumbar Discectomy

A case report of Trichosporon asahii spondylodiscitis. To report the first case of T. asahii spondylodiscitis that developed in a healthy woman at the site of an open lumbar discectomy. Trichosporon is a genus of basidiomycetous yeasts that is common in nature and a member of the normal flora of the mouth, skin, and nails. It causes deep infections and fungemia mainly in immunocompromised patients or patients with underlying hematologic malignancies. To our knowledge, there is no reported case of bone and joint infections caused by T. asahii. A 42-year-old female gynecologist was transferred to our hospital with a chief complaint of severe lower back pain after an open L4-L5 discectomy. The infection indexes showed an elevated erythrocyte sedimentation rate and the C-reactive protein. Despite bed rest and antibiotic therapy, the lower back pain and tingling sensation on both lower extremities continued to worsen. The magnetic resonance imaging showed an abscess-like fluid collection compressing the thecal sac and showed a signal change in the bone marrow of the L4 and L5 vertebral bodies, suggesting spondylodiscitis. Laminectomy, curettage, and debridement of the infected discs were performed. Cultures of the abscess yielded yeasts that were sensitive to fluconazole. The yeast was identified as T. asahii. She received fluconazole therapy for 5 months, and returned to her work after the fourth postoperative month. She has remained in a satisfactory condition since. We present the first case of T. asahii spondylodiscitis, which developed unexpectedly in a healthy woman at the site of an open lumbar discectomy. We successfully treated the patient with surgical debridement and 5 months of fluconazole therapy.

Long-term outcomes of the revision open lumbar discectomy by fenestration: a follow-up study of more than 10 years

To evaluate the long-term clinical results and the factors that influences the outcomes of the revision open lumbar discectomy by fenestration. Fifty-one patients, who underwent the second open discectomy by fenestration from January 1 1988 to December 31 1994, were followed for an average of 146.8 months (range, 120 to 203 months). The long-term follow-up results were evaluated by using the MacNab classification and the Japanese Orthopaedic Association (JOA) scoring system through direct examinations and questionnaires. Radiography was also used in patients who agreed to visit the hospital, and findings were compared with those on preoperative radiographs. At the final follow-up, with the MacNab classification an excellent and good outcome was achieved in 70.6% of the cases, 78.4% were satisfied with their results. The failure rate was 15.7% (8 patients). Excluding those 8 failed cases who needed another reoperation, the average improvement calculated by JOA scores was (64.6 +/- 18.2)%. The disc height of the operation site significantly decreased after surgery, nevertheless, this did not affect the long-term clinical outcome. Factors that were associated with a fair and bad outcome included smoking, isolated trauma or injury, fibrosis and the length of the remaining or recurrent primary postoperative symptoms history. Psychosociological signs were probably known as negative predictors of lumbar disc surgery outcome. The long-term outcome of the revision open lumbar discectomy by fenestration in this series was favorable. Because the revision operation is typically associated with a higher complexity, selection of suitable surgical candidates and determination of valid indications for operative treatment are very important. JOA scores have proved to be easy to perform for patients and clinicians and standardize subjective data.

Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy

The magnitude of the tissue damage from surgery impacts the trauma response. This response is proportional to the severity of surgical stress. Systemic cytokines are recognized as markers of postoperative tissue trauma. Microendoscopic discectomy (MED) recently has become popular for treating lumbar disc herniations, and is associated with favorable clinical outcomes compared with open discectomy (OD). This study postulates that MED is a less traumatic procedure, and therefore has a lower surgical stress response compared to OD. In this study, a quantitative comparison of the overall effects of surgical trauma resulting from MED and OD was performed through analyzing patient systemic cytokines response. From April, 2002 to June, 2003, 22 consecutive patients who had symptomatic lumbar disc herniations were prospectively randomized to undergo either intracanalicular MED ( N = 10) or OD ( N = 12). In this study, the Vertebroscope System (Zeppelin, Pullach, Germany) was used to perform the endoscopic discectomy procedure in all MED patients. Serum levels of tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6), and Interleukin-8 (IL-8) were measured before surgery and at 1, 2, 4, 8 and 24 h after surgery using an enzyme-linked immunosorbent assay. Serum C-reactive protein (CRP) was measured at the same time interval. The results showed the MED patients had shorter postoperative hospital stay (mean, 3.57 ± 0.98 vs. 5.92 ± 2.39 days, p = 0.025) and less intraoperative blood loss (mean, 87.5 ± 69.4 vs. 190 ± 115 ml, p = 0.042). The operating length, including the set-up time, was longer in the MED group (mean, 109 ± 35.9 vs. 72.1 ± 17.8 min, p = 0.01). The mean size of skin incision made for the MED patients was 1.86 ± 0.13 cm (range 1.7–2.0 cm); and 6.3 ± 0.98 cm for the OD patients (range 5.5–8 cm), p = 0.001. The patients’ pain severity of the involved limbs on 10-point Visual Analog Scale before operation in MED group was 7.5 ± 0.3 (range 6–9) and 8 ± 0.2 (range 7–9) in OD group, p = 0.17; and after surgery, 1.5 ± 0.2 (range 1–2) in MED group and 1.4 ± 0.1 (range 1–3) in OD group, p = 0.91. CRP levels peaked at 24 h in both groups, and OD patients displayed a significantly greater postoperative rise in serum CRP (mean, 27.78 ± 15.02 vs. 13.84 ± 6.25 mg/l, p = 0.026). Concentrations of TNF-α, IL-1β, and IL-8 were detected only sporadically. Serum IL-6 increased less significantly following MED than after OD. In the MED group, IL-6 level peaked 8 h after surgery, with the response statistically less than in the open group (mean, 6.27 ± 5.96 vs. 17.18 ± 11.60 pg/ml, p = 0.025). A statistically significant correlation was identified between IL-6 and CRP values ( r = 0.79). Using the modified MacNab criteria, the clinical outcomes were 90% satisfactory (9/10) in MED patients and 91.6% satisfactory (11/12) in OD patients at a mean 18.9 months (range 10–25) follow-up. Based on the current data, surgical trauma, as reflected by systemic IL-6 and CRP response, was significantly less following MED than following OD. The difference in the systemic cytokine response may support that the MED procedure is less traumatic. Moreover, our MED patients had achieved satisfactory clinical outcomes as the OD patients at a mean 18.9 months follow-up after surgery.

Minimally invasive open lumbar discectomy: An alternative to microlumbar discectomy

Lumbar disc surgery has come a long way since its fi rst description by Dandy in 1929. Evolving through the transdural approach and a laminectomy for the removal of a disc, it now surpasses the primal technique with essentially a minimally invasive procedure, an extradural approach without laminectomy. The objective of this study is to ascertain the effectiveness of Minimally Invasive Open Lumbar Discectomy in the treatment of lumbar disc prolapse. It is a descriptive study entailing the patients with paramedian or central disc prolapse at single or two consecutive lumbosacral levels undergoing surgery at the National Institute of Neurological and Allied Sciences, Bansbari, Nepal, over a period of one and a half years. Patients who underwent either laminectomy or bilateral fenestration were excluded. Results of surgery were measured prospectively in terms of primary outcome measure (outcome at six months follow up as measured with Prolo Functional and Economic Scale) and secondary outcome measures (radicular pain relief, mobilisation, complication, and residual disc). In the series of 137 consecutive patients, 120 fulfilled the criteria. 98.33 % of patients had an improvement in the radicular pain and ambulation was commenced from the fi rst post-operative day. There were three instances of inadvertent dural tear without fascicle injury, and one instance of residual disc requiring reoperation. At 6 months, 97.5 % had good to excellent (grade 4, or 5) results reaching the premorbid states in the Prolo Functional and Economic Scale. The results of Minimally Invasive Open Lumbar Discectomy compare favourably with those of a microlumbar discectomy, and could therefore be an alternative to the latter in resource deprived circumstances.