Outcome Of Lumbar Discectomy Research Articles

Outcomes of lumbar discectomy

COMMENTARY ON: Sherman J, Cauthen J, Schoenberg D, et al. Economic impact of improving outcomes of lumbar discectomy. Spine J 2010;10:108–116 (in this issue) .

Economic impact of improving outcomes of lumbar discectomy

Background Lumbar discectomy is usually a successful operation with a relatively low cost. Potential adjunctive procedures, such as repairing the anulus fibrosus or nucleus replacements, necessitate a cost-benefit analysis. Purpose This economic analysis was performed to understand the potential value of advanced implantable technologies designed to improve outcomes after discectomy. Study design/setting Using an insurance claims–based database, the economics of less-than-favorable outcomes after lumbar discectomy were studied. Estimates of improved clinical outcomes because of adjunctive surgical procedural items were modeled. Patient sample Using Current Procedural Terminology (CPT-4) codes and International Classification of Diseases, Clinical Modification procedure codes (ICD-9 CM), all lumbar discectomy patients were identified in a 6-month period from a large, 2002, commercially available claims-based data set representing 3.1 million insured lives. Outcome measures Not applicable. Methods Longitudinal data analysis from 3 years (2002–2004) of the database was performed for evidence of claims after the insured's discectomy (up to 18 months post) as a utilization estimate of surgical and medical treatment resultant of less-than-favorable outcomes. Incidence and cost of secondary operations, medical management, and complications were determined. Using these inputs, an economic model was generated to estimate the effect of improvement in discectomy outcomes. Results Of the 494 patients who had a discectomy within a 6-month period, 137 (28%) had subsequent claims that suggested the outcome was less than favorable within 18 months. Patients whose insurance claims included codes for a second operation (n=52 patients with 56 operations; 11%) and patients being medically/nonsurgically managed (n=85, 17%) were studied. Average reimbursed charges incurred (2006 dollars) of repeated discectomy (80% of cases) was $6,907 and for arthrodesis (20% of cases) was $24,375. Average additional medical treatment cost to diagnose or manage poor outcome requiring another surgery was $3,365. Procedure-related complications within 40 days of surgery were evident in 15% of the group; with additional average cost to manage of $3,939. Conclusions Substantial cost associated with poor discectomy outcomes is often overlooked or underappreciated. Surgical technologies that can improve outcomes of discectomy by 50% to 70% thus improving patient quality of life can be overall cost-neutral between $971 and $1,655 additionally per patient.

Lumbar Discectomy Outcomes Vary by Herniation Level in the Spine Patient Outcomes Research Trial

The Spine Patient Outcomes Research Trial showed an overall advantage for operative compared with nonoperative treatment of lumbar disc herniations. Because a recent randomized trial showed no benefit for operative treatment of a disc at the lumbosacral junction (L5-S1), we reviewed subgroups within the Spine Patient Outcomes Research Trial to assess the effect of herniation level on outcomes of operative and nonoperative care. The combined randomized and observation cohorts of the Spine Patient Outcomes Research Trial were analyzed by actual treatment received stratified by level of disc herniation. Overall, 646 L5-S1 herniations, 456 L4-L5 herniations, and eighty-eight upper lumbar (L2-L3 or L3-L4) herniations were evaluated. Primary outcome measures were the Short Form-36 bodily pain and physical functioning scales and the modified Oswestry Disability Index assessed at six weeks, three months, six months, one year, and two years. Treatment effects (the improvement in the operative group minus the improvement in the nonoperative group) were estimated with use of longitudinal regression models, adjusting for important covariates. At two years, patients with upper lumbar herniations (L2-L3 or L3-L4) showed a significantly greater treatment effect from surgery than did patients with L5-S1 herniations for all outcome measures: 24.6 and 7.1, respectively, for bodily pain (p = 0.002); 23.4 and 9.9 for Short Form-36 physical functioning (p = 0.014); and -19 and -10.3 for Oswestry Disability Index (p = 0.033). There was a trend toward greater treatment effect for surgery at L4-L5 compared with L5-S1, but this was significant only for the Short Form-36 physical functioning subscale (p = 0.006). Differences in treatment effects between the upper lumbar levels and L4-L5 were significant for Short Form-36 bodily pain only (p = 0.018). The advantage of operative compared with nonoperative treatment varied by herniation level, with the smallest treatment effects at L5-S1, intermediate effects at L4-L5, and the largest effects at L2-L3 and L3-L4. This difference in effect was mainly a result of less improvement in patients with upper lumbar herniations after nonoperative treatment.

Kinetics of Regression of Sciatica and Pain in the Low Back After Lumbar Macrodiscectomy in Human Immunodeficiency Virus Carriers

Prospective longitudinal clinical study. To evaluate the pattern of regression of severe sciatica and pain in the low back over 3 months in HIV infected patients in whom monosegmental lumbar macrodiscectomy was performed for lumbar disc herniation. There are very few reported studies, which have been carried out to evaluate the outcome of lumbar discectomy in HIV positive patients. This was a prospective study conducted from January 2004 to December 2006. Patients included were those who knew their HIV serological status before the first consultation. Patients with previous spinal surgery, multilevel lumbar disc herniation, or any neurologic deficit were excluded. The intensity of pain was assessed by the visual analog scale during regular postoperative follow up. Seventy-seven patients suffering from severe sciatica were included; 9 were HIV positive and 68 were HIV negative. In the HIV positive group, the sex ratio was 2:1, and 8 had severe pain in the low back whereas in the HIV negative group, 44 had severe pain in the low back. At 3 months, sciatica relief (VAS <4) was recorded in 66.6% of HIV positive patients and in 70.6% of HIV negative patients. Relief of pain in the low back (VAS <4) was respectively 50.0% and 55.1% in both groups. The pattern of pain regression during the follow-up period was similar in both groups.

Outcomes and presurgery correlates of lumbar discectomy in Utah Workers' Compensation patients

Background context Lumbar discectomy is the most common type of back surgery performed in the United States. Outcomes after this procedure can be variable and it appears that Workers' Compensation patients might be at increased risk for poor outcomes. Purpose To examine long-term multidimensional outcomes of lumbar discectomy within a cohort of Workers' Compensation patients from Utah and identify presurgical biopsychosocial factors related to poor outcomes. Study design/setting A retrospective cohort study consisting of a review of presurgical medical records and assessment of patient outcomes via a telephone survey. Outcomes were assessed at least 2 years postsurgery. Patient sample A consecutive sample of 271 workers from Utah who underwent lumbar discectomy from 1994 to 1999. A total of 134 patients were surveyed at the time of follow-up. Outcome measures Patient satisfaction, Roland-Morris Disability Questionnaire, SF-36v2, and Stauffer-Coventry Index. Methods A retrospective review of presurgical biopsychosocial variables and outcome assessment via telephone survey was conducted. Results Work disability rate for the cohort was 12.7% (17/134). Analysis of patient satisfaction, back pain-related dysfunction, and the Short-Form Health Survey-36 subscales indicated approximately 25% of patients experienced poor outcomes. Older age, number of comorbid health conditions, assigned case manager, litigation, and time delay from injury to surgery were consistently statistically significant predictors (p<.05) of poor outcomes. Conclusions Results of this study suggest that compensated back surgery patients are at greater risk for poor lumbar discectomy outcomes than noncompensation patients. Presurgery correlates of poor outcomes may be useful in identifying high-risk compensation patients.

Comparison of elective lumbar discectomy outcomes between civilians and military personnel.

To determine the results of discectomy surgery for lumbar disc herniation in military personnel and compare it with civilians. A cross-sectional study. This study was conducted in Neurosurgery Department and Trauma Research Center, Baqiyatallah Medical Sciences University, Tehran, Iran, from February to October 2006. One-hundred and seventeen military patients (54 subjects as combat forces and 63 as office personnel) and 115 civilians, who underwent discectomy surgery were included. In a mean duration of 50.8 months, the ability to return to full duty and resolution of complaints were assessed and satisfaction was measured using a Visual Analog Scale. Inability to return to previous duty was significantly higher in military personnel compared to civilians (p = 0.002); and in combat forces compared to office personnel (p < 0.001). The mean (SD) satisfaction was 80.09 (17.8) and 79.32 (9.8) percent in civilian and military personnel, respectively; p = 0.02. However, this difference was not seen in military subgroup forces. Military personnel had less complaints after surgery, 32.1% comparing to 42.7% in civilians; but the difference was not statistically significant. Likewise, fewer complaints were observed in combat forces comparing with office forces; 37% vs. 47.6% (p>0.05). Surgical intervention had relatively poor outcomes in military personnel, specifically in combat forces. Prevention of injury to back region should be considered in military training programs and in case of presence of disc herniation related symptoms, efforts should be made to save patients' effective function by conservation and medical therapies.

68. Long-term Outcomes of Lumbar Discectomy by Fenestration: A 15-year Follow-up Study

BACKGROUND CONTEXT: Many previous investigators have found that the short-term and intermediate results of lumbar discectomy by fenestration are excellent, but there is little data in regards to the long-term results of this procedure (especially longer than 15 years), and there may be unknown factors that may influence the outcomes.

Prospective study of outcomes in lumbar discectomy

Establishing standardized methods to assess outcome is needed to measure the effectiveness of surgery in relieving symptoms and improving quality of life. We prospectively studied 203 patients undergoing primary lumbar discectomy. Data was collected before surgery, at 3 months postoperatively and at long-term follow-up (12 – 60 months, median 24) using both disease-specific (visual analogue scores, Roland – Morris disability scales, and Hospital Anxiety and Depression scales) and generic (SF-36) instruments. Continued significant symptomatic benefit was observed to long-term assessment and the health gains in this patient group compared favourably with other elective surgical procedures. We have used this data to validate the SF-36 for use in this context and we recommend that SF36 should be used as a sole measure of outcome in routine practice, as well as in future studies.

Minimum 25-Year Outcome and Functional Assessment of Lumbar Discectomy

A retrospective, follow-up cohort study. To evaluate the 25-year (or longer) outcome of discectomy for lumbar disc herniation by validated instruments. A comprehensive patient-oriented evaluation should include measurements of pain and disability along with a reliable evaluation of the general health status. There is a paucity of data from validated measuring instruments on the very long-term outcome of lumbar discectomy. We conducted a follow-up study of 201 patients an average of 27.8 years (range 25-32) after lumbar discectomy. The patient-oriented assessment included a Short Form-36 Health Survey questionnaire, Oswestry Disability Index, Cumulative Illness Rating Scale, and a study specific questionnaire dealing with daily life activities and satisfaction with the surgery. The Short Form-36 Health Survey physical scales and summary scores were similar to the normative values for healthy subjects and were better than the scores of patients with untreated sciatica with respect to reported pain. The mean Oswestry disability score was 17.5. Satisfaction with surgery was expressed by 181 of 201 patients (90%). Patients who had undergone lumbar discectomy a minimum of 25 years earlier have a satisfactory self-reported health-related quality of life and less pain than nonsurgically treated subjects.

Surgical treatment of lumbar disc herniation in elderly patients.

Between 1995 and 1999, 12 patients aged 65 years or more (mean 70.2) with lumbar disc herniation, underwent partial laminectomy and nucleotomy. The results were compared with those of 25 younger patients aged between 20 and 40 years (mean 30.1), who underwent the same surgical procedure. The Japanese Orthopedic Association (JOA) score was used to assess the clinical outcome. The minimum follow-up was 12 months. The pre- and post-operative total JOA scores and the rate of improvement of the JOA score were not significantly different between the elderly (11.1, 24.3 points, and 74.1%), and the younger group (11.6, 26.4 points and 84.5%). The results of this study indicate that the outcome of lumbar discectomy in elderly patients is as good as in younger patients.

The Distress and Risk Assessment Method (DRAM)

Our aim was to judge the influence of preoperative psychological disturbance on the outcome of lumbar discectomy. We evaluated 66 patients, before and after operation, using a self-administered questionnaire. Disability was assessed using the Oswestry disability index and psychological disturbance the Distress and Risk Assessment Method (DRAM) score. Patients were classified as normal, at risk or distressed, and the outcome of surgery in the three groups was compared at a follow-up of six months. The mean self-reported preoperative disability was significantly higher in those with psychological disturbance. A total of 54 patients (82%) returned completed postoperative questionnaires. Postoperative disability scores at six months were not significantly different in the three risk groups. Psychological disturbance improved after surgery. Our study suggests that the early outcome of lumbar discectomy is not affected by preoperative psychological disturbance. We conclude that a patient with a symptomatic prolapsed intervertebral disc should not be denied surgery on the basis of preoperative psychological assessment.

The distress and risk assessment method (DRAM).

Our aim was to judge the influence of preoperative psychological disturbance on the outcome of lumbar discectomy. We evaluated 66 patients, before and after operation, using a self-administered questionnaire. Disability was assessed using the Oswestry disability index and psychological disturbance the Distress and Risk Assessment Method (DRAM) score. Patients were classified as normal, at risk or distressed, and the outcome of surgery in the three groups was compared at a follow-up of six months. The mean self-reported preoperative disability was significantly higher in those with psychological disturbance. A total of 54 patients (82%) returned completed postoperative questionnaires. Postoperative disability scores at six months were not significantly different in the three risk groups. Psychological disturbance improved after surgery. Our study suggests that the early outcome of lumbar discectomy is not affected by preoperative psychological disturbance. We conclude that a patient with a symptomatic prolapsed intervertebral disc should not be denied surgery on the basis of preoperative psychological assessment.

Seven- to 20-year outcome of lumbar discectomy.

A retrospective, follow-up study. To assess the effects of conventional surgery for lumbar disc herniation over an extended period of time and to examine factors that might correlate with unsatisfactory results. Although the short-term results of lumbar discectomy are excellent when there is a proper patient selection, the reported success rates in the long-term follow-up studies vary, and few factors have been implicated for an unsatisfactory outcome. One hundred-nine patients with surgically documented herniated lumbar disc were analyzed, retrospectively, by an independent observer. Long-term follow-up (mean 12.2 years) was done by a mailed, self-report questionnaire that included items about pain relief in the back and leg, satisfaction with the results, need for analgesics, level of activity, working capacity, and reoperations. Subjective disability was measured by the Oswestry questionnaire. Radiographic review was carried out in 66% of patients. End results were assessed using the modified Stauffer-Coventry's evaluating criteria. Several variables were examined to assess their influence to the outcome. The late results were satisfactory in 64% of patients. The mean Oswestry disability score was 18.9. Of the 101 patients who had primary procedures, 28% still complained of significant back or leg pain. Sixty-five percent of patients were very satisfied with their results, 29% satisfied, and 6% dissatisfied. The reoperation rate was 7.3% (8 patients), about one-third of which was due to recurrent disc herniation. Sociodemographic factors predisposing to unsatisfactory outcome, including female gender, low vocational education, and jobs requiring significant physical strenuousness. Disc space narrowing was common at the level of discectomy, but was without prognostic significance. The long-term results of standard lumbar discectomy are not very satisfying. More than one-third of the patients had unsatisfactory results and more than one quarter complained of significant residual pain. Heavy manual work, particularly agricultural work, and low educational level were negative predictors of a good outcome. These indicators should be used preoperatively to identify patients who are at high risk for an unfavorable long-term result.

Secondary gain influences the outcome of lumbar but not cervical disc surgery

BACKGROUND The expectation of monetary compensation has been associated with poor outcomes in lumbar discectomy, fueling a reluctance among surgeons to treat worker’s compensation cases. This issue, however, has not been investigated in patients undergoing cervical disc surgery. This study analyzes the relationship between economic forms of secondary gain and surgical outcome in a group of patients with common pay scales, retirement plans, and disability programs. METHODS All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active duty military servicepersons who were treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive for outcome. Financial data were used to create a compensation incentive (CI) which is proportional to the rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome is defined as a return to active duty, whereas a referral for disability is considered a poor surgical result. RESULTS One hundred percent follow-up was obtained for 269 patients who were treated with 307 cervical operations. Only 16% (43/269) of cervical patients received disability, whereas 24.7% (86/348) of lumbar patients obtained a poor result ( p = 0.0082). Although economic forms of secondary gain were not associated with outcome in cervical disease, both the position ( p = 0.002) and duration of an individual’s military career were significant factors ( p = 0.02). Of the medical variables tested, multilevel surgery ( p = 0.03) and revision operations at the same level ( p = 0.03) were associated with referral for medical discharge. CONCLUSIONS Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery; this observation may in part account for the success of cervical surgery relative to lumbar discectomy. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome of cervical disc surgery.

The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy

In a prospective controlled trial on 46 patients undergoing lumbar discectomy, three classes of variables (medical data including MRI-identified morphological abnormalities, general psychological factors and psychosocial aspects of work) were analyzed with regard to their predictive value for the outcome of lumbar disc surgery at 2 year follow-up. Multiple regression analyses were used to identify the best predictor variables of four different outcome measures (i.e. pain relief, reduction of disability in daily activities, return to work and surgical outcome). MRI-identified nerve root compromise and social support from the spouse were independent predictors of pain relief 2 years after surgery ( R 2=0.40, P<0.01). Return to work 2 years after surgery was best predicted by depression and occupational mental stress ( R 2=0.36, P<0.001). MRI-identified extent of herniation and depression were significant predictors of a good surgical outcome after lumbar discectomy ( R 2=0.61, P<0.001). This study has demonstrated that the outcome of discectomy is critically dependent on which outcome variables are selected and that different sorts of predictor variables have a distinct influence on the various outcome variables. Obvious morphological alterations (i.e. disc extrusions, nerve root compromise) proved to be significant predictors of postoperative pain relief and improvement of disability in daily activities justifying a surgical treatment approach in these cases. The most important finding of this study was that return to work was not influenced by any clinical findings or MR-identified morphological alterations, but solely by psychological factors (i.e. depression) and psychological aspects of work (i.e. occupational mental stress).

Long-term outcome of lumbar discectomy in children and adolescents sixteen years of age or younger.

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.

Focus issue on lumbar disc herniation: macro- and microdiscectomy.

This paper is based on a review, analysis, and discussion of the extensive literature on indications, technique, and complications of discectomy (macro and micro) for lumbar disc herniation. Outcomes for lumbar discectomy for disc herniation depend on patient selection. Short-term results of discectomy are excellent when there is agreement between the clinical presentation and imaging studies. Long-term results of surgery are only slightly better than conservative measures and the natural history of a lumbar disc herniation. A review of the literature reveals success rates for lumbar discectomy ranging from 80-96%. The outcome of lumbar discectomy does not appear to be affected by the use of a microscope and depends more on patient selection than on surgical technique.

Anatomic Position of a Herniated Nucleus Pulposus Predicts the Outcome of Lumbar Discectomy

The purpose of this study was to determine whether the anatomic position of a lumbar disc herniation has any significant effect on the clinical outcome of lumbar discectomy. Between January 1988 and March 1993, 80 patients with simple disc herniations underwent lumbar discectomy for herniated nucleus pulposus. We reviewed preoperative computed tomography scans after discography and magnetic resonance imaging of the lumbar spine. Disc herniations were classified as central, paracentral, intraforaminal, extraforaminal, or multiregional broad-based protrusions. The Smiley-Webster evaluation scale, which divided patients into groups with excellent, good, fair, and poor clinical outcome and evaluated the long-term need for pain medication, was applied. The post-operative evaluation period ranged from 6 to 48 months. The clinical outcome was then correlated with the different positions of herniations. The frequencies of the clinical outcomes were compared using the chi 2 test. We found a poorer clinical outcome that was statistically significant in patients with central herniations and with multiregional protrusions. Most herniations occurred at the L4-L5 level (58.7%). However, the level of disc herniation was not found to be a predictor of clinical outcome. Form and anatomic position of the lumbar disc herniation are of prognostic value for the outcome of lumbar discectomy. Further studies are required to confirm our preliminary results and eventually help improve surgical indications for lumbar discectomy.

Results of lumbar discectomy: a study using 15 different evaluation methods

Ninety-two patients who had undergone a primary excision of a lumbar disc were evaluated using 15 different criteria that evaluate the surgical outcome 2-15.5 years (average 8.8 years) following operation. The satisfactory results ranged from 62% to 84%. Criteria which relied on the subjective opinion of the patient gave the best results, while on the contrary the worst results were those that relied on functional criteria, such as return to work, return to previous employment, general activity level and need of further treatment. This variability in results observed with the same group of patients depends to a great extent on the nature of criteria used as well as on the design of those criteria. The study concludes that the reported outcomes for lumbar spinal surgery are influenced by the selection of the criteria used for the assessment of the end results.