Post-discectomy Syndrome Research Articles

106. Seven- to 21-year clinical outcomes of 1,187 patients treated with one- and two-level lumbar total disc arthroplasty

<h3>BACKGROUND CONTEXT</h3> Multiple studies have shown that lumbar total disc arthroplasty (TDA) is not only safe and effective in treating chronic lumbar degenerative disc disease (DDD), but also provides a better surgical alternative to fusion with respect to patient-reported results, restoring motion, and reducing reoperation rates and severity of adjacent level degeneration. Published evidence is limited for follow-up past 5-7 years after TDA. In this study, we expand the evidence favoring TDA with results up to 21 years, of a large patient cohort treated with semi-constrained ball-and-socket lumbar TDA. <h3>PURPOSE</h3> To compare the results for one-level vs two-level patients, and evaluate whether prior surgery at these levels has an effect on clinical outcomes. <h3>STUDY DESIGN/SETTING</h3> Retrospective clinical study. <h3>PATIENT SAMPLE</h3> A total of 1,187 chronic lumbar DDD patients (622 male, 565 female, mean age 43±9.81years, range 17-86 years), underwent lumbar TDA from 1999 to 2013. Of the total, 772 patients had one-level and 415 patients had two-level procedures; 373 out of 1,187 patients (31.5%) had prior index-level surgery (recurrent disc herniation or postdiscectomy syndrome). <h3>OUTCOME MEASURES</h3> Data collected included radiographic, neurological/physical assessment, self-evaluation using the Oswestry Disability Index (ODI) and visual analog back and leg pain Scores (VAS). Complication, reoperation/revision rates, and perioperative data points were also assessed. <h3>Methods</h3> Patients were evaluated preoperatively, then followed postoperatively at 3, 6, 12, and 18 months, then yearly thereafter. Patient follow-up ranged between 7 and 21 years (mean 11 years, 8 months). Patients were stratified into one- (1L) and two-level (2L) procedure groups, then divided into prior (PS) or no-prior surgery (NPS) at the index level for data comparison. Patient demographics (age and gender) were comparable for all groups. <h3>Results</h3> All groups showed dramatic and statistically significant ODI reduction by 3 months postsurgery (p<0.001) and then maintained scores over time. ODI improvement was mean 26 points for groups 1, 2 and 3, while group 4 (2L/PS) had mean 24 points ODI improvement. Although patients with prior surgery took longer to reach final VAS pain levels (6 vs 3 months), there was no statistical difference between groups in pain reduction at 24 months. Although not statistically significant, the group with highest average preoperative VAS pain (group 2) had the greatest reduction in pain. Improvement of ODI and VAS pain is documented in all study groups. Of the 1,187 patients, 49 (4.12%) required new or revision surgery. Revisions were classified into four groups: posterior release/laminectomy at same level; TDA revision; scar/hematoma; and adjacent level surgery (ALS). Rates were too low in all groups to compare them statistically. Total TDA revision and ALS rates over 7-21 years were very low: 0.67% and 1.85%, respectively. <h3>Conclusions</h3> In one of the largest groups of TDA patients evaluated, this study demonstrates the robust long-term clinical success of one- and two-level lumbar TDA, as assessed at 7-21 years postoperatively. Patients had significant and maintained reduction in disability and pain scores over time, and low rates of index revision/reoperation or ALS, when compared to long-term published fusion data. Also, both 1- and 2-level lumbar TDA patients improved and patients with prior surgery at the index level had outcomes equivalent to patients with no prior surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Foraminal Stenosis as a Cause of Postdiscectomy Syndrome.

To reveal the relation between postdiscectomy syndrome and foraminal stenosis due to height loss of disc level in patients operated for one-sided L5-S1 disc herniation. 100 operated patients due to L5-S1 one-sided disc herniation were included. Mean age was 46.60 years (±10.52 years). Foraminal height, width, and intervertebral disc height were measured via CT. The diameters were compared preoperatively and postoperatively. The relation between the measurements and clinic findings was investigated. Six months after discectomy, for the operated side, the mean foraminal height decreased from 16.78 ± 1.75 mm to 14.43 ± 1.62 mm (p 0.05) and the mean foraminal width decreased from 6.30 ± 1.43 mm to 5.34 ± 1.56 mm (p 0.05). According to the correlation test, for the operated side, a statistically significant relationship was observed between the decrease in foramen height and leg pain visual analog scale (VAS) score. Moreover, a statistically significant relationship was observed between the decrease in the posterior side height of the disc level and the leg pain VAS score. Overall, after microdiscectomy, as the height of the foramen decreased, leg pain also increased. Moreover, the decrease in the posterior side height of the disc level was associated with an increase in leg pain. Therefore, over time, the collapse of the disc distance decreases the foramen height, which causes leg pain. After microdiscectomy, in patients whose leg pain was relieved at first but started again after a time, the foramen and disc level diameters should be checked.

Functional and radiological outcome of anterior retroperitoneal versus posterior transforaminal interbody fusion in the management of single-level lumbar degenerative disease.

In this study the authors compared the anterior lumbar interbody fusion (ALIF) and posterior transforaminal lumbar interbody fusion (TLIF) techniques in a homogeneous group of patients affected by single-level L5-S1 degenerative disc disease (DDD) and postdiscectomy syndrome (PDS). The purpose of the study was to analyze perioperative, functional, and radiological data between the two techniques. A retrospective analysis of patient data was performed between 2015 and 2018. Patients were clustered into two homogeneous groups (group 1 = ALIF, group 2 = TLIF) according to surgical procedure. A statistical analysis of clinical perioperative and radiological findings was performed to compare the two groups. A senior musculoskeletal radiologist retrospectively revised all radiological images. Seventy-two patients were comparable in terms of demographic features and surgical diagnosis and included in the study, involving 32 (44.4%) male and 40 (55.6%) female patients with an average age of 47.7 years. The mean follow-up duration was 49.7 months. Thirty-six patients (50%) were clustered in group 1, including 31 (86%) with DDD and 5 (14%) with PDS. Thirty-six patients (50%) were clustered in group 2, including 28 (78%) with DDD and 8 (22%) with PDS. A significant reduction in surgical time (107.4 vs 181.1 minutes) and blood loss (188.9 vs 387.1 ml) in group 1 (p < 0.0001) was observed. No significant differences in complications and reoperation rates between the two groups (p = 0.561) was observed. A significant improvement in functional outcome was observed in both groups (p < 0.001), but no significant difference between the two groups was found at the last follow-up. In group 1, a faster median time of return to work (2.4 vs 3.2 months) was recorded. A significant improvement in L5-S1 postoperative lordosis restoration was registered in the ALIF group (9.0 vs 5.0, p = 0.023). According to these results, interbody fusion is effective in the surgical management of discogenic pain. Even if clinical benefits were achieved earlier in the ALIF group (better scores and faster return to work), both procedures improved functional outcomes at last follow-up. The ALIF group showed significant reduction of blood loss, shorter surgical time, and better segmental lordosis restoration when compared to the TLIF group. No significant differences in postoperative complications were observed between the groups. Based on these results, the ALIF technique enhances radiological outcome improvement in spinopelvic parameters when compared to TLIF in the management of adult patients with L5-S1 DDD.

Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Surgical Management of Post-Discectomy Syndrome.

Study DesignThis was a prospective case series of 30 patients with post-discectomy syndrome with an average of 18 months of follow-up (level IV).PurposeThe efficacy of post-discectomy syndrome managed by minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) was evaluated.Overview of LiteratureIn post-discectomy syndrome wherein conservative treatment had failed, the best surgical treatment modality still remains controversial.MethodsPatients were functionally assessed using the Visual Analog Scale (VAS) for low back pain (LBP) and leg pain (LP) and Oswestry Disability Index (ODI). Radiological fusion was confirmed with plain X-rays and when indicated with computed tomography scan at 12 months postoperatively. A total of 30 patients with 37 operated at lumbar levels with failed discectomy surgery who met our inclusion criteria were treated with MIS-TLIF.ResultsThe ODI of all patients showed significant improvement from a mean of 73.78% preoperatively to 16.67% at 1 month and 14.13% at 12 months postoperatively. The preoperative LBP VAS score (mean, 4.37) showed a significant decrease (p<0.001) to 1.90 at 1 month and 1.10 at 12 months. Preoperative LP VAS score of limb pain averaged 7.53 and showed a significant (p<0.001) decrease to 3.47 at 1 month and 1.10 at 12 months. All patients attained radiological fusion at 12 months.ConclusionsMIS-TILF constitutes a valid and effective treatment option for patients with post-discectomy syndrome.

Cell therapy for intervertebral disc repair: advancing cell therapy from bench to clinics.

Intervertebral disc (IVD) degeneration is a major cause of pain and disability; yet therapeutic options are limited and treatment often remains unsatisfactory. In recent years, research activities have intensified in tissue engineering and regenerative medicine, and pre-clinical studies have demonstrated encouraging results. Nonetheless, the translation of new biological therapies into clinical practice faces substantial barriers. During the symposium "Where Science meets Clinics", sponsored by the AO Foundation and held in Davos, Switzerland, from September 5-7, 2013, hurdles for translation were outlined, and ways to overcome them were discussed. With respect to cell therapy for IVD repair, it is obvious that regenerative treatment is indicated at early stages of disc degeneration, before structural changes have occurred. It is envisaged that in the near future, screening techniques and non-invasive imaging methods will be available to detect early degenerative changes. The promises of cell therapy include a sustained effect on matrix synthesis, inflammation control, and prevention of angio- and neuro-genesis. Discogenic pain, originating from "black discs" or annular injury, prevention of adjacent segment disease, and prevention of post-discectomy syndrome were identified as prospective indications for cell therapy. Before such therapy can safely and effectively be introduced into clinics, the identification of the patient population and proper standardisation of diagnostic parameters and outcome measurements are indispensable. Furthermore, open questions regarding the optimal cell type and delivery method need to be resolved in order to overcome the safety concerns implied with certain procedures. Finally, appropriate large animal models and well-designed clinical studies will be required, particularly addressing safety aspects.

Pyogenic Discitis following Discectomy

To assess the treatment outcome for disc infection in 35 patients. Records of 23 men and 12 women aged 36 to 62 (mean, 43) years who underwent treatment for pyogenic discitis after open discectomy were reviewed. All patients had single-level disc herniation of L4-5 (n=28) or L5-S1 (n=6), except for one who had 2-level disc herniation of L4-S1. Single antibiotic was given one day prior to discectomy and continued for 2 days. All excised discs were found to be sterile. Discitis was classified into acute (n=26), subacute (n=7), and chronic (n=2). Antibiotic therapy was started immediately when the clinical diagnosis was made. 31 patients were treated with antibiotics alone; the remaining 4 underwent surgery entailing simple posterior superficial wound drainage (n=1), anterior radical surgery (n=2), or posterior instrumentation and posterolateral fusion for post-discectomy syndrome (n=1). Six of the 12 patients who had percutaneous disc space aspiration underwent disc space irrigation. The initial symptoms included mild-to-moderate fever (n=4), severe back pain (n=27), back muscle spasms (n=26), back pain radiating to the limb (n=2), Gower sign (n=11), and a draining wound (n=1). The wound aspirates of the 12 patients grew organisms, although blood cultures were negative in all. After antibiotic therapy, symptoms gradually subsided in parallel with normalisation of white blood cell count and inflammatory markers. Surgery was indicated only when symptoms worsened and the disease progressed. Spontaneous intercorporal fusion did not occur. Early diagnosis and treatment with appropriate antibiotics is important for post-discectomy discitis.

Das sog. Postdiskotomiesyndrom - Fehlschläge der Bandscheibenoperation?

The Post-discectomy-Syndrome (PDS) is a clinical entity with various components from individual disposition, sequelae of the underlying disc degeneration and of the operation, as well. These include local back pain, persisting (poly-)radicular pain and facet irritation with pseudoradicular irradiation due to segmental instability, epidural scarring and local arachnoiditis. Diagnosis has to focus on separation from failed-back-surgery-syndromes (FBSS) with single components like insufficient discal or bony decompression or segmental instability. Arachnoiditis seems to be the least modifiable factor and should be excluded if fusion or revision of the spinal canal is planned. A 100 point-score for grading of PDS is presented.

Percutaneous radiofrequency facet ablation for postdiscectomy syndrome in the lumbar spine

Percutaneous radiofrequency facet ablation for postdiscectomy syndrome in the lumbar spine

Prevention of epidural scarring after microdiscectomy: a randomized clinical trial comparing gel and expanded polytetrafluoroethylene membrane

A randomized clinical trial compared two materials used to prevent epidural scarring after microdiscectomy. To determine whether ADCON-L Gel (ALG) or Preclude Spinal Membrane (PSM) was more effective in preventing scarring, reducing pain, and improving quality of life postoperatively. Postdiscectomy syndrome may result from epidural scarring. Various materials have been used in attempts to prevent this problem, but none have provided optimal results. Previous laboratory and clinical studies have found ALG and PSM to be effective, but none compared the two materials. Thirty-one patients undergoing primary microdiscectomy were randomly assigned to receive either ALG or PSM. Postoperatively, patients were evaluated by magnetic resonance imaging (MRI), with contrast, for volume and rostral-caudal extent of scar tissue and nerve root involvement. Back and leg pain and quality of life were assessed by neurologic examinations and standardized patient surveys. Findings at any reoperations were recorded. Results in the PSM (n = 18) and ALG (n = 13) groups were compared statistically. No operative or postoperative complications occurred. Two patients in each group required reoperation. MRI at 6 months showed no, mild or mild-moderate scarring in most patients, with no significant differences between the ALG and PSM groups in scar volume and extent or nerve root involvement. Neurologic examinations and patient surveys showed substantial reductions in pain over time in both groups but no significant differences between groups. PSM was easy to see and remove at reoperation. PSM and ALG are equally effective in preventing epidural scarring associated with postdiscectomy syndrome.

Post-discectomy syndrome treated with lumbar interbody fusion

We studied 27 patients with post-discectomy syndrome. All patients had Lumbar Interbody Fusion with titanium cages and pedicle screw fixation either as Anterior (ALIF, n=18) or as Transforaminal Lumbar Interbody Fusion (TLIF, n=9). Follow-up ranged from 24 to 94 months. The clinical and radiological data were compared. The outcome was evaluated using the Oswestry low back pain disability score and the visual analogue pain intensity scale. Outcomes were similar for all patients regardless of surgical technique and showed a significant improvement at final follow-up.

Comparison of the analgesic effectiveness of oral gabapentine addition to the epidural corticosteroid application in patients with post-discectomy syndrome

Comparison of the analgesic effectiveness of oral gabapentine addition to the epidural corticosteroid application in patients with post-discectomy syndrome

Comparison of the analgesic effectiveness of oral gabapentine addition to the epidural corticosteroid application in patients with post-discectomy syndrome

Comparison of the analgesic effectiveness of oral gabapentine addition to the epidural corticosteroid application in patients with post-discectomy syndrome

Detection of bacterial DNA in painful degenerated spinal discs in patients without signs of clinical infection.

A local inflammatory and potentially painful response, of which the ultimate cause is unknown, has been described in nervous tissues in contact with degenerated disc material in patients with low back and leg pain. With the rationale that a possible cause of such inflammation could be bacterial infection, we utilized PCR (polymerase chain reaction) amplification of the 16S rRNA (ribosomal RNA) gene followed by gene sequencing, to investigate whether bacterial DNA might be detected in the degenerative discs of 10 patients operated for disc herniation or post-discectomy syndrome. One patient with disc hernia harbored DNA homologous to Bacillus cereus, and in one patient suffering from post-discectomy syndrome, Citrobacter braaki/freundii DNA was detected. The finding demonstrates that 16S rRNA PCR can be a useful tool in search of bacterial DNA in degenerated discs, which in turn may be indicative of low-grade infection, manifesting itself only as pain rather than as clinical infection.

The post-discectomy syndrome. Aetiology, diagnosis, treatment, prevention.

The post-discectomy syndrome (PDS) is a common diagnosis in patients with problems following a disc operation. The different causes of PDS make the establishment of the correct diagnosis and its corresponding efficient treatment difficult. A general overview published in the bibliographical data covering the entity of PDS is rare. The following paper aims to specify PDS according to its aetiology, diagnosis, treatment and prevention. The diagnosis should be made efficiently, so that the patient can receive prompt adequate therapy.