Recurrent Disc Herniation Research Articles

Clinical Characteristics and Risk Factors of Recurrent Lumbar Disk Herniation: A Retrospective Analysis of Three Hundred Twenty-One Cases.

Retrospective clinical series. To investigate the clinical features and the risk factors for recurrent lumbar disc herniation (rLDH) in China. rLDH is a common cause of poor outcomes after lumbar microdiscectomy surgery. Risk factors for rLDH are increasingly being investigated. However, results in these previous studies were not always consistent. Between June 2005 and July 2012, 321 consecutive patients with single-level LDH, who underwent surgery, were enrolled in this study. We divided the patients into the recurrent group (R group) and the nonrecurrent group (N group) and compared their clinical parameters and preoperative radiologic parameters. The relationships between the variables and rLDH were evaluated by univariate analysis and multiple logistic regression analysis. There was significant difference between groups in sex (P = 0.003), age (P = 0.003), current smoking (P = 0.004), body mass index (BMI) (P = 0.04), occupational lifting (P < 0.001), trauma history (P = 0.04), procedures (P = 0.04), herniation type (P = 0.006), disc height index (DUI) (P = 0.04), facet orientation (FO) (P = 0.04), facet tropism (FT) (P = 0.04), and sagittal range of motion (from) (P = 0.04). By putting these differences in logistic regression analysis, it showed that being male, young age, current smoking, higher BMI, herniation type (transligamentous extrusion), surgical procedures (bilateral laminectomy or total laminectomy), heavy works, undergoing a traumatic event, a large from, a high DUI, a large FT, and a small FO significantly related with rLDH. Based on our data, sex, age, current smoking, BMI, occupational lifting, trauma, surgical procedures, herniation type, DUI, FO, FT, and from showed a significant correlation with the incidence of rLDH. Patients with these risk factors should be paid more attention for prevention of recurrence after primary surgery. 3.

Risk factors for recurrent lumbar disc herniation after discectomy.

There are many reports about the risk factors for recurrence after lumbar disc surgery. However, there are none about whether lumbosacral transitional vertebrae (LSTV) are associated with recurrent lumbar disc herniation (LDH). We investigated various risk factors for recurrent LDH after discectomy including LSTV. A total of 119 patients who had undergone a discectomy for L4-5 disc herniation were evaluated with a minimum follow-up of twoyears. Clinical parameters including age, gender, body mass index (BMI), and smoking status, and radiological parameters including type of herniated disc, degree of disc degeneration, LSTV, and sagittal range of motion (SROM) in flexion-extension radiography were evaluated. SROM was measured by the difference of the lordotic angle between the flexion and extension view. Recurrent disc herniation at L4-5 developed in 21 (17.6%) of the 119 patients. The mean period between primary surgery and recurrence was 17.6 ± 21.1months. LSTV was found in 11 (52.4%) of the 21 patients who had recurrence and seven (7.1%) of the 98 patients in the non-recurrent group. SROM at L4-5 was 11.68 ± 4.24° in the recurrent group and 9.04 ± 3.65° in the non-recurrent group with a significant difference (p = 0.004). Multiple logistic regression analyses confirmed that LSTV and a larger SROM were significant risk factors for recurrent disc herniation at L4-5. Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography were found to be risk factors for recurrent lumbar disc herniation.

Wallis interspinous device versus discectomy for lumbar disc herniation : Acomparative study.

The aim of this study was to assess the efficacy of the Wallis interspinous device for treating lumbar disc herniation (LDH) as well as to investigate whether the device could reduce the incidence of recurrent herniation in comparison with disc excision alone. Atotal of 72 patients with LDH were treated with primary discectomy and the Wallis interspinous device was implanted in 36. Clinical outcomes were evaluated with avisual analog scale (VAS) for low back and leg pain and the Oswestry Disability Index (ODI) before and after surgery. The incidence of recurrent disc herniation after the operation was also evaluated. There was asignificant improvement (p < 0.01) in the clinical outcomes assessed by the VAS and ODI scores compared with preoperative values in both groups. Up to the final follow-up, there were no significant differences between the two groups in VAS and ODI scores (p > 0.05). In addition, there was no significant difference regarding the incidence of recurrent disc herniation between the two groups (13.9% vs. 16.6%, p > 0.05). Of the patients five underwent second discectomy or fusion surgery. The Wallis interspinous device was unable to improve the already good clinical outcome after discectomy for LDH and prevent or reduce recurrence of herniated disc in the current follow-up interval. Whether the device for should be used for LDH should be carefully considered before surgery.

The modified transforaminal endoscopic technique in treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniations.

To develop a modified transforaminal endoscopic spine system (TESSYS®) technique for treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation (ICFE-LDH), and evaluate the technical efficacy and safety. Twenty-three patients with ICFE-LDH underwent the modified TESSYS technique were enrolled. Magnetic resonance imaging (MRI) was used to verify the reduction of herniated disc. Pre- and post-operative neurological functions were compared by visual analogue scale (VAS) score, Oswestry disability index (ODI) and the modified MacNab criteria. The technical safety was evaluated by surgical complications. MRI demonstrated reductions of disc herniations in 22 patients (95.7%) after surgeries. The VAS scores were significantly improved at 1 year follow-up (low back: P=0.001, lower limbs: P<0.001), as well as ODI scores (P<0.001). 22 patients had achieved excellent and good recovery postoperatively according to the modified MacNab criteria. One patient (4.3%) underwent a reoperation due to postoperative recurrence of disc herniation. Another patient complained postoperative causalgia in 8 weeks, the symptom alleviated after conservative treatment at 1 year follow-up (VAS: back, 3, lower limbs, 0; ODI: 20%). The incidence rate of surgical complication was 8.7%. The modified TESSYS technique is a minimally-invasive, effective and safe surgery for treating ICFE-LDHs in selected patients.

Intra- and Perioperative Complications Associated with Endoscopic Spine Surgery: A Multi-Institutional Study

To report on intra- and perioperative complications associated with working channel endoscopic spine surgery. This study is a retrospective chart review of a multi-institutional patient cohort operated on by surgeons within the Endoscopic Spine Study Group between May 2010 and June2017. Our study cohort consists of a total of 553 consecutive cases with an average age of 57 years. The most common procedure was an endoscopic discectomy (n= 377, 68%) followed by foraminotomy (n= 156, 28.2%), unilateral laminotomy for bilateral decompression (n= 55, 9.9%), and lateral recess decompression (n= 29, 5.2%). Overall, the rate of intra- and perioperative complications was 2.7%. There were 3 durotomies (0.54%), 2 epidural hematomas (0.36%), 2 patients developed a complex pain disorder (0.36%), 4 recurrent disc herniations within 3 months (1.1%), 4 systemic complications (1.1%), and no wound infections. No risk factors were identified with regards to age, sex, approach, or number of segments. Endoscopic spine surgery is associated with a favorable rate of intra- and perioperative complications compared with reported rates of minimally invasive ortraditional open spine surgeries. Our report proposes safe and effective strategies for management of these complications.

Clinical Outcomes after Microdiscectomy for Recurrent Lumbar Disk Herniation: A Single-Center Study.

Revision discectomy is the principal procedure for recurrent lumbar disk herniation (RLDH). The clinical outcomes after this procedure are as good as or slightly poorer than those produced by primary discectomy. In this study, the clinical outcomes of patients treated with microsurgical discectomy for RLDH were analyzed. We examined 179 patients undergoing lumbar microdiscectomy surgery for RLDH. The visual analogue scale (VAS), Prolo scoring system, and Oswestry Disability Index (ODI) were used for evaluating the improvement of symptoms and functional outcomes. Among 179 patients, 101 (56%) obtained good and excellent Prolo scores (group 1), while 78 (44%) obtained fair or poor results (group 2). There was no significant difference between the groups regarding age (P=0.515), gender (P=0.545), body mass index (P=0.523), diabetes mellitus (P=0.074), smoking (P=0.100), interval between primary and revision surgeries (P=0.749), and surgical outcomes (P=0. 749). However, significant improvements were achieved in VAS scores for back (P=0.197) and radicular pain (P=0.606), as well as ODI scores (P= 0.000). Based on the findings, only ODI scores showed a significant inter-group difference in the 12-month follow-up (P=0.038). Limited microsurgical discectomy could be considered as the main surgical method in patients with RLDH without overt instabilities.

Eccentric reaming technique in percutaneous endoscopic lumbar discectomy in the treatment of lumbar lateral recess stenosis: a five-year case series study

Objective To investigate clinical effect and safety of eccentric reamer technique foraminoplasty during percutaneous endoscopic lumbar discectomy for the treatment of lumbar lateral recess stenosis. Methods All of 45 cases diagnosed of lumbar lateral recess stenosis between Apr 2010 to Jun 2012 were analyzed in our study. Among these cases, 28 cases were male and 17 were female. The age of enrolled cases was 39-62 years old and the average age was 49.23±23.96 years old. All the cases were one-level, 25 cases in L 4,5 and 20 cases in L 5S1. All the patients underwent percutaneous endoscopic lumbar discectomy. During surgery, eccentric reamer technique was applied for foraminoplasty. Perioperative data included surgical segment, surgical duration and blood loss during surgery. Oswestry Disability Index (ODI) and Visual analogue scale (VAS) for lower back and leg pain were recorded for the evaluation of surgical effect. All the data were recorded before surgery, 1 day, 1 month after surgery and final follow-up. Recurrent lumbar disc herniation, spinal canal hematoma, intervertebral disc infection, nerve root injury and post-operative dysthesia (POD) were recorded for complications. Results All the cases finished surgery and none of the cases was changed to other surgery method and no other electronic drill were used in these patients. Surgical duration was 45-76 min and average time was 61.23±13.89 min. Blood loss during surgery was 10-25 ml and average blood loss was 15.02±4.33 ml. Post-operative hospitalization days were 1-3 days and 2.80±1.57 days. The follow-up time was 60-84 months and the average time was 73.23±8.47 months. ODI in one-day after surgery was 9.34±6.54%, significantly lower than 68.06±24.14% before surgery and no statistically change had been observed in one-month after surgery and final follow-up. The VAS for lower back was 1.54±0.97 in one-day after surgery, significantly lower than 3.57±3.12 before surgery. The VAS for leg pain was 1.14±0.79 in one-day after surgery, significantly lower than 6.24±2.35 before surgery. During follow-up, 1 case suffered from recurrent lumbar disc herniation (2.22%) and no intervertebral disc infection, spinal canal hematoma and POD was observed. Conclusion Eccentric reamer technique foraminoplasty in percutaneous endoscopic lumbar discectomy is an effective and safe surgical method for the treatment of lumbar lateral recess stenosis. Key words: Lumbar vertebrae; Spinal stenosis; Endoscopy; Surgical procedures, minimally invasive

Annular closure device for disc herniation: meta-analysis of clinical outcome and complications

BackgroundLumbar intervertebral disc herniation is a common cause of lower back and leg pain, with surgical intervention (e.g. discectomy to remove the herniated disc) recommended after an appropriate period of conservative management, however the existing or increased breach of the annulus fibrosus persists with the potential of reherniation. Several prosthesis and techniques to reduce re-herniation have been proposed including implantation of an annular closure device (ACD) – Barricaid™ and an annular tissue repair system (AR) – Anulex-Xclose™. The aim of this meta-analysis is to assist surgeons determine a potential approach to reduce incidences of recurrent lumbar disc herniation and assess the current devices regarding their outcomes and complications.MethodsFour electronic full-text databases were systematically searched through September 2017. Data including outcomes of annular closure device/annular repair were extracted. All results were pooled utilising meta-analysis with weighted mean difference and odds ratio as summary statistics.ResultsFour studies met inclusion criteria. Three studies reported the use of Barricaid (ACD) while one study reported the use of Anulex (AR). A total of 24 symptomatic reherniation were reported among 811 discectomies with ACD/AR as compared to 51 out of 645 in the control group (OR: 0.34; 95% CI: 0.20,0.56; I2 = 0%; P < 0.0001). Durotomies were lower among the ACD/AR patients with only 3 reported cases compared to 7 in the control group (OR: 0.54; 95% CI: 0.13, 2.23; I2 = 11%; P = 0.39). Similar outcomes for post-operative Oswestry Disability Index and visual analogue scale were obtained when both groups were compared.ConclusionEarly results showed the use of Barricaid and Anulex devices are beneficial for short term outcomes demonstrating reduction in symptomatic disc reherniation with low post-operative complication rates. Long-term studies are required to further investigate the efficacy of such devices.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 218. Patients undergoing revision microdiscectomy for recurrent lumbar disc herniation experience worse clinical outcomes and more reoperations compared to patients undergoing a primary microdiscectomy

BACKGROUND CONTEXT When conservative measures fail, lumbar disc herniation has been shown to be successfully treated by a microdiscectomy surgery. The percentage of patients that necessitate revision surgery within 2years varies between 0.5% and 24% in literature, with recurrent herniation being the most common presentation.However, in the setting of a revision discectomy surgery for a recurrent disc herniation, outcomes can be more difficult to predict. Some studies with smaller patient populations and diverse outcome protocols have not found significant clinical outcome differences between these two patient populations. Other studies have begun to elucidate differences at 1 year after surgery. PURPOSE The goal of this study is the compare the demographics and outcomes of patients undergoing primary lumbar microdiscectomy surgery for a disc herniation and those undergoing a revision microdiscectomy surgery for a recurrent disc herniation. STUDY DESIGN/SETTING Retrospectivec cohort series. PATIENT SAMPLE We performed a retrospective analysis of patients who underwent a primary or revision lumbar microdiscectomy between 2009 and 2015 by one of two senior orthopaedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery (other than a microdiscectomy at the recurrent disc herniation level), were under 18 years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into two groups: those undergoing a primary surgery for a lumbar disc herniation (primary) and those undergoing a revision procedure for a recurrent disc herniation (recurrent). OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 296 consecutive patients who fulfilled our inclusion criteria were assessed. The patients in the recurrent group were significantly younger than those in the primary group (44.6±12.7 vs. 53.2±16.2 years; p CONCLUSIONS Patients who presented with symptoms related to a recurrent lumbar disc herniation underwent surgery significantly sooner than those patients who underwent a primary lumbar microdiscectomy for a disc herniation. At 2 years following surgery, patients that underwent a revision lumbar microdiscectomy for a recurrent disc herniation reported significantly worse patient outcomes following surgery. These patients that underwent revision surgery were also significantly less satisfied and felt as though their results did not exceed nor meet their expectations of the procedure. Revision rates were also significantly higher in patients undergoing a revision lumbar microdiscectomy. Although three-quarters or patients will not require a repeat operation following a revision microdiscectomy, preoperative educations should be clearly communicated regarding the elevated risk of a subsequent reherniation and/or worse back pain as well as expectations following this revision procedure.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P133. Clinical outcomes of decompression alone versus and decompression and fusion for first episode recurrent disc herniation

BACKGROUND CONTEXT It is unclear if patients with recurrent disc herniation (RDH) benefit from a concurrent fusion compared to a repeat decompression alone. No studies are available comparing outcomes of decompression alone (D0) versus decompression and fusion (DF) for RDH. PURPOSE The purpose of the study is to compare clinical outcomes and revisions in patients with first episode recurrent disc herniation treated with decompression only compared to decompression and concommittant fusion. STUDY DESIGN/SETTING Multicenter longitudinal observational cohort. PATIENT SAMPLE Patients enrolled in the Quality Outcomes Database (QOD) from three sites with a first episode of RDH and one- to two-level surgery. OUTCOME MEASURES Numeric rating scales (0–10) for back and leg pain, Oswestry Disability Index (ODI), EuroQOL-5D (EQ-5D), revision surgery. METHODS Patients enrolled in QOD from three sites with a first episode of RDH and one- to two-level surgery were identified. Demographic, surgical and radiographic data including the presence of listhesis and extent of facet resection on CT or MRI prior to the index surgery were collected. Patient Reported Outcomes (PROs), including back and leg pain, ODI and EQ-5D, were collected pre-op and at 3 and 12 months post-op. RESULTS Of 94 cases identified, 55 had D0 and 39 had DF. The patients were similar in age, sex distribution, smoking status, BMI, ASA grade and surgical levels. Presence of listhesis (D0=7, DF=5, p=.800) and extent of facet fusion (D0=19%, DF=16%, p=.309) prior to index surgery were similar between the two groups. EBL (D0=26cc DF=329cc p CONCLUSIONS For a first episode recurrent disc herniation, surgeons can expect similar outcomes whether patients are treated with decompression alone or decompression and fusion. Despite similarities in baseline demographic, PRO and radiologic data, variables that lead a surgeon to choose decompression alone or decompression and fusion are unknown and can lead to selection bias. Further studies are needed to identify clear indications for fusion in patients with first episode recurrent disc herniation.

Undiagnosed Peripheral Nerve Disease in Patients with Failed Lumbar Disc Surgery.

Study DesignRetrospective study (level of evidence=3).PurposeWe examine the relationship between residual symptoms after discectomy for lumbar disc herniation and peripheral nerve (PN) neuropathy.Overview of LiteraturePatients may report persistent or recurrent symptoms after lumbar disc herniation surgery; others fail to respond to a variety of treatments. Some PN neuropathies elicit symptoms similar to those of lumbar spine disease.MethodsWe retrospectively analyzed data for 13 patients treated for persistent (n=2) or recurrent (n=11) low back pain (LBP) and/or leg pain after primary lumbar discectomy.ResultsLumbar re-operation was required for four patients (three with recurrent lumbar disc herniation and one with lumbar canal stenosis). Superior cluneal nerve (SCN) entrapment neuropathy (EN) was noted in 12 patients; SCN block improved the symptoms for eight of these patients. In total, nine patients underwent PN surgery (SCN-EN, n=4; peroneal nerve EN, n=3; tarsal tunnel syndrome, n=1). Their symptoms improved significantly.Conclusions Concomitant PN disease should be considered for patients with failed back surgery syndrome manifesting as persistent or recurrent LBP.

The Learning Process of Endoscopic Spinal Surgery for Degenerative Cervical and Lumbar Disorders Using the EasyGO! System

Among spinal surgeons, the safety of endoscopic spinal techniques has been criticized as the result of a prolonged learning curve and divergent surgical technique from traditional microsurgery. In this manuscript, the authors assessed the learning curve of 4 experienced microsurgical neurosurgeons in endoscopic spinal surgery. Retrospectively, the surgical reports, the endoscopic video recording, and the files of all patients who underwent an endoscopic procedure for the treatment of cervical and lumbar disc herniation from January 2011 to December 2017 were reviewed. The learning process was assessed via several parameters: surgical time, intraoperative complications, dural tear, nerve root injury, conversion to microsurgery, new postoperative neurologic deficits, repeated procedure, and early recurrent disc herniation. The learning process of for 4 surgeons was assessed on the basis of 308 procedures. The mean surgical time for the initial procedure ranges from 58 to 97 minutes and improved to 51-85 minutes for the last procedures. A shorter surgical time had no influence on the rate of intraoperative complication and repeated procedure. Increased working space had a significant influence on the surgical time. The number of procedure to reach the asymptote varied from 10 to 20 depending on the endoscopic system and the surgeon. The learning process in endoscopic tubular-assisted spinal surgery is variable, and the asymptote might be reached after 10-20 procedures. The amount of working space and instrument angulation affects the surgical time. The decrease of surgical time had no significant influence on the rate of intraoperative complication and repeated procedures.

Preoperative Risk Factors for Recurrent Lumbar Disk Herniation in L5-S1: Errata.

Preoperative Risk Factors for Recurrent Lumbar Disk Herniation in L5-S1: Errata.

Patients at the Highest Risk for Reherniation Following Lumbar Discectomy in a Multicenter Randomized Controlled Trial.

Background:The purposes of the present study were to (1) confirm the risk of recurrent lumbar disc herniation in patients with a large anular defect who had undergone limited discectomy and (2) assess potential risk factors within this population.Methods:The patient population was extracted from the control cohort of a prospective, randomized, multicenter controlled trial investigating the efficacy of an anular closure device following standard limited discectomy. All control patients underwent limited discectomy for the treatment of a single-level symptomatic posterior or posterolateral lumbar disc herniation. Only patients presenting with a large anular defect (6 to 10 mm wide by 4 to 6 mm long) were included in the study (n = 278). Baseline demographic, clinical, and surgical characteristics were recorded. Follow-up evaluations were performed at 6 weeks and at 3, 6, 12, and 24 months. Imaging modalities included magnetic resonance imaging, low-dose computed tomography, and radiographs. Symptomatic recurrent lumbar disc herniation was defined as any symptomatic postoperative herniation on either side of the index level. A multivariate logistic regression analysis of demographic and surgical variables associated with the incidence of recurrent lumbar disc herniation was performed.Results:The mean anular defect area (and standard deviation) was 39.3 ± 9.1 mm2, and the mean excised nuclear tissue volume was 1.3 ± 0.8 mL. At 2 years, the incidence of symptomatic recurrent lumbar disc herniation was 25.3% (64 of 253), with the herniation occurring at a mean of 264 days after the index procedure. Of the 64 patients with recurrent lumbar disc herniation, 36 underwent a subsequent surgical procedure. Logistic regression analysis identified an increased risk for recurrent lumbar disc herniation in females (odds ratio, 2.2) and in patients with greater anular defect widths (odds ratio, 1.3). Furthermore, multivariate logistic regression analyses revealed a significant interaction between age and sex (p = 0.005).Conclusions:The outcomes of the present study provide the most substantial evidence to date in confirming previous reports of a high risk of reherniation among patients with large anular defects. Among those with large anular defects (width, ≥6 mm), females ≤50 years of age had the highest risk (up to ∼10 times higher) of recurrent lumbar disc herniation. It is recommended that an anular repair or closure should be performed after limited discectomies in patients with large anular defects.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Recurrent Lumbar Disk Herniation: A Systematic Review and Meta-analysis.

Consensus is lacking regarding optimal surgical treatment of recurrent lumbar disk herniation. A systematic search of multiple databases was conducted for studies evaluating outcomes after treatment for recurrent lumbar disk herniation. Treatment options included decompression surgeries and fusion surgeries. Although fusion surgeries eliminated re-recurrence of disk herniation, this coincided with higher incidences of complications and reoperation. Decompression surgeries and fusion surgeries both resulted in improvements in Japanese Orthopaedic Association, Oswestry Disability Index, and visual analog scale back and leg scores postoperatively (P<.05). The complication risk profiles of decompression surgeries and fusion surgeries must be balanced with the risk of disk herniation re-recurrence, as both procedures lead to improvements in functional outcomes. [Orthopedics. 2018; 41(4):e457-e469.].

SOME DIAGNOSTIC OPPORTUNITIES OF FUNCTIONAL ELECTRONEUROMYOGRAPHY IN RADICULAR SYNDROME

Objective. To analyze dynamic changes in the average F-wave latency in non-operated and operated patients with disc herniation and radicular compression syndrome. Material and Methods . A total of 81 patients were examined including 29 with non-operated nerve root compression, 32 with remaining pain syndrome (failed back surgery syndrome) and recurrent disc herniation after surgery, and 20 control patients. All patients underwent electroneuromyographic study of the average F-wave latency using a functional test in the supine and sitting positions. Results. There was no significant change in the average F-wave latency in non-operated patients with radicular syndrome, in the group of operated patients with failed back surgery syndrome and in the group of operated patients with recurrent disc herniation. The average F-wave latency decreased in the group of operated patients with instability of the spinal motion segment and in the group of operated patients with soft-tissue compression of the nerve root. Conclusion . The study of the late neurographic phenomenon of Fwave can be performed not only in the classical static position of a patient, but also in functional tests. The absence of significant changes in the average F-wave latency in a dynamic study indicates organic nerve root compression, while its decrease serves as an indicator of functional compression.

Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients’ clinical history (observing “red flags”), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

Controllable Risk Factors for Neurologic Complications in Posterior Lumbar Interbody Fusion as Revision Surgery

The main concern with revision lumbar surgery is the possibility of neurologic complications. This retrospective study was conducted to clarify the risk factors, especially the effects of nerve stretching, for postoperative neurologic complications in posterior lumbar interbody fusion (PLIF) without excessive nerve retraction by bilateral total facetectomy as revision surgery. Between 2005 and 2015, 50 consecutive patients underwent revision PLIF for recurrent stenosis or recurrent disc herniation. The patients were divided into two groups: patients with neurological complications (NC group) and patients without neurological complications (non-NC group). Radiological examinations to evaluate the magnitude of nerve stretching included the following pre- and postoperative plain radiograph measurements: anterolisthesis at flexion, intervertebral lordosis in the neutral position, and posterior disc height in the neutral position. Sixteen patients (32%) had neurological complications. The decrease in intervertebral lordosis was significantly greater in the NC group than that in the non-NC group (0.8° vs.-1.5°, P<0.05). Distraction of the posterior disc height was significantly greater in the NC group than that in the non-NC group (5.0 mm vs. 2.6 mm, P < 0.01). Neurological complications were seen in all patients with a decrease in intervertebral lordosis >3° and distraction of the posterior disc height >3 mm. Decreased intervertebral lordosis, and distraction of the posterior disc height, which can be controlled by surgeons, appear to be risk factors for neurological complications following revision PLIF. In revision PLIF, surgeons should create segmental lordosis without excessive disc height distraction.

Complication Rate in Minimally Invasive Revision Lumbar Discectomy: A Case Series and Technical Note.

Revision lumbar discectomy, given the disruption of anatomic planes, can be a more technically complicated operation. Historically, it may have higher complication rates than first-time microdiscectomy. Recently, minimally invasive tubular discectomy (MITD) has been reported as an equivalent treatment to traditional approaches and may have better utility for revision surgery. A retrospective review of MITDs performed by the senior surgeon (F.A.S.) on 42 patients with single-level, recurrent disk herniation was analyzed. Surgical technique, preoperative and postoperative visual analogue score, modified Macnab criteria, and complication rate were compared with similar patient series in the literature. One case is reviewed and the technique is described in detail. There were no significant differences across age (49.5±14.1), sex, or obesity status. Visual analogue scores improved significantly from 7.24±1.75 to 2.45±2.12 (P<0.001). Successful clinical outcome (excellent or good Macnab score) was reported in 83.3% of patients. There were no postoperative complications, including dural tears or wound infections: fewer than any reported series of this size to date. MITD can be safely performed for revision discectomies with low morbidity. A paramedian approach helps to decrease the exposure to preexisting scar tissue and may offer a significant advantage over the traditional midline approach to treat recurrent disk herniation.

The effectiveness of non-surgical treatments, re-discectomy and minimally invasive transforaminal lumbar interbody fusion in post-discectomy pain syndrome.

There have been many studies that reported various treatment options about recurrent disc herniation, recurrent sciatica, and low back pain following discectomy. However, evaluation and treatment algorithm of post-discectomy pain syndrome (PDPS) could not be standardized. The purpose of this study was to report the results of patients with PDPS who were treated with various treatment options with a minimum 2-year follow-up. We retrospectively evaluated 54 of 75 patients with PDPS who had no response to 12 weeks of conservative treatment between 2009 and 2014. Fifteen of 21 patients with re-herniation who did not respond to non-surgical treatments benefited from re-discectomy. Twenty-seven patients eventually underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery and 12 patients, who had no need for surgery, responded well to the non-surgical treatments. All patients were evaluated using the 10-point visual analog scale (VAS) and Oswestry Disability Index (ODI) preoperatively and at the post-treatment or postoperative follow-ups. Pre-treatment mean VAS score of the patients who benefited from non-surgical treatments was 7.9. The mean VAS score decreased to 2.1 at the final follow-up. The mean pre-treatment ODI was 46%, which decreased to 25.9% at the final follow-up. Preoperative mean VAS score of the patients who were treated with MIS-TLIF surgery was 8.1. The average VAS score decreased to 1.8 at the final follow-up. The mean preoperative ODI was 48%, which decreased to 24.2% at the final follow-up. Twelve of 54 patients with PDPS regardless of underlying etiology benefited from non-surgical treatments. Fifteen of 21 patients with re-herniation benefited from re-discectomy. MIS-TLIF is found as a highly effective procedure for the relief of post-discectomy pain that is resistant to non-surgical treatment options and for patients who had a second re-herniation.