Recurrent Disc Research Articles

Recurrent Lumbar Disc Herniation after Microendoscopic Discectomy

Recurrent Lumbar Disc Herniation after Microendoscopic Discectomy The purpose of this study was to investigate the incidence and risk factors of recurrent lumbar disc herniation (LDH) after microendoscopic discectomy (MED).

Commentary on four recently published papers on chronic pain and spinal surgery.

This commentary evaluates four articles dealing with chronic pain from very different perspectives. The first paper by Tsantoulas and McMahon entitled “Opening paths to novel analgesics: the role of potassium channels in chronic pain” evaluates the membrane neurochemistry of the neural cells governing the transmission of pain impulses in the spinal cord and trigeminal systems. As potassium membrane potentials diminish excitability in the nociceptive pain pathways, damage to these pathways may result in excessive transmission of impulses that contribute to “chronic pain”. Haneder et al. analyzed degeneration in lumbar discs utilizing 23Na magnetic resonance (MR) imaging to determine whether this would help analyze low back pain versus standard 1H MR imaging. As degenerated discs lose glycosaminoglycan, which attracts 23Na, this imaging could potentially be useful in detecting degenerating intervertebral discs. Mroz et al. analyzed how 445 spinal surgeons handled recurrent lumbar discs (first and second recurrences) herniations in the United States. Surgeons in practice for more than 15 years were more likely to select simple disc revision, while those with fewer years experience and performing more than 200 cases per year were more likely to select revision surgery that included some form of inter-body fusion. Lee et al. performed a multivariate analysis of more than 1532 patients to validate a predictive model of the risk of surgical site infection after various spine surgeries. Outcomes analyzed the frequency of reoperations for irrigation/debridement, and evaluated how patients’ comorbidities helped predict the risk of infection (e.g. obesity, rheumatoid arthritis, and the number of levels/extent of surgery).

RELATIONSHIP BETWEEN BIOCHEMICAL PARAMETERS OF THE SPINAL MOTION SEGMENT AND OUTCOME OF SURGERY FOR HERNIATED LUMBAR INTERVERTEBRAL DISC

Objective. To analyze natural biochemical changes in proteoglycans and glycosaminoglycans of patients with recurrent and nonrecurrent herniations of lumbar intervertebral discs. Material and Methods. Biochemical parameters of primary intervertebral disc hernias were prospectively investigated in 50 patients who underwent repeated surgery for recurrent hernia at the same level, and in 50 patients without recurrence. The quantity and quality of glycosaminoglycans in tissues of the hernia and surrounding annulus fibrosus were determined by analytical biochemistry methods. The properties of proteoglycans in the hernia tissue were studied by composite gel electrophoresis. Results. Type 1 recurrent hernia tissues are characterized by high content of water and glycosaminoglycans, but relatively few glycosaminoglycans tightly bound within the extracellular matrix (ECM) are retained in the tissue after its treatment with 4 M guanidinium chloride. Type 2 hernia tissues showed reduced content of water and glycosaminoglycans, and increased content of neutral hexoses. More than a half of them were tightly bound to ECM structures. On MRI evidence, Type 1 hernias correspond to Grade III disc degeneration, and Type 2 – to Grade IV. Biochemical profile of glycosaminoglycans in intervertebral disc tissues of the recurrence group reliably differed from that of the nonrecurrence group by the higher content of chondroitin sulfates and proteoglycans loosely bound to ECM structures. Conclusion. The tissue structure of nucleus pulposus and annulus fibrosus in recurrent and nonrecurrent intervertebral disc differs in qualitative and quantitative characteristics of glycosaminoglycans.

The efficacy of rehabilitation after reoperation for recurrent lumbar disc herniation

Objective To observe the effect of early rehabilitation therapy on recovery from reoperation for recurrent lumbar disc herniation (RLDH).Methods Sixty-five cases who received surgery for RLDH between 2007 and 2009 were randomly divided into a rehabilitation group and control group.Both groups were treated with the same surgical approach and routine treatment.Early and comprehensive rehabilitation therapy was provided in the rehabilitation group during the perioperative period,including preoperative and postoperative muscle strength training,postoperative sitting and standing balance training,and acupuncture.The control group was instructed only in general exercise.Before the operation and 2 weeks and 3,6,12 and 24 months afterward,the surgical outcomes of all cases were assessed using the JOA score and the improvement rate in the JOA score.Any postoperative complications and intervertebral fusion were also observed.Results The average postoperative JOA scores of both groups were significantly higher than their preoperative scores.At all of the time points after the operation,the average JOA scores and all improvement rates in the rehabilitation group were significantly higher than those in the control group.Postoperative complications such as deep venous thrombosis,urinary retention and constipation were significantly less among the rehabilitation group than among the controls.All the intervertebral bone implants were well fused on time.Conclusion Early rehabilitation can significantly improve the effectiveness of RLDH reoperation and reduce the incidence of postoperative complications.It is recommended for clinical application. Key words: Recurrent herniation; Lumbar disc herniation; Rehabilitation

Agreement between magnetic resonance imaging, myelography, and surgery for detecting recurrent, thoracolumbar intervertebral disc extrusion in dogs

Although magnetic resonance imaging (MRI) is reported to be superior to myelography to determine the location and site of first time disc herniation, comparison of these diagnostic methods in cases of recurrent intervertebral disc disease (IVD) herniation after a first surgery has not been evaluated. The objective was to compare the diagnostic accuracy of MRI and myelography in a series of dogs undergoing repeat surgical decompression for recurrent IVD extrusion when compared to the gold standard of surgery. Ten dogs with recurrent IVD herniation underwent MRI and myelography followed by surgical decompression. Three observers reviewed the images to determine the site and side of the first surgery and the recurrent lesion. Agreement was determined by calculating a kappa (κ) score. Substantial interobserver agreement was noted for recurrent lesion site using MRI and myelography (κ = 0.77 vs. 0.73) and when comparing MRI and myelography to the reported surgical site (κ = 0.73 vs. 0.67). Interobserver agreement was greater with MRI for circumferential location compared to myelography (κ = 0.76 vs. 0.43), similar to what was found when comparing to surgical side (κ = 0.82 vs. 0.49). The previous surgical site in this study had no effect on ability to identify the new lesion. Despite the limitations of MRI, there was greater agreement between observers using MRI for both the recurrent and first lesion.

Pregnancy and childbirth after microsurgery for lumbar disc herniation

The influence of previous lumbar discectomy on pregnancy and childbirth has not been extensively studied. This study reports the course of pregnancies after lumbar discectomy. Twenty-six 31.5 ± 3.6-year-old patients who had delivered 39 children were included. All patients underwent lumbar microsurgical discectomy prior to childbirth. Demographic and surgical data were collected from hospital records and patient questionnaires. The presence and course of low back pain (LBP) and radiculopathy signs were noted. Mean latency between surgery and childbirth was 42.5 ± 34.8 months. Delivery was at gestational week 36 to 42, and the average weight of the newborn was 3,390 ± 0.490 g. Prevalence and new onset of symptoms during pregnancy was as follows: low back pain, 76% and 60%; leg pain 37% and 18%; motor deficits 13% and 6%; and sensory deficits 39% and 19%, respectively. No recurrent lumbar disc herniation was diagnosed within 6 months after pregnancy. Patients suffering from radicular pain during pregnancy were at risk of persistence of symptoms 6 months after delivery. Three patients had had surgery because of recurrent lumbar disc herniation during the follow-up of 7.73 ± 2.66 years. The incidence of radicular pain during pregnancy after microsurgical discectomy for lumbar disc herniation was 18%. The incidence and prevalence of LBP are among the highest reported in the literature. The incidence of low back pain and radiculopathy signs does not change significantly with subsequent pregnancies. The operation rate for recurrent lumbar disc herniation or adjacent level disease after pregnancy seems not to be higher than the overall rate reported in the literature.

The midterm efficacy evaluation of artifical nucleus prosthesis replacement in treatment of lumbar disc herniation

Objective To evaluate the midterm efficacy of prosthetic disc nucleus ( PDN) replacement for the treatment of lumbar disc herniation. Methods Twenty cases of lumbar disc herniation( including one case of recurrent lumbar disc herniation) were treated with PDN. The twenty cases were followed-up 5.4 ～6.2 years( mean 5.7 years). Functional,and radiographic follow-up examinations,MRI and follow-up records of all patients were reviewed carefully. Results Clinical evaluation at the end of follow-up,there were 10 cases in excellent,6 cases in good,2 cases in fair and 2 cases in poor,and good rate was 80%. One patient accepted the revision operation to remove the PDN because of device migration. One patient accepted the fusion because of adjacent segment disease. The others experienced pain relief, and resumed their normal life and work. The average Oswestry score and VAS get better significantly. Conclusion The PDN was effective in treating patients with lumbar disc herniation. However, the medium term complications of device subsidence should be taken seriously. Key words: Lumbar vertebrae; Intervertebral disc displacement; Prosthesis implantation

Morphologic and functional glaucomatous change after occurrence of single or recurrent optic disc hemorrhages

Dear Editor, With much interest we have read the recent paper from de Beaufort et al. about the impact of optic disc hemorrhages (ODH) on the rate of visual field (VF) progression during a mean follow-up of 4.6 years [1]. The study covers an important topic since ODH is a considerable risk factor for occurrence and progression of glaucomatous VF defects in patients with ocular hypertension and open-angle glaucoma. Nevertheless, it seems surprising that the authors did not find a difference in the rate of VF progression between patients with single and recurrent ODH. We would like to add some of our own findings from structural and functional analysis of long-term follow-up of an ongoing cohort study (www. clinicaltrials.gov: ID: NTC00494923). Sixty patients with single or recurrent ODH were recruited from the Erlangen Glaucoma Registry to evaluate the rate of glaucomatous optic disc change and VF deterioration using an event-based approach. All patients underwent annually a complete, standardized ophthalmologic examination including standard static white-on-white perimetry and acquisition of stereographic optic disc slides, which were used for evaluation of ODH. Morphologic assessment of the optic disc was performed by simultaneous projection of optic disc slides in a masked order to determine whether progressive change of the optic disc morphology in comparison to the first date of examination took place or not. Criteria for progression were marked neuroretinal rim (NRR) loss with extension of the optic disc cup or notching accompanied by kinking of small vessels passing the NRR [2]. Morphologic changes had to be confirmed by two experienced examiners independently from each other. Visual field deterioration was defined as significant increasing cluster defects (p<0.01) evaluated with Octopus Field Analysis (Version 2.63). The first two VF tests from each patient were excluded from analysis to avoid learning effects. Subsequent perimetric results just before ODH were used as baseline values. Kaplan-Meier survival analysis and the log-rank test were used to compare the rate of NNR loss and VF deterioration in both groups. The cumulative probability of progressive glaucomatous optic disc change was significantly higher in the recurrent ODH group (p<0.01, Fig. 1). However, no significant difference was found between both groups regarding the incidence of VF progression (p=0.29, Fig. 2). Average follow-up time after the first ODH was 7.2 years for the single group and 8.1 years for the recurrent group. The duration of hemorrhages to disappear varies over a wide range and may reach from a few weeks up to several months. We defined the first observed ODH as the first hemorrhage in our patient group, even if it is not known if any previous hemorrhages occurred. Patients with single ODH may develop another ODH after the maximum followup or between the annual intervals. Indeed, it is very difficult for monitoring ODH patients with both closer time period and long-term follow-up of up to 13 years after occurring ODH. Since the examination interval was standardized and follow-up time is comparable in both groups, we do not Supported by Deutsche Forschungsgemeinschaft SFB 539 “Glaukome und Pseudoexfoliationssyndrom”

Microendoscopic discectomy for recurrent lumbar disc herniation*

Introduction: The purpose of this study is to elucidate the feasibility of microendoscopic discectomy (MED) for the treatment of recurrent lumbar disc herniation. Methods: Thirty-six patients with recurrent lumbar disc herniation were treated using MED (30 men and six women; mean age: 45.7 years, range: 26–80 years; mean follow-up: 24.4 months, range: 12–52 months; mean duration between the primary and revision surgery: 65.9 months, range: 1–320 months) (recurrent group). Sex- and age-matched patients with primary lumbar disc herniation treated by MED served as the control group (primary group). The clinical outcomes were evaluated using the Japanese Orthopaedic Association score for low back pain and questionnaires regarding MED. Results: The average Japanese Orthopaedic Association scores before surgery and at the final follow-up were significantly lower in the recurrent group than in the primary group (10.8 ± 3.4 versus 15.0 ± 4.0 before surgery, P=0.001 and 25.4 ± 2.6 versus 26.8 ± 1.9 at follow-up, P=0.013), while the average recovery rates were not significantly different between the two groups (80.3 ± 14.1% versus 84.5 ± 14.6, P=0.22). The surgical time was significantly longer for the recurrent group than for the primary group (83.0 ± 41.8 min versus 67.1 ± 18.1 min,P=0.042). Of the 18 questionnaire respondents, 17 answered that postoperative pain was milder after MED than after a standard discectomy. Conclusion: MED is a feasible surgical option for recurrent lumbar disc herniation, yielding surgical outcomes comparable to those obtained in primary lumbar disc herniation.

Outcomes of microdiscectomy for treatment of recurrent lumbar disc herniation

Objective To evaluate the outcomes of microdiscectomy for treatment of recurrent lumbar disc hemiations. Methods There were 18 cases of recurrent lumbar disc berniations accepted microdiscectomy (reoperation group), compared with 30 cases of primary lumbar microdiscectomy (primary group). Operating time, blood loss and length of hospital stay were compared between two groups. MacNab criteria were used to evaluate the outcomes. Results Operating time was a mean of 75 min in reoperation group, 52 min in primary group. Blood loss of reoperation group was 70 ml, 50ml in primary group. Length of hospital stay was 8.5d in reoperation group, 6.5d in primary group. There were one dural tear, two Ls root lesions and 5 more numbness reoperation group, but recovery all patients. There were one dural tear in primary group. 17 cases got follow-up mean 12.1 months in reoperation group and 29 cases in primary group mean 11.8 months. The results demonstrated 88.2% success rate in reoperation group and 93.1% in primary group. There was no significant dif-ference in two groups (P ＞ 0.05). Conclusion Outcomes of Lambar mierodisceetomy with mini-open for treatment of recurrent lumbar disc herniations are similar to primary lumbar mierodiscectomy. Key words: Lumbar vertebrae; Lumbar disc herniation; Microdiscectomy

The Multiply Operated Lumbar Spine: Clinical Update 2008

This article focuses on the spectrum of issues and problems associated with the multiply operated lumbar spine. The review covers emergency indications for lumbar spine surgery in the multiply operated spine as well as surgical principles for a recurrent lumbar disc herniation or recurrent lumbar spinal stenosis. The review also approaches issues in the multiply operated lumbar spine with new technology as well as more traditional challenges like instability and nonunion, as well as psychosocial issues that exist in this difficult group of patients. The article ends with a discussion on safety issues and expectations of patients as well as other factors, such as the increasing prevalence of osteoporosis as our revision lumbar spine patient population over the age of 60 steadily increases.

Spontaneous resorption in recurrent intradural lumbar disc herniation

Spontaneous resorption in recurrent intradural lumbar disc herniation

Recurrent Optic Disc and Retinal Vasculitis in a Patient with Drug-Induced Urticarial Vasculitis

The purpose of this study was to report recurrent optic disc and retinal vasculitis in a patient with drug-induced urticarial vasculitis. Complete ophthalmological examination including fluorescein angiography and visual field examination were done. A 53-year-old woman with recurrent painful urticarial skin lesions following trimethoprim sulfamethoxazole usage had the clinical and histopathological diagnosis of urticarial vasculitis. Two years after cutaneous manifestations, she began to notice visual disturbances in both eyes that recurred at 1-year intervals. Her ophthalmological findings were consistent with recurrent vasculitis of the optic nerve and retina. Treatment with high-dose corticosteroids and hydroxychloroquine resulted in the resolution of cutaneous and ocular manifestations. This patient demonstrates that recurrent occlusive vasculitis of the optic nerve and retina can occur in this rare disease. These patients should be examined periodically by ophthalmologists.

Commentary

Background: Failed back surgery syndrome (FBSS) is a condition in which there is failure to improve satisfactorily after back surgery. It is characterized by intractable pain and various degrees of functional disability after lumbar spine surgery. It is estimated that this complication occurs in 5% to 10% of patients after spinal surgeries. The major causes of FBSS are fibrosis and adhesions, spinal instability, recurrent hemiated disk, and inadequate decompression. The purpose of this study is to report on the postsurgical outcome after a redo spinal surgery. Methods: We prospectively studied 50 patients with FBSS. The underlying pathology was identified and all the patients were treated surgically. Redo surgery was targeted at correcting the underlying pathology: removal of recurrent or residual disk, release of adhesions with neural decompression, and fusion with or without instrumentation. The postsurgical outcome was studied using the Oswestry Disability Questionnaire (ODQ). Results: The average preoperative ODQ mean score was 80.8; the average postoperative ODQ mean score was 36.6 at 1 month and 24.2 at 1 year. Best scores were obtained at 3 months of follow-up in most cases. Successful outcome (>50% pain relief) could be achieved in 92% of the patients at 1 year. Conclusion: The current study shows that successful management of patients with FBSS could be achieved with proper patient selection, correct preoperative diagnosis, and adequate surgical procedure targeting the underlying pathology.

Impairment Tutorial: Recurrent Radioculpathy: Recurrent Radioculpathy and Apportionment

Abstract Recurrent radiculopathy is evaluated by a different approach in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, compared to that in the Fourth Edition. The AMA Guides, Fifth Edition, specifies several occasions on which the range-of-motion (ROM), not the Diagnosis-related estimates (DRE) method, is used to rate spinal impairments. For example, the AMA Guides, Fifth Edition, clarifies that ROM is used only for radiculopathy caused by a recurrent injury, including when there is new (recurrent) disk herniation or a recurrent injury in the same spinal region. In the AMA Guides, Fourth Edition, radiculopathy was rated using the Injury Model, which is termed the DRE method in the Fifth Edition. Also, in the Fourth Edition, for the lumbar spine all radiculopathies resulted in the same impairment (10% whole person permanent impairment), based on that edition's philosophy that radiculopathy is not quantifiable and, once present, is permanent. A rating of recurrent radiculopathy suggests the presence of a previous impairment rating and may require apportionment, which is the process of allocating causation among two or more factors that caused or significantly contributed to an injury and resulting impairment. A case example shows the divergent results following evaluation using the Injury Model (Fourth Edition) and the ROM Method (Fifth Edition) and concludes that revisions to the latter for rating permanent impairments of the spine often will lead to different results compared to using the Fourth Edition.

Recidiverende lage-rugpijn en vroegtijdige discusdegeneratie bij jongeren

Recurrent low back pain and early disc degeneration in the young [Spine 1999;24(13):1316-21]

A pilot study of intervertebral disc replacement

The aim of this study was to establish whether disc replacement can restore function reduced by back pain.Forty-six patients deemed suitable for disc replacement were assessed using the Oswestry Disability Scoring system pre-operatively and post-operatively to assess function. The surgery was carried out between 1990 and 1995 using the Link (R) Charite 111 prosthesis. The post-operative assessment was carried out by postal questionnaire.The diagnosis was recorded as degenerative disc disease in 41 patients, contained disc prolapse in one, sequestrated disc in three, foraminal stenosis in one and recurrent disc in two patients. Two or more diagnoses were recorded in six patients. Five patients who had intervertebral disc replacement had undergone previous surgery.The mean duration of follow-up was 3 years (range 11-72 months). Of the 46 patients (17 male and 29 female) two were converted to fusion, one was lost to follow-up and three were excluded because of incomplete data sets. The mean Oswestry Disability score improved from 52.2 pre-operatively to 33.4 at follow-up. This is statistically significant (p = 0.001).This small but carefully studied group suggests that disc replacement can improve function in patients disabled by back pain. The present technology does not fail immediately nor does it simply sink into the vertebral bodies. Interbody fusion does not occur.

Recurrent disc Vs. scar?

Recurrent disc Vs. scar?

Recurrent Disk Versus Scar in the Postoperative Patient

The purpose of this study was to compare computed tomography (CT)/myelography and CT/diskography images, in a given patient, as a method of distinguishing postoperative fibrosis from recurrent herniated disk material. The study population consisted of 20 patients who had undergone lumbar diskectomy and subsequently developed recurrent radicular pain. All patients underwent CT/myelography and CT/diskography, each procedure performed within 72 h of the other. Comparison of transaxial images from CT/myelography and CT/diskography at a given disk space level yielded the following results: in 12 patients the extradural mass seen via CT/myelography corresponded entirely to the contrast-filled disk fragment seen via CT/diskography (recurrent herniated disk); in three patients the extradural mass seen via CT/myelography was larger than the disk fragment seen via CT/diskography (recurrent herniated disk and fibrosis); and in five patients CT/diskography images appeared normal, but CT/myelography showed an extradural mass (fibrosis). Fifteen patients underwent surgical reexploration with the following results: in three of three patients, the suspicion of recurrent herniated disk and fibrosis by radiologic evaluation was confirmed by surgical reexploration; in nine of 12 patients, solely recurrent herniated disk shown by radiologic criteria was similarly confirmed. The remaining five patients presumed to have fibrosis by radiologic criteria were treated nonoperatively.

腰部椎間板ヘルニア再発例の検討

腰部椎間板ヘルニア再発例の検討