Recurrent Lumbar Research Articles

Multiple Nerve Root Injuries after Incidental Durotomy: Case Report with Anatomical Correlation and Review of Literature

CSF leak is one of the most common complications in primary spine surgery. It is even more common in revision surgery. Its causes are multifactorial. It is usually a benign process, but at times it can lead to nerve injury. There have been a number of case reports regarding diagnosis and treatment of spinal nerve injuries due to incidental durotomies. However, they involve either single nerve root or ipsilateral nerves of the cauda equina that were trapped in the durotomy. We present a case of a morbidly obese patient who underwent discectomy for recurrent lumbar disc herniation. During the revision surgery, we encountered a small incidental durotomy through which a significant number of nerve roots exited and as a result were injured. This resulted in bilateral nerve dysfunction, which is a unique aspect of our case presentation. We will discuss the anatomical and pathophysiological bases for this injury. We will also review the literature regarding outcomes after incidental durotomies in regard to spinal nerve injuries.

Recurrent lumbar disc herniation: A clinical experience

Recurrent lumbar disc herniation: A clinical experience

Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis.

Purpose:The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences.Materials and Methods:A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance.Results:In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as “other” was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ2< 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05).Conclusions:The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence.

Percutaneous transforaminal endoscopic discectomy for treatment of degenerative lumbar disc herniation in older adult patients: study protocol for a randomized controlled trial and preliminary results

Background and objectives: Percutaneous transforaminal endoscopic discectomy (PTED) is a major minimally invasive surgical method for the treatment of degenerative lumbar disc herniation. The choice of posture for patients undergoing PTED is controversial. Surgeons tend to perform PTED with the patient in the prone position rather than in the lateral position. Little is documented on which posture has higher efficacy and safety. This study will be performed to investigate the efficacy and safety of the prone position versus lateral position for older adult patients undergoing PTED for the treatment of degenerative lumbar disc herniation. Design: A prospective, single-center, open-label, randomized controlled trial. Methods: This study will include 168 older adult patients with degenerative lumbar intervertebral disc herniation who receive treatment in the Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated to Dalian Medical University, China. These patients will be randomized to undergo PTED in either the prone or lateral position (n = 84 patients in each surgical position). After surgery, all patients will be followed up for 2, 6, and 12 months. Outcome measures and preliminary results: The primary outcome is the Oswestry Disability Index at 12 months postoperatively. This index is used to evaluate the improvement in low back pain. The secondary outcomes are the Oswestry Disability Index preoperatively (at baseline) and at 2 and 6 months postoperatively; X-ray morphology of the lumbar spine, Visual Analog Scale score, and Japanese Orthopaedic Association score preoperatively and at 2, 6, and 12 months postoperatively; modified MacNab grade at 2, 6, and 12 months postoperatively; partial pressures of oxygen and carbon dioxide preoperatively, intraoperatively, and 1 hour postoperatively; mean arterial pressure, Likert score, and times and doses of vasopressor used intraoperatively; and the incidence of recurrent lumbar intervertebral disc herniation and incidence of adverse reactions 12 months postoperatively. The results of 54 patients included in a pilot study of PTED showed that regardless of use of the prone position (n = 24) or lateral position (n = 28), the Visual Analog Scale score and Oswestry Disability Index at 2 months postoperatively were significantly lower than those before surgery (P Discussion: Based on the pilot study, future studies involving larger sample sizes are needed to investigate the short- and medium-term efficacy and safety of the prone versus lateral position for patients undergoing PTED for degenerative lumbar intervertebral disc herniation and to identify a better surgical posture suitable for older adult patients. Ethics and dissemination: This study was approved by Medical Ethics Committee of Dalian Municipal Central Hospital Affiliated to Dalian Medical University, China in May 2018 (approval No. 2018-012-01). This study protocol will be performed in strict accordance with the Declaration of Helsinki. Written informed consent will be obtained from the participants. The study protocol was designed in December 2017. Patient recruitment will begin in August 2018 and end in August 2019. Data analysis will begin in October 2020 and end in November 2020. Results will be disseminated through presentations at scientific meetings and/or by publication in a peer-reviewed journal. Trial registration: This trial was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800016399). Protocol version: 1.0.

True Recurrent Lumbar Disc Herniation And Arterial Hypertension: Is There Any Relation?

Cardiovascular risk factors and atherosclerosis are associated with lumbar disc herniation. However, studies fail to identify a consistent risk factor for the recurrence. To investigate the association between cardiovascular risk factors and true recurrent of lumbar disc herniation, 186 patients who underwent unilateral microdiscectomy for intractable radiculopathy due to lumbar disc herniation were enrolled in this cross-sectional study. One surgeon performed all operations, and all patients were treated with the same procedure. The follow-up period was between 6 months to 5 years. The association between some cardiovascular risk factors e.g. hypertension, diabetes, hyperlipidemia, smoking and true recurrent lumbar disc herniation investigated using logistic regression analysis. Sixty-nine patients with true recurrence of lumbar disc herniation (RLDH group) were compared to 117 patients who were surgically treated with no recurrence of lumbar disc herniation (LDH group). The differences of age, gender, diabetes, morphine addiction, hyperlipidemia and smoking between two groups were not statistically significant. The prevalence of hypertension in RLDH and LDH was 61.5% and 38.5% respectively. The difference was significant (p<0.001). The logistic regression analysis showed the recurrence rate was significantly higher in hypertensive patients (OR: 1.74-7.55, CI: 95%, P = 0.001). Furthermore, there was no correlation between confounding factor of medications, diabetes, history of cardiovascular disease, hyperlipidemia, duration of the symptom-free interval, gender and the true recurrence. The results of this preliminary study showed that there might be a possible relation between arterial hypertension and true recurrence of lumbar disc herniation, so it would be advisable to pay more attention to hypertensive patients who have been operated.

Transforaminal lumbar interbody fusion in recurrent disc herniation

Background Recurrent back and/or leg pain after primary lumbar discectomy is not uncommon. Some spine surgeons believe that fusion is necessary for treating disc reherniation. As repeated discectomy requires the removal of more disc material and posterior elements, such as lamina or facet joint, further invasion at the same surgical level can increase the risk of segmental instability. Patients and methods A total of 20 patients (12 men, eight women) with recurrent lumbar disc herniation were treated via transforaminal lumber interbody fusion. The mean age at the time of operation was 46.6 years (30–62 years). The primary procedures included discectomy with unilateral hemilaminectomy in nine and discectomy with bilateral laminectomy in 11 patients. The time from the primary surgery to that of recurrence averaged 10.6 months (range, 6–18 months). The levels of recurrent disc herniation were nine cases at L4–L5 (six ipsilateral and three contralateral) and 11 at L5–S1 (seven ipsilateral and four contralateral). Results The mean follow-up period was 22.8 months (18–30 months). The mean duration of the operation was 161.75 min (130–190–min), mean intraoperative blood loss was 325 ml (250–500), and mean duration of hospital stay was 4.15 days (3–7 days). At a minimum of 12 months of follow-up, all cases appeared to have solid fusions. Conclusion Transforaminal lumbar interbody fusion technique is an effective procedure with satisfactory clinical results for the treatment of recurrent lumbar disc herniation. The approach achieves a biomechanically stable spine, as it restores the segmental lordosis and has low complication rates.

Reperforming Minimally Invasive Microdiscectomy Approaches for Recurrent Lumbar Intervertebral Disc Prolapse

Background Data: Reperforming minimally invasive discectomy (MID) approaches are typically challenging and demanding for patients with recurrent lumbar disc herniation (rLDH).Purpose: The aim of this study to assess the safety and efficacy of reperforming Minimally invasive discectomy in recurrent lumbar disc herniation surgery.Study Design: Retrospective clinical case study.Patients and Methods: The author reviewed the medical records all patients re-operated after MID during the period from June 2010 to April 2016 via minimally invasive approaches for recurrent lumbar disc herniation. Age, gender, presenting symptoms, disc herniation level and side, type of MID approach used in first surgery, period between 1st and 2nd surgeries, redo surgery duration, intra or post-operative complications, visual analogue scale VAS for pain at 1, 30, and 90 days postoperatively were recorded.Results: We could track 18 patients (12 males, 6 females), with mean age 43.2±6.3 years. The most operated level was L4/5 in 12 patients. Disc herniation on the left side was presented in 11 patients. Mean duration between the two surgeries was 44±19 weeks. Main clinical presentations were recurrent leg pain in 16 patients and new onset of partial foot drop in 2 patients. Duration of redo surgery was 97±37 minutes. Intraoperative minor dural tears were reported in 2 with no serious sequels. VAS for leg pain improved from 7.3±1.2 preoperatively to 2.1±1.1, 1.4±0.5 and 1.2±0.4 at 1, 30 and 90 postoperative days respectively.Conclusion: MID approach for rLDH following initial MID surgery sounds feasible option with better perioperative and short-term outcome. Clinical outcome in the present study showed favourable outcome regarding operative time and incidence of dural tears with CSF leak comparing to open approaches. (2017ESJ151)

Multilevel Contiguous Osteoporotic Lumbar Compression Fractures: The Relationship of Scoliosis to the Development of Cascading Fractures.

Osteoporotic patients can present with either single or multiple fractures secondary to repeated falls and progressive osteoporosis. Multiple fractures often lead to additional spinal deformity and are a sign of more severe osteoporosis. In the thoracic spine, multiple fractures are associated with the development of gradual thoracic kyphosis but neurologic deficits are uncommon. In the lumbar spine, patients with multiple lumbar fractures have more constant lumbar pain, may have symptoms related to concurrent lumbar stenosis or degenerative scoliosis, and may present with radiculopathy, especially with fractures at L4 and L5. In a review of a series of patients with recurrent multiple lumbar fractures or 'cascading' fractures, it was found that all the patients were female, had severe osteoporosis, often untreated, had a previous history of multiple previous thoracic and lumbar fractures, and all had associated scoliotic spinal deformities ranging from 6o to 50o. It was found that if the curve progressed and the greater the degree of curvature, the more frequently subsequent multiple fractures developed, leading to recurrent acute episodes of pain. Forty percent also had additional sacral insufficiency fractures, an unusually high percentage. Biomechanically, the lumbar spine is both more mobile and supports a larger portion of the spinal load compared to the thoracic spine. The existence or worsening of a lumbar spinal deformity from degenerative lumbar scoliosis shifts the mechanical forces more to one side on already weakened osteoporotic lumbar vertebrae and sacrum, leading to an increased incidence of these fractures. Because of the chronic and uneven lower lumbar spinal load with severe vertebral osteoporosis in certain patients with repeat lumbar fractures and worsening degenerative lumbar scoliosis, there may be a rationale to add preventive vertebroplasty at adjacent vertebral endplates when treating acute recurrent lumbar fractures to decrease the incidence of recurrence in other vertebrae.

Recurrent Lumbar Disc Herniation: A Review.

Study Design:Narrative review.Objectives:To identify the risk factors and surgical management for recurrent lumbar disc herniation using a systematic review of available evidence.Methods:We conducted a review of PubMed, MEDLINE, OVID, and Cochrane Library databases using search terms identifying recurrent lumbar disc herniation and risk factors or surgical management. s of all identified articles were reviewed. Detailed information from articles with levels I to IV evidence was extracted and synthesized.Results:There is intermediate levels III to IV evidence detailing perioperative risk factors and the optimal surgical technique for recurrent lumbar disc herniations.Conclusions:Multiple risk factors including smoking, diabetes mellitus, obesity, intraoperative technique, and biomechanical factors may contribute to the development of recurrent disc disease. There is widespread variation regarding optimal surgical management for recurrent herniation, which often include revision discectomies with or without fusion via open and minimally invasive techniques.

Spine Surgeon Treatment Variability: The Impact on Costs.

Study Design:Cross-sectional analysis.Objectives:Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients.Methods:Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts.Results:For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs.Conclusions:Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.

A Consecutive Series of 39 Microendoscopic Discectomies for Recurrent Lumbar Disc Herniation

Background Data: Interlaminar microendoscopic discectomy (MED) for treatment of primary lumbar disc herniation is a fairly established technique in clinical practice. However, in recurrent cases, a concern is raised that anatomy has been distorted thus endoscopic intervention may carry greater risks of morbidity.Purpose: In the present study, the authors report their seven years’ experience with posterior interlaminar MED in recurrent lumbar disc herniation (RLDH), highlighting the surgical technique, its outcome and feasibility.Study Design: A retrospective clinical case study.Patients and Methods: In the period between May, 2009 and July, 2016, 39 consecutive patients with symptomatic RLDH as confirmed by clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) scan underwent posterior interlaminar MED. Mean age was 39.7 years, range: (29-56 years). The approach was similar to a standard interlaminar MED. Patients were followed-up for 7 years (mean follow-up was 47.9 months, range: 3 – 83 months). Clinical outcomes were reviewed and evaluated in terms of pain Visual Analogue Scale (VAS) and Modified Macnab criteria (MMC).Results: Mean operative time was 97 minutes (range: 59–155 min.) with a mean blood loss of 57 ml and an approximate hospital stay of 22.5 hours. There were no new postoperative neurological deficits or major complications. At initial follow-up, according to MMC (3months postoperative) 67% of patients were pain free (26/39) and considered their postoperative status as excellent, 24% as good (9/39), and 8% (3/39) as fair, whereas one patient was unsatisfied. Intraoperatively, there were 3 patients of dural tears, mainly toward the beginning of our study, seven patients of accidental medial facetectomies due to excess bony work and two patients had an unintended fracture of the base of the spine. Postoperatively, 2 patients had temporary weakness of involved root that resolved on follow-up and three patients had transient postoperative neuralgia.Conclusion: Recurrent lumbar disc herniation can be treated safely and adequately with posterior interlaminar MED although of partial loss of anatomy. The technique is associated with satisfactory clinical results as well as short hospital stay. It provides adequate visualization and decompression of the involved nerve root. (2017ESJ127)

Performance of an Annular Closure Device in a 'Real-World', Heterogeneous, At-Risk, Lumbar Discectomy Population.

Study design/settingRetrospective analysis of single-center registry outcomes data.ObjectiveAssess the utility of an annular closure device (ACD) as an adjunct to limited discectomy for lumbar disc herniation (LDH).BackgroundRecurrent lumbar disc herniation (rLDH) following limited discectomy persists at clinically significant rates, especially in large annular defect (at least 6 mm width) patients. While the etiology of reherniation is often multifactorial, inadequate annular occlusion remains one of the foremost considerations. Accordingly, annular closure has emerged as a promising technique and is the focus of this analysis.MethodsThis was a retrospective analysis of 171 patients who underwent limited lumbar discectomy with an ACD for LDH. Standardized patient assessment was performed preoperatively, three months postoperatively, and 12 months postoperatively, in addition to self-presented visits. No minimum last follow-up was required for inclusion. Oswestry Disability Index (ODI) and Visual Analog Scale (VAS Leg/Back) pain scores were collected at all visits. Plain radiographs were obtained at all visits, with magnetic resonance imaging (MRI) scans performed annually and/or when patients presented as symptomatic. ACD-related complications due to partial or complete mesh detachment from the titanium anchor were reported. All secondary surgical interventions were also reported. The Wilcoxon Rank-sum test was used to compare outcomes and events between sub-groups (p < 0.05).ResultsMean last follow-up for all patients was 15 months. Large annular defects were present in 154 patients (90%). Symptomatic reherniations were observed in six patients (3.5%; five were present in the large annular defect subpopulation). All patients demonstrated clinically meaningful improvement in clinical outcome scores at both follow-up intervals. ACD mesh detachment was observed in 15 patients (8.8%; two underwent a subsequent surgical intervention). No symptomatic reherniations were observed in secondary herniation patients compared to six (4.1%) in the primary herniation group (p = 0.60).ConclusionsAnnular closure with the ACD results in clinically meaningful improvements in both primary and secondary LDH patients, with decreased rates of reherniation in high-risk patients compared to previous discectomy reports.

Treatment for Recurrent Lumbar Disc Herniation.

Recurrent lumbar disc herniation (RLDH) is the most common indication for reoperation after a lumbar discectomy. The purpose of this manuscript is to review the incidence, risk factors, and treatment for RLDH. Patients who require revision surgery for RLDH improved significantly compared to baseline; however, the magnitude of improvement is less than in primary discectomy patients. Treatment with either repeat discectomy or instrumented fusion has comparable clinical outcomes. Repeat discectomy patients, however, have shorter operative times and length of stay. Hospital charges are dramatically lower for repeat discectomy compared to instrumented fusion. The incidence of RLDH is somewhere between 5 and 18%. Risk factors include younger age, lack of a sensory or motor deficit, and a higher baseline Oswestry Disability Index (ODI) score. Available evidence suggests that some patients may respond to nonoperative interventions and avoid the need for reoperation. For those that fail a trial of conservative management or present with neurologic deficit, both repeat lumbar discectomy and instrumented fusion appear to effectively treat patients with similar complication rates and clinical outcomes.

Percutaneous Endoscopic Lumbar Reoperation for Recurrent Sciatica Symptoms: A Retrospective Analysis of Outcomes and Prognostic Factors in 94 Patients.

Recurrent symptoms of sciatica after previous surgical intervention is a relatively common and troublesome clinical problem. Percutaneous endoscopic lumbar decompression has been proved to be an effective method for recurrent lumbar disc herniation. However, the prognostic factors and outcomes of percutaneous endoscopic lumbar reoperation (PELR) for recurrent sciatica symptoms were still unknown. The purpose of this study was to evaluate the outcomes and prognostic factors of patients who underwent PELR for recurrent sciatica symptoms. From 2009 to 2015, 94 patients who underwent PELR for recurrent sciatica symptoms were enrolled. The primary surgeries include transforaminal lumbar interbody fusion (n= 16), microendoscopic discectomy (n= 31), percutaneous endoscopic lumbar decompression (PELD, n= 17), and open discectomy (n= 30). The mean follow-up period was 36 months, and 86 (91.5%) patients had obtained at least 24 months' follow-up. Of the 94 patients with adequate follow-up, 51 (54.3%) exhibited excellent improvement, 23 (24.5%) had good improvement, and 7 (7.4%) had fair improvement according to modified Macnab criteria. The average re-recurrence rate was 9.6%, with no difference among the different primary surgery groups (PELD, 3/17; microendoscopic discectomy, 2/31; open discectomy, 3/30; transforaminal lumbar interbody fusion, 1/16). There was a trend toward greater rates of symptom recurrence in the primary group of PELD who underwent percutaneous endoscopic lumbar reoperation compared with other groups, but this did not reach statistical significance (P>0.05). Multivariate analysis suggested that age, body mass index, and surgeon level was independent prognostic factors. Obesity (hazard ratio 13.98, 95% confidence interval 3.394-57.57; P < 0.001) was the risk factor affecting re-recurrence according to logistic regression analysis. PELR is a safe and effective treatment for recurrent sciatica symptoms regardless of different primary operation type. Obesity, inferior surgeon level, and patient age older than 40 years were associated with a worse prognosis. Obesity was also a strong and independent predictor of re-recurrence sciatica symptoms after percutaneous endoscopic lumbar decompression.

The mini-open anterolateral lumbar interbody fusion (MO-ALLIF) with self-anchored stand-alone cage in lumbar revision surgery

Objective To evaluate the safety and efficacy of the mini-open anterolateral lumbar interbody fusion (MO-ALLIF) in lumbar revision surgery. Methods Seventeen patients, seven male and ten female, who underwent revision lumbar surgeries using MO-ALLIF with self-anchored stand-alone polyetheretherketone (PEEK) cage in a single center between April 2013 and April 2016 were studied retrospectively. There were 14 of sing-level cases and 3 of double-level cases. Among them, 11 cases were L4, 5, 4 cases were L3, 4, 5 cases were L5S1. There were 2 cases of cage migration, 3 cases of pseudarthrosis, 6 cases of recurrent lumbar disc herniation of the same level, and 6 cases of lumbar disc herniation on the adjacent level. The average age was 53.9±7.2 years (range, 41-65 years). The clinical manifestation was low back pain and/or leg pain. The operation time, blood loss, and perioperative complications were evaluated. Oswestry disability index (ODI) and visual analog scale (VAS) score of leg and back pain were analyzed preoperatively and at each time point of follow-up postoperatively. Radiological evaluation including fusion, global lumbar lordosis, disc height on the operation level, foraminal height on the operation level, and subsidence were assessed. Results The average follow-up time was 22.7±8.6 months (12-48 months) . Among the seventeen patients that participated in this study with a total of 20 segments, only one patient suffered from peritoneal rupture, but no symptom was observed after suturing. No other approach-related complications were found in all cases. The mean operation time was 74.0±15.5 minutes. The average blood loss was 122.4±28.8 ml. All patients involved achieved solid fusion at the last follow-up (12 months post-operation) with no cage migration. Significant differences were observed between the pre- and post-operation status, with respect to the back pain VAS, leg pain VAS and ODI scores. The post-operative lumbar lordosis, disc height on the operation level and foraminal height on the operation level, were also significantly improved when compared with the pre-operative ones. Conclusion MO-ALLIF with self-anchored stand-alone PEEK cage is a modification of both anterior lumbar interbody fusion and oblique lumbar interbody fusion, which is safe and effective in some revision lumbar surgery with minor surgical trauma, low access-related complication rates, and satisfactory clinical and radiological results. Key words: Lumbar vertebrae; Treatment failure; Reoperation; Spinal fusion

31 - Treatment of Recurrent Lumbar Disc Herniation with or without Fusion in Workers' Compensation Subjects

BACKGROUND CONTEXT: Recurrent lumbar disc herniation (RLDH) is estimated to occur in 7% to 24% of patients after discectomy. The two main surgical options after reherniation are a revision discectomy (RD) or a revision discectomy combined with fusion (RDF).

Posterolateral fusion versus Dynesys dynamic stabilization: Retrospective study at a minimum 5.5 years’ follow-up

IntroductionLumbar fusion is one of the most widespread techniques to treat degenerative lumbar pathology. To prevent complications such as non-union or adjacent segment degeneration, dynamic stabilization techniques were developed, but with controversial results. The aim of the present study was to compare long-term radiologic and clinical results between fusion and dynamic stabilization. Material and methodsA single-center retrospective study included patients with recurrent lumbar discal hernia or lumbar canal stenosis managed by posterolateral fusion or by dynamic stabilization associated to neurologic release. Patients were seen in follow-up for radiological and clinical assessment: visual analog pain scale (VAS), Oswestry Disability Index (ODI), Short Form-12 (SF-12), adjacent segment disease (ASD), and intervertebral range of motion (ROM). ResultsFifty-eight patients were included: 25 in the fusion group (FG), and 33 in the Dynesys® group (DG). VAS scores were significantly lower in DG than FG. ODI was 14.6±2.8 in DG, versus 19.4±3.3 in FG (P=0.0001). SF-12 physical subscore was significantly higher in DG. ROM was 4.1±2° in DG, vs. 0.7±0.5° in FG (P=0.001). Radiologic ASD was significantly greater in FG than DG (36% vs. 12.1%; P=0.012), without difference in clinical expression (DG, 1 case; FG, 2 cases). ConclusionDynamic stabilization provided clinical and radiological results comparable to those of posterolateral fusion in these indications (although level L5-S1 was not studied). Level of evidenceIV.

Smoking Is an Independent Risk Factor of Reoperation Due to Recurrent Lumbar Disc Herniation.

Study Design:Retrospective cohort study.Objectives:The purpose of the present study is to determine if age, gender, smoking status, and body mass index (BMI) are significant risk factors of symptomatic recurrent lumbar disc herniation (rLDH) leading to reoperation.Methods:A cohort of 1378 consecutive patients who underwent discectomy for LDH from June 2010 to January 2015 at our institution were included. Patients who underwent reoperation due to rLDH prior to August 2015 were identified. Data on reoperations, age, gender, smoking status, and BMI were collected from our database. A comparison of age, gender, smoking status, and BMI was made between the controls (non-rLDH) and the cases (rLDH group). Binary logistic regression was performed to determine whether age, gender, smoking status, and BMI were independent risk factors for rLDH.Results:Patients in the non-rLDH group (48.2 years) were older than the rLDH group (44.7 years; P = .013). Gender distribution (54.8% vs 48.5% males; P = .222) and BMI (26.6 vs 26.6; P = .458) were similar between the 2 groups. A significantly higher prevalence of smokers was found in the rLDH group (33.1% vs 51.5%; P < .001). Binary logistic regression analysis showed that smoking was an independent risk factor of rLDH (odds ratio = 2.12; 95% confidence interval = 1.39-3.15; P < .001).Conclusions:Neither age, BMI, nor gender had any statistical significant association with the risk of rLDH. Smoking was associated with higher risk of reoperation due to rLDH.

Evaluation of Treatment of Recurrent Lumbar Disc Prolapse: Fusion Versus Non Fusion

Background Recurrent lumbar disc herniation is one of the most common spinal disorders. The management of recurrent lumbar disc herniation remains somewhat controversial. Surgical treatment for recurrent disc herniation can be broadly categorized as revision discectomy alone or revision discectomy and fusion. Objective The aim of the work is the evaluation of management of recurrent lumbar disc prolapse: fusion versus non fusion aiming to reach ideal method of treatment. Matients and Methods: This is a prospective, randomized, comparative study on 30 patients (19 M, 11 F) with recurrent lumbar disc herniation at Assiut University Hospitals from January 2015 to January 2016 (minimum 12-months follow-up) with an average age of 47.2 years (range: 30–67 years). The patients were classified into 2 groups: Group A (15 patients); who had revision discectomy alone, group B (15 patients); who had revision discectomy with fusion. The clinical and radiographic results were compared between the two groups. Clinical outcome was assessed using the Modified MacNab’s Criteria and radiological outcome was assessed using Lenke classification. Results: Regarding postoperative Modified MacNab’s Criteria, there is no significant difference (P=0.7826) between group A which was excellent in 7 cases (7/15, 46.7%), good in 6 cases (6/15, 40%) and fair in 2 cases (2/15, 13.3%) and group B which was excellent in 6 cases (6/15, 40%), good in 6 cases (6/15, 40%), fair in 2 cases (2/15, 13.3%) and poor in 1 case (1/15, 6.7%). In group A: 1 of 15 patients (6.7%) had dural tear while in group B: 3 of 15 patients (33.3%) have dural tear (P=0.6171) and no infection occur in group A while 2 patients (13.3%) have infection in group B. The intraoperative blood loss and length of operation were significantly less in group A. The post-surgery hospital stay was significantly different between the 2 groups, being least in group A and highest in group B. Conclusion: Surgery for recurrent lumbar disc herniation can be very successful and may approach the success rate for initial operations (80% in our study) provided proper patient selection, good and thorough examination and investigations and proper surgical technique.

Comprehensive rehabilitation is superior to surgical intervention for many patients with recurrent lumbar disc herniation

Objective To compare the effectiveness of comprehensive rehabilitation therapy with that of surgical intervention for patients with recurrent lumbar disc herniation (LDH). Methods A total of 124 LDH patients were recruited and randomly divided into an experimental group and a control group, each of 62. The experimental group was given comprehensive rehabilitation consisting of medicine, physical therapy, and spinal stabilization exercises, while the control group received lumbar spine surgery. The patients′ back and leg pain scores and their Oswestry Disability Index (ODI) scores were compared at admission and discharge, as well as 3 and 12 months after discharge. Anxiety and depression were also assessed at admission and 3 months after discharge. Results At discharge and 3 and 12 months later the average back and leg pain scores and ODI ratings were significantly lower than that at admission for both groups. There were no significant inter-group differences. In terms of anxiety and depression, however, these had decreased significantly in both groups, but the experimental group′s average rating was significantly better at discharge. Conclusions Comprehensive rehabilitation is superior to surgical intervention in relieving the depression of patients with recurrent LDH. Comprehensive rehabilitation should be considered as the first choice for patients with recurrent LDH, and only supplemented by surgical intervention if it is not effective. Key words: Lumbar discs; Herniation; Rehabilitation; Surgery