Single-level Discectomy Research Articles

ANALYSIS OF RESULTS OF THE INTERVERTEBRAL TOTAL DISK ARTHROPLASTY OF THE LUMBAR SPINE BY M6-L PROSTHESIS: A MULTICENTER STUDY

Background: Pain in the lower back is an urgent health issue in industrialized countries. The dominant cause of pain in the lumbosacral spine is the degeneration of the inter vertebral discs (I VD). The total prosthetics I VD is a modern method of surgical treatment of I VD degenerative diseases, an alternative method of rigid stabilization.Aim: To analyze the results of surgical inter vention (I VD prosthesis M6-L implantation) in patients with I VD degeneration of lumbar spine at the 6, 12, 24, and 36 months after the surger y.Materials and methods: The study included 156 patients (92 men, 64 women) aged 23 to 45 years who under went a single-level discectomy with implantation of an artificial IVD prosthesis M6-L at the bases of three neurosurgical centers. For dynamic assessment, clinical parameters (pain intensity from the visual analogue pain scale (VAS), quality of life according to the Oswestry index, subjective satisfaction with the result of surgical treatment on the Macnab scale) and instrumental data (amplitude of movements in the operated spinal-motor segment, degree of heterotopic ossification according to McAfeeSuchomel classification) were applied at 6, 12, 24, and 36 months after surger y.Results: The mean value of the quality of life for the Oswestr y index before surger y was 40.2±6.9%, after ― 12.3±6.1% (t-test, p0.001). The mean value of the level of pain according to VAS before surger y was 6.9±1.6 cm; after surger y ― 1.3±1.2 cm (t-test, p0.001). The average range of motion in the operated segment at baseline was 36.8±2.6°, within 36 months after the operation increased up to 41.2±2.9°. During the entire period of obser vation the initial (13.4%) or moderate (10.2%) signs of heterotopic ossification were revealed. Conclusions: The use of prosthetic I VD M6-L can significantly reduce the level of pain, improve the life quality, and maintain the physiological range of motion in the operated spinal motion segment with a low level of adverse outcomes.

Reoperation Rates After Single-level Lumbar Discectomy.

Retrospective analysis of national insurance billing database. To examine trends in reoperation after single-level lumbar discectomy. Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy caused by disc herniation. Randomized clinical trials have demonstrated the advantage of discectomy over nonsurgical treatment options, allowing for a more rapid reduction in symptoms. However, population-level data regarding reoperation after single level discectomy is limited. Data were collected using the commercially available PearlDiver software for patients billed with the Current Procedural Terminology code for our index procedure, hemilaminotomy and removal of disc material, between January 2007 and September 2014. The index group was then followed for up to 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Analysis of data obtained from 13,654 patient records revealed a rate of additional lumbar surgeries after single-level discectomy of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.9% (370/6274) of patients within 4 years. Patients who received a re-exploration discectomy within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years after the re-exploration discectomy. The average additional cost of lumbar reoperation, as measured by insurance reimbursement, was approximately $11,161 per-patient per year. We report an overall 4-year reoperation rate of 12.2% after single-level discectomy. In addition, we report a rate of progression to lumbar fusion following re-exploration discectomy of 38.4% within 4 years of reoperation. Further studies are needed regarding the best treatment algorithm in patients with reherniation or iatrogenic instability after lumbar discectomy. This study should enhance the shared decision making process by providing surgeons and patients with valuable data regarding the frequency and nature of reoperations after discectomy. 3.

Micro vs. macrodiscectomy: Does use of the microscope reduce complication rates?

ObjectiveA single level discectomy is one of the most common procedures performed by spine surgeons. While some practitioners utilize the microscope, others do not. We postulate improved visualization with an intraoperative microscope decreases complications and inferior outcomes. MethodsA multicenter surgical registry was utilized for this retrospective cohort analysis. Patients with degenerative spinal diagnoses undergoing elective single level discectomies from 2010 to 2014 were included. Univariate analysis was performed comparing demographics, patient characteristics, operative data, and outcomes for discectomies performed with and without a microscope. Multivariable logistic regression analysis was then applied to compare outcomes of micro- and macrodiscectomies. ResultsQuery of the registry yielded 23,583 patients meeting inclusion criteria. On univariate analysis the microscope was used in a greater proportion of the oldest age group as well as Hispanic white patients. Patients with any functional dependency, history of congestive heart failure, chronic corticosteroid use, or anemia (hematocrit<35%) also had greater proportions of microdiscectomies. Thoracic region discectomies more frequently involved use of the microscope than cervical or lumbar discectomies (25.0% vs. 16.4% and 13.0%, respectively, p<0.001). Median operative time (IQR) was increased in microscope cases [80min (60, 108) vs. 74min (54, 102), p<0.001]. Of the patients that required reoperation within 30days, 2.5% of them had undergone a microdiscectomy compared to 1.9% who had undergone a macrodiscectomy, p=0.044. On multivariable analysis, microdiscectomies were more likely to have an operative time in the top quartile of discectomy operative times, ≥103min (OR 1.256, 95% CI 1.151-1.371, p<0.001). In regards to other multivariable outcome models for any complication, surgical site infection, dural tears, reoperation, and readmission, no significant association with microdiscectomy was found. ConclusionsThe use of the microscope was found to significantly increase the odds of longer operative time, but not influence rates of postoperative complications. Thus, without evidence from this study that the microscope decreases complications, the use of the microscope should be at the surgeon’s discretion, validating the use of both macro and micro approaches to discectomy as acceptable standards of care.

Comparison between anterior cervical discectomy with fusion by polyetheretherketone cages and tricortical iliac-crest graft for the treatment of cervical prolapsed intervertebral disc

Anterior cervical discectomy and fusion is effective surgical modality in the treatment of cervical prolapsed intervertebral disc, radiculopathy and myelopathy. Aims of our study is to evaluate fusion of cervical spine by ICG with plating and PEEK cage with bone graft, also assess the donor site morbidity. Thirty patients (male 16; female 14) with mean age 46 ± 9.2 years and were distributed into two treatment groups (PEEK cage group and ICG group). We assess the patients clinically for myelopathy and functional outcome by Nurick scale and Odom's criteria respectively and neck and arm pain by Visual Analogue Scale (VAS). Eighteen patients were operated for single level discectomy and fusion by either ICG or PEEK cages and twelve patients for two levels. After surgery follow up was 2 years and better postoperative score which was assessed by Nurick scale, Odoms criteria and VAS score. Total patients 14(93%)were graded excellent in the PEEK cage group compared to 13 patients (86%) in the ICG group. Statistically it was not significant between two groups and p value was &lt;0.35. Difference was significant in VAS score after 24 months with more reduction of pain in PEEK cage group. Fusion occurred in 13 patients (86%) of the PEEK cage group and 14 patient (93%) of the ICG group. Result showed more fusion rate in ICG group and less donor site morbidity in PEEK group.

Post Operative Discitis- A Review of 10 Patients in A Tertiary Care Neurosurgical Unit.

Background: Postoperative discitis is an uncommon complication of spine surgery with estimated incidence rate usually less than 1% 1 . It is defined as primary infection of nucleus pulposus with secondary involvement of cartilaginous end plates and adjacent vertebral bodies following lumbar disc surgeries 2 . Early diagnosis based on clinical, laboratory, imageological findings and identification of causative agent and appropriate management of discitis is essential to reduce morbidity. The aim of this study was to identify the associated risk factors, most common level of discitis and outcome of conservative management in cases of post operative discitis of single level discectomy. Materials & Methods:The study was carried out retrospectively over a period of 6 months from Jan 2014 to Dec 2015. Total 192 cases were operated electively for single level lumbar spine disorders. Post op discitis was established by clinical, laboratory & radiological findings. Results: During the study period 192 single level discectomies were performed. Out of 192 patients 10 patients(5.2%) were suffered from discitis. The mean age of patients of postop discitis was 44 years with 4 women and 6 men. Among these 10 patients 3 were diabetic under good glycemic control. Most common clinical presentation is moderate to severe low backache. Out of 10 patients 7patients corresponds to L4/L5 level. After 6 weeks of antibiotic therapy (3 weeks i.v.+3 weeks oral) with complete bed rest all patients were improved symptomatically. After 6 months of follow up all patients were able to carry on their daily activities. Conclusions: Post operative discitis is an uncommon but serious complication of disc surgeries. Early diagnosis and appropriate antibiotic therapy along with immobilisation is essential in the management.

Hybrid Decompression and Fixation Technique Versus Plated 3-Vertebra Corpectomy for 4-Segment Cervical Myelopathy

A retrospective comparative study. The purpose of this study was to compare the stability and outcomes of a hybrid technique with those of a 3-vertebra corpectomy in the management of 4-segment cervical myelopathy. Patients with primarily ventral disease and loss of cervical lordosis are considered good candidates for anterior surgery. Cervical corpectomy is commonly performed in patients with multilevel cervical myelopathy. Corpectomies including >3 vertebraes entail an extremely high risk of reconstruction failure. To avoid the need to perform a 3-vertebra corpectomy, we use a hybrid decompression and fixation technique. This hybrid technique is a technique to obtain optimum decompression and fixation in patients with multilevel cervical myelopathy. A total of 81 patients with multilevel cervical myelopathy who underwent 4-segment cervical fixation with a minimum 2-year follow-up were included. The hybrid technique involved combining a plated 2-vertebra corpectomy and single-level discectomy with stand-alone cage fixation. This technique was performed in 39 patients, and the plated 3-vertebra corpectomy was performed in 42 patients. Nine patients (21%) who underwent the plated 3-vertebra corpectomy were treated with halo immobilization, but no patient in the hybrid group required this treatment (P=0.002). There were fewer instances of reconstruction failure in the hybrid group than in the 3-vertebra corpectomy group (0% vs. 10%, respectively; P=0.048) and fewer instances of C5 palsy (3% vs. 17%, respectively; P <0.0001). The incidence of postoperative C5 palsy was 25% for C3-C5 corpectomy, 19% for C4-C6 corpectomy, and 11% for C4-C5 corpectomy+C6-C7 discectomy. The hybrid technique has the following advantages over 3-vertebra corpectomy for 4-segment cervical fixation: a shorter graft bone and plate are required; the fixed segment has greater initial stability; postoperative external immobilization is simplified; and the risk of reconstruction failure and postoperative C5 palsy is reduced markedly.

Reoperation Rates following Single-Level Discectomy

Introduction Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy due to lumbar disc herniation. Randomized trials have demonstrated the advantage of surgical removal of herniated disc material over non-surgical treatment options, allowing for a more rapid reduction in symptoms and return of function. Many small-size studies suggest that long-term outcomes for patients treated with discectomy and non-operative management are similar. Additionally, treatment of recurrent lumbar disc herniation is not standardized. Population-level data regarding reoperation following single level hemilaminotomy and discectomy is limited. Material and Methods Data was collected and analyzed for 13,654 patients undergoing single-level lumbar discectomy between January 2007 and December 2010 using the commercially available PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA). The nationwide Humana private insurance database was queried for patients billed with the Current Procedural Terminology (CPT) code for our index procedure, hemilaminotomy and removal of disc material (CPT-63030). Patients receiving concurrent lumbar surgeries were excluded from the index group. The index group was then followed in retrospective cohorts for 3 months, 6 months, 1 year, 2 years, and 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Results Patients received additional lumbar surgeries following single-level discectomy at a rate of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.90% (370/6274) of patients within 4 years, with interbody fusion in 75.4% (279/370) of cases and multi-level fusion in 47.0% (174/370) of cases. Reoperation for re-exploration discectomy at the same level as the index procedure with no subsequent surgeries occurred in 2.71% (170/6274) of patients followed out to 4 years. Patients who received a re-exploration discectomy at the same intervertebral level within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years following the re-exploration discectomy. Conclusion Data in our study demonstrated a reoperation rate of 12.2% after single level discectomy, a routinely performed procedure for the treatment of symptomatic lumbar disk herniation. Moreover, we show that the rate of progression to lumbar fusion after a re-exploration discectomy was 38.4% within 4 years of reoperation. These data should help surgeons in their operative decision-making and counseling recommendations to patients. To our knowledge, this is the largest population study delineating reoperation rates across the US after single-level lumbar discectomy. Further studies are needed regarding the best treatment algorithm in patients with re-herniation or iatrogenic instability following lumbar discectomy.

The Stand-Alone Cervical Cages with Integrated Screw Fixation: Results in 315 Consecutive Operated Levels

Introduction Background: Cervical disc disease at C2/3, C3/4 and C7/T1 is less common. Fusion with cages &amp; plating is the standard treatment at these levels and in multi-level disc disease. This is not without significant risks related to the need of larger exposure and anterior muscular dissection. Stand-alone cages with integrated screw fixation obviate the need for plating and larger exposure. Material and Methods To assess the exposure / cage related morbidities and fusion rates in Stand-Alone cervical cages with Integrated Screw Fixation. Design: Retrospective chart review. Subjects: 315 levels were operated in 253 patients from February 2009 to February 2015. Single and Multilevel cages were performed in 201 and 52 patients respectively. 201 of the 253 patients underwent single level discectomy with Stand-Alone cervical cages with Integrated Screw Fixation at C3/4 and C7/T1 levels. 52 patients underwent 114 multi-level discectomies with Stand-Alone cervical cages with Integrated Screw Fixation Results Operative time was shorter. There was no reported permanent exposure/ cage related morbidities in all operated levels. 3 patients with traumatic disc disruption required further surgery for lateral mass fixation. 12 patients had mild dysphagia that resolved during follow up with no patient having complains of dysphagia at 3- months follow up. Fusion rates were 95% at single level and 90% at multi-level discectomies at the last follow up. No patient required cage related surgical revision. Conclusion The current results support the use of Stand-Alone cervical cages with Integrated Screw Fixation especially at difficult levels at C3/4 and C7/T1 and in multi-level discectomies as it obviate the need for plating and larger exposure with less reported dysphagia and implant related complications.

Perioperative Effects of Different Narcotic Analgesics Used to Improve Effectiveness of Total Intravenous Anaesthesia.

We aimed to evaluate the depth of anaesthesia, perioperative haemodynamics, postoperative pain scores, analgesic consumption in patients receiving remifentanil- or alfentanil-based total intravenous anaesthesia for single-level lumbar discectomy. Seventy patients undergoing discectomy were enrolled in the study. Patients were intravenously administered an initial bolus dose of 2 mg kg(-1) propofol and 10 mcg kg(-1) alfentanil or 1 mcg kg(-1) remifentanil, followed by 6 mg kg(-1) h(-1) propofol and either 1 mcg kg(-1) min(-1) alfentanil or 0.25 mcg kg(-1) min(-1) remifentanil infusion. Bispectral index (BIS) values, mean arterial pressure, heart rate, end-tidal carbon dioxide and oxygen saturation were recorded. Postoperative pain scores at 0, 30 and 60 min were measured and recorded with additional opioid requirements. Postoperative pain scores at 0 and 30 min, total analgesic consumption and requirement for additional analgesics were significantly high in the remifentanil group. After the first hour, the pain scores were not significantly different. Mean arterial blood pressure was significantly low at 45 and 60 min preoperatively in the remifentanil group. In the remifentanil group, heart rate at 15, 30, 45, 60 min were significantly lower than those in the alfentanil group. BIS values of the two groups were not significantly different at any measurement time point. BIS values of remifentanil group at 30, 45, 60, 90 and 180 min significantly increased compared with those at 15 min. Alfentanil provided more stable BIS and haemodynamic values preoperatively and less opioid consumption, along with lower pain scores, during the early postoperative period compared with remifentanil in patients undergoing single-level discectomy.

Hybrid Decompression and Fixation Technique for the Treatment of Multisegmental Cervical Spondylotic Myelopathy.

Cervical spondilotic myelopathy (CSM) is defined as the compromise of the spinal cord due to degenerative changes of the cervical spine. It is the most common cause of spinal cord dysfunction in patients over 55 years. An early surgical management it is paramount to achieve better neurological outcome. There is still controversy regarding the appropriate surgical treatment for multisegmental CSM involving three or more levels. The hybrid decompression and fixation technique combines one or two level corpectomy and a single level discectomy in order to obtain optimum decompression and fixation in patients with multilevel cervical myelopathy. A prospective case-control study was made between 2011 and 2013. A total of 15 patients with diagnosis of CSM received surgical treatment with an anterior hybrid decompression and fixation technique procedure. Inclusion criteria were myelopathy confirmed by radiographic studies, magnetic resonance image (MRI) and electromyography. During the 2010-2013 period 15 patients were managed by hybrid decompression and fixation technique. Average age 64.8 years SD9.4. The follow up period was 29.6 SD ± 9.8 months. The JOA score improved significantly to 13.8 +/- 1.9 points at follow-up (paired t test, P = 0.001), Nurick Scale preoperative was 3.3 and improved to 2.4 mean, was significantly (Wilcoxon signed rank test p=0.006) The mean C2-C7 lordosis angle was 10.8° +/- 8.9 before surgery, and 14.3° +/- 8.8 at follow-up, there was no significant loss of lordosis angle between the preoperative and follow-up measurements (Wilcoxon signed rank test, P =0.149); At follow-up, graft non fusion was seen in 1 patient (7%, k=1). In this small number, single surgeon, prospective series the use of a single level corpectomy and an adjacent discectomy was shown to provide similar outcomes and complication rates as alternative surgical techniques. The authors thus consider this a viable surgical alternative with some perceived advantages, a low rate of complications and a high rate of spinal fusion. Level of Evidence: IV. This study was approved by the authors' Institutional Review Board and all patients were given informed consent prior to participation in the study.

Pneumocephalus following spinal anaesthesia for spine surgery.

Pneumocephalus following spinal anaesthesia for spine surgery.

Closed Drainage versus Non-Drainage for Single-Level Lumbar Disc Surgery: Relationship between Epidural Hematoma and Fibrosis.

Study DesignA prospective clinical series with prospectively collected data.PurposeThe efficacy of using closed suction drains (CSD) after single-level lumbar disc surgery was evaluated. Postoperative CSD are regularly fitted to prevent postoperative epidural hematomas (EH) after multilevel lumbar decompression, although it remains unclear whether CSD also reduces postoperative EH following single-level lumbar disc surgery.Overview of LiteratureFew articles have addressed the clinical outcome in patients with single-level lumbar disc disease who were treated by two different operative methods (with and without drainage).MethodsBetween 2012 and 2014, 115 patients with a single level discectomy underwent two surgical procedures: with CSD (group A, 60 cases) and without CSD (group B, 55 cases). There were no significant differences in age, sex, segment level, herniation type, or disease duration between the groups. Wound infection, EH, and epidural fibrosis (EF) were evaluated by magnetic resonance imaging. Pain intensity was evaluated using the visual analog scale (VAS) and Oswestry disability index (ODI). Reduction in analgesic treatment and patient satisfaction were also recorded.ResultsThe overall rate of postoperative EH was 5% and 16.3% in group A and B, respectively, whereas the rate of postoperative EF was 11.6% in group A and 21.8% in group B. The postoperative VAS score was 0.32 (standard deviation [SD], 0.45) for group A and 2.62 (SD, 06.9) for group B, whereas ODI was 9.11 (SD, 0.68) and 8.23 (SD, 0.78) for group A and and group B, respectively, with no significant differences observed.ConclusionsIn patients operated on by unilateral, single-level lumbar disc surgery, the use of suction CSD into the operation site results in lower levels of EH and EF radiologically, thereby providing a better clinical outcome.

Effect of Body Mass Index on Inpatient Rehabilitation Outcomes After Single-level Discectomy

Objectives: Disk herniation is a common health problem leading to work disability. Discectomy is the generally used treatment method for cases not responding to conservative care. Rehabilitation improves functional outcomes, but there is little data on outcomes of patients undergoing inpatient rehabilitation after discectomy in Iran. We examined the influence of obesity on inpatient rehabilitation outcomes following single-level discectomy. Methods: This was a prospective study evaluating 143 patients admitted to rehabilitation facility after discectomy between January 2009 and September 2011. Patients were divided into 3 groups based on body mass index: nonobese (<25 kg/m2), overweight (25 to 29.9 kg/m2), and moderately obese (30 to 40 kg/m2). Functional independence measure (FIM) scores, length of stay (LOS), FIM efficiency, as well as standing and walking days for each patient were assessed. FIM was also assessed after 1 month follow-up. Results: FIM at follow-up increased significantly in comparison with admission values in all patients (P<0.001). There was no difference between groups in admission FIM, discharge FIM, FIM change, FIM efficiency, and FIM at follow-up. There was no difference between groups considering the outcomes of standing and walking. Conclusions: Body mass index did not affect FIM after single-level discectomy and does not influence the inpatient rehabilitation outcomes.

Initial Discectomy Associated with Aging Leading to Adjacent Disc Disease and Recurrence.

Failure of surgery for lumbar disc herniation (LDH) can be commonly caused by recurrence. There are many debates regarding the risk factors of recurrent LDH (rLDH) and it is very difficult to define them because many clinical and complicated biomechanical parameters are involved. The purpose of study was to evaluate the long term result of re-discectomy for LDH at the same level and adjacent segments. Between 1999 and 2009, 1898 cases were operated and 142 (6.4%) patients underwent re-discectomy following initial operation. The study included 65 patients who were operated for single level discectomy, and their charts were analyzed retrospectively. There were 33 (50.8%) women and mean age was 45.5 years (24-73 years). rLDH was diagnosed at the initial level in 40 (61.5%) but adjacent and/or opposite level herniation (with or without the first level) was found in the remaining 25 cases (39.1%). Recurrence at the same level (SLG) and adjacent level groups (ALG) were similar according to the clinical outcomes in follow-up (mean 34.1 months). Admission period after initial operation was also parallel in SLG and ALG (54.7 and 53.1 months, respectively). However, the mean age of ALG (49.4 years) was significantly higher (p≤0.05) than SLG (42.8 years). After discectomy, collapsed discs are biomechanically more stable than those with preserved disc heights, and responses to axial compression on intervertebral disc pressure produced deformations of adjacent levels despite limitations. Altered biomechanical loading next to a fusion resulted in ongoing degeneration with aging at the affected entire lumbar spine.

Outcomes of Single-Level Cervical Disc Arthroplasty versus Anterior Discectomy and Fusion: A Single Center, Retrospective Review

Outcomes of Single-Level Cervical Disc Arthroplasty versus Anterior Discectomy and Fusion: A Single Center, Retrospective Review

Standard Single Level discectomy; Evaluation of the Risk Factors for Recurrence

Background Data: Various surgical options exist for lumbar disc herniation. In patients who do not respond to conservative treatment, open discectomy still remains a standard method and it has been reported to have diverse outcomes. Despite a high early success rate with lumbar discectomy procedures, variable long-term results and worsening or recurrence of the patient’s condition overtime have been reported. Purpose: To evaluate the risk factors for recurrence of disc disease in relation to disc pathology, age, and activities. Study Design: A retrospective clinical Case review.Patients and Methods: One hundred twenty patients who had undergone standard discectomy for lumbar disc herniation were studied. All had single level disc herniation. Patients with spondylolysis, spondylolisthesis, or spinal stenosiswere excluded. Indications of surgery were severe radiculopathy of at least two month duration, unresponsive to conservative treatment or neural deficit. A preoperative diagnosis of lumbar disc herniation was based on symptoms, physical examination and MRI findings. A total of 7 patients (6%) were confirmed as having recurrence of disc herniation.Results: All of our 7 patients were in age group of 20-40 years. The recurrence occurred in 2 patients out of 7 through the 1st 5 years after surgery. Most of recurrent patients (5 patients, 71%) had originally a contained disc herniation,2 patients (29%) had originally a protruded discs and none had originally a sequestrated discs. Recurrence in L4-5 level was in 5 patients (71%) while in L5- S1 in 2 cases (29%). Conclusion: The risk of recurrence of disc herniation after open discectomy was higher in young, active men. The recurrence rate of disc herniation increased with time after surgery. Recurrence rate was higher for patients with contained herniation than other types. (2013ESJ043)

Radiation exposure during the lateral lumbar interbody fusion procedure and techniques to reduce radiation dosage

BackgroundFluoroscopy is widely used in spine surgery to assist with graft and hardware placement. Previous studies have not measured radiation exposure to a surgeon during minimally invasive lateral lumbar spine surgery for single-level discectomy and interbody cage insertion. This study was performed to model and measure radiation exposure to a surgeon during spine surgery using the direct lateral lumbar procedure. MethodsThe study was performed using a mannequin substituting for the surgeon and a cadaver substituting for the patient. Radiation was measured with dosimeters attached to 6 locations on the mannequin using a OEC Medical Systems 9800 C-arm fluoroscope (OEC Medical Systems, Salt Lake City, Utah). Three different fluoroscopy setups were tested: a standard imaging setup, a standard setup using pulsed-mode fluoroscopy, and a reversed setup. The experiment was tested 5 times per setup, and the dosimeters' values were recorded. ResultsThe highest amount of radiation exposure occurred when obtaining an anteroposterior view of the spine in the standard setup. Compared with the standard setup, the pulsed-mode setting decreased the radiation exposure to the mannequin by a factor of 6 times (P < .001). Compared with the standard setup, the reversed setup also decreased the radiation exposure to the mannequin by a factor of 6 times (P < .001) and it had the lowest amount of radiation exposure to the eye level (P < .001). ConclusionsCare should be taken when one is obtaining an anteroposterior view of the lumbar spine during lateral lumbar procedures to limit radiation exposure. Radiation exposure to the surgeon can be greatly minimized by using either a pulsed imaging mode or the reversed setup. The reversed setup has the lowest amount of radiation exposure to the eye level.

Bacteriologic Culture of Excised Intervertebral Disc From Immunocompetent Patients Undergoing Single Level Primary Lumbar Microdiscectomy

A consecutive case series from a single center of patients undergoing primary microdiscectomy for lumbar herniated nucleus pulposus (HNP) who received microbiologic laboratory culture of excised disc material. To determine the prevalence of positive bacterial cultures in the disc material of immunocompetent patients without diabetes mellitus or other immune compromise. The intradiscal space is a physiologically tenuous environment in terms of oxygen tension, pH, and vascularity. This space may be susceptible to indolent infections with an unknown effect on the pathogenesis of HNP. This case series included 52 patients with radiculopathy and magnetic resonance imaging positive for HNP who elected for lumbar microdiscectomy after failure of conservative management. All patients received primary surgery at a single spinal level in the absence of diabetes mellitus, systemic steroid use, chemotherapy, other immune compromise, or prior lumbar surgery. Excised disc material was sent for routine bacterial culture. No special culture techniques were used to improve the yield of positive cultures. Cultures were positive in 10 patients (19.2%). Propionibacterium acnes was the sole organism isolated in 7 (13.5%), with Peptostreptococcus and Staphylococcus species accounting for the remainder. There were 24 women (46.2%) and 28 men (53.8%) with a mean age of 43.9 years (SE 1.8). Duration of symptoms was greater than 12 weeks in 35 patients (67.3%). Onset of symptoms was insidious in 22 patients (42.3%), sudden in 16 (30.8%), and the history was unclear in the remainder. Prior epidural steroid injection was received by 17 patients (32.7%), and 11 patients had a history of smoking (21.2%). None of these variables was significantly different in patients with positive and negative cultures (P >0.05). P. acnes was isolated by routine laboratory culture of excised disc material in 13.5% of immunocompetent patients undergoing primary single level discectomy for radiculopathy with lumbar HNP; other organisms were isolated in 6% of patients. Diagnostic level of evidence III.

Rapid Repeated Recurrent Lumbar Disc Herniation after Microscopic Discectomies

The recurrence of lumbar disc herniation after single-level discectomy is a well-known complication. Pain and neurological symptoms during the first week after surgery can be caused by missed pathology or early recurrent disc herniation. However, recurrent disc herniation that causes segmental instability after repeat operation is rare. Here, we report a case of a 42-year-old woman having a rare complication of rapid recurrent lumbar disc herniation after 2 microscopic discectomies within a short period. We suggest that rapid disc fragmentation and rapid growth of annular defect caused rapid repeated recurrence of lumbar disc herniation and segmental instability. Further investigation will be needed to identify the cause of this rapid disc degeneration.

Reduction of postoperative pain after lumbar microdiscectomy with DuraSeal Xact Adhesion Barrier and Sealant System

Background context An excessive amount of scar tissue after lumbar microdiscectomy may increase postoperative pain. Several fibrosis inhibitors have been used in the past in an endeavor for better functional outcome. Purpose The goal of this study was to evaluate DuraSeal Xact Adhesion Barrier and Sealant System (DSX), a polyethylene glycol-based synthetic fibrosis inhibitor, for its ability to reduce postoperative pain after lumbar microdiscectomy. Study design This is a prospective randomized controlled study. Patient sample Twenty patients between 19 and 71 years of age about to undergo elective lumbar single-level discectomy were randomized into two groups of 10. Outcome measures Assessments included the visual analog scale (VAS) pain score, the short form (SF)-36 questionnaire, and the Oswestry low back pain scale, preoperatively and at discharge, and 30, 90, and 180 days after surgery. Methods One group was treated with DSX, and the control group received the local standard of care. DSX was applied as a thin layer on the nerve root and surrounding area after microdiscectomy. Results The VAS pain scale was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 43.9% versus 35.6%, 64.3% versus 44.8%, and 75.4% versus 59.6%. The SF-36 scores in the DSX treatment group showed more improvement than in the control group as soon as 30 days for physical functioning, general health, vitality, social functioning, mental health, and emotional patterns, and by 90 days for bodily pain and general health. The Oswestry pain score was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 41.5% versus 34.3%, 68.2% versus 42.4%, and 73.3% versus 55.4%. Wound healing was normal in the DSX treatment group, there were no complications related to DSX use, and no patient in either group required reoperation. Conclusions Although this study is too small to have conclusions of efficacy and will need confirmation by larger trials, treatment of a microdiscectomy site with DSX for fibrosis prevention shows promising results in terms of safety, reduction of postoperative pain and functional results when compared to control with the additional advantage of being suitable for use in the presence of a dural tear.