Single-level Lumbar Disc Herniation Research Articles

Clinical Outcome of Full-endoscopic Interlaminar Discectomy for Single-level Lumbar Disc Herniation: A Minimum of 5-year Follow-up

Background: Full-endoscopic interlaminar discectomy (FEID) is widely applied for the treatment of lumbar disc herniation (LDH) and satisfactory short-term outcomes have been achieved. However, the long-term evaluation for this technique is still lacking, especially the comparison between FEID and microendoscopic discectomy (MED). Objective: To evaluate the clinical outcome of FEID technique in comparison with MED for singlelevel LDH with a minimum of 5-year follow-up. Study Design: Retrospective study. Setting: Inpatient surgery center. Methods: A total of 152 patients with single-level LDH located at either L4-L5 or L5-S1 who underwent either FEID or MED from August 2008 to April 2011 at our hospital were enrolled in this study. General parameters including operative time, length of hospital stay, mean time to return to work, complications, and recurrences were recorded. Clinical outcomes were evaluated using visual analog scale (VAS) for low back and leg pain, Oswestry Disability Index (ODI) for functional assessment, and modified MacNab criteria for patient satisfaction. Results: At the final follow-up, the VAS of leg and back pain decreased from 7.6 ± 1.6 and 3.1 ± 2.2 points preoperatively to 1.6 ± 1.2 and 1.7 ± 0.9 at the final follow-up, respectively (P < 0.05). The ODI score was 69.5% ± 10.5% preoperatively, and declined to 21.8% ± 7.0% at the final follow-up (P < 0.05). VAS, ODI, and modified MacNab criteria of the FEID group were improved compared to the control group though there were no statistically significant differences between the 2 groups. Limitations: This was a retrospective study with a relatively small sample size. Additionally, this study contained only clinical outcomes, without long-term radiological outcomes. Conclusions: The application of FEID achieved similar satisfactory long-term clinical outcomes for the surgical treatment of LDH as MED. However, compared with MED, FEID exhibits advantages including less operation time, shorter hospital stay, and faster postoperative recovery. Key words: Lumbar disc herniation, full-endoscopic interlaminar discectomy, microendoscopic disectomy, long-term Pain Physician 2017

The prognostic value of preoperative participation in activities of daily living on postoperative outcomes following lumbar discectomy

ObjectivesIn other surgical fields, preoperative level of participation in activities of daily living (ADLs) has been found to be important in predicting outcomes. To date, postoperative ADL measurements have only been used to characterize outcomes following lumbar discectomy. The present study's goal was to determine if patients’ preoperative ability to perform ADLs correlates with their postoperative outcomes after lumbar discectomy at 3 months and 1 year. Patients and methodsThis retrospective study was performed using prospectively collected data from patients prospectively enrolled in a randomized clinical trial. All patients were 18 years or older, spoke English, had not previously had lumbar surgery, and underwent discectomy for a single-level lumbar disc herniation. Oswestry disability index (ODI) and visual analogue scale (VAS) back and leg pain scores were collected preoperatively and at 3 months and 1 year postoperatively. Simple linear regression analysis was performed to detect any significant correlations between three preoperative ODI domain values and postoperative scores. Additionally, regression analysis was used to determine the correlation between the preoperative ODI domains and percentage of good and poor outcomes, where an improvement of at least 18.8 points for ODI and at least 2 points for VAS constituted a good outcome. Results90 subjects satisfied inclusion criteria (average age 42, 53 males, 37 females). Patients’ ability to take care of themselves and to stand preoperatively were correlated with improvement in ODI postoperatively, with worse ability corresponding to more improvement (p<0.001 for both). Only personal care scores correlated with good improvement in leg pain. No significant correlations were found with back pain. When evaluating patients by dichotomized outcome (good or poor), only preoperative ability to participate in personal care was consistently significantly correlated to a good outcome. ConclusionThis is the first study to suggest that lower preoperative ability to take part in personal care might predict better surgical outcomes after discectomy. The current data might prompt reassessment of the importance of ADLs in pre-operative patient evaluation and may help anticipate outcomes following lumbar discectomy.

Percutaneous Transforaminal Endoscopic Discectomy for Lumbar Disk Herniation.

Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive technique to treat lumbar disk herniation from a lateral approach. Performed under local anesthesia, the incision size for PTED is around 8 mm with no paraspinal muscle cutting or detachment from their insertion. PTED has been associated with less blood loss, faster rehabilitation, and less scarring of tissue than conventional open microdiscectomy. High-quality randomized controlled trials comparing PTED with open microdiscectomy have not been conducted yet. However, PTED has been proven to be an effective technique allowing patients to return home only 2 hours after surgery. By the means of this article and video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A1), we would like to show the spine surgeon the PTED technique for the treatment of a single-level lumbar disk herniation.

Transforaminal lumbar interbody fusion using one diagonal fusion cage with unilateral pedicle screw fixation for treatment of massive lumbar disc herniation.

Background:Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation.Materials and Methods:Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification.Results:The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%).Conclusions:TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.

Sagittal balance parameters correlate with spinal conformational type and MRI changes in lumbar degenerative disc disease: results of a retrospective study.

Spinopelvic parameters can be useful in identifying risk factors for lumbar degenerative disc disease, but few studies assess patients with single-level disc herniation and most do not evaluate symptoms. This comparative retrospective study was aimed to analyse spinopelvic parameters, symptoms and MRI changes in patients with single-level lumbar disc herniation undergoing conservative or surgical treatment. Patients with clinical and radiological assessment (Japanese Orthopaedic Association Score) and an MRI evaluation of the lumbar spine were identified and divided into two groups: surgically treated (group A) and not requiring surgery (group B). Spinopelvic parameters were determined on standing profile radiographs of the lumbar spine and pelvis, and mean values were compared to those reported in the literature for normal subjects. MRI findings were graded according to the system described by Pfirrmann et al. The study included 71 patients with single-level lumbar disc herniation: 26 in group A (39.4±12.1years) and 45 in group B (51.4±17.2years). The notable differences in spinopelvic parameter means between the two groups did not reach statistical significance. A positive correlations of age with pelvic tilt and Pfirrmann changes with pelvic incidence was only found in group A, while both groups showed highly significant positive correlations of pelvic incidence with the spine's conformational type (p=0.001). Characteristic changes in spinopelvic parameters identified in patients with lumbar degenerative disc disease were a reduction in pelvic incidence, sacral slope and lumbar lordosis, with an increased pelvic tilt. These were found to correlate with MRI changes in surgically treated patients.

Use of pain drawing as an assessment tool of sciatica for patients with single level lumbar disc herniation.

The objectives of this study were to examine the diagnostic accuracy of pain drawing (PD) in determining the level of involvement and to investigate how the quantitative evaluation results of PD using a grid score (GS) correlates with the results of other clinical evaluation measures in diagnosis and assessment of patients with lumber disc herniation (LDH) involving a single nerve root. Thirty-one patients with single level LDH who were diagnosed and conservatively treated by the first author constituted the study population. In order to assess the diagnostic accuracy of PD, the level of involvement as determined by PD was compared to the final diagnosis. In 26 of the 31 patients who could be followed for more than 6 months of conservative treatment, the GS in PD evaluation was compared to the score assessed by the Japanese Orthopaedic Association scoring system for low back pain (JOA score) and the visual analog scale (VAS) both before and after the treatment. The overall diagnostic accuracy of PD for the determination of the affected level averaged 68.8 %, and the accuracy was higher at the L4/5 and L5/S levels than the L2/3 and L3/4 levels. The average values of VAS and GS significantly decreased and the JOA score significantly improved after the treatment. Moreover, a significant correlation was demonstrated between the scores derived from these three evaluation measures. The present study indicated the potential usefulness of PD in clinical assessment during the treatment course.

Analysis of the Characteristics and Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Upper Lumbar Disc Herniation

Lumbar disc herniations at the L1-L2 and L2-L3 levels have unique characteristics that result in worse surgical outcomes after traditional microdiscectomy compared with herniation at L3-L4. The purpose of this study was to evaluate the characteristics, clinical presentation, and outcomes of patients who underwent percutaneous endoscopic lumbar discectomy (PELD) at L1-L2 and L2-L3, compared with those who underwent PELD at L3-L4. We retrospectively evaluated the clinical data from 55 patients who underwent PELD for single-level lumbar disc herniation between 2008 and 2014, at a mean follow-up of 29.9 ± 16.4 months (12-month minimum; effective rate, 89.1%). Surgical duration; length of postoperative hospital stay; hospitalization cost; recurrence rate; Macnab criteria assessment; visual analog scale (VAS) of back pain, leg pain, and numbness; Japanese Orthopedic Association (JOA) low back pain score; and Oswestry Disability Index (ODI) before and after surgery were evaluated. In the L1-L3 group, 76.9% of the patients had a positive femoral stretch test, compared with only 42.8% of those in the L3-L4 group (P < 0.05). Of the 49 patients with adequate follow-up, 17 (34.7%) exhibited excellent improvement, 23 (46.9%) had good improvement, and 6 (12.2%) had fair improvement according to the Macnab criteria. The VAS scores for back pain, leg pain, and numbness decreased significantly postoperatively in both groups, as did all other outcome measures (P < 0.05). PELD is a safe and effective treatment for upper lumbar disc herniation and may compare favorably with the same procedure for lower lumbar disc herniation. In addition, the positive femoral stretch test was a relatively good diagnostic method for disc herniation at L1-L2 and L2-L3, compared with herniation at L3-L4.

Serum lipid levels are positively correlated with lumbar disc herniation--a retrospective study of 790 Chinese patients.

BackgroundAbnormal serum lipid levels have been shown to be associated with the occurrence of atherosclerosis, but little is known about the relationships of them with the risk of developing intervertebral disc degeneration (IVDD) in Chinese population.MethodsWe performed a case–control study to assess the relationship between serum lipid levels and lumbar disc degeneration. A total of 790 Chinese patients were recruited for this study at the time of hospitalization. We examined fasting serum lipid levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). 396 patients (235 men and 161 women; mean age: 41.07 years) underwent surgery for single-level lumbar disc herniation. A control group of 394 patients (225 men and 169 women; mean age: 42.1 years) underwent surgery for wounded lower limbs during the same period. Patients in the control group were collected randomly from among patients who were age- and sex-matched patients with the case group.ResultsPatients with lumbar disc herniation had significantly higher TC and LDL-C serum concentrations (P < 0.001 for both) than controls. Percentage of High-TC, High-TG, High-LDL-C, borderline High-TC and borderline High-LDL-C were significantly higher in the disc herniation group (P = 0.017, P = 0.002, P = 0.039, P =0.002 and P < 0.001, respectively). Ratios of TC/HDL-C and LDL-C/HDL-C were significantly associated with disc herniation (P < 0.001 for both). Logistic regression revealed that patients with higher serum LDL-C levels had a higher risk of disc herniation, in which odds ratio (OR) was 1.462 and confidence interval (CI) was 1.179 ~ 1.813. Moreover, patients with High-TG and borderline High-LDL-C had a higher probability of disc herniation (OR: 2.974, CI: 1.488 ~ 5.945, statistical power: 100 %; OR: 1.626, CI: 1.012 ~ 2.612, statistical power: 61.4 %, respectively). However, hyperlipidaemia did not seem to be associated with the herniated segment of the lumbar intervertebral disc (p = 0.374).ConclusionsThe present study suggests that dyslipidaemia may be associated with a higher risk of developing lumbar disc herniation. Serum lipid levels could be a useful predictor for intervertebral disc degeneration in Chinese population.

Selective nerve root blocks vs. caudal epidural injection for single level prolapsed lumbar intervertebral disc - A prospective randomized study.

Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year. A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation. Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability. In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively. Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist.

Radiological analysis of upper lumbar disc herniation and spinopelvic sagittal alignment.

A retrospective cross-sectional study was designed to explore the role of spinopelvic sagittal alignment in upper lumbar disc herniation (ULD) development. A total of 207 consecutive patients who underwent surgery for single-level lumbar disc herniation [24 with ULD and 183 with lower lumbar disc herniation (LLD)] and 40 asymptomatic volunteers were enrolled. Full-length radiographs of the spine were taken to evaluate pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), thoracic kyphosis (TK), lumbar lordosis (LL), and sagittal vertical axis (SVA). The Roussouly classification was utilized to categorize all subjects according to their sagittal alignment. Spinopelvic parameters and Roussouly classification results were compared between groups. There were significant differences in PI, SS, PT, LL, and SVA between the ULD, LLD, and control groups. PI in the ULD (40.9°) was significantly lower than in the LLD and control groups (48.8° and 47.6°, respectively). LL was significantly lower in the ULD than in the LLD (-32.4° and -40°, respectively). There were significant differences between the three groups in Roussouly types. The LLD had a significantly higher proportion (62.6%) of type 2 lordosis (flat back), and the ULD had a higher proportion (33.3%) of type 1 lordosis than the other groups. This study demonstrated the importance of PI and lumbar curvature in the pathogenesis of ULD. The higher prevalence of short LL and long TK with low PI in the ULD group implies that an increased mechanical stress at this level may be one of the risk factors of ULD.

Surgery for lumbar disc herniation: Analysis of 500 consecutive patients treated in an interdisciplinary spine centre

Surgical removal of a symptomatic herniated lumbar disc is performed either with or without the support of a microscope. Up to the time of writing, the literature has reported similar clinical outcomes for the two procedures. Five hundred consecutive patients, operated upon for primary single-level lumbar disc herniation in our University Spine Center between 2003–2011, with (n=275), or without (n=225), the aid of a microscope were included. Data were retrospectively analyzed, comparing the primary endpoint of clinical outcome and the secondary endpoints of complications, surgical time and length of hospitalization. Clinical outcomes and reoperation rates were comparable in both groups. Surgical time was significantly shorter with a mean time of 47minutes without use of the microscope compared to the mean time of 87minutes (p<0.001) with the use of the microscope. Mean length of hospitalization was shorter in those operated with the microscope (5.3days) compared to those without (6.1days, p=0.004). There was no difference in rates of complications. Microdiscectomy versus open sequestrectomy and discectomy for surgical treatment of lumbar disc herniation is associated with similar clinical outcomes and reoperation rates. Open sequestrectomy is associated with shorter operation times. Microdiscectomy is associated with shorter hospitalization stays.

Endoscopic lumbar discectomy, cost effective operative procedure at tertiary care centre

Study design: Retrospective study Background: Endoscopic lumbar discectomy using endoscopic tubular retractor system(METRx-MD) are considered popular minimally invasive surgery (MIS) methods for the treatment of lumbar disc herniation. Our main aim is to apread the benefits related endoscopic technique for lumbar disc herniation at tertiary care centre through which we can reduce the huge patient’s workload and patients are also getting best treatment for their respective disease through minimal invasive surgery. Objective: To evaluate the effectiveness of Endoscopic Lumbar Discectomy as cost effective procedure at tertiary care center where there is huge patient’s workload. Methods: It is a retrospective study of 40 patients were operated during the period between August-2013 to August-2015,at B.J Medical college, civil hospital, ahmedabad out of which 29 were males and 11 females between age group of 17 and 72 years and compared with the standard results of open mini incision discectomy. Inclusion criteria: Single level lumbar disc herniation, Unilateral or bilateral radiculopathy. Exclusion criteria: Multiple level disc bulge, Presence of spinal instability, Presence of gross spinal deformity Results: · In our study out of 40 patients, 29(72.5%) were males and 11(27.5%) were females. · 22 (55%) patients had L4-L5 level disc herniation while 18 (45%) patients had L5-S1 level disc herniation. · Out of 40 patients, only 3 patients presented with complications. · Complications observed in our study were dural tear, infection and recurrence of radiculopathy. · Immediate post-op improvement of VAS, oswestry and SF-12 score was noted in all patients. Conclusion and Summary: Endoscopic Discectomy is a minimally invasive spine surgery which has better outcome (as compared with standard mini incision discectomy) in terms of: · Better Pain Relief · �

Evaluation of Degenerative Lumbar Disc Surgeries

Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work (with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry unto itself. Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed surgically and to compare the results of different surgeries performed. Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or impending cauda equina syndrome. Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 % patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic discectomy. L4-L5 level was the most common level to get involved. Mean Pre operative VAS score for male patients was 6.64 and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean Pre operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95 and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed. Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures. We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient satisfaction was high, and a cost savings was realized. Keywords: Degenerative, Lumbar Spine, Disc Surgeries, Microscopic Discectomy, Laminectomy, Decompression

Surgery versus Nerve Blocks for Lumbar Disc Herniation : Quantitative Analysis of Radiological Factors as a Predictor for Successful Outcomes.

ObjectiveTo assess the clinical and radiological factors as predictors for successful outcomes in lumbar disc herniation (LDH) treatment.MethodsTwo groups of patients with single level LDH (L4–5) requiring treatment were retrospectively studied. The surgery group (SG) included 34 patients, and 30 patients who initially refused the surgery were included in the nerve blocks group (NG). A visual analogue scale (VAS) for leg and back pain and motor deficit were initially evaluated before procedures, and repeated at 1, 6, and 12 months. Radiological factors including the disc herniation length, disc herniation area, canal length-occupying ratio, and canal area-occupying ratio were measured and compared. Predicting factors of successful outcomes were determined with multivariate logistic regression analysis after the optimal cut off values were established with a receiver operating characteristic curve.ResultsThere was no significant demographic difference between two groups. A multivariate logistic regression analysis with radiological and clinical (12 months follow-up) data revealed that the high disc herniation length with cutoff value 6.31 mm [odds ratio (OR) 2.35; confidence interval (CI) 1.21–3.98] was a predictor of successful outcomes of leg pain relief in the SG. The low disc herniation length with cutoff value 6.23 mm (OR 0.05; CI 0.003–0.89) and high baseline VAS leg (OR 12.63; CI 1.64–97.45) were identified as predictors of successful outcomes of leg pain relief in the NG.ConclusionThe patients with the disc herniation length larger than 6.31 mm showed successful outcomes with surgery whereas the patients with the disc herniation length less than 6.23 mm showed successful outcomes with nerve block. These results could be considered as a radiological criteria in choosing optimal treatment options for LDH.

Transforaminal full-endoscopic lumbar discectomy in obese patients.

Obese patients are at risk of complications such as slower wound healing and increased infection rates after spinal surgery. Transforaminal full-endoscopic lumbar discectomy (ELD) has advantages over conventional microdiscectomy because it decreases perioperative complications and increases favorable clinical outcomes. No clinical studies have reported ELD in obese patients. The purpose of this study is to evaluate the clinical outcomes of transforaminal ELD in obese patients. Obesity is defined as a body mass index (BMI) of more than 30 kg/m2. Our study included 21 obese patients and 27 normal BMI patients treated by posterolateral transforaminal ELD for radiating pain caused by a single-level lumbar disc herniation with more than 2 years of follow-up. Clinical chart reviews and telephone surveys were conducted. Clinical and functional outcomes using VAS and ODI, perioperative complications, and reherniation were evaluated. Overall clinical and functional outcomes were improved during postoperative follow-up evaluation. There were no immediate perioperative complications, such as infection or durotomy in both groups. In obese group, three patients had late reherniations. Of these, 2 patients had tolerable pain and showed good recovery with conservative treatment; 1 patient who had undergone ELD for recurrent disc herniation underwent open microdiscectomy. In control group, two patients had early reherniation and underwent open microdiscectomy and one patient with late reherniation showed good recovery with conservative treatment. In select cases, ELD is an effective, safe, and minimally invasive technique for obese patients. It decreases perioperative morbidity and allows for both early mobilization and early return to work. level 3b.

Ultrasound volume navigation technology in transforaminal puncture of minimally invasive lumbar surgery with full-endoscopic techniques

Objective To evaluate the effectiveness of ultrasound (US) volume navigation technology in guiding the lumbar transforaminal puncture with full-endoscopic technique through posterolateral approach. Methods From June 2011 to June 2013, 60 patients (37 males and 23 females; mean age: 32.9 years) with single-level lumbar disc herniation who had undergone lumbar transforaminal puncture with full-endoscopic technique through posterolateral approach were enrolled in this retrospective study, and they were randomly divided into 2 groups according to whether the assistance of ultrasound volume navigation technology was used. They received the minimally invasive surgery on L4, 5 (47 cases) and L5S1 (13 cases). In the US-guidance group (29 cases), ultrasound volume navigation was used to guide puncture process, and in the C-arm guided group (31 cases), C-arm was applied to guide the puncture process The total puncture time and C-arm fluoroscopy times were recorded. Parameters including Oswestry disability index (ODI) and visual analogue scale (VAS) were selected to evaluate the clinical efficacy. Results Patients had no obvious discomfort during the puncture procedure and no postoperative complications. In US-guidance group, the preoperative time was 13.7±2.1 min (range, 11-16 min), and the whole process took 20.6±3.1 min (range, 16-28 min), while the average time of C-arm exposure were 4.9±0.8 times (range, 4-7 times). In C-arm guided group, the average time for puncture procedure was 27.9±1.7 min (range, 25-32 min), and the average times of C-arm exposure were 14.3±1.2 times (range, 13-17 times). There were significant differences between two groups. Compared with C-arm guided group, US-guidance group had the same accuracy rate of puncture (the puncture needles all reached the target area), but the fluoroscopy times and puncture timewere decreased significantly. There's no significant difference among the pre and postoperative ODI and VAS indexes. Patients were followed-up at 3 months and 1 year postoperation. The mean follow-up period was 16.4 months (range, 12-26 months). The ODI score of the USguidance group were 72.9%±5.9%, 17.1%±3.6% and 15.9%±3.3% before operation, 3 months postoperation and 1 year postoperation respectively. The ODI score of the C-arm guided group were 73.2%±4.9%, 17.3%±3.3% and 16.1%±2.9% respectively. The VAS were 7.4±0.9,2.2±0.7 and 1.9±0.8 in US-guidance group, and were 7.2±0.9, 2.1±0.7, 1.8±0.8 in C-arm guided group. Conclusion The ultrasound volume navigation can guide the lumbar transforaminal puncture with full-endoscopic technique through posterolateral approach accurately, reducing the puncture time and the amount of X-ray radiation significantly. Its puncture accuracy and efficacy have no significant differences, which could be broadly used in clinical application. Key words: Ultrasonography; Surgery, computer-assisted; Endoscopes

Kirschner wire is more effective than the nerve root retractor in treating patients with disc herniation

ObjectiveTo investigate the value of using Kirschner wire in the intraspinal procedures. MethodsFrom May 2011 to October 2013, a total of 46 patients with a single-level lumbar disc herniation with concomitant lumbar instability were randomly assigned to two groups at the time of admission. Group 1 had 23 patients who underwent posterior lumbar fusion using a nerve root retractor to drag nerve root, and Group 2 also had 23 patients who underwent the same operation by fixing Kirschner wires in the vertebral body to drag nerve root. All of these patients were assessed with visual analog scales (VAS) and Japanese Orthopaedic Association (JOA) scores before surgery, and were followed up at the time points of one week (VAS score only), three, six, and twelve months respectively after surgery. The actual retraction time of the nerve root of each patient was also recorded during the operation. ResultsThe differences in VAS and JOA scores were not significant between Group 1 and 2 before surgery. However, these scores showed significant improvement in Group 2 at one week and three months after surgery compared with those in Group 1. At six and twelve month follow-up time points, no significant difference was observed between these two groups. However, the retraction time of the nerve root of the patients in Group 2 was significantly shorter than in Group 1. ConclusionsUsing Kirschner wires instead of the nerve root retractor to pull nerve root in the patients with a single-level lumbar disc herniation accompanied by the lumbar instability is more effective in reducing the dragging damage of the nerve root at early phases after surgery and in shortening retraction time.

Risk factors for failure of single-level percutaneous endoscopic lumbar discectomy

Few studies have addressed surgical failures and complications following percutaneous endoscopic lumbar discectomy (PELD), and no previous study has investigated the risk factors that lead to surgical failure. The authors report their experience using PELD for single-level lumbar disc herniation (LDH) to provide insights into the rates of surgical failure and identify potential risk factors that lead to this complication. The authors retrospectively reviewed the medical records of 350 patients who underwent PELD for single-level LDH and identified 36 patients (10.3%) who underwent reoperation due to the failure of PELD. Patients' mean visual analog scale of pain scores and Oswestry Disability Index scores improved significantly from 6.6 ± 2.1 and 51.6 ± 19.4 preoperatively to 1.9 ± 1.4 and 28.3 ± 12.0, respectively, at 1 month postoperatively and 1.2 ± 1.1 and 9.3 ± 7.8, respectively, at 1 year postoperatively. The frequencies with which patients took analgesic medications significantly decreased from 74.6% preoperatively to 19.7% at 1 month postoperatively and 10.0% at 1 year postoperatively. Relatively older patients (p = 0.005) and those ≥ 60 years old (p = 0.001) experienced larger numbers of failures compared to younger patients. An analysis of potentially contributing comorbid conditions indicated that significantly more patients with diabetes were present in the PELD failure group (p = 0.017). As surgeons gained familiarity with the procedure, outcomes improved. The failure rate during the authors' early use of the PELD technique (Cases 1-70) was 17.1%; the failure rate then fell to 5.7% (p = 0.034) (Cases 141-210) before finally stabilizing at 10.0% (Cases 211-280 and Cases 281-350). The surgical failure rate following PELD for LDH was 10.3%. Older patients, elderly patients (age ≥ 60 years), and patients with diabetes were at increased risk of surgical failure of PELD, particularly in the early years of the procedure's use.

Characterization and Risk Factor Analysis for Reoperation After Microendoscopic Diskectomy.

A population-based database of 1263 consecutive patients who underwent microendoscopic diskectomy for single-level lumbar disk herniation between 2005 and 2010 was retrospectively analyzed to identify causes and characteristics of reoperation and associated risk factors. A total of 952 patients were eligible. Of these, 58 had revision spinal surgery. Causes and clinical parameters were retrospectively assessed, and possible risk factors were evaluated by multivariate logistic regression analysis. In total, 76 disk herniations were excised with revision diskectomy, with or without interbody fusion. The overall mean interval between primary surgery and revision surgery was 39.05 months (range, 2-95 months). Cumulative overall reoperation rates gradually increased from 1.56% at 1 year to 8.17% after nearly 10 years. Reoperated patients were older and had a higher level of lumbar degeneration, with severe Modic changes (type 1, 17.2%; type 2, 34.5%), vs patients without reoperation (type 1, 1.5%; type 2, 30.6%). In addition, patients with reoperation had a higher rate of obvious adjacent disk degeneration (81.1%). Logistic regression analysis showed that adjacent segment degeneration and Pfirrmann grading for disk degeneration were significant risk factors for reoperation after primary microendoscopic diskectomy (odds ratios, 2.448 and 1.510, respectively). The current study reported a relatively low incidence of reoperation after primary microendoscopic diskectomy. Adjacent segment degeneration and Pfirrmann grading for disk degeneration were identified as risk factors for reoperation after microendoscopic diskectomy to treat lumbar disk herniation. Treatment options for patients with these factors at the first visit should be carefully evaluated.

Efficacy of Percutaneous Epidural Neuroplasty Does Not Correlate with Dural Sac Cross-Sectional Area in Single Level Disc Disease

PurposePercutaneous epidural neuroplasty (PEN) is a minimally invasive treatment. The efficacy of PEN has been relatively well investigated; however, the relationship between the clinical effectiveness of PEN and the severity of spinal canal stenosis by disc material has not yet been established. The purpose of this study was to compare clinical outcomes of PEN according to the dural sac cross-sectional area in single level disc disease.Materials and MethodsThis study included 363 patients with back pain from single level disc disease with and without radiculopathy. Patients were categorized into groups according to spinal canal compromise by disc material: Category 1, less or more than 50%; and Category 2, three subgroups with lesser than a third, between a third and two thirds, and more than two thirds. Clinical outcomes were assessed according to the Visual Analog Scale (VAS) score for back pain and leg pain and Odom's criteria at 1, 3, 6, 12, and 24 months after treatment.ResultsThe demographic data showed no difference between groups according to spinal canal compromise by disc material except age (older age correlated with more spinal canal compromise). The dural sac cross-sectional area did not correlate with the VAS scores for back and leg pain after PEN in single level disc disease in Groups 1 and 2. Odom's criteria after PEN were also not different according to dural sac cross-sectional area by disc material.ConclusionPEN is an effective procedure in treating single level lumbar disc herniation without affecting dural sac cross-sectional area.