Single-level Lumbar Discectomy Research Articles

Comparative Analysis of Learning Curve, Complexity, Psychological Stress, and Work Relative Value Units for CPT 62380 Endoscopic Lumbar Spinal Decompression vs Traditional Lumbar Spine Surgeries: A Paired Rasch Survey Study.

Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT) code 62380. However, no work relative value units (RVUs) are currently assigned to the procedure. An international team of endoscopic spine surgeons conducted a study, endorsed by several spine societies, analyzing the learning curve, difficulty, psychological intensity, and estimated work RVUs of endoscopic lumbar spinal decompression compared with other common lumbar spine surgeries. A survey comparing CPT 62380 to 10 other comparator CPT codes reflective of common spine surgeries was developed to assess the work RVUs in terms of learning curve, difficulty, psychological intensity, and work effort using a paired Rasch method. The survey was sent to 542 spine specialists. Of 322 respondents, 150 completed the survey for a 43.1% completion rate. Rasch analysis of the submitted responses statistically corroborated common knowledge that the learning curve with lumbar endoscopic spinal surgery is steeper and more complex than with traditional translaminar lumbar decompression surgeries. It also showed that the psychological stress and mental and work effort with the lumbar endoscopic decompression surgery were perceived to be higher by responding spine surgeons compared with posterior comparator decompression and fusion surgeries and even posterior interbody and posterolateral fusion surgeries. The regression analysis of work effort vs procedural difficulty showed the real-world evaluation of the lumbar endoscopic decompression surgery described in CPT code 62380 with a calculated work RVU of 18.2464. The Rasch analysis suggested the valuation for the endoscopic lumbar decompression surgery should be higher than for standard lumbar surgeries: 111.1% of the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (CPT 63005), 118.71% of the laminectomy code (CPT 63047), which includes foraminotomy and facetectomy, 152.1% of the hemilaminectomy code (CPT 63030), and 259.55% of the interlaminar or interspinous process stabilization/distraction without decompression code (CPT 22869). This research methodology was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the Mexican Society of Spinal Surgeons (AMCICO), the International Society For Minimally Invasive Spine Surgery (ISMISS), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Surgery (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS). This study provides an updated reimbursement recommendation for endoscopic spine surgery. Level 3.

A Prospective, Single-Center, Single-Blind, Randomized, Confirmatory, Controlled Trial to Assess the Efficacy and Safety of PF-72 Combined with 0.75% Ropivacaine Hydrochloride in Patients Undergoing Single-Level Lumbar Discectomy

A Prospective, Single-Center, Single-Blind, Randomized, Confirmatory, Controlled Trial to Assess the Efficacy and Safety of PF-72 Combined with 0.75% Ropivacaine Hydrochloride in Patients Undergoing Single-Level Lumbar Discectomy

Destandau Tekni̇ğiyle Lomber Diskektomi̇ Kısa Vadede Daha İyi Sonuçlar Veri̇yor

Background: The long-term results of patients who underwent lumbar discectomy using the Desdandau technique (EDDT) and standard open technique (SOD) were compared. Materials and Methods: A retrospective screening was made of patients, aged 18-70 years, who underwent single-level lumbar discectomy between 2007 and 2011. A total of 52 patients met the study criteria and were separated into 2 groups according to the surgical technique used, the EDDT group (n: 27) and the SOD group (n:25). All patients were compared using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria. Results. The mean follow-up period was calculated as 158.2±9.2 months in the EDDT group and 161.2±11.1 months in the SOD group. The preoperative VAS and ODI values were observed to be similar in both groups (p=0.829); p=0.120 respectively). At the early postoperative visit, VAS and ODI values were lower in the EDDT group (VAS: EDDT: 2.2±0.6; SOD: 4.1±0.8, p<0.001; ODI: EDDT: 15.4±1.6, SOD: 29.1±1.9, p<0.001, respectively), however, there was no significant difference in VAS and ODI scores between the two groups at the last control (VAS: EDDT: 2.1±0.4, SOD: 2.4±0.5, p=0.078; ODI: EDDT: 14.6±2.1, SOD: 15.1±1.2, p=0.033, respectively). According to the modified MacNab criteria, good and excellent results were obtained in 88% of the SOD group and 92% of the EDDT group. Conclusion: The study found that the long-term results of both techniques were similar. However, the Destandau technique had better early results. The endoscopic method seems to be better in terms of early return to daily activities.

Open Microdiscectomy or Tubular Discectomy: What Is Better for Lumbar Disc Herniation

Introduction: Many different minimally invasive procedures can be used to treat lumbar disc herniation. In the management of lumbar disc herniation, Open microdiscectomy MD is the gold standard and is used as a benchmark for comparison with more recent techniques like tubular discectomy. The purpose of this study was to assess the complication rates of tubular discectomy and to compare the postoperative outcomes of individuals undergoing tubular discectomy with those undergoing MD. Material & Methods: A retrospective analysis of 250 patients who underwent single-level lumbar discectomy either by tubular TD or MD between JULY 2018- JUNE 2023 was performed. The differences in the 2 groups' demographics, surgical length, intraoperative blood loss, overall hospital stay, pain score on the visual analogue scale (VAS), Oswestry Disability Index (ODI) score both before and after the procedure, and complications were assessed. Results: Out of the 250 patients, 130 patients were treated with MD and 120 by tubular discectomy TD. The mean age in MD and tubular TD group was 45.5 and 45.8 years. There was a improvement in VAS and ODI scores at 4 weeks in both the groups. There was a greater reduction of back pain in the TD group at 2 weeks compared to MD group but at 1 month both are comparable. Average surgical time was shorter in MD (71.6 min) as compared to TD group (80.2 min). the Average blood loss was higher (90.2 mL) in MD group as compared to TD group (35.8 mL) (Table 3 ). Length of incision as measured from the surgical scar was 1.7 cm in TD while it was 3.0 cm in MD group. Average hospital length of stay in TD (1.2 days) which was less than MD group (2.1 days). Likewise, MD group patients took 5.9 weeks to return to activity which was higher than the TD group (4.1 weeks). There were 9 cases (6.9%) of dural tear in MD and 10 cases (8.3%) in TD group. Conclusion: Sciatica caused by disc herniation can be effectively and safely treated with lumbar discectomy, whether it is TD or MD. In comparison to MD, the TD method for treating symptomatic lumbar radiculopathy is superior in that it causes less postoperative back pain, less blood loss, a shorter hospital stay, and a quicker return to work. Despite the learning curve, TD has been demonstrated to be a viable choice for treating lumbar disc herniation in patients who are carefully chosen.

Efficacy of intraoperative subanaesthetic dose of ketamine on post-operative analgesia for patients undergoing single level lumbar discectomy under general anesthesia: A placebo control randomized clinical study

Background: Sub-anesthetic ketamine is becoming increasingly popular for opioid sparing analgesic properties. Aims and Objectives: This study was done to determine the efficacy of intraoperative infusion of sub-anesthetic dose of ketamine on post-operative analgesia in single level lumbar discectomy surgeries. Materials and Methods: A prospective, randomized, and control study was carried on 60 patients of American Society of Anesthesiologists I and II aged between 18 and 65 years undergoing single level lumbar discectomy under general anesthesia. After induction of anesthesia, Group A received Ketamine 0.3 mg/kg intravenous (IV) bolus followed by infusion at 4 μg/kg/min and Group B received 0.9% saline bolus dose of similar volume and infusion was started at similar rate. Post-operative pain relief, opioid sparing effect, and side effects if any were recorded. Results: There was significant difference (P<0.001) in post-operative Numeric Rating scores for initial 6 h in Group A patients compared to Group B and prolonged duration of analgesia (8.5 vs. 4.25 h) along with reduced postoperative tramadol consumption. Conclusion: In lumbar spine discectomy, intraoperative ketamine infusion at sub-anesthetic doses produces more effective post-operative analgesia along with opioid sparing effect without any side effects.

1318 Cross-Sectional Study of Recurrent Disc Herniation Risk Factors and Predictors of Outcomes After Primary Lumbar Discectomy: A STROBE Compliance

Abstract Aim The purpose of this study is to determine if lifting weight, smoking status, occupational work, and diabetes were predictors for recurrent lumbar disk herniation (rLDH) leading to reoperation and if the outcome can be influenced by the reoperated level and side. Method From June 2010 to July 2019, the 2196 consecutive patients who underwent first-time single-level lumbar discectomy at our institution were revised. Data on first and second lumbar spine surgery were brought into the analysis. Multivariate Logistic Regression Analysis was performed to determine whether lifting weight, smoking status, occupational work, and diabetes were predictors for recurrent lumbar disk herniation. Multivariable Cox-regression analysis was performed for repeated lumbar disc herniation excision at the L4L5 and L5S1 levels independently. Results From the 101(4.59%) patients that presented with recurrent lumbar disc herniation (rLDH), 75 cases (3.41%) met the inclusion criteria. There were 54 cases of ipsilateral recurrent herniation and 21 contralateral. The group of diabetes patients who smoke was at high risk (Odds 2.77) of rapid recurrence of lumbar disc prolapse. Only the group of patients reoperated on the opposite side at the L4L5 level showed very less recurrence risk (Odd ratio 1.01) for lumbar disc prolapses compared to those reoperated on the same side who are 6.73 times at risk of recurrence. Conclusions Coexisting diabetes and smoking status increase the risk of rLDH and the patient’s outcome is favorable with pain-free after reoperation without the need for physiotherapy when the recurrence is on the same level and opposite side.

Analysis of the Curative Effect of Diffusion Tensor Imaging-Guided Percutaneous Endoscopic Lumbar Discectomy

Diffusion tensor imaging (DTI), a novel method of describing nerve structure, is a special form of magnetic resonance imaging (MRI). This new imaging method can be used to locate the diseased nerve roots in lumbar disc herniation. The objective of this study is to compare patient outcomes between single-level and doublesection percutaneous endoscopic lumbar discectomy (PELD) in the treatment of lumbar intervertebral disc herniation with single nerve root compression, where single-sided PELD is guided by magnetic resonance diffusion tensor imaging (DTI). The clinical data of patients with lumbar intervertebral disc herniation with double compression of single nerve root symptoms in the Affiliated Hospital of Weifang Medical University from January 2019 to May 2021 were retrospectively summarized and divided into single-level percutaneous endoscopic discectomy (PELD) group after DTI localization and double-section PELD group. The operation time, intraoperative bleeding, VAS score and JOA score of the two groups were compared, as well as the preoperative and postoperative fractional anisotropy (FA) values in the DTI group. The operation time and intraoperative bleeding volume of patients in the DTI group were significantly lower than those in the double segment group, and there was no significant difference between VAS scores and JOA scores in the two groups. After the operation, the nerve root FA value of the responsible compression site of patients in the DTI group increased significantly, but it was still lower than the healthy symmetrical part. The single-level PELD based on DTI has achieved a similar effect to that of the doublesegment PELD in 3 months after the operation, which can improve the FA value of the lesion nerve root. Its bleeding amount is less, and the operation time is shorter, but the efficacy of this technology still requires long-term follow-up of large samples.

The correlation of psoriasis and its treatment medications with lumbar discectomy postoperative infections

BACKGROUND CONTEXTPsoriasis is a chronic, autoimmune disease of the skin that affects approximately 3% of the US adult population. Patients with psoriasis may be predisposed to spine surgical site infections (SSI) related to the condition and/or related medications following surgeries such as lumbar laminotomy/discectomy. PURPOSETo assess the potential correlation of psoriasis and its related treatment medications on the risk of infection-related complications after lumbar laminotomy/discectomy. STUDY DESIGNRetrospective case control, national administrative database study. PATIENT SAMPLEAdult patients who underwent isolated single-level lumbar discectomy between 2010 and Q1 of 2021 were identified in the PearlDiver Mariner Ortho151 national administrative database (excluding those with concurrent diagnoses of fractures, neoplasms, or infections). OUTCOME MEASURESNinety-day postoperative rates of surgical site infection and sepsis. METHODSLumbar laminotomy/discectomy patients with versus without psoriasis were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index. The risk of SSI and sepsis in the 90-day postoperative window between the cohorts were compared with multivariable analyses. Five-year reoperation rates were also compared with log rank test. The matched psoriasis cohort was further subdivided by psoriasis treatment regimens – no medication treatment (NT), topical therapies only (TT), topical therapies with oral systemic treatments (TT/OS), and topical therapies with biologics (TT/B). Multivariable logistic regression was used to assess the risk of SSI and sepsis within 90 days after lumbar laminotomy/discectomy for each treatment subgroup compared to patients without psoriasis. RESULTSIn total, 2,262 patients with psoriasis who underwent single-level lumbar laminotomy/discectomy were identified and matched by age, sex, and Elixhauser Comorbidity Index to 9,044 patients without psoriasis. Multivariable logistic regression showed that, compared to the patients without psoriasis, patients with psoriasis had a 1.795 times higher chance of developing SSI (odds ratio [OR]) (p<.001) and sepsis (OR: 1.743, p=.027) within 90 days of surgery. Having psoriasis did not significantly correlate with 5-year reoperation rates. Of those with psoriasis, NT subcohort had 1,038 patients, TT subcohort 571 patients, TT/OS subcohort 226 patients, and TT/B subcohort 140 patients. Based on multivariable analysis and compared to nonpsoriasis patients, those in the NT, TT, TT/OS were not at greater odds of postoperative SSI or sepsis. Conversely, those in the TT/B subcohort were at significantly greater odds of SSI (OR: 3.102, p=.019) and sepsis (OR: 6.367, p=.027). CONCLUSIONSOf single-level lumbar laminotomy/discectomy patients with psoriasis, only those on topical therapies and biologics were at greater risk of postoperative SSI and sepsis. This subcohort warrants specific attention when undergoing lumbar laminotomy/discectomy and possibly holding such medications for a period prior to surgery may be warranted if possible.

Cross-sectional study of recurrent disc herniation risk factors and predictors of outcomes after primary lumbar discectomy: A STROBE compliance

ObjectivesThe purpose of this study is to determine if lifting weight, smoking status, occupational work, and diabetes were predictors for recurrent lumbar disk herniation (rLDH) leading to reoperation and if the outcome can be influenced by the reoperated level and side. MethodsFrom June 2010 to July 2019, the 2196 consecutive patients who underwent first-time single-level lumbar discectomy at our institution were revised. Data on first lumbar spine surgery, reoperation as well as preoperative data were brought into the analysis. Multivariate Logistic Regression Analysis was performed to determine whether lifting weight, smoking status, occupational work, and diabetes were predictors for recurrent lumbar disk herniation. The outcome level was assessed by the Multivariable Cox-regression Kaplan–Meier analysis for repeated lumbar disc herniation excision at the L4L5 and L5S1 levels independently. ResultsFrom the 101(4.59%) patients that presented with recurrent lumbar disc herniation (rLDH), 75 cases (3.41%) met the inclusion criteria. There were 54 cases of ipsilateral recurrent herniation and 21 contralateral with a male predominance of 64% (n = 48). The average age at the time of recurrence was 48 ± 9.34 years (age range 29–67 years). The group of diabetes patients who smoke is at high risk (Odds 2.77) of rapid recurrence for lumbar disc prolapse; about 3 months after the first surgery followed by the group of diabetes who lift weight (Odds 0.83), about 4 months after the first surgery. At the L4L5 level, only the group of patients operated for opposite side recurrence (Odd ratio 1.01) did well and were pain-free immediately after surgery compared to the group of patients operated for recurrence on the same side (Odd ratio 6.73). ConclusionCoexisting diabetes and smoking status in the same patient increase the risk of rLDH and the patient’s outcome is favorable with pain-free after reoperation without the need for physiotherapy when the recurrence is on the same level and opposite side.

Outcome of back pain and radiculopathy in patients with single level lumbar discectomy

Background: Surgery for lumbar disc herniation is one of the most commonly performed procedures in spine surgery. Questions remain if lumbar discectomy is the optimal treatment for patients with lumbar disc herniation who exhibit a substantial amount of preoperative back pain.&#x0D; Objective: To evaluate the outcome of improvement of back pain and radiculopathy between male and female patients with single-level discectomy and in relation to different indications for the surgery. &#x0D; Patients and Methods: In this retrospective follow-up study, 80 patients (40males and 40 females) with symptoms of radiculopathy and back pain who underwent single-level open discectomy (small incision of 2-3 cm) were followed-up by discharge from the hospital between 2017 and 2019 in Erbil, Iraqi Kurdistan. The patients were included after having the symptoms of radiculopathy as confirmed on magnetic resonance imaging. In addition, patients who had undergone discectomy due to radiculopathy without response after 6 weeks of conservative treatment were included in this investigation.&#x0D; Results: The mean age of the patients was 45.1 (19-70 years old). The study showed that the level of back pain and radicular pain was significantly decreased from the initial step to 3, 6, and 12 months. The levels of back and radicular were not changed significantly from three to six months. The study showed that the prevalence of different levels of back and radicular pain was similar between male and female patients at different periods. The study did not find a significant difference in levels of back and radicular pains among patients with different indications in male and male patients.&#x0D; Conclusion: This study showed that single-level lumbar discectomy improved back and radicular pain by 12 months postoperatively in males and females, regardless of the indication for surgery.

Determination of Work Related to Endoscopic Decompression of Lumbar Spinal Stenosis.

Background: Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT®) code 62380. However, no work relative value units (wRVUs) are currently assigned to the procedure. A physician's payment needs to be updated to commensurate with the work involved in the modern version of the lumbar endoscopic decompression procedure with and without the use of any implants to stabilize the spine. In the United States, the American Medical Association (AMA) and its Specialty Society Relative Value Scale Update Committee (RUC) proposes to the Centers for Medicare and Medicaid Services (CMS) what wRVUs to assign for any endoscopic lumbar surgery codes. Methods: The authors conducted an independent survey between May and June 2022 which reached 210 spine surgeons using the TypeForm survey platform. The survey link was sent to them via email and social media. Surgeons were asked to assess the endoscopic procedure's technical and physical effort, risk, and overall intensity without focusing just on the time required to perform the surgery. Respondents were asked to compare the work involved in modern comprehensive endoscopic spine care with other commonly performed lumbar surgeries. For this purpose, respondents were provided with the verbatim descriptions of 12 other existing comparator CPT® codes and associated wRVUs of common spine surgeries, as well as a typical patient vignette describing an endoscopic lumbar decompression surgery scenario. Respondents were then asked to select the comparator CPT® code most reflective of the technical and physical effort, risk, intensity, and time spent on patient care during the pre-operative, peri- and intra-operative, and post-operative periods of a lumbar endoscopic surgery. Results: Of the 30 spine surgeons who completed the survey, 85.8%, 46.6%, and 14.3% valued the appropriate wRVU for the lumbar endoscopic decompression to be over 13, over 15, and over 20, respectively. Most surgeons (78.5%; <50th percentile) did not think they were adequately compensated. Regarding facility reimbursement, 77.3% of surgeons reported that their healthcare facility struggled to cover the cost with the received compensation. The majority (46.5%) said their facility received less than USD 2000, while another 10.7% reported less than USD 1500 and 17.9% reported less than USD 1000. The professional fee received by surgeons was <USD 1000 for 21.4%, <USD 2000 for 17.9%, and <USD 1500 for 10.7%, resulting in a fee less than USD 2000 for 50% of responding surgeons. Most responding surgeons (92.6%) recommended an endoscopic instrumentation carveout to pay for the added cost of the innovation. Discussion and Conclusions: The survey results indicate that most surgeons associate CPT® 62380 with the complexity and intensity of a laminectomy and interbody fusion preparation, considering the work in the epidural space using the contemporary outside-in and interlaminar technique and the work inside the interspace using the inside-out technique. Modern endoscopic spine surgery goes beyond the scope of a simple soft-tissue discectomy. The current iterations of the procedure must be considered to avoid undervaluing its complexity and intensity. Additional undervalued payment scenarios could be created if technological advances continue to replace traditional lumbar spinal fusion protocols with less burdensome, yet no less complex, endoscopic surgeries that necessitate a high surgeon effort in terms of time required to perform the operation and its intensity. These undervalued payment scenarios of physician practices, as well as the facility and malpractice expenses, should be further discussed to arrive at updated CPT® codes reflective of modern comprehensive endoscopic spine care.

Incidence and risk factors for five-year recurrent disc herniation after primary single-level lumbar discectomy

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre's MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management.

Effectiveness of Lumbosacral Orthosis After Discectomy for Lumbar Disk Herniation: A Prospective Comparative Study.

A prospective comparative study. To investigate the benefits of postoperative application of lumbosacral orthosis after single-level discectomy for lumbar disk herniation (LDH). Although many surgeons use postoperative lumbosacral orthosis for patients with LDH, there is no clear evidence to support or deny its effectiveness. Ninety-nine consecutive patients who underwent the microscopic discectomy were included. They were divided into two groups: orthosis group and nonorthosis group, before surgery. The recurrence rate and reoperation rate were compared between the two groups at four-week, six-month, and one-year follow-up. Japanese Orthopaedic Association Score for lumbar spine (L-JOA score) at two-week and one-year follow-up, lower extremities and low back pain's visual analog scale (VAS) and Oswestry Disability Index (ODI) at six-month and one-year follow-up were compared. Forty-two patients in the orthosis group and 39 patients in the nonorthosis group were followed up for at least one-year after surgery. Recurrence occurred in three patients (7.1%) in the orthosis group and six (15.4%) in the nonorthosis group within one-year. Two patients (4.8%) in the orthosis group and two patients (5.1%) in the nonorthosis group underwent reoperation. There were no significant intergroup differences in the recurrence rate and in the reoperation rate. No significant difference was also observed between the two groups in L-JOA score, ODI, VAS of low back pain, and leg pain at one-year after surgery. Furthermore, at any other follow-up period, no significant differences were observed between the two groups in recurrence rate, reoperation rate, L-JOA score, VAS of low back/leg pain, or ODI. The use of a postoperative orthosis did not reduce recurrence or reoperation rates, nor did it improve postoperative clinical symptoms. The routine use of an orthosis may not be necessary after single-level lumbar discectomy.

Outcome of back pain and radiculopathy in patients with single level lumbar discectomy

Background: Surgery for lumbar disc herniation is one of the most commonly performed procedures in spine surgery. Questions remain if lumbar discectomy is the optimal treatment for patients with lumbar disc herniation who exhibit a substantial amount of preoperative back pain. Objective: To evaluate the outcome of improvement of back pain and radiculopathy between male and female patients with single-level discectomy and in relation to different indications for the surgery. Patients and Methods: In this retrospective follow-up study, 80 patients (40males and 40 females) with symptoms of radiculopathy and back pain who underwent single-level open discectomy (small incision of 2-3 cm) were followed-up by discharge from the hospital between 2017 and 2019 in Erbil, Iraqi Kurdistan. The patients were included after having the symptoms of radiculopathy as confirmed on magnetic resonance imaging. In addition, patients who had undergone discectomy due to radiculopathy without response after 6 weeks of conservative treatment were included in this investigation. Results: The mean age of the patients was 45.1 (19-70 years old). The study showed that the level of back pain and radicular pain was significantly decreased from the initial step to 3, 6, and 12 months. The levels of back and radicular were not changed significantly from three to six months. The study showed that the prevalence of different levels of back and radicular pain was similar between male and female patients at different periods. The study did not find a significant difference in levels of back and radicular pains among patients with different indications in male and male patients. Conclusion: This study showed that single-level lumbar discectomy improved back and radicular pain by 12 months postoperatively in males and females, regardless of the indication for surgery.

120. Revision discectomy: analysis of 1-year incidence and risk factors

<h3>BACKGROUND CONTEXT</h3> Prior reports have noted rates of recurrent disc herniation following discectomy to be as high as 25%. As such, the primary cause of surgical failure and indication for revision following lumbar discectomy is recurrent disc herniation. However, information varies regarding the rate of incidence and timing of disc herniations following discectomies. <h3>PURPOSE</h3> The primary aim of this study was to determine the rate of revision discectomy following single-level lumbar discectomy at various postoperative time points. A secondary aim was to identify risk factors for revision discectomy. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> Patients from the Mariner Claims Database who underwent lumbar microdiscectomy between 2010 and 2018 with 1-year follow-up. <h3>OUTCOME MEASURES</h3> Rates of revision discectomy for reherniation at various postoperative intervals for up to a year following index surgery were calculated. <h3>METHODS</h3> The group was then followed up to one year after the initial indexed lumbar discectomy for revision according to the CPT codes (63030, 63047, 63042). The second part of the study assessed the independent effects of age, gender, and body mass index (BMI kg/m²) on rates of revision. Groups were separated by risk factors of interest and propensity score matched with respect to age, smoking, obesity, morbid obesity, Charlson Comorbidity Index (CCI). Risk factors for revision discectomy were determined using bivariate analyses following by multivariable logistic regression. Log rank test was used to construct Kaplan Meier survival curves. Significance was set at p<0.05. <h3>Results</h3> Of 29,688 patients included in the analysis, 1.1% (N =325) underwent revision surgery for reherniation within seven days of index discectomy, and 18.5% (N=5,476) underwent revision surgery within a year of index discectomy. Compared to men, women had greater odds of revision (OR1.1, 95% CI 1.03-1.16, p<0.01). Compared to patients aged >40, those aged <40 had greater odds of revision (OR 1.29, 95% CI 1.19-1.39, p<0.01). Compared to nonobese patients, both obese (OR 3.60, 95% CI 3.47-3.88, p<0.01) and morbidly obese (OR 3.30, 95% CI 3.07-3.55, p<0.001) patients had significantly greater odds of revision. <h3>Conclusions</h3> The overall rate of 1-year revision surgery for reherniation following lumbar discectomy is 18.5%, and the rate of revision surgery for reherniation within a week of index discectomy is low. These findings can assist surgeons in risk-stratifying patients based on the expected timing of postoperative reherniation in high-risk patients undergoing lumbar discectomy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Recurrence of Disc Herniation After Single-Level Lumbar Discectomy

Objective: Herniated nucleus pulposus is a common disease of the lumbar spine. Recurrence of disc herniation and subsequent disc degeneration are the most common problems following discectomy. Many first-time lumbar discectomy patients experience favorable outcomes; however, same-level recurrent discectomy can occasionally induce unfavorable results. Therefore, in this study, we retrospectively analyzed the risk factors for recurrence of lumbar disc herniation after discectomy.Methods: From January 2013 to December 2015, 226 patients underwent one-level discectomy in our department. We excluded patients with less than two years of follow-up, a previous spine deformity with a compression fracture, foraminal or extraforaminal discs, or a history of previous lumbar operation history, leaving 71 selected patients. Patients were divided into recurrent and non-recurrent groups and various factors were retrospectively compared between the groups.Results: Patients with preoperative disc space narrowing experienced recurrence less commonly; however, this was not statistically significant (10.0% and 25.5%, respectively; p=0.150). A disc height decrease of more than 20% during the follow-up period was a statistically significant risk factor for recurrence (36.4% and 14.3%, respectively; p=0.035), and grades 3 and 4, compared to grades 1 and 2, facet joint degeneration were also statistically significant risk factors for recurrence of disc herniation (41.2% and 14.8%, respectively; p=0.020).Conclusion: Patients who underwent more than a moderate degree of preoperative facet joint degeneration on the operated side and for whom the progression of disc space height decreased during the follow-up period may require closer observation for recurrence of disc herniation.

Burden of preoperative opioid use and its impact on healthcare utilization after primary single level lumbar discectomy

Background ContextThe complication profile and higher cost of care associated with preoperative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models. PurposeTo study the burden of pre-operative opioid use and its effect on postoperative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy. Study DesignRetrospective cohort study. Patient SampleA 29,745 patients undergoing primary single level lumbar discectomy from the IBM MarketScan (2000-2018) database. Outcome MeasuresNinety-day and 1-year utilization of lumbar epidural steroid injections, emergency department (ED) services, lumbar magnetic resonance imaging, hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months postoperatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups. MethodsPatients were categorized in opioid use groups based on the duration and number of oral prescriptions before discectomy (opioid naïve, < 3-months opioid use, chronic preoperative use, chronic preoperative opioid use with 3-month gap before surgery, and other). The risk of association of preoperative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables. ResultsA total of 29,745 patients with mean age of 45.3±9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar epidural steroid injections, magnetic resonance imaging , ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared with patients with < 3-months use and opioid naïve patients (p<.001). Chronic post-operative opioid use was present in 62.6% of the preoperative chronic opioid users as compared with 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described. ConclusionChronic preoperative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year postoperatively. Two-third of chronic preoperative opioid users had continued long-term postoperative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term postoperative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.

Cost analysis of primary single-level lumbar discectomies using the Value Driven Outcomes database in a large academic center

BACKGROUND CONTEXTImproving value is an established point of emphasis to reduce the rapidly rising health care costs in the United States. Back pain is a major driver of costs with a substantial fraction caused by lumbar radiculopathy. The most common surgical treatment for lumbar radiculopathy is microdiscectomy. Research is sparse regarding variables driving cost in microdiscectomies and often limited by cost data derived from payer-based Medicare data. PURPOSETo identify targets for cost reduction by determining variables associated with significant cost variation in microdiscectomies, using cost data derived from the Value Driven Outcomes tool and actual system costs. STUDY DESIGNSingle-center, retrospective study of prospectively collected registry data. PATIENT SAMPLESix hundred twenty-two patients identified by CPT code and manually screened for initial, unilateral, single-level lumbar discectomy performed between 2014 and 2018 at a single institution. OUTCOME MEASURESPrimary outcome measures include total direct cost, clinical length of stay, and OR minutes. Total Direct Cost was further differentiated into facility and nonfacility costs. METHODSUnivariate and multivariate generalized linear models (GLM) were used to identify variables associated with variation in primary outcome measures. Costs were normalized by mean cost for patients with normal body mass index (BMI) and a healthy American Society of Anesthesiologists (ASA) classification. Average marginal effects were reported as percentage of normalized costs. RESULTSAdvanced age, male gender, Hispanic, black, unemployment, obesity, higher ASA class, insurance status, and being retired were positively associated with costs in univariate analysis. Asian, Native American, outpatient procedures, and being a student were associated with decreases in costs. In multivariate analysis, we found that obesity led to higher average marginal total direct (9%), total facility (15%), and facility OR costs (22%), as well as 24 more OR minutes per surgery. While being overweight was not associated with greater total direct costs, it was associated with higher total facility (8%), and facility OR costs (12%), with 11 more OR minutes per surgery. Age was associated with a longer LOS but not with OR costs. As expected, outpatient surgical costs, LOS, and OR time were significantly lower than inpatient procedures. Severe systematic disease was associated with greater total and nonfacility costs. In addition, Medicare patients had higher facility costs (14%) compared to privately insured patients. CONCLUSIONSSignificant drivers of total direct cost in multivariate GLM analysis were obesity, severe systemic disease and inpatient surgery. Average LOS was increased due to age and inpatient status, conversely it was decreased by unemployment and retirement. Significant variables in OR time were male sex, Hispanic race and both obese and overweight BMIs.

Early Outcomes: A Comparison between Biportal Endoscopic Spine Surgery and Open Lumbar Discectomy for Single-Level Lumbar Disc Herniation

Objective: To compare early outcomes between biportal endoscopic spine surgery (BESS) and open lumbar discectomy (OLD) for treating single-level lumbar disc herniation. Materials and Methods: A retrospective cohort study was conducted in 80 cases of single-level lumbar disc herniation that underwent either BESS or OLD. The author compared the perioperative data between BESS and OLD, including operative time (OT), level, side, estimated blood loss (EBL), surgical drain output, hospital stay (HS), hospital costs, visual analogue scale (VAS) scores, morphine consumption, complication, and McNab’s satisfaction outcome. Results: Forty-three patients underwent BESS and 37 underwent OLD. There was 55% female and 45% male. The mean age was 37.8±9.5 years. The BESS group showed significantly (a) lower median morphine consumption than the OLD group (five mg versus nine mg, p&lt;0.001), (b) lower postoperative pain (VAS) at 2-, 4-, 12-, 24-, 48- (p&lt;0.001), and 72-hours post-surgery (p=0.017), and (c) shorter HS (4.8±2.9 days versus 7.4±4.6 days, p=0.003). McNab’s satisfaction outcome of a good or excellent result was comparable between BESS and OLD group (97.7% versus 86.5%, p=0.090). The BESS group, however, had a longer OT than the OLD group (100.4±28.5 versus 67.9±23.2 minutes, p&lt;0.001), and had a higher hospital cost (1,256±360.9 USD versus 910.6±269.8 USD, p&lt;0.001). Complications were not significantly different between the BESS and OLD groups. Conclusion: BESS for single-level lumbar discectomy had less postoperative pain for up to 72 hours, less opioid consumption, and shorter HS, but longer OT and higher hospital costs than OLD. Patient satisfaction outcomes were comparable between the two groups. Keywords: Biportal endoscopic spine surgery, Unilateral biportal endoscopic discectomy, Open lumbar discectomy, Single-level lumbar disc herniation

Preemptive analgesic efficacy of caudal ropivacaine vs bupivacaine- A randomized study in patients undergoing single level lumbar discectomy

Preemptive analgesic efficacy of caudal ropivacaine vs bupivacaine- A randomized study in patients undergoing single level lumbar discectomy