Surgery For Disc Herniation Research Articles

Cost-utility analysis of endoscopic lumbar discectomy following a uniform clinical pathway in the Korean national health insurance system.

Full-endoscopic lumbar discectomy (FELD) is a type of minimally invasive spinal surgery for lumbar disc herniation (LDH). Sufficient evidence exists to recommend FELD as an alternative to standard open microdiscectomy, and some patients prefer FELD due to its minimally invasive nature. However, in the Republic of Korea, the National Health Insurance System (NHIS) controls the reimbursement and use of supplies for FELD, but FELD is not currently reimbursed by the NHIS. Nonetheless, FELD has been performed upon patients' request, but providing FELD for patients' sake is inherently an unstable arrangement in the absence of a practical reimbursement system. The purpose of this study was to conduct a cost-utility analysis of FELD to suggest appropriate reimbursements. This study was a subgroup analysis of prospectively collected data including 28 patients who underwent FELD. All patients were NHIS beneficiaries and followed a uniform clinical pathway. Quality-adjusted life years (QALYs) were assessed with a utility score using the EuroQol 5-Dimension (EQ-5D) instrument. The costs included direct medical costs incurred at the hospital for 2 years and the price of the electrode ($700), although it was not reimbursed. The costs and QALYs gained were used to calculate the cost per QALY gained. Patients' mean age was 43 years and one-third (32%) were women. L4-5 was the most common surgical level (20/28, 71%) and extrusion was the most common type of LDH (14, 50%). Half of the patients (15, 54%) had jobs with an intermediate level of activity. The preoperative EQ-5D utility score was 0.48±0.19. Pain, disability, and the utility score significantly improved starting 1 month postoperatively. The average EQ-5D utility score during 2 years after FELD was estimated as 0.81 (95% CI: 0.78-0.85). For 2 years, the mean direct costs were $3,459 and the cost per QALY gained was $5,241. The cost-utility analysis showed a quite reasonable cost per QALY gained for FELD. A comprehensive range of surgical options should be provided to patients, for which a practical reimbursement system is a prerequisite.

Full-Endoscopic Lumbar Discectomy vs Standard Discectomy: A Noninferiority Study on Clinically Relevant Changes.

Surgery for lumbar disc herniation (LDH) has had a remarkable technological development during the past 20 years. Microscopic discectomy has traditionally been the gold standard method to treat symptomatic LDH before the introduction of full-endoscopic lumbar discectomy (FELD). The FELD procedure allows unsurpassed magnification and visualization and is currently the most minimally invasive surgical technique. In this study, FELD was compared with standard surgery for LDH, with a focus on medically relevant changes in patient-reported outcome measures (PROMs). The purpose of this study was to investigate whether FELD is noninferior to other surgical methods for LDH surgery in the most common PROMs, including postoperative leg pain and disability, while still reaching the necessary thresholds for relevant clinical and medical improvements. Patients undergoing a FELD procedure at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2013 to 2018 were included. A total of 80 (41 men and 39 women) patients were enrolled. The FELD patients were matched 1:5 to controls from the Swedish spine register (Swespine) who had a standard microscopic or mini-open discectomy surgery. PROMs, including the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS), as well as the patient acceptable symptom states (PASS) and the minimal important change (MIC), were used to compare the efficacy of the 2 surgical approaches. The FELD group achieved medically relevant and significant improvements noninferior to standard surgery within the predefined thresholds of MIC and PASS. No differences could be found in disability measured by ODI FELD -28.4 (SD 19.2) vs standard surgery -28.7 (SD 18.9) or leg pain NRSLeg FELD -4.35 (SD 2.93) vs standard surgery -4.99 (SD 3.12). All intragroup score changes were significant. The FELD results are not inferior to standard surgery 1 year postoperatively after LDH surgery. There were no medically significant differences regarding MIC achieved or final PASS in any of the measured PROMs, including leg pain, back pain, or disability (ODI) between the surgical methods. The present study highlights that FELD is noninferior to standard surgery in clinically relevant PROMs.

Lumbar Disc Herniation Cases in Herat Regional Hospital in 2021

Background and Objective: Lumbar disc herniation is the most common reason for spine surgery in the working-age population. Understanding the epidemiological pattern of lumbar disc herniation helps identify predisposing factors for this type of injury. Since epidemiological studies on lumbar disc herniation surgery in Afghanistan are scarce, the aim of this study is to investigate the epidemiological aspects of these cases in the neurosurgical department of Herat city.
 Methods: In this cross-sectional descriptive study conducted from March 2021 to March 2022 at the regional hospital in Herat, data on demographic information, occupation, symptoms, and complications related to lumbar disc herniation surgery were collected and analyzed for 68 patients.
 Results: The findings indicate that the majority of lumbar disc herniation surgeries occurred in individuals over 30 years of age (70.6%) and among males (66.2%), with about two-thirds of cases (69.1%) occurring in construction workers. Based on the results, 76.4% of the cases involved the L4-L5 vertebral level, and 88.2% of patients, in addition to lower back pain, experienced sensory disturbances in their legs. Although the majority of patients (89.7%) had no complications, the most significant complication among the patients was urinary incontinence (5.9%).
 Conclusion: The results of this study emphasize the higher prevalence of lumbar disc herniation surgeries in specific age and gender groups. Public and healthcare worker education regarding the factors and risks of lumbar disc herniation could be beneficial. Conducting broader studies nationwide to determine the exact occurrences and complications of lumbar disc herniation is crucial.

MRI and clinical findings in 133 dogs with recurrent deficits following intervertebral disc extrusion surgery.

Recurrence of neurological signs following surgery for intervertebral disc herniation (IVDH) is reported, yet many cases lack MRI-confirmed diagnosis. This study describes the MRI and clinical findings in dogs presenting with recurrence of neurological signs following surgical treatment of IVDH. Medical records of dogs that underwent decompressive surgery for IVDH followed by a subsequent MRI within 12 months were retrospectively reviewed. One hundred and thirty-three dogs were identified, all of which initially presented with intervertebral disc extrusion (IVDE). Of these,109 (81.9%) had a recurrent IVDE, and 24 (18.1%) had an alternative diagnosis that included haemorrhage (n = 10), infection (n = 4), soft tissue encroachment (n = 3), myelomalacia (n = 3) or other (n = 4). Same-site IVDE recurrence or alternative diagnoses were significantly more likely to present within 10 days postoperatively. Thirty-nine percent of dogs presenting with 'early recurrence' had an alternative diagnosis. Type of surgery, fenestration, neurological grade or IVDE site was not significantly associated with the subsequent MRI diagnosis. Limitations include the retrospective study design, the exclusion of conservatively managed recurrences, the variable length of follow-up and differences in the clinicians' surgical experience. The most common cause for the recurrence of neurological signs following decompressive spinal surgery was IVDE. Just over one-third of dogs presenting with early recurrence had an alternative diagnosis.

The effect of discharge training with the teach-back method on post-discharge challenges in lumbar disc herniation patients: A quasi-experimental study

BackgroundShortened length of hospital stay in patients undergoing lumbar disc herniation surgery forces to undertake interventions that facilitate optimal patient outcomes. AimThe aim of this study was to investigate the effect of discharge training given by teach-back method, and counseling based on individual needs and a study-specific training booklet on postoperative pain and challenges experienced by lumbar disc herniation patients. MethodsThis study had a quasi-experimental design and was conducted with 94 patients. Patients were divided into a control group (n = 48) and an intervention group (n = 46) using the blocking method. The pain was assessed at the time of patient admission, at discharge, and at follow-up; postoperative challenges were evaluated at discharge and follow-up. ResultsMost patients experienced pain and challenges such as kinesiophobia, weakness-exhaustion-fatigue, irritability, constipation, and insomnia. The patients in the intervention group had less back and leg pain and challenges. ConclusionsThe benefits of education given by teach-back method, and counseling in reducing the postoperative problems experienced by patients who underwent surgery for lumbar disc herniation were demonstrated in this study. The findings suggest that study-specific training and counseling may be useful for addressing the pain and challenges of patients with lumbar disc herniation.

Evaluation of Surgical Indications for Full Endoscopic Discectomy at Lumbosacral Disc Levels Using Three-Dimensional Magnetic Resonance/Computed Tomography Fusion Images Created with Artificial Intelligence.

Background and Objectives: Although full endoscopic lumbar discectomy with the transforaminal approach (FED-TF) is a minimally invasive spinal surgery for lumbar disc herniation, the lumbosacral levels present anatomical challenges when performing FED-TF surgery due to the presence of the iliac bone. Materials and Methods: In this study, we simulated whether FED-TF surgery could be safely performed on a total of 52 consecutive cases with L5-S1 or L5-L6 disc herniation using fused three-dimensional (3D) images of the lumbar nerve root on magnetic resonance imaging (MRI) created with artificial intelligence and of the lumbosacral spine and iliac on computed tomography (CT) images. Results: Thirteen of the fifty-two cases were deemed operable according to simulated FED-TF surgery without foraminoplasty using the 3D MRI/CT fusion images. All 13 cases underwent FED-TF surgery without neurological complications, and their clinical symptoms significantly improved. Conclusions: Three-dimensional simulation may allow for the assessment from multiple angles of the endoscope entry and path, as well as the insertion angle. FED-TF surgery simulation using 3D MRI/CT fusion images could be useful in determining the indications for full endoscopic surgery for lumbosacral disc herniation.

Percutaneous Pain Procedures in Patients Who Underwent Lumbar Disc Herniation Surgery: Is It an Important Tool in the Management of Post-Surgical Ongoing Pain?

Treatment of ongoing pain in patients undergoing disc surgery is extremely difficult, and there is no consensus. Our study aimed to evaluate the efficacy of percutaneous pain interventions in these patients. We retrospectively analyzed 48 patients with persistent / recurring complaints who underwent lumbar disc surgery (LDS) and were treated with percutaneous interventions. They were grouped into recurrent disc herniations (RDHs) and other discovertebral pathologies (ODVP). Moreover, patients were evaluated as those who received transforaminal injection (TFI) with facet blockage (FB) and who received both caudal injection (CI) and TFI in addition to FB. Patients were evaluated using Oswestry Disability Index (ODI) and visual analog scale (VAS). Between the recurrent and ODVP groups, preoperative, 1 h postoperative, and 6 mo postoperative ODI (p = 0.867, p = 0.055, p = 0.892) and VAS (p = 0.902, p = 0.136, p = 0.462) scores did not show a statistically significant difference, respectively. Additionally, in the comparison of patients who underwent FB+TFI+CI and only FB+TFI, there was no statistically significant correlation between preoperative and 6 mo postoperative ODI (p = 0.284) and VAS (p = 0.248) scores in both recurrent and ODVP groups, respectively. The success rates at the 3rd and 6th mo of patients with RDH and ODVP were 47.61% (10/21) and 42.85% (9/21) and 70.37% (19/27) and 63.96% (17/27), respectively. There was no statistically significant difference in ODI and VAS scores between recurrent and ODVP groups. The clinical success rate was numerically better in the ODVP group. Thus, we suggest that co-administration of TFI and CI did not significantly contribute to our clinical outcome.

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.

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series.

Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neurosurgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 ± 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients; 63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.

Cost consequence analysis of waiting for lumbar disc herniation surgery

The economic repercussions of waiting for lumbar disc surgery have not been well studied. The primary goal of this study was to perform a cost-consequence analysis of patients receiving early vs late surgery for symptomatic disc herniation from a societal perspective. Secondarily, we compared patient factors and patient-reported outcomes. This is a retrospective analysis of prospectively collected data from the CSORN registry. A cost-consequence analysis was performed where direct and indirect costs were compared, and different outcomes were listed separately. Comparisons were made on an observational cohort of patients receiving surgery less than 60 days after consent (short wait) or 60 days or more after consent (long wait). This study included 493 patients with surgery between January 2015 and October 2021 with 272 patients (55.2%) in the short wait group and 221 patients (44.8%) classified as long wait. There was no difference in proportions of patients who returned to work at 3 and 12-months. Time from surgery to return to work was similar between both groups (34.0 vs 34.9 days, p = 0.804). Time from consent to return to work was longer in the longer wait group corresponding to an additional $11,753.10 mean indirect cost per patient. The short wait group showed increased healthcare usage at 3 months with more emergency department visits (52.6% vs 25.0%, p < 0.032), more physiotherapy (84.6% vs 72.0%, p < 0.001) and more MRI (65.2% vs 41.4%, p < 0.043). This corresponded to an additional direct cost of $518.21 per patient. Secondarily, the short wait group had higher baseline NRS leg, ODI, and lower EQ5D and PCS. The long wait group had more patients with symptoms over 2 years duration (57.6% vs 34.1%, p < 0.001). A higher proportion of patients reached MCID in terms of NRS leg pain at 3-month follow up in the short wait group (84.0% vs 75.9%, p < 0.040). This cost-consequence analysis of an observational cohort showed decreased costs associated with early surgery of $11,234.89 per patient when compared to late surgery for lumbar disc herniation. The early surgery group had more severe symptoms with higher healthcare utilization. This is counterbalanced by the additional productivity loss in the long wait group, which likely have a more chronic disease. From a societal economic perspective, early surgery seems beneficial and should be promoted.

Modic Changes in Ecuadorian Mestizo Patients: Epidemiology, Clinical Significance, and Role in Chronic Low Back Pain.

Modic changes (MC) are bone marrow lesions seen within a vertebral body on MRI, possibly associated with low back pain (LBP). Though the causes and mechanisms responsible for the formation of MC are still poorly understood, progress is being made in linking his spinal phenotype with disc degeneration and LBP. This paper analyzes the epidemiology, clinical signs, lesions type, and treatment of vertebral discopathy associated with MC in Ecuadorian mestizo patients, comparing MC type I-II changes versus MC type III differences. We performed an epidemiological, observational, cross-sectional study with two cohorts of Mestizo patients collected at "Hospital de los Valles" in Quito, Ecuador, between January 2017 and December 2020; 288 patients diagnosed with degenerative lumbar disc disease plus MC was taken who underwent surgery; 144 with MC type I-II (cohort 1) and 144 with MC type III changes (cohort 2). Cohort 1 was characterized by 68.8% of men with a mean age of 45 years who perform minimal or moderate exercise in 82% of cases. They showed only one level lesion in 88.9% of patients with a pain intensity of 7 or more on the visual analog scale, with three or more months of evolution, in 78.5% of cases of degenerative etiology, mainly between the L5-S1 lesion of the left side. Cohort 2 was 53.5% of women with a mean age of 62. In 81.4% of cases, they perform minimal or moderate exercise. They showed two-level lesions in 45.8% of patients with a pain intensity of 7 or more on the visual analog scale, with three or more months of evolution, in 97.9% of cases of degenerative etiology, mostly between L4-L5 lesions of the left side. In both groups, most patients showed a protruded and lateral hernia. There is a greater predisposition to require surgery for lumbar disc herniation in young men and older women. In addition, surgery at an older age has a higher risk of complications, especially infection.

Impact of the number of previous lumbar operations on patient-reported outcomes after surgery for lumbar spinal stenosis or lumbar disc herniation.

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery.

Evaluation of the systemic inflammatory response in patients with a spinal synovial cyst or lumbar disc herniation

Aims: This study aimed to determine whether a systemic inflammatory response occurs in patients with spinal synovial cysts (SSC) and patients with lumbar disc herniation. Methods: Patients who underwent surgery for SSC or lumbar disc herniation between 2016-2022 were included in the study. To compare the results of these patients, patients who applied to the outpatient clinic due to headaches but did not find any abnormal findings in the radiological examinations were also included. Age, gender, duration of stay in the hospital, comorbidity, and histopathological evaluation results were recorded for all patients. The lumbar T2 weighted MR sagittal and axial images obtained on admission to the hospital were examined. The venous blood samples taken from the patients on first admission to the hospital were analyzed biochemically. Results: There was no statistical difference between the three groups regarding age, gender, and blood biochemistry parameters. Furthermore, no statistical difference was found between SSC patients and patients with lumbar disc herniation in age, gender, cyst or herniated disc localization levels, comorbidity, and blood biochemistry analysis results. Correlation analysis for the findings of all patients revealed that no parameters were correlated with the study groups. ROC-Curve test and Logistic Regression tests showed that no parameter could be a predictive marker in differentiating SSC from disc herniation. Conclusion: Study results demonstrated that neither SSC nor disc herniation caused a systemic inflammatory or allergic reaction in the patients. In addition, it was determined that no biochemical parameter could distinguish disc herniation from SSC.

Unilateral Biportal Endoscopic Discectomy versus Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis

Unilateral biportal endoscopic discectomy (UBED) is a novel and minimally invasive surgery for lumbar disc herniation (LDH). However, efficacy and safety of UBED compared to the conventional percutaneous endoscopic lumbar discectomy (PELD) remains to be determined. A meta-analysis was performed in this study to compare between UBED and PELD for LDH. Relevant cohort studies were found by searching Medline, Web of Science, Embase, Wanfang, and CNKI from database inception to October 13, 2022. Results were pooled using a random-effects model incorporating heterogeneity. In this meta-analysis, 12 studies involving 1175 patients with LDH were included. Pooled results showed that compared with PELD, UBED was associated with a longer surgery time (mean difference [MD] 17.62 min, P < 0.001) and hospital stay (MD 1.40 day, P= 0.04). However, UBED and PELD showed comparative efficacies in improving the Visual Analogue Scale of leg and back, and Oswestry Disability Index, scores. The incidence of perioperative complications was not significantly different between the 2 procedures (risk ratio [RR] 1.62, P= 0.25), while UBED was associated with a lower LDH recurrence during follow-up (RR 0.29, P= 0.03). Although UBED is associated with longer surgery time and hospital stay, it shows similar efficacy to PELD in relieving pain and improving functional ability in patients with LDH. In addition, limited evidence suggests that UBED may be associated with a lower LDH recurrence as compared to PELD, while the incidence of perioperative complications is not different. These findings support UBED as a treatment for patients with LDH.

Initial learning curve after switching to uniportal endoscopic discectomy for lumbar disc herniations.

The purpose was to investigate the learning curve for elective endoscopic discectomy performed by a single surgeon who made a complete switch to uniportal endoscopic surgery for lumbar disc herniations in an ambulatory surgery center and determine the minimum case number required to safely overcome the initial learning curve. Electronic medical records (EMR) of the first 90 patients receiving endoscopic discectomy by the senior author in an ambulatory surgery center were reviewed. Cases were divided by approach, transforaminal (46) versus interlaminar (44). Patient-reported outcome measures (visual-analog-score (VAS) and the Oswestry disability index (ODI)) were recorded preoperatively and at 2-week, 6-week, 3-month, and 6-month appointments. Operative times, complications, time to discharge from PACU, postoperative narcotic use, return to work, and reoperations were compiled. Median operative time decreased approximately 50% for the first 50 patients then plateaued for both approaches (mean: 65min). No difference in reoperation rate observed during the learning curve. Mean time to reoperation was 10weeks, with 7(7.8%) reoperations. The interlaminar and transforaminal median operative times were 52 versus 73min, respectively (p = 0.03). Median time to discharge from PACU was 80min for interlaminar approaches and 60min for transforaminal (p < 0.001). Mean VAS and ODI scores 6weeks and 6months postoperatively were statistically and clinically improved from preoperatively. The duration of postoperative narcotic use and narcotics need significantly decreased during the learning curve as the senior author realized that narcotics were not needed. No differences were apparent between groups in other metrics. Endoscopic discectomy was shown to be safe and effective for symptomatic disc herniations in an ambulatory setting. Median operative time decreases by half over the first 50 patients in our learning curve, while reoperation rates remained similar without the need for hospital transfer or conversion to an open procedure in an ambulatory setting. Level III, prospective cohort.

Favorable long-term health-related quality of life after surgery for lumbar disc herniation in young adult patients

BackgroundLumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them.MethodsA total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients’ baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome.ResultsThe mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender–matched general population sample (difference 0.02, 95% CI − 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013).ConclusionPatients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender–matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.

Paraspinal muscle gene expression across different aetiologies in individuals undergoing surgery for lumbar spine pathology

PurposeThe purpose of this study was to understand potential baseline transcriptional expression differences in paraspinal skeletal muscle from patients with different underlying lumbar pathologies by comparing multifidus gene expression profiles across individuals with either disc herniation, facet arthropathy, or degenerative spondylolisthesis.MethodsMultifidus biopsies were obtained from patients (n = 44) undergoing lumbar surgery for either disc herniation, facet arthropathy, or degenerative spondylolisthesis. Diagnostic categories were based on magnetic resonance images, radiology reports, and intraoperative reports. Gene expression for 42 genes was analysed using qPCR. A one-way analysis of variance was performed for each gene to determine differences in expression across diagnostic groups. Corrections for multiple comparisons across genes (Benjamini–Hochberg) and for between-group post hoc comparisons (Sidak) were applied.ResultsAdipogenic gene (ADIPOQ) expression was higher in the disc herniation group when compared to the facet arthropathy group (p = 0.032). Adipogenic gene (PPARD) expression was higher in the degenerative spondylolisthesis group when compared to the disc herniation group (p = 0.013), although absolute gene expression levels for all groups was low. Fibrogenic gene (COL3A1) had significantly higher expression in the disc herniation group and facet arthropathy group when compared to the degenerative spondylolisthesis group (p < 0.001 and p = 0.038, respectively). When adjusted for multiple comparisons, only COL3A1 remained significant (p = 0.012).ConclusionIndividuals with disc herniation and facet arthropathy demonstrate higher COL3A1 gene expression compared to those with degenerative spondylolisthesis. Future research is required to further understand the biological relevance of these transcriptional differences.

Vertebral bone quality score provides preoperative bone density assessment for patients undergoing lumbar spine surgery: a retrospective study.

The novel MRI-based vertebral bone quality (VBQ) score has been described as an opportunistic screening tool for osteoporosis, but the stability and practical value of this score deserve further investigation. The purpose of this study was to assess whether preoperative VBQ scores could assist in identifying reduced bone mineral density (BMD) or osteoporosis and evaluating the consistency between MRI systems with different field strengths. The VBQ scores of the patients who underwent surgery for lumbar disc herniation and the single-level VBQ scores of each L1-4 vertebral body were measured and calculated with preoperative lumbar MRI noncontrast T1-weighted phases. The VBQ scores were evaluated for correlation analysis using dual-energy x-ray absorptiometry (DEXA) T-scores. The receiver operating characteristic (ROC) curve was used to evaluate the ability of the VBQ scores to identify patients with reduced BMD and with osteoporosis. Differences in CSF measurements at different levels of L1-4 were compared. Twenty-four patients who had been examined using another MRI machine were used as controls to test the interdevice agreement of the VBQ scores. The study included 100 patients with mean VBQ scores of 2.81 ± 0.28 (normal BMD), 3.06 ± 0.36 (osteopenia), and 3.43 ± 0.37 (osteoporosis). VBQ scores differed significantly between BMD subgroups (p < 0.001). The Pearson correlation coefficient showed a moderate negative linear correlation between novel VBQ scores and the lowest DEXA T-scores (r = -0.524). ROC analysis showed good discrimination of VBQ scores in patients with reduced BMD (area under the curve [AUC] 0.793) and with osteoporosis (AUC 0.810). The diagnostic thresholds of reduced BMD and osteoporosis according to the maximum Youden index were 3.06 (sensitivity 0.636, specificity 0.870, positive predictive value [PPV] 0.942, negative predictive value [NPV] 0.417) and 3.05 (sensitivity 0.875, specificity 0.618, PPV 0.519, NPV 0.913), respectively. CSF measurements at the L2, L3, and L4 levels were essentially identical and did not significantly affect the final VBQ scores (p > 0.05), whereas CSF measurements at the L1 level were found to be heterogeneous (p < 0.001). No significant differences were found in VBQ scores between the same brand of MRI machines at different field strengths (1.5 and 3.0 T, p = 0.107). The new VBQ score provides an additional screening opportunity for preoperative BMD assessment. A VBQ score < 3.05 essentially excludes osteoporosis, whereas a VBQ score ≥ 3.05 (especially ≥ 3.06) suggests the need for further examination. The VBQ score is comparable between different MRI systems.

Can lumbar paraspinal muscle/fat ratio and spinopelvic parameters predict short-term outcomes after decompressive surgeries in lumbar disc herniation and lumbar spinal stenosis?

We aimed to investigate whether the lumbar paraspinal muscle/fat ratio influences the outcomes of patients who had simple decompressive surgeries for lumbar disc herniation (LDH) or lumbar spinal stenosis. We also wanted to see if the spinopelvic parameters change with surgery and whether this change influences the outcomes. This was a prospective study on patients with lumbar spinal stenosis (20 patients) and LDH (20 patients) who underwent simple discectomy or decompressive surgery between November 2021 and May 2022. Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index, and Japanese Orthopedic Association (JOA) score were performed before and 3 months after surgery. Spinopelvic parameters were measured on whole spine radiographs before and 3 months after surgery. On axial magnetic resonance images, paraspinal muscle volume and muscle/fat ratios were calculated. All data were statistically analyzed with SPSS program. There was a significant improvement in VAS, Oswestry, and JOA scores after surgery. We observed that more preoperative paraspinal muscle mass was positively correlated with lumbar lordosis (LL) and negatively correlated with sagittal vertical axis (SVA), VAS leg scores, and Oswestry scores. Furthermore, we observed a positive correlation between preoperative SVA and VAS leg scores. Despite limited number of patients, and shorter follow-ups, this prospective study demonstrates a correlation among the lumbar paraspinal muscle/fat ratio, preoperative/postoperative spinopelvic parameters, and surgical outcomes. Increased paraspinal muscle ratio was correlated with lower SVA values and increased LL; lower VAS leg scores; higher Oswestry scores which reflects better surgical outcomes.

Rates and Predictors of Surgery for Lumbar Disc Herniation Between the Military and Civilian Health Care Systems.

Retrospective review (level of evidence III). Surgical care patterns for lumbar disc herniation (LDH), a common musculoskeletal condition of high relevance to the Military Health System (MHS), have not been described or compared across the direct care and purchased care MHS components. This study aimed to describe surgery rates in MHS beneficiaries who were diagnosed with LDH in direct care versus purchased care and to evaluate characteristics associated with the location of surgery. Differences in care patterns for LDH may suggest unexpected variation within the centrally managed MHS. We described 1-year rates of surgery among beneficiaries who were diagnosed with LDH in direct care versus purchased care. Among beneficiaries who were diagnosed in direct care and had surgery, multivariable logistic regression models were used to identify characteristics associated with surgery location. We identified 726,638 MHS beneficiaries who were diagnosed with LDH in direct care or purchased care during the 9-year study period. One-year surgery rates were 10.1% in beneficiaries who were diagnosed in direct care versus 11.3% in beneficiaries who were diagnosed in purchased care. Among the 7467 patients who were diagnosed in direct care and had surgery within 1 year, characteristics associated with lower probability of surgery in purchased care versus direct care included diagnosing facility type (hospital with a neurosurgery or spine specialty versus clinic (odds ratio [OR], 0.12 (95% CI, 0.10-0.15)), Navy versus Army (OR, 0.24 (95% CI, 0.21-0.28)), and diagnosing facility specialty (Medical Expense and Performance Reporting System) (surgical care (OR, 0.33 (95% CI, 0.27-0.40)) and orthopedic care (OR, 0.39 (95% CI, 0.33-0.46)) versus primary care. The presence of comorbidities was associated with higher probability of surgery in purchased care versus direct care (OR, 1.20 (95% CI, 1.06-1.36)). The 1-year rate of surgery for LDH was modestly higher in beneficiaries who were diagnosed in purchased care versus direct care. Among patients who were diagnosed in direct care, several patient-level and facility-level characteristics were associated with receiving surgery in purchased care, suggesting potentially unexpected variation in care utilization across components of the MHS.