Symptomatic Lumbar Disc Herniation Research Articles

Tandem Disc Herniation of the Lumbar and Cervical Spine: Case Series and Review of the Epidemiological, Pathophysiological and Genetic Literature.

IntroductionLumbar disc herniation (LDH) and cervical disc herniation (CDH) represent a relevant public health problem. Patients with symptomatic tandem herniations of the cervical and lumbar spine are rare and not described in the literature. In these patients, certain variables may predispose the development of disc herniation which could increase the understanding of the development of disc herniations. Our aim is to present the first case series of tandem disc herniation, and to elucidate whether tandem herniation is attributable to a certain propensity for disc herniation or not.Methods From a prospective registry, patients with symptomatic tandem disc herniations were included, and the literature was reviewed on the comparative pathophysiology, genetics, and epidemiology of disc herniation and disc degeneration.ResultsOut of 3,156 patients with disc herniations in our registry, 16 presented with symptomatic tandem LDH and CDH that required discectomy. Therefore, we estimate the incidence of tandem disc herniation at 0.51% (95% confidence interval (CI): 0.26% - 0.75%) in the surgical population. The mean number of degenerated lumbar discs was 2.1 ± 1.1. Compared to the 1,241 patients with isolated LDH, no investigated factors were significantly associated with tandem herniations.ConclusionFrom a genetic, pathophysiological, and epidemiological position, disc herniation is not commonly a consequence of disc degeneration. Rather, degeneration and herniation seem to exist as two separate and distinctly different processes. Based on the literature, it is tenable that tandem disc herniation does not deviate from the normal pathophysiology, but rather occurs in the rare case that two individual herniated discs coincide.

Letter to the Editor Regarding “Percutaneous Endoscopic Lumbar Discectomy Versus Posterior Open Lumbar Microdiscectomy for the Treatment of Symptomatic Lumbar Disc Herniation: A Systemic Review and Meta-Analysis”: A Critical Appraisal

Letter to the Editor Regarding “Percutaneous Endoscopic Lumbar Discectomy Versus Posterior Open Lumbar Microdiscectomy for the Treatment of Symptomatic Lumbar Disc Herniation: A Systemic Review and Meta-Analysis”: A Critical Appraisal

In Reply to the Letter to the Editor Regarding “Percutaneous Endoscopic Lumbar Diskectomy versus Posterior Open Lumbar Microdiskectomy for Treatment of Symptomatic Lumbar Disk Herniation: Systemic Review and Meta-analysis”

In Reply to the Letter to the Editor Regarding “Percutaneous Endoscopic Lumbar Diskectomy versus Posterior Open Lumbar Microdiskectomy for Treatment of Symptomatic Lumbar Disk Herniation: Systemic Review and Meta-analysis”

Minimally invasive discectomy for lumbar disc herniation: current concepts, surgical techniques, and outcomes.

To date, various minimally invasive surgeries for lumbar disc herniation (LDH) have been performed in many countries, including microendoscopic discectomy (MED) and percutaneous endoscopic discectomy (PED). We herein report the surgical indications, current concepts, and techniques of minimally invasive discectomy for LDH, including MED and PED. The postoperative outcomes and risks of complications compared with conventional discectomy are also discussed. By reviewing past literatures, the current concepts, surgical techniques, and clinical outcomes were described. Minimally invasive discectomy is generally performed using a transmuscular approach with an endoscopic technique and can reduce muscle and soft tissue damage. The minimal invasiveness can also reduce the severity of postoperative pain and improve patient satisfaction compared with conventional open discectomy. Based on the data of previous systematic reviews and meta-analyses, minimally invasive lumbar discectomy, such as MED and PED, appears to be safe and effective alternatives to open discectomy for patients with symptomatic LDH. These minimally invasive surgeries can provide beneficial effects to shorten the hospital stay and time to return to work. However, minimally invasive discectomy has a demanding learning curve. Only a well-trained surgeon and support team should perform these less invasive procedures. Clinical evidence supporting the superiority of MED and PED is still limited. Well-designed prospective multicentered randomized controlled trials with large samples are therefore needed in order to draw a convincing conclusion.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation

BackgroundPercutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital.MethodsPTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm.ConclusionPTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Effectiveness of surgery for sciatica with disc herniation is not substantially affected by differences in surgical incidences among three countries: results from the Danish, Swedish and Norwegian spine registries

PurposeYearly incidence of surgery for symptomatic lumbar disc herniation varies and is 29/100,000 in Sweden, 46/100,000 in Denmark and 58/100,000 in Norway. This variation was used to study whether differences in surgical incidence were associated with differences in preoperative patient characteristics as well as patient-reported outcomes.MethodsData from the national spine registers in Sweden, Denmark and Norway during 2011–2013 were pooled, and 9965 individuals, aged 18–65 years, of which 6468 had one-year follow-up data, were included in the study. Both absolute and case-mix-adjusted comparisons of the primary outcome Oswestry Disability Index (ODI) and the secondary outcomes EQ-5D-3L, and Numerical Rating Scale (NRS) for leg and back pain were performed. Case-mix adjustment was done for baseline age, sex, BMI, smoking, co-morbidity, duration of leg pain and preoperative value of the dependent variable.ResultsMean improvement in the outcome variables exceeded previously described minimal clinical important change in all countries. Mean (95% CI) final scores of ODI were 18 (17–18), 19 (18–20) and 15 (15–16) in Sweden, Denmark and Norway, respectively. Corresponding results of EQ-5D-3L were 0.74 (0.73–0.75), 0.73 (0.72–0.75) and 0.75 (0.74–0.76). Results of NRS leg and back pain behaved similarly. Case-mix adjustment did not alter the findings substantially.ConclusionWe found no clear association between incidence of surgery for lumbar disc herniation and preoperative patient characteristics as well as outcome, and the differences between the countries were lower than the minimal clinical important difference in all outcomes.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Differences in the Incidence of Symptomatic Cervical and Lumbar Disc Herniation According to Age, Sex and National Health Insurance Eligibility: A Pilot Study on the Disease's Association with Work.

The aim of this research was to identify the differences in the incidence of symptomatic cervical and lumbar disc herniation according to age, sex, and national health insurance eligibility. We evaluated the hospital documents of patients who received medical treatment for symptomatic cervical and lumbar disc herniation between 2004 and 2010 and excluded those who claimed to have expenses at oriental medical clinics or pharmacies. Furthermore, any duplicate documents from the labor force population aged 20–69 years were excluded from the analysis. The results showed that the number of individuals diagnosed with symptomatic cervical and lumbar disc herniation increased with age, and the incidence of these diseases was higher in women than in men. Additionally, the incidence differed depending on the subject’s qualification for health insurance. The incidence of lumbar disc herniation showed differences depending on the degree of the lumbar burden. The present study findings may help determine whether lumbar disc herniation is associated with tasks performed at the patient’s workplace. Further research is needed to classify the risk of lumbar disk herniation in the workplace into detailed categories such as types of business, types of occupation, and lumbar compression force.

A common polymorphism of COMT was associated with symptomatic lumbar disc herniation based on a large sample with Chinese Han ancestry

Lumbar disc herniation (LDH) is a common spine disease characterized by a tear in the disc ring and bulges out at the soft portion. COMT is a protein coding gene located at 22q11.21, and its gene product is a major mammalian enzyme involved in the degradation of catecholamines. A total of 2,678 study subjects with Chinese Han ancestry were recruited and 15 SNPs were selected for genotyping in our study subjects. A synonymous coding SNP, rs4633, was identified to be significantly associated with the disease status of LDH after adjusting for BMI (OR = 0.76, P = 4.83 × 10−5). This SNP was also identified to be significantly associated with COMT gene expression in three types of human tissues. Minor alleles of rs4633 (T) increased the expression of COMT in these 3 tissues. We have identified a significant SNP of COMT, rs4633, which is associated with symptomatic LDH in a large Chinese Han-based sample of the study subjects. This significant finding is further replicated by haplotypic analysis. Evidence from bioinformatics analyses have shown that rs4633 is also significantly associated with the gene expression of COMT. Our findings provide additional supportive evidence for an important role of COMT gene in the symptomatic LDH susceptibility.

Endoscopic lumbar discectomy and minimally invasive lumbar interbody fusion: a contrastive review.

Both percutaneous endoscopic lumbar discectomy (PELD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) have been demonstrated as two common and effective choices for lumbar disc herniation (LDH) minimally invasive surgery. In order to get a better understanding of these two procedures, we made this contrastive review. By looking up recent literature and combining it with our clinical practice, the indications/contraindications, advantages/disadvantages as well as complications/recurrences of PELD and MIS-TLIF were summarized in this review. It was concluded that PELD and MIS-TLIF are safe and effective minimally invasive operative techniques for symptomatic LDH treatment. A better understanding of these two procedures will help to improve clinical outcomes by selecting proper indications, and also benefit the further development of minimally invasive spine surgery.

Patients at the Highest Risk for Reherniation Following Lumbar Discectomy in a Multicenter Randomized Controlled Trial.

Background:The purposes of the present study were to (1) confirm the risk of recurrent lumbar disc herniation in patients with a large anular defect who had undergone limited discectomy and (2) assess potential risk factors within this population.Methods:The patient population was extracted from the control cohort of a prospective, randomized, multicenter controlled trial investigating the efficacy of an anular closure device following standard limited discectomy. All control patients underwent limited discectomy for the treatment of a single-level symptomatic posterior or posterolateral lumbar disc herniation. Only patients presenting with a large anular defect (6 to 10 mm wide by 4 to 6 mm long) were included in the study (n = 278). Baseline demographic, clinical, and surgical characteristics were recorded. Follow-up evaluations were performed at 6 weeks and at 3, 6, 12, and 24 months. Imaging modalities included magnetic resonance imaging, low-dose computed tomography, and radiographs. Symptomatic recurrent lumbar disc herniation was defined as any symptomatic postoperative herniation on either side of the index level. A multivariate logistic regression analysis of demographic and surgical variables associated with the incidence of recurrent lumbar disc herniation was performed.Results:The mean anular defect area (and standard deviation) was 39.3 ± 9.1 mm2, and the mean excised nuclear tissue volume was 1.3 ± 0.8 mL. At 2 years, the incidence of symptomatic recurrent lumbar disc herniation was 25.3% (64 of 253), with the herniation occurring at a mean of 264 days after the index procedure. Of the 64 patients with recurrent lumbar disc herniation, 36 underwent a subsequent surgical procedure. Logistic regression analysis identified an increased risk for recurrent lumbar disc herniation in females (odds ratio, 2.2) and in patients with greater anular defect widths (odds ratio, 1.3). Furthermore, multivariate logistic regression analyses revealed a significant interaction between age and sex (p = 0.005).Conclusions:The outcomes of the present study provide the most substantial evidence to date in confirming previous reports of a high risk of reherniation among patients with large anular defects. Among those with large anular defects (width, ≥6 mm), females ≤50 years of age had the highest risk (up to ∼10 times higher) of recurrent lumbar disc herniation. It is recommended that an anular repair or closure should be performed after limited discectomies in patients with large anular defects.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of an annular closure device in a “real-world” population: stratification of registry data using screening criteria from a randomized controlled trial

PurposeIncreased focus has been put on the use of “‘real-world” data to support randomized clinical trial (RCT) evidence for clinical decision-making. The objective of this study was to assess the performance of an annular closure device (ACD) after stratifying a consecutive series of “real-world” patients by the screening criteria of an ongoing RCT.Materials and methodsThis was a single-center registry analysis of 164 subjects who underwent limited discectomy combined with ACD for symptomatic lumbar disc herniation. Patients were stratified into two groups using the selection criteria of a pivotal RCT on the same device: Trial (met inclusion; n=44) or non-Trial (did not meet inclusion; n=120). Patient-reported outcomes, including Oswestry Disability Index (ODI) and visual analog scale (VAS) for leg and back pain, and adverse events were collected from baseline to last follow-up (mean: Trial – 15.6 months; non-Trial – 14.6 months). Statistical analyses were performed with significance set at p<0.05.ResultsPatient-reported outcomes were not significantly different between groups at last (p≥0.15) and clinical success (≥15-point improvement in ODI score; ≥20-point improvement in VAS scores) was achieved in both the groups. Three non-Trial (2.5%) and three Trial (6.8%) patients experienced symptomatic reherniation (p=0.34). Rates of reoperation, ACD mesh dislocation/separation, and other radiographic findings were similar between groups (p=1.00).ConclusionOutcomes with the ACD appeared advantageous in both the groups, particularly in comparison with historical reherniation rates reported in the same high-risk, large annular defect population. Stratification of this “real-world” series on the basis of RCT screening criteria did not result in significant between-group differences. These findings suggest that the efficacy of the ACD extends beyond the strictly defined patient population being studied in the RCT of this device. Furthermore, reducing the reherniation rate following lumbar discectomy has positive clinical and economic implications.

Is Minimally Invasive Tubular Discectomy Better than Conventional Open Microdiscectomy for the Treatment of Symptomatic Lumbar Disk Herniation?

Is Minimally Invasive Tubular Discectomy Better than Conventional Open Microdiscectomy for the Treatment of Symptomatic Lumbar Disk Herniation?

To study the effect of Triamcinolone injection for low back pain due to lumbar disc herniation

Introduction: Low back pain is one of the most common complaints in the general population which represents a significant public health problem. Epidural Steroid Injection is being considered as a simple, effective and minimally invasive treatment modality for lumbar disc herniation. However, most studies only find a short-term benefit. In Bhutan, till date, no study has been done in Bhutan on this subject. The objective of our study was to find the effect of epidural steroid injection for low back pain due to lumbar disc herniation.&#x0D; Methods: An observational one-year-period study completed in Jigme Dorji Wangchuck National Referral Hospital. Symptomatic and positive Magnetic Resonance Imaging patients with lumbar disc herniation were included in our study. Pain scores were collected using Numeric Rating Scale at three different points of study. We also included patients’ age, weight and trauma history as some of the independent variables to study their associations with pain scores. The data obtained were analyzed using the Stata software program. One way repeated measures ANOVA was used to assess the significant difference in pain score.&#x0D; Results: Out of 100 participants recruited for the study, 91 of them completed demographic data and only 81 patients completed follow-up till 4 weeks post-treatment for demographic analysis and analytical analysis, respectively. There was a significant difference in pain scores in all three different points of study (p &lt;0.01). No significant difference was observed in the pain scores amongst different age groups, gender, occupation and trauma history (p &gt;0.05) at all three points of study.&#x0D; Conclusion: Our study observed a significant short-term benefit from epidural Triamcinolone injection for symptomatic lumbar disc herniation.

A Novel Targeted Foraminoplasty Device Improves the Efficacy and Safety of Foraminoplasty in Percutaneous Endoscopic Lumbar Discectomy: Preliminary Clinical Application of 70 Cases

Percutaneous endoscopic lumbar discectomy (PELD) has become a mature and mainstream surgical technique for treating lumbar disc herniation (LDH); however, there is a steep learning curve with PELD, especially for puncture and foraminoplasty. In this study, we assessed the outcome and safety of a novel quantificational and targeted foraminoplasty device named ZESSYS for LDH. From September to December of 2016, 70 patients with symptomatic LDH were enrolled in the study. The patients were assigned randomly to either the ZESSYS group or the conventional TESSYS group. We recorded the cannula introduction time, decompression time, radiation exposure time, intraoperative pain feeling score, visual analog scale, Oswestry Disability Index, and Macnab criteria score of the 2 groups. The mean follow-up period was 14 months. The average cannula introduction time (16.50 ± 3.29 minutes) and the radiation exposure time (40.71 ± 6.23 seconds) in the ZESSYS group were significantly reduced compared with the TESSYS group (cannula introduction time, 20.06 ± 3.37 minutes, P= 0.000; radiation exposure time, 49.20 ± 7.84 seconds, P= 0.000). Intraoperative pain feeling score in the ZESSYS group was significantly improved compared with the TESSYS group (P= 0.021). There were no significant differences between the 2 groups for decompression time (P= 0.617), Macnab criteria (P= 0.769), or visual analog scale and Oswestry Disability Index scores at the same time point (P > 0.05). No serious complication was observed in any patients in either group. The novel targeted foraminoplasty technique with the specially designed double-cannulas is an effective and safe treatment for lumbar intervertebral disc herniation. It reduces the difficulty of PELD learning, minimizes radiation exposure, and decreases intraoperative pain associated with foraminoplasty.

PTED study: design of a non-inferiority, randomised controlled trial to compare the effectiveness and cost-effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) versus open microdiscectomy for patients with a symptomatic lumbar disc herniation

IntroductionLumbosacral radicular syndrome is often caused by a disc herniation. The standard surgical technique to remove a disc herniation is open microdiscectomy. An alternative technique is percutaneous transforaminal endoscopic discectomy...

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

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

Effect of bone mineral density on lumbar discs in young adults: A case-control study.

Bone mineral density (BMD) might be a risk factor for lumbar disc herniation (LDH) in young adults, but there is not enough data concerning this effect. Several studies have been performed on elderly and osteoporotic patients. Thus, we aimed to investigate the effect of BMD on the etiopathogenesis of LDH in young adults.One hundred patients (mean age: 38.45 ± 8.92 years; 50 men and 50 women) were enrolled this case–control study and classified into 2 groups, as follows. The case group (G-I) included 50 patients with symptomatic LDH who were hospitalized in the Physical Medicine and Rehabilitation Clinic, and the control group (G-II) included 50 patients with lower back pain but no finding of LDH detected using magnetic resonance imaging. Patients in the G-II were recruited among those admitted to the outpatient clinic at the time of the study, and whose age and sex were matched to those of the study group. Women in menopause were excluded from the study. BMD analysis by dual energy x-ray absorptiometry was performed in both groups.The mean values of the femur neck and lumbar spine BMD were 1.02 ± 0.13 and 1.19 ± 0.14 g/cm2, respectively. There was no statistically significant relationship between BMD and LDH in this population.This result may mean that in a normal range, BMD does not exert a compressive load on the lumbar discs in young adults and therefore may not lead to LDH by this mechanism and the load.

The Value of Short-Term Pain Relief in Predicting the Long-Term Outcome of Lumbar Transforaminal Epidural Steroid Injections.

A previous report demonstrated predictive power of short-term leg pain relief after lumbar transforaminal epidural steroid injections for 1-month treatment response. The question whether the long-term response could be similarly predicted remained unanswered. A prospective cohort of 57 patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation was followed for 24 months. Leg and back pain on the visual analog scale, health-related quality of life using the 12-Item Short Form Survey, and functional outcome using the Oswestry Disability Index were assessed. Responders were defined as not receiving any additional invasive treatment after a single injection. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders). At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders. Nonresponders left follow-up at 1 month (n= 9), 3 months (n= 9), 6 months (n= 6) and 12 months (n= 2). No patients were injected again or operated on between the 12- and 24-month follow-up. Responders at 24 months had significantly lower visual analog scale leg pain (P < 0.05) than nonresponders starting from the second week after TFESI and better 12-Item Short Form Survey scores and less disability on the Oswestry Disability Index. Most patients with a symptomatic lumbar disc herniation who opt for a second injection or surgery do so within the first 6 months. Reliable prediction of the long-term treatment response based on short-term pain relief is not possible.

Stand-alone Lateral Recess Decompression Without Discectomy in Patients Presenting With Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study.

A prospective study. The aim of this study was to analyze the outcomes of stand-alone lateral recess decompression without discectomy in patients with claudicant radicular pain and magnetic resonance imaging (MRI) showing LRS (lateral recess stenosis) with lumbar disc herniation. Discectomy is the gold standard treatment for symptomatic lumbar disc herniations refractory to conservative care. Typically, patients with positive SLR (Straight leg raising test) and flexion dominant leg pain are the ideal candidates who can be benefited from discectomy. There is a subset of patients with morphological features of lumbar disc herniation with LRS on MRI and presenting with diametrically opposite symptoms such as claudicant leg pain, extension dominant leg pain, relief on flexion, and a negative SLR. Until now, no focused prospective study in the literature highlights stand-alone lateral recess decompression in this group of patients. From January 2007 to June 2013, 55 patients having unilateral claudicant radicular pain were selected to undergo stand-alone lateral recess decompression with tubular retractors. Intraoperatively, disc consistency and presence of sequestrated fragments were analyzed. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) score, and Macnab criteria were used to measure outcomes. Out of 55 patients, stand-alone lateral recess decompression was successfully executed in 51 patients and remaining four patients had sequestrated discs that required removal. Mean age at presentation was 54.5 years (41-67 years), male:female ratio was 1.12:1, and mean follow-up was 3.8 years (3-5.8 years). Significant improvement (P < 0.0001) was noticed between preoperative and postoperative VAS score (8.39 ± 0.84 vs. 2.5 ± 0.48) and ODI score (46.79 ± 1.85 vs. 18.71 ± 2.41). As per Macnab criteria, 94% patients were satisfied with surgery. Stand-alone lateral recess decompression without discectomy is clinically effective for a large majority of patients with claudicant radicular pain and MRI evidence of LRS with associated lumbar disc herniation. The ability to perform it with minimal invasive techniques makes it focused and targeted with minimal morbidity. 4.

Tubular discectomy versus conventional microdiscectomy for the treatment of lumbar disc herniation: long-term results of a randomised controlled trial

BackgroundThe reference surgical procedure for the treatment of lumbar disc herniation is open microdiscectomy. Minimal invasive discectomy with tubular retractors is hypothesised to cause less tissue damage and result in...