Various modalities of treatment from standard discectomy, microdiscectomy, percutaneous discectomy, and transforaminal endoscopic discectomy have been in use for lumbar intervertebral disc prolapse. The access to spine is kept to a minimum without stripping paraspinal muscles minimizing muscle damage by posterior interlaminar endoscopic approach. The aim of this study was to evaluate technical problems, complications, and overall initial results of microendoscopic discectomy.
Materials and Methods:
First 100 consecutive cases aged 19-65 years operated by microendoscopic dissectomy between August 2002 – December 2005 are reported. All patients with single nerve root lesions including sequestrated or migrated and selected central disc at L4-5 and L5-S1 were included. The patients with bilateral radiculopathy were excluded. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases to isolate the single root lesion when MRI was inconclusive (n=7). All patients were operated by a single surgeon with the Metrx system (Medtronics). 97 were operated by 18-mm ports, and only three patients were operated by 16-mm ports. Postoperatively, all patients were mobilized as soon as the pain subsided and discharged within 24–48 h postsurgery. Patients were evaluated for technical problems, complications, and overall results by modified Macnab criteria. Patients were followed up at 2, 6, and 12 weeks.
The mean follow up was 12 months (range 3 months – 4 years). Open conversion was required in one patient with suspected root damage. Peroperatively single facet removal was done in 5 initial cases. Minor dural punctures occurred in seven cases and root damage in one case. The average surgical time was 70 min (range 25-210 min). Average blood loss was 20-30 ml. Technical difficulties encountered in initial 25 cases were insertion of guide pin, image orientation, peroperative dissection and bleeding problems, and reaching wrong levels suggestive of a definitive learning curve. Postoperative MRI (n=11) showed complete decompression. Overall 91% of patients had good-to-excellent results, with four patients having recurrence of whom three were reoperated. Four patients had postoperative discitis. One of the patients required fusion for discitis and rest were managed conservatively. One patient had root damage to L5 root that had paresthesia in L5 region even on 4 years of follow-up.
Microendoscopic discectomy is minimally invasive procedure for discectomy with early encouraging results. Once definite learning curve was over and expertise is acquired, the results of this procedure are acceptable safe and effective.
Lumbar discectomy; microendo system; endoscopic lumbar discectomy
Background and Objectives
Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs.
Eighty-six consecutive patients undergoing lumbar transforaminal ESI at the L3-L4, L4-L5, and L5-S1 levels were studied. Using standard protocol, the foraminal epidural space was attained using fluoroscopic guidance. The measured distance from needle tip to skin was recorded (depth to foraminal epidural space). The differences in the needle depth and BMI were analyzed using regression analysis.
Needle depth was positively associated with BMI (regression coefficient [RC], 1.13; P < 0.001). The median depths (in centimeters) to the epidural space were 6.3, 7.5, 8.4, 10.0, 10.4, and 12.2 for underweight, normal, preobese, obese I, obese II, and obese III classifications, respectively. Sex (RC, 1.3; P = 0.02) and race (RC, 0.8; P = 0.04) were also significantly associated with needle depth; however, neither factor remained significant when BMI was accounted as a covariate in the regression model. Age, intervertebral level treated, and oblique angle had no predictive value on foraminal depth (P > 0.2).
There is a positive association between BMI and transforaminal epidural depth, but not with age, sex, race, oblique angle, or intervertebral level.
A cadaveric study was performed to investigate the relationship between disc degeneration and morphological changes in the intervertebral foramen of cervical spine, including the effect on the nerve root. Seven fresh frozen human cadavers were dissected from C1 to T1, preserving the ligaments, capsules, intervertebral disc and the neural structures. The specimens were scanned with MRI and then scanned through CT scan in the upright position. Direct mid-sagittal and 45 degree oblique images were obtained to measure the dimension of the intervertebral disc height, foraminal height, width, area and segmental angles. Disc degeneration was inversely correlated with disc height. There was a significant correlation between disc degeneration and foraminal width (p<0.005) and foraminal area (p<0.05), but not with foraminal height. Disc height was correlated with foraminal width but not with height. The segmental angles were decreased more in advanced degenerated discs. There was a correlation between nerve root compression and decreased foraminal width and area (p<0.005). This information and critical dimensions of the intervertebral foramen for nerve root compression should help in the diagnosis of foraminal stenosis of the cervical spine in patients presenting with cervical spondylosis and radiculopathy.
Cervical Vertebrae; Intervertebral Disk; Magnetic Resonance Imaging; Tomography, X-Ray Computed
Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.
Lumbar disc herniation; Discectomy; Microdiscectomy; Micro-endoscopic discectomy
In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.
Diskectomy; Percutaneous; Intervertebral disc disease; Endoscope
Endoscopic discectomy method is a novel technique that is increasingly used in spine surgery. Previous studies have reported that some common complications like dural adhesions are lower in this technique compared with the other techniques. Furthermore, treatment outcomes are reportedly higher because of minimal invasion. Thepresent study aims to determine the outcome of percutaneous endoscopic discectomy.
A total of 130 patients underwent the lumbar disc prolapse operations during 2008 to 2012 in all of them the entire procedure was performed endoscopically. All procedures were carried out from a posterior approach using a 4-mm Hopkins 0 degrees-telescope placed in the working insert equipped with channels for suction tube, operative instruments and nerve root retractor (ENDOSPINE instrumentation (Karl STORZ GmbH and Co. KG). The pre- and post-operation pain was assessed using a Visual Analog Scale (VAS). Furthermore, the treatment outcome was assessed using modified MacNab criteria before operation, 24 hours, one month, 2 months, 6 months, one year, and two years after operation .
Good to excellent outcome was achieved in 89% of patients, which is comparable with the results of classic microdiscectomy. The mean age of patients was 35.6 years old and the mean length of follow-up was 3.4 years. There was significant reduction in the severity of back pain and lower limb symptoms at 6 months and 2 years post-operation. There was significant improvement in all aspects of the Quality of Life scores at 6 months and 2 years post-operation. In 3 patients the dural sac was lacerated but none of the tears was exceed a few mm in length with not association with neural injury.
Findings of this study showed that percutaneous endoscopic lumbar discectomy is associated with improvement in back pain and lower limb symptoms. It has the advantage that it can be performed on a day case basis with short length of hospitalization and early return to work thus improving quality of life earlier.
Endoscopic discectomy, Spine surgery, Lumbar disc prolapse operation, Outcome
Percutaneous endoscopic lumbar discectomy (PELD) for migrated disc herniations is technically demanding due to the absence of the technical guideline. The purposes of this study were to propose a radiologic classification of disc migration and surgical approaches of PELD according to the classification. A prospective study of 116 consecutive patients undergoing single-level PELD was conducted. According to preoperative MRI findings, disc migration was classified into four zones based on the direction and distance from the disc space: zone 1 (far up), zone 2 (near up), zone 3 (near down), zone 4 (far down). Two surgical approaches were used according to this classification. Near-migrated discs were treated with “half-and-half” technique, which involved positioning a beveled working sheath across the disc space to the epidural space. Far-migrated discs were treated with “epiduroscopic” technique, which involved introducing the endoscope into the epidural space completely. The mean follow-up period was 14.5 (range 9–20) months. According to the Macnab criteria, satisfactory results were as follows: 91.6% (98/107) in the down-migrated discs; 88.9% (8/9) in the up-migrated discs; 97.4% (76/78) in the near-migrated discs; and 78.9% (30/38) in the far-migrated discs. The mean VAS score decreased from 7.5 ± 1.7 preoperatively to 2.6 ± 1.8 at the final follow-up (P < 0.0001). There were no recurrence and no approach-related complications during the follow-up period. The proposed classification and approaches will provide appropriate surgical guideline of PELD for migrated disc herniation. Based on our results, open surgery should be considered for far-migrated disc herniations.
Percutaneous endoscopic lumbar discectomy; Migrated disc herniation; Radiologic classification
The purpose of this study was to evaluate the efficacy of a transforaminal suprapedicular approach, semi-rigid flexible curved probe, and 3-dimensional reconstruction computed tomography (3D-CT) with discogram in the endoscopic treatment of non-contained lumbar disc herniations.
The subjects were 153 patients with difficult, non-contained lumbar disc herniations undergoing endoscopic treatment. The types of herniation were as follows : extraforaminal, 17 patients; foraminal, 21 patients; high grade migration, 59 patients; and high canal compromise, 56 patients. To overcome the difficulties in endoscopic treatment, the anatomic structures were analyzed by 3D reconstruction CT and the high grade disc was extracted using a semi-rigid flexible curved probe and a transforaminal suprapedicular approach.
The mean follow-up was 18.3 months. The mean visual analogue scale (VAS) of the patients prior to surgery was 9.48, and the mean postoperative VAS was 1.63. According to Macnab's criteria, 145 patients had excellent and good results, and thus satisfactory results were obtained in 94.77% cases.
In a posterolateral endoscopic lumbar discectomy, the difficult, non-contained disc is considered to be the most important factor impeding the success of surgery. By applying a semi-rigid flexible curved probe and using a transforaminal suprapedicular approach, good surgical results can be obtained, even in high grade, non-contained disc herniations.
Intervertebral disc herniation; Percutaneous discectomy; Posterolateal approach
This is a retrospective study that was done according to clinical and radiological evaluation.
We analyzed the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody single level fusion.
Overview of Literature
Minimally invasive transforaminal lumbar interbody fusion is effective surgical method for treating degenerative lumbar disease.
The study was conducted on 56 patients who were available for longer than 2 years (range, 24 to 45 months) follow-up after undergoing minimally invasive transforminal lumbar interbody single level fusion. Clinical evaluation was performed by the analysis of the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) and the Kirkaldy-Willis score. For the radiological evaluation, the disc space height, the segmental lumbar lordotic angle and the whole lumbar lordotic angle were analyzed. At the final follow-up after operation, the fusion rate was analyzed according to Bridwell's anterior fusion grade.
For the evaluation of clinical outcomes, the VAS score was reduced from an average of 6.7 prior to surgery to an average of 1.8 at the final follow-up. The ODI was decreased from an average of 36.5 prior to surgery to an average of 12.8 at the final follow-up. In regard to the clinical outcomes evaluated by the Kirkaldy-Willis score, better than good results were obtained in 52 cases (92.9%). For the radiological evaluation, the disc space height (p = 0.002), and the whole lumbar lordotic angle (p = 0.001) were increased at the final follow-up. At the final follow-up, regarding the interbody fusion, radiological union was obtained in 54 cases (95.4%).
We think that if surgeons become familiar with the surgical techniques, this is a useful method for minimally invasive spinal surgery.
Minimally invasive; Transformainal; Lumbar interbody; Single level fusion
The purpose of this study was to evaluate the outcome of endoscopic decompression surgery for intraforaminal and extraforaminal nerve root compression in the lumbar spine.
The records from seventeen consecutive patients treated with endoscopic posterior decompression without fusion for intaforaminal and extraforaminal nerve root compression in the lumbar spine (7 males and 10 females, mean age: 67.9 ± 10.7 years) were retrospectively reviewed. The surgical procedures consisted of lateral or translaminal decompression with or without discectomy. The following items were investigated: 1) the preoperative clinical findings; 2) the radiologic findings including MRI and computed tomography-discography; and 3) the surgical outcome as evaluated using the Japanese Orthopaedic Association scale for lower back pain (JOA score).
All patients had neurological findings compatible with a radiculopathy, such as muscle weakness and sensory disturbance. MRI demonstrated the obliteration of the normal increased signal intensity fat in the intervertebral foramen. Ten patients out of 14 who underwent computed tomography-discography exhibited disc protrusion or herniation. Selective nerve root block was effective in all patients. During surgery, 12 patients were found to have a protruded disc or herniation that compressed the nerve root. Sixteen patients reported pain relief immediately after surgery.
Intraforaminal and extraforaminal nerve root compression is a rare but distinct pathological condition causing severe radiculopathy. Endoscopic decompression surgery is considered to be an appropriate and less invasive surgical option.
Percutaneous endoscopic lumbar discectomy is a relatively new technique. Very few studies have reported the clinical outcome of percutaneous endoscopic discectomy in terms of quality of life and return to work.
55 patients with percutaneous endoscopic lumbar discectomy done from 2002 to 2006 had their clinical outcomes reviewed in terms of the North American Spine Score (NASS), Medical Outcomes Study Short Form-36 scores (SF-36) and Pain Visual Analogue Scale (VAS) and return to work.
The mean age was 35.6 years, the mean operative time was 55.8 minutes and the mean length of follow-up was 3.4 years. The mean hospital stay for endoscopic discectomy was 17.3 hours. There was significant reduction in the severity of back pain and lower limb symptoms (NASS and VAS, p < 0.05) at 6 months and 2 years. There was significant improvement in all aspects of the Quality of Life (SF-36, p < 0.05) scores except for general health at 6 months and 2 years postoperation. The recurrence rate was 5% (3 patients). 5% (3 patients) subsequently underwent lumbar fusion for persistent back pain. All patients returned to their previous occupation after surgery at a mean time of 24.3 days.
Percutaneous endoscopic lumbar discectomy is associated with improvement in back pain and lower limb symptoms postoperation which translates to improvement in quality of life. It has the advantage that it can be performed on a day case basis with short length of hospitalization and early return to work thus improving quality of life earlier.
Diffusion-weighted imaging (DWI) can provide valuable structural information about tissues that may be useful for clinical applications in evaluating lumbar foraminal nerve root entrapment. Our purpose was to visualize the lumbar nerve root and to analyze its morphology, and to measure its apparent diffusion coefficient (ADC) in healthy volunteers and patients with lumbar foraminal stenosis using 1.5-T magnetic resonance imaging. Fourteen patients with lumbar foraminal stenosis and 14 healthy volunteers were studied. Regions of interest were placed at the fourth and fifth lumbar root at dorsal root ganglia and distal spinal nerves (at L4 and L5) and the first sacral root and distal spinal nerve (S1) on DWI to quantify mean ADC values. The anatomic parameters of the spinal nerve roots can also be determined by neurography. In patients, mean ADC values were significantly higher in entrapped roots and distal spinal nerve than in intact ones. Neurography also showed abnormalities such as nerve indentation, swelling and running transversely in their course through the foramen. In all patients, leg pain was ameliorated after selective decompression (n = 9) or nerve block (n = 5). We demonstrated the first use of DWI and neurography of human lumbar nerves to visualize and quantitatively evaluate lumbar nerve entrapment with foraminal stenosis. We believe that DWI is a potential tool for diagnosis of lumbar nerve entrapment.
Diffusion-weighted imaging; Apparent diffusion coefficient; Lumbar foraminal stenosis; Magnetic resonance (MR) imaging; Neurography
Open discectomy remains the standard method for treatment of lumbar disc herniation, but can traumatize spinal structure and leaves symptomatic epidural scarring in more than 10% of cases. The usual transforaminal approach may be associated with difficulty reaching the epidural space due to anatomical peculiarities at the L5–S1 level. The endoscopic interlaminar approach can provide a direct pathway for decompression of disc herniation at the L5–S1 level. This study aimed to evaluate the clinical results of endoscopic interlaminar lumbar discectomy at the L5–S1 level and compare the technique feasibility, safety, and efficacy under local and general anesthesia (LA and GA, respectively).
One hundred twenty-three patients with L5–S1 disc herniation underwent endoscopic interlaminar lumbar discectomy from October 2006 to June 2009 by two spine surgeons using different anesthesia preferences in two medical centers. Visual analog scale (VAS) scores for back pain and leg pain and Oswestry Disability Index (ODI) sores were recorded preoperatively, and at 3, 6, and 12 months postoperatively. Results were compared to evaluate the technique feasibility, safety, and efficacy under LA and GA.
VAS scores for back pain and leg pain and ODI revealed statistically significant improvement when they were compared with preoperative values. Mean hospital stay was statistically shorter in the LA group. Complications included one case of dural tear with rootlet injury and three cases of recurrence within 1 month who subsequently required open surgery or endoscopic interlaminar lumbar discectomy. There were no medical or infectious complications in either group.
Disc herniation at the L5–S1 level can be adequately treated endoscopically with an interlaminar approach. GA and LA are both effective for this procedure. However, LA is better than GA in our opinion.
General anesthesia; interlaminar approach; local anesthesia; lumbar disc herniation; percutaneous endoscopic discectomy
The study is a prospective blinded randomised controlled trial to compare the efficacy of triamcinolone acetonide, bupivacaine or in combination in managing pain after lumbar discectomy. Patients undergoing primary single-level lumbar discectomy were randomised. Triamcinolone acetonide, bupivacaine or in combination was instilled at the nerve root as decompression. Preoperative, day 1 and 6 weeks pain score, 24-h postoperative opiate requirements and duration of inpatient stay were recorded. Data was analysed using Mann–Whitney test for statistical significance. 100 patients were recruited. A significant difference was noted in day one postoperative mean pain score, mean 24-h opiate requirement and mean inpatient stay in the triamcinolone acetonide and bupivacaine group. At 8 weeks postoperatively, no significant differences were seen in the pain score in all groups. Significant postoperative pain reduction and opiate requirements in the first 24 h, and significantly shortened duration of inpatient stay were achieved in the triamcinolone acetonide and bupivacaine group compared with other groups.
Pain management; Discectomy; Steroid; Local anaesthesia
Cervical disc herniation often results in neck and arm pain in patients as a result of direct impingement of nerve roots and associated inflammatory processes. The clinical presentation usually corresponds with the side of herniation and ipsilateral symptoms predominate the clinical picture.
A 35-year-old Caucasian man presented to our facility with neck pain and left-sided upper and lower extremity pain. A magnetic resonance imaging scan revealed a right paramedian herniated disc at the C5 to C6 level. All other cervical levels were normal without central canal stenosis or neural foraminal stenosis. Results from magnetic reasonance imaging scans of the brain and lumbar spine were negative. An anterior cervical discectomy was performed at the C5 to C6 level, and an inter-body graft and plate were placed. Our patient had complete resolution of his neck and left arm pain.
Anterior discectomy and fusion of the cervical spine resulted in complete resolution of our patient’s neck and left arm symptoms and improvement of his contralateral left leg pain. Cervical disc herniation may present with contralateral symptoms that are different from the current perception of this disease.
Cervical; Contralateral symptoms; Disc herniation; Radiculopathy
The focus of this study was to examine the safety and effectiveness of three different discectomy techniques using a posterior approach for the treatment of herniated lumbar discs. There are only a small number of prospective randomised studies comparing posterior lumbar discectomy techniques, and no recent systematic review has been published on this matter. Using the Cochrane Collaboration guidelines, all randomised or “quasi-randomised” clinical trials, comparing classic, microsurgical, and endoscopic lumbar discectomies using a posterior approach were systematically reviewed. No statistically significant differences were found between these techniques regarding improvement in pain, sensory deficits, motor strength, reflexes, and patient satisfaction. Current data suggest that the microsurgical and endoscopic techniques are superior to the classic technique for the treatment of single level lumbar disc herniations with respect to volume of blood loss, systemic repercussions, and duration of hospital stay. All three surgical techniques were found to be effective for the treatment of single level lumbar disc herniations in patients without degenerative vertebral deformities. No conclusions could be drawn from the clinical randomised studies reviewed regarding the safety of the three techniques studied due to insufficient data on postoperative complications.
A retrospective study.
To determine the feasibility and effectiveness of revisional percutaneous full endoscopic discectomy for recurrent herniation after conventional open disc surgery.
Overview of the Literature
Repeated open discectomy with or without fusion has been the most common procedure for recurrent lumbar disc herniation. Percutaneous endoscopic lumbar discectomy for recurrent herniation has been thought of as an impossible procedure. Despite good results with open revisional surgery, major problems may be caused by injuries to the posterior stabilized structures. Our team did revisional full endoscopic lumbar disc surgery on the basis of our experience doing primary full endoscopic disc surgery.
Between February 2004 and August 2009 a total of 41 patients in our hospital underwent revisional percutaneous endoscopic lumbar discectomy using a YESS endoscopic system and a micro-osteotome (designed by the authors). Indications for surgery were recurrent disc herniation following conventional open discectomy; with compression of the nerve root revealed by Gadolinium-enhanced magnetic resonance imaging; corresponding radiating pain which was not alleviated after conservative management over 6 weeks. Patients with severe neurologic deficits and isolated back pain were excluded.
The mean follow-up period was 16 months (range, 13 to 42 months). The visual analog scale for pain in the leg and back showed significant post-treatment improvement (p < 0.001). Based on a modified version of MacNab's criteria, 90.2% showed excellent or good outcomes. There was no measurable blood loss. There were two cases of recurrence of and four cases with complications.
Percutaneous full-endoscopic revisional disc surgery without additional structural damage is feasible and effective in terms of there being less chance of fusion and bleeding. This technique can be an alternative to conventional repeated discectomy.
Endoscopic discectomy; Interlaminar discectomy; Transforaminal discectomy; Percutaneous discectomy; Recurrent disc herniation; Lumbar spine
Main problem: Previous studies have demonstrated that sciatica patients have poorer postural control than healthy controls and that postural control remains unchanged 3 months after lumbar discectomy in sciatica patients. The aims of the current study were to investigate whether static balance control recovers in pain-free discectomy patients long-term after lumbar discectomy. Next is to determine whether static balance responses of asymptomatic and symptomatic lumbar discectomy patients differed from each other and from healthy controls. In addition, the influence of the extent of disc resection (unilateral/bilateral removal) and the side of operation on static balance control were investigated. Methods: Fifteen pain-free lumbar discectomy patients, 23 lumbar discectomy patients with residual pain and 72 controls performed unilateral stance tasks with eyes open and eyes closed on a force plate were taken up for the investigation. Three repetitions of a 10 s unilateral stance test were performed on each leg. Postural sway was determined. Patients were divided into three age groups. Results: In the eyes open condition, there was no significant difference between postural sway of pain-free lumbar discectomy patients and controls (P=0.68), whereas balance of patients with pain was significantly worse than in controls (P=0.003). In the eyes closed condition, the sway in both groups of lumbar discectomy patients was significantly worse than in controls (pain-free P=0.009/painful P<0.001). No significant differences were found in postural sway between patients with unilateral and bilateral disc resection. In unilateral stance on the leg of the operated side, centre of gravity sway was not significantly different in the eyes open condition compared to the eyes closed condition, whereas in stance on the leg of the non-operated side, postural sway was significantly lower in the eyes open condition compared to the eyes closed condition. In both conditions, postural sway in the age group of 50–65 years was significantly higher than in the age groups of 30–39 years (eyes open P=0.005; eyes closed P<0.001) and 40–49 years (eyes open P=0.002; eyes closed P=0.006). There was no significant difference between the age group of 30–39 years and the age group of 40–49 years (P=0.51). Conclusion: As for long-term following lumbar discectomy, there is no complete recovery of postural control. Patients seem to develop visual compensation mechanisms for underlying sensory–motor deficits, which are, however, sufficient in case of pain relief only. Further study is needed to determine the cause of the balance disturbances in lumbar discectomy patients.
Postural control; Unilateral stance; Lumbar discectomy; Visual compensation
On the basis of preoperative computed tomography (CT) scans, we studied the change of the size of anterior primary division (APD) of the L5 spinal root in the presence of foraminal/extraforaminal entrapment of the L5 spinal root.
Two independent radiologists retrospectively reviewed the preoperative CT scans of 27 patients treated surgically and compared the sizes of the APDs on bilateral L5 spinal roots. If one side APD size was larger than the other side APD size, it was described as left or right "dominancy" and regarded this as "consensus (C)" in case that there was a consensus between the larger APD and the location of sciatica, and regarded as "non-consensus (NC)" in case that there was not a consensus. Oswestry Disability Index (ODI) scores were used for preoperative and postoperative evaluation.
On CT scans, twenty-one (77%) of 27 patients were the consensus group (APD swelling) and 6 (22%) were a non-consensus group (APD no swelling). In 9 patients with acute foraminal disc herniations, asymmetric enlargement of the APD on L5 spinal root was detected in all cases (100%) and detected in 11 (64%) of 17 patients with stenosis. Preoperative ODI score was 75-93 (mean 83) and postoperative ODI scores were improved to 13-36 (mean 21). The mean follow-up period was 6 months (range, 3-11 months).
An asymmetric enlargement of the APD on L5 spinal root on CT scans is meaningfully associated with a foraminal or extraforaminal entrapment of the L5 spinal root on the lumbosacral junction.
Computed tomography; Foraminal-extraforaminal entrapment; Lumbosacral junction; Radiculopathy; Surgery
Lumbar disc herniation (LDH) is a common cause of low back and radicular leg pains. This study aimed to evaluate the Persian Discectomy Successful Score (PDSS) in patients diagnosed with lumbar disc herniation undergoing discectomy. The PDSS first was developed based on the JOA score. It is a linear transformation of patients’ pre-operative JOA score that can predict the successful rate of surgery outcome in advance (PDSS= -1.036 × preoperative JOA + 23.635).
A total of 103 patients with lumbar disc herniation submitted for discectomy operation were entered into the study during two years of study. A sensitivity analysis was carried out to examine the accuracy of the PDSS. For the analysis of the results, patients’ pre- and post-operative JOA score was used as gold standard to calculate the actual difference observed (JOA pre-operation minus JOA post-operation = DJOA) and to compare this measure (difference) with estimation derived from the PDSS.
The mean age of patients was 47.4 ± 9.7 (ranging from 17 to 79) years and were followed for at least three months. The difference between pre and postoperative JOA score (15.4 ± 3.7) was statistically significant (P less than 0.0001). The sensitivity, specificity and accuracy of the PDSS was 93.87%, 80%, and 93.2%, respectively. The PDSS had a positive predictive value of 98.9% and a negative predictive value of 40%.
It seems that the preoperative JOA is able to predict discectomy results in patients with lumbar disc herniation. To confirm the findings of this study, a longitudinal study is recommended.
Discectomy Successful, lumbar disc herniation, Evaluation measure
This is a prospective study.
We compared the outcomes of segmental decompression and wide decompression in patients who had multilevel lumbar foraminal stenosis with back pain.
Overview of Literature
Wide decompression and fusion in patients with multilevel lumbar foraminal stenosis may increase the risk of perioperative complications.
From March 2005 to December 2007, this study prospectively examined 87 patients with multilevel lumbar foraminal stenosis and who were treated by segmental or wide decompression along with posterior fusion using pedicle screw fixation, and these patients could be followed-up for a minimum of 2 years. Of the 87 patients, 45 and 42 patients were assigned to the segmental decompression group (group 1) and the wide decompression group (group 2), respectively. We compared the clinical and radiological outcomes of the patients in these two groups.
There were no significant differences between groups 1 and 2 in terms of the levels of postoperative pain based on the visual analogue scale, the Oswestry Disability Score, the clinical results based on the Kirkaldy-Willis Criteria, the complication rate or the posterior fusion rate. On the other hand, the mean operating times in groups 1 and 2 were 153 ± 32 minutes and 187 ± 36 minutes, respectively (p < 0.05). The amount of blood loss during surgery and on the first postoperative day was 840 ± 236 ml and 1,040 ± 301 ml in groups 1 and 2, respectively (p < 0.05).
These results suggest that segmental decompression offers promising and reproducible clinical and radiological results for patients suffering from multilevel lumbar foraminal stenosis.
Multilevel lumbar foraminal stenosis; Segmental decompression; Wide decompression
Herniated intervertebral disc causes in a great number of cases of lumbar nerve root compression, especially in the segment L5/S1. Other reasons responsible for stress to the lumbar spinal root are the spinal canal stenosis and the postdiscotomy syndrome. For patients without neurological deficiencies, the conservative treatment includes different epidural injection techniques. Steroids are often applied. A specific injection technique needing only a small drug amount is the epidural perineural approach using a special two-needle technique. The anatomical spaces of the nerve roots have received little attention in therapy. We have determined the anterolateral epidural space nerve volume of the nerve root L5/S1, and compared the data collected in an anatomical study with operative measurements during discectomy. The volume determination in the human cadavers was performed with liquid silicone filling the anterolateral space after dissection. The in vivo measurements were performed during surgery at the site of the anterolateral space after discectomy. The anatomical studies showed us a mean value volume of 1.1 ml. The surgical volume determinations result in a mean volume of 0.9 ml. A better understanding of the anterolateral epidural space may allow a reduction of the injection volume in the conservative nerve root compression treatment, especially using the epidural perineural technique, avoiding the risk of side effects of high doses of steroids.
Lumbar nerve root compression; Anatomical volume determination; Epidural–perineural injection technique
We studied 27 patients with post-discectomy syndrome. All patients had Lumbar Interbody Fusion with titanium cages and pedicle screw fixation either as Anterior (ALIF, n=18) or as Transforaminal Lumbar Interbody Fusion (TLIF, n=9). Follow-up ranged from 24 to 94 months. The clinical and radiological data were compared. The outcome was evaluated using the Oswestry low back pain disability score and the visual analogue pain intensity scale. Outcomes were similar for all patients regardless of surgical technique and showed a significant improvement at final follow-up.
Discal cyst is a very rare lesion that can cause refractory low back pain and radiating leg pain. Although there are some reports to remove this lesion, there has been no report of discal cyst removed by percutaneous endoscopic transforaminal approach. Two young patients manifested left gluteal and leg pain due to a discal cyst at L5–S1 level and L4–5 level, respectively. Percutaneous endoscopic transforaminal approach was performed to remove the discal cyst, achieving complete decompression of the nerve root. The symptom was relieved and the patient was discharged the next day. Percutaneous endoscopic transforaminal approach could be a good alternative option in selected cases for the treatment of lumbar discal cyst.
Lumbar; Discal cyst; Percutaneous; Endoscopic transforaminal approach
Surgical treatment of lumbosacral foraminal stenosis requires an understanding of the anatomy of the lumbosacral area in individual patients. Unilateral facetectomy has been used to completely decompress entrapment of the L5 nerve root, followed in some patients by posterior lumbar interbody fusion (PLIF) with stand-alone cages.
We assessed 34 patients with lumbosacral foraminal stenosis who were treated with unilateral facetectomy and PLIF using stand-alone cages in our center from January 2004 to September 2007. All the patients underwent follow-up X-rays, including a dynamic view, at 3, 6, 12, 24 months, and computed tomography (CT) at 24 months postoperatively. Clinical outcomes were analyzed with the mean numeric rating scale (NRS), Oswestry Disability Index (ODI) and Odom's criteria. Radiological outcomes were assessed with change of disc height, defined as the average of anterior, middle, and posterior height in plain X-rays. In addition, lumbosacral fusion was also assessed with dynamic X-ray and CT.
Mean NRS score, which was 9.29 prior to surgery, was 1.5 at 18 months after surgery. The decrease in NRS was statistically significant. Excellent and good groups with regard to Odom's criteria were 31 cases (91%) and three cases (9%) were fair. Pre-operative mean ODI of 28.4 decreased to 14.2 at post-operative 24 months. In 30 patients, a bone bridge on CT scan was identified. The change in disc height was 8.11 mm, 10.02 mm and 9.63 mm preoperatively, immediate postoperatively and at 24 months after surgery, respectively.
In the treatment of lumbosacral foraminal stenosis, unilateral facetectomy and interbody fusion using expandable stand-alone cages may be considered as one treatment option to maintain post-operative alignment and to obtain satisfactory clinical outcomes.
Expandable cage; Foraminal stenosis; Lumbosacral spine