Aim: The aim is to correlate intra-operative findings such as epidural fibrosis (EF), size and type of disc fragment, lateral recess stenosis and dural tear with postoperative residual radiculopathy (RR) and residual low back pain (RLBP). Material and Methods: 246 revision discectomies performed between January 1994 and June 2004 were considered, of which adequate records were available for 215 (201 ipsilateral and 14 contralateral). Of 201 LIRDs, 85 were at L5S1, 101 at L45, 10 at L5S1+L45, 3 at L34 and 2 at L23 level. Patients who had had fusion or instrumentation in addition to LIRD were excluded. For 201 LIRDs average follow-up was 18.5 months (range −1 to 96 months) and 100 LIRDs had a minimum of 12 months’ follow-up. Results: Of the 179 first-time LIRDs, 65 (36.3%) had significant RR, 73 (40.8%) significant RLBP, 3 (1.7%) cauda equina syndrome, 2 (1.1%) infective discitis, and 1 (0.6%) foot-drop. Of the 21 second-time LIRDs, 15 (71.4%) had significant RR, 17 (81%) significant RLBP, 2 (9.5%) infective discitis and 1 (4.8%) cauda equina syndrome. EF was classified as abundant, moderate and scant. Incidence of RR and RLBP was proportional to amount of EF and size of hypertrophic scarred ‘disc’ bulge, but it correlated poorly with size of ‘soft’ disc prolapse. Lateral recess decompression in addition to LIRD did not significantly alter the incidence of RR and RLBP. 25 (12.4%) patients who had dural tear had worse results. Conclusions: Large proportion of LIRDs result in significant residual symptoms. Second-time LIRDs have higher complication rates and even poorer outcomes

Objective: To identify risk factors associated with patients that required revision surgery for sciatica.

Design: A retrospective study of 580 patients who underwent surgery for intractable sciatica attributable to pro-lapsed lumbar intervertebral disc from 1986 to 2000 inclusive.

Subjects: The study included a total of 580 patients. Of these seven patients had an operation at two levels, 25 patients had had a primary operation elsewhere and were therefore excluded; four sets of notes remain missing. The total number of primary operations analysed was therefore 558.

Outcome measures: Parameters such as gender, age, level and side of discectomy were entered into a database for analysis. Diagnostic and clinical parameters were also entered; these included the value of the angle of the straight leg raise recorded and absence or presence of neurological deficit (altered sensation, reduced motor power, and absent or diminished reflexes). Operative findings recorded and entered were the type of disc at operation (i. e. protrusion, extrusion and sequestration) and the presence of free cerebrospinal fluid (CSF), however minor, indicating a dural tear.

Results: The total number of primary discectomies was 558 of which 43 went on to require a second operation, giving a revision rate of 7.71%. Of the primary discectomies, 356 were protrusions, 92 extrusions and 110 sequestration. Of the 43 that went onto revision surgery, 35 were protrusions, two extrusion and six sequestration. A significant association was found with primary disc protrusions, this type of disc prolapse was almost three times more likely to go on to need revision surgery compared to extruded or sequestrated discs. Data analysed on primary protrusions showed these patients had a significantly greater straight leg raise angle and reduced incidence of positive neurological findings and so could be identified clinically.

Conclusions: This lead us to conclude that the group of patients with primary protrusions could be selected out and treated conservatively since they are three times more likely to require revision surgery.

Revision discetomy is a procedure often assumed to give similar results to primary discectomy. There is no level one or level two evidence to support this view and no publications with pre and post surgical spine specific outcome measures. This aim of this study was to evaluate the surgical outcomes of revision discectomies using standard spine instruments and to identify factors which influence the outcome. A prospective cohort study was performed between 1996 and 2004. A revision discectomy was defined as surgery at the same lumbar level as a previous discectomy with a minimum three month interval from the index surgery. Outcome measures were available for all 20 patients from the index primary discectomy. Questionnaires were given to the patients preoperatively and at 2 year follow-up. Among the outcomes measures used were the Oswestry Disability Index (ODI), the Low Back Outcome(LBO), and a Visual Analogue Score(VAS). 20 revision discectomies were performed on 11 males and 9 females, 7 at L4/5 and 13 at L5/S1. The mean age was 41(30–56) and the mean follow-up was 27(24–36) months. The preoperative ODI, LBO and VAS at the index primary discectomy averaged 54(22–82), 19(7–42) and 8(5–10) respectively. The preoperative ODI, LBO and VAS at the revision discectomy averaged 63(34–82), 18(1–46) and 8(1–10) respectively. The ODI, LBO and VAS all improved significantly at follow-up. The ODI averaged 27(2–66) (p< 0.05), the LBO averaged 47 (14–70) (p< 0.05) and the VAS 4(3–9) (p< 0.05). The outcome of revision discectomies is favourable, in this series the average improvement in ODI was 36 points, a clinically significant change. The risk factors which influence the outcome are preoperative ODI, preoperative VAS and Age (p< 0.05). Sex, preoperative LBO, duration between recurrent disc herniation, level of disc herniation and incidental durotomies were not predictive of outcome

Aim. To compare outcomes of revision lumbar discectomy to primary surgery in the same patient cohort. Methods. Prospective outcome data in 36 patients who underwent primary and subsequent revision surgery for lumbar disc herniation between 1995 and 2009. Outcome measures used were Visual Analogue Scores for back (VAB) and leg pain (VAL), the Oswestry Disability Index (ODI) and Low Back Outcome Score (LBO). 5 early recurrences within 3 months were excluded. Results. Complete data was available in 31 patients 13F;18M. The average age was 39 years at index and 45 years at revision. Average interval between surgery of 39 months (range 6-122). Mean Pre op ODI 54 and VAL 73 primary procedure, final follow up of primary procedure ODI 33, VAL 43; prior to revision ODI 57, VAL 75; at last FU ODI 32 and VAL 40. There was no statistical difference between outcomes. In the primary discectomy group there was a statistically significant improvement in the VAL, ODI and LBO scores (P<0.05), with no significant improvement in the VAB (P=0.67). In the revision group there was a statistical significant improvement in all the outcomes (P<0.05). Overall, 45% of patients felt their outcome from revision discectomy was better/much better with 54% of patients rating their treatment as either good/excellent. Conclusion. Primary discectomy produced significant improvement in leg pain, ODI and LBO. Revision discectomy did the same, but also a significant improvement in VAB scores. There was no statistically significant difference in comparing the preoperative and postoperative scores for both procedures. Revision discectomy is a procedure which yields clinically significant and patient perceived improvements in spinal outcome measures with an unexplained improvement in VAB scores as compared to the primary procedure. This may challenge the belief of some surgeons in the need for fusion at the time of revision

In this retrospective study 27 patients who had undergone revision discectomies for recurrent lumbar disc herniations were surveyed to assess their clinical outcomes. The patients chosen for the study were compared to a control group of 30 matched patients who had undergone only a primary discectomy. The spine module of the MODEMS® outcome instrument was used to evaluate the patients’ satisfaction, their pain and functional ability following discectomy, as well as their quality of life. All patients were also asked whether they were improved or worsened with surgery. Those undergoing revision surgery were asked whether the improvement following the second surgery was more or less than the improvement following the first surgery. Differences in residual numbness/tingling in the leg and/or the foot as well as in frequency of back and/or buttock pain were identified. Nevertheless improvement due to the repeat discectomy was not statistically different from those who underwent just the primary operation. Based upon patient derived outcome data with a validated instrument, revision discectomy is as efficacious as primary discectomy in selected patients

Aim. To assess the safety of day case lumbar decompressive surgery. Method. Retrospective study of 233 consecutive patients undergoing DCLDS who were identified from a prospective electronic database. Results. Between Jan 2011 and April 2014, 131 open and 102 microscopic surgeries were done in patients with mean age of 46 (16–88) years and male: female ratio of 136 (59%):97 (41%). Inclusion criteria were no known anesthetic reaction, ASA grade I or II, BMI <35, less than 30 minutes travel time and responsible home carer. Patients were discharged after clinical assessment with cauda equina advice and emergency contact number. 215 (92%) procedures were single level, of which 188(87%) unilateral and 27 (13%) were bilateral procedures. 18 (8%) procedures were multiple levels, of which 12(67%) unilateral and 6 (33%) were bilateral procedures. Majority, 107 (50%), 97 (45%) procedures were done at L5/S1 and L4/L5 levels respectively and rest 11(5%) at higher level. The 7 day and 30 day re-presentation figures were 7 (3%) & 15(6.4%) as following: Pain (n=3), Medication (n=2), Wound issues (n=5), Infection (n=2), Headache (n=2), ?VTE (n=1). Eleven were sent home and 4 (1.7%) were admitted with 2 requiring further surgery, one revision discectomy and one wound washout. No cauda equina or compressive haematoma were encountered. Conclusion. This study demonstrates that open and microscopic lumbar discectomy at single or multiple levels can be performed safely as a day case procedure. The representation rate to the ED can be potentially reduced by better advice and pain management. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

The Dynesys fixation device has fewer side effects and complications than conventional fusion techniques, but indications for its use are still unclear. This prospective study of 50 patients treated since October 2000 aimed to determine its efficacy and to establish contra-indications. Patients considered for lumbar spinal fusions were evaluated to assess whether Dynesys fixation could be used instead of conventional fusion techniques. All patients completed an Oswestry questionnaire preoperatively and again three and six months postoperatively. Postoperatively all patients were mobilised on day one or two, using only a soft back brace. No limitations were placed on sitting or driving. All Oswestry and visual pain analogue scores improved dramatically in the short term. Complications included loosening of screws that made further surgery necessary. Three patients required conversion to fusion and one developed disc reherniation. In the right patient, this method is very effective. All the older patients were clearly better off with this technique, which permits early mobilisation and return to work. The swiftness with which the procedure can be carried out means less exposure, less bleeding and ultimately less fibrosis. Absolute contra-indications are spinal instability (including spondylolisthesis), deformity (including severe degenerative scoliosis), long fixations and revision discectomy. Relative contra-indications include uncomplicated mini-discectomy where no fixation is required and use in very active younger patients

Aim: The aim is to assess the accuracy of post-contrast imaging in identifying recurrent disc prolapse (RDP). Material and methods: 246 revision discectomies performed between January 1994 and June 2004 were considered. Of these, for 192 LIRDs, post-contrast scans (95 CTs and 97 MRIs) within 6 months of operation, and adequate operation records were available. Original scan reports and scan interpretation of an independent observer were taken into account. Results: Of 95 post-contrast CTs, 88 showed RDP (29 large-contained, 12 large-sequestrated, 39 moderate-contained, and 8 small-contained), 2 hypertrophic epidural scar (HES), and 5 lateral recess stenosis but no RDP or HES. From operation records, 30 of these 88 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 21 of 29 large-contained (72.4%), 10 of 12 large-sequestrated (83.3%), 16 of 39 moderate-contained (41%) and 2 of 8 small-contained (25%). Of the 5 which did not show RDP, 2 (40%) were found to have RDP (1 moderate-contained and 1 large-contained) during operation. Of 97 post-contrast MRIs, 85 showed RDP (18 large-contained, 22 large-sequestrated, 26 moderate-contained,4 moderate-sequestrated,13 small-contained, and 2 small-sequestrated), 5 HES, and 7 lateral recess stenosis but no RDP or HES. From operation records, 31 of these 85 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 10 of 18 large-contained (55.6%), 19 of 22 large-sequestrated (86.4%), 8 of 26 moderate-contained (30.8%), 4 of 4 moderate-sequestrated (100%), 6 of 13 small-contained (46.2%) and 1 of 2 small-sequestrated (50%). Of the 7 which did not show RDP, 1 (14.3%) was found to have moderate-contained RDP during operation. Conclusion: Accuracy of post-contrast scans is proportional to the size of RDP. MRI has high accuracy for sequestrated RDP

Introduction: Peridural fibrosis is a reaction that occurs outside the dura and occurs in the healing process following lumber surgery. 1. The fibrosis is recognised as one of the possible causes of the failed back syndrome following lumbar spinal surgery. ADCON-L Anti-Adhesion Barrier Gel has been shown to be of Benefit in patients undergoing discectomy in reducing symptomatic fibrosis. The aim of this prospective study is to elicit the advantages and potential risks of using ADCON-L in more extensive decompression procedures and in instrumented spinal fusions. Method: ADCON-L anti-adhesion barrier gel, has been used in 288 patients undergoing the following surgeries: posterior lumbar interbody fusion (PLIF) (49), decompression and instrumented fusion posterior interbody supplementary fixation (PISF) (96), decompression and Graf ligament stabilisation (31), decompression of stenosis (54), discectomy (41), and revision discectomy or decompression (17). Any adverse clinical events, including pseudarthrosis, new, recurrent or deteriorating leg pain, paraesthesia or neurological deficit, were documented. Patients with neurological symptoms suggestive of fibrosis including deteriorating leg pain were evaluated with an MRI scan with gadolinium enhancement. Fusion rates were evaluated where appropriate. Results: Two patients developed significant early (< 4 weeks) recurrent sciatica. MRI demonstrated a recurrent disc prolapse at the same level in one patient, who required re-operation, but no fibrosis was noted at the surgery. Late developing leg pain occurred in 16 patients. All these patients were evaluated with MRI with gadolinium enhancement. Independent radiological assessment indicated the principal cause of the leg pain to be peridural fibrosis in 9 patients (3.1%). Other causes included recurrent disc prolapse or lateral recess stenosis. Early post-operative wound seepage or superficial wound infections occurred in 5 (1.7%). There were no late infections. Two patients developed a postoperative pseudomeningocoele. One required re-exploration and repair, the other settled with conservative treatment. At review 1 to 4 years (mean 2.7 years) after undergoing PISF and PLIF fusion had achieved in 93.1% of cases. Discussion: Previous prospective randomised multi-centre studies have shown the effectiveness of ADCON-L gel in reducing peridural fibrosis in patients following discectomy. Our study shows that there is low incidence of peridural fibrosis and associated leg pain when ADCON-L is used in all forms of degenerative lumbar spine surgery. There is a low complication rate and good fusion rate

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery. Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature. Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants. 40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively. Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication

Background context: Cauda equina following a prosthetic Disc nucleus replacement has never been reported. Purpose: To describe a case of Cauda equina following migration of the Prosthetic disc nucleus and possible cause. Study design: Case report and review of literature. Patient Sample: Case report. Outcome measures: 2 patients. Report of presenting symptoms and review of radiographs. Method/description: A 24-year-old man presented with progressively worsening pain radiating down his right leg and low back pain. His MRI scan showed a disc bulge at L4/5 for which we underwent decompression and discetomy. 4 months later he presented again with same symptoms. MRI imaging showed a disc prolapse at L4/5. He underwent a revision decompression discectomy and a prosthetic disc nucleus replacement. On the 4th postoperative day he complained of urinary retention and was unable to move his right ankle with loss of sphincter tone. The plain radiographs showed that the prosthetic disc nucleus had migrated posteriorly. He was immediately taken to theatre, which showed posterior migration of the prosthetic disc nucleus compressing the theca and displacing the nerve root. The prosthetic disc nucleus was removed from the space relieving the tension of the nerve root and the theca. Conclusions: Migration of Prosthetic disc nucleus can lead to cauda equina and this needs to be explained to the patient as possible risk factor. The angle of the vertebrae has to be measured before selecting a patient. If angle below 5 degree it is a high risk patient