Aims. 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. Methods. 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. Results. 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. Conclusion. 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. Cite this article: Bone Joint J 2023;105-B(4):422–430

Aims

The aim of this study was to evaluate the time course of changes in parameters of diffusion tensor imaging (DTI) such as fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in patients with symptomatic lumbar disc herniation. We also investigated the correlation between the severity of neurological symptoms and these parameters.

Aims. The purpose of this study was to investigate the risk of additional surgery in the lumbar spine and to describe long-term changes in patient-reported outcomes after surgery for lumbar disc herniation in adolescents and young adults. Patients and Methods. We conducted a retrospective study design on prospectively collected data from a national quality register. The 4537 patients were divided into two groups: adolescents (≤ 18 years old, n = 151) and young adults (19 to 39 years old, n = 4386). The risk of additional lumbar spine surgery was surveyed for a mean of 11.4 years (6.0 to 19.3) in all 4537 patients. Long-term patient-reported outcomes were available at a mean of 7.2 years (5.0 to 10.0) in up to 2716 patients and included satisfaction, global assessment for leg and back pain, Oswestry Disability Index, visual analogue scale for leg and back pain, EuroQol five-dimension questionnaire (EQ-5D), and 36-Item Short-Form Health Survey (SF-36) Mental Component Summary and Physical Component Summary scores. Statistical analyses were performed with Cox proportional hazard regression, chi-squared test, McNemar’s test, Welch–Satterthwaite t-test, and Wilcoxon’s signed-rank test. Results. Any type of additional lumbar spine surgery was seen in 796 patients (18%). Surgery for lumbar disc herniation accounted for more than half of the additional surgeries. The risk of any additional surgery was 0.9 (95% confidence interval (CI) 0.6 to 1.4) and the risk of additional lumbar disc herniation surgery was 1.0 (0.6 to 1.7) in adolescents compared with the young adult group. Both age groups improved their patient-reported outcome data after surgery (all p < 0.001). Changes between short- (mean 1.9 years (1.0 to 2.0)) and long-term follow-up (mean 7.2 years (5.0 to 10.0)) were small. Conclusion. The risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults. All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. Cite this article: Bone Joint J 2019;101-B:1534–1541

Purpose: In recent years, many reports have described spontaneous resorption of lumbar disc herniation evaluated with Gd-enhanced MRI. We also found retrospectively that sequestrated lumbar disc herniation with Gd-enhanced MRI would disappear, and that patient with this type of lumbar disc herniation would improve clinically. But there is a question that Gd-enhanced MRI is really needed to speculate the prognosis of sequestrated lumbar disc herniation. The purpose of this study is to clarify the prognostic value of Gd-enhanced MRI for sequestrated lumber disc herniation. Materials and methods: Since Nov. 1995, 22 patients of sequestrated lumber disc herniation were treated non-operatively under the speculation of getting good clinical result prospectively. From Nov. 1995 to Oct. 1997, 9 patients with sequestrated lumbar disc herniation with ring-enhancement on Gd-enhanced MRI were treated non-operatively (Group A). From Nov. 1997 to July 2000, 13 patients with sequestrated lumbar disc herniation were treated non-operatively without Gd-enhanced MRI examination (Group B). Clinical results and the last MRI findings of Group A were compared with that of Group B. Results: In Group A, all cases were treated non-operatively and all of them improved clinically within a month of the first MRI examinations. Mean period of NSAID administration was 37 days (range 14–67 days), and the last MRI examinations revealed that the herniated masses disappeared in 5 cases and that the size of herniations diminished in 4 cases. All of 9 cases obtained good clinical results. In Group B, all cases were treated non-operatively but one, whose clinical symptoms were not improved within a month of the first MRI examination. Mean period of NSAID administration was 38 days (range 7–110 days), and the last MRI examinations revealed that the herniated masses disappeared in 5 cases and that the size of herniations diminished in 5 cases. Remaining 2 cases, the second MRI was not examined for some reasons. All of 12 cases obtained good clinical results. There were no differences between Group A and Group B by means of clinical results. Conclusions: Gd-enhanced MRI is not needed to speculate the prognosis of sequestrated lumbar disc herniation. In the case of sequestrated lumbar disc herniation, good clinical result could be obtained without Gd-enhanced MRI examination at the first MRI examination

We have treated 15 patients with massive lumbar disc herniations non-operatively. Repeat MR scanning after a mean 24 months (5 to 56) showed a dramatic resolution of the herniation in 14 patients. No patient developed a cauda equina syndrome. We suggest that this condition may be more benign than previously thought

Introduction: Operations inside the spinal canal are afflicted with a certain number of iatrogenic dural lesions. Incidence figures in the literature vary from 1 to 17% and are mainly based on retrospective studies. The Swedish Spine Register, SweSpine, provides a good possibility to study the incidence in a prospective patient material. Patients and Methods: During 5 years more than 9 000 patients had surgical treatment for lumbar disc herniation or lumbar spinal stenosis and were registered according to the protocol of the Swedish Spine Register. One year follow-up data were present for 74 % of the patients. Pre- and postoperative data are entirely based on questionnaires answered by the patient whereas surgical data are completed by the surgeon. Complication and re-operation registration is included. Mean patient age for LDH was 45 (12–88) years, for spinal stenosis 68 (27–93) years and 56% of the disc herniation patients and 43% of the spinal stenosis patients were males. Most common level for LDH operation was L5/S1 followed by L4/L5 and for spinal stenosis L4/L5 followed by L3/L4. The one-year result was studied. Results: The incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in spinal stenosis decompression 7.3%. The risk for dural lesion was more than doubled in patients with previous surgery which, thus, was a significant but also the only risk factor. At one year after surgery the result was similar for patients with and without dural lesion when VAS pain, ODI, SF-36 and patient graded global assessment were studied. Correlation between previous surgery and inferior outcome was seen but was not affected by the dural lesion as such. Three and 5% respectively in the groups were subjected to repeat surgery before discharge from the hospital. The lost-to follow-up group (26%) had similar pre-operative demographics and the same incidence of dural lesion as those followed-up. Conclusion: In a large prospectively studied material, the incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in decompressive spinal stenosis surgery 7.3%. Previous surgery was a significant risk factor for dural lesion. The dural lesion as such did not negatively influence the one-year outcome

We present our four-year experience with a new minimally invasive method for ambulatory treatment of lumbar discal herniation: micro video endoscopic dissectomy. Video endoscopic surgery associates microsurgical procedures similar to those used in conventional surgery with a very precise technique. This method was used for 50 patients presenting lumbar disc herniation diagnosed with magnetic resonance imaging using the MacNab criteria, placing priority on the neurological risk of sensorimotor deficit. Clinical outcome was also evaluated with the MacNab criteria. These patients were able to walk early, resumed work rapidly, and had little lumbar pain and few complications

Introduction Minimally invasive lumbar discectomy using the METRx™ System (MAST discectomy) has been advocated as an alternative to open microdiscectomy for symptomatic posterolateral lumbar disc herniation. This paper presents a quality assurance dual surgeon retrospective study with independent observer minimum twelve month follow-up. Methods This study was approved by the Ethics Committee of the Princess Alexandra Hospital prior to commencement. All patients who underwent MAST discectomy using the METRx™ System for the management of radiculopathy caused by posterolateral lumbar disc herniation under the care of two surgeons (AN and RK) more than twelve months prior to the commencement of assessment were included in the study. The patient demographic data was collected contemporaneously, operation performance data was collected retrospectively from hospital databases and outcome data was collected by telephone interview by independent observers (PL, SO and JP) a minimum of twelve months after discharge from hospital. Results 101 patients (53 males, 48 females) (average age 43 years, range 17 to 83 years) underwent 102 procedures between July 2001 and December 2004. Surgery was performed on the right side in 63 cases and was either at L4/5 (30%) or more commonly L5/S1 (70%). 21 were public patients and 80 private patients with 59 episodes of surgery occurring in a public hospital. 46 operations were performed with the METRx™ MED System and 56 with the METRx™ MD System. The average duration of surgery for patients at the Princess Alexandra Hospital (n = 48) was 88 minutes with an average length of post-operative hospital stay of 22 hrs 35 mins. 16 of these cases were performed as day surgery. Perioperative complications were: conversion to open (3), urine retention (7), nausea and vomiting (3), durotomy (5), wound haematoma not requiring surgery (1) and incorrect level surgery identified and rectified during surgery (1). The average length of time from surgery to independent follow-up was 679 days (range: 382 to 1055) with 78% successful contact. On the Modified McNabb Outcome Scale, 83% reported an excellent or good outcome, 9% reported a fair outcome and 8% a poor outcome. The time until return to work was identified as less than two weeks in 28% and between 2 weeks and 3 months in 39%. Patients whose surgery was funded by Workers Compensation were over-represented in both the poor outcomes and delayed return to work. 4 patients reported progressive severe low back pain, 10 patients reported ongoing lower limb pain (severe in 1 and mild in 9) and 1 patient underwent surgery for a recurrent disc prolapse. Further disc prolapse at different sites was identified in five patients. Discussion The retrospective data in this study forms class IV evidence for efficacy. As a quality assurance exercise it suggests an acceptable level of safety and efficacy to allow further technique development and study. A prospective randomized controlled study is proposed. The high incidence of urine retention early in the series of one surgeon is considered to be related to the practice of placing depot morphine in the operative bed. The reduction in complications in general and the improvement in duration of surgery over the series is evidence of the learning curve for this procedure

Background. Recently, some studies have focused attention on the possibility that anaerobic pathogens of low virulence could constitute an etiological factor in disc herniation. There have been isolated such strains, predominantly Propionibacterium acne, between 7 and 53% of patients undergoing surgery for disc pathology. According to these studies, patients with anaerobic infections of the disc are more likely to develop Modic changes in the adjacent vertebrae. The aim of this work was to test this hypothesis by growing in specific media the disc material extracted in a series of lumbar discectomy and relating this factor with the presence of pre-intervention Modic changes. Methods. A total of 22 consecutive patients undergoing primary unisegmental discectomy for lumbar disc herniation (77.2% male, mean age 40.1 ± 9.1 years) were included. All patients were immunocompetent and none had previously received an epidural steroid injection prior surgery. MRI study confirmed the disc herniation. Following strict antiseptic protocols, the extracted disc material was sent for slow-growth anaerobic enriched culture (>10 days). Results. In total, anaerobic cultures were positive in 7 cases (31.8%) all men. In 5 of these cases, the symptoms developed with an acute onset. The isolated germs were always unique: Propionibacterium acne (3), Streptococcus parasanguinis (1), Actinomyces naeslundii (1), Actinomyces meyeri (1) and methicillin sensitive Staphylococcus epidermidis. Only two (28.6%) of these 7 patients had Modic changes on MRI prior surgery (one type I, one type 2). None of the patients with negative cultures had Modic changes. Conclusions. These findings support the theory that anaerobic infections of low virulence and slow growth may contribute to the pathogenesis of herniated discs. However, these cases do not necessarily develop type 1 Modic changes as previously speculated. Level of evidence. Level IV

Introduction and Objectives: Indications for surgery in the treatment of lumbar disc herniation are still the subject of some controversy, in spite of previous systematic studies demonstrating its effectiveness. Many believe that this treatment should be avoided in working patients, in whom results of vertebral surgery tend to be poorer. Health-related quality of life indicators permit the objective measurement of the degree to which the health of the patient is improved by a particular type of procedure. They also permit a comparision of health improvement for patients with various types of treatment interventions. The goal of this study is to evaluate the impact of lumbar microdiscectomy on health-related quality of life in working patients. Materials and Methods: A total of 105 patients of working age who underwent surgery at the Vertebral Surgery Unit of an On-the-Job Accident Cooperative were evaluated prospectively. Of these patients, 89 (84.8%) were male, and 51% were working in jobs that involved heavy lifting; 68.6% had high-school or less education or no education. Patients were evaluated before and 3 months after surgical intervention using a validated Spanish version of a questionnaire on the following clinical dimensions: Health-Related Quality of Life (SF-36), Lumbar Spine Function (Oswestry’s questionnaire), Lumbar and Radicular Pain (Visual Analogue Scale). Unvalidated versions of Work Situation and Satisfaction with results (GEER scales) were used. Results: Statistically significant and clinically relevant improvement was observed in the following parameters: Intensity of lumbar pain (preoperative: 61.7; postoperative: 33.5; p< 0.001) and radicular pain (preoperative: 76.1; postoperative: 28.4; p< 0.001), specific lumbar spine function (preoperative: 44.3; postoperative, 18.3; p< 0.001), patient satisfaction and the SF 36 Physical Function items (preoperative: 38.1373; postoperative, 71.152; p< 0.001), physical role (preoperative,6.2092;postoperative,24.8366; p< 0.001), bodily pain (preoperative, 24.5196; postoperative, 51.0882; p< 0.001), general health (preoperative, 59.2607; postoperative, 62,901; p< 0.044), vitality (preoperative, 45.8333; postoperative, 58.2843; p< 0.001), social function (preoperative: 55.6373; postoperative: 73.8971; p< 0.001), and mental health (preoperative: 61.9706; postoperative, 70.9706; p< 0.001). A statistically significant improvement was not found in emotional role (preoperative: 65.6766; postoperative, 72.9373; p=0.182). Discussion and Conclusions: Apart from the impact on their work situation, working patients who underwent microdiscetomy for lumbar disc herniation enjoyed significant short-term clinical improvement in multiple areas of their health

Between 1995 and 1999, 12 patients aged 65 years or more (mean 70.2) with lumbar disc herniation, underwent partial laminectomy and nucleotomy. The results were compared with those of 25 younger patients aged between 20 and 40 years (mean 30.1), who underwent the same surgical procedure. The Japanese Orthopedic Association (JOA) score was used to assess the clinical outcome. The minimum follow-up was 12 months. The pre- and post-operative total JOA scores and the rate of improvement of the JOA score were not significantly different between the elderly (11.1, 24.3 points, and 74.1%), and the younger group (11.6, 26.4 points and 84.5%). The results of this study indicate that the outcome of lumbar discectomy in elderly patients is as good as in younger patients

The purpose of this study is to call attention to the diagnosis of spinal cyst caused by lumbar disc herniation. Reviewing a total of 11 cases of lumbar spinal cyst that have been encountered in our spinal practice, we propose our views concerning the pathology of this lesion. The clinical findings of lumbar spinal cyst are identical to those in acute disc herniation such as low back pain and radiculopathy. The characteristics of imaging study are as follows; The magnetic resonance imaging (MRI) demonstrates a relatively large, rounded mass postero-laterally to the vertebral body. These lesions are isointense relative to the intervertebral disc on T1-weighted images and homogeneously hyperintense on T2. A gadolinium -DTPA-enhanced MRI shows a rim-enhancing lesion. A discogram reveals leakage of the contrast medium into the mass. The operative findings demonstrated encapsulated soft tissue masses which contained bloody fluid and small fragments of herniated disc tissue. The pathologic examinations revealed fibrous tissue with hemosiderin deposit in cyst wall and degenerative disc materials with inflammatory cell infiltration. This type of lumbar spinal cyst has been recognized as spinal epidural hematoma in recent years. Wiltse suggested that epidural hematoma may result from tearing of fragile epidural veins due to acute disc disruption. However, MRI characteristics of hematoma are not identical with those with lumbar spinal cyst. It is more likely that the lesions showing the pattern of changes are herniated disc tissue accompanied by hemorrhage and inflammation. If hernial tissue is covered with some membranous susbtance, formation of cystic lesions is understandable. Hence, we hypothesize that lesions, in which lysis liquefaction and absorption of the herniated disc tissue associated with inflammatory response have progressed, and the herniated disc tissue has completely disappeared, may be filled solely with bloody fluid, showing an appearance like cysts

Percutaneous nucleotomy is a relatively new technique for treating lumbar disc herniation. There is no agreement as to the volume of disc material to be removed. A long-term study of clinical and radiological data from patients treated by percutaneous nucleotomy was designed to identify the factors associated with favourable and unfavourable outcomes. We studied 42 patients for at least ten years; the mean follow-up was 10.9 years. They were divided into two subgroups to assess the value of preserving the nucleus pulposus in the central area of the disc. The overall success rate for both subgroups was 50%. A decrease in disc height on plain radiography and a decrease in signal intensity on MRI were observed more infrequently in patients in whom the nucleus pulposus in the central area of the disc had been preserved, than in those in whom it had been extensively removed. These adverse radiological findings correlated closely with increased low back pain during the first one to two years after operation and a poorer overall outcome. We conclude that percutaneous nucleotomy is most likely to be successful when the central area of the disc is preserved

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

Lumbar disc herniation (LDH) is uncommon in youth and few cases are treated surgically. Very few outcome studies exist for LDH surgery in this age group. Our aim was to explore differences in gender in pre-operative level of disability and outcome of surgery for LDH in patients aged ≤ 20 years using prospectively collected data. From the national Swedish SweSpine register we identified 180 patients with one-year and 108 with two-year follow-up data ≤ 20 years of age, who between the years 2000 and 2010 had a primary operation for LDH. Both male and female patients reported pronounced impairment before the operation in all patient reported outcome measures, with female patients experiencing significantly greater back pain, having greater analgesic requirements and reporting significantly inferior scores in EuroQol (EQ-5D-index), EQ-visual analogue scale, most aspects of Short Form-36 and Oswestry Disabilities Index, when compared with male patients. Surgery conferred a statistically significant improvement in all registered parameters, with few gender discrepancies. Quality of life at one year following surgery normalised in both males and females and only eight patients (4.5%) were dissatisfied with the outcome. Virtually all parameters were stable between the one- and two-year follow-up examination. LDH surgery leads to normal health and a favourable outcome in both male and female patients aged 20 years or younger, who failed to recover after non-operative management. Cite this article: Bone Joint J 2015;97-B:1675–82

We reviewed two comparable groups of patients who had been treated for lumbar disc herniation by chymopapain chemonucleolysis (145) or conventional surgical discectomy (91). They were reviewed 10 years after treatment by questionnaire, followed by a personal interview by an independent observer. The results of the surgically treated groups were slightly better than those treated with chymopapain. In particular, there was significantly better early relief of leg and low back pain, and fewer patients needed a second procedure. Complications were few in both groups

Background. Percutaneous endoscopic interlaminar discectomy (PEID) has achieved favorable effects in the treatment of lumbar disc herniation (LDH), as a new surgical procedure. With its wide range of applications, a series of complications related to the operation has gradually emerged. Objective. To describe the type, incidence and characteristics of the complications following PEID and to explore preventative and treatment measures. Study Design. Retrospective, observational study. Setting. A spine center affiliated with a large general hospital. Method. In total, 479 cases of patients with LDH received PEID, which was performed by an experienced spine surgeon between January 2010 and April 2013. Data concerning the complications were recorded. Result. All of the 479 cases successfully received the procedure. A total of 482 procedures were completed. The mean follow-up time was 44.3 months, ranging from 24 to 60 months. The average patient age was 47.8 years, ranging from 16 to 76 years. There were 29 (6.0%) related complications that emerged, including 3 cases (0.6%) of fragment omission, and the symptoms gradually eased following 3–6 weeks of conservative treatment; 2 cases (0.4%) of nerve root injury, and the patients recovered well following 1–3 months of taking neurotrophic drugs and functional exercise; 15 cases (3.1%) of paresthesia, and this condition gradually improved following 3–6 weeks of rehabilitation exercises and treatment with mecobalamin and pregabalin; and recurrence occurred in 9 cases (1.9%), and the condition was controlled in 4 of these cases by using a conservative method, while 5 of the cases underwent reoperation, including 3 traditional open surgeries and 2 PEID. Furthermore, the complication rate for the first 100 cases was 16%. This rate decreased to 3.4% (for cases 101–479), and the incidence of L4–5 (8.2%) was significantly higher than L5-S1 (4.5%). Limitations. This is a retrospective study, and some bias exists due to the single-center study design. Conclusion. PEID is a surgical approach, which has a low complication rate. Fragment omission, nerve root injury, paresthesia and recurrence are relatively common. Some effective measures can prevent and reduce the incidence of the complications, such as strict indications for surgery, a thorough action plan and skilled operation skills

We measured the serum concentration of C-reactive protein (CRP) by a high-sensitive method in patients with lumbar disc herniation. There were 48 patients in the study group and 53 normal controls. The level and type of herniation were evaluated. The clinical data including the neurological findings, the angle of straight leg raising and post-operative recovery as measured by the Japanese Orthopaedic Association (JOA) score, were recorded. The high-sensitive CRP (hs-CRP) was measured by an ultrasensitive latex-enhanced immunoassay. The mean hs-CRP concentration was 0.056 ± 0.076 mg/dl in the patient group and 0.017 ± 0.021 mg/dl in the control group. The difference was statistically significant (p = 0.006). There was no other correlation between the hs-CRP concentration and the level and type of herniation, or the pre-operative clinical data. A positive correlation was found between the concentration of hs-CRP before operation and the JOA score after. Those with a higher concentration of hs-CRP before operation showed a poorer recovery after. The significantly high concentration of serum hs-CRP might indicate a systemic inflammatory response to impingement of the nerve root caused by disc herniation and might be a predictor of recovery after operation

The purpose of this review is to evaluatei the clinical and surgical aspects of lumbar disc herniation in paediatric and adolescent patients. Between 1975 and 1991, a total of 5,160 lumbar disc operations were performed at the Rizzoli Orthopaedic Institutes. We included in this study only 129 patients (2.5%), aged from 9 to 18 years, with a mean age of 16.2 years (S.D. 1.7). Almost half of the patients (66 cases) ranged from 17 to 18 years of age and 49% (63 cases) from 9 to 16. Only three subjects were aged 9, 11 and 12 years. This group consisted of 84 boys and 45 girls. Eleven had noted the onset of symptoms after a trauma and 15 during athletic activities or after lifting heavy objects. Almost all of the patients (106 cases, 82%) had low-back pain with radiculopathy, 13% (17 cases) complained of lumbar pain alone, 5% (six cases) had sciatica and 16% (21 cases) presented with a radicular neurological deficit. Posterior discectomy by conventional procedure without fusion was performed in all patients, except for three cases with associated spondylolisthesis, treated by a posterolateral artrodesis, supplemented in two cases by pedicle screw fusion. Patients were followed in a short-term assessment using medical records. Long-term follow-up was conducted by a mailed, self-report questionnaire that quantified leg and back pain and scored the ability to return to normal activities and satisfaction. Short-term results were excellent for 120 patients (93%) and postoperative complications included one superficial wound infection and one discitis. A total of 98 (76%) long-term responses were obtained with a mean follow-up time of 12.4 years (range, 6-19.4 years). Mean age at long-term follow-up was 28.7 years whereas the functional outcomes were excellent in 56%, good 30% and poor 14%. Eight patients (6.2%) required additional surgical treatment at a mean interval from the first surgery of 9 years (range 2 to 16). Three of them had a re-exploration for a herniated disc at the same level, five at a different level. Our results have confirmed, as in adult patients, a negative trend between the short-term and long-term functional outcomes in young patients treated by discectomy. Furthermore, they have suggested that young individuals with lumbar Scheuermann-type changes are at great risk of experiencing herniation of intervertebral discs (10% in our series)

Aim of the present study was to investigate clinical outcomes and quality of life after standard discectomy for lumbar disc herniation on a minimum 25-year follow-up throughout validated tools. Between 1973 and 1979, a total of 343 patients underwent single or double level standard lumbar discectomy at the Orthopaedic Department of Naples Federico II University Hospital, Italy. Fifty patients died from causes unrelated to disc surgery. Out of the remnants, one hundred fifty-eight patients could be traced and contacted by mail (46.1% survey rate). All of them (100% response rate) completed and sent back three questionnaires: the official Italian version of the Short Form-36 Health Survey (SF-36), the Oswestry Disability Questionnaire, and a questionnaire ideated by the authors to evaluate the degree of satisfaction with surgery. Forty-two patients even accepted to undergo clinic examination. The study population consisted of 97 males and 61 females. The mean age at the time of surgery was 37.8 +/− 8.7 years (18–62), whereas on follow up it was 65.8 +/− 8.9 (44–89). The average follow up in the study group was 27 years (25–31). The eight SF-36 scales averaged 72.53 +/− 31.3 for physical functioning, 63.1 +/− 30.1 for bodily pain, 61.30 +/− 44.4 for role-physical, 54.57 +/− 22.2 for general health, 56.62 +/− 19.2 for vitality, 72.08 +/− 30 for social functioning, 67.56 +/− 41.4 for role-emotional, and 62.28 +/− 19 for mental health. The mean SF-36 physical composite score (PCS) and mental composite score (MCS) were 44.2 +/− 11.6 (17.3–64.5) and 45.7 +/− 9,9 (13.2–62.4), respectively. The mean Oswestry Disability Score was 16.67 +/− 22.82 (0–96). One hundred forty-two patients (89.9%) were satisfied with the results of surgery, whereas sixteen (10.1%) were dissatisfied. One hundred and one (89.2%) would have had the same operation again. Nineteen patients underwent recurrent back surgery, giving a reoperation rate of 12%. As for the objective findings, we noted slight improvement of motor disturbances, hyporeflexia, and radicular tension signs with respect to preoperative period. Lumbar alignment abnormalities and trunk mobility did not show significant changes. On multivariate analysis worst SF-36 PCS scores were associated with increasing age (P = 0.039), low educational level (P = 0.002), and reoperation (P = 0.008). Similar correlations were appreciated for the Oswestry Disability Score. Negative role of female gender (P = 0.012) in determining the score of SF-36 MCS was also detected. To the best of our knowledge, no patient-oriented evaluation of lumbar discectomy outcomes has been reported with a similar ultra-long-term follow-up. The minimum 25-year results obtained in the present study were satisfying for both general health and disability indicators. The general health scores were similar to age-adjusted normative values

We studied the use of gadolinium diethylenetriaminepentaacetic acid-enhanced MRI in the detection of pathological changes in the nerve roots of 25 patients with unilateral sciatica due to lumbar disc herniation. Enhancement was observed in the affected nerve roots within the root sleeve at the caudal edge of the herniation and was classified into three categories: grade 0, none; grade 1, enhancement restricted to a focal region within the sleeve; and grade 2, diffuse and homogeneous. The grade of enhancement correlated well with the severity of the sciatica, and was considered to be due to a disruption of the blood-nerve barrier, leading to oedema

The study was founded by The Regional Institute of Health Sciences Research. Background: There is a need for identifying specific subgroups of LBP, Modic changes might be one of these subgroups. The aim is to describe the relationship between a previous herniated disc and the following Modic changes. Methods: 181 patients with radicular pain below the knee, leg pain ≥ 3, duration of leg pain between 2 and 52 weeks, and age between 18 and 65 years were included. The patients were randomized into one of two active conservative treatment regimes lasting eight weeks. All included patients were scanned at baseline and again at 14 months follow-up. All MRI evaluation was carried out by the same experienced radiologist using a validated evaluation protocol. Results: The prevalence of Modic changes type 1 increased more than 3 fold from 9 % at baseline to 29 % at follow-up; type 2 was respectively 14 % and 13 %. In patients with Modic changes at baseline, extremely few reduced in size or disappeared, on the contrary new type 1 changes developed after the herniation. In patients with a normal disc, 0 % developed Modic changes at follow-up, whereas in those with extrusions and sequestrations 56–63%. There exist a strong association between Modic changes and LBP, 67 % of those with Modic changes had LBP compared to 21 % of the patients without, OR 6.1, (p< 0.0001). Discussion: A lumbar disc herniation is a strong risk factor for developing Modic changes (especially type 1) during the following year. Furthermore, Modic changes are strongly associated with LBP

Aims

The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events.

We analysed prospectively 26 patients who had revision operations for ipsilateral recurrent radicular pain after a period of pain relief of more than six months following primary discectomy. They were assessed before the initial operation, between the two procedures and at a minimum of two years after reoperation. MRI was performed before primary discectomy and reoperation. Fifty consecutive patients who had a disc excision during the study period but did not have recurrent radicular pain, were analysed as a control group.

Of the study group 42% related the onset of recurrent radicular pain to an isolated injury or a precipitating event, but none of the control group did so (p < 0.001). T2-weighted MRI performed before primary discectomy showed that patients in the study group had significantly more severe disc degeneration compared with the control group (p = 0.02). Intraoperative findings revealed recurrent disc herniation in 24 patients and bulging of the disc in two, one of whom also had lateral stenosis. Epidural scarring was found to be abundant, intraoperatively and on MRI, in eight and in nine patients, respectively.

At the last follow-up, the clinical outcome was satisfactory in 85% of patients in the study group and in 88% of the control group (p > 0.05). Work or daily activities had been resumed at the same level as before the onset of symptoms by 81% of the patients in the study group and 84% of the control group. No correlation was found between the amount of epidural fibrosis, as seen intraoperatively and on MRI, and the result of surgery. The recurrence of radicular pain caused no significant changes in the psychological profile compared with the assessment before the primary discectomy.

Of a total of 330 patients requiring operation on a lumbar disc, 20 (6.1%) with lateral disc prolapse had a new muscle-splitting, intertransverse approach which requires minimal resection of bone.

There were 16 men and 4 women with a mean age of 52 years. All had intense radicular pain, 15 had femoral radiculopathy and 19 a neurological deficit. Far lateral herniation of the disc had been confirmed by MRI.

At operation, excellent access was obtained to the spinal nerve, dorsal root ganglion and the disc prolapse. The posterior primary ramus was useful in locating the spinal nerve and dorsal root ganglion during dissection of the intertransverse space.

At review from six months to four years, 12 patients had excellent results with no residual pain and six had good results with mild discomfort and no functional impairment. Two had poor results. There had been neurological improvement in 17 of the 20 patients.

We report a cadaver study of the anatomy of the posterior primary ramus. It is readily identifiable through this approach and can be traced down to the spinal nerve in the intertransverse space.

We recommend the use of a muscle-splitting intertransverse approach to far lateral herniation of the disc, using the posterior primary ramus as the key to safe dissection.

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW).

Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61.

Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc.

We have studied, prospectively, 116 patients with motor deficits associated with herniation of a lumbar disc who underwent microdiscectomy. They were studied during the first six months and at a mean of 6.4 years after surgery. Before operation, muscle weakness was mild (grade 4) in 67% of patients, severe (grade 3) in 21% and very severe (grade 2 or 1) in 12%. The muscle which most frequently had severe or very severe weakness was extensor hallucis longus, followed in order by triceps surae, extensor digitorum communis, tibialis anterior, and others.

At the latest follow-up examination, 76% of patients had complete recovery of strength. Persistent weakness was found in 16% of patients who had had a mild preoperative deficit and in 39% of those with severe or very severe weakness. Muscle strength was graded 4 in all patients with persistent weakness, except for four with a very severe preoperative deficit affecting the L5 or S1 nerve root. They showed no significant recovery. Excluding this last group, the degree of recovery of motor function was inversely related to the preoperative severity and duration of muscle weakness. The patients’ subjective functional capacity was not directly related to the degree of recovery except in those with persistent severe or very severe deficit.

We made a prospective study of 43 consecutive patients treated for intraforaminal (34) or extraforaminal (9) herniations of a lumbar disc by excision through an interlaminar approach, using an operating microscope. The intraforaminal herniations were contained or extruded in 52% and sequestrated in 47%; for extraforaminal herniation the proportions were 66% and 33%, respectively. There was additional posterolateral protrusion or spinal stenosis at the level of the lateral herniation in seven and four cases, respectively. The patients were reviewed at three months and two years after surgery. Radiographs showed three grades of facetectomy: grade I, removal of 50% or less, grade II, excision of 51% to 75%, and grade III, subtotal or total facetectomy.

For intraforaminal herniations the results were excellent or good in 88% of patients when reviewed at three months and in 91% at two years. For extraforaminal herniations, there was an excellent or good outcome in 89% of patients in the short term and in all in the long term. The facetectomy had been grade I in 14 and grade II in 25; it had been grade III in four, but only one had had total facetectomy. No patient had developed vertebral hypermobility as a result of the operation.

An intralaminar approach using an operating microscope can provide adequate access to a lateral protrusion. It has the advantage of allowing the treatment of posterolateral protrusion or posterior annular bulge and of spinal stenosis at the same level.

Aims: To explore the clinical value of foot extensor digi-torum brevis (EDB) muscle in patients with unilateral lumbosacral radiculopathy. Methods: This is a prospective study of 153 patients with low back pain (LBP) and unilateral lumbosacral radiculopathy. The average duration of symptoms was 94 (1–279) days and the average age of patients was 62 (18–75) years. Twenty þve patients had disc herniation with the involvement of L4 nerve root; 32 patients with the L5, and 36 with the S1. There were 31 patients with LBP only. Patients with a history of trauma of the lower legs, repetitive mechanical irritation, or systemic diseases were excluded. In all patients full clinical and neurological examination of the spine was performed. Clinical evaluation of the EDB with resisted dorsal ßexion of the toes was also made. The size and consistency of the EDB muscle was documented and compared with that of the opposite foot. Results: Seventeen patients with L5 and S1 nerve root involvement had isolated atrophy of the EDB muscle as this was compared to the EDB of the opposite side. Conclusions: Clinical evaluation of EDB muscle in patients with unilateral lumbosacral radiculopathy may aid the examiner in understanding the nature and level of the spinal nerve root pathology.

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.

Aims. This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect. Methods. This experiment included three patients diagnosed with lumbar disc herniation who failed conservative treatment. Nucleus pulposus tissue was isolated from these patients when they underwent surgical intervention, and primary NPCs were isolated and cultured. Western blotting, reverse transcription polymerase chain reaction, fluorescence staining, and other methods were used to detect changes in related signalling pathways and the ability of cells to resist pyroptosis. Results. Western blot analysis confirmed the expression of cleaved CASP-1 and melatonin receptor (MT-1A-R) in NPCs. The cultured NPCs were identified by detecting the expression of CD24, collagen type II, and aggrecan. After treatment with hydrogen peroxide, the pyroptosis-related proteins NLR family pyrin domain containing 3 (NLRP3), cleaved CASP-1, N-terminal fragment of gasdermin D (GSDMD-N), interleukin (IL)-18, and IL-1β in NPCs were upregulated, and the number of propidium iodide (PI)-positive cells was also increased, which was able to be alleviated by pretreatment with melatonin. The protective effect of melatonin on pyroptosis was blunted by both the melatonin receptor antagonist luzindole and the nuclear factor erythroid 2–related factor 2 (Nrf2) inhibitor ML385. In addition, the expression of the transcription factor Nrf2 was up- or downregulated when the melatonin receptor was activated or blocked by melatonin or luzindole, respectively. Conclusion. Melatonin protects NPCs against reactive oxygen species-induced pyroptosis by upregulating the transcription factor Nrf2 via melatonin receptors. Cite this article: Bone Joint Res 2023;12(3):202–211

Aims. Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD. Methods. In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated. Results. Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325). Conclusion. Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392–1399

It has been proposed that intervertebral disc degeneration might be caused by low-grade infection. The purpose of the present study was to assess the incidence of herpes viruses in intervertebral disc specimens from patients with lumbar disc herniation. A polymerase chain reaction based assay was applied to screen for the DNA of eight different herpes viruses in 16 patients and two controls. DNA of at least one herpes virus was detected in 13 specimens (81.25%). Herpes Simplex Virus type-1 (HSV-1) was the most frequently detected virus (56.25%), followed by Cytomegalovirus (CMV) (37.5%). In two patients, co-infection by both HSV-1 and CMV was detected. All samples, including the control specimens, were negative for Herpes Simplex Virus type-2, Varicella Zoster Virus, Epstein Barr Virus, Human Herpes Viruses 6, 7 and 8. The absence of an acute infection was confirmed both at the serological and mRNA level. To our knowledge this is the first unequivocal evidence of the presence of herpes virus DNA in intervertebral disc specimens of patients with lumbar disc herniation suggesting the potential role of herpes viruses as a contributing factor to the pathogenesis of degenerative disc disease

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

Aims. The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results. A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days . (sd. 46.5) and 47 days . (sd. 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm . (sd. 10.3) and a mean VAS for arm pain of 6.3 mm . (. sd. 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (. sd. 12.4; p < 0.001); mean NPAD, 19.3 (. sd. 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (. sd. 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (. sd. 6.8; p = 0.103). Conclusion. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71

Purpose. To investigate sociodemographic and clinical characteristics in patients operated for lumbar disc herniation in public and private hospitals, and evaluate whether selection for surgical treatment were different across the two settings. Methods and results. A cross-sectional multicenter study of patients who underwent a total of 5308 elective surgeries for lumbar disc herniation at 41 hospitals. Data were included in the Norwegian Registry for Spine Surgery (NORspine). Of 5308 elective surgical procedures, 3628 were performed at 31 public hospitals and 1680 at 10 private clinics. Patients in the private clinics were slightly younger, more likely to be man, have higher level of education, and more likely to be employed. The proportions of disability and retirement pension were more than double in public as compared to private hospitals. Patients operated in public hospitals were older, had more obesity and co-morbidity, lower educational level, longer duration of symptoms, and sick leave and were less likely to return to work. Patients operated in public hospitals reported more disability and pain, poorer HRQol and general health status than those operated in private clinics. The differences were consistent but small and could not be attributed to less strict indications for surgical treatment in private clinics. Conclusion. Indications for surgical treatment of lumbar disc herniation appear to be similar in public and private hospitals. Patients operated in private clinics seem to be handled more effectively. They were younger, healthier and had more socioeconomic and lifestyle attributes, known to be predictors more favorable outcomes after surgery

Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for decision making, the merit of predictable outcome with THA first, leg weakness as an indication for spine surgery, the concern of THA position with spinal deformity, and the urgency of myelopathy. Conclusion. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial in certain clinical scenarios, even for experienced hip and spine surgeons. Additional outcome studies of these patients are necessary for appropriate decision making

The February 2014 Spine Roundup. 360 . looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side. A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI). There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05). Revision discectomy can give results that are as good as those seen after primary surgery. Cite this article: Bone Joint J 2013;95-B:90–4

Introduction: A far lateral access is required in fullen-doscopic operations of sequestered lumbar disc herniations to achieve a sufficient decompression of the ventral epidural space. The conventional endoscopes and instruments had very narrow limits especially in the mobility and possibility to resect hard tissue and to clean the intervertebral space sufficiently. The aim of this prospective study was to investigate the extended possibilities of the new endoscopes and instruments with regard to the efficacy of decompression, the advantages and problems of this technique in comparison to previous data. Methods: 368 patients with lumbar disc herniations have been treated in 2002 and 2003 in a full endoscopic transforaminal technique using a lateral access. A 7-mm endoscope with 4 mm-working canal and new designed instruments were used. Follow-up lasted at least 12 months. 298 patients (81%) could be followed. Results: No intraoperative complication occurred. 6 patients reported a transient dysaesthesia postoperatively. The average operation time was 28 minutes. A sufficient decompression could be achieved in all cases. 244 patients (82%) reported no more leg pain after surgery, 42 patients (14%) had transient persistence in the first 6 weeks. 8 patients (2,7%) showed a recurrent herniation, 7 of those were reoperated in the same technique. Discussion/Conclusion: As a minimally invasive technique wich efficacy of decompression is equal to an open procedure we see advantages over conventional operations of lumbar disc herniations. Within the inclusion criterias of indication this technique is sufficient and safe. The technical developments on endoscopes and instruments lead to a decrease of recurrence, increase of mobility as well as the possibility of resection of hard tissue and sufficient cleaning of the intervertebral space. The combination of a far lateral access with other approaches extends the spectrum of indications with regard to full endoscopic bony decompression and fusion

The December 2012 Spine Roundup. 360. looks at: the Japanese neck disability index; adjacent segment degeneration; sacroiliac loads determined by limb length discrepancy; whether epidural steroids improve outcome in lumbar disc herniation; spondylodiscitis in infancy; total pedicle screws; and iliac crest autograft complications

The December 2014 Spine Roundup. 360 . looks at: surgeon outcomes;. complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis

Background. Microdiscectomy involves substantial aggressive excision of disc material from the intervertebral space to prevent reherniation. However, the recent trend is towards conservative disc removal and simple fragment excision (sequestrectomy). Aim. To compare the clinical outcome of microdiscectomy and sequestrectomy. Methods. During the 2-year study period, we performed 196 lumbar microdiscectomies for disc herniation. One hundred and one patients met the inclusion criteria: unilateral single level lumbar disc herniation. Cases suitable for sequestrectomy were based on intraoperative assessment (stable fibrous ring without significant disc bulge; posterior longitudinal ligament perforation of < 5mm). Results. Five patients were lost to follow-up, 72 patients underwent conventional microdiscectomy and 24 patients were suitable for sequestrectomy and included in the final analysis. There was no significant difference in terms of age and pre-operative VAS in both groups (p >0.05, unpaired t test. In the microdiscectomy group, 17/31 patients with motor deficit and 34/66 patients with sensory deficit showed post-operative improvement, but in sequestrectomy group, only 1 of 5 patients with motor deficit and 8 of 13 with sensory deficit recovered but this was not statistically significant (p>0.05, Fisher's exact test). Conclusion. In the sequestrectomy group, patients had significantly better improvement in VAS score. There was no significant difference between either group with regards to reherniation or post-operative neurological deficit. In a selected group of patients with single level lumbar disc herniation, clinical outcome of sequestrectomy is comparable to conventional microdiscectomy

The April 2023 Spine Roundup³⁶⁰ looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

The December 2022 Spine Roundup³⁶⁰ looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making

Aims

The aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.