Aims. Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse. Methods. We retrieved data from the Swedish spine register about 3,291 patients who underwent primary surgery for a lumbar disc prolapse between January 2007 and December 2008. These patients were followed until December 2020 to record all additional lumbar spine operations and the reason for them. Results. In total, 681 of the 3,291 patients (21%) needed one or more additional operations. More than three additional operations was uncommon (2%; 15/906). Overall, 906 additional operations were identified during the time period, with a mean time to the first of these of 3.7 years (SD 3.6). The most common reason for an additional operation was recurrent disc prolapse (47%; 426/906), followed by spinal stenosis or degenerative spondylolisthesis (19%; 176/906), and segmental pain (16%; 145/906). The most common surgical procedures were revision discectomy (43%; 385/906) and instrumented fusion (22%; 200/906). Degenerative spinal conditions other than disc prolapse became a more common reason for additional surgery with increasing length of follow-up. Most patients achieved the minimally important change (MIC) for the patient-reported outcomes after the index surgery. After the third additional spinal operation, only 20% (5/25) achieved the MIC in terms of leg pain, and 29% (7/24) in terms of the EuroQol five-dimension index questionnaire visual analogue scale. Conclusion. More than one in five patients operated on for a lumbar disc prolapse underwent further surgery during the 13-year follow-up period. Recurrent disc prolapse was the most common reason for additional surgery, followed by spinal stenosis and segmental pain. This study shows that additional operations after primary disc surgery are needed more frequently than previously reported, and that the outcome profoundly deteriorates after the second additional operation. The findings from this study can be used in the shared decision-making process. Cite this article: Bone Joint J 2022;104-B(5):627–632

Objectives: To establish the side incidence of acute lumbar disc prolapse and to determine whether there is a correlation between the side of the prolapse and hand dominance. Design: A retrospective study of consecutive cases of acute lumbar disc prolapse in which the diagnosis was confirmed at operation and the patients contacted about hand dominance. Summary of background data: The side incidence of operatively confirmed disc herniation does not appear to have been reported. Lifting and turning with the trunk in the flexed position is the commonest cause of an acute disc prolapse. Flexion and rotation of the lumbar spine, under load, may also give rise to unilateral fractures in the lumbar spine in fast bowlers in cricket and in eighty percent of these cases the fracture occurs on the opposite side to the bowling arm (ref . 1. ) Given that the majority of the population (eighty nine percent) are right handed it was speculated that the incidence of lumbar disc prolapse might not be equal and might be greater on the side opposite the dominant hand. Methods: From a review of case notes one hundred and twenty six patients were identified in which a sequestrated disc fragment was confirmed at operation. The side of the prolapse was noted. These patients were contacted to determine their hand dominance. Results: Fifty nine patients (47%) had a disc prolapse on the right side and sixty seven (55%) had a disc prolapse on the left side. There was no statistically significant difference in the numbers. Ninety two of the one hundred and twenty six patients contacted about their hand dominance responded: eighty three patients (90.2%) were right handed, eight (8.7%) were left handed and one patient (1.1%) was ambidextrous. Of the eighty three right handed patients, forty (48.2%) had a left sided disc prolapse and forty three (51.8%) had a right sided disc prolapse. Conclusion: This study revealed no difference in the side incidence of lumbar disc prolapse. There was no correlation either with the side of the prolapse and hand dominance. The findings are considered to support the view that a disc prolapse, and the side on which it occurs, is not a consequence of a single unilateral action but an end product of pre-existing disc degeneration in a midline structure

To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse. Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise. 80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is. the crossed straight leg raise. The straight leg raise has not been shown to have high validity

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between Radiologists’ interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a pre-eminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results Reliability tests show only fair agreement (k=0.36) between the Radiologists and at best only moderate agreement (=0.41) between the Radiologists and surgical findings. Conclusion: MRI is an excellent tool for diagnosis of a disc prolapse. MRI is poor at defining the character of a disc prolapse, and does not appear to help in classifying discs suitable for percutaneous treatment

1. Ten patients with neurological evidence of damage to the intrathecal sacral nerve roots of the cauda equina by verified lumbar disc prolapse are described. 2. The nature of the bladder paralysis has been investigated by cystometry and the findings contrasted with published opinions. 3. The prognosis of the bladder paralysis has been established by review up to six years after removal of the disc prolapse. No evidence of recovery of complete bladder paralysis has been found, but the consequences of persistent bladder paralysis have been much less severe than previous reports have stated. Reasons have been suggested for this. 4. Principles of recognition and management of bladder paralysis due to cauda equina lesions have been stated and methods suggested

Study Purpose. To examine the presence of radicular pain and its relationship to the degree of lumbar nerve root compression in patients with a degenerative lumbar spine condition about to undergo surgery for either lumbar disc prolapse or lumbar canal stenosis. Background. The pathophysiology underlying radicular pain is not completely understood but it is thought that nerve root compression is a key factor and from a surgical perspective, decompressing the nerve root is considered to be the key therapeutic step. However, despite often severe root compression in patients with lumbar stenosis, radicular pain is not a typical feature. Methods. Thirty-nine pre-surgical patients with either lumbar disc prolapse or lumbar canal stenosis were studied using the Standardised Evaluation of Pain (StEP), a clinical assessment tool known to predict with a high degree of sensitivity and specificity the presence or absence of lumbar radicular pain. A nerve root compression score was given from lumbar MRI for each patient by a neuroradiologist blinded to the patients history. Results. The StEP assessment tool was able to distinguish the presence or absence of radicular pain with high sensitivity and specificity. This correlated well with the pre-operative diagnosis of disc prolapse or canal stenosis. The relationship between radicular pain and nerve root compression was less clear and will be discussed. Conclusion. This study confirms StEP as a useful bedside tool for identifying the presence of radicular pain in patients with a degenerative lumbar spine condition. Nerve root compression per se does not necessarily produce radicular pain. Conflicts of Interest. None. Source of Funding. None. This study has not been published or presented at a previous meeting

The pre-operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for prolapsed intervertebral disc were reviewed. Prolapse was recognized as bulging or sequestration of the disc with consequent root compromise. Measurement of the lumbar level of the interiliac line was shown to correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacral junction was significantly higher than normal. A pathological value for the lumbosacral angle could not be identified

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings. Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent. 2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay. 3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided. 4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence". 5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work. 6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation. 7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis. 8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes. 9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space

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

Study design: Prospective longitudinal cohort study with three month and one year follow up.

Objective: To determine what factors influence standard spine and urinary outcome measures at 3 months in cauda equine syndrome with particular attention being given to timing of onset of symptoms and timing of surgery.

Subjects: There were 31 cases submitted from the membership of BASS who underwent urgent surgery for cauda equina syndrome. Three month follow up was achieved in 25 (80%).

Outcome measures: Oswestry disability index (ODI), Visual analogue score for leg pain, Visual analogue score for back pain and incontinence questionnaire using a short form MRC outcome tool.

Results: The average age was 43 years. Ten patients had surgery within 48 hours of onset of symptoms, the remainder had more than 48 hours to surgery. Most patients received prompt attention after reaching secondary care with only four waiting more than 24 hours for surgery after scanning. There was no difference in ODI. VAS leg and back were better in the less than 48 hours group. Urinary symptoms and satisfaction did not appear to be influenced by surgery within 48 hours.

Conclusion: The duration of symptoms prior to surgery does not appear to influence the short-term outcome as measured by the Oswestry Disability Index and specific questions related to satisfaction with urinary outcome measures.

The purpose of this study was to design a questionnaire to evaluate patients’ satisfaction with the healthcare system relating to their spinal procedure, and to gather information relating to pre and post operative management. If successful, this questionnaire will be incorporated into the FASTER (Function after spinal treatment, exercise and rehabilitation) study, with the aim of identifying common care pathways and to understand where stumbling blocks arise.

The questionnaire included three sections: Care before surgery, care after surgery, plus general measures of satisfaction. Patients were randomly selected from the hospital records if they had undergone a lumbar discectomy or lateral nerve root decompression within the past year; this included both NHS and private patients.

34 pilot questionnaires were sent, to date 18 have been returned (9 NHS and 9 private patients). It was found that 79% of patients went to their GP when first experiencing pain/discomfort; however, alarmingly, an overwhelming majority of these patients felt their problem was not dealt with correctly at this stage. Fifty percent of the patients who went through the NHS “Definitely” felt left alone to deal with their problem. Only 10% of patients had physiotherapy prior to surgery and none went to pain management classes. 32% of patients received physiotherapy after leaving hospital; however, in all but one case this was after returning with symptoms.

Despite this, patients in general were very pleased with the care they received during there hospital stay. This pilot data provides an insight into the issues experienced by spinal surgery patients.

Purpose of study and background

The primary aim of the study was to test the feasibility of conducting a full RCT with economic analysis and help to inform the provision of physiotherapy in a specific sub-group of patients with sciatica

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. Methods. Patients were asked to prospectively complete visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores on the day of their MRI scan. All patients with primary disc herniation were included. Exclusion criteria included recurrent disc herniation, cauda equina syndrome, or any other associated spinal pathology. T2 weighted MRI scans were reviewed on picture archiving and communications software. The T2 axial image showing the disc protrusion with the largest cross sectional area was used for measurements. The area of the disc and canal were measured at this level. The size of the disc was measured as a percentage of the cross-sectional area of the spinal canal on the chosen image. The VAS leg pain and ODI scores were each correlated with the size of the disc using the Pearson correlation coefficient (PCC). Intraobserver reliability for MRI measurement was assessed using the interclass correlation coefficient (ICC). We assessed if the position of the disc prolapse (central, lateral recess, or foraminal) altered the symptoms described by the patient. The VAS and ODI scores from central and lateral recess disc prolapses were compared. Results. A total of 56 patients (mean age 41.1 years (22.8 to 70.3)) were included. A high degree of intraobserver reliability was observed for MRI measurement: single measure ICC was 0.99 (95% confidence interval (CI) from 0.97 to 0.99 (p < 0.001)). The PCC comparing VAS leg scores with canal occupancy for herniated disc was 0.056. The PCC comparing ODI for herniated disc was 0.070. We found 13 disc prolapses centrally and 43 lateral recess prolapses. There were no foraminal prolapses in this group. The position of the prolapse was not found to be related to the mean VAS score or ODI experienced by the patients (VAS, p = 0.251; ODI, p = 0.093). Conclusion. The results of the statistical analysis show that there is no direct correlation between the size or position of the disc prolapse and a patient’s symptoms. The symptoms experienced by patients should be the primary concern in deciding to perform discectomy. Cite this article: Bone Joint J 2022;104-B(6):715–720

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively. Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively. Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery. Outcome Measures: Spontaneous reduction of disc herniation on MRI scans. Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain. Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases

Background. Gore and Nadkarni described a ‘Gore sign’ of reproducing radiating leg pain by palpation of distal nerve root endings in the foot for L5 and S1 nerve roots in lumbar radiculopathy due to disc prolapse. Purpose. This sign was explored and observation of symptoms recorded. Results. There were 31 patients, 20 females and 11 males, aged 25 to 76 years. 13 patients had acute disc prolapse, 14 had lumbar canal stenosis, 3 had annular tears and one had a facet cyst. Radiating leg pain was reproduced in all patients by palpation of distal nerve root endings and was immediately relieved by local anaesthetic injection around distal nerve root endings in all patients (second part of Gore test). New clinical signs were observed which have not been described before:. Back pain was reproduced in 21 patients. L4 nerve root pain was reproduced in 13 patients by palpation of the proximal tibia. Crossed leg pain was reproduced in 5 patients. Reproduction of pain by palpation of more than one distal nerve root ending was observed in 16 patients. Cessation of radiating leg pain by palpation of distal nerve root endings in two patients. These test were positive in patients with varied pathology producing radiculopathy, not just disc prolapse. Conclusion. Provocative nerve root tension signs can be difficult in severe pain. The tests described above can be performed without having to move the patient's lower limb. These observations open up discussion on the mechanism of radiculopathy and new ways of treatment. Conflicts of interest: None. Sources of funding: None

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

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