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

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

Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

Purpose:. To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. Methods:. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year. Results:. No serious complications occurred. Of the 50 patients who received the addition of clonidine, 56% were classified as successful injections, with no further intervention required, as opposed to 40% who received the standard injection. This difference did not reach statistical significance (p=0.109, chi-squared test). All secondary measures showed no statistically significant differences between the groups except curiously, the standard group who had been classified as successful had better leg pain relief than the clonidine group (p=0.026) at 1 year. Conclusions:. This pilot study has shown a 16% treatment effect with adding clonidine to lumbar nerve root blocks and that it is a safe injectate for this purpose

Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases. Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined. Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007). Procedures were bilateral, left or right. 126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected. There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice

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

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro). 48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery. Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated. 25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES). Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery

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.

There is no universally agreed definition of cauda equina syndrome (CES). Clinical signs of CES including direct rectal examination (DRE) do not reliably correlate with cauda equina (CE) compression on MRI. Clinical assessment only becomes reliable if there are symptoms/signs of late, often irreversible, CES. The only reliable way of including or excluding CES is to perform MRI on all patients with suspected CES. If the diagnosis is being considered, MRI should ideally be performed locally in the District General Hospitals within one hour of the question being raised irrespective of the hour or the day. Patients with symptoms and signs of CES and MRI confirmed CE compression should be referred to the local spinal service for emergency surgery.

CES can be subdivided by the degree of neurological deficit (bilateral radiculopathy, incomplete CES or CES with retention of urine) and also by time to surgical treatment (12, 24, 48 or 72 hour). There is increasing understanding that damage to the cauda equina nerve roots occurs in a continuous and progressive fashion which implies that there are no safe time or deficit thresholds. Neurological deterioration can occur rapidly and is often associated with longterm poor outcomes. It is not possible to predict which patients with a large central disc prolapse compressing the CE nerve roots are going to deteriorate neurologically nor how rapidly. Consensus guidelines from the Society of British Neurological Surgeons and British Association of Spinal Surgeons recommend decompressive surgery as soon as practically possible which for many patients will be urgent/emergency surgery at any hour of the day or night.

Cite this article: Bone Joint J 2015;97-B:1390–4

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m² (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m², p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m² (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p <  0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m²) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES.