Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Introduction: This study is performed to investigate the efficacy of steroid, local anaesthesia (LA) or combination of both in reducing post operative pain in lumbar discectomy. Materials and Methods: The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups of 1ml of steroid and 1ml of LA, 1ml of steroid and 1ml of saline, 1ml of LA and 1ml of saline and 2mls of saline as control. 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine were used. Combinations of above were applied topically over the nerve root prior to closure. Preoperative, day 1 and eight weeks post operative visual analogue pain score were recorded. 10cm visual analogue pain score chart was used. 24 hours post operative opiate analgesia requirements and duration of inpatient stay were recorded. Data was analysed using Student t-test and Fisher exact t-test. Results: No significant differences seen in the mean pre operative pain score between all groups. Mean Day 1 post operative pain and analgesia requirement in steroid and LA, steroid only, LA only and control group were 0.9, 2.5, 2.1 and 3.3 respectively. Mean opiate analgesia requirement 24 hours post operatively were 32.4mg, 54mg, 32.4mg and 56.8mg respectively. Mean inpatient stay were 2.2day, 3.91day, 4.62day and 3.63day respectively. At 8 weeks post operatively, no significant differences in the pain score in all groups. Conclusions: Significant post operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p< 0.05). The results are reflected as well in significant reduction in the post operative analgesia requirement (p< 0.05) and the significant reduction in inpatient stay. (p< 0.05) We recommended the use of perioperative steroid and LA infiltration in lumbar discectomy. Improved post operative pain control reduces post operative opiate analgesia requirement and reduced inpatient stay

Introduction. This study was performed to investigate the efficacy of steroid and local anaesthesia (LA) in reducing post-operative pain in lumbar discectomy. Materials and methods. The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups, which were (Group 1) 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine, (Group 2) 10mg of adcortyl and 1ml of normal saline, (Group 3) 1ml of 0.5% marcaine and 1ml of normal saline and (Group 4) 2mls of normal saline as control. Combinations of the above were applied topically over the nerve root prior to closure. Pre-operative, day 1 and eight weeks post-operative pain scores were recorded. 24 hours post-operative opiate analgesia requirements and duration of inpatient stay were recorded. Data were analysed using student t-test for statistical significance. Results. 100 patients were recruited into the study. There were no significant differences seen in the mean age, gender and the mean pre-operative pain score between all groups. Mean day one pain score in groups 1,2,3 and 4 was 0.9,2.5, 2.1 and 3.3 respectively. Mean 24 hours post-operative opiate requirement was 32.4mg, 54mg, 48.8mg and 56.4mg respectively. Mean inpatient stay was 2.2 days, 3.9 days, 4.62 days and 3.63 days respectively. A significant different (p<0.05) was noted in day one post-operative mean pain score, mean 24 opiate requirement and mean inpatient stay in the corticosteroid and LA group. At 8 weeks post-operatively, no significant differences were seen in the pain score in all groups. Conclusions. Significant early post-operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p<0.05). A significant reduction in the 24-post operative analgesia requirement (p<0.05) and in inpatient stay (p<0.05) was also observed

We have studied 180 patients (128 men and 52 women) who had undergone lumbar discectomy at a mean of 25.4 years (20 to 32) after operation. Pre-operatively, most patients (70 patients; 38.9%) had abnormal reflexes and/or muscle weakness in the leg (96 patients; 53.3%). At follow-up 42 patients (60%) with abnormal reflexes pre-operatively had fully recovered and 72 (75%) with pre-operative muscle impairment had normal muscle strength. When we looked at patient-reported outcomes, we found that the Short form-36 summary scores were similar to the aged-matched normative values. No disability or minimum disability on the Oswestry disability index was reported by 136 patients (75.6%), and 162 (90%) were satisfied with their operation. The most important predictors of patients’ self-reported positive outcome were male gender and higher educational level. No association was detected between muscle recovery and outcome. Most patients who had undergone lumbar discectomy had long-lasting neurological recovery. If the motor deficit persists after operation, patients can still expect a long-term satisfactory outcome, provided that they have relief from pain immediately after surgery

Objectives: A retrospective study of patients undergoing second operation after initial lumbar discectomy, to investigate the reasons associated. Methods: In a period of three years a total number of 30 patients had a reoperation after lumbar discectomy. The initial operation performed before one month to five years. There is a evaluation of intraoperative findings and of a short period of follow up. Data were obtained from Spine Unit of Errikos Dunan Hospital. Results: Among 30 patients, 60% were recurrent disc herniations, 18% were fusions and 22% were decompressions. The follow up is from two months to three years for 25 patients, 4 patients had further spinal surgery. Very satisfied, satisfied were 80% of patients. Conclusion: Although reoperation after lumbar discectomy is uncommon, it is very possible to face it because of the increasing number of initial discectomies performed

Purpose: Persistent radiculopathy secondary to lumbar disc herniation is a common problem that greatly compromises quality of life. In North America, lumbar discectomies are among the most common elective surgical procedures performed. There is still much debate about when conservative or surgical treatments should be offered to patients. Although the related literature is comprehensive, there are limited systematic reviews on the prognostic factors predicting the outcome of lumbar discectomy. The purpose of this review is to define the preoperative factors predicting clinical outcome after lumbar discectomy. Method: We conducted a computerized literature search using Ovid Medline and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials or prospective studies dealing with lumbar disc surgery. The preoperative predictors had to be clearly identified and correlated with outcome measures in terms of pain, disability, work capacity, analgesia consumption, or a combination of these measures. We assessed the articles as high or low quality studies using the Newcastle-Ottawa Quality Assessment Scale, and summarized the results of High Quality Studies. Results: A total of 39 articles were included. The two most prominent negative predictors were Workers’ Compensation status and depression according to 6 studies. Poor predictors reported in 4 articles were female gender, increasing age, and prolonged duration of leg or back pain. Lower education level, smoking, and higher levels of psychological complaints were negative predictors in 3 articles. A positive Lasègue sign was a positive predictor in 7 articles. Absence of back pain, positive patient expectations, and higher income were good prognostic factors in 3 studies. Patients with contained herniations did worse than those who had uncontained disc extrusions and sequestrations according to 4 studies. The level of herniation was not a predictive factor in 7 studies. Conclusion: Workers’ Compensation, depression, greater back versus leg pain, increasing age, female gender, contained herniations, and prolonged symptoms predict unfavourable postoperative outcomes after lumbar discectomy. Positive Lasègue sign, higher income, uncontained herniations, and positive patient expectations predict favourable postoperative outcomes. The level of herniation is not an established prognostic factor. The results of this review provide a preliminary framework for patient selection for lumbar disc surgery

Background: Traditionally, lumbar discectomy is performed under general anaesthesia because of ability to perform operations of long duration in prone position with a secure airway. Some recent reports suggest better outcomes with regional anaesthesia. Aim: The aim of this study was to compare the intra-operative and short-term post-operative outcome variables in patients undergoing primary single-level lumbar discectomy with epidural and general anaesthesia. Methods: This was a prospective randomized trial involving sixty patients over a two-year period in a tertiary hospital in India. Patients were allocated into two groups: Group A (n=30) patients received general anaesthesia and Group B (n=30) patients received epidural anaesthesia. Baseline and intra-operative haemodynamic parameters, surgical duration, surgical onset time, intra-operative blood loss, cost incurred by patient, nausea and vomiting and post-operative pain score were also recorded. Results: The groups were comparable for demographic data and baseline hemodynamic observations. Patients in the epidural anaesthesia group had significantly lower blood loss (p< 0.001), lower peak pain scores (p< 0.001), lesser surgical time (p< 0.001),and significantly reduced post-operative nausea and vomiting (p< 0.01) as compared to the general anaesthesia group. The cost incurred for epidural anaesthesia was two third of that incurred in general anaesthesia (p< 0.001). Epidural group had significantly more surgical onset time (p< 0.001). Conclusion: Lumbar discectomy can be safely performed using epidural anaesthesia. The intra-operative blood loss, surgical duration, cost incurred by the patient, postoperative nausea, vomiting and pain are significantly reduced in patients receiving epidural anaesthesia, thereby leading to a significantly higher patient satisfaction. In the present climate of NHS, where any initiative to cut down the cost of resources consumed is welcomed as long as the patient safety is not compromised, epidural anaesthetic may provide an effective alternative to general anaesthetic for lumbar discectomy

The optimum timing of lumbar discectomy for sciatica is imprecise. We have investigated a number of prognostic factors in relation to the outcome of radiculopathy after lumbar discectomy. We recruited 113 consecutive patients of whom 103 (91%) were followed up at one year. We found a significant association between the duration of radiculopathy and the changes in the Oswestry Disability Index score (p = 0.005) and the low back outcome score (p = 0.03). Improvement in pain was independent of all variables. Patients with an uncontained herniated disc had a shorter duration of symptoms and a better functional outcome than those with a contained herniation. Our study suggests that patients with sciatica for more than 12 months have a less favourable outcome. We detected no variation in the results for patients operated on in whom the duration of sciatica was less than 12 months

We performed a prospective study to examine the influence of the patient’s position on the location of the abdominal organs, to investigate the possibility of a true lateral approach for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy. Axial images in parallel planes of each intervertebral disc from L1 to L5 were achieved in both supine and prone positions. The most horizontal approach angles possible to avoid injury to the abdominal organs were measured. The results demonstrated that the safe approach angles were significantly less (i.e., more horizontal) in the prone than in the supine position. Obstacles to a more lateral approach were mainly the liver, the spleen and the kidneys at L1/2 (39 of 40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4 (33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach from each side was possible for 30 of the 40 discs at L3/4 (75%) and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more horizontal approach for transforaminal endoscopic lumbar discectomy is possible in the prone position but not in the supine. Prone abdominal CT is more helpful in determining the trajectory of the endoscope. While a true lateral approach is feasible in many patients, our study shows it is not universally applicable.

The indications for lumbar discectomy are pain and neurological dysfunction. This paper considers the extent and timing of neurological recovery following spinal decompression

We treated 137 patients with symptomatic lumbar disc prolapse by automated percutaneous lumbar discectomy (APLD). Seventeen (12%) required further operation. At a mean follow-up of 55 months, the success rate was 45%. Of those who had APLD alone, 52% were graded as either excellent or good. In this group, 76% were employed, and the mean Oswestry score was 28.2%. One-third of those patients initially rated as successful had deterioration in symptoms and increased disability from back pain. The Short Form 36 health survey questionnaire revealed that these patients had a chronic ill-health profile

We used gadolinium-enhanced fat-suppressed MRI to investigate 67 patients with persistent pain after lumbar discectomy. Twenty-five patients had reoperations for lesions diagnosed in this way. Eleven were for recurrent disc prolapse at the same level and sciatica was relieved by all but one. Five operations were for prolapse at an adjacent level and all were successful. The diagnosis of sepsis was less precise, but extension of tissue enhancement into the operated disc space was found to be significant. Only three patients had evidence of arachnoiditis which suggests that this condition has been too often diagnosed as a cause of persisting low back pain

Autologous chondrocyte transplantation is technically feasible and biologically relevant to repairing disc damage and retarding disc degeneration in animal models. Prospective clinical trials with open discectomy, cultivation of disc cells and transplantation by a minimally invasive procedure are ongoing (co.don chondro-transplant DISC). We used the decompressor (Stryker) for percutaneous lumbar discectomy to harvest disc cells for cultivation. A cannula was placed in the degenerated disc. The 1,5mm decompressor was introduced through the cannula. 0,5–1,5 millilitres of disc material was aspirated. In the laboratory the material was cultured using the patients serum. The cells were expandable. The capacity of the cells to produce matrix molecules was proven in vitro. The percutaneous discectomy of contained discs with signes of early degeneration, the expansion and the transplantation of autologous chondrocytes to the disc might be a possibility of repairing disc damage and retarding disc degeneration

Lumbar discectomy is now the operation of choice for lumbosacral radicular syndrome. Few studies of high quality have been performed on the post surgical management of these cases. The studies that have been reported compared one exercise regime to another. This study compares an exercise group with a true control group involving no exercise or formal rehabilitation. This is a randomized controlled trial comparing post surgical lumbar discectomy management regimes. Ninety three lumbar discectomy patients were randomized to two groups. Group A; the control group followed usual surgical advice which was to resume normal activity as soon as pain allowed. Group B; undertook a six month supervised non aggravating gym rehab programme. Both groups were followed for a one year period using validated outcome measures and a questionnaire. The results are based on an intention-to-treat analysis. Patients in both groups improved during the one year follow up period (P=0.001). However there was no statistical difference between groups at the clinical end point (Roland Morris P=0.83, Oswestry Low back index P=0.90). Group B patients returned to work seven days earlier than group A patients and had fewer days off work in the one year follow up period but this difference was not statistically significant. There was no statistical advantage gained by the patients who performed the gym rehabilitation programme after one year follow up. These are the preliminary one year results of a three year follow up study

A randomised double-blind study was carried out on 60 patients undergoing elective lumbar discectomy. Patients in the study group (n = 30) received an injection of 10 ml of 0.5% bupivacaine into the wound; the control group (n = 30) received none. Postoperative pain was measured by a visual analogue pain scale and by the amount of morphine administered by a patient-controlled analgesia system. Patients in the study group had lower pain scores, used less morphine, waited longer until their first demand for analgesia and reported their postoperative pain to be less severe

Design of study: Prospective, observational. Purpose of the study: Obese and morbidly obese patients undergoing lumbar surgery can be a challenge to the operating surgeon. Reports on the perioperative data in this group of patients are scarce. The purpose of the study is to prospectively compare the perioperative data in patients with normal and high BMI, undergoing lumbar spine surgery. Method: We conducted a prospective audit of 50 consecutive patients who underwent primary discectomy or single level decompression under the care of single spine surgeon. Initial Low Back Outcome Score, length of incision, distance from skin to spinous process, distance from skin to lamina, length of hospital stay, blood loss and complications were studied in detail. Results: We used student t test to compare the two groups and Pearson Correlation to correlate the data against high BMI. We were unable to demonstrate a statistically significant difference between those with normal BMI and high BMI in any of the above parameters analysed. Conclusion: A high BMI was not associated with an increased perioperative morbidity in this patient group. Contrary to other areas of orthopaedic surgery, there is no statistically significant difference in the Initial Low Back Outcome Score and perioperative data between patients with normal and high BMI undergoing lumbar discectomy and single level decompression. Conflict of Interest: None. Source of Funding: None

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.

Objective: To assess the clinical effectiveness of dexamethasone wound infiltration post lumbar discectomy. Design: A prospective, double blind, randomised study comparing morphine consumption in two groups of patients in elective lumbar spine surgery via the posterior approach. Subjects: There were forty patients divided into two randomly selected groups, one received postoperative wound infiltration with dexamethasone, the other with saline. Their morphine usage was measured. Outcome measures: These included levels of morphine use postoperatively, pain scores and length of hospital stay. Results: There was no statistically significant difference between postoperative morphine consumption in the two groups or in the length of hospital stay. There appeared to be improvement in pain scores with dexamethasone. There were no complications. Conclusion: Postoperative wound infiltration with dexamethasone may result in some subjective improvement in pain, but none in analgesic consumption. Despite the lack of complications the subjective benefits do not outweigh the risks in the absence of objective improvement in pain

We would like to present a rare case report describing a case in which new-onset tonic-clonic seizures occurred following an unintentional durotomy during lumbar discectomy and decompression. Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%. To our knowledge a case of new onset epilepsy has never been reported in the literature. Although dural rupture during surgery and CSF hypovolemia are thought to be the main contributing factors, one can postulate on the effects of anti-psychiatirc medication with epileptogenic properties. Amisulpride and Olanzapine can lower seizure threshold and therefore should be used with caution in patients previously diagnosed with epilepsy. However manufacturers do not state that in cases were the seizure threshold is already lowered by CSF hypotension, new onset epilepsy might be commoner. Finally, strong caution and aggressive post-operative monitoring is advised for patients with CSF hypotension in combination with possible eplieptogenic medication. Conflict of Interest: None. Source of Funding: None

Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains.

This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure.

To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined.

Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective.

In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective