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

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

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

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

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

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

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

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

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

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.

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

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