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

Aim. To compare outcomes of revision lumbar discectomy to primary surgery in the same patient cohort. Methods. Prospective outcome data in 36 patients who underwent primary and subsequent revision surgery for lumbar disc herniation between 1995 and 2009. Outcome measures used were Visual Analogue Scores for back (VAB) and leg pain (VAL), the Oswestry Disability Index (ODI) and Low Back Outcome Score (LBO). 5 early recurrences within 3 months were excluded. Results. Complete data was available in 31 patients 13F;18M. The average age was 39 years at index and 45 years at revision. Average interval between surgery of 39 months (range 6-122). Mean Pre op ODI 54 and VAL 73 primary procedure, final follow up of primary procedure ODI 33, VAL 43; prior to revision ODI 57, VAL 75; at last FU ODI 32 and VAL 40. There was no statistical difference between outcomes. In the primary discectomy group there was a statistically significant improvement in the VAL, ODI and LBO scores (P<0.05), with no significant improvement in the VAB (P=0.67). In the revision group there was a statistical significant improvement in all the outcomes (P<0.05). Overall, 45% of patients felt their outcome from revision discectomy was better/much better with 54% of patients rating their treatment as either good/excellent. Conclusion. Primary discectomy produced significant improvement in leg pain, ODI and LBO. Revision discectomy did the same, but also a significant improvement in VAB scores. There was no statistically significant difference in comparing the preoperative and postoperative scores for both procedures. Revision discectomy is a procedure which yields clinically significant and patient perceived improvements in spinal outcome measures with an unexplained improvement in VAB scores as compared to the primary procedure. This may challenge the belief of some surgeons in the need for fusion at the time of revision

Background: The usefulness of open (fenestration/ laminotomy) discectomy for the treatment of a herniated lumbar disc has been studied extensively. In the current prospective, randomized study, the results of this procedure were compared with those of Microendoscopic discectomy. Methods: One hundred and twelve patients who had objective evidence of a single level, central or para-central herniation of a lumbar disc caudal to the first lumbar vertebra were randomized into two groups; Group 1 (55 patients) was managed with Microendoscopic discectomy, and Group 2 (57 patients) was managed with open (fenestration/ laminotomy) discectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient’s self-evaluation before and after the operation through Oswestry scoring, the preoperative and postoperative clinical findings, and the patient’s ability to return to a functional status. The patients were followed at one week, 6 weeks, 6 months and for a minimum of one year postoperatively. Results: On the basis of the patient’s preoperative and postoperative self-evaluation, the findings on physical examination, and the patient’s ability to return to work or to normal activity, 53 patients (96 percent) in Group 1 and 54 patients (95 percent) in Group 2 were considered to have had a satisfactory outcome. The mean surgical time, mean anaesthesia time, postoperative stay, was significantly less in Group 1. The overall satisfaction score was higher after the endoscopic microdiscectomies than after the laminotomies and discectomies especially in immediate postoperative period (one and six weeks) as assessed through Oswestry scoring. Conclusions: The data from this randomized, prospective study suggest that Microendoscopic discectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, that are caused by lumbar disc herniation, provided that patients are properly selected—that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperative management and have no evidence of spinal stenosis. All the major advantages of an endoscopic procedure like less hospital stay, lesser morbidity, and early return to work can be passed on to the patients without in anyway compromising the surgical goals viz. decompression of the canal and the compressed nerve root. However, endoscopic microdiscectomy is a demanding technique and should not be attempted without specific instruction and training

Aims: The aim of this study was to compare the results of Micro Endoscopic Discectomy (MED) toMicro Surgical Discectomy (MSD). Methods: 12 Patients were reviewed by an independent observer. This included the þrst 6 patients who underwent MED and 6 patients who underwent MSD selected randomly. There was no signiþcant difference between the two groups concerning age and sex distribution, occupation, preoper-ative time of work and clinical symptomatology. The disc herniations were located at L4-5 in 6 patients and L5-S1 in 6 patients. Patients were followed up for an average of 9 months (Range 2–22 months). They were assessed using the following questionnaires Oswestry low back pain and disability, Modiþed Gre-enough and Fraser and Mc Nab. Results: Both groups faired equally according to Mc Nab. The MED group appeared to require less postoperative analgesia especially opioid based preparations and were discharged earlier. The only complication was one patient in the MED requiring conversion to MSD. Conclusion: Our results indicate that MED is at least as effective as MSD, although it initially takes longer to perform due to the learning curve. However, the decrease in postoperative analgesia requirements and earlier discharge is beneþcial. In addition, we feel it has advantages over the percutaneous posterolateral discectomy for nerve root compression, which cannot treat sequestrated discs, or patients with disc herniations associated with recess stenosis

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

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

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

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

Aims. The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs. Methods. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. Results. This investigation included 739,474 spinal surgeries and 739,215 hospitalizations in Japan. There was an average annual increase of 4.6% in the number of spinal surgeries. Scheduled hospitalizations increased by 3.7% per year while unscheduled hospitalizations increased by 11.8% per year. In-hours surgeries increased by 4.5% per year while after-hours surgeries increased by 9.9% per year. Complication rates and costs increased for both after-hours surgery and unscheduled hospitalizations, in comparison to their respective counterparts of in-hours surgery and scheduled hospitalizations. Conclusion. This study provides important insights for those interested in improving spine care in an ageing society. The swift surge in after-hours spinal surgeries and unscheduled hospitalizations highlights that the medical needs of an increasing number of patients due to an ageing society are outpacing the capacity of existing medical resources. Cite this article: Bone Jt Open 2024;5(8):662–670

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

Although interlaminar endoscopic lumbar discectomy (IELD) is considered to be less invasive than microscopic lumbar discectomy (MLD) in treatment of lumbar herniated nucleus pulposus, the radiologic change of multifidus muscles by each surgery has rarely been reported. The aim of the present study was to compare the quantitative and qualitative changes of multifidus muscles between two surgical approaches and to analyze the correlation between various parameters of multifidus muscles and long term surgical outcome. 21 patients who received MLD and 18 patients who received IELD in a single tertiary hospital were enrolled and their preoperative, postoperative (≤15 days), and follow-up (≥6 months) MRIs were analyzed. The cross-sectional area (CSA) and fatty degeneration rate (FD) were quantitatively estimated at the level of surgery. The correlations among CSA, FD, body mass index, follow-up visual analogue scale(VAS) and Oswestry Disability Index(ODI) were assessed. Mean intervals of postoperative MRI and follow-up MRI from surgery were 3.0±3.7 days and 14.5±10.7 months, respectively. During the follow-up period, VAS was improved from 7.1±1.3 to 2.1±1.8 in MLD and from 8.2±1.4 to 2.2±1.8 in IELD. In cases of MLD, comparing with preoperative MRI, ipsilateral CSA was significantly increased in postoperative MRI (795.6mm. 2. vs. 906.5mm. 2. , p<0.01), but it was not significantly different in follow-up MRI (795.6mm. 2. vs. 814.4mm. 2. , p=1.00). However, in case of IELD, the ipsilateral CSAs in preoperative, postoperative, and follow-up periods were 892.0 mm. 2. , 909.3 mm. 2. , and 900.3 mm. 2. , respectively. These changes were not significant over time (p=0.691). The ipsilateral FDs were not significantly changed between preoperative and follow-up periods in both MLD (21.4% vs. 20.9%, p=0.81) and IELD groups (23.5% vs. 21.8%, p=0.19). The increment of ipsilateral CSA had significant correlations with follow-up ODI (r=−0.368, p=0.02). Comparing with IELD, MLD induced more surgical trauma on multifidus muscle in postoperative period, but the muscular damage was recovered in follow-up period. IELD can minimize surgical trauma on multifidus muscle showing similar pain relief as MLD. Favorable surgical outcome in follow-up period may be related to increment of multifidus muscle volume. Figure 1. (A-C) The multifidus muscles in preoperative, postoperative, and follow-up periods, respectively, in patient with MLD. Comparing with preoperative period, the CSA of right multifidus muscle (ipsilateral side) was increased in postoperative period, but recovered in follow-up period. (D-F) The multifidus muscle in preoperative, postoperative, and follow-up periods, respectively, in patient with IELD. The CSA of left multifidus muscles (ipsilateral side) was not significantly changed over time. Comparing preoperative MRIs with follow-up MRIs, the FDs of multifidus muscles were not significantly changed regardless of surgical technique. Figure 2. The CSA was measured by marking region of interest (ROI) and FD was measured by calculating the rate of pixels beyond the threshold in ROI. All measurements were performed using ImageJ software (version 1.52a, National Institutes of Health, Bethesda, Maryland, USA). For any figures or tables, please contact the authors directly

Single level discectomy (SLD) is one of the most commonly performed spinal surgery procedures. Two key drivers of their cost-of-care are duration of surgery (DOS) and postoperative length of stay (LOS). Therefore, the ability to preoperatively predict SLD DOS and LOS has substantial implications for both hospital and healthcare system finances, scheduling and resource allocation. As such, the goal of this study was to predict DOS and LOS for SLD using machine learning models (MLMs) constructed on preoperative factors using a large North American database. The American College of Surgeons (ACS) National Surgical and Quality Improvement (NSQIP) database was queried for SLD procedures from 2014-2019. The dataset was split in a 60/20/20 ratio of training/validation/testing based on year. Various MLMs (traditional regression models, tree-based models, and multilayer perceptron neural networks) were used and evaluated according to 1) mean squared error (MSE), 2) buffer accuracy (the number of times the predicted target was within a predesignated buffer), and 3) classification accuracy (the number of times the correct class was predicted by the models). To ensure real world applicability, the results of the models were compared to a mean regressor model. A total of 11,525 patients were included in this study. During validation, the neural network model (NNM) had the best MSEs for DOS (0.99) and LOS (0.67). During testing, the NNM had the best MSEs for DOS (0.89) and LOS (0.65). The NNM yielded the best 30-minute buffer accuracy for DOS (70.9%) and ≤120 min, >120 min classification accuracy (86.8%). The NNM had the best 1-day buffer accuracy for LOS (84.5%) and ≤2 days, >2 days classification accuracy (94.6%). All models were more accurate than the mean regressors for both DOS and LOS predictions. We successfully demonstrated that MLMs can be used to accurately predict the DOS and LOS of SLD based on preoperative factors. This big-data application has significant practical implications with respect to surgical scheduling and inpatient bedflow, as well as major implications for both private and publicly funded healthcare systems. Incorporating this artificial intelligence technique in real-time hospital operations would be enhanced by including institution-specific operational factors such as surgical team and operating room workflow

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

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

The recent NICE guidelines on management of osteoarthritis outline weight loss as first line treatment in degenerative joint disease in the obese. There is little data surrounding the effects of obesity on the outcomes in spinal surgical interventions. Intervertebral discectomy is one treatment for prolapse of a lumbar vertebral disc. We aim to investigate the effect of obesity on outcomes for discectomy. Demographic details including age, sex, weight and BMI were recording with a pre-operative Oswestry Disability Index (ODI). The fat thickness was measured at L5/S1 using calibrated MRI scans. Outcome measures included complications, length of surgery and change in ODI at 1 year following surgery. Obesity was defined as a body mass index of over 30. The units Serial patients undergoing discectomy were recruited into the study. Patients with bony decompression, instrumentation, revision surgery or multilevel disease were excluded. Fifty patients with a single level uncomplicated disc prolapse were entered into the study. Sixteen patients had a BMI over 30 and so were obese, whilst 34 had a BMI of less than 30. The mean pre-operative ODI was 46.5 in the obese group and 52 in the normal group this difference was not significant (p> 0.05). The mean post operative ODI was statistically improved in the high BMI group at 28 (18.5 point improvement) and 25.2 (29.1 point improvement) in the normal group. The ODI improvement was significantly better in the low BMI group (p=0.036). There was no significant difference in operative time (p=0.24). Only a single patient had a complication (dural leak), so no valid comparison could be made. The outcomes of spinal surgery in the obese are mixed. We found no increase in the complication rate or intra-operative time associated with an increased BMI. However, the improvement in ODI was significantly better in the normal BMI group

This paper describes the relationship between post-myelographic symptoms and the timing of a subsequent spinal operation. A prospective study was performed comparing the post-operative symptoms of patients who underwent discectomy within 48 hours of myelography (Group 1) with those of patients who underwent discectomy at least seven days after myelography (Group 2). After myelography there was no statistical difference in the incidence of nausea and headache in the two groups. However, after operation the incidence of headache and nausea was significantly greater in patients who underwent early discectomy. The incidence of urinary retention was significantly greater in Group 1 at 24 hours after operation but not at 48 and 72 hours. We conclude that the temptation to perform discectomy shortly after myelography should be resisted until at least one week has elapsed between the two procedures, except in emergency situations

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

Purpose: Since 1990, we have used specific material, presented to us by T. Tajima (Japan) during his visit in 1989 for percutaneous surgical cervical discectomy. French material was developed in 1992. The purpose of this work is to present our experience with this technique over the last ten years. Material and methods: Indications were cervicobrachial neuralgia unresponsive to medical care and secondary to MRI or CT documented cervical disc herniation. We used the right anterolateral approach guided with the image amplifier for patients under local anaesthesia and neuroleptanalgesia ou general anaesthesia. A guide wire was positioned in the centre of the anterior aspect of the disc to insert a 2.5 mm working tube in the middle of the disc. A special trephin with an inverted inside thread induced an aspiration effect when turned into the disc, in line with the posterior wall of the vertebra. This enabled removal of several “carrots” measuring 1 to 2 cm long of discal or even disco-osteophytic material. The removal of the posterior third of the disc and the herniation was completed with a fine disc forceps. Results: There were 85 procedures in 82 patients, mean age 42 years (35 women, 47 men): 57 at one level, mainly C5C6, 27 at two levels simultaneously, and one at three levels during the same operation. Mean follow-up for the 80 results known was 15 months (3–90 months). There were nine failures (two required conventional surgical fusion), 14 fair results, and 57 good results, giving a total of 88.75% good and fair results. Unlike percutaneous surgical lumbar discectomy, where good results at three months may deteriorate at two years, good results at three months after percutaneous cervical discectomy remained good at two years. Discussion: This technique provides results as good as chemonucleolysis. An advantage of the technique that allergy or disco-osteophytic protrusions are not contraindications. We did not have any infection or injury to neighbouring tissue. Conclusion: When rigorous operative procedures are used in this area with potential risk, percutaneous surgical cervical discectomy can be a useful routine therapeutic tool

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.

Introduction: Repetitive undertaking of a physical tasks results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”. Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar micro-endoscopic discectomy (MED), when compared to open microdiscectomy. Methods: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open micro-discectomy immediately predating the current series are used as a cohort for comparison. Results: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred. Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach. The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified. Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”. There was no significant difference in clinical outcome and complications between the two groups. Discussion: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium