Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study.

STUDY DESIGN: Retrospective cohort study using national health insurance data. OBJECTIVE: To provide a longitudinal reoperation rate after surgery for lumbar herniated intervertebral disc (HIVD) disease, and to compare the reoperation rates of surgical methods. SUMMARY OF BACKGROUND DATA: Herniated intervertebral disc disease is the most common cause of lumbar spinal surgery. Despite improved surgical techniques and instrumentation, reoperation cannot be avoided. The reoperation rates were in the range of 6% to 24% in previous studies. A population-based study is less subject to bias; hence, a nationwide longitudinal analysis was warranted. METHODS: A national health insurance database was used to identify a cohort of patients who underwent first surgery for herniated intervertebral disc disease in 2003 and 18,590 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. The primary endpoint was any type of second lumbar surgery. After adjusting for confounding factors, 5 surgical methods (fusion, laminectomy, open discectomy, endoscopic discectomy, and nucleolysis [including mechanical nucleus decompression]) were compared. Open discectomy was used as the reference method. RESULTS: Open discectomy was the most common procedure (68.9%) followed by endoscopic discectomy (16.1%), laminectomy (7.9%), fusion (3.9%), and nucleolysis (3.2%). The cumulative reoperation rate was 5.4% at 3 months, 7.4% at 1 year, 9% at 2 years, 10.5% at 3 years, 12.1% at 4 years, and 13.4% at 5 years. The reoperation rates were 18.6%, 14.7%, 13.8%, 12.4%, and 11.8% after laminectomy, nucleolysis, open discectomy, endoscopic discectomy, and fusion, respectively. Compared with open discectomy, the reoperation rate was higher after laminectomy at 3 months, whereas the other surgical methods had similar rates. CONCLUSION: The cumulative reoperation rate after 5 years was 13.4% and half of the reoperations occurred during the first postoperative year. With the exception of laminectomy, the reoperation rates of the other procedures were not different from that of open discectomy.

A review of current treatment for lumbar disc herniation in children and adolescents.

Lumbar disc herniation (LDH) is a common disorder among adults with degenerated lumbar intervertebral discs. However, its occurrence in childhood and adolescence is much less frequent mostly because children and adolescents tend to have a healthier lumbar spine as compared with adults. This difference indicates that children and adolescents are far from being just little adults. Over the years, there have constantly been published studies concerning this entity where the findings suggested that pediatric LDH is, in many ways, different from that in adults. To date, the prevalence, the etiological and the diagnostic features of pediatric LDH have been fully described in the literature whereas the characteristics regarding to the treatment is yet to be reviewed in details. The aim of the present review is to provide a collective opinion on the treatment of pediatric LDH as well as its outcome. It reviewed the relevant information available in the literature and compared the results among and within various treatments. It was found that pediatric patients responded less favorably to conservative treatment as compared with adults. In addition, the outcome of surgery remained to be satisfactory for at least 10 years after the initial operation, even though it appeared to deteriorate slightly. To the best of our knowledge, this is the first literature review focusing on the treatment of pediatric LDH.

Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. SUMMARY OF BACKGROUND DATA: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS: For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. CONCLUSION: Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review.

STUDY DESIGN: An updated Cochrane Review. OBJECTIVES: To assess the effects of surgical interventions for the treatment of lumbar disc prolapse. SUMMARY OF BACKGROUND DATA: Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions. METHODS: Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007. RESULTS: Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy. CONCLUSION: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.

Chemonucleolysis revisited: a prospective outcome study in symptomatic lumbar disc prolapse.

OBJECTIVE: This prospective study was carried out to assess the functional outcome in patients with symptomatic lumbar disc prolapse treated by chemonucleolysis (CNL). METHODS: The Oswestry Low Back Pain Disability Index (ODI) was used to assess the pre- and postprocedure functional status of 112 patients with magnetic resonance (MR) scan-proven lumbar disc prolapse treated by CNL. Follow-up was for at least 5 years. RESULTS: Ninety-three of 112 patients (83%) had excellent/good results, whereas 11 of 112 (10%) were unchanged and 8 of 112 (7%) were worse after the CNL. The younger patients with single-level discs at L5-S1 had the most successful outcome. Seventy percent of our patients (25-45 years of age) were gainfully employed with a mean return to work at 12 weeks. CONCLUSIONS: CNL is a good procedure to bridge the gap between conservative treatment and surgery for lumbar disc prolapse. CNL is beneficial in 80% of patients with significant leg symptoms. After careful selection of candidates using MR scans, it is an effective procedure that does not compromise future open surgery, should it be necessary.

The different outcomes of patients with disc herniation treated either by microdiscectomy, or by intradiscal ozone injection.

Disc herniation with radiculopathy and chronic discogenic pain are the result of degenerative processes. Treatment approach in face of this problem has largely been debated in the last years. A number of reviews on surgical treatments in the '80s and '90s have been published and various new techniques have been introduced among which ozone discolysis is one non-invasive intradiscal treatment method. In a 3-year follow-up period we have investigated the different outcomes of 150 patients who received microdiscectomy and 150 patients who received intradiscal ozone injection. In this series results are in favour of discolysis for contained disc herniations and of microdiscectomy for large migrated fragments with pain so severe that open surgery was obligatory. Apart from this, our results with the two techniques are equivalent also concerning mild neurological motor deficits.

Nucleoplasty with or without intradiscal electrothermal therapy (IDET) as a treatment for lumbar herniated disc.

BACKGROUND AND OBJECTIVE: In industrialized societies, the prevalence of radicular low back pain has exploded in recent years. The growing economic and personal costs of this challenging entity have led to the development of a wide array of new treatments, ranging from pharmacotherapy with neuropathic medications to open surgical treatment. Among the therapeutic options to emerge are a plethora of minimally invasive treatments aimed at removing nuclear material and lowering intradiscal pressure through devices inserted percutaneously into intervertebral discs. Yet there is a compelling lack of clinical evidence to support the use of these procedures. This study was undertaken to determine the treatment outcomes of 16 consecutive patients with lumbar radicular pain secondary to a herniated disc who underwent nucleoplasty as their primary therapy. METHODS: Included in this series were nine patients with significant axial back pain, sitting intolerance, and positive discography who also underwent intradiscal electrothermal therapy (IDET). Among the 7 patients who only had nucleoplasty, 4 had 2 discs treated and 3 had 1 disc. In the 9 patients who also had IDET, 6 had 1 disc treated and 3 had 2 discs treated. Of the 32 total disc treatments, 20 were at L5-S1, 10 were at L4-5 and 2, one each for IDET and nucleoplasty, were at L3-4. RESULTS: In the overall cohort, the average Visual Analogue Scale (VAS) pain score decreased from 6.7 to 5.6 at a mean follow-up of 9 months. In the seven patients who underwent only nucleoplasty, the mean VAS score decreased from 6.0 to 4.8. Only one patient reported a >/=50% reduction in pain score. CONCLUSIONS: We conclude that with use of the present selection criteria, nucleoplasty is not an effective long-term treatment for lumbar radiculopathy, either alone or with IDET. Before conducting future clinical trials, we recommend modifying these criteria to include only those patients with small (<6-mm) contained disc herniations whose annular integrity is documented by computed tomography discography and corresponding radicular symptoms confirmed by either selective nerve root blocks or electromyography and nerve conduction studies.

[Variation in chemonucleolysis as treatment in herniated intervertebral disk]. / Variatie bij chemonucleolyse als behandeling van hernia nuclei pulposi.

OBJECTIVE: To measure the variation of chemonucleolysis in the management of lumbosacral intervertebral disk herniation in the Netherlands. DESIGN: Descriptive. SETTING: Academic Medical Centre, Amsterdam, the Netherlands. METHOD: The use of chymopapain per specialist from 1987 to 1995 was determined by dividing the amount of chymopapain sold, as given by the pharmaceutical company, by the number of specialists as recorded by the specialist associations. Subsequently, variation of chemonucleolysis in time, between specialists and in place was calculated. RESULTS: Between 1987 and 1995 the number of chemonucleolysis treatments decreased gradually from 2084 to 538. Most neurosurgeons, orthopaedic surgeons and neurologists did not treat patients with herniation of a lumbosacral intervertebral disk with chemonucleolysis. Within the group of specialists which did treat patients with chemonucleolysis, a minority accounted for the majority of treatments. Chemonucleolysis was mainly performed in non-academic hospitals outside urban western Holland. CONCLUSIONS: Variation of chemonucleolysis in the management of lumbosacral intervertebral disk herniation in the Netherlands is considerable. Different preferences of specialists are probably the underlying cause.

Safety of chemonucleolysis. Adverse effects reported in the United States, 1982-1991.

This survey covers 121 "serious" and "unexpected" adverse events after treatment with chymodiactin (chymopapain for injection) among approximately 135,000 patients in the United States. They were reported to the Food and Drug Administration (FDA) within 15 days of notification of the manufacturer between 1982 and the end of 1991. They included fatal anaphylaxis (seven cases), infections (24 cases), hemorrhage (32 cases), and neurologic (32 cases) and miscellaneous (15 cases) events, with a mortality rate of 0.019%. Anaphylactic reactions reported in a postmarketing survey can be attributed to chymopapain itself and infections to lack of asepsis during its administration. The causes of other adverse reactions cannot be as clearly defined, but many are unlikely to have been due to chymopapain or its administration. More careful selection of patients and closer attention to technique during chemonucleolysis have dramatically reduced the incidence of these adverse events, which occur far less frequently than after diskectomy.