Risk factors for prolonged length of stay after first single-level lumbar microdiscectomy.

OBJECTIVE: The objective is to identify risk factors that potentially prolong the hospital stay in patients after undergoing first single-level open lumbar microdiscectomy. METHODS: A retrospective single-centre study was conducted. Demographic data, medical records, intraoperative course, and imaging studies were analysed. The outcome measure was defined by the number of days stayed after the operation. A prolonged length of stay (LOS) stay was defined as a minimum of one additional day beyond the median hospital stay in our patient collective. Bivariate analysis and multiple stepwise regression were used to identify independent factors related to the prolonged hospital stay. RESULTS: Two hundred consecutive patients who underwent first lumbar microdiscectomy between 2018 and 2022 at our clinic were included in this study. Statistical analysis of factors potentially prolonging postoperative hospital stay was done for a total of 24 factors, seven of them were significantly related to prolonged LOS in bivariate analysis. Sex (p = 0.002, median 5 vs. 4 days for females vs. males) and age (rs = 0.35, p ≤ 0.001, N = 200) were identified among the examined demographic factors. Regarding preoperative physical status, preoperative immobility reached statistical significance (p ≤ 0.001, median 5 vs. 4 days). Diabetes mellitus (p = 0.043, median 5 vs. 4 days), anticoagulation and/or antiplatelet agents (p = 0.045, median 5 vs. 4 days), and postoperative narcotic consumption (p ≤ 0.001, median 5 vs. 4 days) as comorbidities were associated with a prolonged hospital stay. Performance of nucleotomy (p = 0.023, median 5 vs. 4 days) was a significant intraoperative factor. After linear stepwise multivariable regression, only preoperative immobility (p ≤ 0.001) was identified as independent risk factors for prolonged length of postoperative hospital stay. CONCLUSION: Our study identified preoperative immobility as a significant predictor of prolonged hospital stay, highlighting its value in preoperative assessments and as a tool to pinpoint at-risk patients. Prospective clinical trials with detailed assessment of mobility, including grading, need to be done to verify our results.

The effect of pedometer-supported walking and telemonitoring after disc hernia surgery on pain and disability levels and quality of life.

AIM: The aim of this study was to determine the effect of pedometer-supported walking and telemonitoring after lumbar disc hernia surgery on pain and disability levels and quality of life. METHODS: This was a randomized controlled trial with two randomly selected groups conducted between March 2018 and January 2019. Sixty-seven participants (33 in the intervention group and 34 in the control group) who had undergone lumbar microdiscectomy were allocated to receive and not to receive walking exercise. Pain and disability levels and quality of life of groups were tested with the McGill Pain Questionnaire, the Oswestry Disability Index and the 36-Item Short Form Survey. Measurements were taken 3 weeks after surgery and following completion of the first, second and third months. RESULTS: Compared with the control group, pain level at the first and second months and disability level at the second and third months in the intervention group were significantly lower (p < 0.05), and in the third month, subdimension scores of quality of life (the physical role difficulty, energy and vitality, mental health, social functionality and pain) were higher (p < 0.05). CONCLUSIONS: Walking after herniated disc surgery decreased pain and disability levels and increased the quality of life; nurses can encourage adherence to walking as an effective intervention.

The efficacy of postoperative bracing after spine surgery for lumbar degenerative diseases: a systematic review.

PURPOSE: Postoperative bracing treatment is widely used after surgery for lumbar degenerative diseases. However, the guidelines are lacking in this regard, and its use is mainly driven by individual surgeon preferences. The objective of the current review was to evaluate the available evidence on the use of postoperative bracing after surgery for degenerative disease of the lumbar spine. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed while conducting a systematic search of the PubMed/Medline, Scopus, and Cochrane databases from January 1990 to January 2019. High-quality studies were included that evaluated disability, pain, quality of life, the rate of fusion, complications, and rate of reoperations in patients who had surgery for lumbar degenerative disease, with and without postoperative bracing. The overall strength of evidence across the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. RESULTS: Of the 391 citations screened, four randomized controlled trials met the inclusion criteria and were included in the review. Based on low- to moderate-quality evidence, postoperative bracing in patients with lumbar degenerative disease does not result in improved disability, pain, and quality of life compared to no bracing patients. Low-quality evidence suggests that there was no significant difference between the two groups in terms of the rate of fusion, complications, and the need for reoperation. CONCLUSIONS: To date, there is not a medical evidence to support the use of bracing after surgery for lumbar degenerative disease. These slides can be retrieved under Electronic Supplementary Material.

Association between MRI findings and clinical outcomes in a period of 5 years after lumbar spine microdiscectomy.

BACKGROUND: To evaluate the associations between magnetic resonance imaging (MRI) findings and pain, disability and quality of life before surgery and up to 5 years after lumbar microdiscectomy. MATERIALS AND METHODS: Sixty-one patients who underwent one-level lumbar microdiscectomy by the same surgeon participated in this analytic, observational, prospective study. Lumbar spine MRI was performed preoperatively and 5 years postoperatively. Pain, disability and quality of life were measured with VAS, ODI, Roland Morris and SF-36 pre- and up to 5 years postoperatively. Subsequently associations between radiological findings and clinical outcomes were recorded. RESULTS: Before surgery patients with disc extrusion or sequestration, with increased thecal sac compression (d > 2/3), with Modic changes (MC) 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and both adjacent discs presented the worst preoperative clinical outcomes. MC preoperatively were not related with postoperative results, in contrast with the type of disc herniation and thecal sac compression. Preoperative Pfirrmann grade IV and V on the operated and both adjacent discs and postoperative MC 2 and 3 on the operated level were related to poor clinical outcomes 36-60 months post-discectomy. CONCLUSIONS: Extrusion or sequestration of the operated disc, increased compression of thecal sac, MC 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and adjacent discs were associated with the worst clinical outcomes. Nerve root impingement, facet joint arthritis, perineural fibrosis and disc granulation tissue had no effect on clinical scores.

[Lumbar microdiscectomy using intraoperative ultrasound]. / Poiasnichnaia mikrodiskéktomiia s primeneniem intraoperatsionnogo ul'trazvukovogo issledovaniia.

OBJECTIVE: To analyze advisability of intraoperative ultrasound during lumbar microdiscectomy. MATERIAL AND METHODS: We used intraoperative ultrasound to identify and localize various tissues and structures of the spinal canal, optimize surgical approach to the herniated disc and assess decompression of neural structures. The study was conducted in 48 patients with herniated discs of the lumbar spine who were operated for the period from 2014 to 2017. We used ultrasound devices BK Medical Pro Focus 2202 and BK Medical Flex Focus 400 with neurosurgical transducer Craniotomy 8862 and Burr-Hole 8863. Examinations were performed before and after flavotomy during neural decompression and after decompression. All patients underwent laboratory, clinical and instrumental survey. We analyzed changes of functional and neurological status and investigated various possibilities of intraoperative ultrasound and its impact on postoperative outcomes. RESULTS: Intraoperative ultrasound is valuable to verify various tissues and structures of the lumbar spine. On-line scanning gives a correct volumetric representation of the various anatomical structures and their spatial relationships that is essential for less traumatic and more radical surgery. CONCLUSION: Intraoperative ultrasound is easy, harmless, inexpensive and widely available method of intraoperative imaging. US data may be comparable with those of intraoperative CT and MRI. Intraoperative ultrasound during lumbar microdiscectomy results better postoperative outcomes.

Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy?

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.METHODSThis study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods-during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II-V or if they were younger than 18 years or older than 65.Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.RESULTSThe ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.CONCLUSIONSERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.

The evidence-based approach for surgical complications in the treatment of lumbar disc herniation.

PURPOSE: The purpose of this article is to review the evidence-based approach for surgical complications following disc herniation. METHODS: A search of the primary English literature was conducted for research examining the outcomes and complications of surgical discectomy. Special regard was given to high-quality prospective randomized studies. RESULTS: The most commonly reported complications of surgical treatment of disc herniation are included in this review. Medical complications, and surgical complications including infection, durotomy, neurological injury, symptomatic re-herniation, and revision surgery are defined and systematically reviewed in detail for incidence, evaluation, and management. CONCLUSION: This article provides the clinician and surgeon with a review of the evidence-based evaluation and management of surgical complications following disc herniation, offering best practice guidelines for informed discussions with patients in shared decision-making.

Clinical outcomes after lumbar spine microdiscectomy: a 5-year follow-up prospective study in 100 patients.

BACKGROUND: To evaluate the effect of lumbar microdiscectomy (LM) in pain, disability and quality of life in a 5-year period and to identify potential demographic and clinical risk factors. METHODS: One hundred patients who underwent LM by the same surgeon participated in this prospective study. Clinical assessment was made with validated questionnaires preoperatively and up to 5 years postoperatively. Subsequently, associations between clinical outcomes and demographic data were recorded. RESULTS: In every assessment questionnaire, there was a significant improvement in the first postoperative month, which lasted up to 1 year post-discectomy. After that, improvement was statistically significant (p < 0.05) but without clinical importance. Women reported more pain preoperatively and 1 month after surgery. Urban residents also presented more pain preoperatively. Older patients had more pain, disability and worse quality of life 1-5 years postoperatively. Similarly, patients with lower education presented the worst scores in every questionnaire at the same time. Smokers reported less pain 1.5-4 postoperative years. Higher alcohol consumption and obesity were associated with lower levels of preoperative pain. However, obese patients had worse SF-36 and ODI scores after the 6th postoperative month. Patients with heavy jobs presented the worst preoperative ODI scores. CONCLUSION: Significant clinical improvement was recorded from the first postoperative month to the first postoperative year; stabilization was noticed later on. Feminine gender, urban residency, older age, low level of education, obesity and heavy physical occupation were negative prognostic factors. Oddly smoking and alcohol were correlated with less pain.

Postoperative MRI findings 5 years after lumbar microdiscectomy.

BACKGROUND: Lumbar microdiscectomy is a common procedure with satisfactory results; however, postoperative events like progressive adjacent level degeneration and perineural fibrosis can contribute to long-term pain. The purpose of the study was to evaluate MRI changes 5 years after lumbar microdiscectomy and assess their association with clinical parameters. MATERIALS AND METHODS: A prospective study enrolling 61 patients who underwent microdiscectomy. Changes between preoperative and postoperative MRI findings were recorded, and these findings were tested for associations with demographic, clinical and perioperative parameters. The measured imaging parameters were degeneration of the operated and adjacent discs and endplates, morphology of the disc herniation, facet joints arthritis and the presence of postoperative perineural fibrosis. RESULTS: Statistically significant differences were found between preoperative and postoperative morphology of the operated disc, facet joints arthritis and degeneration of the operated and caudal adjacent disc. There were no differences between preoperative and postoperative disc degeneration of the superior adjacent disc and in degeneration of the operated and adjacent endplates. Postoperatively perineural fibrosis was common; however, thecal sac compression and nerve root impingement were reduced. Age at the time of surgery was the only parameter associated with postoperative changes. CONCLUSION: Five years after microdiscectomy, several postoperative MRI changes including operated disc's morphology, facet joints arthritis and degeneration of the operated and caudal adjacent disc were shown. Taking into consideration that participants were on average middle-aged, these changes could be attributed not only to the impact of the surgery but also to the natural history of lumbar spine degeneration.

Lumbar microdiscectomy as a day-case procedure: Scope for improvement?

BACKGROUND AND PURPOSE: There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients. METHODS: This was a retrospective observational study of patients undergoing elective lumbar microdiscectomy between August 2012 and December 2014. Age, gender, day of surgery, distance to hospital, ASA grade, regular opiate use, smoking status, order on the operating list, and side and level of surgery were examined by logistic regression to assess their influence on same-day discharge. RESULTS: 28/95 (29.5%) patients were discharged on the day of surgery. Age (p = 0.041), ASA grade (p = 0.016), distance to hospital (p = 0.011), and position on the list (p = 0.004) were associated with day-case discharge by univariate analysis. ASA grade (p = 0.032; OR 0.176), distance to hospital (p = 0.003; OR 0.965), and position on the operating list (morning case; p = 0.011; OR 8.901) remained significant in multivariate analysis. Thirteen (13.7%) patients were identified who could have been managed as day cases had they been listed for morning operations. CONCLUSIONS: Day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimise bed space and improve spinal services.

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis.

OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

Morphological changes after open lumbar microdiscectomy at 2-year follow-up.

BACKGROUND: It is known that a possible decrease in disc height (DH) and foraminal size after open lumbar microdiscectomy (OLM) may cause pain in the long term. However, there is still insufficient information about the short- or long-term pathoanatomical and morphological effects of microdiscectomy. For example, the exact temporal course of the change in DH is not well known. OBJECTIVE: The purpose of this study was to examine morphological changes in DH and foramen dimensions after OLM. METHODS: In patients who underwent OLM for single-level lumbar disc herniation, MRI scans were obtained before surgery, and at an average of two years after surgery. In addition to DH measurements, foraminal area (FA), foraminal height (FH), superior foraminal width (SFW), and inferior foraminal width (IFW), were measured bilaterally. RESULTS: A postoperative increase in DH was observed at all vertebral levels, with an average of 5.5%. The mean right FHs were 15.3 mm and 15.7 mm before and after surgery, respectively (p= 0.062), while the left FHs were 14.8 mm and 15.8 mm before and after surgery (p= 0.271). The mean right SFW was 5.4 mm before surgery and 5.7 mm after surgery, while the mean right IFW ranged from 3.6 mm to 3.9 mm. The mean left SFW was 4.8 mm before surgery and 5.2 mm after surgery, while the mean left IFW ranged from 3.5 mm to 3.9 mm. Before surgery, the FAs were, on average, 77.1 mm2 and 75.6 mm2 on the right and left sides, respectively. At the 2-year follow-up, the mean FAs were 84.0 mm2 and 80.2 mm2 on the right and left sides, respectively. CONCLUSIONS: Contrary to prevalent belief, in patients who underwent single-level unilateral OLM, we observed that there may be an increase rather than a decrease in DH or foramen size at the 2-year follow-up. Our findings need to be confirmed by studies with larger sample sizes and longer follow-ups.

Comparison of lumbar microdiscectomy and unilateral biportal endoscopic discectomy outcomes: a single-center experience.

OBJECTIVE: Lumbar microdiscectomy (LMD) is still the gold-standard treatment for lumbar disc herniations with progressive neurological deficits that are refractory to conservative treatment. With improvement of endoscopic systems in recent years, endoscopic discectomy techniques have been developed as an alternative to LMD. The unilateral biportal endoscopic discectomy (UBE) technique is one of these endoscopic techniques, and its popularity has increased in recent years because it does not require high-cost specialized endoscopes, many microsurgical instruments are compatible with this system, and it is similar to LMD in terms of anatomical orientation. This study compared results between LMD and UBE techniques in patients with lumbar disc herniations performed by the same spine surgeons at a single center. METHODS: The data of patients with lumbar disc herniation who were operated on with LMD and UBE techniques were retrospectively reviewed. The data obtained were statistically evaluated. The operative video of one of the patients who underwent UBE was edited for demonstration. RESULTS: Between January 2021 and June 2022, 93 patients were operated on for lumbar disc herniation. LMD was performed in 39 patients, and UBE was performed in 54 patients. There were no significant differences in the complications, recurrence, postoperative back and leg pain, patient satisfaction rates, and quality of life index results of the patients in the two groups. The operation time was shorter in the LMD group. In the UBE group, estimated blood loss was lower and postoperative hospitalization was shorter. CONCLUSIONS: Although LMD is still the gold-standard treatment for lumbar disc herniation, the results of UBE are comparable to those of LMD, and it may be a good alternative for spine surgeons who prefer minimally invasive surgery.

Effect of Obesity on Surgical Outcomes of Lumbar Microdiscectomy: A Retrospective Analysis of 525 Patients.

INTRODUCTION: Obesity has been implicated in higher rates of intra-operative complications, as well as increased risk for recurrent herniation and re-operation following lumbar microdiscectomy (LMD). However, the current literature is still controversial about whether obesity adversely affects surgical outcomes, especially a higher re-operation rate. In this study, we have compared surgical outcomes such as recurrence of symptoms, recurrence of disc herniation, and re-operation rates in obese and non-obese patients undergoing one segment LMD. METHODS: A retrospective review was conducted on patients undergoing single-level LMD between 2010-2020 at an academic institution. Exclusion criteria included prior lumbar surgery. Outcomes assessed included the presence of persistent radicular pain, imaging evidence of recurrent herniation, and the need for re-operation due to recurrent herniation. RESULTS: A total of 525 patients were included in the study. The mean±SD body mass index (BMI) was 31.2±6.6 (range 16.2-70.0). The mean follow-up was 273.8±445.2 days (range 14-2494). Reherniation occurred in 84 patients (16.0%), and 69 (13.1%) underwent re-operation due to persistent recurrent symptoms. Neither reherniation nor re-operation was significantly associated with BMI (p = 0.47 and 0.95, respectively). Probit analysis did not show any significant association between BMI and the need for re-operation following LMD. CONCLUSION: Obese and non-obese patients experienced similar surgical outcomes. Our results showed that BMI did not adversely affect reherniation or re-operation rate following LMD. If clinically indicated, LMD can be performed in obese patients with disc herniation without a significantly higher re-operation rate.

Adopting the day surgery default in the provision of lumbar discectomy and decompressive surgery.

INTRODUCTION: Provision of day case spinal procedures in the UK is below expected standards and there is a need for the creation of guidance and patient pathways to address this. Here we present a day case lumbar discectomy protocol and evaluate its impact at our institution. METHODS: A new pathway (incorporating defined selection criteria, patient education, anaesthetic protocol and discharge prescriptions) was implemented for all suitable patients within a single surgeon's cohort. Day case rates for lumbar discectomy were compared before and after implementation. Patient feedback was collated using a patient-reported experience measure. RESULTS: Eighteen of 23 patients selected as suitable via the pathway successfully underwent day surgery, leading to an increase in lumbar discectomy day case rates from 25% to 69% at our institution. Nearly all patients were satisfied with their experience, although a significant proportion felt provision of postoperative analgesia could be improved. CONCLUSION: We present a day surgery pathway for lumbar discectomy that is safe and effective. This could be more widely implemented to increase day case rates.

Percutaneous endoscopic lumbar discectomy versus open lumbar microdiscectomy for treating lumbar disc herniation: Using the survival analysis.

Objectives: This study compared the risk of symptomatic recurrent disc herniation and clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) versus open lumbar microdiscectomy (OLM) for lumbar disc herniation with 2 years of follow-up. Materials and Methods: We analyzed 23 patients who underwent PELD and 32 patients who underwent OLM for lumbar disc herniation. The numeric rating scale of back and leg pain, Oswestry Disability Index (ODI), and Roland-Morris Disability Questionnaire (RMDQ) were assessed before and at 12 and 24 months after the surgery. The wound pain and complications were also recorded. Survival analysis was performed to estimate the risk of symptomatic recurrent disc herniation. Results: In the comparison of groups, the reductions in back and leg pain, ODI, and RMDQ were not significantly different at 12 and 24 months. For patients who underwent PELD, the wound pain was significant lower at the day of surgery. The survival rate of patients who were free from symptomatic recurrent disc herniation at 24 months was 0.913 in PELD and 0.875 in OLM, and the log-rank test revealed no significant difference between the two survival curves. The incidence of complication was not significantly different between groups. Conclusion: Both PELD and OLM are effective treatments for lumbar disc herniation because they have similar clinical outcomes. PELD provided patients with less painful wounds. The survival analysis revealed that the risk of symptomatic recurrent disc herniation in 2 years of follow-up was not different between PELD and OLM.

Understanding how the research question impacts trial design: Examples from discectomy trials.

BACKGROUND: Formulating a pertinent research question is of the utmost importance in clinical research. An ill-conceived question may lead to an erroneous trial design, which may adversely affect the care of patients and provide uninformative or even misleading results. METHODS: We review the research question of a randomized trial on the timing of lumbar discectomy. We compare the resulting design with other trials, real or hypothetical, that would have been more appropriate. RESULTS: The RCT we examine randomly allocated patients to early or delayed surgery to answer a theoretical question of the effect of time on the efficacy of surgery. The trial was interpreted to have shown that early surgery was associated with better clinical and functional outcomes as compared to delayed surgery. This conclusion is clinically misleading. Valid comparisons between groups should be performed on intent-to-treat analyses and at the same time points after randomization (and not at a fixed follow-up period after surgery). The clinically pertinent comparison is not between the theoretical efficacy of surgery performed at various times, but between surgery and conservative management in patients presenting at various times. Better-designed trials on the clinical benefits of lumbar discectomy, including the treatment of chronic sciatica, have been published. CONCLUSION: Theoretical research questions inspired from observational data can lead to erroneous trial design. Prospective randomized trials impact practice immediately: they are unique occasions to address clinical problems and optimize care under uncertainty in real time. However, they require the research question to be formulated with great care.

Inferior Mesenteric Artery Injury in Post-lumbar Microdiscectomy: A Case Report.

Iatrogenic vascular injury during lumbar microdiscectomy is a rather rare complication, but it can have fatal consequences. Here, we report a patient who underwent an L5-S1 microdiscectomy, which was complicated by inferior mesenteric artery injury. The patient presented in the recovery room with symptoms of hypotension and tachycardia after the operation which was successfully managed by endovascular embolization. The patient was positioned in a prone position, which may have contributed to the development of vascular injury. To prevent potential complications, we advised using the Jackson table rather than a standard surgical table and thoroughly inspecting the abdomen and pelvis prior to the operation.

High-Frequency Bipolar Coagulation Limits Epidural Fibrosis in Lumbar Microdiscectomy.

BACKGROUND AND AIM: We propose a vast study to examine the effect of high-frequency bipolar coagulation used in the operating room to prevent the development of epidural fibrosis after lumbar microdiscectomy. MATERIALS AND METHODS: A total of 1004 participants were divided into two groups: no high-frequency bipolar coagulation (NC group) and high-frequency bipolar coagulation (C group). Postoperative epidural fibrosis, infection rates, reoperation status, and dural injury complications during the operation were recorded. RESULTS: Considering the epidural fibrosis rates of the two groups, epidural fibrosis was seen in 10.6% of the patients in the NC group. In contrast, it was seen in only 6.2% of the patients in the C group. CONCLUSION: The complication of epidural fibrosis that develops after lumbar microsurgery operations both impairs patient comfort and brings with it the complications of reoperation. After performing hemostasis with bipolar, coagulating the annulus may effectively reduce epidural fibrosis and prevent reoperation.

Understanding crossovers and potential ways to mitigate the problem: Lessons from influential trials on lumbar microdiscectomy.

BACKGROUND: Lumbar microdiscectomy is the most frequent surgical intervention used in the treatment of sciatica from herniated lumbar discs. Many discectomy trials have been plagued with an excessive number of crossovers that have rendered results inconclusive. METHODS: We review the design and results of influential lumbar microdiscectomy trials. We also discuss the various strategies that have been used to decrease the number of crossovers or to mitigate the effects of crossovers on analyses. RESULTS: Randomized trials on lumbar discectomy were affected by crossover rates of 8% to 42%. Various strategies that have been used to decrease that number or to mitigate the effects on results include: patient selection, blinding (placebo-controlled trials), an immediate access to surgery for the surgical group (but limited access to surgery for the conservative group), shortening the follow-up period necessary to reach the primary outcome measure, postponing crossovers to surgery after determination of the primary outcome, and modifying the primary outcome measure to include treatment failures. Crossovers should be anticipated and compensated for by increasing the number of participants. CONCLUSION: Non-adherence to randomly allocated management options can deprive trials of the statistical power needed to inform clinical care. Crossovers and ways to mitigate related problems should be anticipated at the time of trial design.