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Introduction: The number of reoperations increases with the growing number of operations performed. Methods: The clinical material included a group of 2194 patients treated surgically due to degenerative disease of the lumbar spine; we selected a total of 332 patients who were reoperated, and the indications for reoperation were analysed. Results: The percentage of patients operated due to adjacent segment disease in the group of patients with stabilization was on average 8.9%. Conclusions: Indications for stabilizing or preservation of the mobility of the operated segment should provide for the nature of the lesions, and anatomical and surgical conditions.

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AIM: Prospective evaluation of the results of endoscopic lumbar discectomy. METHODS: 95 patients were consecutively enrolled in the study between 2017 and 2021. We monitored low back pain and sciatica according to the Visual Analogue Scale (VAS), the limitations in daily activities (Oswestry Disability Index, ODI), overall satisfaction according to a 0-100 % scale, and the rate of surgical complications and reoperations. RESULTS: Postoperatively, the VAS values of low back pain and sciatica decreased significantly from 5 to 1 point and from 6 to 1 point, respectively, and the pain remained in the tolerable range (VAS 1-2) throughout the follow-up period. The ODI score improved significantly from severe disability (46 %), preoperatively, to moderate disability at discharge and one month after surgery (29 % and 22 %, respectively), down to minimal disability at 3 and 12 months after surgery (12 % and 14 %, respectively). Overall patient satisfaction improved significantly at all follow-up time points (46 %, 70 %, 77 %, 80 %, and 78 %, respectively). Reoperation rate was 6.3 %. Cerebrospinal fluid leakage was observed in one case only (1.1 %). Transient postoperative perianogenital sensory impairment occurred in two patients (2.1 %). There was no evidence of surgical site infection or haematoma. CONCLUSION: Endoscopic discectomy provides significant pain relief and improves the patient's ability to perform activities of daily living, contributing to greater satisfaction. It is a safe method with a low risk of surgical and neurological complications (Tab. 3, Fig. 3, Ref. 27).

Asunto(s)

Desplazamiento del Disco Intervertebral , Dolor de la Región Lumbar , Ciática , Humanos , Ciática/cirugía , Desplazamiento del Disco Intervertebral/cirugía , Dolor de la Región Lumbar/cirugía , Actividades Cotidianas , Resultado del Tratamiento , Vértebras Lumbares/cirugía , Discectomía/métodos , Endoscopía/métodos , Estudios Retrospectivos

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In recent years, full-endoscopic discectomy (FED) has expanded its range of indications with the development of devices and various techniques. The advantage of FED over conventional surgery is that it is a minimally invasive procedure. However, intraoperative and postoperative precautions must be taken to prevent complications. It is necessary to avoid complications that could compromise the outcome of the procedure. Effective perioperative management is necessary to avoid complications; however, there is no set view for perioperative management in FED. In this study, we perform a literature review to examine the effectiveness of perioperative management methods for FED. The key to ensuring the efficacy and minimal invasiveness of FED is prevention of complications. Based on the result and literature review, we believe that the most manageable postoperative management after FED is prevention of recurrent disc herniation and hematoma formation. A drain should be placed to prevent postoperative hematoma formation. It is advisable to evaluate the patient's symptoms and monitor C-reactive protein and erythrocyte sedimentation rate levels during the first week after surgery. Postoperative antibiotics were administered for 1 day.

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Background Recurrent disc herniation is a major cause of morbidity and surgical failure after disc surgery. This study aimed to investigate the feasibility, safety, and effectiveness of the Destandau endospine system (DES) for treating recurrent lumbar disc herniation (LDH). Methodology A total of 44 patients who underwent minimally invasive Destandau endoscopic lumbar discectomy (DELD) for recurrent LDH were included in this study. All data were collected retrospectively. The preoperative and postoperative visual analog scale (VAS) score was used for the evaluation and gradation of pain. The clinical outcome was analyzed according to modified MacNab criteria. The minimum follow-up was two years. Preoperative and postoperative VAS scores were compared using the paired Student's t-test. Statistical significance was set at a p-value <0.05. Results The mean surgical time was 30 ± 20 minutes. The VAS score for leg pain was improved in all cases from 5.9 ± 2.1 to 1.7 ± 1.3 (p< 0.001). In 98% of cases, a successful outcome was noted (excellent or good outcome according to MacNab criteria). In three (7%) patients, incidental durotomy occurred, but there was no neurological worsening, cerebrospinal fluid fistula, or negative influence on the clinical outcome. No recurrence or instability occurred in our series. Conclusions The clinical outcomes of minimally invasive DES for LDH were found to be comparable with the reported success rates of other minimally invasive techniques reported in the existing literature. The dural tear rate was independent of postoperative morbidity and functional outcome. The technique is a safe and effective treatment option for recurrent LDH.

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Background: Recurrent disc herniation is a common condition that often results in months of disabling symptoms and additional costs. Objective: The objective of this study was to investigate the incidence of recurrent disc herniation in patients treated surgically. Materials and Methods: Clinical trials and prospective studies involving patients treated with different techniques, such as open, percutaneous, or microendoscopic discectomy, were included. The incidence of recurrence as well as the level and the time until the recurrent disc herniation was collected. Results: Thirteen studies were included. Recurrence of disc herniation ranged from 0% to 14% of patients. Most recurrences occurred at the same level of herniation and on the same side. The time to recurrence of disc herniation ranged from 1 to 5 years. Conclusion: This study answers the question of how much, when, and where in lumbar recurrent disc herniation.

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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.

Asunto(s)

Desplazamiento del Disco Intervertebral , Estenosis Espinal , Estudios de Seguimiento , Humanos , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Dolor , Prolapso , Estenosis Espinal/cirugía

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BACKGROUND CONTEXT: Lumbar disc herniation (LDH) is a common condition that can affects an individual' quality of life. In patients for whom conservative treatment is ineffective after 3 months, surgical treatment, such as percutaneous endoscopic lumbar discectomy (PELD), is recommended. Because PELD is minimally invasive and produces thorough nerve root decompression, both surgeons and patients often prefer it to other techniques. PURPOSE: Surgeons find it challenging to prevent postoperative recurrent LDH (rLDH) when they use PELD. We created and verified a model for evaluating patients' recurrence risk factors before surgery so that surgeons can choose other surgical techniques when necessary. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: One thousand eight hundred seven patients who underwent PELD at our hospital between 2012 and 2015 were enrolled. OUTCOME MEASURE: The main outcome measure was rLDH at any follow-up time point. METHODS: Data were retrospectively analyzed for 1807 patients who underwent PELD at our hospital at some point between 2012 and 2015; all patients had been monitored for at least 5 years after surgery. They were divided into a recurrence group and a nonrecurrence group. Clinical and radiological risk factors were assessed over time to determine their correlations with recurrence and to exclude less important factors. A nonlinear multivariate logistic regression model was established to predict the recurrence rate before surgery. RESULTS: A total of 1706 patients were monitored after PELD; data were missing for 101 additional patients. The total recurrence rate was 10.38%, and the most common time from surgery to recurrence was 1 year. Ten risk factors were assessed and included in the analysis. Regarding clinical risk factors, patients with hypertension (p < .001; correlation coefficient R [R] = 0.235; odds ratio [OR] = 4.749), diabetes (p < .001; R = 0.381; OR = 16.797), a history of smoking (p < .001; R = 0.347; OR = 9.012), and a history of performing intense physical labor (p < .001; R = 0.409; OR = 19.592) had a higher recurrence rate. Regarding radiological risk factors, patients with disc degeneration (Pfirrmann grade III) (p < .001; R = 0.228; OR = 4.919), Modic changes (level 2) (p < .001; R = 0.309; OR = 7.934), herniation in the form of extrusion (p < .001; R = 0.365; OR = 12.228), a higher disc height index (DHI) (p < .001; R = 0.336), and a larger segmental range of motion (p < .001; R = 0.243) had a higher recurrence rate. When the lumbar motion angle was negative (p < .001; R = 0.318; OR = 13.680), the recurrence rate was high. The overall accuracy of the final model was 97.6% (1665 of 1706). The recognition rate for non-rLDH cases was 99.0% (1514 of 1529), and the rate for rLDH cases was 85.3% (151 of 177); the AUC was 0.9315. A simple model was used. For those patients with postoperative trauma (p < .001; R = 0.382; OR = 13.680), a comparison model was established, and the corresponding recurrence rate was 23.0% ± 25.0% (0-76%). CONCLUSIONS: A large cohort of patients underwent long-term monitoring, and 11 risk factors were verified for assessing each patient's risks before surgery to predict the postoperative recurrence of LDH following PELD. The risk of recurrence may be effectively reduced with the use of alternative surgical techniques in high risk cases.

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Discectomía Percutánea , Desplazamiento del Disco Intervertebral , Discectomía , Discectomía Percutánea/efectos adversos , Endoscopía/efectos adversos , Humanos , Desplazamiento del Disco Intervertebral/cirugía , Modelos Logísticos , Vértebras Lumbares/cirugía , Calidad de Vida , Estudios Retrospectivos , Resultado del Tratamiento

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Detailed surgical management, magnetic resonance imaging (MRI), and computer tomography (CT) images of a broken annular closure device (ACD) have not been reported yet. In this case, a 28-year-old male presented with a new onset of radiculopathy three years after lumbar discectomy and placement of an ACD. The CT-myelography and MRI revealed a recurrent disc herniation (RDH) and dislocation of a broken ACD. ACD removal was performed and confirmed breakage due to RDH with scarring around the RDH and displaced ACD. Implant-associated complications and management should be reported in detail in order to enhance knowledge on device-related complications.

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Discectomía/efectos adversos , Falla de Equipo , Desplazamiento del Disco Intervertebral/etiología , Vértebras Lumbares/cirugía , Complicaciones Posoperatorias/etiología , Radiculopatía/etiología , Adulto , Discectomía/instrumentación , Humanos , Degeneración del Disco Intervertebral/cirugía , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Desplazamiento del Disco Intervertebral/cirugía , Imagen por Resonancia Magnética , Masculino , Complicaciones Posoperatorias/diagnóstico por imagen , Radiculopatía/diagnóstico por imagen , Tomografía Computarizada por Rayos X

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BACKGROUND: Facet tropism (FT) refers to the difference in the orientation of facet joints with respect to each other in the sagittal plane. FT leads to unequal biomechanical forces on facet joint and intervertebral disc during rotation and other physiologic movements. Most of the studies have reported the incidence of FT in the lumbar spine to vary between 40% and 70%, with L4-5 level being the most commonly afflicted level. The objective of this study was to find the association between FT and various lumbar and cervical degenerative disorders. METHODS: A systematic search of PubMed was performed with the keywords "facet tropism" and "facet asymmetry." Data for meta-analysis were extracted from the studies to obtain pooled impact of FT on lumbar disc herniation (LDH) and lumbar degenerative spondylolisthesis (LDS). RESULTS: Eighty-two articles were included in the systematic review and 18 studies had the required data to be included in the meta-analysis. The pooled standard mean difference between FT angles in patients with or without LDH was 0.31 with (P = 0.04). The pooled odds ratio for FT in patients with LDH was 3.27 with (P = 0.02). Subgroup analysis showed that there is no significant difference in the L3/4, L4/5, and L5S1 subgroups. The pooled standard mean difference between FT angles in patients with or without LDS was 0.54 (P = 0.009). CONCLUSIONS: FT is significantly associated with LDH and LDS along with various other lumbar and cervical degenerative diseases.

Asunto(s)

Vértebras Cervicales/diagnóstico por imagen , Degeneración del Disco Intervertebral/epidemiología , Desplazamiento del Disco Intervertebral/epidemiología , Vértebras Lumbares/diagnóstico por imagen , Espondilolistesis/epidemiología , Tropismo , Articulación Cigapofisaria/diagnóstico por imagen , Fenómenos Biomecánicos , Humanos , Disco Intervertebral/fisiopatología , Articulación Cigapofisaria/crecimiento & desarrollo , Articulación Cigapofisaria/fisiopatología

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STUDY DESIGN: Longitudinal cohort. OBJECTIVE: It is unclear if patients with a recurrent disc herniation benefit from a concurrent fusion compared with a repeat decompression alone. We compared outcomes of decompression alone (D0) versus decompression and fusion (DF) for recurrent disc herniation. METHODS: Patients enrolled in the Quality and Outcomes Database from 3 sites with a first episode of recurrent disc herniation were identified. Demographic, surgical, and radiographic data including the presence of listhesis and extent of facet resection on computed tomography or magnetic resonance imaging prior to the index surgery were collected. Patient-reported outcomes were collected preoperatively and at 3 and 12 months postoperatively. RESULTS: Of 94 cases identified, 55 had D0 and 39 had DF. Patients were similar in age, sex distribution, smoking status, body mass index, American Society of Anesthesiologists grade and surgical levels. Presence of listhesis (D0 = 7, DF = 5, P = .800) and extent of facet resection (D0 = 19%, DF = 16%, P = .309) prior to index surgery were similar between the 2 groups. Estimated blood loss (D0 = 26 cm3, DF = 329 cm3, P < .001), operating room time (D0 = 79 minutes, DF = 241 minutes, P < .001) and length of stay (D0 <1 day, DF = 4 days, P < .001) were significantly less in the D0 group. Preoperative and 1-year postoperative patient-reported outcomes were similar in both groups. Three patients in the D0 group and 2 patients in the DF group required revision. Regression analysis showed that presence of listhesis, extent of facet resection and fusion were not associated with the 12-month Oswestry Disability Index (ODI) score. CONCLUSION: For a first episode recurrent disc herniation, surgeons can expect similar outcomes whether patients are treated with decompression alone or decompression and fusion.

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BACKGROUND: The objective of this study is to determine the effectiveness and prognostic factors of revisional full endoscopic interlaminar discectomy (FEID) for recurrent herniation after conventional open disc surgery. The major concerns of the repeated discectomy for recurrent lumbar disc herniation (RLDH) are the epidural scar and postoperative segmental instability. Compared to open discectomy, endoscopic method has advantages of less tissue traumatization, clearer visualization and better tissue identification. With the improvement of endoscopic technique and instrument, the problems related to adhesive scar tissues or postoperative instability could be overcome. METHODS: From June 2014 to December 2016, FEID was performed in consecutive 24 patients for RLDH. The age ranged from 25 to 60 years (mean 44.6 years). The level operated was L5-S1 in 16 cases and L4-5 in 8 cases. To avoid injury to the neural tissue, we started with the bony structure. A small part of facet or lamina might be resected in severe stenotic or adhesive condition. Aggressive separation of the scar from the neural tissue might lead to dural tear and should be avoided. The herniated disc material was removed after neural tissue had been clearly identified and protected. RESULTS: The follow-up period was at least 24 months. The visual analog scale (VAS) for leg pain and back pain, and Oswestry disability index (ODI) showed significant improvement after treatment. Excellent or good outcome by the modified Macnab's criteria was obtained in 22 of 24 patients at two years follow-up. Excellent outcome was noted in 100 percent patients younger than 50 years. Small durotomy occurred in 2 patients and no visible cerebrospinal fluid (CSF) leakage was detected despite repair was not performed. Two additional surgery was performed including one repeated FEID for re-recurrence of disc herniation and one fusion surgery for postoperative back pain. CONCLUSIONS: FEID is a safe and effective alternative for recurrent disc herniation. The successful rate was greater than 90 percent, especially in the younger patients with the advantages of early recovery and no need for fusion.

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OBJECTIVE: To investigate the relationship between Modic changes (MCs) and recurrent lumbar disc herniation (rLDH) and that between the herniated disc component and rLDH following percutaneous endoscopic lumbar discectomy (PELD). METHODS: We included 102 (65 males, 37 females, aged 20-66 years) inpatients who underwent PELD from August 2013 to August 2016. All patients underwent CT and MRI preoperatively. The presence and type of Modic changes were assessed. During surgery, the herniated disc component of each patient was classified into two groups: nucleus pulposus group and hyaline cartilage group. The association of herniated disc component with Modic changes was investigated. The incidence of rLDH was assessed based on a more than 2-year follow-up. RESULTS: In total, 11 patients were lost to follow-up; the other 91 were followed up during 24-60 months. Of the 91 patients, 99 discs underwent PELD; 28/99 (28.3%) had MCs. Type I and II MCs were seen in 9 (9.1%) and 19 (19.2%), respectively; no type III MCs were found. Among 28 endplates with MCs, according to the herniated disc component, 18/28 (64.3%) showed evidence of hyaline cartilage in the intraoperative specimens, including 6/9 and 12/19 endplates with type I and II MCs, respectively. Among 71 endplates without MCs, 14/71 (19.7%) showed evidence of hyaline cartilage in the intraoperative specimens. Hyaline cartilage was more common in patients with MCs (P < 0.05). We found 2 cases of rLDH in the non-MC group (n = 71); 6 cases of rLDH were found in the MC group (n = 28), including 2 and 4 cases for types I and II, respectively. There was no significant difference between types I and II (P > 0.05). rLDH was more common in patients with MCs (P < 0.05). We found 5 rLDH cases in the hyaline cartilage group (n = 32); 3 rLDH cases were found in the nucleus pulposus group (n = 67). rLDH was more common in the hyaline cartilage group (P < 0.05). CONCLUSIONS: rLDH following PELD preferentially occurs when MCs or herniated cartilage are present.

Asunto(s)

Discectomía Percutánea/tendencias , Endoscopía/tendencias , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Adulto , Anciano , Femenino , Humanos , Imagen por Resonancia Magnética/tendencias , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/tendencias , Adulto Joven

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BACKGROUND: This study identified risk factors and postoperative indicators for recurrent lumbar disc herniations (rLDH) following microdiscectomy. METHODS: We retrospectively reviewed the 1-year recurrence rate for LDH in 209 consecutive patients undergoing microdiscectomy (2013-2018). RESULTS: Utilizing a multivariate analysis, higher body mass index (BMI) and postsurgery Oswestry disability index (ODI) were significantly associated with an increased risk of rLDH. CONCLUSION: Elevated postsurgery ODI and higher BMI were significantly associated with increased risk of rLDH.

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BACKGROUND: Lumbar intervertebral disc herniation is a common cause of lower back and leg pain, with surgical intervention (e.g. discectomy to remove the herniated disc) recommended after an appropriate period of conservative management, however the existing or increased breach of the annulus fibrosus persists with the potential of reherniation. Several prosthesis and techniques to reduce re-herniation have been proposed including implantation of an annular closure device (ACD) - Barricaid™ and an annular tissue repair system (AR) - Anulex-Xclose™. The aim of this meta-analysis is to assist surgeons determine a potential approach to reduce incidences of recurrent lumbar disc herniation and assess the current devices regarding their outcomes and complications. METHODS: Four electronic full-text databases were systematically searched through September 2017. Data including outcomes of annular closure device/annular repair were extracted. All results were pooled utilising meta-analysis with weighted mean difference and odds ratio as summary statistics. RESULTS: Four studies met inclusion criteria. Three studies reported the use of Barricaid (ACD) while one study reported the use of Anulex (AR). A total of 24 symptomatic reherniation were reported among 811 discectomies with ACD/AR as compared to 51 out of 645 in the control group (OR: 0.34; 95% CI: 0.20,0.56; I2 = 0%; P < 0.0001). Durotomies were lower among the ACD/AR patients with only 3 reported cases compared to 7 in the control group (OR: 0.54; 95% CI: 0.13, 2.23; I2 = 11%; P = 0.39). Similar outcomes for post-operative Oswestry Disability Index and visual analogue scale were obtained when both groups were compared. CONCLUSION: Early results showed the use of Barricaid and Anulex devices are beneficial for short term outcomes demonstrating reduction in symptomatic disc reherniation with low post-operative complication rates. Long-term studies are required to further investigate the efficacy of such devices.

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Discectomía , Desplazamiento del Disco Intervertebral/cirugía , Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Resinas Sintéticas/uso terapéutico , Reeemplazo Total de Disco/instrumentación , Adolescente , Adulto , Anciano , Fenómenos Biomecánicos , Discectomía/efectos adversos , Femenino , Humanos , Disco Intervertebral/diagnóstico por imagen , Disco Intervertebral/fisiopatología , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Desplazamiento del Disco Intervertebral/fisiopatología , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/fisiopatología , Masculino , Persona de Mediana Edad , Apósitos Periodontales/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Diseño de Prótesis , Recuperación de la Función , Recurrencia , Resinas Sintéticas/efectos adversos , Factores de Riesgo , Factores de Tiempo , Reeemplazo Total de Disco/efectos adversos , Resultado del Tratamiento , Adulto Joven

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BACKGROUND: Intradural disc herniation is a rare phenomenon in spine surgery. Diagnosis is difficult despite current neuroradiologic imaging techniques. METHOD: We present a case of a 59-year-old man with lumbar and radicular pain and a recurrent lumbar herniation. A laminectomy was performed after no clear disc herniation in the epidural space was found and an intradural mass was palpable. A durotomy showed an intradural disc fragment that was removed, followed by an arthrodesis. CONCLUSION: Only intraoperative findings lead to a definitive diagnosis for intradural herniation. A durotomy needs to be performed. In this case, an arthrodesis was necessary to avoid complications of segmental instability.

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Desplazamiento del Disco Intervertebral/cirugía , Laminectomía/métodos , Vértebras Lumbares/cirugía , Complicaciones Posoperatorias/prevención & control , Espacio Epidural/cirugía , Humanos , Laminectomía/efectos adversos , Masculino , Persona de Mediana Edad

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The clinical effectiveness of percutaneous and transforaminal endoscopic discectomy procedures has been evaluated by the system used or compared to open laminectomy or micro-discectomy but are not evaluated based on the location and characteristics of the abnormal disc. This review proposes that outcomes are primarily related to disc size, biomechanics, location, and associated segmental fibrotic and bone changes as well as the surgeon's skill in using various systems rather than the specific system used. In these cases, the surgeon needs to decide if the goal of the procedure is simply internal decompression of an abnormal but contained herniated disc or release of the entrapped nerve root by a large contained disc, extruded and migrated disc fragment, or coexistent foraminal stenosis. Percutaneous and tubular transforaminal procedures are quite different, technically ranging from simple discectomy aspirating probes to larger endoscopic systems, providing the capability to remove large extruded free disc fragments, with or without foraminotomy. Recently, the ability to perform interbody fusion has been added to the range of procedures able to be performed endoscopically. At the same time, biologic solutions to disc degeneration are rapidly evolving and may have a place in combination with these procedures. This article reviews the interrelationship between clinical signs and symptoms, radiologic findings, and the biochemistry and biomechanics of the affected disc segment. Understanding the role played by all these factors enables the surgeon to evaluate both the disc and surrounding bone structures pre-operatively to determine if the clinical signs and symptoms are related to enlargement and displacement of a contained disc or compression or impingement of the nerve root. Based on this, the surgeon can choose different surgical systems, allowing simple decompression of a contained disc, possibly adding biologics, with a 'small' system, while a large herniated disc, or extruded fragment, causing root impingement, would require a 'larger' system that provides direct endoscopic visualization within the epidural space, foraminal decompression with drills, and direct surgical manipulation and freeing of the nerve root. By choosing the surgical system based on characteristics such as disc size, location, and associated inflammatory and fibrotic changes, the effectiveness of minimally invasive procedures will be more consistent and improve as the surgeon's diagnostic and operative skills improve.

RESUMEN

We report a case of a 39-year-old male with sciatica who underwent an L5/S1 microdiscectomy with objective physical activity measurements performed preoperatively and continually postoperatively up to 3-month using wireless accelerometer technology linked to the surgical practice; collecting distance travelled, daily step count (DSC) and Gait Velocity (GV). Preoperative, the patient was walking with a GV of 0.97 m/s and a DSC of less than 2,500. After the first month following surgery, the patient had increased mobility, with a GV of 1.58 m/s, and taking an average of over 4,500 steps per day. At day 57 postop, the patient experienced a recurrence of pain with reduction of GV, DSC and walking distance. Magnetic resonance imaging (MRI) was performed and revealed a recurrent disc herniation with further surgery on day 63, with a rapid return of function post 2nd surgery. The use of wireless accelerometers is practical in obtaining objective physical activity measurements before and after lumbar microdiscectomy, and will assist the surgeon and rehabilitation provider to monitor outcomes, complications and assist in clinical decision making.

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We report the unusual case of a young patient with reoperation after annuloplasty using the Barricaid® (Intrinsic Therapeutics, Woburn, MA, USA) closure device. Our patient, a 32-year-old man underwent lumbar discectomy and annuloplasty of the level L5-S1. Five years later, the patient presented with a new onset of low-back pain radiating into the right leg. Imaging revealed loosening of the annulus repair device. The device was removed surgically and the patient was pain free thereafter. Annular closure devices such as the Barricaid system aim to improve outcome after lumbar discectomy by reducing the risk of recurrent disc herniation of the same level. Data on long-term follow-up are missing. Here we present, to our knowledge, the first case of symptomatic device loosening.

Asunto(s)

Discectomía/efectos adversos , Desplazamiento del Disco Intervertebral/cirugía , Apósitos Periodontales/efectos adversos , Falla de Prótesis/etiología , Infecciones Relacionadas con Prótesis/diagnóstico , Resinas Sintéticas/efectos adversos , Infección de Heridas/diagnóstico , Adulto , Discectomía/métodos , Humanos , Vértebras Lumbares/cirugía , Masculino , Infecciones Relacionadas con Prótesis/etiología

RESUMEN

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage. The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain. ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

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Discectomía , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Polirradiculopatía/cirugía , Fusión Vertebral , Adulto , Discectomía/métodos , Femenino , Humanos , Desplazamiento del Disco Intervertebral/complicaciones , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Polirradiculopatía/diagnóstico por imagen , Polirradiculopatía/etiología , Prolapso , Recurrencia , Fusión Vertebral/métodos

RESUMEN

Autologous disc cell transplantation (ADCT) is a cell-based therapy aiming to initiate regeneration of intervertebral disc (IVD) tissue, but little is known about potential risks. This study aims to investigate the presence of structural phenomena accompanying the transformation process after ADCT treatment in IVD disease. Structural phenomena of ADCT-treated patients (Group 1, n = 10) with recurrent disc herniation were compared to conventionally-treated patients with recurrent herniation (Group 2, n = 10) and patients with a first-time herniation (Group 3, n = 10). For ethical reasons, a control group of ADCT patients who did not have a recurrent disc herniation was not possible. Tissue samples were obtained via micro-sequestrectomy after disc herniation and analyzed by micro-computed tomography, scanning electron microscopy, energy dispersive spectroscopy, and histology in terms of calcification zones, tissue structure, cell density, cell morphology, and elemental composition. The major differentiator between sample groups was calcium microcrystal formation in all ADCT samples, not found in any of the control group samples, which may indicate disc degradation. The incorporation of mineral particles provided clear contrast between the different materials and chemical analysis of a single particle indicated the presence of magnesium-containing calcium phosphate. As IVD calcification is a primary indicator of disc degeneration, further investigation of ADCT and detailed investigations assessing each patient's Pfirrmann degeneration grade following herniation is warranted. Structural phenomena unique to ADCT herniation prompt further investigation of the therapy's mechanisms and its effect on IVD tissue. However, the impossibility of a perfect control group limits the generalizable interpretation of the results.