Recurrence Rate after Herniotomy only versus Discectomy in Lumbar Disc Herniation

OBJECTIVE: Lumbar disc herniation (LDH) recurrence necessitating reoperation can pose problems following spinal surgery, with an overall reported incidence of approximately (3-13%). The purpose of this study is to identify the rate of recurrent disc herniation, to discuss the radiologic indications for herniotomy and to analyze clinical outcomes compared with conventional discectomy. METHODS: This study is a retrospective case control study. The authors retrospectively reviewed 114 patients who underwent herniotomy & conventional discectomy by a single surgeon for single-level LDH between June 2009 and May 2012. Herniotomy group was 57 patients and conventional discectomy group was 57 patients that were selected from 631 patients using stratified randomization. Evaluation for LDH recurrence included detailed medical chart and radiologic review and telephone interview. Postoperative VAS and the Korean version of ODI were examined one week after surgery. Clinical outcome was investigated according to Odom's criteria from three months to three years. RESULTS: Of the 114 patients for whom the authors were able to definitively assess symptomatic recurrence status, four patients (7%) experienced LDH recurrence following single-level herniotomy and three patients (5.2%) conventional discectomy. There were no differences in the VAS and Korean version of ODI between herniotomy group and conventional discectomy group. The herniotomy group had better results than the conventional discectomy group in clinical outcome from three months to three years, but the difference was not significant. CONCLUSION: There were no significant differences in clinical outcome between herniotomy and conventional discectomy. Recurrence rates following herniotomy for LDH compare favorably with those in patients who have undergone conventional discectomy, lending further support for its effectiveness in treating herniotomy.

Clinical and Radiologic Analysis of Posterior Apophyseal Ring Separation Associated with Lumbar Disc Herniation

OBJECTIVE: We analyzed the clinical and radiologic features of posterior apophyseal ring separation (PARS) with lumbar disc herniation and suggest the proper management options according to the PARS characteristics. METHODS: We reviewed case series of patients with PARS who underwent surgery of lumbar disc herniation. Preoperative symptoms, neurologic status, Body Mass Index, preoperative and postoperative Visual Analogue Scale (VAS) and Korean-Oswestry Disability Index (K-ODI) scores, operation types were obtained. PARS size, locations, the degree of resection were assessed. RESULTS: PARS was diagnosed in 109 (7.5%) patients among 1448 patients given surgical treatment for single level lumbar disc herniation. There were 55 (50.5%) small PARS and 54 (49.5%) large PARS. Among the large PARS group, 15 (27.8%) had lower endplate PARS of upper vertebra at the level of disc herniation. Thirty-nine (72.2%) were upper endplate PARS of lower vertebra. Among the group with upper endplate PARS of lower vertebra, unresected PARS was diagnosed in 12 (30.8%) cases and resected PARS was diagnosed in 27 (69.2%) cases. VAS and K-ODI scores changes were 3.6+/-2.9 and 5.4+/-6.4 in the unresected PARS group, 5.8+/-2.1 and 11.3+/-7.1 in the resected PARS group. The group with upper endplate PARS of lower vertebra showed significant difference of VAS (p=0.01) and K-ODI (p=0.013) score changes between unresected and resected PARS groups. CONCLUSION: The large PARS of upper endplate in lower vertebra should be removed during the surgery of lumbar disc herniation. High level or bilateral side of PARS should be widely decompressed and arthrodesis procedures are necessary if there is a possibility of secondary instability.

The Effects of Epidural Anesthesia in Elderly Patients during Single-Level Lumbar Microdiscectomy

OBJECTIVE: To analyze the effect of epidural anesthesia in elderly patients with single-level lumbar discectomy. METHODS: Medical records of 28 patients aged between 60 and 90 years who had undergone single-level lumbar microdiscectomy by two surgeons from January 2004 to December 2008 were retrospectively reviewed. Patients were divided into 2 groups: Group I was comprised of patients with lumbar discectomy under epidural anesthesia and Group II was comprised of patients with lumbar discectomy under general anesthesia. Factors taken into account when comparing the effects of epidural and general anesthesia were surgical time, anesthetic time, starting time of ambulation after surgery, hospital stay, postoperative headache, nausea, vomiting, urinary difficulty, back pain and patient satisfaction. The score on the visual analogue scale(VAS) for back pain was measured after surgery. RESULTS: 15 patients(Group I) underwent discectomy under epidural anesthesia. The mean age of patients in Group I and II were 65+/-6.1 years and 67+/-6.7 years, respectively. 19 patients had underlying co-morbidities, such as cardiovascular, pulmonary, cerebrovascular diseases and cancer. Demographically, there was no statistical diffe- rence between the two groups. Surgical time, anesthetic time, starting time of ambulation after surgery and hospital stay were longer in patients in Group II. The incidences of urinary difficulty and VAS score for back pain were significantly lower in Group I. The incidences of headache, nausea and vomiting and patient satisfaction were not different between Group I and II. CONCLUSION: Epidural anesthesia was as efficacious and as safe as general anesthesia. Elderly patients who need to undergo single-level lumbar discectomy could be offered epidural anesthesia.

Instrumented Fusion of Same-Level Lamina and Transverse Process for the Treatment of Lumbar Spondylolysis: A Preliminary Report

OBJECTIVE: There were many instruments introduced for direct repair of spondylolysis. But those instruments were not designed for direct repair of spondylolysis originally. Dynesys implants consist of pedicle screws and cords or laminar hooks that were designed for lumbar dynamic stabilization. We used pedicle screws and cord or laminar hook of Dynesys spinal system for repairment of spondylolysis. METHODS: July 2005 to March 2009, Six patients with lumbar spondylolysis were treated with a new technique using a pedicle screw with a u-shaped rod or laminar hook combined with bone grafting of the transverse process and lamina of the same level, bypassing the spondylolytic defect. There were 5 males and 1 female. Ages ranged from 18-48 years(average of 34.5 years). A total of 8 vertebral levels were fused(one patient had spondylolytic defects at 3 levels). Five defects were at L5, two at L4, and one at L3. The patients had low back pain that was unimproved after 3-6 months of conservative management. None demonstrated spondylolisthesis or instability, disc degeneration on MRI, nor radiculopathy. All symptoms resolved after isthmus block. The patients were followed-up for a period of 3-27 months(average of 14.8 months). The authors compared pre-operative and post-operative clinical symptoms and radiographic findings retrospectively. Success of the procedure was determined by the following criteria: impro- vement of clinical symptoms(VAS score), absence of isthmic motion on plain radiographs, and evaluation for the presence of a bone mass bridging the transverse processes and laminae using plain radiographs and reconstruction CT scan. RESULTS: All patients demonstrated improvement in pain scores(average of 8.3 to an average of 3.2). A fusion rate of 87.5% was achieved(7 out 8 levels). No complications were noted. The authors were able to demonstrate a potential benefit in using this new technique for the treatment of lumbar spondylolysis. CONCLUSION: Direct repair of spondylolysis with Dynesys spinal system is technically easy and fixes strongly biome- chanically.

Subsequent Vertebral Fracture after Percutaneous Vertebral Augmentation: Adjacent and Non-adjacent Vertebral Fractures

OBJECTIVE: To analyze the incidence and risk factors of subsequent vertebral fracture after percutaneous vertebral augme- ntation(PVA) in patients with osteoporotic compression fractures(OCF). METHODS: The authors reviewed 27 patients(20 women and 7 men, 39 vertebrae) who underwent vertebral augmentation for the treatment of osteoporotic compression fracture at a single institute between January 2000 and January 2009. The patients were divided into 2 groups: Group I included patients without subsequent fracture and Group II included those with subsequent fracture. Subsequent fractures, including adjacent-level and nonadjacent-level vertebral fractures, were confirmed with radiographs or MRI. Factors such as smoking, diabetes mellitus(DM), previous bisphosphonate use, body mass index(BMI), bone mineral density(BMD), the amount of polymethylmethacrylate(PMMA), intradiscal leakage of PMMA and unilateral approach were analyzed statistically. RESULTS: Nine patients(33.3%, Group II) sustained 16 subsequent vertebral fractures(9 adjacent-level vertebral fractures and 7 nonadjacent-level vertebral fractures). Subsequent vertebral fractures at the lumbar level(81.3%) were more fre- quent than those at thoracic level(18.8%). BMI, BMD, smoking, DM, amount of PMMA, unilateral approach, and bis- phosphonate use did not correlate with the risk of subsequent fracture. Intradiscal leakage of PMMA was the only signifi- cant risk factor(P=0.027). CONCLUSIONS: The high rate of subsequent vertebral fracture should be considered before vertebral augmentation with PMMA. The intradiscal leakage of PMMA could increase the risk of subsequent fracture.

The Efficacy of Anterior Lumbar Interbody Fusion in Degenerative Disc Disease and Degenerative Spondylolisthesis: Comparative Review of 44 Single-Level Cases

OBJECTIVE: The authors conduct a retrospective study to evaluate the efficacy of anterior lumbar interbody fusion(ALIF) in treating degenerative disc disease(DDD) and degenerative spondylolisthesis(DS). METHODS: During 1998, eighty-six patients underwent mini-retroperitoneal ALIF with Brantigan carbon cages. Among them, 19 patients were lost during the follow-up period and 23 patients underwent multilevel fusion procedures. The authors evaluated 44 single-level cases(31 with DDD; 13 with DS) with Macnab's criteria for clinical outcomes and the Criteria of Brantigan and Steffee for fusion results. The extent of slippage of patient with DS was not greater than grade 1. The mean follow-up period was 24 months. RESULTS: The overall fusion rate was 88.6%(94% in DDD; 77% in DS). Based on the Macnab's criteria, excellent or good results were achieved in 38 of 44 patients(86.3%). Overall clinical outcome was significantly associated with preoperative diagnosis(p=0.03), radiologically demonstrated fusion(p=0.001), and subsidence of cages(p=0.03). In DDD sub-group, two cases of fusion failure and four of subsidence of cages belonged to excellent or good results. But, in DS sub-group, fusion failure or subsidence rate were significantly high and all three cases with poor result belonged to this sub-group. One of them underwent posterior operation. CONCLUSION: ALIF is considered as a good surgical method for a patient with discogenic back pain caused by degenerative disc disease. But in degenerative spondylolisthesis, considering the comparatively poor clinical and radiological result, it seems that ALIF alone does not provide sufficient strength to overcome the instability. Despite the advantage of minimal invasiveness, more careful application of ALIF is needed in the of degenerative spondylolisthesis.