Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice.

STUDY DESIGN: Retrospective multicenter cohort study. OBJECTIVE: Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. METHODS: This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. RESULTS: The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. CONCLUSIONS: The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Influence of age and severity of Lenke 5 or 6 idiopathic scoliosis on postoperative quality of life in adult patients.

INTRODUCTION: Thoracolumbar adolescent idiopathic scoliosis can continue to progress beyond skeletal maturity. Ideal timing of surgery remains undefined. Earlier intervention, with shorter instrumentation, incurs early partial loss of lumbar motion. Waiting for progression incurs a greater risk of extensive arthrodesis. The aim of the present study was to assess the quality-of-life impact of age and scoliosis severity at surgery. MATERIAL AND METHODS: Patients with Lenke 5 or 6 adolescent idiopathic scoliosis, aged 16-45years, were analyzed based on a prospective clinical registry. Oswestry Disability Index (ODI) and Scoliosis Research Society (SRS)-22 scores were collected preoperatively and at 6months, 1year and 2years. Coronal and sagittal alignments were measured on full-spine radiographs, and curve flexibility was assessed on bending radiographs. A mixed linear model was used to assess the impact of age, Cobb angle and flexibility on quality of life. RESULTS: Thirty-six patients were included. Mean ODI was 20.5% preoperatively and 13.8% at 2years (p=0.017). Mean SRS-22 was 3.2 preoperatively and 3.9 at 2years (p<0.001). Mean Cobb angle was 56.6° preoperatively and 23.2° at 2years (p<0.001), with mean preoperative reducibility of 68.1%. Age and ODI correlated preoperatively (r=0.6; p<0.001) and at 6months (r=0.5; p=0.002), as did age and SRS-22 (r=-0.6; p<0.001 and r=-0.6; p<0.001, respectively). Linear regression found a significant negative correlation between thoracolumbar Cobb angle and change in SRS-22 at 6months. DISCUSSION: In 16-45 year-olds with Lenke 5 or 6 idiopathic scoliosis, age influenced SRS-22 score. Younger patients had better quality of life both pre- and post-operatively. Curve magnitude influenced postoperative score. The present study suggests that early surgical correction in younger patients, where instrumentation can be shorter, does not impair quality of life. LEVEL OF EVIDENCE: IV; prospective registry study.

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients.

BACKGROUND: One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review. METHODS: This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration. RESULTS: The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation. CONCLUSIONS: Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Segmental Lordosis Gain Is a Prognostic Radiological Factor of Good Functional Outcome After the Implantation of a Single-Level Prosthesis or a Hybrid Construct for Lumbar Disc Degeneration.

OBJECTIVE: To identify radiological factors and functional outcomes associated with good results after implantation of a single lumbar disc prosthesis or a hybrid construct (anterior lumbar interbody fusion and lumbar disc prosthesis) in the setting of painful degenerative lumbar discopathy. METHODS: This single-center, retrospective 10-year study included 92 patients ˃18 years old with chronic low back pain evolving for at least 1 year. The patients had degenerative disc disease and had failed conservative treatment and underwent lumbar arthroplasty. Radiographic and clinical outcomes were assessed preoperatively and 1 year after surgery. Functional evaluation was based on the Oswestry Disability Index (ODI) and a numerical rating scale. Radiological analysis was based on lumbar x-rays and magnetic resonance imaging parameters. Patients were assigned to 2 groups according to the reduction in ODI score (>15 points or <15 points), and statistical analysis was done in both groups to find predictive radiological factors for a satisfactory functional outcome. RESULTS: Clinically, 60 patients (65.2%) had a satisfactory functional result and 32 patients (34.8%) had a poor outcome according to ODI score. Radiographically, gain in segmental lordosis was statistically associated with good functional outcomes (8.9° for ODI decrease >15 vs. 3.2° for ODI decrease <15). CONCLUSIONS: This study determined that gain in segmental lordosis is associated with a satisfactory functional outcome after a single-level lumbar disc prosthesis or a hybrid construct. Our study demonstrates that segmental lordosis gain may represent a significative useful positive predictor factor of patient outcome.

Transfacet screws using spinal navigation in addition to anterior or oblique lumbar interbody fusion: technical note and preliminary results.

Transfacet screws (TFS) are an alternative to the classic bilateral pedicular screws (BPS) in addition to anterior (ALIF) or oblique (OLIF) lumbar interbody fusion. Spinal navigation could help the surgeon in technically demanding procedures in order to avoid screw malposition. Although spinal navigation is commonly used in BPS, its contribution in TFS remains unclear. Our aim here was to assess the feasibility of TFS using spinal navigation in addition to anterior lumbar fusion. Five patients suffering from lumbar degenerative disc disease were included. During the same general anaesthesia, we performed successively an ALIF or OLIF and then a TFS according to Boucher technique using spinal navigation (O-arm). No peri-operative complication occurred, and all the screws were successfully positioned (n = 10). All clinical scores (ODI, VAS L and VAS R) improved at 6-month follow-up. Segmental lordosis increased from 6° [2.4°-12°] to 13.6° [8°-17°]. Fusion was achieved for the five patients. TFS using O-arm in addition to ALIF/OLIF is feasible. To confirm our early favourable outcomes on clinical and radiological data, this technique must be evaluated on larger samples of patients.