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   Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 4  |  Page : 238-240  

Lumbar disk herniation: How far should efforts go to minimally invasive procedure?


1 Department of Neurosurgery, Centre Clinical, Chirurgie de Rachis, Soyaux, France
2 Department of Neurosurgery, Neurosurgical Clinic of Dr Gharaei, Tehran, Iran
3 Department of Neurosurgery, Werner Forssmann Hospital, Academic Hospital of Charité – Universitätsmedizin Berlin, Eberswalde, Eggenfelden, Bayern, Germany
4 Department of Orthopedics, Rottal-Inn-Kliniken GmbH, Eggenfelden, Bayern, Germany

Date of Web Publication21-Jan-2019

Correspondence Address:
Dr. Keyvan Mostofi
Department of Neurosurgery, Centre Clinical, Chirurgie de Rachis, Soyaux
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvjs.JCVJS_70_18

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   Abstract 


Background: Minimally invasive surgery (MIS) of lumbar disk herniation allows avoiding less of a mess in crossing structures, reducing muscular and cutaneous scarring, postoperative pain, lengthy recovery times, and the rate of infection. The aim of this study is to explain our experience in MIS of disc herniation. We compare the outcome of three different surgical techniques used for the treatment of lumbar disc herniation.
Materials and Methods: A total of 1147 patients have been operated from July 2008 to December 2015 for lumbar disk herniation by posterior endoscopic approach. Three hundred and seventy-nine patients underwent discectomy and herniectomy (DH), 557 patients have been operated by herniectomy (H), and 211 patients underwent only bone decompression (BD).
Results: The results show 80.10%, 82.06%, and 84.02% excellent outcome, respectively, in BD, DH, and BD techniques.
Conclusion: Analysis of the data demonstrates that the results obtained are equivalent and comparable in different used techniques for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way.

Keywords: Endoscopic surgery, lumbalgia, lumbar disc herniation, minimally invasive surgery, sciatalgia


How to cite this article:
Mostofi K, Moghadam BG, Peyravi M, Khouzani RK. Lumbar disk herniation: How far should efforts go to minimally invasive procedure?. J Craniovert Jun Spine 2018;9:238-40

How to cite this URL:
Mostofi K, Moghadam BG, Peyravi M, Khouzani RK. Lumbar disk herniation: How far should efforts go to minimally invasive procedure?. J Craniovert Jun Spine [serial online] 2018 [cited 2019 Jul 18];9:238-40. Available from: http://www.jcvjs.com/text.asp?2018/9/4/238/250482




   Introduction Top


Minimally invasive surgery (MIS) of lumbar disk herniation allows the same procedure to be performed as in the open surgery without sacrificing the appliance efficiency of the procedure in terms of decompression of nerve root. MIS can provide access to a target-herniated disc-avoiding less of a mess in crossing structures, reducing muscular and cutaneous scarring, postoperative pain, lengthy recovery times, and the rate of infection. Beyond the above benefits, the endoscopic procedure provides to a surgeon a great magnification. The latter offers a safer surgery with lower risk to nerve injury.

This procedure allows a new opportunity to the surgeon to decrease as far as possible the extent of surgery. In MIS of lumbar disk herniation, from experience, we have learned that when a lumbar nerve root is compressed, it does not beat with heart pulsation. Therefore, our criteria for achieving surgical procedure are nerve root and dural sheet pulsation which means the nerve root releasing. We realized that in the vast majority of cases, the nerve root pulsation means the pain disappears. Consequently, for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way. In this study, we explain our experience in the surgical treatment of disc herniation and compare the outcome of three different surgical techniques used for the treatment of lumbar disc herniation.


   Materials and Methods Top


A total of 1147 patients have been operated from July 2008 to December 2015 for lumbar disk herniation by posterior endoscopic approach. Patients operated by transforaminal approach for foraminal and extraforaminal disc herniation and patients had two levels of disc herniation have not been included in the study. In the 1st year, we used to perform discectomy systematically. Since 2011, we have changed our strategy and did not carry out discectomy in all patients. Therefore, in 557 patients, we performed only herniectomy, and in 211 patients, we achieved bone compression. The average age of patients was 42.4 (21–75) years. We operated 607 male patients and 540 female patients (female/male ratio = 1/1.12); 559 patients had an L5-S1 disk herniation, 523 patients had L4-L5, 54 patients had an L3-L4 disk herniation, seven patients had an L2-L3, and four patients had an L1-L2 herniated disk. [Table 1] demonstrates the patients' baseline and characteristics. [Table 2] shows the number of patients according to operated method. The diagnosis of lumbar disk herniation was based on data from the IRM in 1069 patients. In 78 patients, the lumbar disk herniation was diagnosed in therapeutic drug monitoring. On average, the patients had pain for 5.6 months (29 days–24 months).
Table 1: Patients baseline and characteristics

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Table 2: Number of patients according to operated method

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   Results Top


The patients were visited in outpatient control 6 weeks, 12 weeks, 6 months, 1 year, and 2 years after surgery. The outcomes were evaluated by Macnab criteria. In 2 years after surgery, 920 patients had excellent outcomes (80.21%), 119 patients had good outcomes (10.37%), 58 patients had fair outcomes (5.06%), and 50 patients had poor outcomes (4.36%). [Table 3], [Table 4], [Table 5] show the patients outcome according to used technique and date of outpatient control. [Table 6] demonstrates the rate of recurrence 1 and 2 years after surgery according to used technique.
Table 3: Patients' outcome according to used technique in 6 weeks after surgery

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Table 4: Patients outcome according to used method in 6 months after surgery

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Table 5: Patients outcome according to used method in 1 year after surgery

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Table 6: The rate of disc herniation recurrence according to used technique

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   Discussion Top


Analysis of the data collected at the level of various techniques illustrates that there is no significant difference for outcome. Six months after surgery, we had 78.67% of excellent outcome with bone decompression (BD) technique as against 81.79% with discectomy and herniectomy (DH) and 83.66 with herniectomy (H) technique. One year after surgery, we had 78.20% with BD technique as against 81.79% with DH and 82.94% with H technique. The rate of recurrence was only insignificantly higher in BD technique after 1 year compared with the two other techniques. This rate was tending to equalize 2 years after surgery.

As stated above, our criteria for achieving surgical procedure are nerve root and dural sheet pulsation which means the nerve root releasing. Experience has shown us that to obtain nerve root pulsation, we need neither to perform herniectomy systematically nor to perform discectomy in the vast majority of cases. We can merely content to perform BD to release the pain in a considerable number of cases. Consequently, we prefer using the least invasive technique. This is all the more important as an invasive discectomy may lead to chronic low back pain, in the short, medium, and long term.[1],[2],[3],[4],[5] Several previous studies incriminated the role of posterior longitudinal ligament(PLL) in lumbar back pain generation. However, patients claim to have relieved their sciatica and lumbalgia thanks to BD even without opening PLL.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] These results evoke that mechanical role of nerve compression is greater than LPP stretching in lumbar back pain generation in symptomatic disc herniation. As Kojima et al. concluded the role and distribution of the nerve fibers and terminals in the PLL and in pain generation is not clear.[17]


   Conclusion Top


In MIS of lumbar disk herniation, from experience, we have learned that when a lumbar nerve root is compressed, it does not beat with heart pulsation. Therefore, our criteria for achieving surgical procedure are nerve root and dural sheet pulsation which means the nerve root releasing. Consequently, for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sørlie A, Moholdt V, Kvistad KA, Nygaard ØP, Ingebrigtsen T, Iversen T, et al. Modic type I changes and recovery of back pain after lumbar microdiscectomy. Eur Spine J 2012;21:2252-8.  Back to cited text no. 1
    
2.
Chin KR, Tomlinson DT, Auerbach JD, Shatsky JB, Deirmengian CA. Success of lumbar microdiscectomy in patients with Modic changes and low-back pain: A prospective pilot study. J Spinal Disord Tech 2008;21:139-44.  Back to cited text no. 2
    
3.
Albert HB, Manniche C. Modic changes following lumbar disc herniation. Eur Spine J 2007;16:977-82.  Back to cited text no. 3
    
4.
Ohtori S, Yamashita M, Yamauchi K, Inoue G, Koshi T, Suzuki M, et al. Low back pain after lumbar discectomy in patients showing endplate Modic type 1 change. Spine (Phila Pa 1976) 2010;35:E596-600.  Back to cited text no. 4
    
5.
Mostofi K, Moghaddam BG, Peyravi M. Late appearance of low back pain relating to Modic change after lumbar discectomy. J Craniovertebr Junction Spine 2018;9:93-5.  Back to cited text no. 5
    
6.
Edgar MA, Nundy S. Innervation of the spinal dura mater. J Neurol Neurosurg Psychiatry 1966;29:530-4.  Back to cited text no. 6
    
7.
Ferlic DC. The nerve supply of the cervical intervertebral disc in man. Bull Johns Hopkins Hosp 1963;113:347-51.  Back to cited text no. 7
    
8.
Hirsch C, Ingelmark BE, Miller M. The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand 1963;33:1-7.  Back to cited text no. 8
    
9.
Kojima Y, Maeda T, Arai R, Shichikawa K. Nerve supply to the posterior longitudinal ligament and the intervertebral disc of the rat vertebral column as studied by acetylcholinesterase histochemistry. II. Regional differences in the distribution of the nerve fibres and their origins. J Anat 1990;169:247-55.  Back to cited text no. 9
    
10.
Mulligan JH. The innervation of the ligaments attached to the bodies of the vertebrae. J Anat 1957;91:455-65.  Back to cited text no. 10
    
11.
Stilwell DL Jr. The nerve supply of the vertebral column and its associated structures in the monkey. Anat Rec 1956;125:139-69.  Back to cited text no. 11
    
12.
Edgar MA, Ghadially JA. Innervation of the lumbar spine. Clin OrthopRelat Res 1976;115:35-41.  Back to cited text no. 12
    
13.
O'Brien JP. Anterior spinal tenderness in low-back pain syndromes. Spine (Phila Pa 1976) 1979;4:85-8.  Back to cited text no. 13
    
14.
Pedersen HE, Blunck CF, Gardner E. The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerve (sinu-vertebral nerves); with an experimental study of their functions. J Bone Joint Surg Am 1956;38-A: 377-91.  Back to cited text no. 14
    
15.
Taylor JR, Twomey LT. Innervation of lumbar intervertebral discs. Med J Aust 1979;2:701-2.  Back to cited text no. 15
    
16.
Wiberg G. Back pain in relation to the nerve supply of the intervertebral disc. Acta Orthop Scand 1949;19:211-21.  Back to cited text no. 16
    
17.
Kojima Y, Maeda T, Arai R, Shichikawa K. Nerve supply to the posterior longitudinal ligament and the intervertebral disc of the rat vertebral column as studied by acetylcholinesterase histochemistry. I. Distribution in the lumbar region. J Anat 1990;169:237-46.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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