Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Current Approaches to the Management of Lumbar Disc Herniation 14 articles

Articles

Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes

Scott L. Parker MD, Stephen K. Mendenhall BS, Saniya S. Godil MD, Priya Sivasubramanian BS, Kevin Cahill MD, MPH, John Ziewacz MD, MPH, Matthew J. McGirt MD

Long-term postdiscectomy degenerative disc disease and low back pain is a well-recognized disorder; however, its patient-centered characterization and quantification are lacking.

Is Sequestrectomy a Viable Alternative to Microdiscectomy? A Systematic Review of the Literature

Bahram Fakouri MD, Nitin R. Shetty MPhil, FRCS(Orth), Thomas C. H. White MRCS

Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief.

Experimental Disc Herniation in the Rat Causes Downregulation of Serotonin Receptor 2c in a TNF-dependent Manner

Daniel Jonsson MS, Oscar Finskas MS, Yuki Fujioka MD, Anders Ståhlberg PhD, Kjell Olmarker MD, PhD

During recent decades, the knowledge of the pathophysiology of disc herniation and sciatica has drastically improved. What previously was considered a strict biomechanical process is now considered a more complex interaction between leaked nucleus pulposus and the tissue in the spinal canal. An inflammatory reaction, with tumor necrosis factor (TNF) playing an essential role, has been demonstrated. However, the exact mechanisms of the pathophysiology of disc herniation remain unknown.

What Are Long-term Predictors of Outcomes for Lumbar Disc Herniation? A Randomized and Observational Study

Dana Kerr MD, Wenyan Zhao PhD, Jon D. Lurie MD, MS

Although previous studies have illustrated improvements in surgical cohorts for patients with intervertebral disc herniation, there are limited data on predictors of long-term outcomes comparing surgical and nonsurgical outcomes.

Molecular Basis of Intervertebral Disc Degeneration and Herniations: What Are the Important Translational Questions?

Tiffany Kadow MD, Gwendolyn Sowa MD, PhD, Nam Vo PhD, James D. Kang MD

Intervertebral disc degeneration is a common condition with few inexpensive and effective modes of treatment, but current investigations seek to clarify the underlying process and offer new treatment options. It will be important for physicians to understand the molecular basis for the pathology and how it translates to developing clinical treatments for disc degeneration. In this review, we sought to summarize for clinicians what is known about the molecular processes that causes disc degeneration.

Outcomes of Lumbar Discectomy in Elite Athletes: The Need for High-level Evidence

Rueben Nair MD, Cynthia A. Kahlenberg BA, Wellington K. Hsu MD

Although lumbar discectomy for treatment of lumbar disc herniation in the general population generally improves patients’ pain, function, and validated outcomes scores, results of treatment in elite athletes may differ because of the unique performance demands required of competitive athletes.

Nonoperative Treatment for Lumbosacral Radiculopathy: What Factors Predict Treatment Failure?

Pradeep Suri MD, MS, M. Jake Carlson MD, James Rainville MD

Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery.

How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systematic Review

Yiping Li MD, Vance Fredrickson MD, Daniel K. Resnick MD

MRI is the gold standard for evaluating the relationship of disc material to soft tissue and neural structures. However, terminologies used to describe lumbar disc herniation and nerve root compression have always been a source of confusion. A clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers is vital for patient care and future research.

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies

John D. Koerner MD, Jordan Glaser MD, Kristen Radcliff MD

The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored.

A History of Lumbar Disc Herniation From Hippocrates to the 1990s

Eeric Truumees MD In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.

Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine

Peter Fritzell MD, PhD, Björn Knutsson MD, Bengt Sanden MD, PhD, Björn Strömqvist MD, PhD, Olle Hägg MD, PhD

Lumbar disc herniation (LDH) is a common indication for lumbar spine surgery. The proportion of patients having a second surgery within 2 years varies in the literature between 0.5% and 24%, with recurrent herniation being the most common cause. Several studies have not found any relevant outcome differences between patients undergoing surgery for primary LDH and patients undergoing reoperation for a recurrent LDH, but these studies have limitations, including small sample size and retrospective design.

Does Surgical Timing Influence Functional Recovery After Lumbar Discectomy? A Systematic Review

Andrew J. Schoenfeld MD, Christopher M. Bono MD

The impact of the duration of preoperative symptoms on outcomes after lumbar discectomy has not been sufficiently answered in a single study but is a potentially important clinical variable.

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

Laxmaiah Manchikanti MD, Ramsin M. Benyamin MD, Frank J. E. Falco MD, Alan D. Kaye MD,PhD, Joshua A. Hirsch MD

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.