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Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation: A Long-term Follow-up Study
Full text linkThe purpose of this study is to identify some risk factors
and post-operative predictors for recurrent lumbar disc
hernia (rLDH) during a long-term follow-up in patients
treated with microdiscectomy.
Aim of the paper: This study analyzes some risk factors
and postoperative predictors for recurrent lumbar disc
hernia (rLDH) during a long-term follow-up in patients
treated with microdiscectomy.
Material and methods. We analyzed retrospectively a
consecutive series of patients who underwent lumbar
spinal microdiscectomy for lumbar disc herniation
(LDH) from January 2013 to June 2018 at our Institute.
The rate of rLDH during long-term follow-up was
analyzed and correlated with baseline and post-operative
data.
Results. A total of 263 patients were included with a median
follow-up time of 24 months (from 13 to 43 months
Analysis of risk factors and postoperative predictors for recurrent lumbar disc herniation
Full text linkOriginal Article
Analysis of risk factors and postoperative predictors for recurrent lumbar disc herniation
M. Dobran, Davide Nasi, R. Paracino, M. Gladi, M. Della Costanza, A. Marini, S. Lattanzi, M. Iacoangeli
Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
E-mail: M. Dobran - [email protected]; *Davide Nasi - [email protected]; R. Paracino - [email protected]; M. Gladi - [email protected]; M. Della Costanza - [email protected]; A. Marini - [email protected]; S. Lattanzi - [email protected];
M. Iacoangeli - [email protected]
ABSTRACT
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.
Conclusions: Elevated postsurgery ODI and higher BMI were significantly associated with increased risk of rLDH.
Keywords: Discectomy, lumbar disc herniation, lumbar microdiscectomy, recurrent disc herniation
*Corresponding author:
Davide Nasi,
Department of Neurosurgery, Università Politecnica delle Marche - Ospedali Riuniti, Via Conca #71, Ancona - 60020, Italy.
[email protected]
Received : 13 January 19
Accepted : 18 January 19
Published : 26 March 19
DOI
10.25259/SNI-22-2019
Quick Response Code:
INTRODUCTION
Lumbar disc herniation (LDH) is the most common reason for performing lumbar spine surgery. Today, many are managed utilizing a microdiscectomy approach. Nevertheless, these procedures correlate with a recurrence rate at 1 year that ranges from 1% to 21%.[1,3,5] Here, we looked at potential risk factors that may contribute to recurrent LDH (rLDH) following microdiscectomy.
MATERIALS AND METHODS
We retrospectively reviewed consecutive patients who underwent standard lumbar spinal microdiscectomy for disc herniation (LDH) (2013–2018). The follow-up evaluations were performed at 1, 6, and 12 months postoperatively. Recurrence of disc herniation was defined as disc herniation at the same level and side of the previous microdiscectomy after a 3-month postoperative pain-free
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Surgical Neurology International
Editor-in-Chief: Nancy E. Epstein, MD, NYU Winthrop Hospital, Mineola, NY, USA.
SNI: Spine Editor
Nancy E. Epstein, MD
NYU Winthrop Hospital, Mineola, NY, USAOpen Access
Dobran, et al.: Predictors for recurrent lumbar disc herniation
Surgical Neurology International • 2019 • 10(36) | 2
period. Variables contributing to rLDH included age, sex,
weight/body mass index (BMI), smoking status, postoperative
(6 months) Oswestry disability index (ODI), and the level of the
disc herniation. Radiological examination included magnetic
resonance imaging before and after surgery.
Statistical analysis
Analyses include Student’s t-test, Mann–Whitney U-test or
Chi-squared test, logistic regression, and multivariate analysis.
Results were considered significant for P < 0.05 (two-sided). Data
analysis was performed using STATA/IC 13.1 statistical package
(StataCorp LP, Texas, USA).
RESULTS
There were 209 patients included in this study; 20 of 209 (9.6%)
had rLDH at 1 postoperative year. Utilizing a multivariate
analysis, older age, higher BMI, and postsurgery ODI
were significantly associated with increased risk of rLDH
[Tables 1 and 2].
DISCUSSION
Microdiscectomy is a relatively straightforward procedure
but is associated with a complication rate of up to 15–18%.[1-6]
rLDH is the most frequent complication, occurring from 5% to
15% of the time.[6] rLDH is defined as a disc hernia at the same
level of a previous microdiscectomy in patient with a pain-free
interval of at least 3 months long after surgery.[1-6] In patients
treated with microdiscectomy, it is important to avoid a second
surgery due to the attendant increased risks/complications
associated with repeated decompression versus decompression/
fusion.[5,6] In our study, BMI was an independent predictor
of recurrence both at unadjusted logistic regression analysis
(P = 0.004) and adjusted analysis (P = 0.024). In our series,
postoperative 6-month ODI score value correlated with
rLDH. Furthermore, in this study, older age was a predictor of
recurrence.[1-6]
CONCLUSIONS
To summarize, patients with rLDH were older and had higher
BMI and postsurgery ODI score after a pain-free 3-month
interval.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Ambrossi GL, McGirt MJ, Sciubba DM, Witham TF, Wolinsky JP,
Gokaslan ZL, et al. Recurrent lumbar disc herniation after singlelevel
lumbar discectomy: Incidence and health care cost analysis.
Neurosurgery 2009;65:574-8.
2. Dobran M, Brancorsini D, Costanza MD, Liverotti V, Mancini F,
Nasi D, et al. Epidural scarring after lumbar disc surgery: Equivalent
scarring with/without free autologous fat grafts. Surg Neurol Int
2017;8:169.
3. Dobran M, Marini A, Gladi M, Nasi D, Colasanti R, Benigni R, et al.
Deep spinal infection in instrumented spinal surgery: Diagnostic
factors and therapy. G Chir 2017;38:124-9.
Table 1: Characteristics of patients according to 1‐year outcome; relapse: n=20 (9.6%).
Variable Full cohort (n=209) No relapse (n=189) Relapse (n=20) P
Age (years) 44.6 (11.8) 43.9 (11.7) 50.4 (12.0) 0.021a
Male sex 125 (59.8) 115 (60.9) 10 (50.0) 0.347b
BMI (kg/m2) 27 (24–20) 27 (24–28) 29 (27.5–30.5) 0.005c
Smoking 144 (68.9) 129 (68.3) 15 (75.0) 0.535b
VAS 2.6 (1.5) 2.5 (1.5) 3.2 (1.7) 0.076a
ODI 15 (10–20) 15 (5–20) 20 (15–22) 0.002c
Disc hernia level ‐ ‐ 3 (8.6) 0.973b
L3–L4 35 (16.8) 32 (91.4) 10 (9.6) ‐
L4–L5 104 (49.8) 94 (90.4) 7 (10.0) ‐
L5–S1 70 (33.5) 63 (90.0) ‐ ‐
Data are mean (SD) or median (IQR) for continuous variables and n (%) for categorical variables. aTwo‐sample t‐test. bChi‐squared test. cMann–Whitney U‐test.
ODI: Oswestry disability index; VAS: Visual analog scale, BMI: Body mass index, SD: Standard deviation
Table 2: Prediction of 1‐year LDH.
Independent
variable
Unadjusted Adjusted*
OR (95% CI) P OR (95% CI) P
Age 1.05 (1.01–1.09) 0.023 1.04 (1.00–1.09) 0.060
Sex 0.64 (0.26–1.62) 0.350 0.50 (0.18–1.38) 0.178
BMI 1.28 (1.08–1.51) 0.004 1.23 (1.03–1.46) 0.022
Smoking 1.40 (0.48–4.02) 0.537 0.98 (0.30–3.13) 0.968
ODI 1.10 (1.03–1.17) 0.005 1.09 (1.02–1.18) 0.017
Disc hernia level 1.08 (0.55–2.12) 0.824 0.88 (0.41–1.88) 0.740
ORs for every 1 year and 1‐point BMI or ODI increases are obtained with
logistic regression analysis. BMI: Body mass index; CI: Confidence interval;
ODI: Oswestry disability index; OR: Odds ratio, LDH: Lumbar disc herniation
Dobran, et al.: Predictors for recurrent lumbar disc herniation
Surgical Neurology International • 2019 • 10(36) | 3
4. Dobran M, Marini A, Nasi D, Gladi M, Liverotti V, Costanza MD,
et al. Risk factors of surgical site infections in instrumented spine
surgery. Surg Neurol Int 2017;8:212.
5. Huang W, Han Z, Liu J, Yu L, Yu X. Risk factors for recurrent lumbar
disc herniation: A systematic review and meta-analysis. Medicine
(Baltimore) 2016;95:e2378.
6. Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases
the risk of recurrent herniated nucleus pulposus after lumbar
microdiscectomy. Spine J 2010;10:575-80.
How to cite this article: Dobran M, Nasi D, Paracino R, Gladi M, Costanza MD,
Marini A, et al. Analysis of risk factors and postoperative predictors for recurrent
lumbar disc herniation. Surg Neurol Int 2019:10:36
The efficacy of postoperative bracing after spine surgery for lumbar degenerative diseases: a systematic review
Full text linkPurpose: Postoperative bracing treatment is widely used after surgery for lumbar degenerative diseases. However, the guidelines are lacking in this regard, and its use is mainly driven by individual surgeon preferences. The objective of the current review was to evaluate the available evidence on the use of postoperative bracing after surgery for degenerative disease of the lumbar spine. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed while conducting a systematic search of the PubMed/Medline, Scopus, and Cochrane databases from January 1990 to January 2019. High-quality studies were included that evaluated disability, pain, quality of life, the rate of fusion, complications, and rate of reoperations in patients who had surgery for lumbar degenerative disease, with and without postoperative bracing. The overall strength of evidence across the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. Results: Of the 391 citations screened, four randomized controlled trials met the inclusion criteria and were included in the review. Based on low- to moderate-quality evidence, postoperative bracing in patients with lumbar degenerative disease does not result in improved disability, pain, and quality of life compared to no bracing patients. Low-quality evidence suggests that there was no significant difference between the two groups in terms of the rate of fusion, complications, and the need for reoperation. Conclusions: To date, there is not a medical evidence to support the use of bracing after surgery for lumbar degenerative disease. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]
Commentary: A new era in the management of spinal metastasis
Full text linkIntroduction In spinal tumor metastases the gold standard treatment is surgery, followed by chemo and radioterpy (1). Surgery remains the fulcrum of the therapy, especially in cases with spine instability and spinal cord involvement. In literature, the debate regarding the feasibility of the decompressive treatment and its optimal timing for surgery is still open and it is very difficult to determine the optimal surgical timing in patients with vertebral metastases starting with a neurological deficit (2). We strongly believe that surgery timing is an important prognostic factor for the clinical outcome in patients treated for spinal metastases with acute neurological deficit. As reported in our study regarding the cervical spinal cord injury (3) the surgical timing is relevant also for the spinal compression in vertebral metastases. In our previous study we considered 81 patients with traumatic cervical spinal cord injury operated before and after 12 hours. Forty seven of 81 (58%) patients exhibited improved neurological function and 72.% of them was treated <12 hours after the injury. This ultra-early surgical timing in this type of patients was also associated with significantly greater neurological improveme
The evolution of neuroanatomy in the development of neuroscience: the contribution of Bartolomeo Eustachio.
No full textPure and combined endoscopic approach in the surgical treatment of third ventricle tumors.
No full text
Intralesional and subarachnoid bleeding of a spinal schwannoma presenting with acute cauda equina syndrome
No full textWe present an unusual case of spinal neurinoma with intralesional and subarachnoid bleeding with acute cauda equina syndrome. A 38-year-old man was admitted to our department after a minor thoracic spinal trauma with right lower limb plegia and urinary retention. MRI showed a T11 intradural tumour with intralesional and subarachnoid haemorrhage. The patient was operated of spinal cord decompression and complete tumour resection. The histological examination documented a schwannoma with large haemorrhagic intratumoural areas. A full neurological recovery was documented at 6-month follow-up
Mielopatia spondilogena cervicale: risultati in una serie di 52 pazienti trattati con approccio anteriore, posteriore e combinato.
No full textA rare case of nocardial pachymeningitis and osteomyelitis of frontal bone in an immunocompetent young patient
No full textA 36-year-old Caucasian man fell six meters in April 2010. At admission, the Glasgow coma scale was 14/15with stable vital signs. His past medical history was unremarkable. A head computer tomography (CT) scan documented multiple cranio-facial fractures, including the right orbital roof and the right zygomatic arch, the frontal sinus, the bilateral maxillary sinus, associated with thin right acute subdural hematoma and pneumocephalus. The patient underwent maxillofacial surgery to reduce multiple fractures, without complication. Ten days after, the patient experienced a progressive decrease of consciousness with body temperature of 39.5°C. CT scan showed a right frontal epidural and parenchymal collection with ring enhancement after contrast administration, suggestive for an infective process [Figure 1].{Figure 1} Cerebrospinal fluid (CSF) analysis revealed: cell count of 3000/mcL, protein 317 mg/dL, glucose 15 mg/dL, with cultures negative for bacteria and/or mycobacteria. Blood, urinary and bronchoalveolar lavage culture were negative. Intravenous antibiotic therapy with Meropenem (3 g/day) started immediately. The patient underwent bifrontal craniotomy, frontal sinus cranialization by pericranial flap and excision of the abscess. Intraoperatively, right frontal meningeal appeared covered by dense pus with negative culture for bacteria. Intravenous antibiotic therapies were increased with Teicoplanin (800 mg/day) for two weeks. Fever was resolved after 6 days and the 3-month follow-up CT scans confirmed the healing of the infective process. The patient was discharged on day 43, without neurological deficit. In January 2015, the patient was newly admitted to evaluate a right frontal dehiscence of the surgical scar and throbbing headache for 10 days. Physical and neurological examinations were normal. CT scan showed frontal meningeal enhancement and frontal bone flap reabsorption, suggestive for a new infection. Laboratory blood tests documented: white blood cell count of 8600/mm3 (neutrophils 55.7%, lymphocytes 36.6%, monocytes 0.45%), erythrocyte sedimentation rate of 10 mm/hr, and C-reactive protein level of 0.9 mg/dL. Human Immunodeficiency Virus (HIV) antibody was negative. Chest X-Ray was normal. The patient underwent surgery to remove the reabsorbed bone flap and a polyetheretherketone cranioplasty was positioned to repair the bone defect. Under the bone flap, yellowish and turbid pus was evident in the left frontal sinus, associated to a diffuse pachymeningitis [Figure 2]a and [Figure 2]b. Empirical intravenous antibiotics were started with Meropenem (6 g/day). Six days later, gram-positive bacilli were reported growing from the surgical specimens' culture but, only after 4 days, Nocardia asteroides was identified [Figure 2]c. The therapy was increased with Trimethoprim and Sulfameyhoxazole (TMP-SMX) (15 mg/kg TMP and 75 mg/kg SMX per day) and Meropenem (6 g/day) for three weeks, according with the Minimal inhibitory concentration (MIC) testing. The patient was discharged home and continued with oral TMP-SMX therapy for further 6 months. Six and twelve-month follow-up CT scan confirmed meningeal infection resolution [Figure 3].{Figure 2}{Figure 3} Nocardia species are filamentous, Gram-positive, partially acid-fast, branched bacteria ubiquitous in the environment, particularly in the soil and water.[1]Nocardia is considered an opportunistic microorganism because it occurs in immuno compromised patients, particularly those with cell-mediated immunity defects.
There are more than 50 species of Nocardia, but Nocardia asteroides group is responsible for the majority of human nocardial
infections.[1],[2],[3] Infection mainly occurs by direct inhalation or skin inoculation. The most common clinical manifestations are pulmonary,
cutaneous and soft tissue (8.1%) and systemic nocardiosis (13.5%), including central nervous system (CNS) dissemination
(5.4%).[2] Regarding CSN, nocardiosis may present with cerebral abscesses and meningitis, nevertheless meningitis is extremely rare.
CNS infection may be secondary to hematogenous dissemination from a primary site, usually the lungs, or may exist on its
own.[2] Osteomyelitis is an unusual manifestation.[1],[2],[3] Most cases are associated with infections of the vertebral bodies,[4],[5],[6] femur
and tibia but other, less frequent locations include skull, ilium, fibula and metatarsal bones.
A pub med search revealed two cases in literature,[1],[2],[3] but only one of them was similar: a 34-year-old man presented skull vault
osteomyelitis and pachymeningitis, successfully treated with prolonged antibiotic therapy.[3] As in our case, bone infection and
pachymeningitis had probably spread from overlying soft tissue infection, where there was a surgical scar. Diagnosis of Nocardia is
extremely difficult because these species are slow-growing organism and are easily contaminated.
An optimal treatment for cerebral nocardiosis has not been established. Clinical experience has shown that successful therapy requires
appropriate surgical drainage in combination with antimicrobial drugs for a prolonged period. Synergy against Nocardia has been
demonstrated between TMP-SMX, which is the first line therapy, due to good tolerance for the patient and better cerebrospinal fluid
penetration.[3]
Our patient received a combination regimen of TMP-SMX plus Meropenem, which was switched to oral TMP-SMX, for 6 months with a
successful outcome. An interesting point in our case was the completely asymptomatic course of infection, despite cerebral nocardiosis
has a high mortality and morbidity.
Our case highlights how the diagnosis of nocardiosis remains extremely difficult in an immunocompetent patient. Prolonged and specifi
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