Surgical Management of Lumbar Disc Herniation

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Surgical Management of Lumbar Disc Herniation

• Paulo Torres
• SpR Trauma and Orthopaedics
• Northern Deanery

2
Objectives

• Review Current Scientific Evidence
• Absolute and Relative Indications for Surgery
• Timing of Surgery
• List of Available Surgical Interventions
• Comparative Effectiveness of the Various Surgical
  Interventions
• Complications of Surgery
• Intradiscal interventions for discogenic pain
• Results of Surgery

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Literature Review

• Medline
• Ovid
• Cochrane
• Spine
• JBJS Br and Am
• The Cochrane Review of Surgery for Lumbar Disc
  Prolapse and Degenerative Lumbar Spondylosis.
  Gibson, Grant, Waddell. 1999.
• Management of Herniation of the Lumbar Disc.
  Review Article. Postacchini.1999.
• Lumbar Disc Herniations. Surgical vs. Non
  Surgical Treatment. Awad and Moskovich. 2006

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Indications for Surgery

• Absolute
• Cauda Equina Syndrome
• Recent Onset, Severe and Progressive Motor
  Deficit
• Relative
• Failure of adequate trial of non operative
  treatment for radicular pain
• Severe intractable radicular pain
• Herniation into an already stenotic spinal or
  nerve root canal
• Significant motor deficits with positive nerve
  root tension signs
• Large extruded fragments
• Recurrent radicular pain after successful trial
  of non operative treatment
• The presence of a mild or moderate motor deficit
  does not necessarily affect the indication for
  operative or non operative treatment

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Timing of Surgery

• Cauda Equina Syndrome
• ASAP
• Relative Indications
• Lack of scientific evidence on optimal timing
• Rarely lt6 weeks
• Period in which improvement in symptoms generally
  known to occur
• Should not be delayed beyond 3-4 months
• Chances of improvement in radicular pain are
  slight and decrease further after 6 months

6
Available Surgical Interventions

• Open Discectomy
• Microdiscectomy
• Chemonucleolysis with Chymopapain
• Automated Percutaneous Nucleotomy
• Manual Percutaneous Discectomy
• Percutaneous Endoscopic Discectomy
• Endoscopic or Percutaneous Laser Discectomy

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Cochrane Review

• Chemonucleolysis vs. placebo
• Chemonucleolysis vs. discectomy
• Discectomy vs. no surgery
• Open discectomy vs. microdiscectomy
• Automated percutaneous discectomy vs. no surgery
• Automated percutaneous discectomy vs. discectomy
• Laser discectomy vs. no surgery
• Laser discectomy vs. discectomy
• Laser discectomy vs. Automated percutaneous
  discectomy
• 27 RCTs Reviewed

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Cochrane ReviewResults

• Discectomy better than Chymopapain
• Chymopapain better than Placebo
• No significant difference between open and
  microdiscectomy
• Insufficient evidence to support other surgical
  interventions Should be regarded experimental
• Further high quality RCTs required

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Complications of Surgery

• Wrong Level 1.2 3.3
• Durotomy 0.8 7.2
• Nerve Root Lesions 0.2
• Infection 2 3
• Recurrent Herniations 5 15
• Epidural Fibrosis
• Difficult to distinguish from recurrent
  herniation
• Contrast MRI investigation of choice
• No correlation between extent and symptoms
• No intervention or material shown to alter
  incidence
• Epidural Haematoma
• Cauda Equina Syndrome
• Iatrogenic Instability

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Intradiscal Electrothermal Therapy

• Proposed for the management of Discogenic pain
• Passing a thermal resistive coil under
  fluoroscopy into the disc
• Coil heated to 90 degrees C
• Paucity of well controlled studies
• No supportive scientific evidence

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Results of Surgery

• 85 95 good to excellent short term results
• Long Term good to excellent results diminish to
  55 70
• 10 18 having required additional surgery
• Lower back pain usually the cause of
  dissatisfaction
• No difference between surgery or conservative
• Microdiscectomy
• Shorter hospital stay
• Faster return to sedentary work
• No difference c/w open discectomy after 8 12
  weeks
• No statistically significant difference in
  recovery of established motor deficits with or
  without surgery

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Patient Factors Predicting Favourable Outcomes

• Absence of Lower Back Pain
• Radicular pain distribution with positive tension
  signs
• Non work-related injury
• Higher socioeconomic status
• Minimal psychosocial stressors

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Summary

• Open (and probably micro) Discectomy Gold
  Standard
• Adhere to indications for surgery
• Patient selection influences outcome
• Chymopapain has a role to play
• Other interventions remain experimental
• Bear in mind Natural History of LDH

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Questions