Surgical Management of Lumbar Disc Herniation

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Slide 1 : Surgical Management of Lumbar Disc Herniation Paulo Torres SpR Trauma and Orthopaedics Northern Deanery
Slide 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
Slide 3 : 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
Slide 4 : 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
Slide 5 : Timing of Surgery Cauda Equina Syndrome ASAP Relative Indications Lack of scientific evidence on optimal timing Rarely <6 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
Slide 6 : Available Surgical Interventions Open Discectomy Microdiscectomy Chemonucleolysis with Chymopapain Automated Percutaneous Nucleotomy Manual Percutaneous Discectomy Percutaneous Endoscopic Discectomy Endoscopic or Percutaneous Laser Discectomy
Slide 7 : 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 RCT’s Reviewed
Slide 8 : 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 RCT’s required
Slide 9 : 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
Slide 10 : 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
Slide 11 : 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
Slide 12 : 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
Slide 13 : 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
Slide 14 : Questions

 


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