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      Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases

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          Abstract

          Background

          Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.

          Purpose

          This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).

          Methods

          A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.

          Results

          The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle–disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.

          Conclusion

          Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.

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          Most cited references51

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          Magnetic resonance classification of lumbar intervertebral disc degeneration.

          C Pfirrmann, A Metzdorf, M. Zanetti … (2001)
          A reliability study was conducted. To develop a classification system for lumbar disc degeneration based on routine magnetic resonance imaging, to investigate the applicability of a simple algorithm, and to assess the reliability of this classification system. A standardized nomenclature in the assessment of disc abnormalities is a prerequisite for a comparison of data from different investigations. The reliability of the assessment has a crucial influence on the validity of the data. Grading systems of disc degeneration based on state of the art magnetic resonance imaging and corresponding reproducibility studies currently are sparse. A grading system for lumbar disc degeneration was developed on the basis of the literature. An algorithm to assess the grading was developed and optimized by reviewing lumbar magnetic resonance examinations. The reliability of the algorithm in depicting intervertebral disc alterations was tested on the magnetic resonance images of 300 lumbar intervertebral discs in 60 patients (33 men and 27 women) with a mean age of 40 years (range, 10-83 years). All scans were analyzed independently by three observers. Intra- and interobserver reliabilities were assessed by calculating kappa statistics. There were 14 Grade I, 82 Grade II, 72 Grade III, 68 Grade IV, and 64 Grade V discs. The kappa coefficients for intra- and interobserver agreement were substantial to excellent: intraobserver (kappa range, 0.84-0.90) and interobserver (kappa range, 0.69-0.81). Complete agreement was obtained, on the average, in 83.8% of all the discs. A difference of one grade occurred in 15.9% and a difference of two or more grades in 1.3% of all the cases. Disc degeneration can be graded reliably on routine T2-weighted magnetic resonance images using the grading system and algorithm presented in this investigation.
          Article 0 comments Cited 590 times – based on 0 reviews     Review now
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            Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury.

            Paul Hodges, Allison Holm, Tommy Hansson … (2006)
            Experimental study of muscle changes after lumbar spinal injury. To investigate effects of intervertebral disc and nerve root lesions on cross-sectional area, histology and chemistry of porcine lumbar multifidus. The multifidus cross-sectional area is reduced in acute and chronic low back pain. Although chronic changes are widespread, acute changes at 1 segment are identified within days of injury. It is uncertain whether changes precede or follow injury, or what is the mechanism. The multifidus cross-sectional area was measured in 21 pigs from L1 to S1 with ultrasound before and 3 or 6 days after lesions: incision into L3-L4 disc, medial branch transection of the L3 dorsal ramus, and a sham procedure. Samples from L3 to L5 were studied histologically and chemically. The multifidus cross-sectional area was reduced at L4 ipsilateral to disc lesion but at L4-L6 after nerve lesion. There was no change after sham or on the opposite side. Water and lactate were reduced bilaterally after disc lesion and ipsilateral to nerve lesion. Histology revealed enlargement of adipocytes and clustering of myofibers at multiple levels after disc and nerve lesions. These data resolve the controversy that the multifidus cross-sectional area reduces rapidly after lumbar injury. Changes after disc lesion affect 1 level with a different distribution to denervation. Such changes may be due to disuse following reflex inhibitory mechanisms.
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              Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases.

              Kyung-Chul Choi, June Lee, Jin Kim … (2015)
              Percutaneous endoscopic lumbar discectomy (PELD) has remarkably evolved with successful results. Although PELD has gained popularity for the treatment of herniated disc (HD), the risk of surgical failure may be a major obstacle to performing PELD. We analyzed unsuccessful cases requiring reoperation.
              Article 0 comments Cited 76 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Risk Manag Healthc Policy
                Journal ID (iso-abbrev): Risk Manag Healthc Policy
                Journal ID (publisher-id): rmhp
                Journal ID (pmc): rmhp
                Title: Risk Management and Healthcare Policy
                Publisher: Dove
                ISSN (Electronic): 1179-1594
                Publication date (Electronic): 18 December 2020
                Publication date Collection: 2020
                Volume: 13
                Pages: 3051-3065
                Affiliations
                [1 ]Department of Spinal Surgery, The Affiliated Hospital of Qingdao University , Qing’dao, Shandong Province 266000, People’s Republic of China
                [2 ]Department of Medicine, Qingdao University , Qing’dao, Shandong Province 266000, People’s Republic of China
                [3 ]Minimally Invasive Interventional Therapy Center, Qingdao Municipal Hospital , Qing’dao, Shandong Province 266000, People’s Republic of China
                Author notes
                Correspondence: Xuexiao Ma Tel +8618661807895 Email ma_xuexiao@126.com
                Chuanli Zhou Department of Spinal Surgery, The Affiliated Hospital of Qingdao University , No. 59, Hai Er Road, Qing’dao, Shandong Province266000, People’s Republic of ChinaTel +86 18661809796 Email justin_5257@hotmail.com
                [*]

                These authors contributed equally to this work

                Author information
                http://orcid.org/0000-0002-1466-9667
                http://orcid.org/0000-0003-1974-1311
                Article
                Publisher ID: 287976
                DOI: 10.2147/RMHP.S287976
                PMC ID: 7755338
                PubMed ID: 33376428
                SO-VID: 6a4445b5-0eed-4c46-bd5b-49326e4a6467
                Copyright © © 2020 Kong et al.
                License:

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                Date received : 21 October 2020
                Date accepted : 17 November 2020
                Page count
                Figures: 9, Tables: 8, References: 51, Pages: 15
                Categories
                Subject: Original Research

                ScienceOpen disciplines: Social policy & Welfare
                Keywords: percutaneous endoscopic transforaminal discectomy,recurrent ldh,risk factor
                Data availability:
                ScienceOpen disciplines: Social policy & Welfare
                Keywords: percutaneous endoscopic transforaminal discectomy, recurrent ldh, risk factor

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