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      MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation

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          Abstract

          Study Design:

          Retrospective cohort study.

          Objective:

          To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients.

          Methods:

          Patients with primary treatment for an HNP at a single academic institution between November 2012 to March 2017 were divided into MLD and nonoperative treatment groups. Using magnetic resonance imaging (MRI), axial HNP area; axial canal area; HNP canal compromise; HNP cephalad/caudal migration and HNP MRI signal (black, gray, or mixed) were measured. T test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors.

          Results:

          A total of 285 patients (78 MLD, 207 nonoperative) were included. Risk factors for MLD treatment included larger axial HNP area ( P < .01, OR = 1.01), caudal migration, and migration magnitude ( P < .05, OR = 1.90; P < .01, OR = 1.14), and gray HNP MRI signal ( P < .01, OR = 5.42). Cutoff values for risks included axial HNP area (70.52 mm 2, OR = 2.66, P < .01), HNP canal compromise (20.0%, OR = 3.29, P < .01), and cephalad/caudal migration (6.8 mm, OR = 2.43, P < .01). MLD risk for those with gray HNP MRI signal (67.6% alone) increased when combined with axial HNP area >70.52 mm 2 (75.5%, P = .01) and HNP canal compromise >20.0% (71.1%, P = .05) cutoffs. MLD risk in patients with cephalad/caudal migration >6.8 mm (40.5% alone) increased when combined with axial HNP area and HNP canal compromise (52.4%, 50%; P < .01).

          Conclusion:

          Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

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          Most cited references21

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          Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence.

          The surgical treatment of sciatica with discectomy is ineffective in a sizable percentage of patients, and reherniation occurs after 5% to 15% of such procedures. The purpose of the present study was to determine if competence of the disc anulus and the type of herniation could be used to predict postoperative clinical outcomes following lumbar discectomy. A prospective observational study of 187 consecutive patients undergoing single-level primary lumbar discectomy was conducted. A single surgeon performed all of the procedures, and an independent examiner evaluated 180 of the patients clinically at a minimum of two and a median of six years after surgery. The extent of anular deficiency and the presence of disc fragments were determined. On the basis of these intraoperative findings, disc herniations were classified into four categories: (1) Fragment-Fissure herniations (eighty-nine patients), (2) Fragment-Defect herniations (thirty-three patients), (3) Fragment-Contained herniations (forty-two patients), and (4) No Fragment-Contained herniations (sixteen patients). The effects of disc herniation morphology and preoperative variables on subsequent clinical outcome were determined with the Student t test for continuous variables and chi-square analysis for categorical variables. Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001). Intraoperative findings, as described in the present study, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy. Prognostic study, Level I-1 (prospective study). See p. 2 for complete description of levels of evidence.
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            Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study

            Objectives Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting. Methods A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting. Results Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (−0.97; 95% CI −1.89 to −0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (−3.7; 95% CI −7.4 to −0.1). The other assessments showed minimal between-group differences with CIs, including the null effect. Conclusions Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.
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              Treatment of lumbar disc herniation: Evidence-based practice

              Clinical question: What is the best treatment for lumbar disc herniations? Results: For patients failing six weeks of conservative care, the current literature supports surgical intervention or prolonged conservative management as appropriate treatment options for lumbar radiculopathy in the setting of disc herniation. Surgical intervention may result in more rapid relief of symptoms and restoration of function. Implementation: While surgery appears to provide more rapid relief, many patients will gradually get better with continued nonoperative management; thus, patient education and active participation in decision-making is vital.
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                Author and article information

                Journal
                Global Spine J
                Global Spine J
                GSJ
                spgsj
                Global Spine Journal
                SAGE Publications (Sage CA: Los Angeles, CA )
                2192-5682
                2192-5690
                13 June 2019
                February 2020
                : 10
                : 1
                : 63-68
                Affiliations
                [1 ]Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
                Author notes
                [*]Aaron J. Buckland, Spine Research Center, NYU Langone Medical Center–Hospital for Joint Diseases, 306 East 15th Street, New York, NY 10003, USA. Email: aaronbuckland@ 123456me.com
                Author information
                https://orcid.org/0000-0002-9424-0843
                Article
                10.1177_2192568219856345
                10.1177/2192568219856345
                6963358
                32002351
                c6e286fd-ff27-43bf-b42a-6478c7e3eb9f
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                herniated nucleus pulposus,mri,microscopic lumbar discectomy,surgery,lumbar spine

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