Journal List > J Korean Soc Spine Surg > v.24(4) > 1076145

Ko, Ha, Park, Huh, Park, Park, and Park: Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Abstract

Study Design

A retrospective study.

Objective

To analyze the effectiveness of percutaneous endoscopic lumbar discectomy (PELD) for adjacent lumbar disc herniation through radiologic evaluations.

Summary of Literature Review

PELD minimizes posterior structural damage, allowing rapid rehabilitation.

Subjects and Methods

This study was conducted on 45 patients who were followed up for 1 year after PELD for adjacent lumbar disc herniation from March 2014 to February 2016. The modified Macnab criteria, the modified Suezawa and Schreiber score (MSS score), and visual analogue scales for the back (VAS-B) and legs (VAS-L) were evaluated. The disc height ratio and segmental angulation change were compared before posterolateral fusion and before PELD. Moreover, spinal stenosis was confirmed on magnetic resonance imaging (MRI) before PELD.

Results

Based on the modified Macnab criteria, 53.3% patients received an evaluation of at least “good,” and the mean MSS score improved from 4.77 to 6.99 at 1 year after the operation. The mean VAS-B score decreased from 7.02 to 4.67, and the mean VAS-L score decreased from 8.15 to 4.24 at 1 year after the operation. The mean disc height ratio was 87.1%, and the mean segmental angulation change was 6.5°, with a greater change in the “fair” or “poor” group, and the rate of spinal stenosis on MRI was also higher in the “fair” or “poor” group.

Conclusion

The clinical outcomes of PELD, which is accompanied by degenerative changes on simple radiographic images such as disc space narrowing and increased segmental angulation or spinal stenosis on MRI, may not be satisfactory. Therefore, decisions regarding surgery should be made carefully in such cases.

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Fig. 1.
Mochida method for measuring the disc height ratio. Radiographic measurement of the disc height ratio: a/A (at the final follow-up)×[a/A (before the operation)], a=disc height, A=vertebral height.
jkss-24-221f1.tif
Fig. 2.
Measuring the segmental angulation. The angle between the line on the lower endplate of the upper vertebra and the line on the upper endplate of the lower vertebra is measured on flexion and extension radiographs. In addition, the difference (B-A) is calculated.
jkss-24-221f2.tif
Fig. 3.
(A) A 62-year-old female patient with spinal stenosis at L4-5: simple anteroposterior (AP) and lateral radiographs before lumbar posterolateral fusion. (B) Flexion-extension lateral radiographs before lumbar posterolateral fusion. (C) At 63 months postoperatively, simple AP and lateral radiographs before percutaneous endoscopic lumbar discectomy show almost no interval change of L3-4 disc height. (D) Flexion-extension lateral radiographs show an L3-4 segmental angulation change of 5.4°. (E) Left-side central disc herniation of the L3-4 segment without spinal stenosis on magnetic resonance imaging taken before percutaneous endoscopic lumbar discectomy (PELD). (F) The disc material removed after PELD; the patient's prognosis was good.
jkss-24-221f3.tif
Fig. 4.
(A) A 71-year-old female patient with spinal stenosis at L4-S1: simple anteroposterior (AP) and lateral radiographs before lumbar posterolateral fusion. (B) Flexion-extension lateral radiographs before lumbar posterolateral fusion. (C) At 78 months postoperatively, simple AP and lateral radiographs before percutaneous endoscopic lumbar discectomy show decreased L3-4 disc height. (D) Flexion-extension lateral radiographs show an L3-4 segmental angulation change of 9.8°. (E) Left-side posterolateral disc herniation of the L3-4 segment with spinal stenosis on magnetic resonance imaging taken before percutaneous endoscopic lumbar discectomy (PELD). (F) Removed disc material after PELD. (G) Recurrent disc herniation in the same region after PELD (dotted line).
jkss-24-221f4.tif
Table 1.
Modified macnab criteria
  Surgical success   Surgical failure
Excellent Free of pain No restriction of mobilization Able to return to normal work and activity Fair Some improved functional capacity Still handicapped and / or unemployed
Good Occasional non-radicular pain Relief of presenting symptoms Able to return to modified work Poor Continued objective symptoms of root involvement Additional operative intervention needed at the same level irrespective of repeat or length of postoperative follow-up
Table 2.
MSS score
Symptoms Score 2 Score 1 Score 0
Low back pain None Activity related At rest
Sciatica None With SLRT At rest
Sensory deficit None Dysesthesia or paresthesia Hypesthesia or anesthesia
Motor weakness None Full function with slight resistance Two reflexes impaired
Reflex changes None One reflex impaired Two reflexes impaired

MSS: Modified Suezawa and Schreiber, SLRT: Straight leg raising test.

Table 3.
Modified macnab criteria evaluation
  POD 6months POD 12months p-value
Excellent 2 (4.4%) 4 (8.8%) <0.05
Good 22 (48.8%) 20 (44.4%) <0.05
Fair 15 (33.3%) 15 (33.3%) <0.05
Poor† 6 (13.3%) 6 (13.3%) <0.05

POD: Post percutaneous endoscopic lumbar discectomy operative day.

Table 4.
MSS score evaluation (mean)
  Preoperation POD 6months POD 12months p-value
All patient (43) 4.77 6.34 6.99 <0.05
Satisfied patient (24) 4.79 7.67 7.83 <0.05
Dissatisfied patient (19) 4.75 5.01 6.15 <0.05

MSS: Modified Suezawa and Schreiber, ∗Satisfied patient: Patients who were evaluated “Excellent” or “Good” by Modified Macnab criteria

Dissatisfied patient: Patients who were evaluated “Fair” or “Poor” by Modified Macnab criteria and who undergone revision open discectomy were excepted

POD: Post percutaneous endoscopic lumbar discectomy operative day.

Table 5.
VAS evaluation (mean)
    Preoperation POD6 months POD 12 months p-value
All patient (43) VAS-B 7.02 5.16 4.67 <0.05
  VAS-L§ 8.15 4.73 4.24 <0.05
Satisfied patient (24) VAS-B 7.01 4.44 3.92 <0.05
  VAS-L§ 8.15 3.51 3.14 <0.05
Dissatisfied patient (19) VAS-B 7.03 5.88 5.42 <0.05
  VAS-L§ 8.16 5.96 5.35 <0.05

Satisfied patient: Patients who were evaluated “Excellent” or “Good” by Modified Macnab criteria

Dissatisfied patient: Patients who were evaluated “Fair” or “Poor” by Modified Macnab criteria and who undergone revision open discectomy were excepted

VAS-B: Visual analogue scale-Back

§ VAS-L: Visual analogue scale-Leg

POD: Post percutaneous endoscopic lumbar discectomy operative day.

Table 6.
Disc height ratio and segmental angulation change on simple radiography measured by comparing before PLF and before PELD (mean)
  Disc height ratio Segmental angulation change
All patient (45) 87.1% 6.5°
Satisfied patient (24) 92.2% 4.4°
Dissatisfied patient (21) 82.1% 8.7°
p-value <0.05 <0.05

PL: Posterolateral fusion, PELD: Percutaneous endoscopic lumbar discectomy, ∗Satisfied patient: Patients who were evaluated “Excellent” or “Good” by Modified Macnab criteria

Dissatisfied patient: Patients who were evaluated “Fair” or “Poor” by Modified Macnab criteria and who undergone revision open discectomy were included.

Table 7.
Difference of disc height ratio and segmental angulation change between satisfied patient and dissatisfied patient (mean)
  Mean p-value 95% CI
Difference of disc height ratio 10.10 <0.05 8.99∼11.20
Difference of segmental angulation change 4.30 <0.05 3.56∼5.03
CI: Confidence interval.
Table 8.
Disc herniation accompanied by spinal stenosis on MRI before PELD
  Stenosis on MRI before PELD Central canal stenosis Foraminal stenosis
All patient (45) 18 8 10
Satisfied patient (24) 5 3 2
Dissatisfied patient (21) 13 5 8

MRI: Magnetic resonance imaging, PELD: Percutaneous endoscopic lumbar discectomy, ∗Satisfied patient: Patients who were evaluated “Excellent” or “Good” by Modified Macnab criteria

Dissatisfied patient: Patients who were evaluated “Fair” or “Poor” by Modified Macnab criteria and who undergone revision open discectomy were included.

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