Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Young-Chul Ko; Dong-Jun Ha; Man-Jun Park; Jung-Wook Huh; Sook-Hyun Park; Tae-Hong Park; Joon-Hyung Park

doi:10.4184/jkss.2017.24.4.221

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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

Original Article

Journal of Korean Spine Surg 2017;24(4):221-230.

Published online: 31 December 2017

DOI: https://doi.org/10.4184/jkss.2017.24.4.221

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Young-Chul Ko, M.D., Dong-Jun Ha, M.D., Man-Jun Park, M.D., Jung-Wook Huh, M.D., Sook-Hyun Park, M.D., Tae-Hong Park, M.D., Joon-Hyung Park, M.D.

Department of Orthopedic Surgery Busan Medical Center, Busan, Korea

Corresponding author: Dong-Jun Ha, M.D Department of Orthopedic Surgery, Busan Medical Center, 359 WorldCup-daero, Yeonje-gu, Busan, Korea TEL: +82-51-607-2550, FAX: +882-51-607-2551 E-mail: doctordj@paran.com

Received 11 July 201724 July 2017 Accepted 10 November 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Lumbar posterolateral fusion, Adjacent segment disease, Adjacent lumbar disc herniation, Percutaneous endoscopic lumbar discectomy, Radiologic evaluation

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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.

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.

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.

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).

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	POD^∥6 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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