MICRODISCECTOMY IN TREATMENT OF SACROLUMBAR INTERVERTEBRAL DISC HERNIATION Ardashev I.P., Vosmirko B.N., Semenov V.V., Ardasheva E.I., Shternis T.A., Kalistkaya U.B., Yagodkina T.V.
Kemerovo State Medical University,
Regional Clinical Hospital of Emergency Medical Care, Kemerovo, Russia
Intervertebral disk herniation develops in 61 % of cases in the lumbar spine, with 40 % at the level of L4-L5, L5-S1 [1]. It decreases the life quality, causes long term working disability in 70 %, and serious medical and economic problems [2, 3].
Currently, the number of young patients has been increasing. It is associated with insufficient physical activity and sedentary lifestyle [2].
Conservative methods often do not result in positive effect, and one has to use surgical techniques. Microsurgical technique for treatment of disk herniation is conducted with low invasive approach, with lower injuries to tissues and lower time of surgery [1-6].
Objective – to analyze the results of microsurgical discectomy in the treatment of sacrolumbar intervertebral disc herniation.
MATERIALS AND METHODS
A retrospective study included 50 patients (25 men, 25 women, mean age – 45.6) with L4-L5 and L5-S1 disk herniation who received the microsurgical management in the neurosurgery unit of Podgorbunsky Emergency Regional Clinical Hospital. The indications for surgery were inefficient conservative treatment during 25.-3 months, frequent recurrence of pain syndrome with neurological symptoms in the lower extremities, L4-L5 and L5-S1 herniation with compressed roots identified with radial and electromyographic examinations. The study did not include patients who received recurrent surgery. All patients received the complex clinical, neurological and electroneurographic examination for estimation of sensitivity and the injury level. The radial methods include lumbar radiography with two planes, CT and MRI.
Presurgical and postsurgical life quality was estimated with Oswestry questionnaire, pain – with VAS. MacNab was used for estimation of treatment results [7].
Microsurgery was carried out with CarlZeiss surgical microscope with 10-fold magnification and Aesculap tools. After preliminary radial examination, a skin decision (3-5 cm) was made in the middle line in region of spinous processes in prone position with rollers under the chest and pelvic bones. An ovalary incision was made for opening the aponeurosis. The skeletization of lateral surface of spinous processes and vertebral arches was carried out. The bipolar coagulator was used for hemostasis. Caspar wound extensor was used for extending the wound channel. The yellow ligament was dissected under microscopic control. Disk hernia was removed after meningoradikulolysis. Revision of the root and its release from adhesions were performed. Root pulsation was controlled. The wound was sutured layer-by-layer. The rubber drain was not removed. All patients received antibacterial agents. The patients initiated their activity 24 hour after surgery.
The statistical analysis of the results was performed with IBM SPSS Statistics Base Campus Edition (the license 20170918). Non-parametric methods were used. Shapiro-Wilk test identified the disparity to normal distribution of quantitative values, which were included in the study (p > 0.05). Moreover, most data is presented as discrete scales.
The mean level of a sign and a degree of its spreading are presented as median and interquartile range (Me (25th; 75th)). The qualitative signs are described as absolute and relative (%) values.
For testing the statistical hypotheses of significance of differences in samples, χ2 and Mann-Whitney (U) tests were used.
Wilcoxon’s test (W) was used for comparison of dependent samples.
The correlation analysis was conducted with Spearman’s rank coefficient (Pxy).
The critical level of statistical significance during testing the null hypotheses was p = 0.05.
The study was approved by the local ethical committee and corresponded to ethical principles of Helsinki Declare (revision 2013). All patients gave their informed consent for participation in the study.
RESULTS
According to MacNab, 12 months after surgery, 12 % (6 persons) patients estimated the surgical results as excellent. The good result was in 48 % (24 patients). The satisfactory results were in 24 % (12 patients; χ2 = 15.6; сс = 3; р = 0.001).
The mean inverse correlation was found between satisfaction with treatment and patients’ age (Pxy = 0.491; р = 0.001).
So, the symptoms disappeared at the age of 27.25 (33; 40). The patients returned to normal life and professional activity (excellent results). At the age of 33.75 (39.5; 54), the result was good, and the symptoms decreased significantly. Functional capabilities improved slightly, but return to professional activity was impossible in patients at the age of 38 (40.0; 41.0). Such result was satisfactory. The prognosis for professional activity was unfavorable in older age group – 64 (55.0; 67.0).
Pain syndrome was estimated with VAS before and after 12 months after surgery. It showed the decrease in clinical intensity from 10.0 (10.0; 10.0) to 5.0 (3.0; 7.25) points (Pw = 0.0001).
Pain syndrome intensity decreased from 10.0 (10.0; 10.0) to 4.0 (2.0; 6.0) point in the age group of 40 years, whereas the age of 41 and older showed the decrease from 10.0 (10.0; 10.0) to 5.0 (7.0; 10.0) points (Pu = 0.0001).
Oswestry Disability Index (ODI) was used for estimation of vital activity disorders caused by spinal abnormality. ODI was 67 % (62.0; 76.0) in the study group before treatment, and 28.0 % (12.0; 50.0) after it (Pw = 0.0001). Therefore, one could achieve the significant improvement in life quality.
The most favorable course of life quality was at the age < 40 (Pu = 0.0001). According to ODI, the life quality level was 64 % (62.0; 68.0 %) at admission and 16.0 % (6.0; 28.0; Pw = 0.00010 12 months after surgery. In the older age group (41 years and older), ODI was 74.0 % (68.0; 80.0) and 38.0 % (30.0; 74.0; Pw = 0.0001) before and after treatment correspondingly.
DISCUSSION
Our results were excellent and good in 30 patients (60 %) 12 months after surgery. Pain syndrome and neurological symptoms disappeared, and the patients could return to their professional activity. It corresponds to the literature data showing the favorable results after microdiscectomy [8-10]. The highest values of life quality were in the patients at the age < 40, with disease history from 3 till 5 months with earlier stages of the degenerative process of the disk. Unsatisfactory results of microdiscectomy were in 8 (16 %) patients with persistent radicular syndrome and neurological symptoms. According to the literature data, microdiscectomy for hernia shows good results in 80-90 %. However 5-25 % of patients complain of postsurgical radicular pain syndrome in the lumbar spine and in the lower extremities [10-12].
Microdiscectomy, which is a high tech surgery for intervertebral disk hernia, shows the high amount of unsatisfactory results, which are presented by radicular syndrome in the lumbar spine and in the lower extremities. One of the main causes is formation of scar adhesions in peridural space [10, 12-15]. Intrasurgical and infectious complications were absent.
CONCLUSION
According to our data, microdiscectomy is a safe surgery, which has the highest efficiency for persons at the age before 40 with less intense degenerative changes of the intervertebral disk.
Microsurgical discectomy for treatment of lumbar hernia is an efficient and low traumatic surgical intervention. It rapidly removes the pain syndrome and neurological symptoms, restores the working ability and improves the life quality for most patients.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of the article.