Suresh hnp

Short Term Outcome of
operative treatment of Disc
Herniation
Dr Suresh Pandey
MBBS, MS Orthopaedics
Associate Professor
College of Medical Sciences, Bharatpur
Spine Conference 2019, Kathmandu

Disc Herniation problem magnitude
• Most common cause of sciatic
pain
• Most common reason for spine
surgery

• 1-3% symtomatic prevalence
• Men:female 2-3:1
• Most common age group: 30-50

Why herniation and radiculopathy?
• Consequence of degenerative
changes in the annulus due to
repeated loading, tension or
torsional strain
• Cause of radicular pain is
mechanical compression and
inflammation

Treatment Options
• Conservative
• Epidural steroid: 1952 first
record.
• Variable efficacy
• Short term relief 47-90%
• Shorter the duration of pain,
the higher the success rate
• Better result in extrusion than
contained disc

Operative Options
• Standard or open discectomy
(laminotomy/laminectomy
followed by discectomy)
• Microscopic discectomy
• Endoscopic discecetomy

Role of intraoperative local steroid injection
• Better short term relief of pain
and less analgesia
postoperatively
• Controversy about its benefit vs
risk
• Which Steroid?
• Dose?

Study
• Retropsective analysis of data of lumbar and cervical disc herniation
over 3 years with at least 6 mths follow up
• Short term result in terms of pain relief, complications and difference
between use of intraoperative local steroid vs no steroid

Materials and Methods
• 53 L-S standard discectomy
• 39 FU at least 6 mths with range upto 3 years
• L4-L5: 18
• L5-S1: 20
• L2-L3 with CES: 1
• Mean age:41
• M:F=28:11

• Prior use of epidural steroids:21(53.8%)
• Local intraoperative use of steroid: 17 (43.5%)
• No local steroid: 22 (56.5%)

Indications for Operations
• Severe disabling pain despite trial of conservative means for at least 6
weeks
• Increasing weakness of limbs
• Cauda Equina syndrome

• All had undergone adequate trial of conservative treatment except
case of CES
• Average duration of symptoms 4.6 months
• All had axial pain along with radiculitis with positive SLR
• Diagnosis was clinical with MRI correlation

Operative details Standard discectomy
• GA
• Prone with table jack knife position
• Incision 2 inch centered over the
lesion midline
• Skin, subut tissue, fascia and
retraction of paraspinal muscle on
one side only on the affected side
• Laminotomy and excision of
ligamentum flavum

• Expose dura, root and retract them
and identify herniation and do
herniotomy
• Local Inj Triamconolone 40 mg and
closure in layer without fat pad

Outcome measurement
• Post op pain at 24 hours, 6 mth
and last FU
• Use of analgesia post op
• Discharge
• Complications
• Recurrence
• Patient’s satisfaction with
MacNab Criteria

MacNab Criteria
• Excellent: No pain; no restriction of activity.
• Good: Occasional back or leg pain of sufficient severity to interfere
with the patient’s ability to do his normal work or his capacity to
enjoy himself in his leisure hours.
• Fair: Improved functional capacity, but handicapped by intermittent
pain of sufficient severity to curtail or modify work or leisure
activities.
• Poor: No improvement or insufficient improvement to enable
increase in activities; further operative intervention required.

Cervical disc
• ACDF in 8 cases of failed conservative treatment
• Mean age: 48 (39-59) yrs
• M:F=6:2
• C5-6=5
• C6-7=3

Operative details
• Anterior dissection

• Disc excision, BG and plating

Result
• Mean FU 2.3 yrs
• Minimum 6 mth follow up
• Mean VAS pain score improved from 7 to 2 in lumbar discectomy at 6
mth
• Mac Nab criteria good to excellent cases (33) 84%
• Fair: 5 (12%)
• Poor 1 (2.5) case of cauda equina L3-L4

Local steroid vs no steroid
• Less complain of pain postoperatively
• Less use of analgesics (sos anlgesics vs regular)
• Early discharge (4 days vs 6 days)

Local intraoperative steroid
• Mean VAS at 24 hrs post op improved from preoperative7.6 to 2.5
• No increased risk of infection or any other complications

complications
• None had recurrence, list, motor deficit, discitis, wound site infection
• Case of cauda equine improved from motor power 2 to 4 in LL and
became ambulatory but bladder control was poor till 2 yrs of follow
up

ACDF
• All improved in terms of pain
• Preop mean VAS improved from 8.6 to 1.2 at 6 mth post op
• Motor and sensory improvement in all 2 cases of preoperative motor
weakness from 4 to 5
• No wound site infection
• No dysphagia or hoarseness of voice
• Fusion occurred in all
• Good to excellent result in all according to Mac Nab criteria

Discussion
• 95% of disc herniation L4-5-S1
• Treatment controversy: No long term clear benefit with surgery
• Operative vs non operative?

Conservative. 90% relieve in 3 mths
• Analgesics,
• Advice to stay active
• Antidepressants,
• Gabapentin
• Bed rest
• Exercise therapy
• Heat,
• Ice
• Massage,
• Muscle relaxants,
• Spinal manipulation,
• Traction.
• Acupuncture,

Discussion
• Operative Techniques
• Standard discectomy
• Microdiscectomy
• Endoscopic discectomy

Conservative vs operative
BMJ Open. 2016; 6(12): e012938
Surgical versus conservative treatment for lumbar disc herniation: a
prospective cohort study
Marinella Gugliotta,1 Bruno R da Costa,2 Essam Dabis,3 Robert Theiler,3,4 Peter Jüni,5,6 Stephan
Reichenbach,7,8 Hans Landolt,1 and Paul Hasler3
Conclusion of 370 patients
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.

Long-Term Results of Various Operations for Lumbar Disc Herniation: Analysis of over
39,000 Patients
Dohrmann G.J. · Mansour N.
Conclusions: The analysis of 39,048 patients with various operations for lumbar
disc herniation revealed the same pattern of long-term results. Patients who had
microdiscectomy, endoscopic microdiscectomy or the classical operation
(laminectomy/laminotomy with discectomy) all had approximately 79%
good/excellent results. None of the operative procedures gave a different outcome.

Lumbar Disk Herniation Surgery: Outcome and Predictors
Mahsa Sedighi, Ali Haghnegahdar
Global Spine Journal 2014
Conclusion
Surgery for lumbar disk herniation is effective in reducing radicular pain (93.4%).
All three surgical approaches resulted in significant decrease in preoperative
radicular pain and low back pain, but intergroup variation in the outcome was
not achieved

Role of epidural steroid
Treatment of lumbar disc herniation: epidural steroid injection compared with
discectomy. A prospective, randomized study.
J Bone Joint Surg Am. 2004 Apr;86(4):670-9
CONCLUSIONS:
Epidural steroid injection was not as effective as discectomy with regard to
reducing symptoms and disability associated with a large herniation of the lumbar
disc. However, epidural steroid injection did have a role: it was found to be effective
for up to three years by nearly one-half of the patients who had not had
improvement with six or more weeks of noninvasive care.

Intraop epid steroid
• Used for more than 2 decades
• Lacks universal consensus about routine use, types of steroid, dose
and adjuvants after Lumbar discectomy

Intraoperative steroid injection
• Complications of intraoperative epidural steroid use in lumbar
discectomy: A systematic review and meta-analysis
Neurosurgical FOCUS 39(4):E12 · October 2015
Conclusions There is good evidence that epidural steroids can decrease pain in the short term and
decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal
disease. The authors' results demonstrate a trend toward increased infection with epidural steroid
use, but there was not a statistically significant difference

Surg Neurol Int. 2017; 8: 42
Perioperative steroids for lumbar disc surgery: A meta-analysis of
randomized controlled trials
Muhammad Waqas, Hussain Shallwani, Muhammad S. Shamim,* and Khabir Ahmad
Conclusion:
Intraoperative epidural steroid administration offers some benefit in pain control
with a significant reduction in the length of hospital stay. However, there is
insufficient evidence to support the routine use of oral and intravenous steroids in
the perioperative period.

Standard discectomy

L2-3 HNP with Cauda Equina

Conclusion
• Standard discectomy is good choice to achieve back pain and
radiculitis in lumbar disc herniation who fail to respond with
adequate conservative treatment
• Result of cervical disc operation with ACDF have higher success rate
than Lumbar
• Intraoperative epid steroid injection gives better pain relief in early
post operative period without adding further risk or complications

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