Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits: The Impact of Surgical Timing on Functional Outcome.
Acute Disease
Adult
Aged
Aged, 80 and over
Body Mass Index
Diskectomy
Female
Follow-Up Studies
Humans
Intervertebral Disc Degeneration
/ complications
Intervertebral Disc Displacement
/ complications
Lumbar Vertebrae
Male
Middle Aged
Paresis
/ etiology
Recovery of Function
Retrospective Studies
Sciatica
/ etiology
Severity of Illness Index
Somatosensory Disorders
/ etiology
Time Factors
Time-to-Treatment
Treatment Outcome
Young Adult
Journal
Spine
ISSN: 1528-1159
Titre abrégé: Spine (Phila Pa 1976)
Pays: United States
ID NLM: 7610646
Informations de publication
Date de publication:
01 04 2019
01 04 2019
Historique:
pubmed:
29
6
2017
medline:
8
1
2020
entrez:
29
6
2017
Statut:
ppublish
Résumé
A retrospective cohort study. The aim of the study was to assess the impact of time to surgery in patients with motor deficits (MDs) on their functional outcome. The current single-center study presents results of emergency surgery for LDH in a group of patients with acute paresis in a "real-world" setting. MDs are a frequent symptom of lumbar disc herniation (LDH). Although surgery within 48 hours has been recommended for cauda-equina syndrome, the best timing of surgery for acute MDs continues to be debated. The effect of early surgery has been proposed but remains to be unproven. A total of 330 patients with acute paresis caused by LDH acutely referred to our department and surgically treated using microsurgical discectomy from January 2013 to December 2015 were included. Based on the duration of MD and surgical timing, all patients were classified into two categories: Group I included all patients with paresis <48 hours and Group II included all patients with paresis >48 hours. Patient demographics, LDH/clinical/treatment characteristics, and outcomes were collected prospectively.Severity of paresis [Medical Research Council (MRC) Grade 0-4], surgery-related complications, functional recovery of motor/sensory deficits, sciatica, retreatment/recurrence rates, and overall neurological outcome were analyzed. Group I showed significantly faster recovery of moderate/severe paresis (MRC 0-3) at discharge, and 6-weeks/3-months follow up (P ≤ 0.001), whereas there were no significant differences in recovery for mild paresis (MRC 4). Sensory deficits also recovered substantially faster in Group I at 6-weeks (P = 0.003) and 3-months follow up (P = 0.045). Body mass index, preoperative MRC-grade, and duration of MDs were identified as significant predictors for recovery of paresis at all follow ups with substantial impact on patient reported outcomes including sciatica and/or dermatomal sensory deficits. Given the superior rates of neurological recovery of acute moderate/severe MDs, immediate surgery should be the primary option. However, a prospective randomized clinical trial is needed to confirm the superiority of emergency surgery. 3.
Sections du résumé
STUDY DESIGN
A retrospective cohort study.
OBJECTIVE
The aim of the study was to assess the impact of time to surgery in patients with motor deficits (MDs) on their functional outcome. The current single-center study presents results of emergency surgery for LDH in a group of patients with acute paresis in a "real-world" setting.
SUMMARY OF BACKGROUND DATA
MDs are a frequent symptom of lumbar disc herniation (LDH). Although surgery within 48 hours has been recommended for cauda-equina syndrome, the best timing of surgery for acute MDs continues to be debated. The effect of early surgery has been proposed but remains to be unproven.
METHODS
A total of 330 patients with acute paresis caused by LDH acutely referred to our department and surgically treated using microsurgical discectomy from January 2013 to December 2015 were included. Based on the duration of MD and surgical timing, all patients were classified into two categories: Group I included all patients with paresis <48 hours and Group II included all patients with paresis >48 hours. Patient demographics, LDH/clinical/treatment characteristics, and outcomes were collected prospectively.Severity of paresis [Medical Research Council (MRC) Grade 0-4], surgery-related complications, functional recovery of motor/sensory deficits, sciatica, retreatment/recurrence rates, and overall neurological outcome were analyzed.
RESULTS
Group I showed significantly faster recovery of moderate/severe paresis (MRC 0-3) at discharge, and 6-weeks/3-months follow up (P ≤ 0.001), whereas there were no significant differences in recovery for mild paresis (MRC 4). Sensory deficits also recovered substantially faster in Group I at 6-weeks (P = 0.003) and 3-months follow up (P = 0.045). Body mass index, preoperative MRC-grade, and duration of MDs were identified as significant predictors for recovery of paresis at all follow ups with substantial impact on patient reported outcomes including sciatica and/or dermatomal sensory deficits.
CONCLUSION
Given the superior rates of neurological recovery of acute moderate/severe MDs, immediate surgery should be the primary option. However, a prospective randomized clinical trial is needed to confirm the superiority of emergency surgery.
LEVEL OF EVIDENCE
3.
Identifiants
pubmed: 28658038
doi: 10.1097/BRS.0000000000002295
pii: 00007632-201904010-00006
doi:
Types de publication
Comparative Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
454-463Références
Overdevest GM, Vleggeert-Lankamp CL, Jacobs WC, et al. Recovery of motor deficit accompanying sciatica: subgroup analysis of a randomized controlled trial. Spine 2014; 14:1817–1824.
Jacobs WC, Arts MP, van Tulder MW, et al. Surgical techniques for sciatica due to herniated disc: a systematic review. Eur Spine J 2012; 21:2232–2251.
Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. New Engl J Med 2007; 356:2245–2256.
Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am Vol 2004; 86-a:670–679.
Osterman H, Seitsalo S, Karppinen J, et al. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine 2006; 31:2409–2414.
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006; 296:2441–2450.
Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996; 21:1787–1794. discussion 94–5.
Davis RA. A long-term outcome analysis of 984 surgically treated herniated lumbar discs. J Neurosurg 1994; 80:415–421.
Weber H. The effect of delayed disc surgery on muscular paresis. Acta Orthop Scand 1975; 46:631–642.
Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: evidence-based practice. Intern J Gen Med 2010; 3:209–214.
Ahn UM, Ahn NU, Buchowski JM, et al. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine 2000; 25:1515–1522.
Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine 2000; 25:348–351. discussion 52.
Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery 1993; 32:743–746. discussion 6–7.
Kostuik JP, Harrington I, Alexander D, et al. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am Vol 1986; 68:386–391.
Sabnis AB, Diwan AD. The timing of surgery in lumbar disc prolapse: a systematic review. Ind J Orthop 2014; 48:127–135.
Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am Vol 2011; 93:1906–1914.
Compston A. Aids to the investigation of peripheral nerve injuries. Medical Research Council: Nerve Injuries Research Committee. His Majesty's Stationery Office: 1942; pp. 48 (iii) and 74 figures and 7 diagrams; with aids to the examination of the peripheral nervous system. By Michael O’Brien for the Guarantors of Brain. Saunders Elsevier: 2010; pp. [8] 64 and 94 Figures. Brain 2010; 133:2838–2844.
Scott PJ. Bladder paralysis in cauda equina lesions from disc prolapse. J Bone Joint Surg Brit Vol 1965; 47:224–235.
Shephard RH. Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disk. Brit Med J 1959; 2:1434–1439.
Andersen JT, Bradley WE. Neurogenic bladder dysfunction in protruded lumbar disk and after laminectomy. Urology 1976; 8:94–96.
Lonne G, Solberg TK, Sjaavik K, et al. Recovery of muscle strength after microdiscectomy for lumbar disc herniation: a prospective cohort study with 1-year follow-up. Eur Spine J 2012; 21:655–659.
Dubourg G, Rozenberg S, Fautrel B, et al. A pilot study on the recovery from paresis after lumbar disc herniation. Spine 2002; 27:1426–1431. discussion 31.
Fisher C, Noonan V, Bishop P, et al. Outcome evaluation of the operative management of lumbar disc herniation causing sciatica. J Neurosurg 2004; 100:317–324.
Folman Y, Shabat S, Catz A, et al. Late results of surgery for herniated lumbar disk as related to duration of preoperative symptoms and type of herniation. Surg Neurol 2008; 70:398–401. discussion-2.
Junge A, Frohlich M, Ahrens S, et al. Predictors of bad and good outcome of lumbar spine surgery. A prospective clinical study with 2 years’ follow up. Spine 1996; 21:1056–1064. discussion 64–5.
Ng LC, Sell P. Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study. J Bone Joint Surg Brit Vol 2004; 86:546–549.
Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up. J Neurosurg 2000; 92:131–134.
Thome C, Barth M, Scharf J, et al. Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. J Neurosurg Spine 2005; 2:271–278.
Parker SL, Mendenhall SK, Godil SS, et al. Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clinic Orthop Rel Res 2015; 473:1988–1999.
Koerner JD, Glaser J, Radcliff K. Which variables are associated with patient-reported outcomes after discectomy? review of SPORT Disc herniation studies. Clinic Orthop Rel Res 2015; 473:2000–2006.