Mark P. Arts

Tubular Diskectomy vs Conventional Microdiskectomy for Sciatica: A Randomized Controlled Trial

CONTEXT Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica due to lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking of its efficacy. OBJECTIVE To determine outcomes and time to recovery in patients treated with tubular diskectomy compared with conventional microdiskectomy. DESIGN, SETTING, AND PATIENTS The Sciatica Micro-Endoscopic Diskectomy randomized controlled trial was conducted among 328 patients aged 18 to 70 years who had persistent leg pain (>8 weeks) due to lumbar disk herniations at 7 general hospitals in The Netherlands from January 2005 to October 2006. Patients and observers were blinded during the follow-up, which ended 1 year after final enrollment. INTERVENTIONS Tubular diskectomy (n = 167) vs conventional microdiskectomy (n = 161). MAIN OUTCOME MEASURES The primary outcome was functional assessment on the Roland-Morris Disability Questionnaire (RDQ) for sciatica (score range: 0-23, with higher scores indicating worse functional status) at 8 weeks and 1 year after randomization. Secondary outcomes were scores on the visual analog scale for leg pain and back pain (score range: 0-100 mm) and patients self-report of recovery (measured on a Likert 7-point scale). RESULTS Based on intention-to-treat analysis, the mean RDQ score during the first year after surgery was 6.2 (95% confidence interval [CI], 5.6 to 6.8) for tubular diskectomy and 5.4 (95% CI, 4.6 to 6.2) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, -0.2 to 1.7). At 8 weeks after surgery, the RDQ mean (SE) score was 5.8 (0.4) for tubular diskectomy and 4.9 (0.5) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, -0.4 to 2.1). At 1 year, the RDQ mean (SE) score was 4.7 (0.5) for tubular diskectomy and 3.4 (0.5) for conventional microdiskectomy (between-group mean difference, 1.3; 95% CI, 0.03 to 2.6) in favor of conventional microdiskectomy. On the visual analog scale, the 1-year between-group mean difference in improvement was 4.2 mm (95% CI, 0.9 to 7.5 mm) for leg pain and 3.5 mm (95% CI, 0.1 to 6.9 mm) for back pain in favor of conventional microdiskectomy. At 1 year, 107 of 156 patients (69%) assigned to tubular diskectomy reported a good recovery vs 120 of 151 patients (79%) assigned to conventional microdiskectomy (odds ratio, 0.59 [95% CI, 0.35 to 0.99]; P = .05). CONCLUSIONS Use of tubular diskectomy compared with conventional microdiskectomy did not result in a statistically significant improvement in the Roland-Morris Disability Questionnaire score. Tubular diskectomy resulted in less favorable results for patient self-reported leg pain, back pain, and recovery. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN51857546.

Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomized controlled trial.

Objective To assess whether interspinous process device implantation is more effective in the short term than conventional surgical decompression for patients with intermittent neurogenic claudication due to lumbar spinal stenosis. Design Randomized controlled trial. Setting Five neurosurgical centers (including one academic and four secondary level care centers) in the Netherlands. Participants 203 participants were referred to the Leiden-The Hague Spine Prognostic Study Group between October 2008 and September 2011; 159 participants with intermittent neurogenic claudication due to lumbar spinal stenosis at one or two levels with an indication for surgery were randomized. Interventions 80 participants received an interspinous process device and 79 participants underwent spinal bony decompression. Main outcome measures The primary outcome at short term (eight weeks) and long term (one year) follow-up was the Zurich Claudication Questionnaire score. Repeated measurements were made to compare outcomes over time. Results At eight weeks, the success rate according to the Zurich Claudication Questionnaire for the interspinous process device group (63%, 95% confidence interval 51% to 73%) was not superior to that for standard bony decompression (72%, 60% to 81%). No differences in disability (Zurich Claudication Questionnaire; P=0.44) or other outcomes were observed between groups during the first year. The repeat surgery rate in the interspinous implant group was substantially higher (n=21; 29%) than that in the conventional group (n=6; 8%) in the early post-surgical period (P<0.001). Conclusions This double blinded study could not confirm the hypothesized short term advantage of interspinous process device over conventional “simple” decompression and even showed a fairly high reoperation rate after interspinous process device implantation. Trial registration Dutch Trial Register NTR1307.

Vertebral body replacement systems with expandable cages in the treatment of various spinal pathologies: a prospectively followed case series of 60 patients.

OBJECTIVEVertebral body reconstruction after corpectomy has become a common surgical procedure. The authors describe a prospectively followed case series of patients treated with expandable cages for various indications. METHODSSixty patients underwent single or multilevel corpectomy for degenerative stenosis (13 patients), herniated disc (7 patients), deformity (14 patients), traumatic fracture (3 patients), infection (1 patient), or tumor (22 patients). Six different expandable vertebral body systems were used in the cervical spine (41 patients), thoracic spine (15 patients), and lumbar spine (4 patients). All patients were evaluated clinically and radiographically. RESULTSThirty-nine patients underwent single-level corpectomy, 18 patients underwent two-level corpectomy, and 3 patients underwent three-level corpectomy. Anterior reconstruction alone was performed in 30 patients; circumferential reconstruction was performed in 30 patients, 9 of whom underwent reconstruction through a posterior approach only. At the time of the final follow-up examination (mean, 9 mo), the Nurick grade improved significantly. Ninety-five percent of the patients maintained or improved their Frankel score and 67% had good clinical results. The regional angulation was corrected significantly (4.0 ± 9.0 degrees, P = 0.002), and the segment height increased significantly (3.5 ± 8.0 mm, P = 0.002). Bony fusion was achieved in 93% of the cases. Subsidence was documented in nearly half of the patients (1.4 ± 2.0 mm) and was reduced after circumferential fusion (0.9 ± 1.9 mm, P = 0.08). Eighteen patients (30%) had complications and 12 patients (20%) underwent revision surgery. CONCLUSIONExpandable vertebral body replacement systems can provide solid anterior column constructs with restoration of height and sagittal alignment. Favorable clinical outcome was shown in most patients, although the complication and reoperation rates are rather high.

Tubular diskectomy vs conventional microdiskectomy for the treatment of lumbar disk herniation: 2-year results of a double-blind randomized controlled trial

BACKGROUND:Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking. OBJECTIVE:To evaluate the 2-year results of tubular diskectomy compared with conventional microdiskectomy. METHODS:Three hundred twenty-eight patients with persistent leg pain caused by lumbar disk herniation were randomly assigned to undergo tubular diskectomy (167 patients) or conventional microdiskectomy (161 patients). Main outcome measures were scores from Roland-Morris Disability Questionnaire for Sciatica, Visual Analog Scale for leg pain and low-back pain, and Likert self-rating scale of global perceived recovery. RESULTS:On the basis of intention-to-treat analysis, there was no significant difference between tubular diskectomy and conventional microdiskectomy in Roland-Morris Disability Questionnaire for Sciatica scores during 2 years after surgery (between-group mean difference [Δ] = 0.6; 95% confidence interval [CI], −0.3-1.6). Patients treated with tubular diskectomy reported more leg pain (Δ = 3.3 mm; 95% CI, 0.2-6.2) and more low-back pain (Δ = 3.0 mm; 95% CI, −0.2-6.3) than those patients treated with conventional microdiskectomy. At 2 years, 71% of patients assigned to tubular diskectomy documented a good recovery vs 77% of patients assigned to conventional microdiskectomy (odds ratio, 0.76; 95% CI, 0.45-1.28; P = .35). Repeated surgery rates within 2 years after tubular diskectomy and conventional microdiskectomy were 15% and 10%, respectively (P = .22). CONCLUSION:Tubular diskectomy and conventional microdiskectomy resulted in similar functional and clinical outcomes. Patients treated with tubular diskectomy reported more leg pain and low-back pain, although the differences were small and not clinically relevant.

Serum creatine phosphokinase as an indicator of muscle injury after various spinal and nonspinal surgical procedures

OBJECT Muscle injury is inevitable during surgical exposure of the spine and is quantified by the release of creatine phosphokinase (CPK). No studies have been conducted on different spinal approaches and nonspinal surgery with regard to muscle injury. The present prospective cohort study was conducted to evaluate the results of postoperative serum CPK as an indicator of muscle injury in relation to various spinal and nonspinal procedures. METHODS The authors analyzed data in 322 consecutive patients who had undergone 257 spinal and 65 nonspinal procedures. Primary procedures were performed in 264 patients and revision surgeries in 58. Spinal procedures were subdivided according to the degree of surgical invasiveness as follows: minimally invasive (microendoscopic lumbar discectomy, unilateral transflaval discectomy, and minithoracotomy), average invasiveness (bilateral lumbar discectomy, laminectomy, and anterior cervical discectomy), and extensive surgery (instrumented single or multilevel spondylodesis of the entire spinal column). Spinal localization, number of spinal levels involved, surgical approach, duration of surgery, and body mass index (BMI) were recorded. Creatine phosphokinase was measured before surgery and 1 day after surgery, and the CPK ratio (that is, the difference within one patient) was used as the outcome measure. RESULTS There was a significant dose-response relationship between the CPK ratio and the degree of surgical invasiveness; extensively invasive surgery had the highest CPK ratio and minimally invasive surgery had the lowest. Thoracolumbar surgery had a significantly higher CPK ratio compared with those for cervical and nonspinal surgery. There was a slightly negative relationship between the number of spinal segments involved and the CPK ratio. The CPK ratio in revision surgery was significantly higher than in primary surgery. Posterior surgical approaches had a higher CPK ratio, and the ratios for unilateral compared with bilateral approaches were not significantly different. The duration of surgery and preoperative serum level of CPK significantly influenced postoperative CPK. There was also a significant association between CPK ratio and nonspinal surgery. Age, sex, and BMI were not significant factors. CONCLUSIONS Data in this study have shown a dose-response relationship between CPK and the extent of surgical invasiveness. Thoracolumbar surgery, posterior approaches, duration of surgery, revision surgery, and preoperative value of CPK were significant influencing factors for the CPK ratio. The clinical significance of the results in the present study is not known.

Tubular diskectomy vs conventional microdiskectomy for the treatment of lumbar disk-related sciatica: cost utility analysis alongside a double-blind randomized controlled trial.

BACKGROUND:Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica caused by lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence of its efficacy is lacking. OBJECTIVE:To determine whether a favorable cost-effectiveness for tubular diskectomy compared with conventional microdiskectomy is attained. METHODS:Cost utility analysis was performed alongside a double-blind randomized controlled trial conducted among 325 patients with lumbar disk related sciatica lasting >6 to 8 weeks at 7 Dutch hospitals comparing tubular diskectomy with conventional microdiskectomy. Main outcome measures were quality-adjusted life-years at 1 year and societal costs, estimated from patient reported utilities (US and Netherlands EuroQol, Short Form Health Survey-6D, and Visual Analog Scale) and diaries on costs (health care, patient costs, and productivity). RESULTS:Quality-adjusted life-years during all 4 quarters and according to all utility measures were not statistically different between tubular diskectomy and conventional microdiskectomy (difference for US EuroQol, −0.012; 95% confidence interval, −0.046 to 0.021). From the healthcare perspective, tubular diskectomy resulted in nonsignificantly higher costs (difference US

Management of sciatica due to lumbar disc herniation in the Netherlands: a survey among spine surgeons

460; 95% confidence interval, −243 to 1163). From the societal perspective, a nonsignificant difference of US

Cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in the treatment of lumbar disc herniation: a prospective randomised controlled trial (ISRCTN51857546)

1491 (95% confidence interval, −1335 to 4318) in favor of conventional microdiskectomy was found. The nonsignificant differences in costs and quality-adjusted life-years in favor of conventional microdiskectomy result in a low probability that tubular diskectomy is more cost-effective than conventional microdiskectomy. CONCLUSION:Tubular diskectomy is unlikely to be cost-effective compared with conventional microdiskectomy.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment.

OBJECT Although clinical guidelines for sciatica have been developed, various aspects of lumbar disc herniation remain unclear, and daily clinical practice may vary. The authors conducted a descriptive survey among spine surgeons in the Netherlands to obtain an overview of routine management of lumbar disc herniation. METHODS One hundred thirty-one spine surgeons were sent a questionnaire regarding various aspects of different surgical procedures. Eighty-six (70%) of the 122 who performed lumbar disc surgery provided usable questionnaires. RESULTS Unilateral transflaval discectomy was the most frequently performed procedure and was expected to be the most effective, whereas percutaneous laser disc decompression was expected to be the least effective. Bilateral discectomy was expected to be associated with the most postoperative low-back pain. Recurrent disc herniation was expected to be lowest after bilateral discectomy and highest after percutaneous laser disc decompression. Complications were expected to be highest after bilateral discectomy and lowest after unilateral transflaval discectomy. Nearly half of the surgeons preferentially treated patients with 8-12 weeks of disabling leg pain. Some consensus was shown on acute surgery in patients with short-lasting drop foot and those with a cauda equina syndrome, and nonsurgical treatment in patients with long-lasting, painless drop foot. Most respondents allowed postoperative mobilization within 24 hours but advised their patients not to resume work until 8-12 weeks postoperatively. CONCLUSIONS Unilateral transflaval discectomy was the most frequently performed procedure. Minimally invasive techniques were expected to be less effective, with higher recurrence rates but less postoperative low-back pain. Variety was shown between surgeons in the management of patients with neurological deficit. Most responding surgeons allowed early mobilization but appeared to give conservative advice in resumption of work.

Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: a randomized controlled trial.

BackgroundOpen discectomy is the standard surgical procedure in the treatment of patients with long-lasting sciatica caused by lumbar disc herniation. Minimally invasive approaches such as microendoscopic discectomy have gained attention in recent years. Reduced tissue trauma allows early ambulation, short hospital stay and quick resumption of daily activities. A comparative cost-effectiveness study has not been performed yet. We present the design of a randomised controlled trial on cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in patients with lumbar disc herniation.Methods/DesignPatients (age 18–70 years) presenting with sciatica due to lumbar disc herniation lasting more than 6–8 weeks are included. Patients with disc herniation larger than 1/3 of the spinal canal diameter, or disc herniation less than 1/3 of the spinal canal diameter with concomitant lateral recess stenosis or sequestration, are eliglible for participation. Randomisation into microendoscopic discectomy or conventional unilateral transflaval discectomy will take place in the operating room after induction of anesthesia. The length of skin incision is equal in both groups. The primary outcome measure is the functional assessment of the patient, measured by the Roland Disability Questionnaire for Sciatica, at 8 weeks and 1 year after surgery. We will also evaluate several other outcome parameters, including perceived recovery, leg and back pain, incidence of re-operations, complications, serum creatine kinase, quality of life, medical consumption, absenteeism and costs. The study is a randomised prospective multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 2 years.DiscussionCurrently, open discectomy is the golden standard in the surgical treatment of lumbar disc herniation. Whether microendoscopic discectomy is more cost-effective than unilateral transflaval discectomy has to be determined by this trial.