Milorad Vilendecic

A prospective cohort study of close interval computed tomography and magnetic resonance imaging after primary lumbar discectomy: factors associated with recurrent disc herniation and disc height loss.

Study Design. Prospective cohort study. Objective. We performed a prospective cohort study with standardized postoperative lumbar imaging every 3 months for a year then annually to assess the incidence and factors associated with same-level recurrent disc herniation. Summary of Background Data. The true incidence of same-level recurrent disc herniation after lumbar discectomy is unclear. Retrospective studies have reported widely varying incidences between 3% and 18%. Prospective controlled studies are lacking. Methods. A total of 108 patients undergoing first-time lumbar discectomy for refractory radiculopathy were enrolled. Baseline lumbar CT and MRI and standardized clinical data were assessed before surgery, and CT and MRI scans repeated 6 weeks, 3, 6, 9, 12, and 24-months after surgery and at the time of recurrent sciatica. Age, weight, preoperative disc volume, and height, volume of disc removed, and size of anular defect were compared with postoperative disc height loss and recurrent disc herniation using regression analysis. Results. One hundred patients (41 ± 10 years old) were available for 1-year (93%) and 76 (70%) for 2-year follow-up (mean follow-up: 25 ± 12 months). Improvement in all outcome measures was observed by 6 weeks after surgery (P < 0.005). An 18% loss of disc height was observed 3 months after surgery, progressing to 26% by 2 years. Eleven (10.2%) patients experienced recurrent disc herniation requiring revision discectomy a mean 10.5 months after surgery. Subjects with larger anular defects (P = 0.019) and with smaller percentage of disc volume removed (P = 0.028) were associated with an increased risk of recurrent disc herniation. Conversely, those from whom greater disc volumes were removed (P = 0.024) had more progressive disc height loss by 6 months after surgery. Conclusion. Larger anular defects and less disc removal increased the risk of reherniation. Greater volumes of disc removal were associated with accelerated disc height loss. In the setting of larger anular defects or less aggressive disc removal, concern for recurrent herniation should be increased during outpatient follow-up. In this situation effective anular repair may be helpful.

Effect of An Annular Closure Device (Barricaid) on Same Level Recurrent Disc Herniation and Disc Height Loss After Primary Lumbar Discectomy: Two-Year Results of a Multi-Center Prospective Cohort Study.

Study Design:A prospective cohort study. Objective:To evaluate whether an annular closure device could be implanted safely to reduce same-level recurrent disk herniation, or attenuate disk height loss and improve the outcome after lumbar discectomy. Summary of Background Data:Same-level recurrent disk herniation, disk height loss, and progressive degeneration are common complications and sequelae after lumbar discectomy. Techniques to reduce these consequences may improve outcomes. Methods:Forty-six consecutive patients undergoing lumbar discectomy for single-level herniated disk at 2 institutions were followed prospectively with clinical and radiographic evaluations at 6 weeks and 3, 6, 12, and 24 months (control cohort). A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed similarly. Incidence of recurrent disk herniation, disk height loss, the leg and back pain visual analog scale (VAS), and the Oswestry Disability Index were assessed at each follow-up. Results:Cohorts were well matched at baseline. By 2 years of follow-up, symptomatic recurrent same-level disk herniation occurred in 3 (6.5%) patients in the control cohort versus 0 (0%) patients in the annular repair cohort (P=0.27). A trend of greater preservation of disk height was observed in the annular repair versus the control cohort 3 months (7.9 vs. 7.27 mm, P=0.08), 6 months (7.81 vs. 7.18 mm, P=0.09), and 12 months (7.63 vs. 6.9 mm, P=0.06) postoperatively. The annular closure cohort reported less leg pain (VAS-LP: 5 vs. 16, P<0.01), back pain (VAS-BP: 13 vs. 22, P<0.05), and disability (Oswestry Disability Index: 16 vs. 22, P<0.05) 1 year postoperatively. Conclusions:Implantation of a novel annular repair device was associated with greater maintenance of disk height and improved 1-year leg pain, back pain, and low-back disability. Recurrent disk herniation did not occur in any patient after annular repair. Closure of annular defect after lumbar discectomy may help preserve the physiological disk function and prevent long-term disk height loss and associated back and leg pain.

Nightmare complication after lumbar disc surgery: cranial nontraumatic acute epidural hematoma.

Study Design. Case report. Objective. The nontraumatic cranial epidural hematoma is an extremely rare clinical entity and it commonly occurs in the presence of infectious diseases as complication of sinusitis, coagulopathy, vascular malformation of the dura, hemorrhagic tumor, in patients with sickle cell disease, systemic lupus erythematosus, after open heart surgery, and in patients on hemodialysis. Summary of Background Data. We reported a case of spontaneous epidural hematoma that occurred after herniated disc surgery. There was no history of preceding head trauma and patient medical history was unremarkable. To date, no report is found of cranial epidural hematoma after lumbar discectomy. Methods. A 58-year-old woman was operated because of a herniated disc at lumbar L3-L4 level and spinal stenosis. Bilateral L3-L4 interlaminectomies and L3-L4 discectomy were performed. Hemovac drain was placed in epidural space. Four hours after surgery, the patient developed left side weakness accompanied with nausea, vomiting, and severe headache. Urgent computed tomography of the head showed acute cranial epidural hematoma and the patient underwent emergent surgery. There was no evidence of trauma of the scalp or any other anatomical abnormality. Control computed tomography 14 hours after evacuation of the hematoma showed new extradural hematoma at the site of the previous one. Patient underwent second surgery. Results. Nine days after operation of the spine, patient recovered completely with no neurological deficit, but the cerebrospinal fluid showed at the place of spinal wound. Patient was operated once more and a minor dural tear was revealed, which was repaired. The patient was discharged on ninth postoperative and she recovered completely. Conclusion. There have been described rare cases of spontaneous subdural, intracerebral, and intracerebellar hematoma caused by intracranial hypotension, but this is the first described case of spontaneous cranial epidural hematoma after lumbar disc surgery caused by intracranial hypotension.

Charcot shoulder caused by Chiari type I malformation with syringomyelia with six-year follow-up.

ZusammenfassungWir berichten radiologische und klinische Details einer Patientin mit einer durch Syringomyelie und Chiari Typ 1 Malformation ausgelösten neuropathischen Gelenkserkrankung der Schulter. Neuropathische Gelenke sind 1868 erstmals von Charcot beschrieben worden. In der Folge wurden sie bei vielen Arten von peripheren und zentralen Nervenerkrankungen beobachtet. Es gibt viele Gründe für eine Syringomyelie – einer davon ist die Chiari Typ 1 Malformation. Schulter und Ellbogen sind am häufigsten von der Syringomyelie-induzierten Neuropathie befallen. Unsere Patientin wurde 6 Jahre seit der Diagnosestellung einer neuropathischen Arthropathie verbunden mit einer durch Chiari Typ 1 Malformation induzierten Syringomyelie kontrolliert. Nach der Operation zeigte sie keinerlei Progression der Erkrankung.SummaryWe are presenting a case report of neuropathic arthropathy of the shoulder secondary to a syringomyelia and Chiari type I malformation, with detailed clinical and radiological findings. Neuropathic joints were first described in 1868 by Charcot, and subsequently were described in many types of peripheral diseases and central neuron diseases. There are many causes of syringomyelia, and one of the causes of this disease is a Chiari type I malformation. Subsequently, shoulders and elbows are most commonly affected by syringomyelia-induced neuropathy. Our patient was observed for six years after being diagnosed with neuropathic arthropathy and syringomyelia caused by Chiari and did not show any disease progression after their surgery.

Cost savings associated with prevention of recurrent lumbar disc herniation with a novel annular closure device: a multicenter prospective cohort study.

OBJECTIVE Same-level recurrent disc herniation is a well-defined complication following lumbar discectomy. Reherniation results in increased morbidity and health care costs. Techniques to reduce these consequences may improve outcomes and reduce cost after lumbar discectomy. In a prospective cohort study, we set out to evaluate the cost associated with surgical management of recurrent, same-level lumbar disc herniation following primary discectomy. METHODS Forty-six consecutive European patients undergoing lumbar discectomy for a single-level herniated disc at two institutions were prospectively followed with clinical and radiographic evaluations. A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed at the same hospitals and same follow-up intervals. Cost estimates for reherniation were modeled on Medicare national allowable payment amounts (direct cost) and patient work-day losses (indirect cost). RESULTS Annular closure and control cohorts were matched at baseline. By 2 years follow-up, symptomatic recurrent same-level disc herniation occurred in three (6.5%) patients in the control cohort versus zero (0%) patients in the annular closure cohort. For patients experiencing recurrent disc herniation, mean estimated direct and indirect cost of management of recurrent disc herniation was

Effect of anular closure on disk height maintenance and reoperated recurrent herniation following lumbar diskectomy: two-year data.

34,242 and

Sinus pericranii in the left frontal region involving the superior eyelid: a case report.

3,778, respectively. Use of an annular closure device potentially results in a cost savings of

Unrecognized hemangiopericytoma of posterior cervical region with intracranial extension

222,573 per 100 primary discectomy procedures performed (or

The high-risk discectomy patient: prevention of reherniation in patients with large anular defects using an anular closure device.

2,226 per discectomy), based solely on the reduction of reoperated reherniations when modeled on U.S. Medicare costs. CONCLUSIONS Recurrent disc herniation did not occur in any patients after annular closure within the 12-month follow-up. The reduction in the incidence of reherniation was associated with potentially significant cost savings. Development of novel techniques to prevent recurrent lumbar disc herniation is warranted to decrease the associated morbidity and health care costs associated with this complication.

Endplate changes following discectomy: natural history and associations between imaging and clinical data.

OBJECTIVE To assess the potential benefits of disk reherniation reduction and disk height maintenance in limited diskectomy combined with the implantation of the anular closure device. SUMMARY AND BACKGROUND DATA Postoperative disk height loss is apparent in most patients undergoing lumbar diskectomy for herniated nucleus pulposus. Less favorable patient outcomes are associated with significant loss in disk height that can occur after aggressive disk tissue removal. More conservative disk removals, however, are often burdened by the increased risk of recurrent disk herniation. METHODS Two prospective single-arm studies on patients treated with limited diskectomy and an anular closure device were conducted. Outcome measures included disk height maintenance relative to preoperative values, Oswestry Disability Index, back pain, leg pain, and complications such as reherniations. Patients were evaluated preoperatively and postoperatively at 6 weeks and at 3-, 6-, 12-, and 24-month time points. RESULTS A total of 75 patients were included in this cohort consisting of 40 men and 35 women with an average age of 40 years. Disk height maintenance within the group overall was 90% at 24 months. Overall, 97% of the treated disks demonstrated disk height maintenance of at least 75% of preoperative levels at 12 months and 92% at 24 months. Disk height maintenance was correlated with less nucleus removal. Patient disability, back pain, and leg pain were significantly improved from preoperative levels at 6 weeks and maintained over the course of study. There was a single symptomatic reherniation requiring surgical intervention within this series. CONCLUSIONS Limited lumbar diskectomy combined with the use of an anular closure device provided very low rates of disk reherniation and exhibited excellent disk height maintenance and sustained disability, leg pain, and back pain improvement within a 24-month postoperative study period. As with prior diskectomy studies, disk height maintenance was correlated with lower nucleus removal, although recurrence was less than in prior reports of limited diskectomy. Anular closure may allow for achievement of both objectives.