Long-term back pain after a single-level discectomy for radiculopathy: incidence and health care cost analysis.
ABSTRACT The most common spinal procedure performed in the US is lumbar discectomy for disc herniation. Longterm disc degeneration and height loss occur in many patients after lumbar discectomy. The incidence of mechanical back pain following discectomy varies widely in the literature, and its associated health care costs are unknown. The authors set out to determine the incidence of and the health care costs associated with mechanical back pain attributed to segmental degeneration or instability at the level of a prior discectomy performed at their institution.
The authors retrospectively reviewed the data for 111 patients who underwent primary, single-level lumbar hemilaminotomy and discectomy for radiculopathy. All diagnostic modalities, conservative therapies, and operative treatments used for the management of postdisectomy back pain were recorded. Institutional billing and accounting records were reviewed to determine the billed costs of all diagnostic and therapeutic measures.
At a mean follow-up of 37.3 months after primary discectomy, 75 patients (68%) experienced minimal to no back pain, 26 (23%) had moderate back pain requiring conservative treatment only, and 10 (9%) suffered severe back pain that required a subsequent fusion surgery at the site of the primary discectomy. The mean cost per patient for conservative treatment alone was $4696. The mean cost per patient for operative treatment was $42,554. The estimated cost of treatment for mechanical back pain associated with postoperative same-level degeneration or instability was $493,383 per 100 cases of first-time, single-level lumbar discectomy ($4934 per primary discectomy).
Postoperative mechanical back pain associated with same-level degeneration is not uncommon in patients undergoing single-level lumbar discectomy and is associated with substantial health care costs.
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ABSTRACT: OBJECT The authors investigated quality of life (QOL) outcomes after primary versus revision discectomy. METHODS A retrospective review was performed for all patients who had undergone a primary or revision discectomy at the Cleveland Clinic Center for Spine Health from January 2008 through December 2011. Among patients in the revision cohort, they identified those who needed a second revision discectomy. Patient QOL measures were recorded before and after surgery. These measures included responses to the EQ-5D health questionnaire, Patient Health Questionnaire-9, Pain and Disability Questionnaire, and quality-adjusted life years (QALYs). Cohorts were compared by using independent-sample t-tests and Fisher exact tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to adjust for confounding. RESULTS A total of 196 patients were identified (116 who underwent primary discectomy and 80 who underwent revision discectomy); average follow-up time was 150 days. There were no preoperative QOL differences between groups. Postoperatively, both groups improved significantly in all QOL measures. For QALYs, the primary cohort improved by 0.25 points (p < 0.001) and the revision cohort improved by 0.18 points (p < 0.001). QALYs improved for significantly more patients in the primary than in the revision cohort (76% vs 59%, respectively; p = 0.02), and improvement exceeded the minimum clinically important difference for more patients in the primary cohort (62% vs 45%, respectively; p = 0.03). Of the 80 patients who underwent revision discectomy, yet another recurrent herniation (third herniation) occurred in 14 (17.5%). Of these, 4 patients (28.6%) chose to undergo a second revision discectomy and the other 10 (71.4%) underwent conservative management. For those who underwent a second revision discectomy, QOL worsened according to all questionnaire scores. CONCLUSIONS QOL, pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy.Journal of Neurosurgery Spine 12/2014; 22(2):1-6. DOI:10.3171/2014.10.SPINE14359 · 2.36 Impact Factor
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ABSTRACT: Background & aim Intraoperative epidural corticosteroids have been used to decrease post-operative pain post-discectomy. The objective of this study is to assess the efficacy of epidural corticosteroids on post-operative pain and length of post-operative hospital stay in patients undergoing unilateral lumbar microdiscectomy. Methods 150 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively allocated randomly to receive either a sponge soaked in epidural corticosteroids or saline at the end of the operative procedure. The intensity of spontaneous pain was quantified by using the Oswestry low back pain index pre-operatively, at discharge, at week 1 follow-up and at 1st month of follow up. At the same intervals, each patient underwent the passive straight leg-raising test (PSLRT) and Visual Analogue Scale (VAS) testing. The duration of hospital stay, time taken to return to daily life activities and quantity of analgesia consumed post-operatively were also recorded. Results The mean hospital stay was 1.3 ± 0.9 days in the corticosteroids group (group 1) compared to 3.2 ± 1.2 in the control group (group 2). The mean interval until return to daily life activities was 6.7 ± 2.1 days in group 1 versus 9.6 ± 4.1 days in group 2. No statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. Differences in the OLBI scores were statistically significant at all post-operative intervals. At baseline (preoperatively), group 1 (DepoMedrol™ group) had an average score of 72.3% (±2.6%) compared to 74.6% (±3.1%) in group 2 (Control group) (P = 0.45). At discharge, OLBI scores declined to 49.7% (±4.5%) in group 1 compared to 63.5% (±3.9%) in group 2 (P = 0.034). At week 1 follow-up, OLBI scores further declined to 41.3% (±2.9%) in group 1 versus 54.2% (±5.3%) in group 2 (P = 0.014). After one month of follow-up, OLBI scores were 34.1% (±6.7%) in group 1 and 42.6% (±4.1%) in group 2 (P = 0.004). Results of VAS and PSLRT are also documented in the manuscript. The mean postoperative analgesic medications consumed was 15.6 ± 1.9 mg of morphine equivalent in the corticosteroid group versus 10.3 ± 1.8 mg of morphine equivalent in the control group. No complications of treatment occurred in either groups. Conclusion Intraoperative application of epidural corticosteroids, Depomedrol, significantly reduces post-operative pain, length of post-operative stay and duration to return to daily living activities following lumbar discectomy.The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 06/2014; DOI:10.1016/j.surge.2014.03.012 · 2.21 Impact Factor
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ABSTRACT: Surgery for same level multi-focal extruded lumbar disc herniations is technically challenging and the optimal method controversial. The subarticular disc herniation may pose the most challenging subtype requiring partial or complete facetectomy with or without fusion. The far-lateral disc herniation, often treated using a Wiltse approach, can also be difficult to access especially in the obese patient. When both the subarticular and far-lateral subtypes are simultaneously present at the same level with or without a paracentral disc herniation, a total facetectomy and interbody fusion (TLIF) or a total disc replacement (TDR) may be necessary. Endoscopic surgical techniques may reduce the need for these more invasive methods. Fifteen patients (6 male and 9 female) who had same level multi-focal (subarticular as well as far-lateral and/or paracentral) extruded disc herniations underwent single incision unilateral endoscopic disc excision by the same surgeon at a single institution. Patients were prospectively followed for an average of 15.3 months (range 14-18 months) and outcomes were evaluated radiographically and clinically (Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). The mean operative time was 52 minutes with minimal blood loss in all cases. Fourteen of the 15 patients were discharged to home on the day of their surgery. The mean ODI and leg VAS scores improved from 22.9 ± 3.2 to 12.9 ± 2.7 (p < 0.005), and from 8.6 ± 1.6 to 2.1 + 0.4 (p < 0.005), respectively. After an average of 15.3 months of follow-up, the clinical and radiographic results of full endoscopic surgical treatment of single level multi-focal (subarticular as well as far-lateral and/or paracentral) disc herniations are excellent. This study is a case series with mid-term follow-up (Level IV). Foraminal and extra-foraminal full endoscopic decompression appears to offer a safe minimally invasive solution to a complex pathologic problem.