Long-term back pain after a single-level discectomy for radiculopathy: Incidence and health care cost analysis - Clinical article

The Johns Hopkins Spinal Column Biomechanics and Surgical Outcomes Laboratory, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Journal of neurosurgery. Spine (Impact Factor: 2.38). 02/2010; 12(2):178-82. DOI: 10.3171/2009.9.SPINE09410
Source: PubMed


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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    • "Although removal of pathologic IVD fragments during discectomy alleviates radicular symptoms, the remaining tissue and enlarged hole in the annulus fibrosus (AF) may promote or accelerate degenerative changes resulting in long-term clinical problems [8] [9] [11]. Imaging studies suggest that degenerative changes such as loss of IVD height, facet joint arthritis, and end-plate changes are likely to occur within months after discectomy [12], and these changes are significantly associated with functional disability and low back pain [8] [9] [10]. The concept of accelerated degeneration after injury is also supported by in vivo studies where experimentally induced annular puncture leads to significant changes in the biomechanical properties of IVDs [13] [14] [15] resulting in decreased glycosaminoglycan content and increased expression of catabolic and inflammatory mediators [16] [17]. "
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    ABSTRACT: Lumbar discectomies are common surgical interventions that treat radiculopathy by removing herniated and loose intervertebral disc (IVD) tissues. However, remaining IVD tissue can continue to degenerate resulting in long-term clinical problems. Little information is available on the effects of discectomy on IVD biology. Currently no treatments exist that can suspend or reverse the degeneration of the remaining IVD. To improve knowledge how discectomy procedures influence IVD physiology and to assess the potential of growth-factor treatment as an augmentation during surgery STUDY DESIGN: To determine effects of discectomy on IVDs with and without TGFβ3 augmentation using bovine IVD organ culture. This study determined effects of discectomy with and without TGFβ3 injection using 1, 6, and 19 days organ culture experiments. Treated IVDs were injected with 0.2μg TGFβ3 in 20μl PBS+BSA into several locations of the discectomy site. Cell viability, gene expression, nitric-oxide release, IVD height, aggrecan degradation, and proteoglycan content were determined. Discectomy significantly increased cell death, aggrecan degradation and nitric-oxide release in healthy IVDs. TGFβ3 injection treatment prevented or mitigated those effects for the 19 days culture period. Discectomy procedures induced cell death, catabolism and nitric-oxide production in healthy IVDs, and we conclude that post-discectomy degeneration is likely to be associated with cell death and matrix degradation. TGFβ3 injection augmented discectomy procedures by acting to protect IVD tissues by maintaining cell viability, limiting matrix degradation and suppressing nitric-oxide. We conclude that discectomy procedures can be improved with injectable therapies at the time of surgery although further in vivo and human studies are required.
    Full-text · Article · Apr 2014 · The spine journal: official journal of the North American Spine Society
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    • "In the U.S., Medicare spending (in 2003) on discectomy/laminectomy surgeries exceeded 300 million dollars [1]. However, long-term surgical outcomes for more than one third of the patients undergoing discectomy were not satisfactory and more than one quarter continue to have significant residual pain after surgery [2,3]. Additionally, reoperation rates after lumbar discectomy range from 9% to 25% [3-5]. "
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    ABSTRACT: Lumbar Disc Herniation (LDH) surgery is usually recommended when conservative treatments fail to manage patient's symptoms. However, many patients undergoing LDH surgery continue to report pain and disability. Preoperative psychological factors have shown to be predictive for postoperative outcomes. Our aim was to systematically review studies that prospectively looked at the prognostic value of factors in the Fear Avoidance Model (FAM), including back pain, leg pain, catastrophizing, anxiety, fear-avoidance, depression, physical activity and disability, to predict postoperative outcomes in patients undergoing LDH surgery. We performed a systematic literature review of prospective studies that measured any FAM factors preoperatively to predict postoperative outcomes for patients undergoing LDH surgery. Our search databases included PubMed, CINAHL, and PsycINFO. We assessed the quality of each included study using a certain quality assessment list. Degree of agreement between reviewers on quality assessment was assessed. Results related to FAM factors in the included studies were summarized. Thirteen prospective studies met our inclusion criteria. Most studies were considered high quality. Heterogeneity was present between the included studies in many aspects. Several studies included baseline pain, disability and depression FAM factors. In, general, depression, fear-avoidance behaviors, passive pain coping, and anxiety FAM factors seem to have negative influence on LDH surgical outcome. Baseline back pain and leg pain appear to have a different prognostic value on the LDH surgical outcomes. FAM factors seem to influence LDH surgical outcomes. Patients with high levels of depression, anxiety and fear-avoidance behaviors are more likely to have poor LDH outcomes. On the other hand, high levels of leg pain, but not back pain seem to be predictor for favorable LDH surgery outcome. More research is needed to determine the exact role of each FAM factor on LDH surgical outcome and the value for screening of these factors.
    Full-text · Article · Nov 2013 · Chiropractic and Manual Therapies
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    • "There are two specific clinical situations for which the impaired function of the AF plays a crucial role: as the source of discogenic low back pain (LBP) and, in the case of insufficiency, as the origin of disc herniation. Both conditions are very common and have an enormous socio-economic impact with no established satisfactory treatment options to date (Gore et al., 2012; Mehra et al., 2012; Parker et al., 2010; Weinstein et al., 2006a; Weber, 1994). "
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    ABSTRACT: Lumbar discectomy is the surgical procedure most frequently performed for patients suffering from low back pain and sciatica. Disc herniation as a consequence of degenerative or traumatic processes is commonly encountered as the underlying cause for the painful condition. While discectomy provides favourable outcome in a majority of cases, there are conditions where unmet requirements exist in terms of treatment, such as large disc protrusions with minimal disc degeneration; in these cases, the high rate of recurrent disc herniation after discectomy is a prevalent problem. An effective biological annular repair could improve the surgical outcome in patients with contained disc herniations but otherwise minor degenerative changes. An attractive approach is a tissue-engineered implant that will enable/stimulate the repair of the ruptured annulus. The strategy is to develop three-dimensional scaffolds and activate them by seeding cells or by incorporating molecular signals that enable new matrix synthesis at the defect site, while the biomaterial provides immediate closure of the defect and maintains the mechanical properties of the disc. This review is structured into (1) introduction, (2) clinical problems, current treatment options and needs, (3) biomechanical demands, (4) cellular and extracellular components, (5) biomaterials for delivery, scaffolding and support, (6) pre-clinical models for evaluation of newly developed cell- and material-based therapies, and (7) conclusions. This article highlights that an interdisciplinary approach is necessary for successful development of new clinical methods for annulus fibrosus repair. This will benefit from a close collaboration between research groups with expertise in all areas addressed in this review.
    Full-text · Article · Jan 2013 · European cells & materials
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