General Session: Lumbar
Presented by: G. Edgard-rosa - View Audio/Video Presentation (Members Only)
G. Edgard-rosa(1), G. Geneste(1), T. Marnay(1)
(1) Clinique du Parc, Centre de Chirurgie Vertébrale, Castelnau le Lez, France
Introduction: Anterior lumbar disectomy with a total disc replacement (TDR) or interbody fusion (ALIF) is usually performed in patients suffering more from back pain than leg pain [VAS-B (back) > VAS-L (leg)]. Some of the patients in the VAS-B group, where anterior surgery would be indicated for their discogenic back pain, may also have concomitant disc herniation(s) that result in radicular symptoms that can often exceed the low back pain. It has not been determined whether these patients would benefit more from anterior surgery with decompression and TDR or ALIF, as opposed to performing a conventional posterior discectomy.
Materials and Methods: Between October 2011 and December 2013, 850 patients with chronic lumbar back pain underwent anterior surgery in our department, either undergoing a TDR, ALIF or both at one to four disc levels. All patients were followed prospectively evaluating clinical and radiographic parameters at 3, 6, 12 and 24 month intervals. In this current study, a group of patients with both a disc herniation at 1 or 2 levels and a VAS-L > VAS B were selected and were categorized as the Hernia group (n= 140). At surgery, these patients underwent a thorough anterior discectomy, resection of the posterior longitudinal ligament, and removal of any protruded/extruded disc material in the spinal canal. The postoperative clinical and radiolographic results in these patients were compared to a Control groupe (n= 614) consisting of patients that underwent the same anterior discectomy without posterior/posterlolateral herniation. The postoperative clinical outcome scores were assessed by auto-questionnaires. Standard radiographs and CT-scans were performed pre- and postoperatively and at last follow-up, with attention to specific measurements of the vertebral canal area.
Results: VAS-L, VAS-B and ODI scores were improved in both the Hernia and Control groups immediately postoperatively and at last follow-up; there were no statistical significant differences between the groups (p< 0.001). Preoperatively, the VAS-L score was the only parameter that had been higher in the Hernia group and the decrease in score (improvement) was significant (p< 0,001). At the last assessment, the average rate of satisfaction among all patients of the study was 8.4/10 and 91.8% said they would undergo a repeat operation if necessary, with no statistical difference between the groups. Radiographically, it was shown that the vertebral canal area at the operated disc level increased significantly after the surgery, indicationg that it is possible to decompress the nerves roots through an anterior approach to the lumbar spine.
Conclusion: In patients experiencing chronic discogenic lumbar back pain accompanied with a recent primary or recurrent disc herniation, disc replacement surgery combined with the decompression of the disc herniation is an effective treatment for relieving the discogenic lumbar back pain and pain of radicular origin. This procedure has been shown to be safe and successful with a very low rate of complications when performed by experienced spine surgeons.
Removal of disc material through anterior approach