Surgery for lumbar disc herniation: Analysis of 500 consecutive patients treated in an interdisciplinary spine centre

Highlights

• The clinical outcome after surgery for lumbar disc herniation with a microsurgical approach is similar to the open procedure.

• No differences regarding complications between a microdiscectomy versus open sequestrectomy and discectomy have been shown.

• These results strengthen the importance of an interdisciplinary training concept of spine surgeons in their residency.

Abstract

Surgical removal of a symptomatic herniated lumbar disc is performed either with or without the support of a microscope. Up to the time of writing, the literature has reported similar clinical outcomes for the two procedures. Five hundred consecutive patients, operated upon for primary single-level lumbar disc herniation in our University Spine Center between 2003–2011, with (n = 275), or without (n = 225), the aid of a microscope were included. Data were retrospectively analyzed, comparing the primary endpoint of clinical outcome and the secondary endpoints of complications, surgical time and length of hospitalization. Clinical outcomes and reoperation rates were comparable in both groups. Surgical time was significantly shorter with a mean time of 47 minutes without use of the microscope compared to the mean time of 87 minutes (p < 0.001) with the use of the microscope. Mean length of hospitalization was shorter in those operated with the microscope (5.3 days) compared to those without (6.1 days, p = 0.004). There was no difference in rates of complications. Microdiscectomy versus open sequestrectomy and discectomy for surgical treatment of lumbar disc herniation is associated with similar clinical outcomes and reoperation rates. Open sequestrectomy is associated with shorter operation times. Microdiscectomy is associated with shorter hospitalization stays.

Introduction

In 1934 Mixter and Barr first described herniated disc material as a cause of neural compression in the lumbar spine [1]. Initially, surgical removal was performed as an open procedure. In the 1970s the microscopic approach was introduced and a sequestrectomy alone was proven to show even better clinical outcomes compared to conventional disc removal on the supposition that it caused less surgical collateral tissue damage by removing only the damaged herniated part of the disc [2], [3], [4], [5], [6], [7]. The aim of this new approach was to achieve less postoperative low-back pain and prevent potential segmental instability caused by an aggressive discectomy.

Currently, open sequestrectomy and discectomy (OD) as well as sequestrectomy and discectomy with the aid of a microscope (MD) for lumbar disc herniation are both considered as well established treatment options for lumbar disc herniation in patients with sciatica. Large systematic reviews comparing both procedures have identified no differences in clinical outcomes. Additionally it has to be kept in mind that often these procedures are performed by residents under guidance of a board certified spine surgeon. The advantages of using a microscope for OD are better visualization of the deep surgical field and the anatomical structures in order to identify the cause of compression of the neural structures and to avoid nerve root damage. On the contrary OD without the aid of a microscope is reported to require less time and surgical equipment [4], [8]. With a complication rate for dural tears or wound infections between 1–5%, studies with several hundred patients are needed to show a statistical difference. Jacobs et al. recommended in his 2012 systematic review to perform such a study with several hundred patients [8]. Therefore, the purpose of this study was to compare clinical outcome, reoperation rate, surgical time and length of hospital stay postoperatively between lumbar disc herniation patients treated surgically with or without the use of the microscope.