Surgical Treatment and Outcomes of Lumbar Radiculopathy

Pathophysiology of radiculopathy

To justify surgery for radiculopathy, one must prove that surgery actually relieves the cause of the radiculopathy. Although the causes of radiculopathy are not fully understood, Olmarker and colleagues performed a series of studies on pigs that provide some answers. It is useful to divide those causes of radiculopathy into 2 main categories: mechanical and chemical.

Natural history of the herniated lumbar disk

To fully understand the benefits of surgery, the natural history of untreated lumbar disk herniations must be established as a benchmark. Bozzao and colleagues³³ demonstrated a reduction in size of disk herniation of at least 30% in 63% of patients. Clinical symptoms worsened in only 8% in that study. Saal and Saal³⁴ performed a retrospective cohort study on 64 patients, and their patient series had 90% good-to-excellent outcomes and 92% return-to-work status. Both studies suffer from small

Surgical options

Since 1939, many approaches to lumbar diskectomy have been described (Fig. 1). Three techniques encompass most of the surgical approaches used in practice today. Each has advantages and disadvantages, and studies have been done over the last decade to compare the outcomes and complications of these techniques.

Indications for surgical intervention

The indications for lumbar diskectomy are widely debated. Only one absolute indication for surgery exists, and that is in a patient with a documented progressive neurologic deficit. This group of patients represents a small minority of operative candidates. An ideal operative candidate is one who has failed a reasonable conservative management program and has a clinical examination that correlates with radiologic findings. Specifically, the disk herniation should be on the ipsilateral side of

Complications

All procedures carry risks, lumbar diskectomies being no different, whether they are done open or under a microscope. Dural tears are one of the more common complications,⁴⁶ particularly early in a surgeon’s career. In the SPORT study,¹⁸ dural tears were reported in 3% to 4% of cases. All their cases were done through open diskectomy. One study compared outcomes in surgeons based on their experience, finding surgeons with the least experience (50–100 prior cases) had durotomies in 7% of their

Outcomes trials

The case for surgical management of lumbar radiculopathy secondary to lumbar disk herniation has been debated for decades. Many studies have attempted to provide clinicians with data that can assist in decision making. Despite countless hours of research and a seemingly endless number of articles in the scientific literature regarding lumbar disk herniation, there is still no clear answer on who best benefits from lumbar diskectomy. There are 2 landmark prospective studies that have

Outcomes and specific groups

The 3 studies discussed earlier have established that surgical treatment of sciatica due to lumbar disk herniation has some significant benefit, at least in the short term. Another question that must be answered is which populations benefit the most or least from surgical intervention. Many variables have been studied, but a few stand out in the literature and help to guide surgeons in directing their patients.

One main concern in a patient’s history is the presence of a worker’s compensation

Cauda equina syndrome

In the same paper that described a transdural approach to lumbar disk herniations, Mixter and Barr also provided the first description of cauda equina syndrome.1, 66 Unlike in other lumbar disk herniations in which a trial of nonoperative management is appropriate and the indications for surgery are unclear, herniations associated with cauda equina syndrome are surgical urgencies.

Summary

More than 75 years have passed since Mixter and Barr described surgical intervention for lumbar disk herniation. Although many questions have been answered regarding the surgical management of lumbar disk herniation, great debate still exists on which treatment provides the best outcomes. Surgical intervention seems to provide better outcomes when compared with nonsurgical management in patients with correlating radiologic and clinical findings who have failed an appropriate 4- to 6-week