Short Term Clinical Outcome of Micro Lumbar Discectomy in Tertiary Care Center

Background: Minimal invasive open lumbar microdiscectomy has been associated with good success rate and low morbidity. The present study is aimed to evaluate the clinical outcome of patients who underwent open minimal invasive open lumbar microdiscectomy for herniated intervertebral disc. Materials and Methods: This is a prospective observational hospital based study of prolapsed lumbar intervertebral disc operated in the department of neurosurgery at Nobel Medical College Teaching Hospital, Biratnagar, Nepal from January 2018 to June 2021. All patients of lumbar herniated intervertebral disc subjected for surgery were included. Recurrent prolapsed intervertebral disc, Disc surgery requiring stabilization was excluded from the study. During surgery types of prolapsed intervertebral disc, level and operative time were noted. In the post-operative period Visual Analogue Scale was used to assess the change in severity of pain. Duration of hospital stay and the complications occurred were also noted. Results: The mean age of the study population was was 41.50 (±14.56) years ranging from 20 years to 79 years. The commonest lumbar prolapsed intervertebral disc was at L4-L5 level. The mean operative time was 42 minutes excluding the time for anaesthesia preparation. There was statistically significant difference (p<0.001) in pre-operative and post-operative Visual Analogue Scale. Mean duration of hospital stay was 5.58 (1.87) days. Conclusion: A through workup and surgical planning is associated with better outcome avoiding complications in minimal invasive open micro lumbar discectomy.

Efficacy of manual therapy interventions in management of lumbar prolapsed intervertebral disc: A pilot randomized controlled trial

Background. This pilot trial reports the initial estimates of the efficacy of manual therapy interventions in lumbar prolapsed intervertebral disc and determines the feasibility and acceptability of full powered “randomized controlled trial” on efficacy of “spinal mobilization with leg movement (SMWLM)”, high velocity low amplitude thrust (HVLA) and neural mobilization (NM) in lumbar PIVD (Prolapsed Inter-Vertebral Disc) and pilot data will be used to perform sample size calculation for full trial. Material and methods. 48 subjects diagnosed lumbar PIVD were randomly distributed into 4 groups. The primary outcomes were feasibility, assessment procedure, retention rate, adherence and acceptability to the intervention. The secondary outcomes measures were pain, disability and straight leg raise (SLR) range of motion. Results. 90 subjects were screened based on selection criteria. Out of them, 50 (55.55%) were eligible. 48(96%) subjects accepted to participate in study. Baseline data of all the groups was similar but post-intervention score were significant when compared the data between the groups. Highest mean change for visual analog scale (VAS), oswestry disability index (ODI) and SLR were found in SMWLM group. No adverse effects were reported by subjects. Results also suggest that the outcome measures were feasible and acceptable and the treatment considered as the beneficial approach. Conclusions. Present study suggests that it is feasible and acceptable to do a fully powered “randomized controlled trial (RCT)” to evaluate the efficacy of manual therapy interventions in management of lumbar PIVD. This study also reveals that manual therapy interventions are effective in management of lumbar PIVD.

CASE REPORT: CLINICAL MANAGEMENT OF KATIGATVATA WSR TO PIVD

In India, nearly 80% of people have significant back pain due to lumbar pathology. In this case study patient’s main complaint was severe low backache, stiffness in the back due to which he was unable to do his routine activ- ities. He was diagnosed with Prolapsed intervertebral disc (PIVD) which can be correlated to katigatvata (low backache) which comes under vatavyadhi. Panchkarma therapies like katibasti and panchtikta ksheer basti in ka- la basti format are given with oral vatashamak medicines. In course of treatment satisfactory improvement was noted. Keywords: Katigatavata, Vatavyadhi, Katibasti, PTKB.

Effects of One-Fifth, One-Third, and One-Half of the Bodyweight Lumbar Traction on the Straight Leg Raise Test and Pain in Prolapsed Intervertebral Disc Patients: A Randomized Controlled Trial

The prolapsed intervertebral disc (PIVD) at the lumbar spine is one of the most common causes of low back pain (LBP) affecting humans worldwide. Lumbar traction is widely used as a part of physiotherapeutic modalities for its treatment; however, reports on its effectiveness and dosage are conflicting. This study is aimed at comparing the acute effects of three traction forces on the straight leg raise (SLR) test and LBP intensity. A total of 45 (age 35.53 yrs., ±3.09) participants with 15 participants in each group were recruited for the study. Participants were divided into groups A, B, and C wherein traction forces equal to one-fifth, one-third, and one-half of their bodyweight were applied, respectively. SLR range of motion (ROM) and pain were examined before and immediately after the application of traction. Significant improvement was observed in SLR ROM in all three groups ( p < 0.05 ). However, for pain, significant improvement ( p < 0.05 ) was observed only in the group with one-half of bodyweight force. There was no significant difference ( p > 0.05 ) between the three groups for both variables. All three forces were equally effective in immediately improving SLR ROM in patients suffering from lumbar PIVD; however, pain improvement was observed with one-half of bodyweight only.

Extradural Sacral Arachnoid Cyst - An Institutional Experience from Rajasthan, India

BACKGROUND Arachnoid cyst of spinal cord (ACS) is a very uncommon lesion of the spinal cord. The problem with these lesions is that they can stimulate the pain of prolapsed intervertebral disc pathology and patient may be misdiagnosed for the same. In this study we wanted to diagnose and establish a surgical treatment in such patients. METHODS This study is a case series and comprised of 12 patients which was conducted in Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, in which all patients having arachnoid cyst of spinal cord were operated and follow-up for reliving of symptoms or development of new symptoms. RESULTS Our study demonstrates that surgical result is good when spinal arachnoid cyst is better. All patients who underwent surgery were having significant improvement in symptoms and quality of life. CONCLUSIONS Surgical management is primary treatment modality in patients of arachnoid cyst of spinal cord and the results of surgery in such patients are good. KEYWORDS Spinal Arachnoid Cyst, Lumber Pain, Radiculopathy

Microdiscectomy compared with transforaminal epidural steroid injection for persistent radicular pain caused by prolapsed intervertebral disc: the NERVES RCT

Background Sciatica is a common condition reported to affect > 3% of the UK population at any time and is most often caused by a prolapsed intervertebral disc. Currently, there is no uniformly adopted treatment strategy. Invasive treatments, such as surgery (i.e. microdiscectomy) and transforaminal epidural steroid injection, are often reserved for failed conservative treatment. Objective To compare the clinical effectiveness and cost-effectiveness of microdiscectomy with transforaminal epidural steroid injection for the management of radicular pain secondary to lumbar prolapsed intervertebral disc for non-emergency presentation of sciatica of < 12 months’ duration. Interventions Patients were randomised to either (1) microdiscectomy or (2) transforaminal epidural steroid injection. Design A pragmatic, multicentre, randomised prospective trial comparing microdiscectomy with transforaminal epidural steroid injection for sciatica due to prolapsed intervertebral disc with < 1 year symptom duration. Setting NHS services providing secondary spinal surgical care within the UK. Participants A total of 163 participants (aged 16–65 years) were recruited from 11 UK NHS outpatient clinics. Main outcome measures The primary outcome was participant-completed Oswestry Disability Questionnaire score at 18 weeks post randomisation. Secondary outcomes were visual analogue scores for leg pain and back pain; modified Roland–Morris score (for sciatica), Core Outcome Measures Index score and participant satisfaction at 12-weekly intervals. Cost-effectiveness and quality of life were assessed using the EuroQol-5 Dimensions, five-level version; Hospital Episode Statistics data; medication usage; and self-reported cost data at 12-weekly intervals. Adverse event data were collected. The economic outcome was incremental cost per quality-adjusted life-year gained from the perspective of the NHS in England. Results Eighty-three participants were allocated to transforaminal epidural steroid injection and 80 participants were allocated to microdiscectomy, using an online randomisation system. At week 18, Oswestry Disability Questionnaire scores had decreased, relative to baseline, by 26.7 points in the microdiscectomy group and by 24.5 points in the transforaminal epidural steroid injection. The difference between the treatments was not statistically significant (estimated treatment effect –4.25 points, 95% confidence interval –11.09 to 2.59 points). Nor were there significant differences between treatments in any of the secondary outcomes: Oswestry Disability Questionnaire scores, visual analogue scores for leg pain and back pain, modified Roland–Morris score and Core Outcome Measures Index score up to 54 weeks. There were four (3.8%) serious adverse events in the microdiscectomy group, including one nerve palsy (foot drop), and none in the transforaminal epidural steroid injection group. Compared with transforaminal epidural steroid injection, microdiscectomy had an incremental cost-effectiveness ratio of £38,737 per quality-adjusted life-year gained and a probability of 0.17 of being cost-effective at a willingness to pay threshold of £20,000 per quality-adjusted life-year. Limitations Primary outcome data was invalid or incomplete for 24% of participants. Sensitivity analyses demonstrated robustness to assumptions made regarding missing data. Eighteen per cent of participants in the transforaminal epidural steroid injection group subsequently received microdiscectomy prior to their primary outcome assessment. Conclusions To the best of our knowledge, the NErve Root Block VErsus Surgery trial is the first trial to evaluate the comparative clinical effectiveness and cost-effectiveness of microdiscectomy and transforaminal epidural steroid injection. No statistically significant difference was found between the two treatments for the primary outcome. It is unlikely that microdiscectomy is cost-effective compared with transforaminal epidural steroid injection at a threshold of £20,000 per quality-adjusted life-year for sciatica secondary to prolapsed intervertebral disc. Future work These results will lead to further studies in the streamlining and earlier management of discogenic sciatica. Trial registration Current Controlled Trials ISRCTN04820368 and EudraCT 2014-002751-25. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 24. See the NIHR Journals Library website for further project information.

Quality of life after lumbar microsciopic discectomy

Introduction Lumbar disc herniation also known as prolapsed intervertebral disc is one of the well-known causes of low back pain. Among various modalities of treatment, surgery is often kept as the last resort when conservative treatment fails. Conventional surgical methods have been replaced by minimally invasive surgeries like microscopic, endoscopic and percutaneous lumbar discectomy in the hopes of decreasing post-operative pain. However, it is not uncommon for patient to have residual pain even after discectomy. Patients also complains of reduced quality of life (QOL). SF-36 is a standardized questionnaire for measuring QOL. Few studies have used this questionnaire to look into QOL of these patients but no such study is available in Nepalese perspective. Materials and Methods A prospective cross-sectional study was conducted among all patients undergoing single level unilateral microscopic lumbar discectomy in Upendra Devkota Memorial National Institute of Neurological Sciences from February 1st 2017 to January 31 2018. After taking informed consent, subjects were asked to respond to the preformed questionnaire and SF-36 survey. Interviews were individually conducted by the same investigator at two different time points: i) before lumbar discectomy. ii) 3 months after lumbar discectomy. QOL scores before and after were compared. Results Total of 50 patients meeting the inclusion criteria were studied. The mean age of the study group was 38.7 ± 9.9 years with male preponderance of 76%. The median duration of exacerbation of symptoms was 4 weeks. Along with pain, 64% had sensory deficit whereas 52% had motor deficit. Surgery led to significant improvement in pain score as well as marked improvement of SF 36 quality of life score at 3 months of surgery. However, age, gender, duration of symptoms or presence of sensory or motor deficit before surgery did not predict improvement in overall QOL. Conclusion Patients undergoing microscopic lumbar discectomy for prolapsed intervertebral disc have significant improvement in pain score and QOL after 3 months of surgery.

Spinal Epidural varicosity resembling prolapsed intervertebral disc on MRI: A diagnostic dilemma for lumbar canal stenosis

Sciatica is generally caused by such well-recognized entity as lumbar disc herniation in neurosurgical practice. However rare patholo­gies such as epidural varices may mimic them by causing radicular symptoms. In this case report, we present a 20-years-old man with the complaint of low back pain and bilateral sciatica (Lt>Rt) & neurogenic claudication who was operated for right L5–S1 disc herniation. The lesion interpreted as an extruded disc herniation pre­operatively on MRI but was found to be an epidural varix compressing the nerve roots intraoperatively. The varicosity of veins was found in epidural space causing canal stenosis.