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Effectiveness of open discectomy for IVDP--a prospective study.

INTRODUCTION: In industrialized countries, approximately 50-80% of the adult population has low back pain at sometimes in their lives. There are various causes for low back pain like injury to the supporting paraspinal muscles, ligaments, facet joint cartilage, vertebral bones and compression of neuronal structures due to herniated nucleus pulposus of lumbar disc (1), out of which the lumbar disc herniation is one of the most frequent reason for physical, functional restriction in patients (2). Impairments of the back and spine are ranked as the most frequent cause of limitation of activity in people younger than 45 years as mentioned by the National centre for Health Statistics (3). Patients with symptoms that persist beyond six weeks and when there is a demonstratable MRI disc pathology are candidates for surgical removal. (4) The Oswestry Disability Index (5) helps to find out disease specific disability and studies support that ODI score was the better determinant of post operative functional outcome. (6)

METHODOLOGY: The present study includes 30 cases of lumbar disc prolapse treated during the period of May 2011 to September 2013 in KIMS hospital, Bangalore. The patients underwent radiological investigations (MRI) to confirm the diagnosis and to know the level of lesions.

The study was carried out on the patients with ODI score more than 40% (severe disability) and having the age of above 18 years and admitted in the orthopedic wards. All patients were treated surgically by open discectomy.

Inclusion Criteria:

* Un-relieved pain radiating along the course of the nerve in the lower-limb respectively,

* Nerve tension signs-positive

* Associated neurological deficits.

Exclusion criteria:

Age less than 18 yrs.

1. Thoraco--lumbar injuries.

2. Lumbar--canal stenosis.

3. Spondylolisthesis.

4. Fail back syndrome.

5. Medically unfit for surgery.

6. Peripheral neuropathy.

7. Infective conditions.

8. Tumors (neoplastic) lesion.

Collection of data: After the detailed history and clinical examination, based on selection criteria, on 30 patients, ODI was administered and the MRI was screened for conclusive disc prolapse.

Sample procedure: prospective study: Patients with signs and symptoms of disc prolapse, ODI >40%, MRI showing conclusive disc prolapse and who come under the inclusion criteria were selected and admitted.

1. Investigations required for surgery was done.

2. A pre anaesthetic evaluation was carried out.

3. Pre operative preparations were made and informed written consent was taken.

4. Methods such as fenestration, extended fenestration, hemi laminectomy, total laminectomy was chosen according to the per-operative requirement for discectomy.

5. Follow ups--6, 12 and 24 weeks.

RESULTS: The descriptive statistics of frequency and percentage were used for analyzing the sociodemographic data such as gender, age, occupation, symptoms, nerve tension signs, surgical approaches, complications, etc. The inferential statistics 't' test was used to compare pre and post operative total ODI score and also the 10 sub scale scores of ODI.

The above table no:01 indicated that 43.34 percent(n=13) of the patients were between the age group of 31-40 years, 30 percent of the patients fall in the category of above 50 years. Another 13.33 percent of the patients respectively belong to the age group of 18 to 30 years and 41 to 50 years.

The study revealed that majority of the patients (43.34 %) fall in the age group of 31 to 40 years. Mean age: 43.3 years.

Data compiled from the patients at KIMS, Bangalore

The above table no: 02 highlighted the occupation of the study subjects. Out of total number of the subjects 36.67 percent (n=11) were Agriculturists, 26.6 percent (n=8) were house wives, 16.67percent (n=5) were coolies, 10 percent (n=3) were Merchants, another 3.33 percent (n=1) were respectively Clerks, Students, Mechanics.

The studies revealed that majority (36.67 percent) of the patients were agriculturists.

Data compiled from the patients at KIMS, Bangalore

The above table no:03 indicates that majority 100%(n=30) had lower backache and radicular pain among them 23.3%(n=7) had paraesthesia, 20%(n=6)had weakness, 40%(n=12)had sensory loss and none had bladder bowel involvement.

The study revealed that majority 100 %( n=30) had low backache and radicular pain.

The above table no: 04 revealed that 90 percent (n=27) of the patients had positive SLRT. Another 83.3 percent (n=25) of the patients had positive lasegues test.

Data compiled from the patients at KIMS, Bangalore

The study revealed that majority (90 percent) of the patients had positive SLRT.

The above table No:05 depicts that majority 80%(n=24) had a presentation of para central type and others had 10%(n=3) foraminal type, 6.6%(n=2) far lateral and 3.4%(n=1) central. The study revealed that majority 80% (n=24) had a presentation of para central type.

The above table No: 06 reveals that majority 70% (n=21) of the patients underwent fenestration, 20% (n=6) patients underwent extended fenestration, 6.6% (n-2) of patients underwent hemi laminectomy and 3.4% (n=3.4) of patients underwent partial laminectomy. The study revealed that majority 70% (n=21) of the patients underwent fenestration.

Data compiled from the patients at KIMS, Bangalore

The above said table no: 07 depict that 93.3 percent (n=28) of the patients did not had the post operative complications after the surgery. Only 6.7 percent (n=2) of the patients had the postoperative complication as a Dural Puncture.

The study revealed that majority (93.3 Percent) of the patients did not develop any complication after the surgery.

The table no: 08 explains that 70 percent (n=21) of the study subjects showed excellent improvement after the surgical treatment, another 23.33 percent (n=7) of them showed good improvement and only 6.7 percent (n=2) of them showed poor improvement after the surgical treatment.

The study revealed that majority 70percent of the patients showed excellent result after the surgical treatment.

The table no: 09 and Table No. 10 show that total and subscales mean scores obtained on ODI scale among the study subjects. The pre operative total mean score was 58.28 [+ or -] 5.06 and post operative total mean score was 15.38 [+ or -] 2.40. The comparison of the pre and post-operative total mean score was done with paired t test (38.56). The P Value showed P-<0.001. Similar findings were seen in all the 10 sub scales where post operative mean scores were lesser than the pre-operative ODI scores The p value suggest that there is a significant improvement of functional outcome between pre operative and post operative level of function.

DISCUSSION: Lumbar disc prolapse is an important cause for backache. It is the most prominent problem in the 3rd and 4th decades of life. IVDP at Lumbar region is a major contributor of functional disability. Open disectomy (Fenestration) is found to be the most appropriate operative intervention in patients with lumbar intervertebral disc prolapse. Hence, in the present study an attempt is made to evaluate the effectiveness of the open discectomy by comparing the pre-operative ODI score with post-operative ODI score as well as finding out the complications following the open disectomy for IVDP.

Patients with IVDP who have para central type herniation are treated well with open disectomy using Fenestration. It is the surgical approach performed on the majority of the patients (70%) in the present study (Table 6). Complications after open discectomy in the present study was dural tear (6.6%) (Table 7) correlates well with the study by Richard Davis (7) (4.2%) and study by Sangwan et al (7) (3.9%). Open disc excision under direct vision offers sufficient adequate exposure for lumbar disc excision with smaller incision, lesser morbidity, shorter convalescence and hence, the lesser complications rates.

The treatment outcome of the present study Table 8 shows 70% of the patients, excellent result in, after the open discectomy. This finding correlates well with the figures of studies by Pappes et al (8) (77.6%) and with that of studies by Richard Davis (89%) (9)

The functional outcome after open discectomy by fenestration is compared between Pre operative ODI score, (Mean 58.28 with standard deviation of 5.06) and post operative ODI score (Mean 15.38 with standard deviation of 2.40), there was a significant reduction in the ODI score (Table 9), and also in all 10 sub-scales (Table 10). This finding correlates well with the study of Chen et al (10), where pre operative ODI mean score was 57.43 and it came down to Post operative mean score of 11.52 showing excellent improvement in the function outcome.

CONCLUSION: The results demonstrated that, the procedure of open discectomy (fenestration) for lumbar intervertebral disc prolapse in relieving symptoms and restoring the function of patients is excellent.

* Open discectomy by fenestration is an easy procedure, economical, with least complication and the most effective means of treating lumbar disc prolapse.

* Standard open discectomy is still the "gold standard" in operative treatment of lumbar disc prolapse.

DOI: 10.14260/jemds/2014/1990

BIBLIOGRAPHY:

(1.) Bruce Carl Anderson. Lumbosacral Spine, Chapter-9. Office Orthopaedic for Primary Care: Diagnosis. Elsevier Health Science, 3rd edition-2005:150.

(2.) Figen Yilmaz, Adem Yilmaz, Funda Merdol, Demet Parlar, Fusun Sahin and Banu Kuran. Efficacy of Dynamic Lumbar Stabilization Exercise in Lumbar Microdiscectomy. Journal of Rehabilitation Medicine 2003; 35:163-7.

(3.) Wood, George W. Lower back pain and disorders of intervertebral disc. Chapter 39, Campbell's Operative orthopaedics, Vol. II. 10th Edn, Edt, Canale S. Terry, Missouri, Mosby, 2003:1955-2029.

(4.) Andrew J. Schoenfeld and Bradley K Weiner. Treatment of lumbar disc herniation: Evidence-based practice. Available from: http://www.nchi.nlm.nih.gov/pmc/articles/PMC2915533.

(5.) Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980; 66(8): 271-3.

(6.) Puolakka, K, Ylinen J, Neva M.H, Kautiainen H, Hakkinen A. Risk factors for back pain-related loss of working time after surgery for lumbar disc herniation: a 5-year follow-up study. European Spine Journal. 2008; 17(3):386-92.

(7.) Sangwan SS, Kundu ZS, Raj Singh, Kamboj P, Siwach RC, Aggarwal. Lumbar disc excision through fenestration. Indian Journal of Orthopaedics. 2006; 40:86-89.

(8.) Pappes CT. Harrington T, Sonntag VK. Outcome analysis in 645 surgically treated lumber disc herniation, Neurosurgery 1993; 32(5): 879.

(9.) Davis RA. A long term outcome analysis of 984 surgically treated herniated lumbar discs. Journal of Neurosurgery 1994; 80(3):415-21

(10.) Chen HT, Tsai CH, Chao SC, Kao TH, Chen YJ, Hsu HC, Shen CC, Tsou HK. Endoscopic discectomy of L5-S1 disc herniation via an interlaminar approach: Prospective controlled study under local and general anaesthesia. Surgical Neurology International, 2011:2:93.

Ranganath H. D [1], J. N. Sridhara Murthy [2], M. Prabu [3]

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Orthopaedics, Kempegowda Institute of Medical Sciences.

[2.] Professor and HOD, Department of Orthopaedics, Kempegowda Institute of Medical Sciences.

[3.] Final Year M.S. (Ortho) Student, Department of Orthopaedics, Kempegowda Institute of Medical Sciences.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Ranganath H.D, #1072, 11th Main, 2nd Stage, WOC Road, Mahalakshmipuram, Bangalore-86.

Email-ranganath.kims@gmail.com

Date of Submission: 07/12/2013.

Date of Peer Review: 08/12/2013.

Date of Acceptance: 18/12/2013.

Date of Publishing: 04/02/2014
Table 1: Distribution of the study subjects based on the gender and age

S. No    Gender     Above 18 years    31-40    41-50
                   & upto 30 years    Years    Years

1         Male            03            09       04
2        Female           01            04       00
     Total                04            13       04
   percentage           13.33         43.34    13.33

S. No    Gender      Above      Total    percentage
                   50 years

1         Male        05         21          70%
2        Female       04         09          30%
     Total            09         30        100.00
   percentage        30.00     100.00

n=30

Data compiled from the patients at KIMS, Bangalore

Table 2: Distribution of the study subjects based on the Occupation

S.No    occupation     Number of    Percentage of
                        Patients     the patients

1       Agriculture        11           36.67
2       Housewife          8            26.67
3       Coolie             5            16.67
4       Clerk              1            03.33
5       Merchant           3            10.00
6       Student            1            03.33
7       Mechanic           1            03.33
        Total              30           100.00

n=30

Data compiled from the patients at KIMS, Bangalore

Table 3: Distribution of the study subjects based on the Symptoms

S.No        Symptoms       Number of patients      %

1       Low Back ache              30             100
2       Radicular pain             30             100
3       Paraesthesias              07            23.33
4       Weakness                   06            20.00
5       Sensory Loss               12            40.00
6       B/B Involvement             0              0

n=30

Data compiled from the patients at KIMS, Bangalore

Table 4: Distribution of the study subjects based on Nerve Tension
Signs

S.No    Nerve tension signs   Number of patients     %
                                    (n=30)

1              SLRT                   27            90
2          Lasegues test              25           83.3

n=30

Data compiled from the patients at KIMS, Bangalore

Table 5: Distribution of the study subjects based on the quadrants of
IVDP

S.NO    QUADRENTS OF IVDP    NUMBER      %

1            Central            1       3.4
2          Para central        24       80
3           Foraminal           3       10
4          Far lateral          2       6.6

Table 6: Distribution of the study subjects based on the approach.

S. No    Approaches               Patients     %

1        Fenestration                21        70
2        Extended fenestration        6        20
3        Partial laminectomy          1       3.4
4        Hemi laminectomy             2       6.6

Table 7: Distribution of the study subjects based on the Complications

S.No              Complications            Number of patients     %

1                     Absent                       28           93.3
2         Present & Dural Puncture (DP)            2             6.7
                      Total                        30            100

(n=30)

Data compiled from the patients at KIMS, Bangalore

Table 8: Distribution of Results of the Surgical Treatment

S. No     Results     Number of patients       %
                            (n=30)
1        Fair                 02             06.67
2        Good                 07             23.33
3        Excellent            21             70.00
Total                         30            100.00

Table 9: Comparison of pre-operative and post-operative ODI score

ODI       N        Pre -Op           Post -Op
Score
                Mean      SD      Mean      SD       t      P Value

         30    58.28     5.06    15.38     2.40    38.56    .000 *

* Significant at p < 0.001

Table 10: Comparison of pre -operative and post operative ODI Sub
scale score

                          Pre -Op
Section
                    n     Mean     SD

Pain intensity     30     3.00     .27
Personal care      30     3.13     .35
Lifting            30      3.1     .48
Walking            30     3.03     .62
Sitting            30     3.47     .82
Standing           30     1.80    1.16
Sleeping           30     2.97     .72
Sex life           30     2.53    1.04
Social Life        30     3.23     .77
Traveling          30     2.96     .81

                              Post -Op
Section
                  Mean     SD        t      P Value

Pain intensity     .79     .41    28.828    .000 *
Personal care      .93     .69    15.832    .000 *
Lifting            .60     .62    16.699    .000 *
Walking            .70     .60    13.857    .000 *
Sitting            .66     .71    12.930    .000 *
Standing           .56     .63     5.401    .000 *
Sleeping           .86     .73    11.562    .000 *
Sex life           .80     .76     8.308    .000 *
Social Life        .96     .72    13.145    .000 *
Traveling          .86     .63    13.001    .000 *

* Significant at p < 0.001
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Title Annotation:ORIGINAL ARTICLE
Author:D., Ranganath, H.; Murthy, J.N. Sridhara; Prabu, M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Feb 10, 2014
Words:2479
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