Lumbar discectomy
Lumbar discectomy is one of the most common spinal surgery worldwide.
The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction in open lumbar discectomy are being replaced by muscle-sparing, targeted, stability-preserving surgical routes. The increasing speculation on lumbar disc herniation and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results.
Through the analysis of papers by Lofrese et al. it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation.
The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions. 1).
Classification
Indications
Lumbar discectomy is an effective therapy for neurological decompression in patients suffering from lumbar disc herniation, which can be safely performed via minimal invasive procedures 2) 3).
Technique
History
In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in The New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined.
Outcome
Complications
Postoperative recommendations
The literature concerning postoperative recommendations on patients' return to work is sparse. The aim of this study is to assess spine surgeons' consensus regarding postoperative recommendations, including return to work, restart of daily-living activities, analgesic medication usage and rehabilitation referral.
Methods: An online GoogleForms survey was sent, via electronic mail, during January 2022, to 243 surgeons described as having expertise in spine surgery, using the dissemination means of Sociedade Portuguesa de Patologia da Coluna Vertebral and Sociedade Portuguesa de Neurocirurgia. Participants (n = 59) had predominantly hybrid clinical practice in Neurosurgery field.
Results: Only in a minority of cases (1.7%) no recommendation was given to patients. Nearly 68% of participants advised patients to return to sedentary professional work up until the 4th postoperative week. Light and heavy workload workers were advised to wait longer until initiating work activity. Low mechanical impact activities are started up to 4 weeks, and higher stress activities should be further postponed. Half of the surveyed surgeons estimates to refer to rehabilitation 10% or more patients. No differences were found when comparing recommendations given by more and less experienced surgeons-as defined by number of years in practice and number of annual surgeries-for most activities.
Conclusion: Despite not having clear guidelines in postoperative management of surgically treated patients, Portuguese practice is in line with international experience and literature 4).