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Study Design: Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample., Objective: To compare in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation at national level., Summary of Background Data: Surgical treatment for thoracic disc herniation can be largely divided into anterior and nonanterior approach procedures. An anterior approach necessitates invasion of the thoracic cavity, which may subject the patient to increased risk of certain complications. Large sample studies comparing anterior and nonanterior procedures in terms of morbidity and mortality are lacking., Methods: The Nationwide Inpatient Sample was used to identify patients who underwent surgical treatment for thoracic disc herniation from 2000 to 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes. Patients were then divided into those who underwent anterior approach procedures and those who received nonanterior approach procedures using the appropriate ICD-9 codes. Patient- and health care system-related demographic data were retrieved and analyzed., Results: There were 25,413 patients included in this study. Anterior approach procedures were associated with a significantly higher overall in-hospital complication rate (26.8% vs. 9.6%) and mortality rate (0.7% vs. 0.2%), as well as a longer hospital stay (7.6 vs. 4.8 d) and increased hospital charges ($84,199 vs. $46,837) compared with nonanterior approach procedures. Risk factors for mortality in surgical treatment for thoracic disc herniation included age 85 years or more, female sex, and the presence of complications (respiratory, cardiac, and urinary and renal)., Conclusion: Anterior approach procedures for thoracic disc herniation were associated with increased in-hospital morbidity and mortality rates, as well as increased health care burden, compared with nonanterior approach procedures. If thoracic disc herniation can be adequately excised by either approach, a nonanterior approach procedure may be a better option.

The objectives of this study were to examine charge data and long-term outcomes of two approaches for anterior lumbar interbody fusion: a mini-open lateral approach (extreme lateral interbody fusion, XLIF) and an open anterior approach (anterior lumbar interbody fusion, ALIF) through retrospective chart review. A total of 202 patients underwent surgery: 87 with ALIF (Open) and 115 with XLIF (Mini-open) procedures, all with transpedicular fixation. Complications occurred in 16.7% of Open, and 8.2% of Mini-open, procedures (p = 0.041). The mean charges ($US) for one-level Mini-open and Open procedures were $91,995 and $102,146, and for two-level procedures were $124,540 and $144,183, respectively. All differences were statistically significant (p < 0.05). This represents a 10% cost-savings, based on charges, for one-level and 13.6% for two-level Mini-open compared to Open procedures. Functional outcomes improved significantly at two years for both cohorts, although the difference between groups was not statistically significant. In conclusion, the Mini-open approach, compared to the Open, resulted in clinical as well as cost benefits with similar long-term outcomes., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

Total lumbar disc replacement (TDR) has been widely used as a treatment option for 2-level symptomatic degenerative disc disease. However, recent studies have presented conflicting results and some authors concluded that outcome deteriorated when disc replacement was performed bisegmentally, with an increase of complications for bisegmental replacements in comparison with monosegmental disc arthroplasty. The goal of the present retrospective study is to investigate results in a group of patients who have received bisegmental TDR with SB Charitè III artificial disc for degenerative disc disease with a minimum follow-up of 3 years, and to compare the results of 2-level disc replacement versus 1-level patients treated with the same prosthesis. A total of 32 patients had at least 3-years follow-up and were reviewed. The average age of the patients was 38.5 years. There were 11 males and 21 females. About 16 patients received 2-level TDR (SB Charitè III) and 16 received 1-level TDR (SB Charitè III). Both radiographic and functional outcome analysis, including patient's satisfaction, was performed. There were no signs of degenerative changes of the adjacent segments in any case of the 2- or 1-level TDR. There was no statistically significant difference between 2- and 1-level TDR both at 12 months and at 3-years follow-up on functional outcome scores. There was a statistically insignificant difference concerning the patients satisfaction between 1- and 2-level surgeries at the last follow-up (P = 0.46). In the 2-level TDR patients, there were 5 minor complications (31.25%), whereas major complications occurred in 4 more patients (25%) and required a new surgery in 2 cases (12.5%). In the 1-level cases there were 2 minor complications (12.5%) and 2 major complications (12.5%) and a new revision surgery was required in 1 patient (6.25%). In conclusion, the use of 2-level disc replacement at last follow-up presented a higher incidence of complications than in cases with 1-level replacement. At the same time it was impossible to delineate a clear difference in evaluating the questionnaires between the follow-up results of patients receiving 2- and 1-level TDR: the 2-level group presented slightly lower scores at follow-up, but none was statistically significant.

A prospective randomised 2-year follow-up study on patients undergoing lumbar disc herniation surgery. The objective was to investigate the relationship between peridural scarring and clinical outcome, the scar development 6 and 24 months postoperatively by using MRI, and if ADCON-L (a bioresorbable carbohydrate polymer gel) has an effect on scar size and/or improve patients' outcome after lumbar disc herniation surgery. The association between peridural scarring and recurrent pain after lumbar disc herniation surgery is debated. Numerous materials have been used in attempts to prevent or reduce postoperative peridural scarring; however, there are conflicting data regarding the clinical effects. The study included 119 patients whose mean age was 39 years (18-66); 51 (47%) were women. Sixty patients (56%) were perioperatively randomised to receive ADCON-L, and 48 (44%) served as controls. All patients underwent MRI at 6 and 24 months postoperatively, and an independent radiologist graded the size, location and development of the scar, by using a previously described scoring system. Pre- and 2-year postoperatively patients graded their leg pain on a visual analogue scale (VAS). At the 2-year follow-up patients rated their satisfaction with treatment (subjective outcome) and were evaluated by an independent neurologist (objective outcome), using MacNab score. There was no relationship between size or localisation of the scar and any of the clinical outcomes (VAS, subjective and objective outcome). The scar size decreased between 6 and 24 months in 49%, was unchanged in 42% and increased in 9% of the patients. Patients treated with ADCON-L did not demonstrate any adverse effects, nor did they demonstrate less scarring or better clinical outcome than control patients. No significant association between the presence of extensive peridural scar or localisation of scar formation and clinical outcome could be detected in the present study. Further, no positive or negative effects of ADCON-L used in disc herniation surgery could be seen.

Study Design: Retrospective follow-up study of patients undergoing multiple (two or more) reoperations after initial lumbar discectomy using an administrative database., Objectives: To identify the population-based risk of multiple reoperations after lumbar discectomy and to analyze factors associated with the risk., Summary of Background Data: Although multiple reoperations after initial lumbar discectomy are likely uncommon, research to better understand reasons for and outcomes of reoperations is needed because of the large number of discectomies performed., Methods: Data on all lumbar spine operations during 1987-1998 were obtained from the Finnish Hospital Discharge Register. The patient's initial disc operation during the study period was linked to subsequent operations, and patients with two or more reoperations were analyzed further. The risk of multiple reoperations was determined using the methods of event history analysis., Results: Among 35,309 patients undergoing an initial discectomy, 4943 (14.0%) had at least one reoperation and 803 (2.3%) had two or more reoperations. A total of 63% of the second reoperations were discectomies, 14% were fusions, and the remaining 23% were decompressions. Patients with one reoperation after lumbar discectomy had a 25.1% cumulative risk of further spinal surgery in a 10-year follow-up. Reduced risk was seen when the first reoperation took place more than 1 year after the initial discectomy (relative risk 0.83, 95% confidence interval 0.72-0.96), in patients for whom the first reoperation had been a fusion (relative risk 0.27, 95% confidence interval 0.12-0.61), and in patients 50-64 years of age (relative risk 0.62, 95% confidence interval 0.48-0.79)., Conclusion: Patients with one reoperation after lumbar discectomy are at considerable risk of further spinal surgery.

In this article the author reviews outcomes of thoracic disc surgery reported in the literature. Care was taken to include only series in which none or a few patients underwent laminectomy for the treatment of thoracic disc lesions. The author found that thoracic discectomy may be performed in an efficacious and safe manner via the transthoracic, lateral extracavitary, transpedicular, or endoscopic approach. In the vast majority of patients, preoperative symptoms of pain (radiculopathy or axial loading pain) and myelopathy were improved after surgery. Measurements of operative time, blood loss, length of hospital stay, and patient satisfaction were often inadequately reported. Complications (systemic and neurological) were well documented and were not common. A plea is made for uniformity in documenting outcome in future series so that today's procedures for thoracic discectomy may be more accurately compared with future cases regardless of the inevitable advances in surgical techniques for removal of thoracic discs.

Background: Thoracic discectomy has evolved over the last 60 years from resection through standard laminectomy, to posterolateral procedures to open thoracotomy and finally thoracoscopy. Comparison of relative morbidity and mortality between these approaches is now possible., Methods: Peer-reviewed publications reporting clinical data relating to thoracic discectomy, and which provided sufficient information to enable adequate assessment of mortality and morbidity were reviewed. These articles were determined via review of the results of MedLine searches and articles gathered through compilation of references from those articles., Results: Articles reviewed spanned a period of over 60 years. Surgical procedures used for thoracic discectomy included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, anterolateral thoracotomy, and thoracoscopy. Complications included death, paralysis, paresis, loss of bowel and/or bladder control, pulmonary embolism, pneumonia, atelectasis, compression fracture, infection, pleural tear, bowel obstruction, and anesthesia dolorosa. Mortality dropped to nearly zero after development of anterior and posterolateral approaches. Morbidity seems relatively similar between most procedures other than laminectomy. Not enough procedures have been reported using thoracoscopy to adequately assess its morbidity., Conclusion: Comparison of relative rates of morbidity and mortality between surgical approaches to thoracic discectomy suggest that laminectomy does not provide adequate access for the safe removal of these lesions. Choice of approach among the alternatives should be based on the evacuation of the herniated fragment and experience of the surgeon. Thoracoscopy, although promising, has not had sufficient time for evaluation of morbidity to make definite statements regarding its safety.

Symptomatic perforation of the anterior annulus fibrosus/anterior longitudinal ligament during surgery for herniated lumbar disc disease is one of the more solemn and sobering complications experienced by neurosurgeons or orthopedic surgeons. This complication frequently results in the death of the patient. Its occurrence is probably more common than the medical community would expect. The authors report 21 cases since 1985 in which an injury to an intra-abdominal vessel or viscera occurred. In all cases litigation resulted and a settlement or verdict was rendered. A review of the literature is presented and the medicolegal implications of symptomatic ventral perforations of the annulus fibrosus/anterior longitudinal ligament are discussed.