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MICRODISCECTOMY REDUCES LOW BACK PAIN IN LUMBAR HERNIATED DISC PATIENTS

Received on 11 May 2016

Abstract

Objective: It is estimated that approximately 80% of the population will suffer from low back pain, which may be caused by lumbar disc herniation, impairing the quality of life of patients. Surgical intervention may be necessary in some cases when conventional treatment fails. Thus, we aim to assess quality of life and the low back pain score in patients who underwent surgical treatment for lumbar herniated disc through microdiscectomy. Methods: Prospective and comparative study in which we compared the results of questionnaires for quality of life (SF-36) and low back pain (Roland Morris) in patients during pre- and postoperative microdiscectomy, through Student’s t-test, p Results: We evaluated 25 patients, 16 men and 9 women, with a mean age of 32.8 years old. There was an improvement in quality of life as indicated by the increase on the scores of all eight components of the SF-36 questionnaire: 1) physical functioning: 15.4 to 82.1; 2) role-physical: 0 to 83.3; 3) bodily pain: 16.6 to 80.9; 4) general health: 56.2 to 80.3; 5) vitality: 50.6 to 78.8; 6) social functioning: 32.3 to 88.5; 7) role-emotional: 20.8 to 81.9; 8) mental health: 60.2 to 79.5. Furthermore, there was significant decrease in Roland Morris questionnaire scores (preoperative: 17.5 ± 5.1 vs. postoperative: 0.9 ± 2.2), reflecting a reduction of low back pain during the postoperative period.

Conclusion: We conclude that low back pain is present and often disabling for herniated disc patients and that there is reduction or complete relief from back pain after lumbar microdiscectomy is performed.

Keywords

Low Back Pain; Intervertebral Disc Degeneration; Discectomy; Quality of Life

Introduction

Low back pain and lumbar sciatic pain are highly prevalent conditions among the world’s population and often present lumbar disc herniation as their etiology, being one of the most common complaints of patients who seek for health care in emergency rooms and at doctors’ offices. They are cause of significant disabling in everyday activities and growing labor absences due to the pain. Despite its high prevalence, there is still controversy among specialists and in medical literature regarding the proper way to manage the disease, leading to several different treatments and results.1

The initial treatment for most of the disc herniations is usually conservative, through the association of rest, analgesics, anti-inflammatory drugs and physical therapy. However, if the conservative approach fails for at least twelve weeks, there is indication for surgical treatment. Among the diverse surgical interventions indicated for disc herniations, it is important to mention microdiscectomy, low back arthrodesis associated to discectomy and, more recently, the interspinous dynamic stabilization or still the disc prosthesis.

Microdiscectomy or simple discectomy still remain the gold standard treatments since both procedures present less comorbidity, in which only the herniated segment is resected and there is neither overload of the levels adjacent to the discectomy, nor restriction to the lumbar arc of movement. The main advantage of the surgical procedure seems to be better seen in short term, showing relief of symptoms in 90% of cases when properly indicated.2

According to our group experience, we believe the low back pain is highly associated to lumbar disc herniation and, after microdiscectomy surgical intervention, there is significant relief of symptoms and an improvement in the quality of life for patients who suffer from the condition.

Thus, the aim here was to improve the understanding and management of the disease, with the objective of assessing the influence of microdiscectomy in quality of life and in low back pain for patients presenting lumbar disc herniation, quantifying these parameters via instruments validated by the medical literature: SF-36 and Roland Morris questionnaires, distributed in preoperative and late postoperative, for comparative analysis of the results.

Method

Comparative prospective study, conducted from the survey data collected via valid questionnaires, between pre- and postoperative periods. The study was undertaken from July 2009 to January 2010 with an average follow-up of 6 (six) months.

This work was authorized by the Research Ethic Committee at EMESCAM, under the number 012/2010, complying with the requirements of Resolution no. 196/96 of the National Health Council / Ministry of Health.

Patients included in the study suffered from low back pain for over three months, showing no response to conservative treatment (rest, analgesics and anti-inflammatory drugs and at least 20 sessions of physical therapy). All of them had lumbar disc herniation diagnoses confirmed by Magnetic Resonance Imaging (MRI).

Patients who showed previous surgical interventions on the spinal cord, radiographic parameters of intervertebral instability, lumbar canal stenosis, previous spinal cord trauma records, osteometabolic diseases and equine tail syndrome have been excluded from this study.

Initially, patients’ personal and anthropometric data were collected via a questionnaire to assess quality of life, being applied during the preoperative period, named SF-36, and another questionnaire used to assess low back pain, named Roland Morris. The fill out of these specific forms was repeated after 6 months of post-operative.

SF-36 is a questionnaire for general health care assessment, validated and adapted to the Portuguese language, composed of 36 items, organized in 8 domains or components, which were determined in order to represent the most commonly assessed concepts in health care questionings, such as physical functioning, physical aspects, bodily pain, general health, vitality, social functioning, emotional aspects and mental health.3-5

Roland Morris questionnaire, also validated and adapted to the Portuguese language, is composed of 24 items and is a specific instrument for assessing low back pain. It allows the analysis of functional disabling in patients with low back pain, showing 24 situations which represent the individual’s difficulty in performing daily tasks due to their low back pain, referring to the current symptoms.6-8

After the distribution of the questionnaires at the preoperative period, the patients underwent microdiscectomy. All of them received antibiotic prophylaxis in anesthetic induction and underwent hemilaminectomy for resection of the herniated disc fragment. The amount of disc removed was decided by the surgeon during the operation and the performing of microdiscectomy was in accordance with literature description.9

After the surgical procedure, the patients stayed in hospital for about 72 hours. After hospital discharge, they were evaluated every two months or when necessary. Six months after the surgery, the patients were reassessed and replied to the SF-36 and Roland Morris questionnaires again.

Data analysis

Data regarding age, gender, weight, height and BMI were analyzed and described and, after that, the results of both forms, for assessing quality of life (SF-36) and for low back pain (Roland Morris) were analyzed individually at the preoperative period and also six months after the surgery, when a comparative analysis was performed.

For the evaluation of the results obtained from SF-36, the answers for each question were turned into a score which, afterwards, formed the final score calculus for the 8 components. Each component was scored separately, ranging from 0 (zero) to 100 (one hundred) in which zero is the worst result possible and one hundred represents the best result for each component. The way of interpreting SF-36 may vary among different authors. In Figure 1, a summary of how the final results for each SF-36’s component can be interpreted is shown.4

Figure 1: Summary of the possible results interpretation of each SF-36’s component. Adapted from Ware, 2004.

It is worth emphasizing that the SF-36 application result analysis of and its comparisons must be performed for each component at study and not in an overall form in which the result is the sum of all answers given by the patient when filling out the form.3

The Roland Morris questionnaire6-8 presents a single result that is represented by the amount of statements checked in by the patient, among the 24 situations exposed in the instrument. The absolute value does not imply absolute conclusions. It has to be compared with other situations for the same patient – in this case, the pre- with the postoperative period.

Results

25 patients were evaluated, 16 males (64%) and 9 females (36%), with a mean age of 32.8 ± 9.9 years old. The mean weight was 70.8 kg ± 10.5 and the mean height was 1.69m ± 0.1m, being the mean BMI 24.7 ± 1.7 kg.m-2.

All the patients presented some reduction in quality of life, verified via the SF-36 questionnaire, mainly regarding the following components: physical functioning, role-physical and bodily pain. All the patients also presented low back pain, confirmed via Roland Morris questionnaire distributed at the postoperative period. The mean score was 17.5 ± 5.1, which shows that among 24 situations described in the questionnaire, 72% caused low back pain in the patients assessed in this study.

There was improvement in quality of life verified by the increase of all 8 components in the SF-36: 1) physical functioning: 15.4 ± 11.8 to 82.1 ± 21.2; 2) role-physical: 0 to 83.3 ± 35.9; 3) bodily pain: 16.6 ± 6.4 to 80.9 ± 22.8; 4) general health: 56.2 ± 24.3 to 80.3 ± 21.2; 5) vitality: 50.6 ± 27.9 to 78.8 ± 21.1; 6) social functioning: 32.3 ± 25.8 to 88.5 ± 22.7; 7) role-emotional: 20.8 ± 37.8 to 81.9 ± 39.0; 8) mental health: 60.2 ± 22.9 to 79.5 ± 19.9. The results in the first 4 components are grouped in Figure 2, as they represent physical health and the last 4 components are grouped in Figure 3, since they reflect mental health, as many authors have already suggested.10

Discussion

Lumbar sciatic pain is a frequent complaint among patients evaluated in emergency rooms and ambulatory care facilities for spinal surgery. It is estimated an incidence of 1 to 2% in the North American population, with approximately 200,000 discectomies performed annually in that country.11 Among the available treatments, literature shows that lumbar arthrodesis surgeries increased about 200% between 1979 and 1987, in contrast to an increase of 23% in laminectomy and 75% discectomy in the same period. In spite of its high prevalence, there is much controversy regarding the physiopathology and the treatment of lumbar discpathology.

The main risk factors for disc herniation are: sedentarism, prolonged driving habits, chronic cough, pregnancy, smoking habits and heavy objects lifting.12-14

The natural history of the disease shows a benign evolution in the long term for the most of the lumbar disc herniations. Several authors showed similar results between conservative and surgical treatments after a long postoperative observation, thus being the statistically relevant short term relief of pain the main advantage of the surgical treatment.2,15,16

The initial treatment of every lumbar discpathology is always conservative, except in cases when the patient shows progressive neurological deficit or equine tail syndrome, when it is indicated urgent surgical decompression, due to the risk of permanent sequel. The size of the herniation cannot be taken into consideration for surgery indication, since large herniations are the ones which present the highest reabsorbing rates, since they are mostly formed by water, different from the small ones, which are not so frequently reabsorbed.16-18

The surgical treatment is reserved for those patients who suffer from disabling and unbearable pain after 12 weeks of conservative treatment and, at least, 20 physical therapy sessions.

Early surgical interventions with discectomy present more than 90% of positive results.
However, when evaluated in the long term, the scores are less positive, 40% to 79% in a minimum 7-year follow up. It shows there is a deterioration of the results as the time passes after the surgery.19,20

Many surgical techniques are indicated, such as laminotomy and discectomy, endoscopic discectomy and microdiscectomy, with similar postoperative results.21 Many factors influence the postoperative prognosis, such as the classification of the herniation, the level, the surgeon experience and the psychosocial aspects.

Complications related to the surgery include dura mater lesion, infection, nerve root lesion, recidivism, among others. Reherniation rates after discectomy vary from 3% to 18% in the literature.22-24 Among the related aspects are great defect in the fibrous annulus and a bigger residual volume in the disc after surgery. In other words, fewer parts of the disc were extracted during the surgical procedure.25

In the last few years, the assessment questionnaires are becoming useful instruments either for evaluating postoperative results or to refer for treatments when there are several treatment options available for the same disease.5,10,26 The objective analysis performed via clinical, laboratorial and radiological exams are being complemented by the assessment of subjective aspects, such as quality of life regarding health, physical functioning, pain and satisfaction scores, once it provides scarce information regarding the functional, social and mental aspects of the patient.26 It has been aiding doctors to manage patients who suffer from lumbar sciatic pain.27,28 For assessing quality of life, SF-36 was used, which evaluates the patient’s health under their own perception. In this study, it was observed the significant improvement of subjective parameters related to the quality of life affected by the disease, namely physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health.

The SF-36 and Roland Morris questionnaires were selected due to their more responsive approach to the prospective evaluation of patients with lumbar sciatic pain. Besides that, they are widely known, studied and reproduced in the scientific community.8,29 Another well-known assessment method for low back pain is the Oswestry Low Back Disability Questionnaire30, whose main disadvantage – in comparison with Roland Morris – is the difficulty and the longer time required to fill it out. This subjective analysis combined with the objective clinic evaluation allows the surgeon to have a more precise indication to the proper surgical procedure, improving the results and decreasing the number of postoperative complications, also allowing the quantification of subjective data at the postoperative period.

Another important aspect evaluated in our study was the association between lumbar disc herniation and low back pain. In developed countries, the “back pain” is quite prevalent and incident; approximately 70% of the people will suffer from it at some moment in life, being its incidence around 15% to 20% per year. It also represents the main cause of disability in adults under 40 years old and the second most frequent complaint in medical appointments. Approximately 1% of the North-American population presents low back pain constantly disabling associated to other 1% with temporarily disabling low back pain.31

We observed that miscrodiscectomy for the treatment of disc herniation reduces the low back pain condition in patients through the analysis of data obtained via Roland Morris and the bodily pain component in SF-36. Our results suggest that the unnecessary use of invasive surgeries in young patients can be avoided, since their high morbidity rates and complications.32

Clinical studies show no significant difference between patients who have undergone discectomy only and those who have been subject to discectomy combined with arthrodesis in the absence of instability19. The main advantage of arthrodesis compared with standard discectomy is the lower rate of disc disease recurrence33, despite its higher morbidity.32

The lateral flexion-extension radiograph of the spinal cord was used as a method to determine intervertebral instability, considering the following criteria to indicate instability: vertebral slippage higher than 3mm, posterior opening of the vertebral bodies higher than 5 degrees, stenosis in the lumbar canal or disc herniation that requires extended decompression and multiple discectomies.34

For representing a non-consensual subject among experts, more studies are necessary to further evaluate the best way to understand and manage these patients. This study has showed that low back pain is present and, in most cases, disabling in patients with disc herniations and that, after undergoing lumbar microdiscectomy, there is a decrease or a complete relief from low back pain, followed by a significant improvement in quality of life, which strongly supports our idea that low back pain as a single criterion, without any instability sign to be seen in supplementary exams, must not be used for indicating lumbar spinal arthrodesis.

References

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Attachments

tab1

tab2

Source: author. Note: translated.

tab3

Source: author. Note: translated.

Besides that, there was a significant reduction in the Roland Morris questionnaire’s score (preoperative: 17.5 ± 5.1 vs. postoperative: 0.9 ± 2.2), which shows reduction in low back pain at the postoperative period (Figure 4).

tab4

Authors

Thiago Cardoso Maia1*, Charbel Jacob Junior2, Igor Machado Cardoso3, Marcus Alexandre Novo Brazolino4, José Lucas Batista Junior5, Tadeu Gervazoni Debom6

 

1* Specialist – Resident Doctor at Hospital Municipal Cármino Caricchio, São Paulo, SP.

2 Master’s Degree in Public Policies and Local Development, School of Sciences of Santa Casa de Misericórdia de Vitória – EMESCAM, Vitória-ES, Brasil.

3 Specialist in Spinal Cord Surgery, Universidade Estadual de Campinas, São Paulo, SP.

4 Specialist – Resident Doctor at Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, SP.

5 Specialist – Resident Doctor at Santa Casa de Misericórdia de Juiz de Fora – MG.

6 Specialist – Resident Doctor at Hospital Regional de Presidente Prudente – SP.

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