The Outcome of Lumber Discectomy: A Comparative Study of Fenestration Discectomy Versus Hemilaminectomy and Discectomy

Ali Abd-Alnibi Alwan Al-Tamimi
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Keywords : Lumber Discectomy, Fenestration Discectomy, Hemilaminectomy. Discectomy
Medical Journal of Babylon  14:2 , 2017 doi:1812-156X-14-2
Published :15 October 2017

Abstract

Lumber disc prolapse accounts for only 5% of all low back pain problems but is the most common cause of radiating nerve root pain which called sciatica. In the 20th century, techniques were developed to remove the herniated disc with minimal invasiveness, with these minimally invasive techniques; authors demonstrated decreased soft tissue manipulation, operative time, blood loss, and hospital stay, allowing early recovery. This is a prospective study carried in Sulaimaniyah Teaching hospital for 111 patients (72 male and 39 female) complained from lumber disc prolapse from May 2010 till May 2015. Two different surgical discectomy procedures were done to these patients as follows: 1-Fenestration discectomy was performed to 53 patients through 2-5 cm skin incision. 2-Hemilaminectomy and discectomy had done to 58 patients through skin incision 4-7 cm. The patients were evaluated preoperatively and 6 months postoperatively by PROLO score. 111 patients (72 male and 39 female with ratio 1.8:1) underwent surgical discectomy. The mean age of the patient was 36.2 + 6.2 years. 53 patients (47.7%) underwent fenestration discectomy. The operation time was ranging from 48 – 92 minutes with mean operative duration 69.13 ± 8.96 minutes. The mean hospital stay was 1.31 ± 0.73 days ranging from 16 hours to 3days. According to PROLO score, fair results were reported in four (7%) patients while good result obtained in 12 patients (23%) and 37 patients (70%) showed excellent result. No patient expressed poor result. 58 patients (52.3%) underwent hemilaminectomy and discectomy. The operation time was ranging from 56 – 103 minutes with mean operative time 78.66 ±10.31 minutes. The mean hospital stay was 2.46 ± 1.42 days ranging from 1 day to 10 days. According to PROLO score, 9 patients (16%) obtained fair results while good results obtained in 15 patients (26%) and excellent results founded in 34 patients (58%). No patient showed poor results. Duration of the operation and hospital stay were significantly shorter in fenestration discectomy group than hemilaminectomy and discectomy one (P value less than 0.001). Through PROLO score both procedures showed significant improvement postoperatively in both economic and functional assessments. Most of our patients gain excellent results according to PROLO score in both surgical procedures.In this series 92% of patients treated with fenestration discectomy improved postoperatively with good or excellent score, while 85% of the patients treated with hemilaminectomy have that improvement. Both fenestration discectomy and hemilaminectomy with discectomy showed the same final postoperative outcome but the fenestration discectomy is superior since the operation duration, hospital stay are less and overall improvement is relatively better.

Introduction

Lumber disc prolapse accounts for only 5% of all low back pain problems. It may irritate the dural covering of the adjacent nerve root causing pain in the buttock, posterior thigh and calf, which called sciatica [1]. Although back pain is common from the second decade of life on, intervertebral disc herniation is most prominent in otherwise healthy people in the third and fourth decades of life [2]. Lumbar discectomy is the most common operation performed in the United States for lumbar-related symptoms [3]. Mixter and Barr described the first surgical procedure to remove the herniated lumbar disc in 1934 through a laminectomy and durotomy, with later enhancement by Semmes, who described approaching the herniated disc through hemilaminectomy and retraction of the dural sac. This became popularized as the “classical discectomy technique” [4]. During the latter half of the 20th century, more techniques were developed to remove the herniated disc with minimal invasiveness [5]. With these minimally invasive techniques, authors demonstrated decreased soft tissue manipulation, operative time, blood loss, and hospital stay, allowing early recovery [5].

Materials and methods

This is a prospective study carried in Sulaimaniyah Teaching hospital, Iraq, for 111 patients (72 male and 39 female) complained from lumber disc prolapse from May 2010 till May 2015.
All the patients were interviewed 2-3 days prior the surgery. Detailed history was taken from the patients with special attention to the exact complaint, the duration, the radiation of the pain to the lower limb, numbness, paresthesia, lower limbs weakness, history of previous spine surgery, history of previous spine pathology and any history of conservative management.
The patient examined thoroughly concentrating on neurological status to exclude any sensory or motor deficit and orthopedically to elicit any abnormal gait, sciatica scoliosis and or any sign of root irritation. Tension tests were done in form of straight leg raising test (SLRT), cross leg raising test and Laseaque test.
All patients underwent plain radiographic examination with AP view to exclude sacralization and lumberlization of the spine and lateral view in flexion and extension to exclude any instability. All the patients should have recent MRI within the last three months.
Preoperative blood test like CBC, blood sugar, viral test and any other test recommended by the anesthesiologist like ECG or ECHO.
All operations done under general anesthesia, intraoperative antibiotic in a form of 1 gram ceftriaxone is given during the induction of the anesthesia.  Knee – Chest position was performed to all patients, the level of the prolapsed disc was determined prior to skin incision by the assistance of C- arm fluoroscopy.
1-Fenestration discectomy was performed to53 patients through 2-5 cm skin incision done according to the intervertebral level.
2-Hemilaminectomy and discectomy had done to 58 patients through skin incision 4-7 cm according to the affected levels.
    Radivac drain was inserted in some cases according to the state of haemostasis. The patient kept in supine position in the operative day, the drain removed in the first postoperative day and the patient allowed to get up from bed and start walking, no belt was used and the patient discharged from hospital. Stiches removed in the 10th postoperative day, and then after the patient also examined neurologically for any progress. The patients followed and examined every month for the first 6 months and every 3 months for 2 years.
Patients with intraoperative or post-operative complications were treated and followed postoperatively according to each case.
At the end of the follow up PROLO scale6(Economical and Functional scale) was used to evaluate the final outcome of the surgery




Results

111 patients (72 male and 39 female with ratio 1.8:1) underwent surgical discectomy. The mean age of the patient was 36.2 + 6.2 years; ranged between 18 – 45 years.60% of our patients were aged between 31 – 40 years. (Histogram 1). The back pain was radiated to the left lower limb in 63 patients (56.7%) and to the right lower limb in 40 patients (36%) and to both limb in 8 patients (7.2%).Sciatic scoliosis was complained by 17 patients (15.3%). All patients (100%) presented with sciatica. Numbness was founded in 59 patients (53.2%). SLRT was positive in all patients at angle 30 – 60°, cross leg raising test was positive in 42 patients (37.8%), sensory deficit was found in 47 patients (42.3%), motor deficit was found in 67 patients (60.4%) and deep ankle reflex was altered in 23 patients (20.7%).(Table 1)

Discussions

Lumber disc prolapse consider as one of most common causes of spine surgery. Many surgical procedures were described for discectomy like full or total laminectomy with discectomy, hemilamin-ectomy and discectomy, fenestration discectomy, microscopic discectomy and endoscopic discectomy. In this study we compare between two modalities of discectomy, which are fenestration discectomy and classical hemilaminectomy and discectomy. Since most of lumber disc prolapse affected young adults in their productive life, so we need to evaluate which procedure provide quick return to normal life. In this study 60% of our patients aged between 31 – 40 years with males affected as twice as the females. This is a known fact in all literatures in which they showed that lumber disc prolapseis more common young active healthy people in their third and fourth decades of life, this is because the prolapse happen due to heavy exertion, repetitive bending, twisting, or heavy lifting; things that usually done by young adult male [2, 7]. In this study the back pain radiated (sciatica) more to left lower limb 56.7% and only 7.2% of patients, the pain was radiated to both limbs. There were no any difference in the outcome and the complication that related to the side of pain radiation. SLRT was positive in all cases while cross leg raising test was positive in 37.8% of cases; this is comparable to study done by Ujwal et al [8]. Sensory deficit was elicited in 42.3% of the patients; motor deficit in 60.4% and diminished ankle reflex was founded in 20.7%. Sciatic scoliosis was found in 15.3% of the patients in this study. Most of prolapsed disc was found at L4-L5 level (64%) and only 12% of the patients suffered from L4-L5 and L5-S1 simultaneously. 75% of the prolapsed discs was found extruded, while sequestrated discs were diagnosed in 7% of the patients. Most of the patients were presented with pure lateral disc herniation (80%). In this study; the level of the prolapsed discs, the location of the discs and the type of the disc prolapse play no role in the selection of the type of surgery, the complications and the final outcome. Omidi-Kashani Fet al[9] reported thatthe ultimate satisfaction rates at final follow-up visit are similar and comparable between the L4-5 and L5-S1 levels. Fenestration discectomy was performed to 53 patients (47.7%) and discectomy through hemilaminectomy were done to 58 patients (52.3%). We compare both procedures in the following points: In the fenestration group, the mean operative time was 69.13 ± 8.96 minutes which was significantly shorter than the hemilaminectomy group which was 78.66 ± 10.31 minutes (p value >0.001), this is can be attributed to less soft tissue dissection, minimal bonny procedure with flavectomy and smaller incision which need less time for closure. Ujwal et al [8] reported 75 minutes as a mean operative time for fenestration discectomy. A study done by Adam et al[10] showed significant shorter operative time with fenestration (mean time was 70 minutes) than the time of laminectomy (mean time 105 minutes). In this series, the hospital stay in fenestration group (mean 1.31 ± 0.73 days) was significantly less than the hemilaminectomy group (mean 2.46 ±1.42 days) with P value less than 0.001. The small incision, less muscle dissection will decrease the postoperative pain in which will decrease hospital stay. Harrington [11] stated that reduced postoperative pain in minimally invasive techniques would reduce hospital stay. From the data collected in this series one can notice that, although the complications reported in the hemilaminectomy were more than those in fenestration group there were no significant differences between both procedures (P value > 0.05).Two root injuries one in each group were recorded in this study, it is well known fact that root injury is represent 1%of all discectomy procedures, although Nancy E. Epstein [12] stated that the minimal invasive techniques carries more nerve root injuries than the classical one. Dural tear was reported in one patient of the hemilaminectomy group and not recorded in fenestration one this was happened accidently while retracting the Dura to separate a very adherent sequestrated disc. Superficial stitch infection recorded in 8 patients in both groups and treated conservatively by antibiotics without any effect on the overall result of surgery. In this series, most of the patients in both groups are preoperatively economically scored E2 which is No gainful occupation, including ability to do housework, or continue retirement activities and functionally scored F2 which is Difficulty in walking, needing a cane or crutch or persistent moderate motor weakness (able to perform tasks of daily living). There were no statistical differences between the fenestration and hemilaminectomy groups preoperatively and postoperatively in both economical and functional scores (P value more than 0.05). Six months postoperatively, the score is significantly improved in both procedures economically and functionally (P value less than 0.001). PROLO score assessed the patient economically and functionally and it describes more details than other score systems like Macnabs, although the end score of both systems are the same [8]. PROLO score when created in 1986, it was for evaluation of vertebral interbody fusion. This rating scale is easily applicable and can delineate pre- and postoperative conditions of patients on a semiquantitative basis [13]. Several researchers administered the original PROLO score as a main outcome or in association with other outcome measures, mostly in studies conducted on degenerative pathologies of the lumbar spine. Some authors used the PROLO by properly adapting items for the postoperative evaluation of function of other spinal districts, for example, the thoracic spine in case of fracture stabilization or discectomy or the cervical spine [6]. PROLO score system consist of two scores the first one is Economic (E), in which the patient evaluated according to the ability to return back to his previous job in complete or part time, need modification of the job, need to change the entire job or should retired. The other score is the functional (F) which related to the degree of pain, motor and sensory deficit postoperatively. In this series 38 patients out of 53 (71.69%) in fenestration group and 33 patients out of 58 (56.89%) in hemilaminectomy group were returned back to their previous jobs within 6 months postoperatively. These results in fenestration group were comparable with Ujwal et al [8] who stated that; according to PROLO economical scale, (72%) of cases were able to work at their previous job without any recurrences while (12%) were able to work at previous occupation but part time or limited status while (16%) cases were able to work but had to abandon their previous occupation. In our study 15% of fenestration group and 22% of hemilaminectomy group were able to returned back to their previous job but in part time or with limited effort, while the rest of the patients were able to work but they changed their previous jobs. In this series, there were a considerable number of patients even if their final functional score were F3 or F4, they scored E5 in economic score. This is due to that many of our patients (especially the governmental employers) were not able to change their jobs style easily, so they were enforced to continue with their previous jobs even with remnant postoperative symptoms. In this study, 45 patients (85%) of fenestration group and 45 patients (77.5%) in hemilaminectomy group were free of pain (F4 and F5) at the end of 6 months. This is also comparable with Ujwalet al8 study in which they recorded that 88% of their patients were relieved of pain at the end of 6 months. Most of the patients in this study gain excellent results according to PROLO score in both surgical procedures. Excellent results were more in fenestration group (37 patients) than that in hemi-laminectomy group (34 patients). There was no significant statistical differences between the two procedures (P vale more than 0.05). Overall most of the patients improve in both economic and functional scores in both procedures, which mean that final satisfactory outcome, were gained in both procedures. In this series 92% of patients treated with fenestration discectomy improved postoperatively to good or excellent, while 85% of the patients treated with hemi-laminectomy and discectomy group were improved to good or excellent postoperatively. This is comparable to study of Dennis Antony et al [14] who recorded good improvement in 88% of the patients. Ujwal et al [8] in their study reported good improvement in 84% of their cases. Out of 111 patients, only 13 patients with fair outcome at the end of 6 months (4 patients in fenestration and 9 in hemi-laminectomy groups); although the number of patients was much less in fenestration group, this difference was statistically not significant (P value more than 0.05). Both Dennis14 and Ujwal8 drop excellent from their studies and they consider score below 5 as poor, 6-7 as fair and 8-10 as good.

Conclusions

From this study you can conclude that although fenestration discectomy and discectomy through hemilaminectomy carries almost the same successful and satisfactory final outcome, fenestration discectomy is superior in minimizing dissection, operation duration, posto-perative pain and hospital stay. PROLO score is easy, dependable and predictable way to evaluate the economic and the functional outcome of the patients treated with lumber discectomy.

References

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