Establishment Of Cases Follow-up And Evaluation System For Minimally Invasive Surgical Treatment Of Degenerative Low Back Pain And Related Clinical Study

Part Ⅰ Establishment of Cases Follow-up and Evaluation System for MinimallyInvasive Surgical Treatment of Degenerative Low Back PainSection A Establishment of Cases Follow-up and Evaluation System for SurgicalTreatment of Degenerative Low Back PainBackgroud Chronic degenerative low back pain (LBP) is a common disorder of thelumbar spine and and it is occasionally treated surgically when conservative treatment isinvalid. Traditional surgical therapies are often open surgeries. Recently, minimal invasivetechniques were also widely used in this field. However, there were contentious controversiesin clinical efficacy of these techniques. How to evaluate the efficacy of these techniques isvery important for the development of minimally invasive spine surgery. Follow-up isessential for the evaluation of clinical efficacy. Using traditional follow-up model, we can notsearch quickly and the cases always lost to follow-up easily. Objective To establish a casesfollow-up and evaluation system for surgical treatment of degenerative LBP. Methods andResults Reference to widely used rating scales for LBP, the evaluation indicators wereselected out. The follow-up questionnaire and follow-up process were also established.Through the medical record system "No.1Military" project, we put clinical data and healtheconomics indicators of patients together with the rating scales for LBP, established the casesfollow-up and evaluation system for surgical treatment of degenerative LBP. Conclusion Thecases follow-up and evaluation system is safe and reliable. It provides fast entry andconvenient query. It can fully demonstrate the preoperative, intraoperative and postoperativeconditions. The system also provides a data platform to evaluate the minimally invasivesurgical treatment for degenerative LBP and to establish the LBP scoring system for Chinese.Section B Establishment and Preliminary Evaluation of Low Back Pain Outcome Score ScaleBackgroud Current common rating scales for LBP are not very suitable for the short-term efficacy assessment of minimally invasive surgery. Some of items in these ratingscales are not very suitable for Chinese. At present, we are still far from a simple and practicalevaluation method for LBP which is fit for Chinese people. Objective To establish a LBPoutcome score scale which is suitable for Chinese and can be used to make the assessment forminimally invasive surgical treatment of degenerative LBP. Methods Using the follow-upquestionnaire, the follow up for LBP were proceeded and the items fit for Chinese wereselected out to construct the low back pain outcome score (LBPOS) scale. Minimally invasiveand open surgical treatments for degenerative LBP were evaluated by Japanese orthopaedicassociation low back pain score (JOA), Oswestry Disability Index (ODI) and LBPOS scale.The validity and reliability of LBPOS scale are verified. Results LBPOS scale is suitable forChinese. With good compliance, internal consistency and split-half reliability, LBPOS scorehas a significant correlation with JOA score and ODI. Conclusion With good validity,reliability and sensitivity, LBPOS scale can be used to make the assessment for minimallyinvasive surgical treatment of degenerative LBP.Part Ⅱ Related Clinical Research About Evaluation for Minimally InvasiveSurgical Treatment of Lumbar Disc HerniationSection A Evaluation for Minimally Invasive Surgical Treatment of Lumbar DiscHerniationBackgroud Microendoscopic discectomy (MED) and percutaneous endoscopic lumbardiscectomy (PELD) are the most commonly used minimally invasive surgeries for lumbardisc herniation (LDH). With no strict evidence-based control research, the difference ofclinical outcomes between them remains unclear. Objective To prospectively compare theclinical results and cost utility of PELD with MED, and to verify the feasibility andeffectiveness of LBPOS scale. Methods Through cases follow-up and evaluation system weestablished, a series of LDH patients underwent single level endoscopic discectomy werefollowed up for2years. In addition to general and cost utility parameters, the followingmeasuring instruments were used: VAS, JOA, ODI, LBPOS, and modified MacNab criteria.The compliance and validity of LBPOS scale were also verified. Results285patients wereincluded in,170men and115women with a mean age of46.2years. One hundredeighty-three patients underwent PELD and102underwent MED. General preoperative data included VAS score, JOA score, ODI and LBPOS score, showed no statistical differencebetween the2groups (p>0.05). There were no serious complications observed duringfollow-up. The hospitalization costs in2groups are similar. The time of operation in PELDgroup is longer than that in MED group, but the blood loss was less and the hospital stay wasshorter than that in MED group. The success rate (excellent and good) in PELD group was alittle lower than that in MED group (78.1%vs.80.9%). Within3months after surgery, theimprovements in pain and functional disability were rapidly, and improvements of JOA score,ODI and LBPOS were significantly better in PELD group than in MED group (p＜0.01).From6months to2years after surgery, the improvements in pain and functional disabilitybecame slowly, and improvements of VAS score, ODI and LBPOS were similiar in PELDgroup than in MED group (p＞0.05). With good compliance and sensitivity, LBPOS score hasa significant correlation with JOA score and ODI. Conclusion PELD presents a safe andeffective treatment for LDH as well as MED. The improvements in functional disability weresignificantly better within3months after PELD than that after MED. LBPOS scale can beused to make the assessment for minimally invasive surgical treatment of LDH.Section B Reoperation after Different Surgical Treatments for Lumbar Disc HerniationBackgroud Despite the development of surgical techniques,2.8%to24%of patientsunderwent reoperations after their primary surgeries for LDH. The rates of reoperation afterdifferent primary surgical methods were reported to be different, but the comparative studyabout the causes and characteristics among different surgical methods have not been reported.Objective To compare the causes and characteristics of reoperations after different primarysurgeries for LDH. Methods Out of a series of5280patients who underwent surgeries forLDH between2001and2012,207patients (135male and72female, mean age47.7years)underwent primary and revision operations, which were included in this study. The followingclinical parameters were retrospectively assessed: the primary surgical methods, the intervalsbetween primary and revision surgeries, and surgical findings in reoperations. Results In total,232lumbar discs underwent reoperations. One hundred and nineteen reoperations wereperformed after microendoscopic discectomy (MED group),68after percutaneous endoscopiclumbar discectomy (PELD group) and45after open disc surgery (open group). The locationsof revision surgeries had priority over those of primary surgeries, with a moderate correlation (kappa coefficient=0.533).46.6%of reoperations were performed within0.5years afterprimary surgery, and35.3%were performed in1-5years. Real recurrent herniation(homolateral herniations at the same level) was significantly more common than otherreoperative surgical findings (70.6%in PELD group,47.1%in MED group,37.8%in opengroup). The overall mean interval until revision surgery was18.9months (8.1months inPELD group vs.19.7months in MED group vs.33.1months in open group, p <0.01).Conclusion For LDH, different reoperation peak occurred after different primary operation.Real recurrent herniation was the most common cause of reoperations, and more reoperationsfor real recurrent herniations and shorter intervals were found after minimally invasiveendoscopic discectomy than after open disc surgery.Part Ⅲ Related Clinical Research About Diagnosis and Minimally InvasiveSurgical Treatment for Discogenic Low Back PainSection A Posterolateral Transforaminal Selective Endoscopic Discectomy withThermal Annuloplasty for Discogenic Low Back PainBackgroud recent years posterolateral transforaminal selective endoscopic discectomyand thermal annuloplasty (PEDTA) is reported to be used in treatment for discogenic lowback pain (DLBP) with contentious controversies in clinical efficacy. A small number ofrecent studies focusing on invasive treatments for DLBP noted that single-level degenerationmight respond better to invasive treatment than multi-level degeneration, but no comparativestudies. Objective To evaluate the clinical results of therapy for DLBP with PEDTA，and tocompare the clinical results between DLBP with isolated and consecutive disc degeneration.Methods One hundred and one consecutive DLBP patients with positive concordant pain indiscography underwent PEDTA. These patients included47men and54women with a meanage of42.8years. Based on modified Pfirrmann criteria, the preoperative disc degenerationgrade was evaluated, and Patients were divided into2groups. Patients with isolated discdegeneration constituted Group1(49cases). Patients with consecutive degeneration made upGroup2(52cases). Clinical results of2groups were evaluated by Visual analog scale (VAS)score, JOA score, ODI and modified MacNab criteria. Results101cases were followed upfor a mean period of2.5years. The percentages of excellent, good, fair and poor were10.9%,40.6%,28.7%and19.8%overall. General preoperative data included age, sex, duration of pain, VAS score, JOA score and ODI, showed no statistical difference between the twogroups (p>0.05). After surgery, both groups show significant reliefs in pain and functionaldisability. Improvements of VAS score, JOA score and ODI were significantly better in group1than in group2(p<0.05). The success rate (excellent and good) was65.3%in group1and38.5%in group2. Conclusion PEDTA presents a safe and effective treatment for carefullyselected DLBP patient. Better clinical results occurred in patients with isolated discdegeneration.Section B Diagnosis and Treatment for Discogenic Low Back Pain with IntradiscInjection of RopivacaineBackgroud Provocative discography is considered as the gold standard for diagnosingDLBP with controversy. Recently discoblock is reported to be used in diagnosis for DLBP. Atherapeutic effect for DLBP was found in our initial clinical trial on discoblock withropivacaine, but no public report. Objective To evaluate the diagnosis and clinical therapyresults of DLBP with intradisc injection of ropivacaine. Methods Fourteen patients (5maleand9female, mean age46.0years) patients with chronic degenerative LBP were evaluated bydiscoblock (intradisc injection of2mL of0.2%ropivacaine). The VAS score, ODI andLBPOS score were recorded before and after discoblock. Clinical results were evaluated bymodified MacNab criteria. Results The discoblock were carried out successfully with noserious complications. The patients were followed up for12months. Twelve patients whoexperienced pain relief with discoblock were evaluated. The percentages of excellent, good,fair and poor were25.0%,16.7%,33.3%and25.0%. Twelve DLBP patients show significantimprovements in VAS score, ODI and LBPOS score at each follow-up point after discoblock.Two patients with no pain relief after discoblock showed poor results at each follow-up.Conclusion Intradisc injection of ropivacaine was a useful tool for the diagnosis of DLBP aswell as an economical and effective treatment for carefully selected DLBP patient.