Clinical Research For Adolescent Lumbar Disc Herniation

Objective:To explore the general epidemiology,possible etiology,clinical features and treatment of adolescent lumbar disc herniation(ALDH).Methods:1.We summarize the medical history,clinical and radiological features of the 103 ALDH patients who underwent surgery in our hospital from November 2011 to June 2015,and compared with the randomly selected 103 cases of 30-50 years adult patients with lumbar disc herniation who underwent surgery in the same period.2.The above 103 ALDH cases constitute ALDH group,then we selected the 92 cases of 14-20 years old adolescence who hospitalized in other departments except the orthopedic department of our hospital in the same period with KUB X-rays for various reasons that met the inclusion criteria without spinal diseases as the control group.We compare the incidence of Lumbosacral Transitional Vertebrae(LSTV)between the two groups,and explore the relationship between LSTV and herniation segment within ALDH group.3.We followed up the treatment outcome of ALDH patients underwent conservative or surgical treatment in our therapy group from November 2011 to June 2015,and measured the lumbar-pelvic parameters(LL,PI,PT,and SS)of ALDH patients before and after surgery.Results:1.ALDH constitutes 2.88% of all patients underwent surgery for lumbar disc herniation,the average age was 18.2 ± 1.5 years old(14-20 years old),the mean duration of symptoms was 13.1±14.6 months,low back pain with radiculopathy was the most common initial symptoms(73.8%),dysesthesia was present in 45.6% ALDH patients and muscle strength weakness in 66%,87.2% with a positive straight-leg raise test.The most common segments in ALDH was L4/5(42.7%),following by L5/S1(35%).Compared with adult patients,the male proportion(76.7% vs 58.3%,P=0.005),trauma history before onset(29.1% vs 4.9%,P<0.001),alone leg pain(24.3% vs 11.7%,P=0.014),reactive lumbar scoliosis(20.4% vs 8.7%,P=0.018),positive contralateral straight-leg raise test(24.3% vs 8.7%,P=0.003)were significantly more common in ALDH.2.The incidence of LSTV was significant higher in ALDH group than the control group(26.2% vs 7.6%,P=0.001).The incidence of L4/5 herniation and L5/S1 herniation was similar in ALDH patients without LSTV(48.2% vs 51.8%),but the incidence of L4/5 herniation was significant higher than L5/S1 in ALDH patients with lumbar sacralization(81.3% vs 18.7%,P=0.019).3.A total of 23 conservative treated ALDH patients were eligible for follow-up,the mean follow-up was 16.7 months,the pre-and post-treatment back pain VAS scores(3 vs 2.1,P=0.047),leg pain VAS scores(2.9 vs 2.3,P=0.078),Oswestry disability index(15.1 vs 9.2,P=0.01),the treatment excellent or good rate according to Macnab criteria was 65.2% and the satisfaction rate was 56.5%.A total of 33 surgical treated ALDH patients can obtain a complete clinical and radiological follow-up,the mean follow-up was 24.7 months,the pre-and post-operative back pain VAS scores(3.8 vs 1.2,P=0.001),leg pain VAS scores(7 vs 0.8,P<0.001),Oswestry disability index(45 vs 6.9,P<0.001),the surgical excellent or good rate was 96.9% and the satisfaction rate was 93.9%.Compared with the 56 surgical treated adult patients that were randomly selected and eligible for follow-up in our therapy group during the same period,adolescent patients seem to gain higher excellent or good rate(96.9% vs 85.7%,P=0.146)and satisfaction rate(93.9% vs 82.1%,P=0.198),however,there was no statistical difference.The improvement for leg pain VAS scores and Oswestry disability index was similar between discectomy and arthrodesis in ALDH patients,but discectomy gain better improvement for back pain VAS scores than arthrodesis(0.8 vs 1.6,P=0.025).4.The pre-and post-operative lumbar-pelvic parameters changes in ALDH patients: LL(26.8°vs 39.3°,P<0.001),PI(42.3°vs 42.5°,P=0.55),PT(19.7°vs 13.9°,P<0.001),SS(22.5°vs 28.7°,P<0.001),the above parameters can get similar improvements after either discectomy or arthrodesis surgery.Conclusion: 1.ALDH is relatively rare,constituting 2.88% of all patients underwent surgery for lumbar disc herniation,male preponderance was found and trauma may be an important predisposing factor.The clinical manifestations and herniation segments was similar with adult patients,but alone leg pain without back pain,reactive lumbar scoliosis,positive contralateral straight-leg raise test are more common in ALDH.2.LSTV is associated with the pathogenesis of ALDH,and lumbar sacralization may promote L4/5 herniation in ALDH patients.3.The conservative treatment of ALDH is not as effective.Surgical treatment can achieve satisfactory short-term outcome,but the importance of longterm follow-up should be emphasized.ALDH patients can often accompany with structural abnormalities that may lead to lumbosacral junction instability,compared to discectomy,discectomy plus interbody fusion and fixation with pedicle screws(arthrodesis)could restore the lumbosacral stability,but it does not increase additional efficacy,instead,it is not as effective as discectomy for back pain relief.4.The loss of lumbar lordosis(LL)in ALDH may be a postural change secondary to an analgesic response,and then cause pelvic tilt for compensation(SS decreased,PT increased),resulting in abnormal lumbar-pelvic sagittal alignment presented as flattened lumbar and vertical sacrum,LL increased significantly as the pain relief after either discectomy or arthrodesis surgery.