Radiologic Analysis of Causes of Early Recurrence after Percutaneous Endoscopic Transforaminal Discectomy

doi:10.21203/rs.3.rs-944800/v1

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Radiologic Analysis of Causes of Early Recurrence after Percutaneous Endoscopic Transforaminal Discectomy

https://doi.org/10.21203/rs.3.rs-944800/v1

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Objective: To retrospectively analyze causes of, and factors influencing, early recurrence after percutaneous endoscopic transforaminal discectomy (PETD) used to treat lumbar-disc herniation.

Methods: We included 285 patients with single-segment lumbar-disc herniation, treated using PETD from January 2017 to December 2019 in the First Affiliated Hospital of the University of South China. Patients were classified into early recurrence and non-early recurrence groups based on clinical symptoms and MRI reexamination. Differences in disc-height index (DHI), sagittal range of motion (sROM), base-width of intervertebral disc degeneration, and postoperative intervertebral annulus-fibrosus tear size were compared using independent-sample t test. Differences in degree of intervertebral disc degeneration and herniation sites were analyzed using rank-sum and chi-square tests. Logistic regression was used for multivariate analysis of factors associated with early recurrence after PETD.

Results: Two hundred and eighty five patients completed surgery and underwent clinical follow-up. Mean follow-up duration was 15.5 months (12–24 months). During follow-up, 19 patients relapsed within 6 months post-surgery. Early recurrence rate was 6.7%, and mean recurrence duration was 73.4 days (3–168 days). Differences in DHI, base-width, postoperative annulus-fibrosus tear size, degree of intervertebral disc degeneration, and herniation sites between early recurrence and non-early recurrence groups were statistically significant (P<0.05). Herniation site and base-width of herniation were significantly correlated with early recurrence after PETD.

Conclusions: DHI, postoperative annulus-fibrosus tear size, and degree of intervertebral disc degeneration were associated with early recurrence after PETD. Increased base-width of herniation was a risk factor for early recurrence after PETD. Central-herniation patients with were more prone to postoperative early recurrence than paracentral-herniation patients.

Orthopedics

Orthopedic Surgery

Lumbar-disc herniation

Percutaneous endoscopic transforaminal discectomy

Early recurrence

Radiologic

Lumbar-disc herniation (LDH) is the most common cause of lumbago and leg pain. Approximately 70–85% of people will develop lumbago or leg pain at least once in their lifetime.^[1] Surgery is required when standardized conservative treatment is ineffective. Compared with conventional open surgery, percutaneous endoscopic transforaminal discectomy (PETD) has advantages such as decreased probability of paravertebral muscle injury or destruction of bone structure, shortened duration of surgery, and decreased intraoperative bleeding and length of hospitalization.^{[2, 3, 4, 5]} Additionally, PETD has been shown efficacious in the treatment of LDH, rendering this approach the commonly surgical procedure presently used in the treatment of LDH. Despite these advantages of PETD, the postoperative recurrence rate for recurrent lumbar-disc herniation (rLDH) after PETD is higher than that after conventional discectomy and endoscopic nucleus-pulposus resection.^{[6, 7]} Additionally, rLDH after PETD occurs earlier than that occurring after discectomy and endoscopic nucleus-pulposus resection.^[8] Suk defined rLDH as disc herniation at the same level in a patient after a pain-free period of greater than 6 months from the initial surgery; these criteria are widely used to diagnose rLDH diagnosis.^[9] In recent years, reherniation occurring within 6 months after postoperative remission has been classified as early recurrence, while late recurrence is defined as reherniation occurring more than 6 months after postoperative remission. Late recurrence is determined by individual constitution and genetics of the patient, while early recurrence often results from a technical failure.^{[10, 11, 12]} At present, few studies have examined the factors influencing postoperative early recurrence. In this study, we compared the patient radiologic data to retrospectively analyze the incidence of early LDH recurrence after PETD and factors influencing this early recurrence.

General information

This study was approved by the ethics committee of the First Affiliated Hospital of the University of South China. All the study participants had provided their signed informed consent. For this study, we selected patients with LDH who underwent PETD at the First Affiliated Hospital of the University of South China,Department of Spine Surgery from January 2017 to December 2019. Diagnosis of LDH was confirmed using clinical and radiological manifestations. In addition, all patients failed 3 months of strict conservative treatment. Inclusion criteria were as follows: 1) Definitive diagnosis of LDH not accompanied by other lumbar vertebral diseases such as central canal stenosis, spondylolisthesis, or instability; 2) significant postoperative improvement in symptoms, with MRI showing complete decompression of nerve-root compression; 3) reherniation at the same segment of lumbar vertebra; 4) complete radiologic results of preoperative/postoperative or reherniation assessment performed at our hospital; 5) unilateral single-segment surgery. Exclusion criteria were as follows: 1) Other lumbar vertebral comorbidities such as lumbar vertebral tumor, lumbar vertebral infection, lumbar spondylolisthesis, or spinal stenosis; 2) absence of a remission period after the first surgery; 3) reherniation of newly developed other level disc; 4) missing radiologic data. A total of 285 patients met our screening criteria. Of these 285 patients, 162 were men and 123 were women. Mean patient age was 54.9 ± 12.8 years (14–90 years). Additionally, 1, 33, 237, and 14 patients had herniation in L_2/3, L_3/4,L_4/5, and L₅/S₁ discs, respectively. Visual analog scale (VAS) was used to assess the pain level in all the study participants immediately before and after surgery. (Table 1). Follow-up period was 12–24 months.

Surgical methods

Each patient was placed in a lateral recumbent position on contralateral side, and a cushion was placed under the waist. After confirming the target segment, a longitudinal incision of approximately 7 mm long was made through the skin, subcutaneous tissue, and deep facia, with a 3-stage cannula used to expand the incision step by step. After the cannula position was satisfactory, a working cannula and foraminoscope were inserted through the intervertebral foramen under C-arm fluoroscopy navigation. A disposable bipolar radiofrequency knife was used to perform complete hemostasis under endoscopic observation prior to observing anatomical structures such as the superior articular process and target intervertebral disc. Under endoscopic observation, the nucleus-pulposus forceps and blue forceps were used to resect the herniated nucleus-pulposus tissue and free the nucleus pulposus at the target intervertebral disc in order to decompress the nerve root and dural sac as much as possible. The nerve root was carefully examined, and compression was not observed. During resection, care was exercised not to damage the nerves and dura. Finally, a disposable bipolar radiofrequency knife was used to ablate the annulus-fibrosus tear, and hemostasis was carefully performed. After confirming that there was no enormous bleeding and no dural tear, the foraminoscope and working cannula were removed. The incision was sutured once and bandaged with sterile dressing. All PETD surgeries were performed by spinal surgeons who were deputy chief physicians and above.

Postoperative management

On day 2 post-surgery, patients wore waist braces and were allowed to leave the bed for exercise. MRI was performed within 48 h of surgery, and patients wore a waist brace for at least 4 weeks after surgery. Patients were instructed to avoid bending, carrying heavy loads, and strenuous exercise for 3 months after surgery, and to gradually resume normal physical activity after 3 months post-surgery. All patients underwent a lumbar vertebrae MRI at 6 months after surgery to assess whether the operated segment was recovering. Postoperative follow-up was conducted for at least 12 months after surgery.

Diagnostic criteria for early recurrence

Diagnostic criteria for early recurrence were as follows: significant alleviation of nerve-root—related symptoms after PETD and immediately postoperative review of MRI showed complete loosening of the compressed nerve roots, recurrence of nerve-root—related symptoms within 6 months after PETD, and MRI scan showing reherniation, displacement of ipsilateral or contralateral neural structures and contralateral nerve in the operated segment. Recurrence after 6 months after surgery was seen as a non-early recurrence. At least one spinal surgeon and radiologist determined whether recurrence had occurred in the patient.

Observation markers

Two spinal surgeons performed measurements using radiologic data, and the average of measurement results was obtained. Observation markers included disc-height index (DHI), sagittal range of motion (sROM), base-width, degree of intervertebral-disc degeneration, herniation site, and postoperative annulus-fibrosus tear size.

DHI is defined as the ratio of the sum of the anterior and posterior edge heights of an intervertebral disc to the sum of the neighboring endplate widths, as assessed using lateral X-rays (Figure 1).^[13]
sROM is defined as the difference in the angle between adjacent vertebral bodies at hyperflexion and hyperextension positions, as assessed using lumbar vertebrae dynamic posture X-rays (Figure 2).^[14] An sROM greater than 11° was considered indicative of lumbar vertebral instability.^[15]
Pfirrmann grading based on MRI sagittal plane signals, which is divided into grades I–V, was used to assess the degree of intervertebral disc degeneration.^[16]
Herniation sites were classified as central, paracentral, foraminal, and far lateral.
Base-width was expressed as width of the overlap between the herniated nucleus pulposus and outermost layer of annulus fibrosus on the transverse plane in MRI (Figure 3).
Postoperative annulus-fibrosus tear size was defined as annulus-fibrosus tear size on the outermost layer of the transverse plane in MRI (Figure 4).

The same equipment was used for all preoperative and postoperative MRI scans and X-rays, and all imaging was performed using the same settings. T1- and T2-weighted Turbo spin echo sagittal images were used for MRI measurements. Available software (CarestreamVue PACS, Canada) was used for measuring all parameters.

Statistical analysis

SPSS 25.0 (Chicago, Illinois, USA) was used for statistical analysis. Independent sample t test was used to compare differences in disc-height index, sagittal range of motion, base-width, and postoperative annulus-fibrosus tear size between the two groups of patients. Rank-sum and chi-square tests were used to analyze the degree of intervertebral disc degeneration and herniation sites. Logistic regression analysis was used for multivariate analysis of factors associated with early recurrence after PETD. A difference of P<0.05, as assessed using a two-tailed test, was considered statistically significant.

Two hundred and eighty five patients underwent clinical follow-up. The mean follow-up duration was 15.5 months, and complete radiologic records were obtained for all patients. The preoperative and postoperative VAS scores for all the patients enrolled in the present study were 7.38 ± 0.79 and 2.74 ± 0.89, respectively. After surgery, 19 patients recurred within 6 months, accounting for 79.2% (19/24) of all patients with recurrence. Early recurrence rate was 6.7%, and mean recurrence time was 73.4 days (3–168 days). Thirteen patients were readmitted for treatment after recurrence. Of these 13 patients, 2 patients underwent open spinal fusion surgery, 6 patients underwent PETD surgery, and 5 patients received conservative treatment. Symptoms were significantly alleviated after treatment in these patients (Figure 5).

Univariate analysis showed that DHI, base-width, postoperative annulus-fibrosus tear size, degree of intervertebral disc degeneration, and herniation sites were correlated with early recurrence after PETD (P<0.05); however, sagittal range of motion was not significantly correlated with early recurrence after PETD (Table 2). Multivariate logistic regression analysis was used to construct a prediction model based on the relationship between early recurrence after PETD and DHI, base-width, postoperative annulus-fibrosus tear size, and herniation site. Our results show that herniation site and base-width of herniation were significantly correlated with early recurrence after PETD (Table 3).

Repeated LDH (rLDH), a common complication after lumbar-disc—herniation surgery, is the most common cause of repeated surgery after LDH. The incidence of rLDH is approximately 5.7–15%.^{[17, 18, 19, 20]} The time period for the occurrence of rLDH is currently undefined. One essential condition for a diagnosis of recurrence states that there must be a symptom-free period for a segment of the nerve root before postoperative symptoms appear.^{[21, 22, 23, 24]} Studies show that approximately 60–80% of patients experience recurrent LDH within 6 months after PETD ^{[24, 25, 26]}; similar results were obtained in our present study. Therefore, examining the risk factors for early recurrence of LDH after PETD surgery is important for decreasing the incidence of rLDH. Factors that affect the recurrence of LDH after discectomy include: age, sex, body-mass index, occupation, smoking, presence of other comorbidities, segments with intervertebral disc degeneration, number of discs showing degeneration, site of herniation, as well as the type and degree of intervertebral disc degeneration, lumbar vertebral mobility, postoperative exercise intensity, and the learning curve of the operating surgeon; these factors, however, remain debated.^{[14, 23, 27, 28, 29]} Thus far, few studies have reported on the factors influencing early recurrence of LDH after PETD.

Intervertebral disc degeneration is the root cause of LDH. The results obtained in our present study indicate that the risk of developing rLDH increases with the increasing severity of intervertebral disc degeneration, which has also been shown in other studies.^{[11, 30]} During intervertebral disc degeneration, the content of type I collagen increases, while that of type II collagen decreases. Concurrently, proteoglycan and elastin content decreases, causing the nucleus pulposus to lose elasticity and enabling tears in the annulus fibrosus. As intervertebral disc degeneration becomes more severe, the self-repair capacity of annulus fibrosus decreases, leading to nucleus-pulposus herniation.^[31]

Sagittal range of motion is a marker used to reflect lumbar vertebral stability. Studies have shown that increased sROM (particularly when sROM >10°) is associated with increased risk of rLDH.^{[29, 32, 33]} sROM is mainly affected by intervertebral disc and facet joints. When sROM increases, instability between lumbar vertebrae, and the resultant stress, may cause rLDH. ^[30]We found no significant correlation between sROM and rLDH, which may have been due to the low number of patients with early recurrence enrolled in our present study. It is also possible that extension was affected by lumbago during the acquisition of preoperative X-ray images, which were acquired in the extended position.

DHI can objectively reflect intervertebral disc height. One study reported that DHI is a risk factor for rLDH^{[34, 35]}; however, that study did not find that DHI is significantly lower in patients with recurrence compared with those without recurrence, which agreed with the results of Kong.^[36] We speculate that this is because increased DHI may provide sufficient space for surgical resection of nucleus pulposus. In addition, Hasegawa theorized that postoperative intervertebral-disc collapse can result in greater intervertebral disc stability.^[37] However, our study did not prove that low DHI is a risk factor for rLDH (P=0.076).

Kim et al.^[11] found that the risk of recurrence is higher in patients with paracentral herniation than in those with central and far lateral herniation. Conversely, we found that patients with central herniation were more prone to postoperative recurrence than those with paracentral herniation, which agreed with the results of Yao et al.^[28] Yin et al.^[26] also found that central herniation is an independent risk factor for recurrence after PETD. We believe that this discrepancy may be related to the working positioning of the foraminoscope during the intervertebral-foramen approach used for nucleus-pulposus resection. Therefore, performing this procedure for central herniation using a working cannula will inevitably result in further damage to the annulus fibrosus, which may account for the likely recurrence of central herniation.

Park et al.^[24] found that small herniated discs are associated with early recurrence; the smaller the size of the herniated disc, the earlier it recurred. Conversely, we found that patients with increased base-width and postoperative annulus fibrosus tear tended to develop early recurrence after PETD. This may occur because an increased base-width usually indicates that the annulus-fibrosus tear, caused by LDH, is also increased, as is the tendency for residual nucleus pulposus fragmentation during surgery. Hence, to achieve complete decompression, the surgeon may further expand the area for the resection of annulus fibrosus. Annulus-fibrosus tears and defects will accelerate intervertebral disc degeneration, increase the likelihood of nerve-root adhesion and sterile inflammation, and are the main cause of chronic lumbago after discectomy.^[38] Lee et al.^[25] found that the site of rLDH is generally identical to the original herniation site. This finding indicates that nucleus-pulposus herniation in most rLDH patients is caused by reherniation via the original annulus-fibrosus tear, which may be related to the repair of the annulus-fibrosus tear after PETD. The intervertebral disc is the largest avascular organ in the human body, and its self-repair capacity is limited. Using animal models, Melrose^[39] showed that only the outer 1/3 of the annulus-fibrosus tissue can slowly heal using scar formation after damage to the annulus fibrosus. Therefore, a larger tear indicates an increased risk of reherniation at early postoperative stage when the annulus fibrosus has not yet been repaired; this notion is consistent with the results obtained in previous studies.^{[34, 40, 41]} In addition, suturing and repair of the annulus fibrosus during discectomy can effectively decrease the rate of recurrence. ^{[42, 43]} This finding also indirectly proves that defects in the annulus fibrosus are associated with recurrence after discectomy.

The results obtained in our present study will aid spinal surgeons in decreasing the recurrence rate of rLDH. Our results indicate that first, relevant radiologic examinations should be completed before surgery. A personalized approach to a surgical procedure should be used if risk factors for postoperative recurrence are discovered. In addition, it is important to implement a postoperative, as well as a 6-month postoperative, follow-up plan for these patients. Second, damage to the annulus fibrosus should be minimized while ensuring complete nerve-root decompression during PETD; this approach is reliant on the surgical techniques used by the surgeon.

Our present study had several limitations. First, the number of patients with early recurrence was low, resulting in statistical limitations stemming from sample size. Second, we only analyzed the relationship between several radiologic factors and early recurrence after PETD, and did not perform a multivariate analysis of epidemiological, anatomical, postoperative-care, and other factors, which may have affected study results. Therefore, a study using detailed statistical analysis will be used in the future to verify the results of our present study.

Disc-height index, postoperative annulus-fibrosus tear size, and degree of intervertebral disc degeneration were associated with early recurrence after PETD. Increased base-width of herniation was a risk factor for early recurrence after PETD, and patients with central herniation were more prone to postoperative early recurrence than those with paracentral herniation. Decreasing intraoperative damage to the annulus fibrosus and implementing early postoperative follow-up was positively associated with decreased incidence of early recurrence after PETD.

PETD：percutaneous endoscopic transforaminal discectomy

LDH：Lumbar-disc herniation

rLDH：recurrent lumbar-disc herniation

DHI：disc-height index

sROM：sagittal range of motion

VAS：Visual analog scale

Ethics approval and consent to participate：

The retrospective study was approved by the Ethics and Academy Committee of The First Affiliated Hospital of University of South China. All patients were informed the surgical and follow-up details and written consent of data application for future clinical studies was obtained preoperatively, and informed consent was obtained from all patients. The study was conducted in accordance with the Declaration of Helsinki.

Consent for publication:

Not applicable.

Availability of data and material:

Data and materials used in this study can be made available upon reasonable request from Jingbo Xue.

Competing interests:

All authors have no competing interests.

Funding:

The study was supported by:

Hunan Provincial Clinical Medical Technology Innovation and Guidance Project (grant 2020SK51807）

Hunan Provincial Natural Science Foundation (grant 2020JJ4549）

Scientific Research Project of Hunan Provincial Health Commission (grant 202104070077）

Authors' contributions：

Zepeng Li, Yiguo Yan and Jingbo Xue designed experiments; Zepeng Li, Lulu Liu, Jingbo Xue and Zhun Xu carried out experiments; Hao Liu and Jinghua Tan were in charge of contacting the patient. Cheng Wang, Xuelin Li and Zhihua Ouyang analyzed experimental results. Zepeng Li and Jingbo Xue wrote the manuscript. All authors read and approved the final manuscript.

Acknowledgements:

Not Applicable.

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Due to technical limitations, tables are only available as a download in the Supplemental Files section.

No competing interests reported.

Table1.xlsx
Comparison of General data between early recurrence and non-early recurrence groups of patients
Table2.xlsx
Comparison of radiologic data between early recurrence and non-early recurrence groups of patients
Table3.xlsx
Multivariate logistic regression analysis

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Radiologic Analysis of Causes of Early Recurrence after Percutaneous Endoscopic Transforaminal Discectomy

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Abstract

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Introduction

Patients And Methods

General information

Surgical methods

Postoperative management

Diagnostic criteria for early recurrence

Observation markers

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

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