MILITARY MEDICINE, 173, 9:924, 2008

Interlaminar in Lumbar Disc Herniation: Shorten Postoperative Return to Work Period in Recruits Undergoing Military Training

Lieutenant Haydar Celik, Turkish Armed Forces*; Lieutenant Alihan Derincek, Turkish Armed Forces†; Major Atilla Arslanoglu, Turkish Armed Forces‡

ABSTRACT The operative treatment of lumbar disc disease has long challenged spine surgeons. In this study, we aimed to show that recruits with lumbar disc herniation managed by the interlaminar approach could return to work after Downloaded from https://academic.oup.com/milmed/article/173/9/924/4372355 by guest on 30 September 2021 6 weeks. Forty male recruits were included in this study and interlaminar discectomy was adequate in 40 cases. Early postoperative rehabilitation had a positive effect on early return to work. We believe that interlaminar lumbar discectomy is an effective technique for treating patients with herniated lumbar discs; with early postoperative rehabilitation, recruits can return to work 6 weeks after .

INTRODUCTION this series were progressive neurological deficit and failure of The operative treatment of lumbar disc disease has chal- conservative treatment. Plain lumbosacral spine roentgeno- lenged spine surgeons since the first reported case in 1929 by grams were obtained in all cases. Dandy.1 The first publications documenting the microsurgical After general anesthesia was obtained, the patient was discectomy procedure were in 1977 by both Yasargil and placed in a prone position. We preferred the abdomen to be Caspar.2,3 In 1982, Spengler described limited disc excision, free of compression, thus lowering central and vena cava only the ligamentum flavum, and if necessary, a small uni- pressure and diminishing intraoperative blood loss. A stan- lateral foraminotomy was performed to expose the affected dard vertical midline incision (ϳ2.5 cm), centered over the disc space.4 The advantage of interlaminar lumbar disc excision appropriate interspace, was used and the underlying fascia is a decrease in the manipulation of the thecal sac and subse- was identified. The midline fascia was then split and the quent diminished perineural fibrosis. Small incision, less muscle paraspinal musculatures were stripped in a subperiostal man- dissection, interlaminar entrance without bone removal, and ner with Cobb elevators. After the interlaminar space was limited perineural fibrosis decrease the postoperative recovery identified on the affected side, a self-retaining retractor was period and allow for a quicker return to work. placed. Surgical level or levels were checked by using direct Management of the disease with less invasive roentgenograms. The ligamentum flavum was dissected with can help early mobilization and shorten the hospital stay. We Cobb curettes both from the superior lamina of the inferior aimed to show that recruits with lumbar disc herniation and the inferior lamina of the superior vertebra. managed by the interlaminar approach can return to work After all the flavum was removed by a Kerrison rounger, a after 6 weeks. foraminotomy was performed if necessary. The lamina, facet, and facet capsule were left intact. After the root was exposed, METHODS the exiting nerve root was retracted medially to find the disc Forty consecutive patients who underwent lumbar interlami- space. With the root retracted medially, the disc was incised nar discectomy for lumbar disc herniation, between January vertically to allow the entry of a pituitary into the disc space 2006 and December 2006, were selected. The clinical diag- and removal of the herniated portion of the disc material. The nosis was confirmed by magnetic resonance imaging in all spinal canal was examined for additional extruded or seques- patients (Fig. 1). The indications for lumbar discectomy in trated fragments. After meticulous hemostasis, fascia and skin were closed in the usual fashion, using bioabsorbable sutures. *Department of Neurosurgery, Van Military Hospital, Iskele Street, The patient was allowed to stand with assistance on the 65001, Van, Turkey. evening after surgery to go to the bathroom. Most patients †Department of Orthopedics and Trauma Surgery, Van Military Hospital, Iskele Street, 65001, Van, Turkey. were discharged within 24 hours after surgery. A program of ‡Department of Radiology, Van Military Hospital, Iskele Street, 65001, lumbar extension exercises was initiated. Heavy lifting, bend- Van, Turkey. ing from the waist, and prolonged sitting were discouraged Oral presentation at the 1st Congress on Minimal Invasive Spine Surgery for the first 6 weeks after surgery. Meeting, April 6, 2008, Ankara, Turkey. The clinical results were evaluated by using both the Oswe- This manuscript was received for review in November 2007. The revised manuscript was accepted for publication in May 2008. stry Disability Index (ODI) and the Visual Analog Scale (VAS,) Reprint & Copyright © by Association of Military Surgeons of U.S., which were recorded before and after the surgery. The Os- 2008. westry Low Back Disability Questionnaire can be used

924 MILITARY MEDICINE, Vol. 173, September 2008 Clinical Report Downloaded from https://academic.oup.com/milmed/article/173/9/924/4372355 by guest on 30 September 2021

FIGURE 1. (a) Sagittal and (b) transverse T2-weighted magnetic resonance images showing left posterolateral disc herniation at the L4–L5 level. to assess patients with low by determining its RESULTS impact on the activities of daily living (calculation of level of Forty recruits were included in this study (Table I). The disability: point total/50 ϫ 100 ϭ % disability). Results can average age at surgery was 21.5 years (range, 21–23 years). be explained as 0% to 20% (minimal disability), 21% to 40% All the patients were male. The average operating time for (moderate disability), 41% to 60% (severe disability), 61% to lumbar discectomy was 50 minutes, with a range of 45 to 75 80% (crippled), 81% to 100% (exaggerating symptoms).5 minutes. The average blood loss was 170 mL. No patient A VAS is a measurement instrument that tries to measure required a blood transfusion. Three cases required laminot- a characteristic or attitude that is believed to range across a omy during the interlaminar entrance at the L4–L5 level continuum of values and cannot easily be directly measured. (7.5%). The average hospital stay after surgery was 1.2 days For example, the amount of pain that a patient feels ranges (range, 1–3 days). Among immediate complications, a patient across a continuum from none to an extreme amount of pain. required antibiotic treatment for a superficial wound infec- Operationally, a VAS is usually a horizontal line, 100 mm in tion. All of the patients took 6 weeks of rest after surgery. length, anchored by word descriptors (no pain on left hand– All patients were assessed at 1 and 6 months postopera- very severe pain on right hand) at each end. Patients mark on tively, usually with longer follow-up. The average follow-up the line the point they feel represents their perception of their was 13 months, with a range of 6 to 18 months. Both VAS current state. The VAS score is determined by measuring in and ODI were improved after surgery (p Ͻ 0.05; Tables I and millimeters from the left end of the line to the point that the II). All neurological deficits were resolved completely at patient marks. Results can be explained as 0 (no pain), 0 to 2 6-month follow-up. No statistical differences were recorded (annoying), 2 to 4 (uncomfortable), 4 to 6 (dreadful), 6 to 8 between L4 and L5 and L5 and S1 levels in terms of oper- (horrible), 8 to 10 (agonizing). ating time, blood loss, and clinical outcome (p Ͻ 0.05). All Statistically, clinical outcomes of both preoperative and patients returned to their previous positions after 6 weeks. postoperative ODI and VAS scores were compared using the None of the patients needed additional surgery or any treat- paired t test. ments during longer follow-up.

TABLE I. Interlaminar Discectomy with or without Laminotomy and Clinical Outcome

Disc No. of Interlaminar Interlaminar Preoperative 1-Month 6-Month Preoperative 1-Month 6-Month Level Patients Discectomy Discectomy ϩ Laminotomy Mean VAS Mean VAS Mean VAS Mean ODI Mean ODI Mean ODI L4–L5 15 15 3 8.8 1.0 1.13 87.7 11.7 10.1 L5–S1 23 23 8.65 0.56 0.52 87.2 13.4 9.8 L4–L5 ϩ 2 2 9.5 1.0 0.5 90 17 9 L5–S1 Total 40 40

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TABLE II. Descriptive Statistics of Clinical Outcome

Mean N Minimum Value Maximum Value Statistic SE SD VAS preoperative 40 6.00 10.00 8.7500 0.16699 1.05612 VAS postoperativea 40 0.00 3.00 0.7500 0.15504 0.98058 ODI preoperative 40 74.00 94.00 87.5500 0.71428 4.51749 ODI postoperativea 40 6.00 16.00 9.9000 0.44693 2.82661 a Postoperative 6 months.

DISCUSSION Even if early clinical results were good, heavy sports and field Success rates for lumbar disc surgery range from 46% to marching were restricted 6 more weeks after return to work. Downloaded from https://academic.oup.com/milmed/article/173/9/924/4372355 by guest on 30 September 2021 96%.4 The outcome of lumbar discectomy depends more on Interlaminar lumbar discectomy is an effective and reliable patient selection than on surgical technique.6,7 A few authors surgical technique for treating patients with herniated lumbar have reported higher rates of success, a shorter hospital stay, discs. With early postoperative rehabilitation, recruits can and quicker return to work after microdiscectomy, which has return to work 6 weeks after surgery. not been established in well-controlled studies.8–10 In our series, the operating time, inpatient stay, and success rates REFERENCES were comparable to the results of microdiscectomy reported 1. Dandy WE: Loose cartilage from simulating tumor of in various studies. This might be due to the similarity of the the spinal cord. Arch Surg 1929; 10: 660–72. two techniques. Lagarrigue and Chaynes11 showed no dif- 2. Yasargil MG: Microsurgical operations for herniated lumbar disc. Adv ference, regarding the outcome, between microscopic and Neurosurg 1977; 4: 81–2. 3. Caspar W: A new surgical procedure for lumbar herniation causing less nonmicroscopic removal of disc herniation. Interlaminar tissue damage through a microsurgical approach. Adv Neurosurg 1977; discectomy can offer good opportunity for minimal invasive 4: 74–80. discectomy in regional hospitals even if a microscope is not 4. Spengler DM: Lumbar discectomy—results with limited disc excision available. and selective foraminotomy. Spine 1982; 7: 604–7. In the present study, interlaminar discectomy was ade- 5. Fairbank JC, Pynsent PB: The Oswestry Disability Index. Spine 2000; 25: 2940–52. quate in 40 cases. Three cases with a disc pathology at L4–L5 6. Daneymez M, Sali A, Kahraman S, et al: Outcome analysis in 1072 (7.5%) required laminotomy. At the L5–S1 level, the broad surgically treated lumbar disc herniations. Minim Invasive Neurosurg interlaminar space allowed easy entrance to the disc space, so 1999; 42: 63–8. there was no need for a laminotomy at this level. We also 7. McCulloch JA: Focus issue on lumbar disc herniation: macro and observed that the patients who required a laminotomy were microdiscectomy. Spine 1999; 21(Suppl 24): 455–65. 8. Stolke D, Sollman WP: Intra and postoperative complications in lumbar operated on during the early phases of the learning curve. disc surgery. Spine 1989; 14: 56–9. Early postoperative rehabilitation has a positive effect on 9. Silvers HR: Microsurgical versus standard lumbar discectomy. Neuro- early return to work. Choi et al.12 showed the positive effects surgery 1988; 22: 837–41. of the “postoperative early lumbar extension muscle-strength- 10. Wilson DH, Harbaugh R: Microsurgical and standard removal of the ening program” on pain, return to work, and strength of back protruded lumbar disc: a comparative study. Neurosurgery 1981; 8: 422–7. muscles in patients operated on for a herniated lumbar disc. 11. Lagarrigue J, Chaynes P: Comparative study of disk surgery with or We also think that the high success rates may be correlated to without microscopy: a prospective study of 80 cases. Neurochirurgie the younger population in our series. Asch et al.13 showed that 1994; 40: 116–20. patient age had a negative effect which was linear with 12. Choi G, Raiturker PP, Kim MJ, et al: The effect of early isolated lumbar increasing age between 25 and 56 years old—that is, the ages extension exercise program for patients with herniated disc undergoing lumbar discectomy. Neurosurgery 2005; 57: 764–72. most commonly encountered in cases of herniated disc. 13. Asch HL, Lewis PJ, Moreland DB, et al: Prospective multiple outcomes Our cases returned to work after 6 weeks. At 4 weeks, the study of outpatient lumbar microdiscectomy: should 75 to 80% success mean VAS score was 0.75 and the mean ODI was 12.95. rates be the norm? J Neurosurg 2002; 96(suppl 1): 34–44.

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