Lumbar Discectomy: A National Survey of Neurosurgeons and Literature Review

Abstract

The prevalence of symptomatic lumbar disc herniation is approximately 2% in the adult population 1 . When conservative therapy (e.g., analgesia, physiotherapy) does not provide optimum symptom relief, lumbar discectomy is regarded as the treatment of choice with a success rate of 74 to 98% 2 . However, the adjuvant pre-, intra-and post-operative management principles vary among practising neurosurgeons, such as the use of various diagnostic imaging techniques, epidural steroids, ABSTRACT: Background: To ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population. Methods: One page questionnaire faxed to each Neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. All data analyzed using Chi-square statistics. Results: 112 completed surveys were returned hence, giving a 64% response rate with the respondents being predominantly adult neurosurgeons. Of the respondents, 88% perform lumbar discectomy in adults. Only 15% of respondents had a Spine Fellowship. For preoperative imaging, 44% use BOTH CT and MRI whereas 28% use only MRI and 15% use only CT. Prior to initial skin incision, 57% use a localization X-ray image. Preoperative antibiotics are prescribed by 92% of respondents. Majority of respondents (60%) use a pre-incision local anesthetic, whereas only a minority (44%) of respondents employ pre-closure intramuscular injection. With respect to magnification, 70% use microscope, 19% loupes, and 8% neither. Only 12% use minimally invasive tubular retractors. 68% remove "as much disc as possible", while 31% remove "ONLY herniated part". In the case of dural tears, 77% of respondents use fibrin glue (Tisseel®). Prior to skin closure, majority of neurosurgeons do NOT use a fat graft (72%), whereas 61% of respondents use epidural steroids. With respect to discharge from the hospital, 58% are discharged on the next day, 18% on the same day, and 23% in two days. Return to work is not recommended until at least six weeks post-op (96%). Most neurosurgeons (93%) would not operate on an individual with a chief complaint of low back pain. Conclusions: Our survey has identified variations in practice patterns amongst Canadian Neurosurgeons with respect to performing one-level lumbar discectomies. This survey is expected to form a basis for the design of a randomized controlled trial in the evaluation of the best management approach for this common neurosurgical procedure.RÉSUMÉ: Discectomie lombaire : enquête nationale chez les neurochirurgiens et revue de la littérature. Contexte : Le but de l'étude était d'examiner les pratiques chirurgicales concernant la discectomie lombaire à un seul niveau dans la population canadienne adulte. Méthodes : Un questionnaire d'une page, qui portait sur les techniques neurochirurgicales employées, a été envoyé par FAX à tous les neurochirurgiens du Canada. Toutes les données ont été analysées au moyen du test de Chi-carré. Résultats : Cent douze neurochirurg...

Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review

“…Four more trials have been published since [2-5]. In addition a survey of 112 Canadian neurosurgeons in 2009 showed that 61% of participants do not use epidural steroids in lumbar discectomy [6]. This would indicate that the clinical use of intraoperative steroids in lumbar discectomy is still a matter of controversy.…”

Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis

“…In a Canadian study published in 2009, 49% of surgeons routinely used epidural steroids after surgery. 6 With this widespread but nonstandardized use of epidural steroids after lumbar discectomy, a better understanding of their associated risk is warranted.…”

Timing and minimal access surgery for sciatica: a summary of two randomized trials

“…Generally, unilateral transflaval discectomy with loupes or microscopic magnification are both considered as microdiscectomy and internationally defined as the standard method of treatment of lumbar disc-related sciatica. This is supported by a Canadian and Dutch survey held among spine surgeons showing that the majority of the respondents performed unilateral transflaval microdiscectomy as the standard surgical procedure in their practice [6, 8]. …”