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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 134-137

Functional outcome after fenestration and discectomy in young adults presenting with unilateral radiculopathy


1 Department of Orthopaedics, Sri Venkateshwara Medical College and Research Center, Puducherry, India
2 Department of Orthopaedics, Pondicherry Institute of Medical Science, Puducherry, India
3 Department of Spine Surgery, Sakra World Hospital, Bengaluru, Karnataka, India

Date of Submission06-Apr-2021
Date of Acceptance30-Sep-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Prince Solomon
Department of Orthopaedics, Pondicherry Institute of Medical Science, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_22_21

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  Abstract 


Introduction: Lumbar disc herniation is one of the common ailments in young adults. The common levels of L4-L5 and L5-S1 have been chosen for ours. The Evaluation was done based on the level of disc herniation and also with different types of disc herniation such as contained, extruded, or sequestrated disc herniations. The outcomes were evaluated using the Japanese Orthopedic Association (JOA) scoring system. Methods: Thirty-three patients with a single-level disc herniation at L4-L5 or L5-S1 who did not show significant improvement of radiculopathy even after a conservative trial were included in the study. All patients were consented and subjected to surgery-unilateral fenestration and fragment discectomy. Patients were evaluated based on their JOA Scoring which was done preoperatively and postoperatively on day 10 and at 1 month, 3 months, 6 months, and 1 year. The functional outcome in percentage was calculated using the “recovery rate” by the Hirabayashi index. Results: Following fenestration discectomy, the functional outcome of the patient was found to be good. O the 33 patients operated, males n = 20 and females n = 13. According to Hirabayashi's recovery rate, 48% (n = 16) patients were found to have an excellent result with recovery rate of >80%. Good results were seen in 43% (n = 14) with recovery rates ranging between 70% and 80%. About 3% (n = 1) had a fair result with recovery rate of 56% and 6% (n = 2) had poor results with recovery rate < 50% following surgery. Applying the paired t-test, P was calculated and was 0.0001 which is statistically significant. Complications included incidental durotomy, pseudomeningocele, recurrent disc herniation, and spondylodiscitis. Conclusion: Patients who underwent fenestration discectomy for single-level lumbar disc herniation at L4/5 or L5/S1 showed significant functional improvement as per JOA scoring and Hirabyashi's recovery rate. The results were comparable with newer techniques such as micro and endoscopic discectomy.

Keywords: Fenestration discectomy, Japanese Orthopaedic Association, lumbar disc herniation, radiculopathy


How to cite this article:
Adimoolam M, Solomon P, Murugan Y, Govindaswamy R, Ganadoss JJ, Najimudeen S. Functional outcome after fenestration and discectomy in young adults presenting with unilateral radiculopathy. J Orthop Traumatol Rehabil 2021;13:134-7

How to cite this URL:
Adimoolam M, Solomon P, Murugan Y, Govindaswamy R, Ganadoss JJ, Najimudeen S. Functional outcome after fenestration and discectomy in young adults presenting with unilateral radiculopathy. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 26];13:134-7. Available from: https://www.jotr.in/text.asp?2021/13/2/134/333556




  Introduction Top


Lumbar disc herniation is one of the common ailments in young adults. At a productive age, this problem is debilitating and if timely intervention is not made the outcome is quite disabling. In the past, lumbar disc herniations have been treated both by conservative and surgical modalities with good outcomes. Weber et al.[1] in his study has found that the long-term outcome in patients treated both surgically and conservatively for lumbar disc herniations was the same. According to Morgan et al.[2] the current evidence is consistently in favor of discectomy, rather than continuing nonsurgical care, for greater and/or faster alleviation of pain, reduction of disability, and higher patient satisfaction.

Since the time of the first lumbar discectomy done by Oppenheim and Krause[3] in 1909 using a transdural approach, lumbar disc surgeries have evolved over a period of time and recent advances such as microdiscectomy and percutaneous endoscopic discectomy shows good results.[4],[5] Despite these advancements, fenestration discectomy is still a useful option at a medical college hospital, where the minimal access facility is not available. In our study, we analyze the outcome of fenestration discectomy done for single-level lumbar disc herniation in young adults presenting with unilateral radiculopathy.


  Materials and Methods Top


Between October 2013 and May 2015, patients who presented to the outpatient clinics with low back pain and lumbar radiculopathy were screened and young adults with single-level disc herniation with unilateral radiculopathy were initially chosen for our study.

All these patients were initially given a trial of conservative management for 4–6 weeks and observed for the recovery of radicular symptoms. Then, 33 patients with no significant improvement of radicular symptoms or worsening radiculopathy were included in our study. All the 33 patients were consented and subjected to surgery– unilateral fenestration and fragment discectomy.

Procedure

All patients were operated on through a standard protocol. A midline skin incision over the spinous process of the affected level, the paraspinal muscles erased subperiosteally on the affected side to expose the lamina with the interlaminar space below. Ligamentum flavum was removed with part of the inferior edge of the lamina, exposing the dura using a Kerrison's rongeur. The thecal sac along with the traversing nerve root retracted medially and the herniated disc was identified. If it was a sequestrated fragment, it was removed in toto, in the case of the contained disc an incision was made over the posterior annulus and the herniated disc fragment removed and the disc space was inspected for any other loose fragments. As a protocol always the offending fragment alone was removed and the disc space was not curetted. The wound was closed in layers following complete hemostasis with a suction drain.

All patients were mobilized on the 1st postoperative day. Spinal core strengthening exercises were started once the surgical pain subsided. Forward bending, crossed leg sitting, and squatting were started after 4 weeks. All patients were allowed to return to moderate work by 12 weeks. Patients were evaluated based on their Japanese Orthopedic Association (JOA) scoring[6] which was done preoperatively and postoperatively on day 10 and at 1 month, 3 months 6 months, and 1 year. Statistical analysis was performed using the SPSS software (SPSS ver: 1.0.0.1406 by IBM, Armonk, N.Y, USA).


  Results Top


Gender distribution among the 33 patients showed, males n = 20 (60.6%) were more commonly affected than females n = 13 (39.4%). The age of the patient included in this study varied between 25 and 60 years with the mean at 42.06 years. The highest incidence of 45.5% (n = 15) was noted between the age group of 41–50 years and the second most common was between 31 and 40 years (n = 9). L4-L5 level was the most commonly affected level with 22 (66.6%) patients followed by L5S1 level with 11 (44.4%) patients. All the patients were assessed with Hirabayashi's recovery rate calculated from the JOA score preoperatively and postoperatively at various intervals.

According to Hirabayashi's recovery rate, 48% (n = 16) patients were found to have an excellent result with the recovery rate of >80%. Good results were seen in 43% (n = 14) patients with recovery rate ranging between 70% and 80%. 3% (n = 1) had a fair result with recovery rate of 56% and 6% (n = 2) had poor results with recovery rate <50% following surgery. [Figure 1] and [Figure 2] shows the pre operative, Intra operative and post operative pictures of patients with excellent functional outcome following Fenestration and discectomy.
Figure 1: (a and b) Preoperative list, (c) Magnetic resonance imaging image, (d and e) Intra op images, (f and g) Postoperative clinical image

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Figure 2: (a) Preoperative list, (b and c) Magnetic resonance imaging images, (d) Intra op images, (e) Postoperative SLRT

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The mean preoperative JOA was 6 and the mean postoperative JOA was 25. The mean recovery rate by Hirabayashi scoring was 80.2%. Applying the paired t-test, P was calculated and was 0.0001 which is statistically significant [Table 1]. Complications [Table 2] included were one incidental durotomy (repaired primarily) and two pseudomeningoceles (excision and repair). One postoperative infective spondylodiscitis (fusion) and one recurrent disc herniation (redo discectomy).
Table 1: Paired t-test

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Table 2: Complications

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  Discussion Top


Low back pain and lumbar radiculopathy secondary to lumbar disc herniation are common among young adults. A missed disc herniation during the initial evaluation may result in neurological involvement and disability. Such a problem at a productive age can have economical and psychological impacts on the patient's life. Once the early diagnosis is made, the treatment options vary from conservative trial (rest/medications), minimally invasive options (epidural steroid injections/selective nerve root blocks), or surgical interventions. Each option has its own merits and demerits.

Conservative trial being the first step includes a brief period of bed rest, analgesics, and intermittent traction followed by exercises (physiotherapy). Although the advantage is that it negates all the complications of surgical intervention, the prolonged duration of treatment costs valuable man-hours. Studies have also shown that conservative treatment can fail and the patient may still end up having a surgical procedure after a prolonged conservative trial. Surgical options range from open laminectomy and discectomy, fenestration discectomy, microdiscectomy to endoscopic discectomy. In this era of microendoscopic discectomies becoming popular, the advantages of simple fenestration discectomy can be overlooked, hence we decided to do a prospective study on the role of fenestration discectomy in young adults presenting with unilateral radiculopathy.

In our study, the most common presentation was low back pain with unilateral radiculopathy. Examination revealed a positive Straight leg raising test (SLRT), paraspinal spasm (sciatic scoliosis) in almost all patients, and neurological involvement in 60% of the individuals. The study population had a male preponderance (73.5%) which was similar to Weber et al.[1] and Dewing et al.[7] studies. Male predominance could be attributed to heavy mechanical work.

Patient selection plays a crucial factor in the successful outcome following surgery. All the patients in our study were given a course of conservative trial. If the patient did not have a significant improvement in pain or if they had a neurological worsening then they were taken up for surgery-fenestration discectomy. The patients were evaluated using the JOA scoring system. The outcomes were compared with other studies involving fenestration discectomy as well as microdiscectomy and microendoscopic discectomies.

Our study had 90% good/excellent results, which was comparable to Smith et al.[8] study on functional outcome following microdiscectomy in 2010. Rasouli et al.[4] concluded that potential advantages of minimally invasive discectomy have a lower risk of surgical site infections and may be associated with shorter hospital stay but the evidence was inconsistent. On the contrary Ram Ishwar et al.[9] said both open and minimally invasive methods are equally effective in relieving radicular pain; however, microendoscopic discectomy is superior in terms of total hospital stay, morbidity, earlier return to work, anesthetic exposure, blood loss, and intraoperative time as compared to the open method. Alvin et al.[10] in his study had a greater rate of complication with tubular discectomy and lower incidence of revision surgery in patient undergoing open/microdiscectomy. Kim et al.[5] concluded in their study “While percutaneous endoscopic lumbar discectomy showed better results than open lumbar microdiscectomy in some items, open lumbar microdiscectomy still showed good clinical results, and it is therefore reckoned that a randomized controlled trial with a large sample size would be required in the future to compare these two surgical methods.“


  Conclusion Top


Patients who underwent fenestration discectomy for single-level lumbar disc herniation at L4/5or L5/S1 levels showed significant functional improvement as per JOA scoring and Hirabayashi's recovery rate. The results were comparable with newer techniques such as microdiscectomy and endoscopic discectomy. Fenestration discectomy is still a safe and cost-effective option for patients with single-level lumbar disc herniation with unilateral radiculopathy, where minimal access facility is not available.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983;8:131-40.  Back to cited text no. 1
    
2.
Lorio M, Kim C, Araghi A, Inzana J, Yue JJ. International society for the advancement of spine surgery policy 2019Surgical treatment of lumbar disc herniation with radiculopathy. Int J Spine Surg 2020;14:1-17.  Back to cited text no. 2
    
3.
Oppenheim H, Krause F. About entrapment or strangulation of the cauda equina. Dtsch Med Wochenschr1909;35:697-700.  Back to cited text no. 3
    
4.
Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev 2019:CD010328. [doi: 10.1002/14651858.CD010328.pub2].  Back to cited text no. 4
    
5.
Kim M, Lee S, Kim HS, Park S, Shim SY, Lim DJ. A comparison of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for lumbar disc herniation in the Korean: A meta-analysis. Biomed Res Int 2018;2018:9073460.  Back to cited text no. 5
    
6.
Clinical Outcomes Committee of the Japanese Orthopaedic Association;, Subcommittee on Evaluation of Back Pain and Cervical Myelopathy;, Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committe of the Japanese Orthopaedic Association;, Fukui M, Chiba K, Kawakami M, Kikuchi S, et al. JOA back pain evaluation questionnaire: Initial report. J Orthop Sci 2007;12:443-50.  Back to cited text no. 6
    
7.
Dewing CB, Provencher MT, Riffenburgh RH, Kerr S, Manos RE. The outcomes of lumbar micro discectomy in a young, active population: Correlation by herniation type and level. Spine (Phila Pa 1976) 2008;33:33-8.  Back to cited text no. 7
    
8.
Smith JS, Ogden AT, Shafizadeh S, Fessler RG. Clinical outcomes after micro-endoscopic discectomy for recurrent lumbar disc herniation. J Spinal Disord Tech 2010;23:30-4.  Back to cited text no. 8
    
9.
Yadav RI, Long L, Yanming C. Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation. Medicine (Baltimore) 2019;98:e16627.  Back to cited text no. 9
    
10.
Alvi MA, Kerezoudis P, Wahood W, Goyal A, Bydon M. Operative approaches for lumbar disc herniation: A systematic review and multiple treatment meta-analysis of conventional and minimally invasive surgeries. World Neurosurg 2018;114:391-407.e2.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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