This is an interesting article describing a novel method for treating a common problem that really poses a dilemma for spinal surgeons, which is the recurrence of disabling back and/or leg pain after primary lumbar discectomy, the so called post discectomy syndrome (PDS).
The authors introduce the problem satisfactorily and elaborate their description using the relevant literature.
The procedure used to treat patients with PDS is described and the technique they developed (the salient features of less invasive posterior lumbar interbody fusion (LI-PLIF) technique), which differs from the standard PLIF, is analysed. The authors mention the initial publication of this technique as well1
The technique is depicted in instructive drawings, for a more didactic presentation; therefore, more surgeons can easily comprehend this novel and enhanced technique.
It is concluded that LI-PLIF is as effective as other surgical modalities and its added advantages are given. The authors feel that it can be offered as a better surgical option for patients with PDS.
In general, there are some points that could be discussed with reference to this article.
The suboptimal results of such a revision lead us to pose some questions. Why do we have to proceed to a revision? Was the patient selection improper? Was the initial diagnosis incorrect? On a worse scenario, was there a loose indication? Was the operative level incorrect? Was the applied surgery incorrect? Is the PDS iatrogenic? Is the outcome the result of an idiosyncratic personality?
As it is also very important to remember, the poor results of the ODS and VAS reported in the group of social benefit pensioners suggest that factors other than a successful clinical and radiological fusion are responsible for the low outcome scores with respect to leg and back pain and for the low rate of re-employment. In other words, other reasons might be implicated which are not pertinent and related to the technique used2.
It is well established that, to some extent, the functional outcomes are not in accordance with the percentages of fusion rates.
This means that the pain producing the problem is probably not properly addressed. It is indeed reported that in patients suffering from chronic low back pain related to a post-discectomy syndrome, a good clinical and functional outcome after lumbar interbody fusion is particularly difficult to achieve, and the results reported can only confirm that the functional outcome is not influenced and is independent of the fusion technique2, a statement that it is also repeated in other publications3.
For the treatment of a single problem that is PDS, numerous surgical options are offered, each of them resulting to dissimilar outcomes. The authors of the article elegantly describe the many surgical techniques reported in order to achieve fusion, namely anterior-posterior fusion with transpedicular stabilisation system, anterior lumbar interbody fusion (ALIF), posterolateral fusion (PLF), transforaminal interbody fusion (TLIF) and ALIF with percutaneous pedicle screw fixation, documenting the citations as well.
If we were certain about the cause of this single problem, we would also be able to offer a single solution to treat it. Unfortunately for the “same” problem there are several solutions offered, a fact that confirms our uncertainty in selecting the proper patient and the lack of diagnostic accuracy.
In conclusion, with specific regard to the technique offered, the authors believe that their method can be offered as a better surgical option for patients with PDS. This remains to be verified, as it can only be confirmed if the method in question can be efficiently used in a moderate spinal surgical hand, resulting at least in the same or better outcomes than those presented in this article. Anyhow, this is an axiom for all the surgical methods proposed.
1. Kasis AG, Marshman LA, Krishna M, Bhatia CK. Significantly improved outcomes with a less invasive posterior lumbar interbody fusion incorporating total facetectomy. Spine 2009;34:572-7.
2. Niemeyer T, H Halm, L Hackenberg, U Liljenqvist, AS Bövingloh. Post-discectomy syndrome treated with lumbar interbody fusion. Int Orthop 2006;30:163–6.
3. Fritzell P, Haegg O, Wessberg P, Nordwall. A Chronic low back pain and fusion: a comparison of three surgical techniques. Spine 2002;27:1131–41.
"Tzanio" General Hospital, Piraeus, Attica, Greece