Article
Emergency surgery in symptomatic lumbar disc herniation with acute motor deficits – overkill therapy or appropriate treatment?
Akutoperation bei symptomatischem lumbalen Bandscheibenvorfall mit Parese – notwendig oder übertrieben?
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Authors
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Ondra Petr
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
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Nikolaus Kögl
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
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Konstantin Brawanski
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
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Christian Preuß Hernández
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
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Martin Dostal
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
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Claudius Thomé
- Medizinische Universität Innsbruck, Abteilung für Neurochirurgie, Innsbruck, Austria
| Published: | June 26, 2020 |
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Outline
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Objective: Patients with lumbar disc herniation (LDH) undergo disc surgery in case of persisting pain or neurologic deficits. Recently published literature suggests early surgical nerve decompression in case of moderate or severe motor deficits. In cauda equina syndrome urgent surgery within 48 hours has been advocated.
The aim of this high-volume single-centre analysis was to assess the role of early surgical intervention in patients with acute LDH associated paresis in order to achieve favourable long-term outcome.
Methods: Three hundred and thirty patients who underwent microscopic disc surgery between 01/2013 and 12/2015 were included. All patients presented with a motor deficit (MRC 0-4) at the time of admission. Patient demographics, neurologic deficits, duration of motor deficit, treatment characteristics, and short-term outcome measurements were collected retrospectively. Long-term follow-up was performed prospectively to assess the motor recovery over time. Patients were subdivided into groups according to the severity of the paresis (MRC ≤2/5 vs. MRC 3/5 vs. MRC 4/5). Groups were retrospectively analysed regarding the duration and degree of the neurologic deficits.
Results: Patients with moderate and/or severe paresis (MRC ≤3/5) benefit from very early surgical intervention within 48 hours as they showed significantly higher complete recovery rates at long-term (5-years-) follow-up (94.8% vs. 37.3%; p<0.001). The recovery rate in patients with LDH associated mild motor deficits (MRC 4/5) also decreased significantly (97% vs. 72.2%) if surgery was delayed (>7 days) (p=0.005). Overall, 95.2% of all patients treated within a 48hour period showed full-strength (MRC 5/5) during manual testing at last follow-up compared to only 26.5% if treated after 7 days (p<0.001).
Conclusion: Immediate surgery should be offered to patients with severe and moderate motor impairment to increase the likelihood of long-term neurological recovery. Early surgical intervention shows better long-term outcome also in patients with mild paresis and must be considered in particular cases.
