Luca Ambrosio, Jordy Schol, Stone Sima, Clara Ruiz-Fernandez, Victor Chen, Fabrizio Russo, In-Ho Han, Daisuke Sakai, Gianluca Vadalà, Vincenzo Denaro, Ashish D. Diwan, AO Spine Knowledge Forum Degenerative
Neurospine 2026;23(1):3-28. Published online January 31, 2026
Lumbar disc herniation (LDH) is one of the most common causes of low back and leg pain. While mechanical and degenerative factors have long been considered the main contributors, persistent or recurrent symptoms in many patients suggest additional biological mechanisms. Recent research has highlighted the microbiome as a potential modulator of inflammation, immune response, and pain sensitization, introducing the “gut-spine axis” concept. This scoping review summarizes the current evidence on the role of both gut and local disc microbiota in LDH. A systematic search of PubMed/MEDLINE and Scopus was conducted up to June 2025, following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Twenty-six studies were included, encompassing preclinical and clinical investigations. Animal models showed that LDH may alter gut microbial composition and that microbiome-targeted interventions can reduce inflammation, neuroinflammatory signaling, and pain sensitivity. In human studies, low-virulence bacteria, particularly Cutibacterium acnes, were frequently detected in surgically excised intervertebral discs, although results were inconsistent due to methodological heterogeneity and potential contamination. Some studies reported associations between bacterial colonization and Modic changes, disc height loss, or chronic pain. Additionally, genetic and metabolomic data suggest that gut dysbiosis and related microbial metabolites may influence systemic immune and metabolic pathways implicated in disc degeneration and pain perception. Overall, the current evidence suggests the biological plausibility of microbiome involvement in LDH pathophysiology, acting through both systemic and local mechanisms. However, the available data remain preliminary, and no mechanistic study has confirmed the observed correlations to date. Further standardized, contamination-aware studies are required to clarify causality and explore microbiome-targeted therapeutic strategies.
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Patients With Chronic Low Back Pain Without Advanced Disk Degeneration Exhibit Gut Microbiome Dysbiosis: Evidence From an Age‐, Sex‐, and BMI‐Matched Pilot Study Stone Sima, Thomas Jeffries, Alisha Sial, Suhani Sharma, Neha Chopra, Fan Zhang, Georgina Hold, Wentian Li, Ji Tu, Victor Chen, Ashish Diwan JOR SPINE.2026;[Epub] CrossRef
Objective This systematic review and meta-analysis aimed to compare endoscopic discectomy (ED) with microdiscectomy (MD) for lumbar disc herniation, evaluating patient-reported outcomes, perioperative parameters, and complications to determine if ED could replace MD as the gold standard.
Methods Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we searched PubMed, Embase, Scopus, and Web of Science (January 2000–June 2025) for randomized controlled trials (RCTs) and prospective cohort studies comparing MD with ED subtypes (transforaminal endoscopic lumbar discectomy [TELD], interlaminar endoscopic lumbar discectomy [IELD], and unilateral biportal endoscopy [UBE]). Outcomes included Oswestry Disability Index (ODI), visual analogue scale (VAS) for pain, operative time, hospital stay, complications, and recurrence. Pooled mean differences and odds ratios (ORs) were calculated using random-effects models, with subgroup analyses by ED subtype. Risk of bias was assessed using RoB 2.0 and ROBINS-I tools.
Results Seventeen studies (9 RCTs, 8 cohorts; n=3,115) were included. ED significantly reduced hospital stay (mean difference, -2.43 days; 95% CI, -3.62 to -1.23; p<0.05) and showed greater short-term ODI improvement (mean difference, 2.13; 95% CI, 0.58–3.67). No differences were observed in operative time, long-term ODI, or VAS scores. ED had lower wound complications but a higher recurrence risk with TELD (OR, ~2.0). High heterogeneity (I²>95%) and limited long-term data (>2 years) were noted.
Conclusion ED offers perioperative advantages and comparable efficacy but does not surpass MD due to TELD’s increased recurrence risk. IELD and UBE are promising alternatives, but MD remains the benchmark. Long-term RCTs are needed.
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Letter to Editor: Practice preference of revision surgery for recurrent lumbar disc herniation: an international survey of AO spine members Borriwat Santipas, Jin-Sung Kim European Spine Journal.2026;[Epub] CrossRef
Luca Ambrosio, Sathish Muthu, Patrick C. Hsieh, S. Tim Yoon, Jeffrey C. Wang, Gianluca Vadalà, Hans Jörg Meisel, Stipe Ćorluka, Zorica Buser, AO Spine Knowledge Forum Degenerative
Neurospine 2026;23(1):31-39. Published online January 31, 2026
Objective This study aimed to characterize international practice patterns in the surgical management of primary lumbar disc herniation (LDH) among AO Spine surgeons.
Methods A cross-sectional online survey was distributed in September 2024 to AO Spine members. The questionnaire collected detailed information on demographic characteristics, surgical indications, preferred techniques, and approaches for primary LDH treatment. Data on specialty, practice setting, fellowship training, and surgical case volume were analyzed using univariate and multivariate logistic regression to identify significant associations between surgeon characteristics and treatment preferences.
Results A total of 714 surgeons participated, representing diverse regions: North America (9.0%), Latin America (18.7%), Europe & Southern Africa (34.7%), Middle East & Northern Africa (12.8%), and Asia Pacific (24.8%). Neurological status was the most critical factor influencing early operative treatment in nonurgent cases, while bladder/bowel dysfunction and severe motor deficits were the primary indications in urgent scenarios. The majority of respondents (54.2%) preferred a mini-open technique—using either a surgical microscope or loupes—with partial laminotomy (58.1%) and partial discectomy (63.2%) being the most frequently performed procedures. Regional variations and differences in surgeon training were significantly associated with the choice of surgical approach and overall case volume.
Conclusion The findings reveal substantial variability in the surgical management of primary LDH across regions and specialties. This comprehensive dataset underscores the need for standardized, evidence-based guidelines to harmonize treatment strategies and optimize patient outcomes.
Objective This study aims to evaluate the clinical benefits of the integrated optical and magnetic surgical navigation system in assisting transforaminal endoscopic lumbar discectomy (TELD) for the treatment of lumbar disc herniation (LDH).
Methods A retrospective analysis was conducted on patients who underwent TELD for LDH at Beijing Chaoyang Hospital, Capital Medical University from November 2022 to December 2023. Patients treated with the integrated optical and magnetic surgical navigation system were defined as the navigation-guided TELD (Ng-TELD) group (30 cases), while those treated with the conventional x-ray fluoroscopy method were defined as the control group (31 cases). Record and compare baseline characteristics, surgical parameters, efficacy indicators, and adverse events between the 2 patient groups.
Results The average follow-up duration for the 61 patients was 11.8 months. Postoperatively, both groups exhibited significant relief from back and leg pain, which continued to improve over time. At the final follow-up, patients’ lumbar function and quality of life had significantly improved compared to preoperative levels (p < 0.05). The Ng-TELD group had significantly shorter total operation time (58.43 ± 12.37 minutes vs. 83.23 ± 25.90 minutes), catheter placement time (5.83 ± 1.09 minutes vs. 15.94 ± 3.00 minutes), decompression time (47.17 ± 11.98 minutes vs. 67.29 ± 24.23 minutes), and fewer intraoperative fluoroscopies (3.20 ± 1.45 vs. 16.58 ± 4.25) compared to the control group (p < 0.05). There were no significant differences between the groups in terms of efficacy evaluation indicators and hospital stay. At the final follow-up, the excellent and good rate of surgical outcomes assessed by the MacNab criteria was 98.4%, and the overall adverse event rate was 8.2%, with no statistically significant differences between the groups (p > 0.05).
Conclusion This study demonstrates that the integrated optical and magnetic surgical navigation system can reduce the complexity of TELD, shorten operation time, and minimize radiation exposure for the surgeon, highlighting its promising clinical potential.
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Sang-Min Park, Kwang-Sup Song, Dae-Woong Ham, Ho-Joong Kim, Min-Seok Kang, Ki-Han You, Choon Keun Park, Dong-Keun Lee, Jin-Sung Kim, Hong-Jae Lee, Hyun-Jin Park
Neurospine 2024;21(4):1190-1198. Published online December 31, 2024
Objective To compare the safety profiles of biportal endoscopic spinal surgery (BESS) and microscopic spinal surgery (MSS) for lumbar disc herniation and spinal stenosis by analyzing the associated adverse events.
Methods We pooled data from 2 prospective randomized controlled trials involving 220 patients (110 in each group) who underwent single-level lumbar surgery. Participants aged 20–80 years with radiating pain due to lumbar disc herniation or spinal stenosis were included in this study. Adverse events were recorded and analyzed over a 12-month follow-up period.
Results The overall adverse event rates were 9.1% (10 of 110) in the BESS group and 17.3% (19 of 110) in the MSS group, which were not statistically significantly different (p=0.133). Notably, wound dehiscence occurred in 8.2% of MSS cases but in none of the BESS cases. Both groups showed similarly low rates of complications, such as dural tears, epidural hematoma, and nerve root injury. The most common adverse event in the BESS group was recurrent disc herniation (2.7%), whereas that in the MSS group was wound dehiscence (8.2%).
Conclusion BESS demonstrated a safety profile comparable to that of MSS for the treatment of lumbar disc herniation and spinal stenosis, with a trend towards fewer overall complications. BESS offers particular advantages in terms of reducing wound-related complications. These findings suggest that BESS is a safe alternative to conventional MSS and potentially offers the benefits of a minimally invasive approach without compromising patient safety.
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Objective Lumbar disc herniation (LDH) represents an increasingly encountered condition in patients with rheumatoid arthritis (RA). The aim of the present study is to assess the progress of health-related quality of life following transforaminal endoscopic lumbar discectomy (TELD) for LDH in patients suffering from RA.
Methods Seventy-four patients, scheduled to undergo elective TELD for LDH, were prospectively enrolled in the study. Group A included 36 otherwise healthy individuals and group B 38 patients complementarily diagnosed with RA according to the 2010 ACR/EULAR (American College of Rheumatology/European League Against Rheumatism) criteria. The Medical Outcomes Study 36-item Short Form health survey (SF-36) was selected for the outcome assessment at baseline and postoperatively, at selected intervals at 6 weeks, 3, 6, and 12 months postoperatively.
Results Group A presented statistically significantly higher scores in all SF-36 domains and all selected intervals (p<0.001), except for mental health parameter. All aspects of SF-36 questionnaire significantly improved postoperatively (p<0.001) and in each group independently. Nevertheless, the absolute improvement between consecutive time intervals did not differ significantly between the 2 groups.
Conclusion Patients diagnosed with RA who undergo TELD for LDH demonstrate statistically significant improvement in their health status, as measured by SF-36 questionnaire, one year after the procedure. This improvement is comparable with normal individuals.
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Objective This study aimed to evaluate the effects of 2 endoscopic spine surgeries on the biomechanical properties of normal and osteoporotic spines.
Methods Based on computed tomography images of a healthy adult volunteer, 6 finite element models were created. After validating the normal intact model, a concentrated force of 400 N and a moment of 7.5 Nm were exerted on the upper surface of L3 to simulate 6 physiological activities of the spine. Five types of indices were used to assess the biomechanical properties of the 6 models, range of motion (ROM), maximum displacement value, intervertebral disc stress, maximum stress value, and articular protrusion stress, and by combining them with finite element stress cloud.
Results In normal and osteoporotic spines, there was no meaningful change in ROM or disc stress in the 2 surgical models for the 6 motion states. Model N1 (osteoporotic percutaneous transforaminal endoscopic discectomy model) showed a decrease in maximum displacement value of 20.28% in right lateral bending. Model M2 (unilateral biportal endoscopic model) increased maximum displacement values of 16.88% and 17.82% during left and right lateral bending, respectively. The maximum stress value of L4–5 increased by 11.72% for model M2 during left rotation. In addition, using the same surgical approach, ROM, maximum displacement values, disc stress, and maximum stress values were more significant in the osteoporotic model than in the normal model.
Conclusion In both normal and osteoporotic spines, both surgical approaches were less disruptive to the physiologic structure of the spine. Furthermore, using the same endoscopic spine surgery, normal spine biomechanical properties are superior to osteoporotic spines.
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Objective We attempted to investigate the potential risk factors of recurrent lumbar disc herniation (rLDH) after tubular microdiscectomy.
Methods We retrospectively analyzed the data of patients who underwent tubular microdiscectomy. The clinical and radiological factors were compared between the patients with and without rLDH.
Results This study included 350 patients with lumbar disc herniation (LDH) who underwent tubular microdiscectomy. The overall recurrence rate was 5.7% (20 of 350). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) at the final follow-up significantly improved compared with those preoperatively. There was no significant difference in the preoperative VAS score and ODI between the rLDH and non-rLDH groups, while the leg pain VAS score and ODI of the rLDH group were significantly higher than those of the non-rLDH group at final follow-up. This suggested that rLDH patients had a worse prognosis than non-rLDH patients even after reoperation. There were no significant differences in sex, age, body mass index, diabetes, current smoking and drinking, disc height index, sagittal range of motion, facet orientation, facet tropism, Pfirrmann grade, Modic changes, interdisc kyphosis, and large LDH between the 2 groups. Univariate logistic regression analysis revealed that rLDH was associated with hypertension, multilevel microdiscectomy, and moderate-severe multifidus fatty atrophy (MFA). A multivariate logistic regression analysis indicated that MFA was the sole and strongest risk factor for rLDH after tubular microdiscectomy.
Conclusion Moderate-severe MFA was a risk factor for rLDH after tubular microdiscectomy, which can serve as an important reference for surgeons in formulating surgical strategies and the assessment of prognosis.
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Objective Full-endoscopic spine surgery is gaining interest as a less-invasive alternative to treat sciatica caused by a lumbar disc herniation. Concerns, however, exist with the learning curve as percutaneous transforaminal endoscopic discectomy (PTED) appears to be more difficult to be performed compared to other techniques. In this study, the clinical outcomes during and after the learning curve are presented of 3 surgeons naïve to PTED.
Methods In the first phase of a randomized controlled, noninferiority trial comparing PTED with microdiscectomy, 3 surgeons were trained in the PTED-procedure by a senior surgeon. After performing up to 20 cases under supervision, they started performing PTED on their own. Results of the early cases were compared to the later cases (>20). Furthermore, complications and reoperations were compared. Finally, differences in clinical outcomes between surgeons were compared.
Results At 12 months of follow-up, 87% of the patients had follow-up data available. In general, there were no significant differences in patient-reported outcomes between the early and later PTED cases. Furthermore, outcomes of the early PTED cases were comparable to the outcomes of microdiscectomy, while the later PTED cases had small, but more favorable outcomes compared to microdiscectomy. Two learning curve surgeons had substantially higher rates of reoperations within 1 year, compared to the senior surgeon or the microdiscectomy group. Duration of surgery was also longer for all learning curve surgeons. Finally, when comparing clinical outcomes of patients undergoing PTED versus microdiscectomy, there appears to be some statistically significant differences in outcomes compared between the senior and 3 learning curve surgeons.
Conclusion PTED appears to be safe to be adopted by surgeons naïve to the procedure when they are initially supervised by an experienced senior surgeon. Duration of surgery and risk of repeated surgery are increased during the learning curve, but patient-reported outcomes of the early PTED cases are similar to the outcomes of later PTED cases, and similar to the outcomes of microdiscectomy cases. This study underlines the need for an experienced mentor for surgeons to safely adopt PTED.
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Objective Percutaneous transforaminal endoscopic discectomy (PTED) is gaining popularity by both surgeons and patients as a less invasive treatment option for sciatica. Concerns, however, exist for its learning curve. No previous study has assessed the learning process of PTED. Hereby we present the learning process of 3 surgeons learning PTED.
Methods This analysis was conducted alongside a multicenter randomized controlled trial. After attending a cadaveric workshop, 3 spine-dedicated surgeons started performing PTED, initially under the supervision of a senior surgeon. After each 5 cases, and up to case 20, the learning process was evaluated using the validated questionnaires (objective structured assessment of technical skills [OSATS], global operative assessment of laparoscopic skills [GOALS]) and a 10-step checklist specifically developed for PTED.
Results In total, 3 learning curve surgeons performed a total of 161 cases. Based on self-assessment, surgeons improved mostly in the domains “time and motion,” “respect for tissue,” and “knowledge and handling of instruments.” Learning curve surgeons were more able to detect differences in performances on the OSATS than the senior surgeon. Based on the GOALS, the biggest improvements could be seen in “depth-perception” and “autonomy.” Based on the 10-item specific checklist, all surgeons performed all 10 steps by case 10, while only 1 surgeon performed all steps adequately by case 15.
Conclusion Based on these study results, PTED appears to be successfully adopted stepwise by 3 spine-dedicated surgeons. From 15 cases on, most steps are performed adequately. However, more cases might be necessary to achieve good clinical results. Validated tools are needed to determine the cutoff when a surgeon should be able to perform PTED independently.
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Operative time, recurrence, and complications throughout the initial learning curve in transforaminal endoscopic lumbar discectomy Michelle D. Poelman, Annegien Boeykens, Biswadjiet S. Harhangi, Marc L. Schröder, Victor E. Staartjes Acta Neurochirurgica.2026;[Epub] CrossRef
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Letter to the editor regarding, “Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: A randomized controlled trial” by Park et al. Concepts, analyses and interpretation of noninferiority randomized controlled trials Pravesh S. Gadjradj, Fabian Sommer, Rodrigo Navarro-Ramirez, Judith D. de Rooij The Spine Journal.2023; 23(3): 467. CrossRef
Reply to letter to the editor regarding, “Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial” Sang-Min Park, Ho-Joong Kim The Spine Journal.2023; 23(3): 469. CrossRef
Objective The purpose of this study was to investigate the learning curve and complications of unilateral biportal endoscopy (UBE) in the treatment of lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS).
Methods This was a retrospective cohort analysis of 197 consecutive patients who received UBE unilateral laminotomy bilateral decompression (UBE-ULBD) or lumbar discectomy (UBE-LD) surgery, including 107 males and 90 females with an average age of 64.83 ± 14.29 years. Cumulative sum (CUSUM) and risk-adjusted cumulative sum analysis (RA-CUSUM) were used to evaluate the learning curve, with the occurrence of complications defined as surgical failure, and variables of different phase of the learning curve were compared.
Results The cutoff point of learning curve of UBE surgery was 54 cases according to CUSUM analysis. The learning curve of UBE-ULBD and UBE-LD were divided into 3 phases. The first cutoff points were 31 and 12 cases, and the second cutoff point were 67 and 32 cases respectively. With the progress of the learning curve, the operation time and postoperative hospital stays decreased. The visual analogue scale and Oswestry Disability Index at the last follow-up were significantly lower than that before surgery. The incidence of surgical failure was 6.11% and began to decrease after the 89th case based on RA-CUSUM analysis. The surgical failure rate decreased from 10.11% to 2.78 after the 89th case with significant different.
Conclusion UBE surgery is effective in the treatment of LDH and LSS with low incidence of complications. But a learning curve of at least 54 cases still required for mastering UBE surgery.
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Objective The 5-repetition-sit-to-stand (5R-STS) test is an objective test of functional impairment- commonly used in various diseases, including lumbar degenerative disc diseases. It is used to measure the severity of disease and to monitor recovery. We aimed to evaluate reference values for the test, as well as factors predicting 5R-STS performance in healthy adults.
Methods Healthy adults ( > 18 years of age) were recruited, and their 5R-STS time was measured. Their age, sex, weight, height, body mass index (BMI), smoking status, education level, work situation and EuroQOL-5D Healthy & Anxiety category were recorded. Linear regression analysis was employed to identify predictors of 5R-STS performance.
Results We included 172 individuals with mean age of 39.4 ± 14.1 years and mean BMI of 24.0 ± 4.0 kg/m2. Females constituted 57%. Average 5R-STS time was 6.21 ± 1.92 seconds, with an upper limit of normal of 12.39 seconds. In a multivariable model, age (regression coefficient [RC], 0.07; 95% confidence interval [CI], 0.05/0.09; p < 0.001), male sex (RC, -0.87; 95% CI, -1.50 to -0.23; p = 0.008), BMI (RC, 0.40; 95% CI, 0.10–0.71; p = 0.010), height (RC, 0.13; 95% CI, 0.04–0.22; p = 0.006), and houseworker status (RC, -1.62; 95% CI, -2.93 to -0.32; p = 0.016) were significantly associated with 5R-STS time. Anxiety and depression did not influence performance significantly (RC, 0.82; 95% CI, -0.14 to 1.77; p = 0.097).
Conclusion The presented reference values can be applied as normative data for 5R-STS in healthy adults, and are necessary to judge what constitutes abnormal performance. We identified several significant factors associated with 5R-STS performance that may be used to calculate individualized expected test times.
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Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy.
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Distance to first symptoms measured by the 6-min walking test differentiates between treatment success and failure in patients with degenerative lumbar disorders Anna M. Zeitlberger, Marketa Sosnova, Michal Ziga, Oliver P. Gautschi, Luca Regli, Oliver Bozinov, Astrid Weyerbrock, Martin N. Stienen, Nicolai Maldaner European Spine Journal.2022; 31(3): 596. CrossRef
External Validation of the Minimum Clinically Important Difference in the Timed-up-and-go Test After Surgery for Lumbar Degenerative Disc Disease Nicolai Maldaner, Marketa Sosnova, Michal Ziga, Anna M. Zeitlberger, Oliver Bozinov, Oliver P. Gautschi, Astrid Weyerbrock, Luca Regli, Martin N. Stienen Spine.2022; 47(4): 337. CrossRef
External Validation of the Timed Up and Go Test as Measure of Objective Functional Impairment in Patients With Lumbar Degenerative Disc Disease Martin N Stienen, Nicolai Maldaner, Marketa Sosnova, Anna M Zeitlberger, Michal Ziga, Astrid Weyerbrock, Oliver Bozinov, Oliver P Gautschi Neurosurgery.2021; 88(2): E142. CrossRef
Patients undergoing surgery for lumbar degenerative spinal disorders favor smartphone-based objective self-assessment over paper-based patient-reported outcome measures Marketa Sosnova, Anna Maria Zeitlberger, Michal Ziga, Oliver P. Gautschi, Luca Regli, Astrid Weyerbrock, Oliver Bozinov, Martin N. Stienen, Nicolai Maldaner The Spine Journal.2021; 21(4): 610. CrossRef
Assessment of the Minimum Clinically Important Difference in the Smartphone-based 6-minute Walking Test After Surgery for Lumbar Degenerative Disc Disease Anna M. Zeitlberger, Marketa Sosnova, Michal Ziga, Luca Regli, Oliver Bozinov, Astrid Weyerbrock, Martin N. Stienen, Nicolai Maldaner Spine.2021; 46(18): E959. CrossRef
Evaluation of the 6-minute walking test as a smartphone app-based self-measurement of objective functional impairment in patients with lumbar degenerative disc disease Nicolai Maldaner, Marketa Sosnova, Anna M. Zeitlberger, Michal Ziga, Oliver P. Gautschi, Luca Regli, Astrid Weyerbrock, Martin N. Stienen, _ _ Journal of Neurosurgery: Spine.2020; 33(6): 779. CrossRef
Objective While it has been established that surgery for lumbar disc herniation, excluding emergent indications, should only be performed after weeks of conservative treatment, it has also been established that late surgery is associated with poorer outscomes in terms of leg pain. However, nothing is known concerning the timinig and functional outcome. We quantify the association of time to surgery (TTS) with functional impairment outcome and identify a maximum TTS cutoff.
Methods A consecutive series of patients who underwent tubular microdiscectomy for lumbar disc herniation was included. A reduction of ≥ 30% in the Oswestry Disability Index from baseline to 12 months was defined as the minimum clinically important difference (MCID). TTS was defined as time of symptom onset to surgery in weeks. The maximum TTS cutoffs were derived both quantitatively by an area under the curve (AUC) analysis, as well as qualitatively based on cutoff-specific MCID rates.
Results Inclusion was met by 372 patients, among which 327 (87.9%) achieved MCID. MCID achievement was associated with lower TTS (hazard ratio, 0.725; 95% confidence interval, 0.557–0.944; p = 0.014). The optimum maximum TTS based on AUC was 21.5 weeks. The qualitative analysis showed a continuous drop of MCID rates with increasing TTS, with values > 80% until week 14.
Conclusion Our findings suggest that longer TTS is associated with a poorer patient-reported outcome in terms of functional impairment, and that—depending on the calculation method and according to the literature—a maximum TTS of between 14 to 22 weeks should likely be aimed for.
Citations
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