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Epidural buprenorphine for relieving postoperative pain in patients undergoing lumbar laminectomy: A preliminary study
Sl06
Spine - Lumbar Spine
of operations were performed by this technique the problem is still disputable. We analysed the results of operations performed from 1989. In 249 cases the traditional technique was used (laminectomy, hemilaminectomy, posterior spondylodesis of different types etc) and in 752 - microdiscectomy. After the traditional in1ervention the outcomewas good in 73% and in the othercases the results were mild or poor. After microdiscectomy good results were achieved in 92%. There was a smaller number of postoperative complications when microdiscectomy was performed: wound infection 1.9% vs. 5.7%, discitis 0.6% vs 3%, neurological deficit 1.3% vs. 1.9%, urinary catheter 0.6% vs 1.9%, reoperation 5% vs 13%. According to our results we conclude that microdiscectomy is the method of choice in the treatmentof vertebral diseases, taking into consideration the low price of operations and the short postoperative period.
I0-16-228 1 Evaluation of the postoperative clinical
improvement in patients with serious radicular paresis operated on for lumbar disc herniation
H. Toplamaoglu, N. $i~li, R. Atabey, B. Bozyigit, T. Kiri~, M. AsiitUrk. Bakurkoy MentalHospital, Neurosurgery Department, Istanbul, Turkey Between 1992and1995,1387patientswereoperated for lumbardischerniation. From these patients, 287 consecutive patients with severe paresis (3/5 or less strength on the involved muscle groups) due to radicular compression were evaluatedretrospectively. 90 patientswere excludedfromthisstudybecause 22 couldnot be followedup in the postoperative period, and 68 because the period of paresis could not be determined from their records. Included were95 women (48.2%) and 102 men (51.8%), with a mean age of 46.5 years (range 21-72) . The purpose of this study was to evaluate the influences of the preoperative degree of paresis and the period of time of paresis on the post operative (first and sixth months) results. The duration of the paresis ranged from 1 day to 6 months(mean 1.2 months). The patientswere classifiedaccording to thedegree of paresis 0/5. 1/5, 2/5, 3/5, there were 30 patients, 28 patients. 48 patients, 91 patients, respectively. We compared these preoperative valueswith the post operative results. In the first month.46.1% of the patients had excellent, 41.6% good and 12.1% poor results, whereas in the sixth month 81.7% of the patients had excellent, 12.1 % good and 6.1% poor results. The results werestatistically analyzed by the One-way ANOVAand Wilcoxon matched-pairs signed-ranks tests. A positive correlation was found between the preoperative degree of intensity of paresis and the post operative improvement. However, the duration of the paralytic symptomshad no significant effect on a successful outcome.
I0-16-2291
Far lateral disc prolapses of the lumbar spine. Lateral approach and postoperative results
U. Wildforster, M. Hardenack, K. Schmieder, M. Zell, M. Scholz, A. Harders. Department of Neurosurgery, Ruhr-University, Bochum, Germany Introduction: Lateral prolapses of the lumbar spine have an incidence of 4% up to 8% of all herniated lumbardiscs which require surgical therapy. A special operative approach is necessaryto avoid damageto the smallfacetjoint. Method: In the period of 1990 to 1995 we performed 100 operations on extraforaminal disc prolapses. Our incidence was 6.9%. In 85 cases only the lateral approach was performed, in 15 cases a combined approach including intraspinal conventional approach was used. All patients received the same postoperative care, all of themwere examinedat least 6 months after operation. ReSUlts: There were neither statistical differences regarding age, sex, segments, durationof symptoms, nor postoperative useof analgetics nor the time to mobilize patient. The postoperative hospital care was 1.5 dayslongerthan after only intraspinal approach. Among those 100 cases we saw 2 complications of deep wound infection and 2 cases of early recurrence. At the lime of follow-up examination 78"k of the patients were excellent whereas 9% did not improve from their complaints.
I0-16-230 I Long-term results after far lateral approach to lateral lumbar disc herniations
F. Porchet, A. Chollet, N. De Tribolet. Departement of Neurosurgery, University Hospital, Lausanne, Switzerland Introduction: The extraforaminal lumbar disc herniation (ELDH) became fully appreciated since the introduction of computed tomography (CT), showing an incidence of 3 to 11% . In 1987our groupdescribedthe microsurgical transrnuscular far lateral approach to ELDH. The purpose of this study was to evaluate the long term resultsof patientsoperated by this newtechnic. Method: Datafrom the hospitaland officechartsof 202 consecutive patients treatedduring a 7-yearperiodwere reviewed retrospectively by an independent physician. The mean length of follow up was 50 months. Results: Almostone third (63) of the ELDHwerelocatedat the upperlurnbar levels (Ll-L2 to L3-L4). There were 82 ELDH at the L4-L5 level and 57 at the
Tuesday, 8 July 1997 L5·S1 level. 77% (155) of the patients presented with a motor deficit which resolved in 87% after surgery. Preoperative sensorydeficits were noted in 58% (117) of all patients and were still present in 21% of the patients at the last follow up. According to Mac Nab's outcome criterias 73% of the patients had an excellent or good longterm outcome. There were 9 caseswith recurred disc herniations (4.5%) at the same level whereof 8 were located paramedially. No secondary spinal instability occured needing a fusion procedure. 10 patients (5%) had complications only 3 of which were directly related to the surgical procedure. Conclusion : The far lateral approach is a save and minimally invasive procedure, achieving competitive results at long term follow up and exciudlnp the risk of secondaryinstability due to a facetectomy.
I0-16-231 I Epidural buprenorphine for relieving postoperative pain in patients undergoing lumbar laminectomy: A preliminary study Nikhil Shah. Department of Neurosurgery, K.E.M. Hospital, Bombay, India This was a prospective, doubleblind, randomized trial on 26 patientswho had undergone laminectomy for disc diseaseand where the dura was not opened. Coded ampoules, indentical in appearance, containing either Buprenorphne (600 micrograms) or placebo were used. One patient has been excluded as the dura was inadvertently opened during laminectomy. There were 12 patients in the Buprenorphine group and 13 in the control group. The pain could not be assessed in one patient in each group as they were put on ventilator post-operatively as they were hypersensitive to muscle relaxants. 8 of the 11 patients in whom pain could be assessed (72.73%) responded well to epidural Buprenorphine. 3 patients did not respond to Buprenorphine and needed additional analgesics. 3 patients in the placebo group responded well. The duration of analgesia varied between 6 hours to 10 hours. Dizziness, drowsiness, vomiting, pruritis, hypotension, changes in pulse or reduction in respiratory rate were not observed in any patients in this study in eithergroup. Urinary retention was noted in 2 patients in the Buprenorphine group and 1 patient in the control group. These were relieved by a change of posture from that 01 supine to erect. Buprenorphine can be safely used as an epidural analgesic in patients undergoing lumbarspinallaminectomy. The exposed and intact durameter after spinal laminectomyhas provided a unique opportunity for pain relief, without the need of carrying out a needlepuncture or a need to pass an epidural catheter for analgesia in these patients.
I0-16-232 1 Combined approaches in spinal stenosis and extreme lateral disc herniations
M.D. Woodtli. Toronto Hospital Western Division UOT, Toronto, Canada, DL Kaech Kantonspital, Chur, Switzerland This is a fellow-up study comparing a total of 52 patients treated surgically between November 89 and November 94 for lumbar monoradicular, and biradicular syndromes resistant to conservative therapy. The clinicalfeaturesand postoperativeresults of 25 casesof extremelateral disc herniations (ELDH) presenting with monoradicular syndromes and 23 cases of biradicular syndromes requiring combined intralaminar-extralaminar approaches (CIEA) for additional intraspinal root entrapment were studied. Four patients treated in the same interval but undergoing CIEAand additional spinal fusion procedures were excluded from the outcome analysis. The mean follow-up period was 47 weeks with a rangeof 2 months to 60 months. The mean age for ELDH was 54 years (range 24-76) and 56 (range 4G-76) in the CIEA group. There was a clear male preponderance in the ELDH group (Male/Female = 22/3) but a balanced ralio (Male/Female 11 /12) in the CIEA group. Subjectively the approval of the outcome was very high (> 90%) in both series, howeverthe ELDHseries was betteroff in terms of subjective life quality than the CIEA. Retumto full-time work was 75% for the CIEA and 80% for the ELDH. In the follow-up interval so far no patient with CIEA required secondary fusion for symptomatic instability. The incidence of minor symptoms compatible with some reduced instability was even lower in the CIEA group with 4% than in the ELDH groupwith 8%. This finding is in favor of preserving a pars interarticularis bridge of at least 5 mm, thus preserving the so-called posterior spinal column of Louis. There was a significant amountof minor residual neurological deficits and complaints, which did not recover in both series. Thus roughly three quartersof thepatientshadresidual sensory disturbances andepisodesof lower back pain, and43% of the CIEAand 36% of the ELDHgroup had minor residual paresis though not affecting daily activities. Overall we concludefrom our data that the outcome for ELDHis better than for CIEA. This may be due to the fact that the degreeof degenerative changes in CIEA is greater and the pathology is moreoften multifocal, whereas ELDHpatients havealmostexclusively (96%) unilateral and single level lesions.
Spine - Lumbar Spine
of operations were performed by this technique the problem is still disputable. We analysed the results of operations performed from 1989. In 249 cases the traditional technique was used (laminectomy, hemilaminectomy, posterior spondylodesis of different types etc) and in 752 - microdiscectomy. After the traditional in1ervention the outcomewas good in 73% and in the othercases the results were mild or poor. After microdiscectomy good results were achieved in 92%. There was a smaller number of postoperative complications when microdiscectomy was performed: wound infection 1.9% vs. 5.7%, discitis 0.6% vs 3%, neurological deficit 1.3% vs. 1.9%, urinary catheter 0.6% vs 1.9%, reoperation 5% vs 13%. According to our results we conclude that microdiscectomy is the method of choice in the treatmentof vertebral diseases, taking into consideration the low price of operations and the short postoperative period.
I0-16-228 1 Evaluation of the postoperative clinical
improvement in patients with serious radicular paresis operated on for lumbar disc herniation
H. Toplamaoglu, N. $i~li, R. Atabey, B. Bozyigit, T. Kiri~, M. AsiitUrk. Bakurkoy MentalHospital, Neurosurgery Department, Istanbul, Turkey Between 1992and1995,1387patientswereoperated for lumbardischerniation. From these patients, 287 consecutive patients with severe paresis (3/5 or less strength on the involved muscle groups) due to radicular compression were evaluatedretrospectively. 90 patientswere excludedfromthisstudybecause 22 couldnot be followedup in the postoperative period, and 68 because the period of paresis could not be determined from their records. Included were95 women (48.2%) and 102 men (51.8%), with a mean age of 46.5 years (range 21-72) . The purpose of this study was to evaluate the influences of the preoperative degree of paresis and the period of time of paresis on the post operative (first and sixth months) results. The duration of the paresis ranged from 1 day to 6 months(mean 1.2 months). The patientswere classifiedaccording to thedegree of paresis 0/5. 1/5, 2/5, 3/5, there were 30 patients, 28 patients. 48 patients, 91 patients, respectively. We compared these preoperative valueswith the post operative results. In the first month.46.1% of the patients had excellent, 41.6% good and 12.1% poor results, whereas in the sixth month 81.7% of the patients had excellent, 12.1 % good and 6.1% poor results. The results werestatistically analyzed by the One-way ANOVAand Wilcoxon matched-pairs signed-ranks tests. A positive correlation was found between the preoperative degree of intensity of paresis and the post operative improvement. However, the duration of the paralytic symptomshad no significant effect on a successful outcome.
I0-16-2291
Far lateral disc prolapses of the lumbar spine. Lateral approach and postoperative results
U. Wildforster, M. Hardenack, K. Schmieder, M. Zell, M. Scholz, A. Harders. Department of Neurosurgery, Ruhr-University, Bochum, Germany Introduction: Lateral prolapses of the lumbar spine have an incidence of 4% up to 8% of all herniated lumbardiscs which require surgical therapy. A special operative approach is necessaryto avoid damageto the smallfacetjoint. Method: In the period of 1990 to 1995 we performed 100 operations on extraforaminal disc prolapses. Our incidence was 6.9%. In 85 cases only the lateral approach was performed, in 15 cases a combined approach including intraspinal conventional approach was used. All patients received the same postoperative care, all of themwere examinedat least 6 months after operation. ReSUlts: There were neither statistical differences regarding age, sex, segments, durationof symptoms, nor postoperative useof analgetics nor the time to mobilize patient. The postoperative hospital care was 1.5 dayslongerthan after only intraspinal approach. Among those 100 cases we saw 2 complications of deep wound infection and 2 cases of early recurrence. At the lime of follow-up examination 78"k of the patients were excellent whereas 9% did not improve from their complaints.
I0-16-230 I Long-term results after far lateral approach to lateral lumbar disc herniations
F. Porchet, A. Chollet, N. De Tribolet. Departement of Neurosurgery, University Hospital, Lausanne, Switzerland Introduction: The extraforaminal lumbar disc herniation (ELDH) became fully appreciated since the introduction of computed tomography (CT), showing an incidence of 3 to 11% . In 1987our groupdescribedthe microsurgical transrnuscular far lateral approach to ELDH. The purpose of this study was to evaluate the long term resultsof patientsoperated by this newtechnic. Method: Datafrom the hospitaland officechartsof 202 consecutive patients treatedduring a 7-yearperiodwere reviewed retrospectively by an independent physician. The mean length of follow up was 50 months. Results: Almostone third (63) of the ELDHwerelocatedat the upperlurnbar levels (Ll-L2 to L3-L4). There were 82 ELDH at the L4-L5 level and 57 at the
Tuesday, 8 July 1997 L5·S1 level. 77% (155) of the patients presented with a motor deficit which resolved in 87% after surgery. Preoperative sensorydeficits were noted in 58% (117) of all patients and were still present in 21% of the patients at the last follow up. According to Mac Nab's outcome criterias 73% of the patients had an excellent or good longterm outcome. There were 9 caseswith recurred disc herniations (4.5%) at the same level whereof 8 were located paramedially. No secondary spinal instability occured needing a fusion procedure. 10 patients (5%) had complications only 3 of which were directly related to the surgical procedure. Conclusion : The far lateral approach is a save and minimally invasive procedure, achieving competitive results at long term follow up and exciudlnp the risk of secondaryinstability due to a facetectomy.
I0-16-231 I Epidural buprenorphine for relieving postoperative pain in patients undergoing lumbar laminectomy: A preliminary study Nikhil Shah. Department of Neurosurgery, K.E.M. Hospital, Bombay, India This was a prospective, doubleblind, randomized trial on 26 patientswho had undergone laminectomy for disc diseaseand where the dura was not opened. Coded ampoules, indentical in appearance, containing either Buprenorphne (600 micrograms) or placebo were used. One patient has been excluded as the dura was inadvertently opened during laminectomy. There were 12 patients in the Buprenorphine group and 13 in the control group. The pain could not be assessed in one patient in each group as they were put on ventilator post-operatively as they were hypersensitive to muscle relaxants. 8 of the 11 patients in whom pain could be assessed (72.73%) responded well to epidural Buprenorphine. 3 patients did not respond to Buprenorphine and needed additional analgesics. 3 patients in the placebo group responded well. The duration of analgesia varied between 6 hours to 10 hours. Dizziness, drowsiness, vomiting, pruritis, hypotension, changes in pulse or reduction in respiratory rate were not observed in any patients in this study in eithergroup. Urinary retention was noted in 2 patients in the Buprenorphine group and 1 patient in the control group. These were relieved by a change of posture from that 01 supine to erect. Buprenorphine can be safely used as an epidural analgesic in patients undergoing lumbarspinallaminectomy. The exposed and intact durameter after spinal laminectomyhas provided a unique opportunity for pain relief, without the need of carrying out a needlepuncture or a need to pass an epidural catheter for analgesia in these patients.
I0-16-232 1 Combined approaches in spinal stenosis and extreme lateral disc herniations
M.D. Woodtli. Toronto Hospital Western Division UOT, Toronto, Canada, DL Kaech Kantonspital, Chur, Switzerland This is a fellow-up study comparing a total of 52 patients treated surgically between November 89 and November 94 for lumbar monoradicular, and biradicular syndromes resistant to conservative therapy. The clinicalfeaturesand postoperativeresults of 25 casesof extremelateral disc herniations (ELDH) presenting with monoradicular syndromes and 23 cases of biradicular syndromes requiring combined intralaminar-extralaminar approaches (CIEA) for additional intraspinal root entrapment were studied. Four patients treated in the same interval but undergoing CIEAand additional spinal fusion procedures were excluded from the outcome analysis. The mean follow-up period was 47 weeks with a rangeof 2 months to 60 months. The mean age for ELDH was 54 years (range 24-76) and 56 (range 4G-76) in the CIEA group. There was a clear male preponderance in the ELDH group (Male/Female = 22/3) but a balanced ralio (Male/Female 11 /12) in the CIEA group. Subjectively the approval of the outcome was very high (> 90%) in both series, howeverthe ELDHseries was betteroff in terms of subjective life quality than the CIEA. Retumto full-time work was 75% for the CIEA and 80% for the ELDH. In the follow-up interval so far no patient with CIEA required secondary fusion for symptomatic instability. The incidence of minor symptoms compatible with some reduced instability was even lower in the CIEA group with 4% than in the ELDH groupwith 8%. This finding is in favor of preserving a pars interarticularis bridge of at least 5 mm, thus preserving the so-called posterior spinal column of Louis. There was a significant amountof minor residual neurological deficits and complaints, which did not recover in both series. Thus roughly three quartersof thepatientshadresidual sensory disturbances andepisodesof lower back pain, and43% of the CIEAand 36% of the ELDHgroup had minor residual paresis though not affecting daily activities. Overall we concludefrom our data that the outcome for ELDHis better than for CIEA. This may be due to the fact that the degreeof degenerative changes in CIEA is greater and the pathology is moreoften multifocal, whereas ELDHpatients havealmostexclusively (96%) unilateral and single level lesions.