Surgical Timing in Lumbar Disc Herniation Surgery

Neurospine Neurospine 2020;17(1):213-214. https://doi.org/10.14245/ns.2040068.034 Editorial Corresponding Author Chi Heon Kim E-mail: https://orcid.org/0000-0003-0497-1130 Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea See the article “Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes” via https://doi. org/10.14245/ns.1938448.224. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2020 by the Korean Spinal Neurosurgery Society pISSN 2586-6583 eISSN 2586-6591 Surgical Timing in Lumbar Disc Herniation Surgery In response to article titled “Timing of Surgery in Tubular Microdiscectomy for Lumbar Disc Herniation and Its Effect on Functional Impairment Outcomes,”1 lumbar disc herniation (LDH) is a major spinal degenerative disease. The treatments are largely categorized as exercise, medication, intervention and surgery. Pain is the major symptom in most cases and it could be controlled with relevant treatments. Nonsurgical treatment is successful for majority of patients, but surgery is required for medically intractable cases. The treatment strategy looks simple. However, it is not straightforward. Surgeons operate LDH when nonsurgical treatment fails or major neurological symptom persisted over 6 weeks and the surgical outcomes are satisfactory in more than 90% of cases.2 However, 6 weeks of conservative period is subject to make misunderstanding among health care providers, physicians and patients and limits physician (surgeon)’s discretionary decision. The surgical techniques could be broken down into standard open discectomy, tubular retractor assisted discectomy or endoscopic surgery and the surgical outcomes of those techniques did not seem to be different based on previous studies.3-6 However, the efficacy of surgery may be mostly evident only for a short-term follow-up period ( < 2 years).7 This may be one of major reasons for the patients to be reluctant to get surgery when it is really necessary. However, more often than not, we encounter patients ended up in suffering from a chronic pain, even after successful removal of LDH by surgery. There are many factors influencing on the outcomes, such as duration of symptom, accompanying neurological deficit, psychological factor, occupation, and so on.8 If we failed to address LDH in a timely manner, the chance for a successful outcome would go down either with surgery or nonsurgical treatment.9 Therefore, we have to figure out how to address LDH relevantly, especially with surgery.2,7 In this regards, this study is meaningful in adding information regarding the issue of “When should we operate on LDH?” I appreciate the authors’ effort. However, the evidence level of this study would be level IV, considering retrospective subgroup analysis for prospectively collected data. In addition, the method to assess duration of symptom may subject to recall bias. I hope the readers to acknowledge the limitations of this study. REFERENCES 1. Siccoli A, de Wispelaere MP, Schröder ML, et al. Timing of surgery in tubular microdiscectomy for lumbar disc herniation and its effect on functional impairment outcomes. Neurospine 2020;17:204-12. 2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial  www.e-neurospine.org 213 Kim CH (SPORT). Spine (Phila Pa 1976) 2008;33:2789-800. 3. Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976) 2008;33:931-9. 4. Qin R, Liu B, Hao J, et al. Percutaneous endoscopic lumbar discectomy versus posterior open lumbar microdiscectomy for the treatment of symptomatic lumbar disc herniation: a systemic review and meta-analysis. World Neurosurg 2018; 120:352-62. 5. Birkenmaier C, Komp M, Leu HF, et al. The current state of endoscopic disc surgery: review of controlled studies comparing full-endoscopic procedures for disc herniations to standard procedures. Pain Physician 2013;16:335-44. Surgical Timing in Lumbar Disc Herniation Surgery 6. Butler AJ, Alam M, Wiley K, et al. Endoscopic lumbar surgery: the state of the art in 2019. Neurospine 2019;16:15-23. 7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006;296:2441-50. 8. Lurie JD, Henderson ER, McDonough CM, et al. Effect of expectations on treatment outcome for lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 2016;41:803-9. 9. Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 2011;93:190614. Title: Paul, the artist’s son, ten years’ old Artist: Pablo Picasso Year: 1923 © 2020 - Succession Pablo Picasso - SACK (Korea) 214 www.e-neurospine.org https://doi.org/10.14245/ns.2040068.034  (...truncated)