Elsevier

Surgical Neurology

Volume 66, Issue 5, November 2006, Pages 470-473
Surgical Neurology

Spine
A prospective evaluation of the role for intraoperative x-ray in lumbar discectomy. Predictors of incorrect level exposure

https://doi.org/10.1016/j.surneu.2006.05.069Get rights and content

Abstract

Background

Lumbar discectomy is among the most frequently performed procedures by spine surgeons. Among the potential difficulties encountered during this procedure, incorrect spinal level surgery remains a significant concern for surgeons and patients. Multiple groups have advocated the use of intraoperative x-ray to reduce the incidence of incorrect level surgery; however, this technique has not been prospectively evaluated.

Methods

In an effort to determine the incidence of incorrect level exposure during lumbar discectomy and to define patient characteristics predictive of wrong level exposure, we examined 100 consecutive patients who underwent lumbar discectomy by a single surgeon. After exposure, the surgeon was asked to identify the level exposed, which was confirmed by intraoperative x-ray. Several patient characteristics were then examined by logistical regression to identify features predictive of a mismatch between level of exposure and level of pathology.

Results

The study population was composed of 48 men and 52 women who were aged 18 to 83 years. Patient weights ranged from 105 to 410 lb. There were 51 patients who had pathology at the L5-S1 level; 44 patients, L4-L5; 3 patients, L3-L4; and 1 patient, L2-L3. Four patients had transitional vertebrae. The intended level was initially exposed in 85% of cases. Age and level of pathology (P < .05) were identified as factors predictive of a mismatch between intraoperative level of exposure and preoperative level of pathology.

Conclusions

Pathology above L5-S1 and patient age have been shown to reliably predict incorrect level exposure. Based upon the findings of this study, the routine use of intraoperative x-ray to confirm the level of exposure should be considered in all cases of lumbar discectomy.

Introduction

Since the initial reports by Dandy [4] in 1929 and Mixter and Barr [12] in 1934, the surgical management of lumbar disk disease has evolved into the most common procedure performed by neurosurgical and orthopedic spine surgeons. According to the National Hospital Discharge Survey and National Survey of Ambulatory Surgery data, over 120,000 laminectomies for spinal disease are performed annually.

Despite the great frequency with which spine surgeons perform lumbar laminectomy, there remain multiple, potential difficulties encountered during this procedure including bleeding, infection, cerebrospinal fluid leak, nerve root injury, and operation at an incorrect spinal level. In an effort to reduce the incidence of incorrect level surgery, a number of techniques have been described to identify which spinal levels have been exposed during surgery before performing the laminectomy. Among these techniques, intraoperative x-ray is felt by many surgeons to be the most accurate method. In an effort to define the incidence of incorrect level exposure during lumbar laminectomy and to better define the role for intraoperative x-ray during these procedures, we prospectively examined a cohort of consecutive patients undergoing lumbar discectomy.

Section snippets

Clinical data

Between December 2003 and November 2005, 100 consecutive patients with unilateral, symptomatic, lumbar disk herniations were prospectively evaluated and treated. All patients had failed conservative therapy consisting of a combination of physical therapy, epidural steroids, anti-inflammatories, and/or muscle relaxants before surgical intervention. Patients were excluded if they had undergone previous lumbar spine surgery. Preoperative MRI and/or myelography were correlated with patient

Patient demographics

The study population was composed of 48 men and 52 women, ranging in age from 18 to 83 years (mean age, 45.7 ± 15.0; median, 45.4); 25% of patients were less than 35 years of age, 50% less than 45 years, and 75% less than 55 years. Right-sided symptoms were observed in 45 patients, and left-sided symptoms were observed in 55 patients. Patient weights ranged from 105 to 410 lb (average, 176.8 ± 49.9; median, 171). A total of 16 patients weighed more than 225 lb, 7 patients more than 250 lb, and

Discussion

Up to 80% of individuals will experience at least 1 episode of low back pain during their lifetime, with lumbar disk disease being a significant contributor. This common condition generates between $20 and $50 billion in total health care costs [13]. Despite a vast and increasing number of nonsurgical therapies for disk disease, surgical removal of the compressive disk herniation remains a widespread and highly effective treatment option for symptomatic lumbar disk disease [1], [2], [7], [10],

Conclusion

Exposure of the wrong spinal level is a significant surgical risk during lumbar discectomy. To the authors' knowledge, this is the first study to define what factors predict wrong level exposure. Pathology above the L5-S1 level and advancing patient age has been shown to reliably predict wrong level exposure. Based upon the findings of this study, the routine use of intraoperative x-ray to confirm the level of exposure should be considered in all cases of lumbar discectomy.

Acknowledgment

We thank Dr James Leiphart, George Washington University, Department of Neurosurgery, for his assistance with manuscript editing.

References (18)

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