Analiza razlika u kliničkom toku i ishodu operativnog lečenja pacijenata obolelih usled lumbalne diskus hernije nakon standardne i mikrodiskektomije

Abstract

Standardna diskektomija (SD) je prvi put upotrebljena u svrhu lečenja lumbalne diskus hernije (LDH) 1932. godine, dok je mikrodiskektomija (MD) uvedena u kliničku praksu krajem 70ih godina dvadesetog veka. U poređenju sa SD, MD je omogućila bolju vizuelizaciju odnosa neuralnih struktura i patološkog supstrata uz značajno manju jatrogenu traumu. Iako se po mišljenju brojnih autora MD smatra za zlatni standard hirurškog lečenja LDH, u svakodnevnoj kliničkoj praksi mnogih centara dve hirurške metode imaju ravnopravan status. Cilj našeg istraživanja je bio da se uporede klinički tok, učestalost komplikacija i reoperacija, kao i krajnji funkcionalni ishod lečenja nakon MD i SD. Glavno pitanje našeg istraživanja je bilo da li je opravdano da dva modaliteta operativnog lečenja u našoj kliničkoj praksi budu ravnopravna. Istraživanje je dizajnirano kao klinička opservaciona, nerandomizirana prospektivna studija i njom je obuhvaćeno 206 pacijenata koji su operativno lečeni usled LDH na jednom spinalnom nivou, tokom trogodišnjeg perioda. Za procenu ishoda lečenja su korišćeni upitnici za pacijenta koji su bili sastavljeni iz Oswestry Disability Index-a (ODI) i vizuelno-analognih (VA) skala za bol. Kao dopuna studiji sprovedena je i retrospektivna analiza stope rekurentne diskus hernije koja je zahtevala reoperaciju, koja je obuhvatila 545 pacijenata tokom devetogodišnjeg perioda. Naši rezultati su pokazali da je mikrodiskektomija udružena sa značajno nižom stopom reoperacije, kraćom hospitalizacijom i manjom postoperativnom upotrebom analgetika, ali i dužim vremenom trajanja operacije. Takođe zadovoljstvo pacijenata operativnim lečenjem, na osnovu indeksa zadovoljstva, je bilo značajno bolje nakon MD. Ipak funkcionalni ishod lečenja i redukcija bolnog sindroma (prema ODI i VA skalama) nisu bili povezani sa izborom hirurške metode. Na pozitivan ishod operacije su uticali i kraće trajanje preoperativnih tegoba i preoperativna fizikalna terapija. Iz dobijenih rezultata se može zaključiti da treba dati prednost MD u odnosu na SD, ali i da je to metoda koja u skladu sa razvojem racionalnijeg zdravstvenog sistema.

Standard discectomy (SD) was first used for the treatment of lumbar disc herniation (LDH) in 1932, while microdiscectomy (MD) was introduced into clinical practice at the end of the 1970's. Compared to SD, MD has enabled better visualization of the relationship between neural structures and pathological substrate with significantly less iatrogenic trauma. Although MD is considered a gold standard for surgical treatment of LDH by many authors, the daily clinical practice of many centers shows that the two surgical methods have equal status. The aim of the study was to compare the clinical course, the frequency of complications and reoperations, and the ultimate functional outcome of treatment after MD and SD. The main issue of the research was is the equality of the two operative treatment modalities in our clinical practice justified. The study was designed as an observational clinical, non-randomized prospective study, encompassing 206 patients who were operatively treated for LDH at a single spinal level over the three-year period. For an outcome assessment, in patient questionnaires both the Oswestry Disability Index (ODI) and the Visual Analogue (VA) scales were used. In addition to the study, a retrospective analysis of the rate of recurrent disc herniation requiring reoperation was carried out. It included 545 patients during the nine-year period. The results have shown that microdiscectomy is associated with a significantly lower rate of reoperation, shorter hospitalization, reduced use of analgesics postoperatively, as well as an increased duration of operation. Also, based on satisfaction index, patient satisfaction with operative treatment was significantly higher after MD. However, the functional outcome of treatment and reduction of pain syndrome (according to ODI and VA scales) were not related to the choice of surgical method. The positive outcome of surgery was also affected by shorter duration of preoperative symptoms and preoperative physical therapy. According to the obtained results it can be concluded that MD should be given priority over SD, but also that it's a method in accordance with the development of a more efficient health care system.