Virk Sohrab, Vaishnav Avani S, Mok Jung Kee, McAnany Steven, Iyer Sravisht, Albert Todd J, Gang Catherine Himo, Qureshi Sheeraz A
1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York; and.
2Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York.
J Neurosurg Spine. 2020 Aug 7;33(6):772-778. doi: 10.3171/2020.5.SPINE20373. Print 2020 Dec 1.
Preoperative pain assessment is often used to gauge the amount of disability in patients with lumbar disc herniation. How high preoperative pain scores impact the clinical course and outcomes of patients after lumbar microdiscectomy is not always clear. Here, the authors aimed to determine whether patients reporting higher preoperative pain scores have worse outcomes after lumbar microdiscectomy than those reporting lower preoperative scores.
The authors performed a retrospective review of patients with symptomatic lumbar disc herniations that had failed to improve with nonsurgical methods and who had undergone tubular lumbar microdiscectomy. Health-related quality of life (HRQOL) scores had been collected in the preoperative and postoperative period. The anatomical severity of disease was graded based on lumbar disc health (Pfirrmann classification), facet degeneration, thecal sac cross-sectional area, and disc herniation grade. Data on each patient's narcotic consumption and length of stay were collected. A Student t-test and chi-square test were used to compare patients with high preoperative pain scores (HP cohort) and those with lower preoperative scores (non-HP cohort).
One hundred thirty-eight patients were included in this analysis. The 47 patients in the HP cohort had taken more preoperative opioids (12.0 ± 21.2 vs 3.6 ± 11.1 morphine equivalent doses, p = 0.01). However, there was no statistically significant difference in Pfirrmann classification (p > 0.15), facet grade (p > 0.11), thecal sac cross-sectional area (p = 0.45), or disc herniation grade (p = 0.39) between the HP and non-HP cohorts. The latter cohort had statistically significant higher preoperative PROMIS scores (36.5 ± 7.0 vs 29.9 ± 6.4, p < 0.001), SF-12 mental component summary scores (48.7 ± 11.5 vs 38.9 ± 16.1, p < 0.001), and SF-12 physical component summary scores (PCS; 32.4 ± 8.6 vs 27.5 ± 10.0, p = 0.005), but a lower Oswestry Disability Index (56.4 ± 22.1 vs 35.4 ± 15.5, p < 0.001). There were only two time points after microdiscectomy when the HP cohort had worse HRQOL scores: at the 2-week follow-up for SF-12 PCS scores (32.4 ± 8.6 vs 29.3 ± 7.1, p = 0.03) and the 12-week follow-up for PROMIS scores (45.2 ± 9.5 vs 39.5 ± 7.1, p = 0.01). All other postoperative HRQOL measurements were similar between the two cohorts (p > 0.05).
A patient's perceived severity of disease often does not correlate with the actual clinical pathology on imaging. Although patients who report high pain and have a symptomatic lumbar disc herniation may describe their pain as more extreme, they should be counseled that the outcomes of microdiscectomy are positive.
术前疼痛评估常用于衡量腰椎间盘突出症患者的残疾程度。术前疼痛评分升高如何影响腰椎间盘显微切除术患者的临床病程和预后，目前尚不完全清楚。在此，作者旨在确定术前疼痛评分较高的患者在腰椎间盘显微切除术后的预后是否比术前评分较低的患者更差。
作者对经非手术治疗无效且接受了管状腰椎间盘显微切除术的有症状腰椎间盘突出症患者进行了回顾性研究。在术前和术后收集了与健康相关的生活质量（HRQOL）评分。根据腰椎间盘健康状况（Pfirrmann分类）、小关节退变、硬脊膜囊横截面积和椎间盘突出分级对疾病的解剖严重程度进行分级。收集了每位患者的麻醉药物消耗量和住院时间数据。采用Student t检验和卡方检验比较术前疼痛评分高的患者（HP队列）和术前评分低的患者（非HP队列）。
138例患者纳入本分析。HP队列中的47例患者术前服用了更多的阿片类药物（12.0±21.2 vs 3.6±11.1吗啡当量剂量，p = 0.01）。然而，HP队列和非HP队列在Pfirrmann分类（p>0.15）、小关节分级（p>0.11）、硬脊膜囊横截面积（p = 0.45）或椎间盘突出分级（p = 0.39）方面无统计学显著差异。后者队列术前PROMIS评分（36.5±7.0 vs 29.9±6.4，p<0.001）、SF-12精神成分汇总评分（48.7±11.5 vs 38.9±16.1，p<0.001）和SF-12身体成分汇总评分（PCS；32.4±8.6 vs 27.5±10.0，p = 0.005）在统计学上显著更高，但Oswestry功能障碍指数更低（56.4±22.1 vs 35.4±15.5，p<0.001）。在显微切除术后只有两个时间点HP队列的HRQOL评分更差：SF-12 PCS评分在2周随访时（32.4±8.6 vs 29.3±7.1，p = 0.03），PROMIS评分在12周随访时（45.2±9.5 vs 39.5±7.1，p = 0.01）。两个队列之间所有其他术后HRQOL测量结果相似（p>0.05）。
患者对疾病严重程度的感知通常与影像学上的实际临床病理不相关。虽然报告疼痛严重且患有有症状腰椎间盘突出症的患者可能将其疼痛描述得更为剧烈，但应告知他们椎间盘显微切除术的预后是积极的。
