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Results of Lumbar Discectomy in Children
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Posted on: 02/11/2010
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Imagine a 12-year-old with low back pain from a herniated disc. You might think disc problems only affect adults but it happens even in children. Fortunately, it doesn't happen very often so we don't know a lot about it. But thanks to the surgeons at Children's Hospital in Boston, we now have some data to give us a better idea of what happens to these children.
One surgeon performed 87 lumbar microdiscectomies in children ages 12 to 18 over a 10 year period of time. By going back through the charts and performing a medical review, it was possible to get a composite view of this group. Their symptoms, clinical findings on exam, and MRI results were reviewed. The researchers helping on this project took a look at how the surgery went -- amount of blood loss, length of stay in the hospital, and complications.
What does a herniated disc look like in this age group? Well, like adults, the affected children suffer from back and leg pain (sciatica). The majority (60 per cent) were female athletes, which left the surgeons scratching their heads? Is this a sex-based injury or merely a reflection of the increased number of girls participating in sports? This study was unable to answer that question.
One-fourth of this group had muscle weakness and decreased deep tendon reflexes (tested at the knee and ankle). Almost half of the pediatric patients had numbness and/or tingling (sensory changes). Painful symptoms did not resolve with conservative (nonoperative) care. The children were unable to resume their daily activities or participate in sports, so surgery was advised.
The surgery performed was minimally invasive (referred to as microdiscectomy) with a tiny incision that didn't require cutting through back muscles. Instead of cutting away a large portion of the vertebral bone to get to the damaged disc, a tiny keyhole is made through the bone. Then the surgeon used a special operating microscope to see inside and remove the disc material.
Complications such as infection, neurologic symptoms, and cerebrospinal fluid leakage from this procedure are few and far between in adults. And this study showed the same for children. In fact, only one per cent of the group had any problems of this sort. A few more (six per cent) ended up having a second surgery because not all of the disc material was removed the first time causing further painful symptoms.
The authors conclude that this is the first published record on children having microdiscectomies. Many times children with disc herniation respond well to epidural steroid injections (ESI) and physical therapy. Conservative care of this kind is always recommended first as the standard of care. Children who recovered after conservative care were not included in this study. Only those with leg pain that wouldn't go away had surgery.
A final note was made for surgeons. The high rate of reoperations to remove residual (leftover) disc material can be avoided. The surgeon must appreciate how different discs are in children compared to adults. Despite herniation, the disc is tough and hasn't started to deteriorate like adult disc material.
In many cases, there wasn't a single piece or fragment of disc to remove. The surgeon had to cut away the protruding disc and make sure there was no more compression present at the time of the operation. Children generate new bone quickly and can end up with a hardened shell around the herniated disc as the body tries to repair the damage itself. That requires a chisel to break up the shell before removing the disc.
Despite these unique challenges to microdiscectomy, the procedure is safe and effective in this age group. Almost all of the 87 children in this particular study were pain free and able to return to their regular activities including sports eight to 12 weeks after surgery. The authors predict that these early disc problems will NOT put the children at risk for future back problems but this remains to be seen. The children will be followed into adulthood and long-term results studied.
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References:
Kevin S. Cahill, MD, PhD, MPH, et al. Lumbar Microdiscectomy in Pediatric Patients: A Large Single-Institution Series. In Journal of Neurosurgery: Spine. February 2010. Vol. 12. No. 2. Pp. 165-170.
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