INTRODUCTION

The surgical management of prolapse of lumbar intervertebral discs (PLID) stands as a critical intervention in the realm of spinal healthcare, aiming to alleviate pain and restore functionality for individuals grappling with this debilitating condition. In Bangladesh, a country with a burgeoning healthcare landscape, evaluating surgical outcomes is paramount. The vertebral disc comprises an outer tough annulus fibrosis and an inner gel-like nucleus pulposus. Degenerative changes in the annulus fibrosis result in the protrusion of the inner nucleus pulposus. Disc degeneration can be attributed to both degenerative disc disease and ageing. This condition is commonly known as disc prolapse or a slipped disc [1]. In our community, disc prolapse holds significance, particularly for individuals engaged in stressful occupations, as they are more prone to spinal injuries that eventually lead to disc prolapse. Postero-lateral disc prolapse is predominant due to the presence of the posterior longitudinal ligament, although central disc herniation does occur [2]. Most disc prolapses (95%) manifest in the lumbar region at the L4/L5 or L5/S1 levels [3]. Professionals with prolonged sitting, smokers, weightlifters, individuals experiencing trauma, and drivers are all at an increased risk of disc prolapse. Age is a contributing factor to disc wear and tear, with degenerative diseases being considered a more significant cause than trauma, according to most authors [4]. Professional athletes are also susceptible to disc injuries [5,6]. The initial presentation of disc prolapse often includes backache due to ligament pressure and sciatica due to nerve compression. Compression of other nerve roots can lead to muscle weakness, limb numbness, paraesthesia, and urinary retention, attributed to the compression of cauda equina nerves. The lifetime incidence of sciatica in the general population ranges from 13 to 40% [7]. During the examination, lower back tenderness and spasms of paravertebral muscles may be observed. A straight leg raising test might reveal limited movement on the affected side. Crossed sciatic tension, performed by raising the unaffected leg, may induce increased pain on the affected side, though this is not a common finding. The femoral stretch test, indicating L3/L4 nerve involvement, is another particular test. At the level of prolapse, paraesthesia, muscle weakness, and reduced reflexes may be noted. L5 nerve root impairment results in loss of sensation on the dorsal side of the foot and lateral side of the leg, along with weakness in significant toe extension. S1 nerve root impairment causes weakness in ankle jerk reflex, plantar flexion, foot eversion, and loss of sensation on the lateral and plantar aspects of the foot. Compression of cauda equina nerves can lead to loss of lower back sensation and urinary retention. The differential diagnosis for disc prolapses includes tuberculosis, spinal stenosis, vertebral abscess, ankylosing spondylitis, vertebral hematomas, vertebral tumours, nerve tumours, paravertebral muscle sprain, and mechanical pain. Given the substantial disease burden in our community, we conducted a study to determine outcomes for patients treated at our center for prolapsed intervertebral discs. The study aimed to explore the various demographic aspects of patients undergone PLID surgery, focusing on clinical presentation, complications, and surgical outcomes.

Methodology and Materials

This prospective observational study was conducted in a different private Hospital, Satkhira, Bangladesh, from 2020 to 2021. A total of 112 patients undergoing PLID surgery were enrolled and analyzed in this study. MRI was utilized to confirm the diagnosis, focusing on identifying disc prolapse at the specific level and side corresponding to the clinical symptoms and physical examination findings. Dynamic View X-ray of L/S Spine was done to see instability. In this study, a purposive sampling technique was employed to select participants. Detailed demographic and clinical information for each participant was meticulously recorded. The study population comprised individuals who voluntarily agreed to participate in a standardized clinical follow-up program, which included consultations and the collection of patient-based outcome measures. These assessments were conducted at various times, including preoperatively, day one post-surgery, after one week, after 12 weeks and after 1 year of follow-up. To ensure the integrity of the study, specific exclusion criteria were applied.

Inclusion criteria:

• • Patients aged 18-60 with symptomatic low-back pain from lumbar intervertebral disc prolapse
• • Patients who failed from conservative treatment
• • Cauda equina Syndrome.

Exclusion criteria:

• • Patients with prolapsed lumbar intervertebral disc (PLID) associated with other spinal pathologies such as spinal tumors, infections, and inflammation, those who had undergone repeat lumbar disc surgery due to symptom recurrence, and individuals with PLID caused by direct trauma resulting in vertebral fracture-dislocation, severe co-morbidity unfit for surgery were excluded from the study.

Pain was assessed using VAS scores [10], and functional outcomes were evaluated using modified Macnab outcome criteria [11]. The data analysis used MS Office tools to facilitate accurate and comprehensive research outcomes. All statistical analyses were performed using the statistical package for the social science (SPSS) program and Windows. Continuous parameters were expressed as mean±SD and categorical parameters as frequency and percentage.

Result

The study was conducted at a tertiary care hospital in Bangladesh and focused on evaluating surgery outcomes for the prolapse of lumbar intervertebral discs (PLID) among 112 participants. Among the participants, the majority were in the age group of 31-40 years, constituting 52(46.43%) of the total sample. The second most represented age group was 21-30 years, comprising 40(35.71%) participants. A smaller proportion of 17(15.18%) participants were in the age groups of 41-50 years, and only 2.68% were aged 51-60 years (Table 1). Figure 1 illustrates the gender distribution, with females comprising the majority (61.61%) and males (38.39%). Sixty-five patients experienced PLID on the left (58.04%) and 35.71% on the right. Bilateral involvement, where both sides were affected, was noted in a smaller proportion of cases (6.25%) (Figure 2). The standard level of disc prolapses observed was at L4-L5 (56.25%) and L5-S1 (36.61%). Less commonly, disc prolapse involved multiple levels simultaneously: L4-L5 and L5-S1 together were observed in 6(5.36%) of cases, and L4-L5 and L3-L4 together in 2(1.79%) of cases (Table 2). Before surgery, participants reported a mean VAS score of 7.4±1.2. Immediately postoperative on Day 1, the mean VAS score decreased to 6.8±1.1. At the 12-week follow-up, the mean VAS score significantly dropped to 2.8±0.4 (Table 3). In this study, only two patients had surgical complication (wound infection), but they were managed properly and recovered. Regarding table 4, 85(75.89%) patients were achieved an excellent outcome, 20(17.86%) reported a good outcome, 5(4.46%) experienced a fair outcome, and 2(1.76%) reported a poor outcome following surgery.

Table 1: Age distribution of participants (N=112).

Figure 1: Gender distribution of participants (N=112).

Figure 2: Side involvement (N=112).

Table 2: Levels of disc prolapse (N=112).

Table 3: VAS score distribution to assess pain (N=112).

Table 4: Outcomes distribution of the study population (N=112).

Discussion

The demographic characteristics observed in our study show a majority of male participants, accounting for 61%, with the remaining 39% being female. Moreover, the age distribution in our research spanned a wide range, from 17 to 63 years, with the highest proportion of cases, precisely 46%, falling within the 41-50 age group. This age group is particularly significant as it represents a stage in life when lumbar disc-related conditions are more prevalent, thereby emphasizing the relevance of our study's findings. Interestingly, these findings closely correspond with those reported in a study conducted by Audat, Ziad, as referenced in [12]. In their study, they treated a total of seventy-one patients, with a similar gender distribution of 60% male and 40% female, who had herniated intervertebral disc conditions in one or two levels of the lower lumbar spine. The age range of patients in their study also mirrors ours, ranging from 17 to 63 years, with a mean age of 36.48 and a standard deviation of 10.057 years. These parallels in demographic characteristics underline the consistency of these parameters across studies focusing on lumbar disc-related conditions. In our study, when examining the side involvement of prolapsed lumbar discs among the cases, it was evident that most, specifically 58% of cases, were affected on the left side. In contrast, 35% of cases exhibited right-sided involvement, while 7% had bilateral involvement. These findings align closely with another study [13], which reported that most cases (57%) had involvement on the left side. Furthermore, when considering the level of disc prolapse among the participants in our study, most cases, accounting for 56%, had disc prolapse at the L4-L5 level. Additionally, 36% of cases had disc prolapse at the L5-S1 level, 6% had involvement at both the L4-L5 and L5-S1 levels, and 2% had prolapse affecting both the L4-L5 and L3-L4 levels. These results closely resemble those reported in another study [14], where 55.2% of patients had a disc prolapse at the L4-L5 level, 35.5% at the L5-S1 level, 6.9% had involvement at both the L4-L5 and L5-S1 levels, and 3.4% had a disc herniation at the L4-L5 and L3-L4 levels. This study's mean VAS score was 7.4±1.2 before surgery, indicating a high pain level. However, the positive news is that on the first-day post-surgery, the mean VAS score decreased to 6.8±1.1; after one week, there was a further reduction in pain, with a mean VAS score of 3.9±0.7. At the 12-week mark, the mean VAS score dropped even further to 2.8±0.4, indicating a significant improvement in pain management and overall patient comfort. These findings were comparable with a previous study [14]. Several points are considered when assessing the results of lumbar disc surgery [15]. In our study, as per the modified Macnab outcome criteria, 72% of our participants got excellent results, followed by 18% who got good results. In the previous study [14], most patients (75.9%) had excellent functional outcomes, 13.8% good, 6.9% fair, and 3.4% had poor functional outcomes per the modified Macnab criteria. Only two patients had wound infection but they were managed properly and recovered. Some randomized control trials comparing early surgery with conservative treatment and delayed surgery, as referred to by Peul et al., found similar results [16].

Limitations of the study:

This study was limited by its single-center design and relatively small sample size, which may affect the generalizability of the findings to other populations and healthcare settings. Additionally, the follow-up period of 1year may not capture long-term outcomes and complications post-surgery. The exclusion criteria, including patients with recurrent lumbar disc surgery and those with concurrent spinal pathologies, may result in a selection bias, potentially skewing the outcomes.

Conclusion

The study concluded that surgical management of lumbar intervertebral discs (PLID) prolapse at a district-level private hospital in Bangladesh yielded predominantly positive outcomes. Among the 112 patients studied, there was a significant reduction in pain post-surgery, with mean VAS scores dropping from 7.4 preoperatively to 2.8 at the 12-week follow-up. Most patients (75.89%) achieved excellent results based on the modified Macnab outcome criteria. Complications were minimal, with only two cases of wound infection, which were effectively managed. These findings underscore the effectiveness of PLID surgery in improving patient outcomes in a district-level healthcare setting.

Funding:

No funding sources

Conflict of interest:

None declared

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