Original Article |
Corresponding author: Milan N. Mladenovski ( mladenovskinhk@gmail.com ) © 2023 Mladen E. Ovcharov, Milan N. Mladenovski, Igor N. Mladenovski, Iliya V. Valkov, Stanislava B. Vasilkova.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Ovcharov ME, Mladenovski MN, Mladenovski IN, Valkov IV, Vasilkova SB (2023) Lumbar disc herniation in children and elderly patients. Folia Medica 65(4): 631-637. https://doi.org/10.3897/folmed.65.e97233
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Introduction: Lumbar disc herniation is a common pathology of young and middle-aged patients. Fissures and tears in the annulus fibrosus become weak points that facilitate herniation of the nucleus pulposus, especially when extreme forces ‘attack’ the intervertebral disc. A significant biomechanical force applied to a healthy (‘normal’) disc can have the same effect. Disc protrusions and herniations to varying degrees penetrate the spinal canal.
Aim: This study aims to present features of lumbar disc herniation in pediatric and elderly patients and evaluate them with respect to data reported in the literature.
Materials and methods: Five hundred eighty-nine patients were assessed, 64 of whom were children (0-18 years), and 98 were elderly patients (>60 years). The operated patients were followed up for at least three years. All data were recorded at the regular follow-ups (at 1 and 3 months, and at 1 and 3 years after surgery). We used chi-square tests and directional measures to determine statistically significant data. Operative treatment in children and elderly patients was 28% (162) of our cohort’s total number of patients.
Results: Analyzing postoperative MacNaB, our result showed that children have 23.4% excellent and 76.6 good self-assessment, while in elderly patients, on the one hand, MacNaB used to be excellent or good in 78.5%, and on the other hand, 21.5% had fair or poor self-assessment (p<0.05).
Conclusions: Long-term postoperative outcomes were worse in elderly patients than in children. This was mainly due to the poor status of the intervertebral discs according to the Phirman scale and the associated pathologies at other levels.
aged-related LDH, operative results, incidence
Lumbar disc herniation (LDH) is a common pathology of young and middle-aged patients. The intervertebral disc is a complex structure composed of collagen, proteoglycans, and ‘rare’ fibrochondrocyte cells, whose task is to buffer various forces on the human spine standing vertically in the three-dimensional space. Normal age-related changes lead to a decrease in the production of proteoglycans. This causes the disc to collapse, and overstresses the annular fibrous ring surrounding the nucleus pulposus. Fissures and tears in the annulus fibrosus become weak points that facilitate herniation of the nucleus pulposus, especially when extreme forces ‘attack’ the intervertebral disc. A significant biomechanical force applied to a healthy (‘normal’) disc can have the same effect. Disc protrusions and herniations to varying degrees penetrate the spinal canal. Pain in the lumbosacral region combined with radicular pain is a direct consequence of root ischemia and neurochemical (aseptic) inflammation caused by inflammatory factors existing in the disc material itself. Sensory disorders in the genital area, together with loss of control of the pelvic reservoirs (the cauda equina syndrome) and loss of motor function in the legs, are indications for urgent diagnosis and, most often, surgical treatment. The naturally expected clinical outcomes of the treatment are the elimination of the underlying pain, the correction of motor and sensory deficits, and the restoration of working capacity.
The aim of this study was to present the characteristics of LDH in pediatric and adult patients and compare them to data from the literature.
Between 2012 and 2017, 614 patients were studied at the Neurosurgery Clinic (Dr. Georgi Stranski University Hospital, Pleven). Twenty-five patients (4.7%) dropped out of the study. The reasons were insufficient and missing documentation, inability to communicate in the early postoperative period, and some technical issues.
Five hundred eighty-nine patients remained in the study, of whom 64 were children (0-18 years) and 98 were elderly patients (>60 years). The follow-up time of the operated patients was at least 3 years. All data were recorded on regular follow-ups (at 1 and 3 months, and at 1 and 3 years after surgery). We used chi-square tests and directional measures to determine statistically significant data.
Operative treatment in children and elderly patients was 28% (162) of the total number of patients in our cohort (Table
Thirty-one percent of all patients associated the onset of complaints with an acute moment, commonly weight lifting, sports, and spine trauma. That was most familiar in young patients (1-44 years). The relationship between the acute moment – ‘weight lifting’ and the severity of the clinical picture (VAS input, ODI) is impressive, but not statistically significant (Table
Twenty-nine percent of all patients had accompanying diseases distributed as follows: 54% with arterial hypertension; 34% with diabetes mellitus; 5% with carcinoma, and 7% with coxarthrosis. Thirty-six patients had more than one accompanying disease, most often a combination between arterial hypertension and diabetes mellitus. This data was most familiar to the elderly than children (p<0.05).
In a sample of 20 patients, we evaluated the MRI findings in the lumbar region according to Phirman scale, the VAS score for lumbar and leg pain (at discharge), and the self-assessment of the patient’s condition at discharge according to the MacNab criteria (Table
Categorically, in younger patients with low grades (І, ІІ) of the Phirman criteria at levels other than the level of disc prolapse, the final postoperative VAS & MacNab scores were significantly more favorable. Conversely, as a rule, in elderly patients with ‘worse’ scores according to the Phirman criteria, the postoperative VAS & MacNab scores were in the less favorable spectrum. (Fig.
The analysis of the postoperative MacNaB scores revealed that 23.4% of the children had an excellent self-assessment and 76.6% of them had a good self-assessment. In contrast, for elderly patients, on the one hand, the MacNaB scores were either excellent or good in 78.5% of the cases, and on the other hand, 21.5% of them had a self-assessment score of either fair or poor (p<0.05) (Table
Analysis of the parameters - mean VAS values of lumbar pain/leg pain (for both groups– children and elderly patients) postoperatively and within 1 month after surgery shows statistically significant differences (p<0.05) between standard (SD) and microdiscectomy (MD) in both age groups. Lumbar and leg pain was prolonged in SD, probably due to operative wound extent, the tissue healing process, and iatrogenic nerve root irritation, respectively (Tables
The analysis of mean VAS scores of lumbar/leg pain postoperatively and within one month after surgery showed that there was a statistically significant difference (p<0.05) between young and elderly patients. Children (1–18 years) responded more difficultly and postoperatively reached the optimal surgical outcome later, most likely as a result of the activity of inflammatory and neuromodulatory agents (Fig.
Patients group (by age) | Number of patients | Percentage |
0–18 years | 64 | 11% |
19–60 years | 427 | 72% |
>60 years | 98 | 17% |
Relationship between the acute moment - ‘weight lifting’ and the severity of the clinical picture
LDH (other) | LDH due to ‘weight lifting’ | p value | |
n = 468 | n = 121 | ||
Oswestry disability index (0-100) | 50±21 | 61±17 | 0.10 |
Visual analog scale leg pain (0-10) | 6.9±2.4 | 7.8±2.3 | 0.19 |
Visual analog scale back pain (0-10) | 5.1±3.3 | 5.6±3.8 | 0.54 |
Phirman scale | Sample | L1-2 | L2-3 | L3-4 | L4-5 | L5-S1 | VAS at discharge Low back pain | VAS at discharge Leg pain | MacNab |
Age | |||||||||
Patient 1 | 28 | I | II | I | I | V | 1 | 1 | Excellent |
Patient 2 | 17 | I | I | I | I | V | 1 | 1 | Excellent |
Patient 3 | 47 | III | IV-a | V | III | II | 2 | 2 | Good |
Patient 4 | 44 | I | II | III | V | II | 1 | 1 | Excellent |
Patient 5 | 58 | III | IV-b | III | IV-a | II | 2 | 2 | Good |
Patient 6 | 37 | I | I | I | V | I | 1 | 1 | Excellent |
Patient 7 | 70 | IV-a | III | III | III | V | 3 | 1 | Fair |
Patient 8 | 33 | I | I | I | IV-b | I | 1 | 1 | Excellent |
Patient 9 | 43 | II | I | II | I | IV-b | 2 | 1 | Good |
Patient 10 | 55 | II | II | III | III | IV-b | 2 | 2 | Good |
Patient 11 | 63 | IV-b | IV-b | V | V | IV-b | 3 | 2 | Fair |
Patient 12 | 63 | II | III | IV-b | IV-a | II | 2 | 2 | Good |
Patient 13 | 50 | I | II | II | II | V | 1 | 1 | Excellent |
Patient 14 | 65 | II | II | III | IV-a | V | 2 | 2 | Good |
Patient 15 | 51 | II | II | II | IV-b | II | 1 | 1 | Excellent |
Patient 16 | 48 | I | II | II | III | IV-a | 2 | 1 | Good |
Patient 17 | 54 | III | III | IV-a | IV-a | V | 3 | 3 | Fair |
Patient 18 | 15 | I | I | I | V | I | 1 | 1 | Excellent |
Patient 19 | 52 | I | II | II | I | IV-b | 1 | 1 | Excellent |
Patient 20 | 40 | I | I | II | II | V | 1 | 1 | Excellent |
A 63-year-old patient with L4-5 lumbar stenosis and L3-4 lumbar disc herniation with poor MacNab self-assessment. Note: Multilevel decompression followed by fusion could be performed in such patients.
A 17-year-old patient with one ‘pathologic’ level and excellent self-assessment according to MacNab.
Age group | Total | ||||||||
1-18 | 19-60 | >60 | |||||||
MACNAB | 1 | N | 15 | 272 | 33 | 320 | |||
% | 23.4% | 63.7% | 33.6% | 54.4% | |||||
2 | N | 49 | 155 | 44 | 248 | ||||
% | 76.6% | 36.3% | 44.9% | 42.1% | |||||
3 | N | 0 | 0 | 21 | 21 | ||||
% | 0% | 0% | 21.5% | 3.5% | |||||
Total % | N | 64 | 427 | 98 | 589 | ||||
100% | 100% | 100% | 100% | ||||||
Chi-square tests | |||||||||
Value | df | Asymptotic significance (2-sided) | |||||||
Pearson chi-square | 42.557 | 4 | 0.000 | ||||||
Likelihood ratio | 41.476 | 4 | 0.000 | ||||||
Linear-by-linear association | 7.652 | 1 | 0.006 | ||||||
N of valid cases | 589 |
ANOVA analysis (lumbar pain) | SD (N=91) | MD (N=71) | P |
Postoperative | 1.22±0.64 | 0.97±0.52 | <0.05 |
1 month after operation | 0.51±0.50 | 0.25±0.43 | <0.05 |
ANOVA analysis (leg pain) | SD (N=91) | MD (N=71) | P |
Postoperative | 1.20±0.64 | 0.96±0.51 | <0.05 |
1 month after operation | 0.43±0.49 | 0.22±0.41 | <0.05 |
Graphic expression by age groups and lumbar pain (Kaplan-Meier analysis). Note: Children (1-18 years) responded more difficultly and post-operatively reached later the optimal surgical outcome.
The role of trauma in causing lumbar disc herniation in children is more significant than in adults.[
The literature on discectomy in children reveals mixed results over time. Initial results are excellent. At a one-year follow-up, Papagenlopoulos et al.[
On the one hand, LDH is much less common in elderly patients than in active-age patients (17 vs. 71%), but on the other hand, LDH is less common in children than in elderly patients (11% vs. 17%). The nucleus pulposus dehydrates with age and is less likely to herniate. Lumbar stenosis and joint hypertrophy are frequent problems.[
Recurrent lumbar disc herniation (rLDH) is the most unsatisfactory and undesirable result for surgeons, patiеnts and health-insurance organizations.[
The long-term postoperative outcome in elderly patients is worse than in children and is mainly due to the poor status of the intervertebral discs according to the Phirman scale and associated pathologies at other levels.
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The authors have declared that no competing interests exist.
All listed authors have contributed to the preparation of this manuscript and have permitted their names to be included as co-authors.
The research was conducted in accordance with the updated Declaration of Helsinki and all patients, whose data are used for analysis, signed informed consent.