Minimally Invasive Spine Surgery in Patients who Present Late for Surgery; Doing Too Good, Too Late
Authors: Assous Muhammed , Zeyad Mohammed , Hamdan Saad 
Published: April 2016

Introduction There remains a huge reluctance to undergo spine surgery in Jordan, which is probably related to misbeliefs and/or bad experiences. Recently, there has been a surge in Minimally Invasive Spine Surgery (MISS) procedures with patients specifically requesting to have their operations done using this technique. However, this often happen after many years of pain, disability and even weakness in muscle power. We reviewed patients who underwent either MISS discectomy or MISS decompression to assess whether delayed presentation for surgery had a negative impact on outcome. Materials and Methods We retrospectively reviewed 172 patients who underwent MISS discectomy or MISS decompression at a single center between 2013 and 2014. Procedures included 114 discectomies and 58 decompressions, using the cross over unilateral technique. All patients had a minimum of twelve months follow up and all procedures were done using a tubular retractor, microscope and general anesthetic. Pain and functional outcomes were assessed using VAS for back and leg pain and Eq. 5D. We then compared outcome measures between patients who had symptoms for less than twelve months prior to surgery with those with twelve months or more. Statistical analysis was done using independent t-test. We also looked at a subgroup of patients who presented with neurological deficit. Results A total of 172 patients were reviewed. There were 97 (56%) males and 75 (44%) females with a mean age of 47.6 years. All patients in discectomy and decompression groups significantly improved post operatively in all three outcome measures (VAS back pain mean pre op 49.4, post op 7.7, VAS leg pain mean pre op 78.8, post op 29.7, Eq. 5D mean pre op 0.31, post op 0.72 with P value < 0.001 for all measures). Duration of symptoms prior to surgery ranged from 1 month to 144 months (mean 16.8 months). Almost one third (31%) of the patients waited more than twelve months before they had their operations. Nevertheless, they still had outcome comparable to patients who waited less than twelve months (P value 0.883). The exception to this was the group of 14 patients who presented with painful foot drop from L4/5 disc herniation (9 patients) or lateral recess stenosis (5 patients). Two patients only had the surgery within 4 weeks from the onset of weakness and both fully recovered. Half (6) of the remaining patients presented after one year from onset of foot weakness, strongly indicating reluctance to undergo surgery. Of those, only two showed partial recovery. Interestingly, more than half of the 172 patients (52%) would have still categorically refused surgery if it was not offered with MISS techniques, and would have continued to suffer with pain and disability. Conclusion Deeply rooted reluctance to undergo spine surgery in general often results in several years of chronic pain, disability and even neurological deficit. When those patients eventually agreed to undergo MISS procedures, results were very satisfactory and comparable to those who agreed to surgery when first recommended. This may be explained by high level of satisfaction following years of pain, frustration and disability. The same however cannot be said in cases of neurological deficit, which should continue to be done urgently.