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Magnetic Resonance Imaging Predictors of Surgical Outcome in Patients With Lumbar Intervertebral Disc Herniation

Lurie, Jon D., MD, MS*; Moses, Rachel A., MD, MPH; Tosteson, Anna N. A., ScD; Tosteson, Tor D., ScD; Carragee, Eugene J., MD§; Carrino, John A., MD, MPH; Kaiser, Jay A., MD; Herzog, Richard J., MD**

doi: 10.1097/BRS.0b013e31828ce66d

Study Design. A retrospective cohort design.

Objective. To determine whether baseline magnetic resonance imaging findings, including central/foraminal stenosis, Modic change, disc morphology, facet arthropathy, disc degeneration, nerve root impingement, and thecal sac compression, are associated with differential surgical treatment effect.

Summary of Background Data. Intervertebral disc herniation remains the most common source of lumbar radiculopathy treated either with discectomy or nonoperative intervention. Although magnetic resonance imaging remains the reliable “gold standard” for diagnosis, uncertainty surrounds the relationship between magnetic resonance imaging findings and treatment outcomes.

Methods. Three hundred seven “complete” images from patients enrolled in a previous trial were de-identified and evaluated by 1 of 4 independent readers. Findings were compared with outcome measures including the Oswestry Disability Index. Differences in surgery and nonoperative treatment outcomes were evaluated between image characteristic subgroups and TE determined by the difference in Oswestry Disability Index scores.

Results. The cohort comprised 40% females with an average age of 41.5 (±11.6) years, 61% of whom underwent discectomy for intervertebral disc herniation. Patients undergoing surgery with Modic type I endplate changes had worse outcomes (−26.4 vs. −39.7 for none and −39.2 for type 2, P = 0.002) and smaller treatment effect (−3.5 vs. −19.3 for none and −15.7 for type 2, P = 0.003). Those with compression of ≥1/3 showed the greatest improvement within the surgical group (−41.9 for ≥1/3 vs. −31.6 for none and −38.1 for <1/3, P = 0.007) and the highest TE (−23 compared with −11.7 for none and −15.2 for <1/3, P = 0.015). Furthermore, patients with minimal nerve root impingement demonstrated worse surgical outcomes (−26.5 vs. −41.1 for “displaced” and −38.9 for “compressed,” P = 0.016).

Conclusion. Among patients with intervertebral disc herniation, those with thecal sac compression of 1/3 or more had greater surgical treatment effect than those with small disc herniations and Modic type I changes. In addition, patients with nerve root “compression” and “displacement” benefit more from surgery than those with minimal nerve root impingement.

Level of Evidence: 2

Uncertainty surrounds IDH MRI findings and treatment outcomes. Images from 307 IDH patients were evaluated and compared to post intervention Oswestry index scores. Patients with thecal sac compression ≥1/3 showed the greatest improvement with surgery. Patients with Modic type one changes and minimal nerve root impingement demonstrated worse surgical outcomes.

From the Departments of *Medicine

Orthopaedics, and

Community and Family Medicine, Dartmouth Medical School, Lebanon, NH

§Department of Orthopaedic Surgery, Stanford School of Medicine, Palo Alto, CA

Department of Radiology, John's Hopkins Medical School, Baltimore, MD

National Orthopaedic Imaging Associates, Greenbrae, CA; and

**Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY.

Address correspondence and reprint requests to Rachel A. Moses, MD, MPH, Departments of Orthopaedic Surgery and Medicine, Dartmouth Medical School, Lebanon, NH 03756; E-mail:

Acknowledgment date: November 27, 2012. Revision date: February 6, 2013. Acceptance date: February 8, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444-01A1) and the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention funds were received to support this work.

The Multidisciplinary Clinical Research Center in Musculoskeletal Diseases is funded by NIAMS (P60-AR062799).

Relevant financial activities outside the submitted work: consultancy, board membership, stocks, expert testimony, grants.

© 2013 Lippincott Williams & Wilkins, Inc.