Prolapse of the lumbar intervertebral disc (PLID) refers to the displacement of disc material beyond the normal boundaries of the intervertebral space, leading to significant clinical symptoms [1]. PLID is a common musculoskeletal disorder that manifests as lower back pain and sciatica, caused by the rupture of the annulus fibrosus, which allows the inner nucleus pulposus to protrude into the dorsal or dorsolateral disc spaces. Though lumbar disc prolapses accounts for less than 5% of all cases of lower back pain, it is the leading cause of nerve root pain, also known as sciatica [2]. In many cases, PLID causes significant leg pain that can impair an individual's quality of life and mobility.

The condition's prevalence ranges between 1.9% and 7.6% in men and from 2.2% to 5.0% in women [3]. PLID is also one of the most common causes of injury-related work absences [4]. Despite the numerous available treatment options, the optimal management strategies for PLID remain elusive. For most patients, symptoms resolve spontaneously within six weeks of onset, with conservative treatment being the most appropriate course of action [5]. However, surgical intervention is sometimes required when conservative measures fail, or when there are significant neurological deficits. Unfortunately, surgical outcomes are not always ideal, with inconsistent results and cases of recurrence [6]. When surgery is necessary, the standard procedure involves nerve root decompression while preserving the spine's bony and ligamentous structures [7-10]. However, even after surgery, the unsatisfactory outcome rate can range from 3% to 20% [8,11-13]. Recurrence of disc prolapse at the same level, regardless of whether it is ipsilateral or contralateral, is reported to be between 5% and 11% [8,11,12,14,15]. Revision surgeries tend to have more favorable results, with success rates ranging from 50% to 90% [11,12,16]. Historically, the first successful surgical removal of a herniated disc was performed by Oppenheim and Krause in 1909, although they misidentified the removed tissue as an enchondroma [17]. Mixter and Barr, in 1934, introduced lumbar fusion following disc excision to prevent instability [18]. However, later studies, including those by Frymoyer et al. (1979) suggested that spinal fusion provides minimal, if any, additional benefit [19]. Failed surgeries can often be attributed to incorrect identification of the prolapsed disc or recurrence at the same or adjacent levels.

The purpose of this study is to provide a detailed analysis of the demographic, clinical, and surgical characteristics of patients undergoing surgery for prolapsed lumbar intervertebral disc (PLID). By doing so, the study aims to improve surgical approaches and enhance patient outcomes in the treatment of PLID.

This cross-sectional descriptive study was meticulously designed and conducted at the Department of Orthopedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, over a comprehensive one-year timeframe from 1^st August 2009 to 31^st July 2010. A purposive sampling strategy was employed to recruit a cohort of 59 patients who presented with back pain and sciatica, ensuring that none had a previous history of trauma or engaging in heavy lifting activities. This rigorous selection process adhered strictly to pre-established inclusion and exclusion criteria, guaranteeing the integrity and relevance of the study population.

Inclusion Criteria

Patients aged between 18 and 65 years who were deemed medically fit to undergo the entire treatment protocol were included in the study.

Exclusion Criteria

Patients suffering from severe illnesses or conditions that would impede participation were excluded.

The diagnosis for all participants was confirmed through magnetic resonance imaging (MRI). Each participant was thoroughly informed about the study's objectives, goals, and procedures, and written informed consent was obtained prior to their inclusion in the study. Baseline demographic data for each participant were carefully gathered, with strict compliance to data confidentiality protocols. Ethical approval for the study was granted by the institutional ethics committee.

Statistical Analysis

The data were systematically organized into tables and figures, each accompanied by detailed explanatory notes to enhance clarity. Statistical analysis was performed using SPSS software (version 26) on a Windows platform. Continuous variables were presented as mean ± standard deviation (SD), while categorical variables were described using frequencies and percentages, ensuring comprehensive data interpretation.

In this study, the demographic profile of the 59 participants was comprehensively analyzed, revealing a mean age of 35.31±3.24 years. A substantial portion of the study population fell within the age range of 36-45 years (28.81%), which represented the most prevalent age group. This was followed closely by the 26-35 years category (25.42%) and the 18-25 years category (20.34%). A smaller proportion of participants was observed in the 46-55 years age group (13.56%), while the lowest representation was seen in those aged over 56-65 years (11.86%). Regarding gender distribution, there was a marked male predominance, with males constituting 71.19% of the sample, while females comprised 28.81% (Table 1). In terms of clinical presentation, radicular pain emerged as the most frequently reported preoperative symptom, affecting nearly half of the participants (49.15%). Low back pain was identified as the second most common symptom, reported by 37.29% of the participants, while lower extremity numbness was documented in 13.56% of cases (Table 2). Figure 1 illustrates the percentage distribution of disc prolapse across three lateral regions: right, left, and bilateral. The majority of disc prolapses were localized on the left side, accounting for 59.32% of cases. Disc prolapses on the right side were observed in 35.59% of cases, whereas bilateral involvement was relatively infrequent, seen in only 5.08% of the participants. Table 3 delineates the distribution of disc prolapse severity across various vertebral levels. The most frequently affected vertebral level was L4-L5, accounting for the majority of cases at 54.24%. This was followed by L5-S1 with 23.73% of cases, and L3-L4 with 15.25%. The least affected level was L2-L3, representing only 6.78% of the cases. Postoperative outcomes, specifically regarding the presence of back pain, are depicted in Figure 2. The vast majority of patients (91.53%) reported the absence of back pain following surgery, while a smaller subset of patients (8.47%) experienced occasional postoperative back pain.

Table 1: Demographic profile of the study population (N=59).

Table 2: Pattern of preoperative symptoms across patient cohorts (N=59).

Table 3: Severity level distribution of disc prolapse cases (N=59).

To achieve optimal outcomes from disc surgery, proper patient selection is crucial. The ideal candidates are those presenting with unilateral leg pain extending below the knee, persisting for at least six weeks. This pain should temporarily improve with rest and anti-inflammatory medication, but should return to its previous intensity after a minimum of six weeks of conservative treatment [17]. Physical examination should reveal signs of sciatic irritation, potentially accompanied by objective evidence of localized neurological impairment. Imaging studies such as CT, MRI, or myelography should confirm disc involvement consistent with the patient's clinical presentation. When conservative treatment fails, surgical intervention becomes the next logical step. Both the surgeon and the patient must understand that disc surgery is not a definitive cure but rather a means to alleviate symptoms. It does not reverse the underlying pathological process that leads to herniation, nor does it restore the disc to its original condition. Postoperative adherence to proper posture and body mechanics is essential for long-term success. In this study, 59 patients were evaluated for surgical interventions addressing lumbar intervertebral disc prolapse. Of these, 28.81% were in the age group 36–45 years, and 25.42% were between 26–35 years. These findings align with those of Akbar et al. (2002), where the majority of patients ranged from 31 to 45 years [20]. Our study also revealed a male predominance, with 71.19% of the patients being male, yielding a male-to-female ratio of 2.47:1. This gender distribution is consistent with the results reported by Akbar et al. (2002) and Ahsan et al. (2012) [20,21]. In terms of preoperative symptomatology, the majority of patients (49.15%) experienced radicular pain, 37.29% suffered from low back pain, and 13.56% reported lower extremity numbness. These findings are consistent with Akbar et al. (2002), who reported similar preoperative symptoms [20]. Regarding the distribution of disc prolapse by side, this study found a higher prevalence on the left side (59.32%), compared to the right side (35.59%) and bilateral involvement (5.08%). Ahsan et al. (2012) also reported a similar pattern of side distribution in their study [21]. The most commonly affected disc level in our study was L4-L5, accounting for 54.24% of cases, followed by the L5-S1 level, which accounted for 23.73%. These results are consistent with those of Ahsan et al. (2012), further supporting our findings [21]. In our study, 91.53% of patients reported being pain-free post-surgery, with only 8.47% experiencing occasional back pain. These outcomes differ from those reported by Spangfort (1972), who reviewed 2504 lumbar disc excisions and found that 30% of patients continued to experience back pain following surgery, which contradicts our findings [22]. The favorable outcomes in our study can be attributed to careful patient selection, adherence to standardized surgical techniques, effective postoperative management, and the provision of comprehensive discharge instructions.

Limitations of the study: This study is limited by its small sample size, single-center design, and lack of a control group for non-surgical treatment comparison, which may affect the generalizability of the results. The cross-sectional approach restricts the evaluation of long-term outcomes. Variability in surgical techniques was not accounted for, potentially influencing outcome consistency.

This study reinforces the efficacy of surgical intervention for prolapsed lumbar intervertebral disc (PLID), emphasizing the importance of precise patient selection and adherence to standardized surgical protocols for achieving optimal outcomes. The findings suggest that refining surgical techniques and improving postoperative care can enhance clinical success and contribute to better patient recovery. Further research should focus on optimizing treatment strategies to ensure consistent long-term benefits.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee.

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