Serum creatine phosphokinase activity and histological changes in the multifidus muscle: a prospective randomized controlled comparative study of discectomy with or without retraction

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Object

The aim of this study was to determine the extent of muscle injury caused by continuous or intermittent muscle retraction during macro- and microdiscectomy in lumbar disc surgery. Pain scores, serum creatine phosphokinase (CPK) levels, and histological findings obtained in muscle specimens were compared.

Methods

Sixty patients who underwent surgery for a one-level disc herniation during a 1-year period (January 2004–January 2005) and who had similar demographic characteristics were randomly assigned to one of four groups, each consisting of 15 patients: Group A, microdiscectomy in which the retractor was never released; Group B, microdiscectomy in which the retractor was released every 15 minutes; Group C, macrodiscectomy in which the retractor was never released; and Group D, macrodiscectomy in which the retractor was released every 15 minutes.

Muscle biopsy samples were acquired in each group, and biochemical studies were conducted to determine serum CPK levels. The duration of muscle retraction was 15 minutes followed by 3 minutes of relaxation in Groups B and D. In all groups, muscle degeneration and elevation in serum CPK levels were observed immediately after surgery. The overall results, however, were different. The decline of serum CPK levels started 1 week after surgery. The smallest degree of muscle injury (reflected by the lowest serum CPK level) was observed in Group B. When the pre- and postoperative CPK values were compared in all groups, the patients in Groups B and D reported the least amount of back pain (p < 0.001). No significant differences in serum CPK levels were observed between Groups A and C or between Groups B and D. The extent of back pain was evaluated using a visual analog scale, and the consumption of analgesics was also assessed. The groups exhibited significantly different responses: the lowest analgesic consumption and the lowest pain scores were demonstrated in Groups B and D.

Conclusions

In this prospective randomized clinical trial, the authors determined that muscle injury during lumbar disc surgery was closely related to muscle retraction and relaxation times whereas the size of the paravertebral skin incision had no effect on postoperative back pain and disability. There was no significant difference among the groups in terms of back pain during the long-term follow-up period (18–19 months).

Abbreviations used in this paper:CPK = creatine phosphokinase; VAS = visual analog scale.

Article Information

Address reprint requests to: Kadir Kotil, M.D., Băgdat Cad. Hasan Ali Yücel Sok Senil, Apt. 34-14 Çiftehavuzlar, Istanbul 34728, Turkey. email: kadirkotil@superonline.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graphs. A: Intergroup and intragroup comparisons of CPK activity. The graph shows the changes in CPK serum levels in the postoperative period. There was no difference in the level of activity among all groups in the 3rd month. The activity increased postsurgery and drew a plateau at the day after surgery in Group C. It subsequently recovered to the value (p < 0.0001). Bars from left to right indicate Day 1, Day 7, and Month 3 postoperatively. B: Changes in VAS score as a function of duration of back pain. There was no significant difference between Groups A and D (p < 0.001). Bars from left to right indicate preoperative, Day 1, Day 7, and Month 3 values. C: Intergroup comparison of the severity of muscle atrophy. There was a significant difference in muscle atrophy between Groups A and B (p < 0.0001), but none among Groups A, C, and D (Groups A–C, p < 0.015; Groups A–D, p < 0.0001; Groups B–C, p < 0.004; Groups B–D, p < 0.016; and Groups C–D, p < 0.267).

  • View in gallery

    Photomicrographs. A: In this representative Group B (microdiscectomy with intermittent relaxation) specimen, there is slight edema and ischemia (black arrow) and minimal necrosis with opaque fibers (white arrow); however, most of the muscle fibers are intact. Muscle volume loss (atrophy) is approximately 25%. B: In this representative Group D (macrodiscectomy with intermittent relaxation) specimen, there is also slight edema (black arrow) and minimal necrosis with opaque fibers (white arrow). Muscle volume loss (atrophy) is approximately 25%. C: In this representative Group A (microdiscectomy with continuous retraction) specimen, there is marked edema (black arrow) and slight ischemic necrosis (white arrow). D: In this representative Group C (macrodiscectomy with continuous retraction) sample, there is slight edema (black arrows) and slight ischemic necrosis with infiltration of fat cells (white arrow). H & E, original magnification × 100.

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