Surgical versus nonoperative treatment: how do we choose the right approach to lumbar disk herniation?

Artificial intelligence in spine surgery

The continuous progress of research and clinical trials has offered a wide variety of information concerning the spine and the treatment of the different spinal pathologies that may occur. Planning the best therapy for each patient could be a very difficult and challenging task as it often requires thorough processing of the patient's history and individual characteristics by the clinician. Clinicians and researchers also face problems when it comes to data availability due to patients' personal information protection policies. Artificial intelligence refers to the reproduction of human intelligence via special programs and computers that are trained in a way that simulates human cognitive functions. Artificial intelligence implementations to daily clinical practice such as surgical robots that facilitate spine surgery and reduce radiation dosage to medical staff, special algorithms that can predict the possible outcomes of conservative versus surgical treatment in patients with low back pain and disk herniations, and systems that create artificial populations with great resemblance and similar characteristics to real patients are considered to be a novel breakthrough in modern medicine. To enhance the body of the related literature and inform the readers on the clinical applications of artificial intelligence, we performed this review to discuss the contribution of artificial intelligence in spine surgery and pathology.

Transforaminal Endoscopic Discectomy Under General and Local Anesthesia: A Single-Center Study

Percutaneous spinal endoscopy is used for the treatment of disorders of the lumbar spine, as it has several advantages over traditional surgical methods. The performance of percutaneous spinal endoscopy is not possible without applying anesthesia methods. Two types (local and general) of anesthesia are used for percutaneous spinal endoscopy. Both, local and general anesthesia approaches contribute to safety in surgical procedures. Although it is believed that the method of local anesthesia has more benefits over general anesthesia, such as lowering the risk of postoperative neurological complications in a patient, the literature on the topic is inconclusive. The study aims to perform a comparative analysis of the two anesthesia methods using a prospective case-control design. Patients were divided into two groups: those who received local anesthesia (LA) (20 patients), and those who underwent general anesthesia (GA) (20 patients). As a result of the study, 40% of the patients experienced moderate pain and 5% of the patients experienced excruciating pain intraoperatively in the LA group. Although Visual Analog Scale and Oswestry Disability Index scores improved more rapidly in LA group, at the 12-month check-up point there was no significant difference between cases and controls. Nevertheless, there were postoperative complications such as nerve root injury in 10% of the patients; nausea, vomiting, dizziness, drowsiness in 15% of the patients in the GA group, and an insignificant or no such complications in patients of the LA group. The present study demonstrates that LA contributes to more positive short-term outcomes for patients as it facilitates nerve root damage prevention, and has no postoperative side effects on patients' well being.

Artificial intelligence facilitates decision-making in the treatment of lumbar disc herniations

PURPOSE

Apart from patients with severe neurological deficits, it is not clear whether surgical or conservative treatment of lumbar disc herniations is superior for the individual patient. We investigated whether deep learning techniques can predict the outcome of patients with lumbar disc herniation after 6 months of treatment.

METHODS

The data of 60 patients were used to train and test a deep learning algorithm with the aim to achieve an accurate prediction of the ODI 6 months after surgery or the start of conservative therapy. We developed an algorithm that predicts the ODI of 6 randomly selected test patients in tenfold cross-validation.

RESULTS

A 100% accurate prediction of an ODI range could be achieved by dividing the ODI scale into 12% sections. A maximum absolute difference of only 3.4% between individually predicted and actual ODI after 6 months of a given therapy was achieved with our most powerful model. The application of artificial intelligence as shown in this work also allowed to compare the actual patient values after 6 months with the prediction for the alternative therapy, showing deviations up to 18.8%.

CONCLUSION

Deep learning in the supervised form applied here can identify patients at an early stage who would benefit from conservative therapy, and on the contrary avoid painful and unnecessary delays for patients who would profit from surgical therapy. In addition, this approach can be used in many other areas of medicine as an effective tool for decision-making when choosing between opposing treatment options, despite small patient groups.

Relationship between serum levels of miR-204 and clinical features of patients with lumbar disc herniation - an analysis based on 1,589 cases

This study aims to investigate the relationship between serum miR-204 and clinical features of patients with lumbar disc herniation (LDH). Clinical data of 1589 LDH patients were retrospectively analyzed. There were 953 patients (group A) with a duration of disease shorter than 3 months, and another 636 patients (group B) with a duration of disease longer than 3 months. A total of 300 healthy volunteers were also selected in the same period. Results showed that there was no significant difference in miR-204 expression between males and females (p>0.05). No significant differences in miR-204 expression level were found among different ages (p>0.05). miR-204 in patients with LHD at or below the fourth lumbar vertebrae was significantly higher than those in patients with LHD above the fourth lumbar vertebrae (p<0.05). miR-204 in 1485 patients with abnormal lumbar spine activity was higher than those in healthy controls (p<0.05). miR-204 expression levels was higher in patients with low back pain than those in patients without low back pain. Among patients with low back pain, miR-204 level in patients with spasm-like waist pain was significantly higher than that in patients with persistent dull low back pain (p<0.05). miR-204 increased with the increase in degree of limited walking (p<0.05). There was no significant difference in miR-204 expression level between patients with bilateral lower limb symptoms and patients with unilateral lower limb symptoms (p>0.05), while miR-204 was significantly higher in patients with lower limb symptoms than that in patients without the symptoms (p<0.05). miR-204 was correlated with knee tendon reflex, heel tendon reflex and degree of straight leg raise abnormality. miR-204 was significantly decreased in patients with improvement after treatment. miR-204 level was closely related to the clinical characteristics of LDH. miR-204 may potentially serve as a prognostic marker for patients with LDH.

Effects of dexmedetomidine on perioperative stress response, inflammation and immune function in patients with different degrees of liver cirrhosis

Effects of dexmedetomidine (DEX) on perioperative stress response, inflammation and immune function in patients with different degrees of liver cirrhosis were investigated. A total of 94 patients with liver cirrhosis who were admitted to the Affiliated Hospital of Shandong University of Traditional Chinese Medicine from December 2016 to November 2017 were included, and randomly divided into control and observation group (n=47). Patients in control group were given remifentanil for anesthesia, while patients in observation group were treated with remifentanil and for DEX anesthesia. Venous blood was collected immediately before induction of anesthesia (T1), 10 min (T2) after the beginning of surgery, immediately after surgery (T3) and 2 h after surgery (T4). Hemodynamic parameters, stress response factors, adverse reactions and levels of inflammatory cytokines and T lymphocyte subsets were compared between the two groups. The mean arterial pressure in both groups was lower at T2-T4 than that at T1 (p<0.05), and mean arterial pressure was lower in observation group than in control group (p<0.05). Visual analogue pain score (VAS) of observation group was significantly lower than that of control group at 6, 12 and 24 h after operation (p<0.05). There was no significant difference between the two groups in incidence of nausea, vomiting, hypoxemia and delayed awakening (p>0.05). Incidence of postoperative agitation in observation group was significantly lower than that in control group (p<0.05). The levels of CD3⁺, CD4⁺, and CD4⁺/CD8⁺ in both groups were significantly lower at T2-T4 than those at T1 (p<0.05). Levels of IL-10 and TNF-α in both groups were significantly higher at T2-T4 than those at T1, but levels of IL-2 and TNF-α were significantly lower in observation group than in control group (p<0.05). In conclusion, the use of DEX for anesthesia in patients with liver cirrhosis can improve hemodynamic stability, reduce stress response and reduce inflammation level without affecting immune function, which has important clinical significance.

Combined acupuncture and general anesthesia on immune and cognitive function in elderly patients following subtotal gastrectomy for gastric cancer

This study investigated the effects of acupuncture combined with general anesthesia on postoperative immune and cognitive functions in elderly patients undergoing subtotal gastrectomy. We recruited 96 elderly patients who received anesthesia for subtotal gastrectomy and randomly divided them into control (n=48) and experimental (n=48) groups. The control group received general anesthesia and the experimental group received combined acupuncture and general anesthesia. We measured hemodynamic immediately before and after anesthesia induction, and immune observations before and after surgery. We found no significant differences in mean heart rate (HR), mean oxygen saturation (SpO2), and partial pressure of end-tidal carbon dioxide (PETCO2) in the perioperative period between the two groups. Mean arterial pressure (MAP) was lower in the experimental group than that in the control group (P<0.05). The levels of cluster of differentiation 3 (CD3⁺), CD4⁺ and CD4⁺/CD8⁺ in both groups were significantly lower after surgery in both groups (P<0.05). We also found some time-points in which the immune markers where significantly higher in the experimental group. In terms of adverse reactions, there were no differences in nausea, vomiting, and hypoxemia between the two groups (P>0.05), but the incidence of delayed recovery and postoperative agitation were significantly lower in the experimental group compared with those in the control group (P<0.05). One day after surgery, the experimental group showed better protection of cognitive function than the control group (P<0.05). Overall, combined acupuncture and general anesthesia in elderly gastric cancer patients receiving subtotal gastrectomy showed more stable hemodynamics and fewer stress responses during surgery. Thus, combined acupuncture and general anesthesia can shorten the recovery time from anesthesia, have less negative effects on immune function and decrease the incidence of postoperative cognitive impairment.

Effects of different anesthesia methods on postoperative transient neurological syndrome in patients with lumbar disc herniation

The objective of the present study was to investigate the effects of different anesthesia methods on postoperative transient neurologic syndrome (TNS) in patients with lumbar disc herniation (LDH). Ninety-six patients with LDH were selected from November 2015 to October 2016 in Cangzhou Central hospital. All patients were treated with percutaneous transforaminal endoscopic discectomy. The patients were randomly divided into the control group and observation group, with 48 patients each. Combined spinal-epidural anesthesia was performed for patients in the control group, while epidural anesthesia was applied in the observation group. The levels of T lymphocyte subsets (CD4⁺ and CD8⁺) and inflammatory factors (IL-2 and TNF-α) were measured and compared before and 1 week after surgery. The incidence rate of TNS within 1 week after surgery was compared between the two groups. Fugl-Meyer Assessment was used to evaluate lower limb motor function and sensory disturbances at 1, 3 and 5 days after treatment. One week after treatment, the serum levels of CD4⁺ and CD8⁺ in the two groups were significantly lower than those before surgery (p<0.05), but no significant differences were found between the groups (p>0.05). The incidence rate of TNS within 1 week after surgery was significantly lower in the observation group than in the control group (p<0.05). The scores of lower limb motor function and sensory disturbances in the observation group evaluated at 1, 3 and 5 days after treatment were significantly higher than those in the control group (p<0.05). In conclusion, combined spinal-epidural anesthesia and epidural anesthesia caused no significant differences in immune function or inflammatory indexes in patients with LDH. However, the application of epidural anesthesia significantly reduced the incidence rate of postoperative TNS, which in turn reduced nerve damage.

Effects of different methods of anesthesia and analgesia on immune function and serum tumor marker levels in critically ill patients

This study investigated the effects of different anesthesia and analgesia methods on immune function and serum tumor marker levels of critically ill patients undergoing tumor resection surgery. Seventy-six critically ill patients with indications for tumor resection surgery were selected in The Second Affiliated Hospital of Zhengzhou University from September 2015 to August 2016. The patients were randomly divided into a control and an observation group (38 patients each). The patients in the control group were treated with general anesthesia and postoperative intravenous analgesia, while the patients in the observation group were treated with general anesthesia and epidural anesthesia and postoperative epidural analgesia. Venous blood samples were collected at 30 min before anesthesia (T1), 2 h after the beginning of the surgery (T2), immediately after surgery (T3), 24 h after surgery (T4) and 72 h after surgery (T5). The viable cell percentage of T lymphocyte subsets (CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺) and natural killer (NK) cells were measured by flow cytometry. The levels of carcinoembryonic antigen, sugar chain antigen 199, sugar chain antigen 125, neuron specific enolase and cytokeratin 19 were detected by electrochemiluminescence at 24 h before and after operation. Our results showed the levels of CD3⁺, CD4⁺ and CD4⁺/CD8⁺ in the control group at T3-T5 were significantly lower than those at T1 (p<0.05). The CD3⁺ level in observation group at T3 was also significantly lower than the level at T1 (p<0.05), but it increased at T4 and T5 and showed no significant difference compared with the initial level (p>0.05). The levels of CD4⁺ and CD4⁺/CD8⁺ in the observation group were significantly higher than those in the control group at T2-T5 (p<0.05). And, the levels of CD3⁺ and CD4⁺ were significantly higher than those in the control group at T4 (p<0.05). The level of CD4⁺/CD8⁺ was significantly higher than that in the control group at T5 (p<0.05). No significant differences were found in the levels of CD8⁺ and NK cells between the 2 groups at any of the time-points (p>0.05). No significant differences were found either in any of the tested tumor markers in either group after 24 h. Even without differences on the tumor marker levels, these results suggest that general anesthesia combined with epidural anesthesia and analgesia produces milder deleterious effects on the immune function of perioperative critically ill patients than general anesthesia combined with intravenous analgesia.

Role of Epidural Injections to Prevent Surgical Intervention in Patients with Chronic Sciatica: A Systematic Review and Meta-Analysis

Objective: The aim of this study is to evaluate the efficacy of the different types of epidural injections (EI) to prevent surgical intervention in patients suffering from chronic sciatica due to lumbar disc herniation (LDH).

Material and Methods: Studies were identified by searching PubMed, MEDLINE, and Google Scholar to retrieve all available relevant articles. Lists of references of several systematic reviews were also used for scanning further references. Publications from the past ten years (2006-2016) were considered, and all studies selected were in the English language only. The studies employed specified the use of EI to treat sciatica caused by LDH. A total of 19 papers meeting the eligibility criteria (mentioned below) were included in this study. The pain scores, functional disability scores, and surgical rates from these studies were considered, and meta-analysis was performed.

Outcome measures: Pain scores, functional disability scores, and surgical rates were assessed from the included studies. The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) have been the most commonly used baseline scales for pain evaluation followed by the Verbal Numerical Rating Scale (VNRS) and Japanese Orthopedic Association (JOA). The Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) scales were used for the functional disability scoring system in the literature.

Results: Significant improvement in the pain scores and functional disability scores were observed. Additionally, greater than 80% of the patients suffering from chronic sciatica caused by LDH could successfully prevent surgical intervention after EI treatment with or without steroids.

Conclusion: The management of sciatica with EI treatment results in significant improvements in the pain score, functional disability score, and surgical rate. We concluded that EI provides new hope to prevent surgical intervention in patients suffering from sciatica caused by LDH.