Genetic predisposition of BMP7 polymorphisms to lumbar disk herniation in the Chinese Han population

Bone morphogenetic protein 7 (BMP7) can induce skeletal formation, promote the differentiation of chondrocytes and osteoblasts, and ameliorate intervertebral disc degeneration. The study was designed to evaluate the relationship of BMP7 variants to LDH risk in the Chinese Han population. BMP7 variants were genotyped with the Agena MassARRAY system among 690 LDH patients and 690 healthy controls. The odds ratio (OR) and 95% confidence interval (CI) were calculated by logistic regression. Multi-factor dimension reduction (MDR) (version 3.0.2) software was used to evaluate the effect of BMP7 variant-variant interaction on the susceptibility to LDH. Here, the risk-reducing association between rs230189 and LDH occurrence was found (p = 0.005, OR = 0.79). Specially, rs230189 was associated with decreased LDH risk in females (p = 0.001, OR = 0.60), elder group (p = 0.025, OR = 0.76), subjects with BMI < 24 kg/m2 (p = 0.027, OR = 0.48), nonsmokers (p = 0.001, OR = 0.66), and nondrinkers (p = 0.011, OR = 0.72). Moreover, rs1321862 might be the risk factor for LDH susceptibility among the participants with BMI < 24 kg/m2 (p = 0.024, OR = 1.84). MDR results displayed that rs230189 was the greatest attribution factor on LDH risk in the single-locus model, with an information gain of 0.44%. The present study demonstrated that BMP7 rs230189 g.55771443A>C may play a protective role against LDH risk. Our findings may help to understand the potential mechanism of BMP7 in LDH susceptibility.

Development and validation of a nomogram to predict the risk of residual low back pain after tubular microdiskectomy of lumbar disk herniation

OBJECTIVE

Tubular microdiskectomy (tMD) is one of the most commonly used for treating lumbar disk herniation. However, there still patients still complain of persistent postoperative residual low back pain (rLBP) postoperatively. This study attempts to develop a nomogram to predict the risk of rLBP after tMD.

METHODS

The patients were divided into non-rLBP (LBP VAS score < 2) and rLBP (LBP VAS score ≥ 2) group. The correlation between rLBP and these factors were analyzed by multivariate logistic analysis. Then, a nomogram prediction model of rLBP was developed based on the risk factors screened by multivariate analysis. The samples in the model are randomly divided into training and validation sets in a 7:3 ratio. The Receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the diskrimination, calibration and clinical value of the model, respectively.

RESULTS

A total of 14.3% (47/329) of patients have persistent rLBP. The multivariate analysis suggests that higher preoperative LBP visual analog scale (VAS) score, lower facet orientation (FO), grade 2-3 facet joint degeneration (FJD) and moderate-severe multifidus fat atrophy (MFA) are risk factors for postoperative rLBP. In the training and validation sets, the ROC curves, calibration curves, and DCAs suggested the good diskrimination, predictive accuracy between the predicted probability and actual probability, and clinical value of the model, respectively.

CONCLUSION

This nomogram including preoperative LBP VAS score, FO, FJD and MFA can serve a promising prediction model, which will provide a reference for clinicians to predict the rLBP after tMD.

Back morphology and walking patterns mean 13.8 years after surgery for lumbar disk herniation in adolescents

Introduction

In many pain conditions, there is lingering pain despite healed tissue damage. Our previous study shows that individuals who underwent surgery for lumbar disk herniation (LDH) during adolescence have worse health, more pain, and increased disk degeneration mean 13 years after surgery compared with controls. It is unclear if walking patterns segregate surgically treated LDH adolescents and controls at mean 13-year follow-up.

Objectives

Here, we analyzed the relationship between gait, back morphology and other health outcomes in a cohort of individuals treated surgically because of lumbar disk herniation compared with controls.

Methods

We analyzed gait during a walking paradigm, back morphology at the site of surgery, and standardized health outcomes, among individuals who received surgery for LDH as adolescents, "cases" (n = 23), compared with "controls" (n = 23).

Results

There were gait differences in head (P = 0.021) and trunk angle (P = 0.021) between cases and controls in a direction where cases exhibited a posture associated with sickness. The gait variance was explained by subjective pain and exercise habits rather than objective disk degeneration.

Conclusion

Over a decade after surgery for LDH during adolescence, health among cases is worse compared with controls. The head and trunk angles differ between cases and controls, indicating that the residual pain lingers and may cause changes in movement patterns long after a painful episode in early life. Gait may be a useful target for understanding maintenance of pain and disability among individuals treated surgically for LDH during adolescence.

Unilateral biportal endoscopic discectomy versus microdiscectomy for lumbar disc herniation: a systematic review and meta-analysis

PURPOSE

This study aimed to compare unilateral biportal endoscopic discectomy (UBED) with microdiscectomy (MD) for treating lumbar disk herniation (LDH).

METHODS

A comprehensive literature search was conducted in the Embase, PubMed, Cochrane Library, CNKI, and Web of Science databases from database inception to April 2023 to identify studies comparing UBED and MD for treating LDH. This study evaluated the visual analog scale (VAS) score, Oswestry disability index (ODI), Macnab scores, operation time, estimated blood loss, hospital stay, and complications, estimated blood loss, visual analog scale (VAS) score, Oswestry disability index (ODI), and Macnab scores at various pre- and post-surgery stages. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

The meta-analysis included 9 distinct studies with a total of 1001 patients. The VAS scores for low back pain showed no significant differences between the groups at postoperative 1-3 months (P = 0.09) and final follow-up (P = 0.13); however, the UBED group had lower VAS scores at postoperative 1-3 days (P = 0.02). There were no significant differences in leg pain VAS scores at baseline (P = 0.05), postoperative 1-3 days (P = 0.24), postoperative 1-3 months (P = 0.78), or at the final follow-up (P = 0.43). ODI comparisons revealed no significant differences preoperatively (P = 0.83), at postoperative 1 week (P = 0.47), or postoperative 1-3 months (P = 0.13), and the UBED group demonstrated better ODI at the final follow-up (P = 0.03). The UBED group also exhibited a shorter mean operative time (P = 0.03), significantly shorter hospital stay (P < 0.00001), and less estimated blood loss (P = 0.0002). Complications and modified MacNab scores showed no significant differences between the groups (P = 0.56 and P = 0.05, respectively).

CONCLUSION

The evidence revealed no significant differences in efficacy between UBED and MD for LDH treatment. However, UBED may offer potential benefits such as shorter hospital stays, lower estimated blood loss, and comparable complication rates.

Impact of surgical treatment on lipid metabolism in patients with lumbar spinal disorders: Prospective observational study

PURPOSE

It is still unclear how lumbar spinal surgery affects the lipid metabolism of patients with lumbar spinal disorders (LSDs) such as lumbar spinal canal stenosis and lumbar disk herniation. The present study aimed to assess the impact of lumbar spinal surgery on lipid metabolism in patients with LSDs and clarify the factors associated with changes in visceral fat (VF) accumulation before and after lumbar spinal surgery.

METHODS

Consecutive patients with lumbar spinal surgery for LSDs were prospectively included. Abdominal computed tomography images and blood examination of the participants were evaluated before surgery and at 6 months and 1 year after surgery. The cross-sectional VF area (VFA) was measured at the level of the navel using computed tomography images. Blood examination items included triglycerides and high-density lipoprotein (HDL).

RESULTS

The study enrolled a total of 138 patients. Female patients with LSDs had significantly increased VFA and serum triglyceride levels after lumbar spinal surgery. On multivariable analysis, the group with > 100 cm2 of preoperative VFA and a postoperative decrease in VFA had a significantly worse preoperative walking ability based on the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (relative risk 2.1; 95% confidence intervals 1.1-4.1).

CONCLUSIONS

The present study demonstrated that patients with LSDs did not necessarily improve their lipid metabolism after lumbar spinal surgery. Instead, female patients with LSDs had significantly deteriorated lipid metabolism after lumbar spinal surgery. Finally, a worse preoperative walking ability was associated with the improvement in excess VF accumulation after lumbar spinal surgery.

Intraoperative Ultrasound and Findings of Lumbar Intradural Disk Herniation Causing Cauda Equina Syndrome

Intradural lumbar disk herniation (ILDH) is a rare variant and accounts for 0.33%-1.5% of lumbar disk herniations. Although clues exist on preoperative imaging, they remain subtle and most cases of ILDH are diagnosed intraoperatively. Intraoperative ultrasound is a useful adjunct in diagnosing and managing ILDH. We present a case to demonstrate the features of an intradural herniated disk on ultrasound imaging and highlight the utility of intraoperative ultrasonography in establishing diagnosis, guiding dural opening, and confirming adequate nerve root decompression following diskectomy.

The diagnostic accuracy of straight leg raise test in patients more than 60 years of age suffering lumbar disk herniation with low back pain and sciatica

Objective

To determine the diagnostic accuracy of the SLR test in elderly patients suffering from lumbar disk herniation with sciatica and low back pain, using magnetic resonance imaging (MRI) as the gold standard.

Materials and Methods

A cross-sectional study was conducted at Jinnah Postgraduate Medical Center and a total of 120 patients, above 60 years of age, with symptomatic lumbar disk herniation were enrolled. SLR test was performed and the results recorded. MRI of the lumbar spine was undertaken for confirmation of disk herniation.

Results

The sensitivity of the SLR test in patients 60 years and older is 33.3%. A decrease in the diagnostic accuracy of the SLR test with an increment in age was also noted.

Conclusion

It was found that with an increment in age, there is a steady decline in the diagnostic accuracy of SLR Test.

One-hole split endoscopy technique versus unilateral biportal endoscopy technique for L5-S1 lumbar disk herniation: analysis of clinical and radiologic outcomes

BACKGROUND

Lumbar disk herniation (LDH) is one of the most common diseases of the spine, especially occurring in L4-5 and L5-S1 intervertebral disks, and surgery is a choice when conservative treatment is ineffective. The purpose of this study is to investigate the clinical efficacy and radiologic outcomes of one-hole split endoscopy (OSE) technique versus unilateral biportal endoscopy (UBE) technique in the treatment of L5-S1 lumbar disk herniation (LDH).

METHODS

A total of 133 patients of a single center surgically treated for L5-S1 LDH between 2019 and 2021 were retrospectively included in this study, of which 70 were treated by UBE technique and the rest were treated by OSE technique. Hospitalization time, operative time, intraoperative blood loss, fluoroscopy times, incision length and related complications were recorded. Bone resection area (BRA), articular process resection rate, range of motion (ROM), sagittal translation (ST), disk height (DH), Visual Analog Score (VAS), Oswestry Disability Index (ODI) and Macnab criteria were used to evaluated the clinical efficacy.

RESULTS

There was no statistically significant difference in hospitalization time or fluoroscopy times between the two groups. The operation time was shorter in the UBE group than that in the OSE group; however, the incision length was longer. Intraoperative blood loss and BRA were larger in the UBE group than in the OSE group. There was no significant difference in ROM, ST, DH, or postoperative facet resection rate between the two groups. There was no significant difference in ROM, ST, or postoperative facet resection rate compared with preoperative indicators in each group, but there was a significant difference in DH among distinct groups. At any time point, the lower back and leg VAS and ODI in each group were significantly improved compared to those before the operation, with no significant difference between the two groups. There was one case of dural tear in the UBE group. One case of transient hypoesthesia occurred in each of the two groups. The excellent-good rates of the UBE group and the OSE group were 88.6% and 90.5%, respectively.

CONCLUSION

The OSE technique is an effective minimally invasive surgical option as well as the UBE technique in the treatment of L5-S1 LDH.

Lever positioning manipulation alters real-time brain activity in patients with lumbar disc herniation: An amplitude of low-frequency fluctuation and regional homogeneity study

INTRODUCTION

Lumbar disk herniation (LDH) is the preeminent disease of lever positioning manipulation (LPM), a complex disorder involving alterations in brain function. Resting-state functional magnetic resonance imaging (rs-fMRI) has the advantages of non-trauma, zero radiation, and high spatial resolution, which has become an effective means to study brain science in contemporary physical therapy. Furthermore, it can better elucidate the response characteristics of the brain region of LPM intervention in LDH. We utilized two data analysis methods, the amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) of rs-fMRI, to assess the effects of LPM on real-time brain activity in patients with LDH.

METHODS

Patients with LDH (Group 1, n = 21) and age-, gender- and education-matched healthy controls without LDH (Group 2, n = 21) were prospectively enrolled. Brain fMRI was performed for Group 1 at two-time points (TPs): before LPM (TP1) and after one LPM session (TP2). The healthy controls (Group 2) did not receive LPM and underwent only one fMRI scan. Participants in Group 1 completed clinical questionnaires assessing pain and functional disorders using a Visual Analog Scale and the Japanese Orthopaedic Association (JOA), respectively. Furthermore, we employed MNL90 (Montreal Neurological Institute) as a brain-specific template.

RESULTS

Compared to the healthy controls (Group 2), the patients with LDH (Group 1) had significant variation in ALFF and ReHo values in brain activity. After the LPM session (TP2), Group 1 at TP1 also showed significant variation in ALFF and ReHo values in brain activity. In addition, the latter (TP2 vs TP1) showed more significant changes in brain regions than the former (Group 1 vs Group 2). The ALFF values were increased in the Frontal_Mid_R and decreased in the Precentral_L in Group 1 at TP2 compared with TP1. The Reho values were increased in the Frontal_Mid_R and decreased in the Precentral_L in Group 1 at TP2 compared with TP1. The ALFF values were increased in the Precuneus_R and decreased in the Frontal_Mid_Orb_L in Group 1 compared with Group 2. Only three brain areas with significant activity in Group 1 compared with Group 2: Frontal_Mid_Orb_L, Frontal_Sup_Orb_L, and Frontal_Mid_R. ALFF value in the Frontal_Mid_R at TP2 correlated positively with the change rates of JOA scores between TP1 and TP2 (P = 0.04, r = 0.319, R2 = 0.102).

DISCUSSION

Patients with LDH showed abnormal brain ALFF and ReHo values, which were altered after LPM. The default mode network, prefrontal cortex, and primary somatosensory cortex regions could predict real-time brain activity for sensory and emotional pain management in patients with LDH after LPM.

Comparative analysis of perioperative characteristics and early outcomes in transforaminal endoscopic lumbar diskectomy: general anesthesia versus conscious sedation

PURPOSE

To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS).

METHODS

We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up.

RESULTS

A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant.

CONCLUSION

In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.

Incidence and risk factors of spinal cord stimulation for persistent or recurrent pain after lumbar spine surgery: a population-based study

PURPOSE

This study aims to elucidate the incidence of and independent risk factors for spinal cord stimulator implantations for patients who underwent lumbar spine surgery.

METHODS

The PERFormance, Effectiveness, and Cost of Treatment (PERFECT) episodes database, which was established for selected diseases and procedures in Finland, includes all patients who underwent lumbar spine surgery for degenerative spine conditions or spinal cord stimulation (SCS) in Finland from 1986 to 2018. The data on age, sex, hospital diagnoses, surgical procedures, and causes of death were imported from the Finnish national registers into the PERFECT database.

RESULTS

Between 1986 and 2018, 157,824 patients had their first lumbar spine procedure and for 1769 (1.1%) of them, a subsequent SCS procedure was observed during the follow-up. The cumulative incidence of SCS for persistent or recurrent pain after lumbar disk herniation, spinal stenosis, degenerative disk disease, and spondylolysis and spondylolisthesis surgery at 15 years was 1.2%, 1.0%, 2.7%, and 2.6% respectively. At 15 years, the cumulative incidence of SCS for persistent or recurrent pain after lumbar spine surgery after five or more lumbar spinal operations was 11.9%.

CONCLUSION

Repeated surgery was the most prominent significant risk factor for SCS for persistent or recurrent pain after lumbar spine surgery. The risk of SCS for persistent or recurrent pain after lumbar spine surgery increases significantly along with the number of lumbar spine procedures. When considering repeated lumbar spine surgery, careful evaluation of treatment options should take place to ensure good patient outcomes.

Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair

OBJECTIVE

There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion.

METHODS

Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36.

RESULTS

Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution.

CONCLUSIONS

Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

Transcriptome profiling of microRNAs reveals potential mechanisms of manual therapy alleviating neuropathic pain through microRNA-547-3p-mediated Map4k4/NF-κb signaling pathway

BACKGROUND

Local neuroinflammation secondary to spinal nerve compression in lumbar disk herniation (LDH) is a key driver contributing to neuropathic pain. Manual therapy (MT), a widely used nonsurgical therapy, can relieve LDH-mediated pain by reducing inflammation. MT has attracted extensive attention; however, its mechanism remains poorly understood. MicroRNAs (miRNAs) are important regulators of pain signaling transduction, but are rarely reported in the chronic compression of dorsal root ganglia (CCD) model, and further investigation is needed to decipher whether they mediate anti-inflammatory and analgesic effects of MT.

METHODS

We used a combination of in vivo behavioral and molecular techniques to study MT intervention mechanisms. Neuropathic pain was induced in a CCD rat model and MT intervention was performed according to standard procedures. Enzyme-linked immunosorbent assay (ELISA) was used to detect inflammatory cytokine levels in dorsal root ganglia (DRG). Small RNA sequencing, immunofluorescence, Western blot, and qRT-PCR were performed to screen miRNAs and their target genes and determine core factors in the pathway possibly regulated by miRNA-mediated target gene in DRG of MT-treated CCD rats.

RESULTS

Compared with naive rats, small RNA sequencing detected 22 differentially expressed miRNAs in DRG of CCD rats, and compared with CCD rats, MT-treated rats presented 19 differentially expressed miRNAs, which were functionally associated with nerve injury and inflammation. Among these, miR-547-3p was screened as a key miRNA mediating neuroinflammation and participating in neuropathic pain. We confirmed in vitro that its function is achieved by directly regulating its target gene Map4k4. Intrathecal injection of miR-547-3p agomir or MT intervention significantly reduced Map4k4 expression and the expression and phosphorylation of IκBα and p65 in the NF-κB pathway, thus reducing the inflammatory cytokine levels and exerting an analgesic effect, whereas intrathecal injection of miR-547-3p antagomir led to opposite effects.

CONCLUSIONS

In rats, CCD-induced neuropathic pain leads to variation in miRNA expression in DRG, and MT can intervene the transcription and translation of inflammation-related genes through miRNAs to improve neuroinflammation and alleviate neuropathic pain. MiR-547-3p may be a key target of MT for anti-inflammatory and analgesia effects, which is achieved by mediating the Map4k4/NF-κB pathway to regulate downstream inflammatory cytokines.

Factors associated with the recurrence of lumbar disk herniation: biomechanical-radiological and demographic factors

Many risk factors associated with recurrent lumbar disk herniation (RLDH) following lumbar discectomy (LD) have been reported. This study aimed to elucidate the biomechanical-radiological, clinical, and demographic factors that affect symptomatic RLDH prospectively.We collected prospective data of 988 consecutive patients with LDH who underwent LD at our department from January 2014 to December 2015. Patients who met the study criteria and were followed up postoperatively for more than 5 years were included (n = 816). Patients were divided into 3 groups; group 1 included patients who experienced symptomatic RLDH within the first postoperative 24 months (PO24M), group 2 included patients with symptomatic RLDH after PO24M, and group 3 included the patients who hadn't experienced symptomatic RLDH/LDH. The preoperative biomechanical-radiological, clinical, and the patients' demographic characteristics were compared among the groups.A total of 816 patients with 842 LDH met our study criteria. The mean age at the first LD was 46.9 years. The mean follow-up period was 72.8 months. The preoperative trauma history, postoperative trauma history, and BMI > 24.5 kg/m² were independent risk factors for RLDH. Large sROM at the L4-5 level and a higher intervertebral disk height index (IDH) were significantly higher in groups 1 and 2.Biomechanical-radiological and demographic factors can affect the incidence of symptomatic RLDH. To reduce the risk of RLDH, patients with these risk factors should receive more attention during surgical interventions. The patients should avoid gaining weight and potential traumatic accidents.

Overweight and smoking promote recurrent lumbar disk herniation after discectomy

PURPOSE

Recurrent lumbar disk herniation (rLDH) following lumbar microdiscectomy is common. While several risk factors for primary LDH have been described, risk factors for rLDH have only sparsely been investigated. We evaluate the effect of Body mass index (BMI) and smoking on the incidence and timing of rLDH.

METHODS

From a prospective registry, we identified all patients undergoing primary tubular microdiscectomy (tMD), with complete BMI and smoking data, and a minimum 12-month follow-up. We defined rLDH as reherniation at the same level and side requiring surgery. Overweight was defined as BMI > 25, and obesity as BMI > 30. Intergroup comparisons and age- and gender-adjusted multivariable regression were carried out. We conducted a survival analysis to assess the influence of BMI and smoking on time to reoperation.

RESULTS

Of 3012 patients, 166 (5.5%) underwent re-microdiscectomy for rLDH. Smokers were reoperated more frequently (6.4% vs. 4.0%, p = 0.007). Similarly, rLDH was more frequent in obese (7.5%) and overweight (5.9%) than in normal-weight patients (3.3%, p = 0.017). Overweight smokers had the highest rLDH rate (7.6%). This effect of smoking (Odds ratio: 1.63, 96% CI: 1.12-2.36, p = 0.010) and BMI (Odds ratio: 1.09, 95% CI: 1.02-1.17, p = 0.010) persisted after controlling for age and gender. Survival analysis demonstrated that rLDH did not occur earlier in overweight patients and/or smokers.

CONCLUSIONS

BMI and smoking may directly contribute to a higher risk of rLDH, but do not accelerate rLDH development. Smoking cessation and weight loss in overweight or obese patients ought to be recommended with discectomy to reduce the risk for rLDH.

Lumbar Disk Herniations and Radiculopathy in Athletes

Lumbar disk herniation is the most common surgical condition of the spine. High-level athletes participate in activities that place extreme loads on the intervertebral disks. These repetitive loads may lead to an elevated risk for degenerative disk disease, which in turn predisposes to disk herniations. Treatment algorithms for athletes with disk herniations are similar to those in the nonathletic population; however, success in the athletic population is often measured in the ability to return to play. Both nonoperative and operative treatment show a high success rate in return to play in athletes treated for disk herniations.

Surgeons preference for lumbar disk surgery: a discrete choice experiment

PURPOSE

Multiple surgical techniques are practiced to treat sciatica caused by lumbar disk herniation. It is unknown which factors surgeons find important when offering certain surgical techniques. The objective of this study is threefold: 1) determine the relative weight surgeons place on various characteristics of sciatica treatment, 2) determine the trade-offs surgeons make between these characteristics and 3) identify preference heterogeneity for sciatica treatment.

METHODS

A discrete choice experiment was conducted among members of two international neurosurgical organizations. Surgeons were asked on their preferences for surgical techniques using specific scenarios based on five characteristics: effectiveness on leg pain, risk of recurrent disk herniation, duration of postoperative back pain, risk of complications and recovery period.

RESULTS

Six-hundred and forty-one questionnaires were filled in, the majority by neurosurgeons. All characteristics significantly influenced the preferences of the respondents. Overall, the risk of complications was the most important characteristic in the decision to opt-in or opt-out for surgery (35.7%). Risk of recurrent disk herniation (19.6%), effectiveness on leg pain (18.8%), postoperative back pain duration (13.5%) and length of recovery period (12.4%) followed. Four latent classes were identified, which was partly explained by the tenure of the surgeon. Surgeons were willing to trade-off 57.8% of effectiveness on leg pain to offer a treatment that has a 1% complication risk instead of 10%.

CONCLUSION

In the context of this discrete choice experiment, it is shown that neurosurgeons consider the risk of complications as most important when a surgical technique is offered to treat sciatica, while the risk of recurrent disk herniation and effectiveness are also important factors. Neurosurgeons were prepared to trade off substantial amounts of effectiveness to achieve lower complication rates.

Percutaneous transforaminal endoscopic discectomy in a nine-year-old patient with sciatica: case report, technical note and overview of the literature

Percutaneous transforaminal endoscopic discectomy (PTED) is an alternative procedure to open microdiscectomy (OM) to treat sciatica caused by lumbar disk herniation. Even though robust evidence comparing PTED with OM is lacking, PTED is becoming increasingly popular to treat spinal disorders. In this technical report, the surgical technique and outcomes of PTED in a 9-year-old patient are described. Furthermore, an overview of the literature on full-endoscopic techniques to treat sciatica is given, showing that PTED is feasible, safe and effective to treat lumbar disk herniation in the pediatric population.

Resorption of upwardly displaced lumbar disk herniation after nonsurgical treatment: A case report

BACKGROUND

The spontaneous resorption of lumbar disk herniations (LDHs) has been widely reported. However, the majority of these reports analyze the resorption of LDHs that were displaced backwards or downwards. There have been few reports on the spontaneous resorption of upwardly displaced L4/5 LDH that has caused femoral nerve symptoms.

CASE SUMMARY

A 55-year-old woman presented to our hospital with acute pain in her left leg. She had been suffering from recurrent lower back pain for approximately 1 year and began to feel pain accompanied with numbness at the anterior aspect of her left leg 7 d previously. On examination, a typical L4 nerve stimulation was noted. An upwardly displaced LDH at the L4/5 level was revealed by magnetic resonance imaging. The patient attained complete relief of her symptoms after 10 wk of nonsurgical treatment and the upwardly displaced herniation almost entirely disappeared. There was no recurrence during a follow-up of 2 years.

CONCLUSION

Clinicians should be aware that the nerves disturbed by LDHs vary according to the direction of the herniations and the probable resorption of upwardly displaced LDHs should be considered before making a decision on surgery.

Activation of p38MAPK in spinal microglia contributes to autologous nucleus pulposus-induced mechanical hyperalgesia in a modified rat model of lumbar disk herniation

Recent studies have implicated the activation of p38 mitogen-activated protein kinase (MAPK) and glial cells contribute to hyperalgesia following nerve injury or nerve compression. In our work, we investigated the underlying mechanisms of autologous nucleus pulposus (NP)-induced mechanical hyperalgesia in a modified rat model of lumbar disk herniation (LDH). Firstly, our results showed that 50% mechanical withdrawal threshold (50% MWT) decreased on postoperative day (POD) 1 and significantly minimally reduced on POD 7 and lasted for day 28 after surgery (P < 0.05). Secondly, phosphorylation of p38MAPK (p-p38MAPK) and glial cells were monitored on POD 1, 3, 7, 14 and 28 using immunofluorescence staining. P38MAPK activation, observed in the spinal cord, began to increase on POD 1, peaked on POD 3, and significantly decreased on POD 14 and POD 28 (P < 0.05). Microglia activation was initiated at day 1, maximal at day 3, and maintained until day 14 after surgery (P < 0.05). Astrocytic activation was found in 7 to 14 days after modelling (P < 0.05). Then, double immunostaining method was applied to observe the co-expression of p-p38MAPK and glial cells, and it showed that p-p38MAPK was mainly expressed in activated microglia, rarely in neurons, and none in astrocytes. Lastly, we discovered that both SB203580 (50ug, p38MAPK inhibitor) and minocycline (0.5 mg, microglial inhibitor) would inhibit the p-p38MAPK protein expression tested by western blot analysis and reduce mechanical hyperalgesia. In conclusion, current study suggest that activation or phosphorylation of p38MAPK in spinal microglia contributes to autologous NP-induced mechanical hyperalgesia in our animal model.

Estimation and influence of blood loss under endoscope for percutaneous endoscopic lumbar discectomy (PELD): a clinical observational study combined with in vitro experiment

PURPOSE

The purpose of this study is to come up with new methods to quantitate the blood loss under endoscope and explore the influence of blood loss on percutaneous endoscopic lumbar discectomy (PELD).

METHODS

Clinical research and in vitro experiment are combined. In the in vitro experiment, 2.0-ml blood was diluted in different ratio to simulate the rinse solution of PELD, the hematocrit method (HCT-M) and red blood cell count method (RBC-M) were came up to estimate blood loss and the new methods were calibrated with the direct measurement method (Direct-M). In clinical research, 74 patients with L5/S1 disk herniation were treated with PELD, and HCT-M and the empirical method (EMP-M) were used to estimate the blood loss under endoscope. According to blood loss, all patients were divided into group A (≤ 10 ml) and group B (> 10 ml). The blood loss, operation time, fluoroscopy frequency, visual analog scale (VAS), and Oswestry Disability Index (ODI) scores were compared between the two groups.

RESULTS

In the in vitro experiment, the hematocrit of the rinse solution was always stable over time. The estimated blood loss by HCT-M was stable and quite approximate to actual blood volume (2.0 ml) whatever the blood dilution ratio, while according to RBC-M, the estimated blood loss was close to the actual blood volume only when the dilution ratio was greater than 300 times. In clinical research, the blood loss estimated by HCT-M was higher than that by EMP-M in both groups (P < 0.05). There was a significant difference between group A and group B in blood loss (7.40 ± 1.61 vs 19.91 ± 10.94 ml), operation time (80.51 ± 34.70 vs 136.51 ± 41.88 min), and fluoroscopy frequency (6.92 ± 1.52 vs 11.11 ± 2.32 times) (P < 0.05). The VAS and ODI scores in group B were higher than that in group A 1 week after operation (P < 0.05); however, the scores were not different between the two groups at pre-operation (P > 0.05).

CONCLUSION

HCT-M is a reliable method to estimate endoscopic blood loss in PELD. The amount of endoscopic blood loss affects the operative procedure in operation time and fluoroscopy frequency, as well as clinical effects in VAS and ODI scores after operation in short term.

Involvement between social defeat stress and pain-related behavior in a rat lumbar disk herniation model

INTRODUCTION

Psychological and social factors are involved in the disability and chronicity of pain. Our study aim was to investigate whether social defeat stress (SDS) as a psychophysical stress affected mechanical withdrawal thresholds in the lumbar disk herniation (LDH) rat model. Changes in microglia and astrocytes, which play important roles in neuropathic pain states, were also investigated.

MATERIALS AND METHODS

For the LDH model, nucleus pulposus (NP) was applied to the L5 dorsal root ganglion (DRG) in adult female Sprague-Dawley rats. SDS was performed 15 min daily for 8 days. Mechanical withdrawal thresholds were measured, and immunoreactive cells of glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor molecule-1 (Iba-1), which were used as markers of microglia, satellite glial cells, and astrocytes, were assessed in the DRG, spinal cord (SC), and ventrolateral periaqueductal gray matter (VLPAG).

RESULTS

Mechanical withdrawal thresholds decreased in the NP group for 21 days and for 35 days in the NP + SDS group. Expression of GFAP and Iba-1 in the DRG and SC increased up to day 21 in the NP and NP + SDS groups. In the sham + SDS and NP + SDS groups, expression of GFAP in the VLPAG decreased until day 35.

CONCLUSION

SDS prolongs mechanical allodynia induced by NP. Changes of GFAP expression in the VLPAG were associated with mechanical allodynia of the NP + SDS group during the late phase. These results suggest that psychological chronic stress might delay recovery from mechanical allodynia induced by the LDH model.

Assessment and Post-Intervention Recovery After Surgery for Lumbar Disk Herniation Based on Objective Gait Metrics from Wearable Devices Using the Gait Posture Index

OBJECTIVE

Surgery for lumbar disk herniation (LDH) presents an option for patients when conservative measures fail. The objective of this clinical study is to investigate a novel, objective outcome measure in patients undergoing lumbar microdiscectomy.

METHODS

Twenty-four patients were evaluated pre- and postoperatively using the Oswestry Disability Index (ODI), and a novel objective scoring tool, the Gait Posture index (GPi). The score is calculated from 4 key physical health metrics: daily step count, walking speed, step length, and walking posture. The GPi ranges from 0 (nonambulant) to 100 (excellent walking performance). Wearable accelerometers and observational recordings were used to evaluate the components of the GPi. The GPi was calculated and compared with the ODI, pre- and postintervention. The study was designed as a proof of concept and confirmation of validity for use of the GPi in LDH.

RESULTS

At follow-up (average 66 ± 36 days), 23 of 24 patients had an improvement in their GPi after surgery. The average GPi of the cohort improved from 59.33 ± 16.06 to 85.75 ± 9.22 with P < 0.001, with significant changes in all 4 components. The average preoperative ODI was 54.54 ± 20.70, improving to 16.33 ± 14.095 with P < 0.001. The Pearson correlation coefficient was r = 0.56, indicating a correlation between change in ODI and change in GPi.

CONCLUSIONS

The GPi score is a new, objective descriptor of mobility in spinal surgery which can be used to augment traditional subjective outcome scoring surveys such as the ODI. Significant changes are seen in the GPi and its constituent metrics in patients undergoing surgery for LDH.

Are There Any Risk Factors Associated with the Presence of Cauda Equina Syndrome in Symptomatic Lumbar Disk Herniation?

OBJECTIVE

Risk factors for developing cauda equina syndrome (CES) caused by lumbar disk herniation (LDH) remain controversial and have not been established yet. The aim of the study was to investigate whether there is a relationship among age, sex, body mass index (BMI), or the degree of spinal canal compromise and the presence of CES in patients undergoing lumbar microdiskectomy.

METHODS

Between 2015 and 2019, 506 patients who had an operation for LDH compressing the dural sac were prospectively identified. The "prolapse-to-canal ratio" (PCR) was calculated as a proportion of the cross-sectional area of the disk prolapse compared with the total cross-sectional area of the spinal canal.

RESULTS

In total, 35 CES (6.9%) patients were identified. Multivariate logistic regression, adjusted for age, gender, BMI, and PCR, shows that only PCR was associated with the presence of CES (P < 0.001, area under the curve 0.7431). BMI was not associated with an increased risk of CES.

CONCLUSIONS

This study demonstrates a significant correlation between the size of LDH relative to size of the spinal canal and the presence of CES. A finding of LDH causing >60% obstruction of the spinal canal should be considered a red flag, and such patients need to be watched more closely.

Full Endoscopic Lumbar Diskectomy for Lumbar Disk Herniation in the Presence of a Low-Lying Cord

BACKGROUND

The distal extent of the spinal cord is most often at the level of the L1 or L2 vertebral body. In rare cases, a low-lying cord extends more distally. In this scenario, pathology that normally causes radiculopathy may cause myelopathy due to compression of the cord rather than nerve roots of the cauda equina.

CASE DESCRIPTION

A 40-year-old man presented with progressive leg pain, sensory changes, hyperreflexia, and gait disturbance 1 month after a fall. The patient was myelopathic and had central L1/2 and L2/3 disk herniations. After unsuccessful unilateral laminotomy bilateral decompression, it was decided that an endoscopic diskectomy would be the best technique to remove the disk herniation without trauma to the cord or destabilizing the spine to require fusion. A percutaneous endoscopic lumbar diskectomy at L1/2 was performed under local anesthesia. The patient's leg pain, sensory changes, hyperreflexia, and gait disturbance resolved after surgery, and he was doing well at 6 months' follow-up.

CONCLUSIONS

In patients with spina bifida occulta who present with myelopathy, lumbar disk herniation should be considered if the patient has a low-lying cord. This is the first report of percutaneous endoscopic lumbar diskectomy for lumbar disk herniation in the presence of a low-lying spinal cord. We have demonstrated that this approach can treat this condition effectively and safely.

A comparison of sciatica in young subjects and elderly person

BACKGROUND

Sciatica is a common symptom for many people with degenerative lumbar spine diseases. It is by far the most common symptom of disc herniation. However, disc herniation is not the only cause of sciatica. Other degenerative lumbar spine diseases can provoke Sciatica. To date, few studies have analysed the cause of sciatica in particularly in elderly patients.

MATERIAL AND METHODS

We analysed retrospectively records of patients aged between 35 and 55 (first group) and between 65 and 85 (second group) visited in our departments for sciatica between December 2009 and November 2018.

RESULTS

In elderly patients, disc herniation from upper levels (L2-L3 and L3-L4) is more common than younger people. Sciatica as a result of exclusive disc herniation reduces with age. Foramen stenosis produces sciatica in elderly patients more than twice as high in younger patients. Statistically, more patients needed to surgery in elderly patients in comparison with younger population.

CONCLUSION

Sciatica in elderly patients takes a different clinical aspect in comparison with younger population. The clinical picture associates pain less severe but more persistent, more resistant to treatment. It is caused in less than 50% by disc herniation.

Learning Curve for Percutaneous Endoscopic Lumbar Diskectomy in Bi-needle Technique Using Cumulative Summation Test for Learning Curve

BACKGROUND

The purpose of this study was to determine the number of cases needed to achieve the level of competence for percutaneous endoscopic lumbar diskectomy (PELD) via the bi-needle technique using the cumulative summation test for learning curve (LC-CUSUM).

METHODS

A retrospective design was used. We included 60 patients who underwent a single-level PELD via the bi-needle technique performed by a single surgeon. The surgeon had 5 years of experience in open surgery including the transforaminal endoscopic spine system and Yeung endoscopic spine system but no experience in the bi-needle technique. Surgery success was defined as an operative time <60 minutes, and the acceptable procedure was completed within 3 times of C-arm fluoroscopies. The LC-CUSUM was used to analyze the data.

RESULTS

The average operative time for PELD via the bi-needle technique was 58.3 ± 12.4 minutes. The mean operative time was 65.7 ± 12.1 minutes in the early learning period (30 cases) and 51.0 ± 7.5 minutes in the late learning period (30 cases) (P < 0.05). On the basis of the evaluation indexes of the operative time and radioactive exposure, the LC-CUSUM signaled proficiency for the bi-needle technique at the 50th-54th operation. Seven cases of complications were observed during the whole learning process, with 6 in the early period and 1 in the late period (P < 0.05).

CONCLUSIONS

The novel bi-needle technique is safe and effective for PELD with appropriate patients, and the learning curve is acceptable. A substantial learning period (50-54 cases) is needed before a spine surgeon can master the bi-needle technique.

Percutaneous Endoscopic Lumbar Diskectomy for Axillar Herniation at L5-S1 via the Transforaminal Approach Versus the Interlaminar Approach: A Prospective Clinical Trial

OBJECTIVE

To evaluate the results of percutaneous endoscopic transforaminal diskectomy (PETD) in comparison with percutaneous endoscopic interlaminar diskectomy (PEID) for axillar herniation at L5-S1.

METHODS

From January 2017 to March 2018, 80 patients admitted with axillar herniation at L5-S1 were randomly recruited into 2 groups: 40 cases in the PETD group and 40 in the PEID group. Each group separately underwent PETD or PEID. Patient sex, age, body mass index, axillar herniation size, number of C-arm fluoroscopies, operation time, postoperative bed time, complications, and clinical effect were compared. Both groups were followed-up using the Oswestry Disability Index (ODI), visual analog scale (VAS), and Macnab criteria.

RESULTS

Except for 1 case in the PETD group that switched to the PEID group, the patients completed the study as expected. All patients were followed-up. Preoperative demographics were not significantly different (P > 0.05) between the 2 groups. The mean number of C-arm fluoroscopies (12.44 ± 3.21) and the operation time (66.49 ± 16.29 minutes) of the PETD group were significantly improved compared with the PEID group (number of fluoroscopies: 3.41 ± 0.81, P < 0.001; operation time: 53.56 ± 10.82 minutes, P < 0.001), but the postoperative bed rest time and complication rate were not (P > 0.05). The postoperative ODI and VAS scores were obviously improved in both groups when compared with preoperation (P < 0.001). There were no significant differences between the 2 groups in the Macnab criteria or VAS and ODI scores at the same time point (P > 0.05).

CONCLUSIONS

For axillar herniation at L5-S1, PEID can ignore the anatomic obstruction with advantages including a shorter operation time and less intraoperative radiation exposure. PETD has a clinical effect similar to that of PEID, but the process of it is more dangerous and harder than PEID.

How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation

BACKGROUND

Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital.

METHODS

PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm.

CONCLUSION

PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Open Discectomy vs. Microdiscectomy: Results from 519 Patients Operated for Lumbar Disc Herniation

Objective

The aim of this study was to evaluate the outcomes of patients with lumbar disk hernia operated between 2012 January and 2017 August and to compare the differences between open discectomy (OD) and microdiscectomy (MD).

Materials and Methods

Files of 519 patients who presented at our neurosurgical department with lumbar disk herniation were retrospectively reviewed and recorded. Preoperatively, all patients routinely underwent spinal lumbar magnetic resonance imaging (MRI) and anteroposterior as well as lateral lumbar vertebrae X-rays. During the early postoperative period, there was no need for imaging. Surgical interventions were performed using the two currently accepted OD and MD methods.

Results

We reviewed 519 patients with lumbar disk herniation who were operated in our clinic between 2012 and 2017. The mean age of 276 patients who underwent OD was 44.85±9.92 y, and that of the remaining 243 patients who underwent MD was 47.69±12.87 y. There was no difference in the demographic distributions of patients; levels of lumbar disk herniations; postoperative clinical outcomes; and long-term reoperation rates due to root injury, wound infection, dural tear, or the recurrence of lumbar disk herniation (p>0.05). The duration of operation was significantly shorter for OD (37.82±7.15 vs. 49.07±6.88 min; t=-18.184, p<0.001).

Conclusion

The long-term results of patients who underwent OD and MD for lumbar disk herniation were similar. We believe that both methods can be safely used under appropriate conditions and surgical experience and that surgical experience has an impact on their outcomes.

Spontaneous Regression of Posterior Ring Apophysis Separation in Lumbar Spine

The pathogenesis of spinal posterior ring apophysis separation (PRAS) remains controversial, and spontaneous regression of PRAS has not been established previously. This is a case report about a 33-year-old man with a PRAS of the posterior superior end plate of S1 who presented with spontaneous low back pain followed by right leg pain. The patient was managed conservatively. A control lumbar spinal computed tomography scan performed 3 years later revealed complete spontaneous regression of the detached bony fragment.

A Modified Percutaneous Endoscopic Technique to Remove Extraforaminal Disk Herniation at the L5-S1 Segment

OBJECTIVE

To introduce a modified percutaneous endoscopic lumbar diskectomy (PELD) technique to remove extraforaminal disk herniation at the L5-S1 segment, including the technical essentials and preliminary results.

METHODS

The geometric parameters of the transverse process, facet joint, and sacrum (TFS) space based on imaging examination were measured in 100 common patients. The technical essentials, including working cannula placement and disk removal involved in the technique, were described. Ten cases (7 men and 3 women) with extraforaminal disk herniation at L5-S1 were surgically treated with the PELD technique through the TFS space from June 2015 to March 2017.

RESULTS

The maximum diameter of the TFS space varied from 2.73 to 11.81 mm (6.84 ± 2.01 mm) on the left and 3.00 to 10.47 mm (7.02 ± 2.05 mm) on the right. The distance of possible skin entry points from midline varied from 33.28 to 84.18 mm, and the distance of external iliac vessels to skin varied from 70.05 to 119.14 mm. All 10 patients who underwent the modified PELD technique were back to previous activities in 1 month. Visual analog scale (VAS) or Oswestry Disability Index (ODI) scores reduced to 2.5 ± 2.0 or 25.4 ± 10.8 from 7.5 ± 1.3 or 75.2 ± 13.3, respectively, 1 day after operation. At 30 days after the operation, the VAS score was 1.0 ± 0.6 and ODI score was 10.2 ± 3.2. No neurologic deficit or surgical site infection occurred.

CONCLUSIONS

We introduced a modified PELD technique to remove extraforaminal disk herniation at the L5-S1 segment. This technique was less invasive, effective, and safe. We also summarized a detailed protocol to identify and remove the herniated disk for nerve protection.

Association of decision-making in spinal surgery with specialty and emotional involvement-the Indications in Spinal Surgery (INDIANA) survey

BACKGROUND

Although recent trials provided level I evidence for the most common degenerative lumbar spinal disorders, treatment still varies widely. Thus, the Indications in Spinal Surgery (INDIANA) survey explores whether decision-making is influenced by specialty or personal emotional involvement of the treating specialist.

METHOD

Nationwide, neurosurgeons and orthopedic surgeons specialized in spine surgery were asked to answer an Internet-based questionnaire with typical clinical patient cases of lumbar disc herniation (DH), lumbar spinal stenosis (SS), and lumbar degenerative spondylolisthesis (SL). The surgeons were assigned to counsel a patient or a close relative, thus creating emotional involvement. This was achieved by randomly allocating the surgeons to a patient group (PG) and relative group (RG). We then compared neurosurgeons to orthopedic surgeons and the PG to the RG regarding treatment decision-making.

RESULTS

One hundred twenty-two spine surgeons completed the questionnaire (response rate 78.7%). Regarding DH and SS, more conservative treatment among orthopedic surgeons was shown (DH: odds ratio [OR] 4.1, 95% confidence interval [CI] 1.7-9.7, p = 0.001; SS: OR 3.9, CI 1.8-8.2, p < 0.001). However, emotional involvement (PG vs. RG) did not affect these results for any of the three cases (DH: p = 0.213; SS: p = 0.097; SL: p = 0.924).

CONCLUSIONS

The high response rate indicates how important the issues raised by this study actually are for dedicated spine surgeons. Moreover, there are considerable variations in decision-making for the most common degenerative lumbar spinal disorders, although there is high-quality data from large multicenter trials available. Emotional involvement, though, did not influence treatment recommendations.

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial

BACKGROUND

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos.

OBJECTIVE

Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH.

METHODS

Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO).

RESULTS

The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N = 43) and No-Catheter Group (N = 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group.

LIMITATIONS

The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy.

CONCLUSION

Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

Transforaminal Percutaneous Endoscopic Discectomy using Transforaminal Endoscopic Spine System technique: Pitfalls that a beginner should avoid

Transforaminal Percutaneous Endoscopic Discectomy (TPED) is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Factors associated with lumbar disc hernia recurrence after microdiscectomy

INTRODUCTION

Lumbar disc hernias are a common cause of spinal surgery. Hernia recurrence is a prevalent complication.

OBJECTIVE

To analyse the risk factors associated with hernia recurrence in patients undergoing surgery in our institution.

MATERIALS AND METHODS

Lumbar microdiscectomies between 2010 and 2014 were analysed, patients with previous surgeries, extraforaminales and foraminal hernias were excluded. Patients with recurrent hernia were the case group and those who showed no recurrence were the control group.

RESULTS

177 patients with lumbar microdiscectomy, of whom 30 experienced recurrence (16%), and of these 27 were reoperated. Among the risk factors associated with recurrence, we observed a higher rate of disc height, higher percentage of spinal canal occupied by the hernia and presence of degenerative facet joint changes; we observed no differences in sex, body mass index or age.

DISCUSSION

Previous studies show increased disc height and young patients as possible factors associated with recurrence.

CONCLUSION

In our series we found that the higher rate of disc height, the percentage of spinal canal occupied by the hernia and degenerative facet joint changes were associated with hernia recurrence.

How to treat lumbar disc herniation in pregnancy?Eur Spine J. 2017;26:496-504. [PMID: 28429143 DOI: 10.1007/s00586-017-5040-8]

PURPOSE

In this systematic review, we aim to illustrate the current and safe concepts in the assessment, diagnosis and management of herniated lumbar disc (HLD) during pregnancy.

METHODS

A systematic review and reporting on the diagnosis, treatment and clinical results of HLD during pregnancy is performed.

RESULTS

The MRI represents the first level and safest diagnostic tool for pregnant women affected by spinal problems allowing for a noninvasive and detailed radiological examination of the spine. The initial management of pregnant women affected by HLD is conservative, and primarily aimed to pain therapy. Whenever radicular pain and progressive neurological deficits unresponsive to medical management occur, surgery should be considered. Few case reports regarding the operative management of HLD in pregnant women have been published up to date. Laminectomy and/or microdiscectomy represent the classical and most commonly used techniques that can be safely performed without affecting pregnancy, delivery, or baby's health. Endoscopic discectomy may be an alternative. The most adequate timing and surgical position are chosen based on to the fetal gestational age and site of the pathology.

CONCLUSIONS

Surgical treatments during pregnancy impose multiple medical and ethical problems. Timely diagnosis by MRI, careful clinical evaluation, and surgical treatment represent safe and effective procedures. Ongoing evolution of surgical, anesthesiological and obstetrical procedures results in favorable outcomes. However, interdisciplinary management and a wide knowledge of pregnancy-related pathologies are crucial for the best outcome for both mother and child.

Herniated disks unchanged over time: Size reduced after oxygen-ozone therapy

The spontaneous regression of disk herniation secondary to dehydration is a much-debated topic in medicine. Some physicians wonder whether surgical removal of the extruded nucleus pulposus is really necessary when the spontaneous disappearance of a herniated lumbar disk is a well-known phenomenon. Unfortunately, without spontaneous regression, chronic pain leads to progressive disability for which surgery seems to be the only solution. In recent years, several studies have demonstrated the utility of oxygen-ozone therapy in the treatment of disk herniation, resulting in disk shrinkage. This retrospective study evaluates the outcomes of a series of patients with a history of herniated disks neuroradiologically unchanged in size for over two years, treated with oxygen-ozone therapy at our center over the last 15 years. We treated 96 patients, 84 (87.5%) presenting low back pain complicated or not by chronic sciatica. No drug therapy had yielded significant benefits. A number of specialists had been consulted in two or more years resulting in several neuroradiological scans prior to the decision to undertake oxygen-ozone therapy. Our study documents how ozone therapy for slipped disks "unchanged over time" solved the problem, with disk disruption or a significant reduction in the size of the prolapsed disk material extruded into the spinal canal.

Paraplegia caused by giant intradural herniation of a lumbar disk after combined spinal-epidural anesthesia in total hip arthroplasty

Total paraplegia after epidural or spinal anesthesia is extremely rare. We herein report a case of total paraplegia caused by a giant intradural herniation of a lumbar disk at the L3-L4 level after total hip arthroplasty for coxarthrosis. The patient had no preoperative neurologic abnormalities. Intraoperative anesthetic management involved combined spinal-epidural anesthesia at the L3-L4 level with continuous intravenous propofol administration. Postoperatively, the patient complained of numbness and total paraplegia of the lower extremities. Magnetic resonance imaging showed a giant herniation of a lumbar disk compressing the spinal cord at the L3-L4 level. The intradural herniation was surgically treated, and the patient's symptoms completely resolved.

Cauda equina syndrome secondary to lumbar disc herniation: Surgical delay and its relationship with prognosis

OBJECTIVE

To determine whether surgical treatment delayed for more than 48 hours in patients with cauda equina syndrome (CES) influenced the clinical outcome.

MATERIAL AND METHODS

A retrospective study of 18 patients treated in our hospital from March 2000 to January 2012, after presenting with CES. The pre- and post-operative clinical status was determined: existence of back pain and/or sciatica, sensory disturbance in the perineum, sensory and motor deficits in the lower extremities, and the degree of sphincter incontinence (complete or incomplete CES). A clinical assessment was performed using the Oswestry disability index.

RESULTS

As regards the onset of symptoms, 44% (8 of 18) of patients were treated at an early stage (within 48 hours). None of the patients with complete CES operated in the early stage had urinary incontinence, and also had greater motor recovery. Of the 5 patients with complete CES who underwent delayed surgery, 3 showed residual urinary incontinence. A mean of 12.55 was obtained on the Oswestry disability index scale at the end of follow-up.

CONCLUSION

Although no statistically significant difference was found in our study, we observed greater motor and sphincter recovery in patients who were operated on within 48 hours.

Percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar decompression for lateral recess stenosis through transforaminal approach: Technique notes and 2 years follow-up

OBJECTIVE

To evaluate the outcome and safety of percutaneous lumbar foraminoplasty (PLF) and percutaneous endoscopic lumbar decompression (PELD) with specially designed instrument for lumbar lateral recess stenosis with/without herniated discs (HDs).

METHOD

From August of 2011 to August of 2013, 96 patients met the inclusion criteria were treated with PLF-PELD and 85 cases were followed up to 2 years postoperatively. MRI or CT checkup performed in the next morning after operation. Outcomes of symptoms were evaluated by follow-up interviews at 3 months, 6 months, 1 year and 2 years after surgery. Low back pain and leg pain were measured by Visual Analog Scale (VAS) score (1-100). Functional outcomes were assessed by using Oswestry Disability Index (ODI) and modified MacNab criteria.

RESULT

Two years follow-up data were obtained from 85 cases, including 14 cases on unilateral L3-4, 1 case on bilateral L3-4, 49 cases on unilateral L4-5, 3 cases on bilateral L4-5, 12 cases on unilateral L5S1, 1 case on bilateral L5S1, 3 cases on unilateral L3-5 and 2 cases on unilateral L4-S1. So totally 95 lumbar lateral recesses were decompressed. Patients ranged in age from 46-78 years (mean age, 56.7 years), including 36 males and 49 females. 56 cases combined with HDs. Low back pain and leg pain were significantly relieved after surgery in all patients. 3 patients were complicated with dysesthesia in distribution of exiting nerve that was all operated at L5S1. Postoperative MRI/CT examination showed adequate decompression of lateral recess and removal of combined HDs in all patients. No patient had postoperative infection, dysfunctional nerve root injury or iatrogenic segmental instability. 2 cases experienced recurrence of combined HDs (2.4%), but could not undertake further revision surgery because of infirm condition. All the 85 cases were analyzed with complete follow-up data. VAS scores and ODI values were significantly lower in all time-points after surgery than before surgery. MacNab scores at 2 years after surgery were obtained from all the 85 patients. 29 cases were given "excellent"; 48 were given "good". 6 patients experienced heavier low back pain, thus being classified as "fair". 2 cases with recurrence were given "poor".

CONCLUSIONS

PLF-PELD with specially designed instrument is a less invasive, effective and safe surgery for lumbar lateral recess stenosis with/without combined HDs.

New instrument for percutaneous posterolateral lumbar foraminoplasty: case series of 134 with instrument design, surgical technique and outcomes

Current solutions for treating uncontained lumbar disk herniation include laser assisted endoscopic foraminoplasty and Transforaminal Endoscopic Spine System, both of which have some issues in clinical practice. This study aims to report the design of a new instrument for percutaneous posterolateral foraminoplasty. 148 patients with uncontained lumbar disk herniation were treated with percutaneous foraminoplasty followed by transforaminal endoscopic discectomy. Follow up were obtained for 134 cases. The VAS scores of pre-operative and post-operative low back pain and sciatica were compared. Oswestry Disability Index (ODI) and MacNab scores were also obtained. Follow-up was up to 5 years postoperatively. There were 75 of excellent, 49 of good and 5 of fair according to MacNab score system, with total successful rate up to 92.5%. 5 cases with L5S1 disc herniation complained about irritation to the dorsal root ganglion. In conclusion, the new transforaminal endoscopic discectomy instrument is safe and effective for percutaneous foraminoplasty.

Misunderstanding of foot drop in a patient with charcot-marie-tooth disease and lumbar disk herniation

We report the case of 57-year-old woman diagnosed with Charcot-Marie-Tooth (CMT) disease and lumbar disk herniation (LDH). She had left leg weakness and foot numbness, foot deformity (muscle atrophy, high arch, and clawed toes). The lumbar spine MRI showed LDH at L4-5. Additionally, electrophysiology results were consistent with chronic peripheral motor-sensory polyneuropathy (axonopathy). In genetic testing, 17p11.2-p12 duplication/deletions characteristic of CMT disease were observed. We confirmed the patient's diagnosis as CMT disease and used conservative treatment.

MRI DWI/ADC signal predicts shrinkage of lumbar disc herniation after O2-O3 discolysis

PURPOSE

Evaluate the discal morpho-structural changes as a predictive sign in the clinical outcome after ozone therapy in lumbar disc herniation using the T2-shine through effect in diffusion-weighted imaging (DWI).

METHOD

One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; age range, 23-62 years) were included, previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences, and were randomly assigned to two groups. Seventy-seven patients (control group) underwent conservative treatment with intraforaminal injection of steroid and anaesthetic. The remaining 77 patients (study group) underwent the same treatment with the addition of oxygen-ozone (O2-O3). During the following six months, a MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ² test, Student's t test and analysis of covariance were used for comparison of variables.

RESULTS

In the study group, 58 of 77 patients had a successful outcome (responders). In the responders group, DWI T2-shine through effect was present during MRI follow-up and in particular in 53 of 77 patients in six months of follow-up (p < 0.05). Moreover, in the same group a statistically significant disc shrinkage was shown by IDVA in sixth months of follow-up (p < 0.05).

CONCLUSIONS

T2-shine through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen-ozone treatment.

Case report: The operation for the lumbar disk herniation just after cesarean delivery in the third trimester of pregnancy

INTRODUCTION

Low back pain is common during pregnancy. However, the incidence of symptomatic lumbar disc herniation during pregnancy is very rare. We report a case of lumbar disc herniation underwent discectomy just after cesarean delivery in the third trimester of pregnancy.

PRESENTATION OF CASE

A 33-year-old woman presented at 32 weeks gestation. She had a low back pain and the left-sided leg pain below the knee. At 34 weeks gestation, she had severe weakness of the left extension halluces longus, left ankle dorsiflexion. MRI showed a large disc herniation at L4/5 expanded to the spinal canal more. The cesarean delivery was performed in the supine position. The patient was then turned to a prone position, and a left L4/5 discectomy was performed. But the day after surgery, she had a severe low back pain and the right leg pain below the knee. MRI showed a disc herniation at L4/5 on the right side of the spinal canal. At 6 days after the first surgery, a right L4/5 discectomy was performed. In the immediate postoperative period, the patient experienced complete relief of the right leg pain.

DISCUSSION

It is necessary to cooperate with a pediatrician, an obstetrician, and an anethesiologists. For obtaining the best outcome on mother and child, it is important to discuss in advance to be able to respond quickly for changeable situation.

CONCLUSION

It is necessary to conduct the operation under pregnancy in consideration of the great influence on mother and child.

A meta-analysis of interlaminar minimally invasive discectomy compared to conventional microdiscectomy for lumbar disk herniation

A meta-analysis was conducted to evaluate the evidence that compared the safety and efficacy of interlaminar minimally invasive discectomy (ILMI) and conventional microdiscectomy (MD) for treating lumbar disk herniation (LDH) patients and to develop GRADE based recommendations for using the procedures to treat LDH. Eleven studies, encompassing 1012 patients, met the inclusion criteria. Overall, the results of the meta-analysis indicated that there were significant differences between the two groups in blood loss (SMD=-0.93, 95% CI -1.84, -0.02; p=0.05), and the number of days stays in hospital (SMD=-0.79, 95% CI -1.55, -0.04; p=0.04). However, there were no significant differences in the short-term back visual analog scale (VAS) scores (SMD=-0.34, 95% CI -0.81, 0.14; p=0.16), the long-term back VAS scores (SMD=0.13, 95% CI -0.04, 0.30; p=0.14), the short-term leg VAS scores (SMD=0.14, 95% CI -0.01, 0.29; p=0.07), the long-term leg VAS scores (SMD=0.12, 95% CI -0.05, 0.30; p=0.17), the short-term Oswestry disability index (ODI) scores (SMD=0.01, 95% CI -0.14, 0.15; p=0.92), the long-term ODI scores (SMD=0.11, 95% CI -0.03, 0.25; p=0.14), and the incidence of complications (RR=1.22, 95% CI 0.88, 1.69; p=0.24). The results of this meta-analysis demonstrate that ILMI and MD are both safe and effective surgical procedures for treating LDH. Compared with MD, ILMI can shorten days in hospital, decrease the mounts of blood loss during surgery. However, the overall GRADE evidence quality was very low. Therefore, further validation is required, and medical institutions should conduct high-quality studies.

Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon's training level of minimally invasive spine surgery

PURPOSE

To evaluate the differences of learning curve for PELD depending on the surgeon' s training level of minimally invasive spine surgery.

METHODS

We retrospectively reviewed the medical records of 120 patients (surgeon A with his first 60 patients, surgeon B with his first 60 patients) with sciatica and single-level L4/5 disk herniation who underwent PELD by the two surgeons with different training level of minimally invasive spine surgery (Group A: surgeon with little professional training of PELD; Group B: surgeon with 2 years of demonstration teaching of PELD).

RESULTS

Significant differences were observed in the operation time (p=0.000), postoperative hospital stay (p=0.026) and reoperation rate (p=0.050) between the two groups. In the operation time, significant differences were observed between the 1-20 patients group and 41-60 patients group in Group B (p=0.041), but there were no significant differences among the 1-20 patients group, 21-40 patients group and 41-60 patients group in Group A. In the postoperative hospital stay, the significant differences were observed in the 1-20 patients group between Group A and Group B (p=0.011). Significant differences were observed between preoperative and postoperative VAS back score, VAS leg score and JOA score. Higher improvement in the VAS leg score was observed in Group B than Group A (p=0.031). In the rate of reoperation, the significant difference was observed between the 1-20 patients group and 41-60 patients group in Group A (p=0.028) but there were no significant differences among the 1-20 patients group, 21-40 patients group and 41-60 patients group in Group B.

CONCLUSIONS

The surgeons' training level of minimally invasive spine surgery was an important factor for the success of PELD, especially the demonstration teaching of PELD for the new minimally invasive spine surgeons.