Histological analysis of nucleus pulposus tissue from patients with lumbar disc herniation after condoliase administration

Background

Condoliase is an enzyme used as a treatment for lumbar disc herniation (LDH). This enzyme degrades chondroitin sulfate (CS) in the nucleus pulposus of the intervertebral disc (IVD). However, there are cases in which symptoms do not improve, despite condoliase administration. This study reports histological analysis of lumbar disc tissue of LDH patients who underwent surgery because condoliase had no therapeutic effect.

Methods

Between March 2019 and August 2019, 12 LDH patients who underwent full endoscopic spine surgery (FESS) discectomy at the Dezawa Akira PED Clinic were the subjects of the study. There are two study groups: six cases underwent FESS after condoliase administration, while six underwent FESS without condoliase administration. The average duration from drug administration to surgery was 152 days. Herniated disc removed at surgery was evaluated by histological staining including immunohistochemistry by anti-CS antibodies.

Results

Multiple large clusters (40-120 μm in diameter) were observed in the nucleus pulposus of those who received condoliase, but no clusters were observed in those who did not. The lumbar disc tissues, including the nucleus pulposus of recipients, were stained with anti-CS antibodies that recognize the CS unsaturated disaccharide, but non-administration tissue was not stained. These findings suggest that the enzyme acted on the nucleus pulposus, even in cases where symptoms were not improved by condoliase administration. Furthermore, there was no histological difference between stained images of the extracellular matrix in those who did or did not receive condoliase, suggesting that condoliase acted specifically on CS in the nucleus pulposus.

Conclusions

We demonstrated that CS in the nucleus pulposus was degraded in patients in whom condoliase did not have a therapeutic effect. Moreover, condoliase acts in human IVD without causing necrosis of chondrocytes and surrounding tissues.

Exploring the body surface temperature of the lumbosacral region and relevant back-shu points in patients with lumbar disc herniation induced low back pain based on infrared thermography

OBJECTIVES

To observe the body surface temperature of the lumbosacral region and relevant back-shu points in patients with lumbar disc herniation (LDH) induced low back pain utilizing infrared thermography, and to explore the functional attribute changes of acupoints under pathological conditions.

METHODS

A total of 50 patients with LDH induced low back pain were included as the observation group, and 45 healthy subjects were included as the control group. Using infrared thermography, the body surface temperature of the lumbosacral region and bilateral Sanjiaoshu (BL 22), Shenshu (BL 23), Qihaishu (BL 24), Dachangshu (BL 25), Guanyuanshu (BL 26), Xiaochangshu (BL 27), and Pangguangshu (BL 28) was measured in both groups. The temperature difference values between the bilateral lumbosacral regions and back-shu points of the two groups were calculated. Additionally, the body surface temperature of the affected and healthy sides of the lumbosacral region and relevant back-shu points was compared in the observation group.

RESULTS

Compared with the control group, the body surface temperature of the lumbosacral region and the bilateral temperature difference values of the lumbosacral regions were increased in the observation group (P<0.001). The body surface temperature difference values of bilateral Shenshu (BL 23), Qihaishu (BL 24), Dachangshu (BL 25), Guanyuanshu (BL 26) and Xiaochangshu (BL 27) in the observation group were higher than those in the control group (P<0.05, P<0.01, P<0.001). In the observation group, the body surface temperature of the affected side of the lumbosacral region as well as Shenshu (BL 23) and Dachangshu (BL 25) was elevated compared with that of healthy side (P<0.001).

CONCLUSIONS

The patients with LDH induced low back pain have imbalanced and asymmetrical distribution of body surface temperature in the lumbosacral region and related back-shu points, Shenshu (BL 23) and Dachangshu (BL 25) have the relative specificity.

Characteristics of Sciatic Scoliotic List in Lumbar Disc Herniation

STUDY DESIGN

Retrospective radiological study.

OBJECTIVES

Physical examination reveals sciatic scoliotic list (SSL) in some patients with lumbar disc herniation (LDH). We aimed to evaluate the coronal and sagittal parameters of the SSL curve, describe their characteristics, and establish a new classification system.

METHODS

We retrospectively reviewed 230 patients (SSL group = 96; non-SSL group = 134) diagnosed with single-segment LDH from January 2018 to December 2020. The control group comprised 70 healthy volunteers. Radiographic parameters were compared between the groups.

RESULTS

In the SSL group, the Cobb's angle was 12.5 ± 5.3° (4.2-31.2), trunk shift 26.2 ± 17.9 mm (.0-88.2 mm), and apical vertebral translation 31.7 ± 16.0 mm (1.18-8.58 mm). Further, 62.5% of patients had L4/5 disc herniation, 76.0% had disc herniation at the convex side of the lumbosacral scoliosis, and 81.3% had disc herniation at the opposite side of the trunk shift. Compared to the control group, lumbar lordosis and thoracic kyphosis decreased, pelvic tilt increased, and the sagittal vertical axis moved forward in the other patients. The sagittal imbalance in the SSL group exacerbated. Using the positional relationship between vertebrae and the central sacral vertical line (CSVL), we identified two main SSL patterns with which 95.8% of the patients were defined as Type 1.

CONCLUSIONS

The SSL curve is characterized by a long thoracic or thoracolumbar curve, with a relatively straight sagittal profile and little rotation. Further, the lumbar and thoracic vertebrae shifts are on the same side as the CSVL. These features of the SSL curve differentiate it from other types of structural scoliosis.

Risk factors for surgical site infection after percutaneous endoscopic lumbar discectomy

The objective of this study was to investigate the risk factors associated with surgical site infection (SSI) after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH). A retrospective analysis was performed on a cohort of 335 patients who underwent PELD between January 2016 and January 2023. Data were derived from the Hospital Information System (HIS), and a comprehensive statistical assessment was performed using IBM SPSS Statistics version 25.0. Both univariate and multivariate logistic regression analyses assessed a range of risk determinants, such as age, body mass index (BMI), comorbidities, laboratory test parameters and surgery-related variables. The incidence of SSI after PELD was 2.7% (9/335). Univariate analysis highlighted BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant predictors of SSI. Multivariate logistic regression identified BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant risk factors for SSI after PELD. High BMI, diabetes mellitus, long-term corticosteroid consumption, long surgical time and postoperative cerebrospinal fluid leakage are predisposing factors for SSI in patients undergoing PELD. Precise interventions focused on such risk components, including careful preoperative assessment and strategic postoperative care, are essential to reduce the incidence of SSI and improve surgical efficacy.

Comparison of the Outcomes of Microendoscopic Discectomy Versus Full-Endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation

STUDY DESIGN

Retrospective Comparative Study.

OBJECTIVES

To compare the outcomes of microendoscopic discectomy (MED) versus full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).

METHODS

A retrospective study was performed on patients with L4/5 LDH treated using MED (n = 249) or FED (n = 124). A 16-mm tubular retractor and endoscope was used for MED, while a 4.1-mm working channel endoscope was used for FED. Patient background and operative data were collected. The Oswestry Disability Index (ODI) and European Quality of Life-5 Dimensions (EQ-5D) scores were recorded preoperatively and at 1 and 2 years postsurgery.

RESULTS

The background data of the two groups were similar. The mean operation times for MED and FED were 59.3 and 47.7 min (respectively), and the mean volumes of removed nucleus pulposus were .65 and 1.03 g, respectively. These differences were significant (P < .001). Six dural tears and one postoperative hematoma were observed in the MED group; none were observed in the FED group. During the follow-up period, 16 MED and 7 FED patients required re-operation due to recurrence (P = 1.00). Although the ODI and EQ-5D scores significantly improved at 1 and 2 years postsurgery in both groups, the differences were not statistically significant.

CONCLUSIONS

Operative outcomes were almost identical in both groups. We did not observe any operative or postoperative complications in FED. We, therefore, recommend FED as the first option for the treatment of L4/5 LDH since it has a better safety profile and is minimally invasive.

The Emerging Roles of Nanocarrier Drug Delivery System in Treatment of Intervertebral Disc Degeneration-Current Knowledge, Hot Spots, Challenges and Future Perspectives

Low back pain (LBP) is a common condition that has substantial consequences on individuals and society, both socially and economically. The primary contributor to LBP is often identified as intervertebral disc degeneration (IVDD), which worsens and leads to significant spinal problems. The conventional treatment approach for IVDD involves physiotherapy, drug therapy for pain management, and, in severe cases, surgery. However, none of these treatments address the underlying cause of the condition, meaning that they cannot fundamentally reverse IVDD or restore the mechanical function of the spine. Nanotechnology and regenerative medicine have made significant advancements in the field of healthcare, particularly in the area of nanodrug delivery systems (NDDSs). These approaches have demonstrated significant potential in enhancing the efficacy of IVDD treatments by providing benefits such as high biocompatibility, biodegradability, precise drug delivery to targeted areas, prolonged drug release, and improved therapeutic results. The advancements in different NDDSs designed for delivering various genes, cells, proteins and therapeutic drugs have opened up new opportunities for effectively addressing IVDD. This comprehensive review provides a consolidated overview of the recent advancements in the use of NDDSs for the treatment of IVDD. It emphasizes the potential of these systems in overcoming the challenges associated with this condition. Meanwhile, the insights and ideas presented in this review aim to contribute to the advancement of precise IVDD treatment using NDDSs.

Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study

Aim: The aim of this study is to analyze the real-world outcomes of transforaminal epidural steroid injections (TFESIs) in all patients with radiculopathy and their long-term outcomes. Methods: Patients with radiculopathy and failure of conservative treatment were included in a prospective, multicenter, observational cohort study. Results: In total, 117 patients were treated with one or two TFESIs. The mean duration of follow-up was 116 (±14) weeks. In total 19,6% (95% CI: 12.9-28.0%) patients were treated with surgery after insufficient symptom improvement. The evolution to surgery was not associated with etiology, symptom duration or previous spine surgery. Conclusion: Real-world data confirms that TFESIs is an effective treatment with satisfactory results in about 80% of patients for a period of 2 years.

Comparison of lumbar microdiscectomy and unilateral biportal endoscopic discectomy outcomes: a single-center experience

OBJECTIVE

Lumbar microdiscectomy (LMD) is still the gold-standard treatment for lumbar disc herniations with progressive neurological deficits that are refractory to conservative treatment. With improvement of endoscopic systems in recent years, endoscopic discectomy techniques have been developed as an alternative to LMD. The unilateral biportal endoscopic discectomy (UBE) technique is one of these endoscopic techniques, and its popularity has increased in recent years because it does not require high-cost specialized endoscopes, many microsurgical instruments are compatible with this system, and it is similar to LMD in terms of anatomical orientation. This study compared results between LMD and UBE techniques in patients with lumbar disc herniations performed by the same spine surgeons at a single center.

METHODS

The data of patients with lumbar disc herniation who were operated on with LMD and UBE techniques were retrospectively reviewed. The data obtained were statistically evaluated. The operative video of one of the patients who underwent UBE was edited for demonstration.

RESULTS

Between January 2021 and June 2022, 93 patients were operated on for lumbar disc herniation. LMD was performed in 39 patients, and UBE was performed in 54 patients. There were no significant differences in the complications, recurrence, postoperative back and leg pain, patient satisfaction rates, and quality of life index results of the patients in the two groups. The operation time was shorter in the LMD group. In the UBE group, estimated blood loss was lower and postoperative hospitalization was shorter.

CONCLUSIONS

Although LMD is still the gold-standard treatment for lumbar disc herniation, the results of UBE are comparable to those of LMD, and it may be a good alternative for spine surgeons who prefer minimally invasive surgery.

An evidence-based guideline on treating lumbar disc herniation with traditional Chinese medicine

BACKGROUND

Lumbar disc herniation (LDH), as one of the most common causes of lower back pain, imposes a heavy economic burden on patients and society. Conservative management is the first-line choice for the majority of LDH patients. Traditional Chinese medicine (TCM) is an important part of conservative treatment and has attracted more and more international attention.

STUDY DESIGN

Evidence-based guideline.

METHODS

We formed a guideline panel of multidisciplinary experts. The clinical questions were identified on the basis of a systematic literature search and a consensus meeting. We searched the literature for direct evidence on the management of LDH and assessed its certainty-generated recommendations using the grading of recommendations, assessment, development, and evaluation (GRADE) approach.

RESULTS

The guideline panel made 20 recommendations, which covered the use of Shentong Zhuyu decoction, Shenzhuo decoction, Simiao San decoction, Duhuo Jisheng decoction, Yaobitong capsule, Yaotongning capsule, Osteoking, manual therapy, needle knife, manual acupuncture, electroacupuncture, Chinese exercise techniques (Tai Chi, Baduanjin, or Yijinjing), and integrative medicine, such as combined non-steroidal anti-inflammatory drugs, neural nutrition, and traction. Recommendations were either strong or weak, or in the form of ungraded consensus-based statement.

CONCLUSION

This is the first LDH treatment guideline for TCM and integrative medicine with a systematic search, synthesis of evidence, and using the GRADE method to rate the quality of evidence. We hope these recommendations can help support healthcare workers caring for LDH patients.

Links among MRI features in paraspinal muscles, inflammatory processes, and related back pain in patients with lumbar disc herniation

Background

Recent studies have provided evidence that structural changes in paraspinal muscles are associated with intervertebral disc degeneration (IDD), ubiquitous with low back pain (LBP), and potentially thought to be regulated by inflammatory processes. However, the links remain unclear.

Objective

The aims of this study were to investigate structural changes in paraspinal muscles that differed in healthy and lumbar disc herniation (LDH) patients, and LDH patients with and without LBP, and to determine the link with the expression of inflammatory marker(s).

Methods

Cross-sectional areas (CSAs) and fatty degeneration of muscles were measured in this prospective cohort study. Multifidus muscle (MM) tissue was procured from included individuals undergoing surgery. Gene expression was quantified using qPCR assays. Independent t-test, Chi-square, and Spearman correlation were used for evaluating the links among structural changes, expression of inflammatory markers, and clinical outcomes.

Results

Functional CSA and fatty degeneration of MM were larger in healthy group than LDH group. A significant increase in fat infiltration in MM in LBP group than in non-LBP group. TNF-alpha (TNF-α) was 28-fold greater in high-fat infiltration group than low-fat infiltration group within MM. Expression of TNF-α and IL-1β in MM was moderately correlated with functional CSA and fatty degeneration of MM, which was moderately correlated with clinical outcomes.

Conclusions

Results support the hypothesis that IDD is associated with dysregulation of inflammatory state of local MM, which provides initial evidence that inflammatory dysregulation in paraspinal muscles has the potential for a broad impact on tissue health and LBP symptoms.

Lumbar disc herniation is an independent predictor of plaque burden in the patients with unstable angina

Objective

Assessing the impact of lumbar disc herniation (LDH) on the plaque burden of coronary atherosclerosis is our objective.

Methods

In this study, a total of 212 patients (age 46-80 years) with unstable angina (UA) who underwent coronary angiography (CAG) in our hospital from January 2018 to July 2022 due to UA were included. Patients were divided into LDH group (n = 106) and no LDH group (n = 106). Gensini scores were calculated to assess the plaque burden of coronary. Logistic analysis was used to examine potential risk variables linked to the Gensini score. The association between lumbar disc lesions grading and coronary plaque burden was analysed by Spearman's correlation test. LDH patients with higher plaque burden (n = 56) were further divided into evolocumab treatment group (n = 28) and conventional treatment group (n = 28). Cox regression analysis were performed.

Results

Patients with LDH had higher Gensini scores (P < 0.01) and triglyceride (TG) levels (P = 0.04), but HDL-C (P = 0.01) levels were lower. LDH was found to be an independent risk factor for higher Gensini scores (OR = 2.38, P < 0.01) by logistic analysis. The Spearman's correlation test suggested that the degree of lumbar disc lesions was related to the Gensini score and the level of blood lipid. Cox regression analysis showed that evolocumab treatment could significantly reduce the composite MACE events (cardiac death, nonfatal myocardial infarction, nonfatal stroke, and readmission due to angina) (HR = 0.26, P = 0.04) in higher coronary plaque burden patients.

Conclusion

LDH is an independent risk factor for the higher coronary plaque burden. Evolocumab treatment significantly reduced the occurrence of cardiovascular events in LDH patients with higher plaque burden. Additionally, our data indicate that LDH is associated with increased blood lipid, which may contribute to the development of plaque burden.

Non-Surgical Approaches to the Management of Lumbar Disc Herniation Associated with Radiculopathy: A Narrative Review

Lumbar disc herniation associated with radiculopathy (LDHR) is among the most frequent causes of spine-related disorders. This condition is triggered by irritation of the nerve root caused by a herniated disc. Many non-surgical and surgical approaches are available for managing this prevalent disorder. Non-surgical treatment approaches are considered the preferred initial management methods as they are proven to be efficient in reducing both pain and disability in the absence of any red flags. The methodology employed in this review involves an extensive exploration of recent clinical research, focusing on various non-surgical approaches for LDHR. By exploring the effectiveness and patient-related outcomes of various conservative approaches, including physical therapy modalities and alternative therapies, therapists gain valuable insights that can inform clinical decision-making, ultimately contributing to enhanced patient care and improved outcomes in the treatment of LDHR. The objective of this article is to introduce advanced and new treatment techniques, supplementing existing knowledge on various conservative treatments. It provides a comprehensive overview of the current therapeutic landscape, thereby suggesting pathways for future research to fill the gaps in knowledge. Specific to our detailed review, we identified the following interventions to yield moderate evidence (Level B) of effectiveness for the conservative treatment of LDHR: patient education and self-management, McKenzie method, mobilization and manipulation, exercise therapy, traction (short-term outcomes), neural mobilization, and epidural injections. Two interventions were identified to have weak evidence of effectiveness (Level C): traction for long-term outcomes and dry needling. Three interventions were identified to have conflicting or no evidence (Level D) of effectiveness: electro-diagnostic-based management, laser and ultrasound, and electrotherapy.

Altered spontaneous brain activity in lumbar disc herniation patients: insights from an ALE meta-analysis of neuroimaging data

Objective

To explore the characteristics of spontaneous brain activity changes in patients with lumbar disc herniation (LDH), and help reconcile the contradictory findings in the literature and enhance the understanding of LDH-related pain.

Materials and methods

PubMed, Web of Science, Embase, Chinese National Knowledge Infrastructure (CNKI), SinoMed, and Wanfang databases were searched for literature that studies the changes of brain basal activity in patients with LDH using regional homogeneity (ReHo) and amplitude of low-frequency fluctuation/fraction amplitude of low-frequency fluctuation (ALFF/fALFF) analysis methods. Activation likelihood estimation (ALE) was used to perform a meta-analysis of the brain regions with spontaneous brain activity changes in LDH patients compared with healthy controls (HCs).

Results

A total of 11 studies were included, including 7ALFF, 2fALFF, and 2ReHo studies, with a total of 269 LDH patients and 277 HCs. Combined with the data from the ALFF/fALFF and ReHo studies, the meta-analysis results showed that compared with HCs, LDH patients had increased spontaneous brain activity in the right middle frontal gyrus (MFG), left anterior cingulate cortex (ACC) and the right anterior lobe of the cerebellum, while they had decreased spontaneous brain activity in the left superior frontal gyrus (SFG). Meta-analysis using ALFF/fALFF data alone showed that compared with HCs, LDH patients had increased spontaneous brain activity in the right MFG and left ACC, but no decrease in spontaneous brain activity was found.

Conclusion

In this paper, through the ALE Meta-analysis method, based on the data of reported rs-fMRI whole brain studies, we found that LDH patients had spontaneous brain activity changes in the right middle frontal gyrus, left anterior cingulate gyrus, right anterior cerebellar lobe and left superior frontal gyrus. However, it is still difficult to assess whether these results are specific and unique to patients with LDH. Further neuroimaging studies are needed to compare the effects of LDH and other chronic pain diseases on the spontaneous brain activity of patients. Furthermore, the lateralization results presented in our study also require further LDH-related pain side-specific grouping study to clarify this causation.

Systematic review registration

PROSPERO, identifier CRD42022375513.

Foraminoplasty Performed with a Trephine and a New Tool in Transforaminal Endoscopic Lumbar Discectomy: A Single-Center Retrospective Study

OBJECTIVE

Foraminoplasty is an important step in transforaminal endoscopic lumbar discectomy (TELD). A trephine is widely used in foraminoplasty. However, foraminoplasty using a trephine alone sometimes fails to remove the resected bone, resulting in the bone remaining in the foramen or spinal canal, which can potentially cause neurological irritation or injury. The objective of this study is to introduce a self-designed tool, referred to as an anchoring drill, for use with a trephine in foraminoplasty in TELD and to evaluate its advantages.

METHODS

A retrospective review was performed to identify patients who underwent L4-5 TELD between January 2019 to January 2022. Foraminoplasty was performed in all patients. Depending on whether the anchoring drill was used or not, patients were divided into two groups. Surgery-related parameters and complications were reviewed. Visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores were also assessed for all patients. SPSS statistical software was used for statistical calculation.

RESULTS

A total of 100 patients were included (55 in the anchoring drill group and 45 in the trephine group). The incidence of residual bone fragments after foraminoplasty of the anchoring drill group was 9.09%, which was lower than that of the trephine group, at 33.33% (p < 0.05). The mean endoscopic operation time of the anchoring drill group was shorter than that of the trephine group (p < 0.05). The mean fluoroscopy time and duration of foraminoplasty showed no significant differences between the two cohorts. The total perioperative complication incidence was lower in the anchoring drill group, in which the neural irritation incidence showed a significant difference (anchoring drill group: 3.64%, trephine group: 17.78%, p < 0.05). VAS and JOA scores were significantly improved after the operation for all patients (p < 0.001), however, no statistical differences were found between the two groups at each follow-up visit.

CONCLUSION

The combination of a trephine with an anchor drill was demonstrated to be safe and effective in foraminoplasty in TELD, improving the success rate of foraminoplasty and reducing neurological complications compared to using trephine alone.

Hidden blood loss in three different endoscopic spinal procedures for lumbar disc herniation

Purpose

This study compared hidden blood loss (HBL) among three different endoscopic spinal procedures and investigated its risk factors.

Patients and methods

This single-centre retrospective analysis collected data from consecutive hospitalized patients with single-segment lumbar disc herniation (LDH) undergoing unilateral biportal endoscopic discectomy (UBE), percutaneous endoscopic transforaminal discectomy (PETD), or percutaneous endoscopic interlaminar discectomy (PEID) from December 2020 to October 2022. HBL was calculated using Nadler's and Gross's formulas. The authors used Pearson's or Spearman's correlation analysis to explore the relationship between patient characteristics and HBL. Multivariate linear regression analysis was used to identify independent risk factors for HBL.

Results

In total, 122 consecutive patients (68 females and 54 males) were enroled in this study. The average HBL was 381.87±218.01 ml in the UBE group, 252.05±118.44 ml in the PETD group and 229.63±143.9 ml in the PEID group (P<0.05). Pearson's or Spearman's correlation analysis showed that operative time, preoperative haemoglobin, preoperative haematocrit, and preoperative Albumin (ALB) were correlated with HBL in the UBE group, while sex, age, operative time, postoperative ALB, and patients' blood volume (PBV) were related to HBL in the PETD group (P<0.05). Operative time and preoperative activated partial thromboplastin time were related to HBL in the PEID group (P<0.05). Multiple linear regression analysis showed a positive correlation between HBL and operative time in all three groups (P<0.001, P<0.001, P<0.05).

Conclusion

HBL was higher in the UBE group than in the PETD and PEID groups, and operative time may be a common risk factor for the three groups.

The Microsurgical Translaminar Approach: A Technical Note

Lumbar disc herniation (LDH) is a very common cause of low back pain and unilateral radiculopathy. This pathology is traditionally approached via interlaminotomy with variable amounts of bony extensions, such as partial or total facetectomy and disturbance of soft tissue structures. However, the extensive bone removal may be the cause of spinal instability, thus necessitating lumbar fusion procedures in the longer-term perspective. A novel surgical technique that spares the facet joint, the ligamentum flavum, and the epidural soft tissues was previously proposed. We present a detailed overview of the microsurgical translaminar approach for large LDH.

Different approaches to percutaneous endoscopic lumbar discectomy for L5/S1 lumbar disc herniation: a retrospective study

OBJECTIVE

To observe the surgical procedure and outcome of percutaneous endoscopic lumbar discectomy for L5/S1 lumbar disc herniation (LDH) by the interlaminar and transforaminal approach.

METHODS

A total of 153 patients with L5/S1 LDH who were treated using percutaneous endoscopic transforaminal discectomy (PETD, n = 84) or percutaneous endoscopic interlaminar discectomy (PEID, n = 69) from January 2016 to January 2018 were enrolled in this retrospective study. The time of puncture, operation under the endoscope, total operation and number of fluoroscopy of the two groups were compared. All groups were followed up for two years by using the Oswestry disability index (ODI) and the Visual Analogue Scale (VAS). Additionally, the incidence of complications, reoperation and postoperative low back pain were compared between the two groups.

RESULTS

There were no significant difference in general information between the two groups. Compared to the PEID group, the PETD group had a decreased operation time under the endoscope and an increased puncture time, total operation time, and the number of fluoroscopy (p < 0.05). The preoperative VAS and ODI scores of the PETD and PEID group were decreased at the last follow-up (p < 0.05). There were no difference in the preoperative or last follow-up VAS and ODI scores, as well as complications, reoperation between the two groups (p > 0.05). The incidence of postoperative low back pain in the PETD group was lower than that in the PEID group (p > 0.05).

CONCLUSIONS

The two-year clinical outcome of PETD is equal to that of PEID for L5/S1 LDH. Compared to those with PETD, the puncture time, total operation time and radiation exposure are lower with PEID, but the incidence of postoperative low back pain is higher.

A new surgical method to treat intracanal lumbar disc herniation using the unilateral biportal endoscopic transforaminal approach: patient series

BACKGROUND

Unilateral biportal endoscopic lumbar discectomy (UBELD) is a new minimally invasive spine surgery. The purpose of this study is to describe a new surgical method to treat intracanal lumbar disc herniation (LDH) using the unilateral biportal endoscopic transforaminal approach (UBE-TFA). The first 15 patients who had undergone UBELD for single-level LDH were included in this study. Operative time, intraoperative blood loss, postoperative stay, and intraoperative complications were recorded. The Oswestry Disability Index (ODI), numeric rating scale (NRS) score for leg pain, and modified MacNab criteria were assessed at 3 months postoperatively.

OBSERVATIONS

The mean operative time was 52.0 ± 13.8 minutes. The mean intraoperative blood loss was 10.5 ± 10.2 mL. The mean postoperative stay was 1.1 ± 0.3 days. There were no complications. The postoperative mean ODI was significantly improved from 44.9 ± 14.4 to 7.7 ± 11.2 at the final follow-up (p < 0.001). There was a significant decrease in the postoperative mean NRS score for leg pain, from 6.1 ± 1.9 to 0.8 ± 1.3 at the final follow-up (p < 0.001). Based on the modified MacNab criteria, good to excellent results were obtained in 86.7% of the patients.

LESSONS

We considered UBELD-TFA as not only one of the promising surgical methods for UBELD, but also a new surgical implementation of the TFA.

Reference values of lumbar spine range of motion by sex and age based on the assessment of supine trunk lateral bending-A preliminary study

[Purpose] The purpose of this study was to clarify the preliminary reference values for the lumbar spine range of motion associated with lateral bending exercises by gender and age group. [Methods] Subjects were 82 volunteers without low back pain, including five males and five females in each age group from 16-19 to 80-89 years. All subjects underwent radiographs of the lumbar spine with lateral flexion; the range of lateral flexion of the vertebrae from T12 to the sacrum (ROLB) was measured twice by three observers. [Results] The ROLB of the entire T12-S1 of all subjects showed a significant negative correlation with age in both sexes (p < 0.01). The ROLB of the lumbar spine tended to be greater in females, with a statistically significant difference between those aged 16-19 and 70-79 (p < 0.05). Lateral flexion angles for each intervertebral segment were largest at L3-L4 and smallest at L5-S1 (0.7°). [Conclusion] Lumbar ROLB reference values were examined by gender and age group; ROLB was greatest in L3-L4, and ROLB tended to be lower in older age groups.

Clinical effects and biological mechanisms of exercise on lumbar disc herniation

Lumbar Disc Herniation (LDH) is a syndrome in which lumbar disc degeneration, rupture of the annulus fibrosus, and herniation of the nucleus pulposus irritate and compress the nerve roots and cauda equina, resulting in the main manifestations of lumbar pain and/or lower extremity pain. There is evidence in various clinical areas that exercise is effective in treating LDH, and exercise intervention for more than 2 weeks reduces disease activity in LDH. However, the mechanism of exercise's action in reducing disease activity in LDH is unclear. In this article, we first summarize and highlight the effectiveness of exercise in treating LDH and provide guideline recommendations regarding exercise type, intensity, frequency, and duration. Then, we integrate the existing evidence and propose biological mechanisms for the potential effects of exercise on neuromechanical compression, inflammatory chemical stimuli, and autoimmune responses from the perspective of LDH pathogenesis as an entry point. However, a large body of evidence was obtained from non-LDH populations. Future research needs to investigate further the proposed biological mechanisms of exercise in reducing disease activity in LDH populations. This knowledge will contribute to the basic science and strengthen the scientific basis for prescribing exercise therapy for the routine clinical treatment of LDH.

Stability simulation analysis of targeted puncture in L4/5 intervertebral space for PELD surgery

Introduction: The application prospects of percutaneous endoscopic lumbar discectomy (PELD) as a minimally invasive spinal surgery method in the treatment of lumbar disc herniation are extensive. This study aims to find the optimal entry angle for the trephine at the L4/5 intervertebral space, which causes less lumbar damage and has greater postoperative stability. To achieve this, we conduct a three-dimensional simulated analysis of the degree of damage caused by targeted puncture-based trephine osteotomy on the lumbar spine. Methods: We gathered clinical CT data from patients to construct a lumbar model. This model was used to simulate and analyze the variations in trephine osteotomy volume resulting from targeted punctures at the L4/5 interspace. Furthermore, according to these variations in osteotomy volume, we created Finite Element Analysis (FEA) models specifically for the trephine osteotomy procedure. We then applied mechanical loads to conduct range of motion and von Mises stress analyses on the lumbar motion unit. Results: In percutaneous endoscopic interlaminar discectomy, the smallest osteotomy volume occurred with a 20° entry angle, close to the base of the spinous process. The volume increased at 30° and reached its largest at 40°. In percutaneous transforaminal endoscopic discectomy, the largest osteotomy volume was observed with a 50° entry angle, passing through the facet joints, with smaller volumes at 60° and the smallest at 70°. In FEA, M6 exhibited the most notable biomechanical decline, particularly during posterior extension and right rotation. M2 and M3 showed significant differences primarily in rotation, whereas the differences between M3 and M4 were most evident in posterior extension and right rotation. M5 displayed their highest stress levels primarily in posterior extension, with significant variations observed in right rotation alongside M4. Conclusion: The appropriate selection of entry sites can reduce lumbar damage and increase stability. We suggest employing targeted punctures at a 30° angle for PEID and at a 60° angle for PTED at the L4/5 intervertebral space. Additionally, reducing the degree of facet joint damage is crucial to enhance postoperative stability in lumbar vertebral motion units.

Annulus Fibrosus Repair for Lumbar Disc Herniation: A Meta-Analysis of Clinical Outcomes From Controlled Studies

STUDY DESIGN

Meta-analysis.

OBJECTIVES

This study aimed to summarize the clinical efficacy and safety of the various annular defect repair methods that have emerged in recent years.

METHODS

A meta-analysis of randomized and non-randomized controlled trials was conducted. Articles from PubMed, Embase, and the Cochrane Library (CENTRAL) on Lumbar disc herniation treatment with annular repair published from inception to April 2, 2022 were included. We summarized the clinical efficacy and safety of annular repair techniques based on a random-effects model meta-analysis.

RESULTS

7 randomized controlled studies and 8 observational studies with a total of 2161 participants met the inclusion criteria. The pooled data analysis showed that adding the annular repair technique reduced postoperative recurrence rate, reoperation rate, and loss of intervertebral height compared with lumbar discectomy alone. Subgroup analysis based on different annular repair techniques showed that the Barricaid Annular Closure Device (ACD) was effective in preventing re-protrusion and reducing reoperation rates, while there was no significant difference between the other subgroups. The annulus fibrosus suture (AFS) did not improve the postoperative Oswestry Disability Index (ODI). No statistically significant difference was observed in the incidence of adverse events between the annular repair and control groups.

CONCLUSIONS

Lumbar discectomy combined with ACD can effectively reduce postoperative recurrence and reoperation rates in patients with LDH. AFS alone was less effective in reducing recurrence and reoperation rates and did not improve postoperative pain and function.

Chiropractic Management of Lumbar Disc Herniation in a Patient With Co-existing Liver Cancer: A Case Report

The current case report outlines the chiropractic management of a 30-year-old male construction worker who presented with symptoms of lumbar disc herniation with co-existing stage IV liver cancer. The patient reported experiencing substantial lower back pain and decreased sensation in his right leg following a fall at work, impacting his mobility and quality of life. The complexity of this case is underscored by the challenge of differentiating between pain due to metastatic disease and that related to the fall. The chiropractic treatment plan included gentle joint mobilization, instrument-assisted soft tissue mobilization, and low-impact exercises tailored to the patient's overall health status. The treatment protocol markedly improved pain levels, range of motion, and overall quality of life. This case highlights the potential role of chiropractic care in managing complex cases of lumbar disc herniation, even in the presence of severe illnesses such as liver cancer. This study provides valuable insights into the importance of personalized and adaptable treatment strategies in managing such cases, contributing a unique perspective to the scientific literature.

Morphological changes after open lumbar microdiscectomy at 2-year follow-up

BACKGROUND

It is known that a possible decrease in disc height (DH) and foraminal size after open lumbar microdiscectomy (OLM) may cause pain in the long term. However, there is still insufficient information about the short- or long-term pathoanatomical and morphological effects of microdiscectomy. For example, the exact temporal course of the change in DH is not well known.

OBJECTIVE

The purpose of this study was to examine morphological changes in DH and foramen dimensions after OLM.

METHODS

In patients who underwent OLM for single-level lumbar disc herniation, MRI scans were obtained before surgery, and at an average of two years after surgery. In addition to DH measurements, foraminal area (FA), foraminal height (FH), superior foraminal width (SFW), and inferior foraminal width (IFW), were measured bilaterally.

RESULTS

A postoperative increase in DH was observed at all vertebral levels, with an average of 5.5%. The mean right FHs were 15.3 mm and 15.7 mm before and after surgery, respectively (p= 0.062), while the left FHs were 14.8 mm and 15.8 mm before and after surgery (p= 0.271). The mean right SFW was 5.4 mm before surgery and 5.7 mm after surgery, while the mean right IFW ranged from 3.6 mm to 3.9 mm. The mean left SFW was 4.8 mm before surgery and 5.2 mm after surgery, while the mean left IFW ranged from 3.5 mm to 3.9 mm. Before surgery, the FAs were, on average, 77.1 mm2 and 75.6 mm2 on the right and left sides, respectively. At the 2-year follow-up, the mean FAs were 84.0 mm2 and 80.2 mm2 on the right and left sides, respectively.

CONCLUSIONS

Contrary to prevalent belief, in patients who underwent single-level unilateral OLM, we observed that there may be an increase rather than a decrease in DH or foramen size at the 2-year follow-up. Our findings need to be confirmed by studies with larger sample sizes and longer follow-ups.

Predictors of successful treatment after transforaminal epidural steroid injections in patients with lumbar disc herniation

BACKGROUND

Epidural steroid injections are common procedures used to treat lumbosacral radicular pain due to lumbar disc herniation (LDH). It is crucial for the clinician to anticipate which patients can benefit from interventional treatment options.

OBJECTIVE

This study aimed to examine the effect of radiological and clinical parameters on lumbar transforaminal epidural steroid injections (TFESI)/local anesthetic injection outcomes in patients with LDH.

METHODS

This study included 286 patients with LDH (146 males and 140 females). All patients received a fluoroscopically guided TFESI (triamcinolone acetonide 40 mg, lidocaine 2%, and 2.5 ml of physiological saline). Patients were evaluated according to radicular pain, the Oswestry Disability Index (ODI) and the Hospital Anxiety and Depression Scale at baseline and 3 months after the injections. Demographic, clinical and magnetic resonance imaging (MRI) findings were recorded to assess the predictive factors for TFESI outcomes. Pfirrmann Grades 1 and 2 were classified as low-grade nerve root compression and Grade 3 was classified as highgrade nerve root compression.

RESULTS

Compared to baseline measurements there were significant improvements in radicular pain, ODI score, Laseque angle, and Schober test scores 3 months after injection. Improvements of at least 50% in radicular pain relief and the ODI functionality index were (n= 214) 82%, (n= 182) 70% respectively at 3 months. Correlation analyses revealed that a shorter duration of symptoms, lowgrade nerve root compression and foraminal/extraforaminal location on MRI findings were associated with a favorable response.

CONCLUSIONS

Lowgrade nerve root compression was a predictor of a favorable response to TFESI.

A comparison between transforaminal lumbar epidural injection performed under picture archiving and communication systems-based magnetic resonance imaging planning and injection under immediate X-ray guidance

OBJECTIVES

The study aimed to compare the treatment cost, operation time, clinical effect, and complications between punctures done under magnetic resonance imaging (MRI) planning based on picture archiving and communication systems (PACS) and punctures done under immediate X-ray fluoroscopy guidance in the treatment of lumbar disc herniation by transforaminal lumbar epidural injection.

PATIENTS AND METHODS

In this prospective study conducted between October 2016 and June 2021, 128 patients were randomly divided into Groups A and B by the random number table method. In Group A (n=66; 36 males, 30 females; mean age: 64.5±2.4 years, range, 50 to 72 years), puncture was performed by planning with PACS-based MRI; in Group B (n=62; 34 males, 28 females; mean age: 65.3±2.6 years; range, 48 to 73 years), puncture was performed under immediate X-ray guidance. The cost of treatment, duration of procedure, clinical outcome, and complications were compared between the two groups.

RESULTS

The difference in treatment cost in Groups A and B was statistically significant (p<0.001), with 755.67±29.45 yuan and 1.158.08±43.92 yuan, respectively. The mean treatment time was statistically significant (p<0.001) between the groups, with 21.16±1.91 min in Group A and 37.26±2 min in Group B. However, there was no significant difference between Group A and Group B in terms of improvement in pain scores and Oswestry disability index (both p>0.05). There was also no significant difference between Group A and Group B in terms of complication rates (both p>0.05).

CONCLUSION

Compared to immediate X-ray guided puncture, the puncture method using PACS for MRI planning shortened the transforaminal lumbar epidural injection procedure time and reduced the treatment costs without exposing the physician or patient to additional radiation, while there was no significant difference in the short-term clinical outcome or complication rate.

Clinical feasibility of MRI-based synthetic CT imaging in the diagnosis of lumbar disc herniation: a comparative study

BACKGROUND

Computed tomography (CT) and magnetic resonance imaging (MRI) are indicated for use in preoperative planning and may complicate diagnosis and place a burden on patients with lumbar disc herniation.

PURPOSE

To investigate the diagnostic potential of MRI-based synthetic CT with conventional CT in the diagnosis of lumbar disc herniation.

MATERIAL AND METHODS

After obtaining prior institutional review board approval, 19 patients who underwent conventional and synthetic CT imaging were enrolled in this prospective study. Synthetic CT images were generated from the MRI data using U-net. The two sets of images were compared and analyzed qualitatively by two musculoskeletal radiologists. The images were rated on a 4-point scale to determine their subjective quality. The agreement between the conventional and synthetic images for a diagnosis of lumbar disc herniation was determined independently using the kappa statistic. The diagnostic performances of conventional and synthetic CT images were evaluated for sensitivity, specificity, and accuracy, and the consensual results based on T2-weighted imaging were employed as the reference standard.

RESULTS

The inter-reader and intra-reader agreement were almost moderate for all evaluated modalities (κ = 0.57-0.79 and 0.47-0.75, respectively). The sensitivity, specificity, and accuracy for detecting lumbar disc herniation were similar for synthetic and conventional CT images (synthetic vs. conventional, reader 1: sensitivity = 91% vs. 81%, specificity = 83% vs. 100%, accuracy = 87% vs. 91%; P < 0.001; reader 2: sensitivity = 84% vs. 81%, specificity = 85% vs. 98%, accuracy = 84% vs. 90%; P < 0.001).

CONCLUSION

Synthetic CT images can be used in the diagnostics of lumbar disc herniation.

Percutaneous endoscopic lumbar discectomy in lumbar disc herniation with posterior ring apophysis fracture: A case report in a 15-year-old child

RATIONALE

Lumbar disc herniation (LDH) with posterior ring apophysis fracture (PRAF) is rather rare in children, and in all age-stratified LDH patients, the incidence of RAF was 5.3% to 7.5%. Interestingly, the incidence of LDH with RAF in children (15%-32%) is several times higher than in adults, the mis-diagnosis of which may lead to delayed treatment.

PATIENT CONCERNS

Here, we report a 15-year-old schoolboy who suffered from sudden low back pain and radiating pain in both lower limbs after sport activities. Symptoms persisted after 3 months of conservative treatment. Computer radiography and magnetic resonance imaging indicated central disc herniation with PRAF at L4-5.

DIAGNOSIS

LDH with PRAF.

INTERVENTIONS

The herniated disc and epiphyseal fragments were successfully excised by the percutaneous endoscopic lumbar discectomy minimal-invasive technique.

OUTCOMES

Surgery was successful. Symptoms were immediately relieved postoperatively with a wound of only about 7.0 mm. Discharged on the next day. No perioperative complications occurred. Moreover, the imaging and clinical outcomes were also more satisfactory during the post-operative 15 months outpatient follow-up.

LESSONS

Pediatric LDH with PRAF is extremely uncommon, and there is a lack of training among physicians for such cases, which may lead to delayed diagnosis and treatment. Once a diagnosis for LDH with PRAF is established, percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive treatment to be considered, and we hope that this technique can provide more assistance in the future.

Why does such a cyst appear after unilateral biportal endoscopy surgery: A case report and literature review

BACKGROUND

Unilateral biportal endoscopy (UBE) has been widely and skillfully used in the treatment of lumbar disc herniation and spinal canal stenosis. UBE surgery also brings some complications, such as dural tear, epidural hematoma, residual nucleus pulposus, etc. And we found a rare case of arachnoid cyst after UBE.

CASE PRESENTATION

A 48 years old female who had a history of cholecystectomy, nephrolithiasis, hyperthyroidism, chronic atrophic gastritis, and colonic polyps with several years of low back pain and numbness in both lower limbs was found have arachnoid cyst 3 years after UBE operation. We hope that we can give a new aspect of complication after the UBE treatment in the future.

CONCLUSION

We believe that the postoperative hypertension and the lack of postoperative back muscle strength training and some personal factors are the possible reasons for the arachnoid cyst in this case.

Postoperative Time Course of Avulsion-Type Herniation Focused on the Development of New Modic Changes and Their Effect on Short-Term Residual Low Back Pain

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the characteristics of newly developing Modic changes following discectomy and their impact on residual low back pain (LBP) in the early postoperative stage of lumbar disc herniation.

METHODS

We included 96 patients who underwent microscopic discectomy. Through MRI, we assessed new developments of Modic changes and the progression of disc degeneration at the surgical level. The presence of cartilaginous endplates was evaluated using resected specimens, and the main outcome was assessed using the visual analog scale (VAS). Further, the prevalence and time course of Modic changes, and their effects on clinical outcomes in the early postoperative period were examined.

RESULTS

A new development of Modic changes was detected in 28% of cartilaginous herniations at 6 months. Modic changes were observed more frequently in patients with cartilaginous herniation than in those without cartilaginous herniation postoperatively (P < .001). The VAS scores for LBP up to 6 months were greater in patients with Modic changes (P < .001) than those without; however, no significant differences were identified in the presence or absence of Modic changes over the year follow-up. The development of Modic changes was closely associated with residual LBP at 6 months (β:0.511, P < .001).

CONCLUSIONS

Modic changes develop predominantly in patients with avulsion-type herniation than in those with annular rupture at an earlier phase after discectomy. Furthermore, disc herniation with cartilaginous endplates may be associated with a slower decrease in LBP for up to 6 months, supporting the notion that newly developing endplate changes may cause residual LBP.

Effects of spinal manipulation or mobilization as an adjunct to neurodynamic mobilization for lumbar disc herniation with radiculopathy: a randomized clinical trial

OBJECTIVES

To determine the long-term clinical effects of spinal manipulative therapy (SMT) or mobilization (MOB) as an adjunct to neurodynamic mobilization (NM) in the management of individuals with Lumbar Disc Herniation with Radiculopathy (DHR).

DESIGN

Parallel group, single-blind randomized clinical trial.

SETTING

The study was conducted in a governmental tertiary hospital.

PARTICIPANTS

Forty (40) participants diagnosed as having a chronic DHR (≥3 months) were randomly allocated into two groups with 20 participants each in the SMT and MOB groups.

INTERVENTIONS

Participants in the SMT group received high-velocity, low-amplitude manipulation, while those in the MOB group received Mulligans' spinal mobilization with leg movement. Each treatment group also received NM as a co-intervention, administered immediately after the SMT and MOB treatment sessions. Each group received treatment twice a week for 12 weeks.

OUTCOME MEASURES

The following outcomes were measured at baseline, 6, 12, 26, and 52 weeks post-randomization; back pain, leg pain, activity limitation, sciatica bothersomeness, sciatica frequency, functional mobility, quality of life, and global effect. The primary outcomes were pain and activity limitation at 12 weeks post-randomization.

RESULTS

The results indicate that the MOB group improved significantly better than the SMT group in all outcomes (p < 0.05), and at all timelines (6, 12, 26, and 52 weeks post-randomization), except for sensory deficit at 52 weeks, and reflex and motor deficits at 12 and 52 weeks. These improvements were also clinically meaningful for neurodynamic testing and sensory deficits at 12 weeks, back pain intensity at 6 weeks, and for activity limitation, functional mobility, and quality of life outcomes at 6, 12, 26, and 52 weeks of follow-ups. The risk of being improved at 12 weeks post-randomization was 40% lower (RR = 0.6, CI = 0.4 to 0.9, p = 0.007) in the SMT group compared to the MOB group.

CONCLUSION

This study found that individuals with DHR demonstrated better improvements when treated with MOB plus NM than when treated with SMT plus NM. These improvements were also clinically meaningful for activity limitation, functional mobility, and quality of life outcomes at long-term follow-up.

TRIAL REGISTRATION

Pan-African Clinical Trial Registry: PACTR201812840142310.

Estimating surgical probability: Development and validation of a prognostic model for patients with lumbar disc herniation treated with acupuncture

Lumbar disc herniation (LDH) is a common cause of pain in the lumbar spine and legs. While acupuncture has become the primary conservative treatment for LDH, some patients experience treatment failure and require surgery, causing substantial concern for clinicians. We developed an effective personalized clinical prediction model to identify the independent risk factors associated with acupuncture failure in patients with LDH. Our model aimed to predict the probability of surgery within 6 months of acupuncture failure in patients with LDH. A total of 738 patients with LDH who underwent acupuncture at 4 Chinese hospitals between January 2019 and October 2021 were selected. The patients were divided into training (n = 496) and validation (n = 242) cohorts. Seven predictive variables, including smoking, Oswestry Disability Index (ODI) score, lower-limb herniation, disc herniation type, lumbar spinal stenosis, lumbar lateral recess stenosis, and acupuncture frequency, were selected as risk factors using least absolute shrinkage and selection operato (LASSO) regression. A prediction model was developed using multivariate logistic regression analysis and a nomogram was constructed. The model exhibited good discrimination, with an area under the ROC curve (AUC) of 0.903 for the development cohort and 0.899 for the validation cohort. The Hosmer-Lemeshow goodness-of-fit test was a good fit for both cohorts (P = .956 for the development cohort; P = .513 for the validation cohort). Decision curve analysis (DCA) demonstrated that the threshold probabilities for the 2 cohorts ranged from > 4% and 5-95%, respectively. Therefore, the prediction model had a good net benefit. The nomogram established in this study, incorporating 7 risk factors, demonstrated a good predictive ability. It could predict acupuncture failure in LDH patients and the risk of surgery within 6 months, enabling physicians to conduct individualized treatment measures.

[Baimai Ointment relieves chronic pain induced by chronic compression of dorsal root ganglion in rats by regulating neuroactive ligand-receptor interaction and HIF-1 signaling pathway]

The Baimai Ointment with the effect of relaxing sinew and activating collaterals demonstrates a definite effect on Baimai disease with pain, spasm, stiffness and other symptoms, while the pharmacodynamic characteristics and mechanism of this agent remain unclear. In this study, a rat model of chronic compression of L4 dorsal root ganglion(CCD) was established by lumbar disc herniation, and the efficacy and mechanism of Baimai Ointment in the treatment of CCD were preliminarily explored by behavioral tests, side effect evaluation, network analysis, antagonist and molecular biology verification. The pharmacodynamic experiment indicated that Baimai Ointment significantly improved the pain thresholds(mechanical pain, thermal pain, and cold pain) and gait behavior of CCD model rats without causing tolerance or obvious toxic and side effects. Baimai Ointment inhibited the second-phase nociceptive response of mice in the formalin test, increased the hot plate threshold of normal mice, and down-regulated the expression of inflammatory cytokines in the spinal cord. Network analysis showed that Baimai Ointment had synergistic effect in the treatment of CCD and was related to descending inhibition/facilitation system and neuroinflammation. Furthermore, behavioral tests, Western blot, and immunofluorescence assay revealed that the pain-relieving effect of Baimai Ointment on CCD may be related to the regulation of the interaction between neuroactive ligand and receptors(neuroligands) such as CHRNA7, ADRA2A, and ADRB2, and the down-regulation of the expression of NOS2/pERK/PI3K, the core regulatory element of HIF-1 signaling pathway in spinal microglia. The findings preliminarily reveal the mechanism of relaxing sinew and activating collaterals of Baimai Ointment in the treatment of Baimai disease, providing a reference for the rational drug use and further research of this agent.

Traditional Chinese exercises on pain and disability in middle-aged and elderly patients with lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials

Background

Traditional Chinese exercises (TCEs) have played a significant role in treating various diseases. However, there is limited research assessing the efficacy of TCEs in treating Lumbar disc herniation (LDH). This study aimed to systematically evaluate the effects of four commonly used TCEs (Baduanjin, Yijinjing, Taichi, and Wuqinxi) on pain and disability in elderly patients with LDH.

Objectives

To assess the quality of relevant randomized controlled trials (RCTs) to provide evidence support for the treatment of LDH.

Methods

RCTs were identified through eight databases. Meta-analysis and trial sequence analysis (TSA) were conducted using RevMan 5.4, Stata 17.0, and TSA 0.9.

Results

A total of 22 RCTs, involving 1931 patients, were included in the analysis. TCEs exhibited a superior effectiveness in treating LDH compared to the control group. However, the TSA analysis suggested the possibility of false positives, indicating the need for more high-quality RCT evidence. Nevertheless, TCEs showed reliable results in significantly improving the VAS score and JOA score of LDH patients.

Conclusion

Current evidence indicates that the four TCEs have advantages in treating LDH in middle-aged and elderly individuals. However, considering the limitations of this study, we need to exercise caution in drawing conclusions, and further research is required to validate these findings.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO, identifier [CRD42023431633].

Ultrasound-Guided Lumbar Intradiscal Injection: A Case Report With a High-Resolution Ultrasound Image

We present a case report demonstrating a new technique for intradiscal injection under ultrasound guidance in treating lumbar disc herniation. A 16-year-old female gymnast underwent this procedure and experienced relief from pain. Traditional methods have been noted for their technical challenges and potential risk of nerve root damage. In this case, our approach visualized the lateral side of the disc and improved needle visibility. This technique potentially offers a clearer high-resolution confirmation of the needle's position within the disc. It is considered that this technique is effective not only for performing precise injections but also for enhancing safety due to the clear depiction of the needle tip entering the intervertebral disc.

Risk factor of residual leg numbness after lumbar microdiscectomy for lumbar disc herniation

Although patients with lumbar disc herniation (LDH) can achieve significant relief from lower back and leg pain after lumbar microdiscectomy, a few patients complain of discomfort due to residual leg numbness (RLN). This study aimed to identify potential risk factors for RLN after lumbar microdiscectomy. We prospectively collected and analyzed patients with LDH who underwent microdiscectomy between September 2016 and December 2020. All included patients had preoperative LN symptoms. Patients with RLN were defined as those with LN at the last follow-up. The relationships between RLN and sex, age, body mass index (BMI), current smoking status, diabetes mellitus, revision surgery, preoperative LN Numeric Rating Scale (NRS) score, duration of preoperative LN, RLN at discharge, sagittal range of motion (SROM), Modic change, disc Pfirrmann grade were analyzed. The RLN was observed in 33.5% (112/334) of patients at the last follow-up. No significant differences were observed in age, sex, BMI, current smoking status, or diabetes between the RLN and non-RLN groups. The preoperative LN NRS score, preoperative LN duration, rate of RLN at discharge, and revision surgery were significantly higher in the RLN group than those in the non-RLN group. Multivariate logistic regression analysis identified the preoperative LN NRS score, duration of preoperative LN, RLN at discharge, revision surgery, and SROM as risk factors for RLN in the long-term follow-up. Patients with higher preoperative LN NRS scores and SROM, longer preoperative LN duration, RLN at discharge, and revision surgery were more likely to experience RNL after lumbar microdiscectomy.

Research Trends of Percutaneous Endoscopic Lumbar Discectomy in the Treatment of Lumbar Disc Herniation Over the Past Decade: A Bibliometric Analysis

Objective

This study aimed to explore the research trends of percutaneous endoscopic lumbar discectomy in treating lumbar disc herniation using bibliometrics over the past ten years.

Methods

Relevant publications on the clinical application of percutaneous endoscopic lumbar discectomy in lumbar disc herniation were searched in the Web of Science Core Collection. Subsequently, the characteristics of all these articles were collected. Visualizing data of annual publications, journals, cited journals, authors, cited authors, countries, institutions, keywords, and cited references was performed by using CiteSpace (6.1.R6).

Results

A total of 642 publications were extracted between 2013 and 2022. The number of publications peaked in the year 2020. The most prolific journal was World Neurosurgery (81), and Spine (597) as the cited journal was the most popular one. China (393) was the most prolific country, followed by South Korea (100). The institution with the most productivity was Tongji University (35). Yue Zhou (20) was the most prolific author, and Sebastian Ruetten (310) was the most cited author. The keyword "interlaminar" was top of research developments with the highest citation burst (8.69). "Lumbar disc herniation", "surgical technique", and "complication" were popular keywords. The surgical procedures and complications of percutaneous endoscopic lumbar discectomy have been the hot topics of recent research.

Conclusion

This study summarized the current situation and development trends of percutaneous endoscopic lumbar discectomy clinical research in the form of visualization, and these findings may help researchers explore new directions in the future.

Systematic review and meta-analysis of predictive factors for spontaneous regression in lumbar disc herniation

OBJECTIVE

Relatively little evidence exists on predictive factors for the spontaneous regression of lumbar disc herniation (LDH), although it is a well-documented phenomenon. Therefore, current care is not optimized to identify those who would benefit from early surgery versus those who could avoid surgical risks and pursue nonsurgical therapy. In this study, the authors aimed to analyze and summarize all literature to date on predictive factors for spontaneous LDH regression as well as suggest future research strategies to aid in the decision-making for this cohort.

METHODS

A literature search was conducted of the Cochrane, Embase, and MEDLINE databases for articles that described LDH in terms of the North American Spine Society task force definitions: bulging, protruded, extruded, and sequestered disc morphologies. All articles described a nonsurgical primary symptomatic LDH cohort with at least two MR images to assess regression. Those with concomitant spinal disease were excluded. The primary outcome was to assess the probability of disc regression for each disc morphology, with a secondary analysis for any other predictive factors identified. The authors synthesized their results with the only previous review (examining articles published before March 2014) to comprehensively describe the literature. A qualitative analysis of the wider literature was also performed for those studies with differing definitions of LDH but meeting all remaining inclusion criteria.

RESULTS

Sixteen articles describing 360 cases of LDH were identified. Participants tended to be younger and male and presented with radiculopathy and L4-5 or L5-S1 LDH. The mean time to follow-up imaging was 11.5 months. The probabilities of spontaneous regression with bulging, protruded, extruded, and sequestered discs were 13.3%, 52.5%, 70.4%, and 93.0%, respectively (χ2 = 126.01, p < 0.001). Extruded and sequestered discs were also significantly more likely to completely regress than smaller morphologies. Other predictors of regression were larger baseline herniation volume (1260.16 vs 1006.71 mm3, p < 0.002), transligamentous herniation (χ2 = 13.321, p < 0.001), and higher Komori types (χ2 = 14.5132, p < 0.001). The authors also found similar trends in qualitative data as well as confirmed that symptom improvement was associated with disc regression.

CONCLUSIONS

This study shows further evidence of the influence of disc morphology on predicting LDH regression as well as provides the first meta-analysis of data indicating additional predictive factors. Further investigation of predictive factors for early (< 6 months) LDH regression is suggested to optimize clinical use.

Management of Lumbar Disc Herniation: A Systematic Review

A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. It is a common cause of back pain. The patients who experience pain related to a herniated disc often remember an inciting event that caused their pain. This activity reviews the evaluation and management of lumbar disc herniation and discusses the role of the healthcare team in evaluating and improving care for patients with this condition. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2010 to 2023) according to the PRISMA guidelines. Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 777 studies; 7 were eligible for inclusion in the analysis. Further understanding of spinal disc herniation and treatment protocols may help improve evaluation and management in the future. Our research covered a range of management options. Disc herniation is a frequent problem for internists, emergency department doctors, nurse practitioners, and primary care physicians. To manage efficiently, an interprofessional team is needed. The first course of treatment is conservative, with paracetamol and anti-inflammatories being frequently used to relieve pain. A chemist must supervise the use of opioid analgesics in certain situations. Although surgery is sometimes the final option, patients frequently have neurological damage and lingering discomfort. In circumstances where physical treatment is not working, MRI interpretation becomes necessary. Primary care physicians or mental health professionals should handle back pain as it is frequently linked to mental health issues. Results can be enhanced by regular exercise and preserving a healthy body weight.

Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers

OBJECTIVE

To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy.

STUDY DESIGN

A cross-sectional study.

METHODS

Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups.

RESULTS

There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI.

CONCLUSIONS

Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

Factors determining postoperative and outpatient follow-up period in patients undergoing single lumbar disc herniation

The precise evaluation of postoperative outcomes in patients with lumbar disc surgery is quite difficult since the pre-operative factors and patient responses differ. Several questionnaires assess the outcome of herniated lumbar disc surgeries. However, the clinical outcome may vary widely, indicating the significance of precise preoperative assessments to ensure better outcome prediction. Previous long-term studies suggest fewer positive outcomes in cases with prolonged preoperative history. In the present retrospective study, we aimed to assess the outcome of patients with lumbar discectomy in Iraqi patients by evaluating the surgical outcome. This research was performed in the orthopedic center of the Teaching Hospital of Adiwaniyah Province, Iraq. The study was based on retrieving hospital records of patients who were subjected to surgical intervention for lumbar disc herniation from 2018 to 2022. The sample consisted of patients with lumbar disc herniation who were subjected to discectomy at one level even in cases where both approaches were used. Age, gender, income, education level, and degree of disc involvement did not significantly correlate with the type of surgical approach (p>0.05); however, there were significant positive correlations to body mass index and duration of disease (p<0.05). Therefore, the body mass index and duration of disease are significant predictors of prolonged postoperative follow-up and hospital stay duration.

Are Primary Outcomes Really Primary? An Exploratory Cross-Sectional Nationwide Web-Based Survey Study for Outcomes Reflecting Real Symptoms and Needs of Patients with Lumbar Disc Herniation

As primary outcomes differ among clinical lumbar disc herniation (LDH) studies, this study aimed to explore outcomes reflecting real-world patient experiences through an exploratory questionnaire survey. Those diagnosed with LDH having radiating leg pain in South Korea in November of 2022 (N = 500) were administered a questionnaire including basic characteristics, disease onset, symptoms and severity, priority symptoms for improvement, and important treatment factors. Outcome measures included the identification of priority symptoms and disabilities. Most common symptoms were numbness in the leg (N = 435, 87.0%) and back pain (N = 406, 81.2%); most common disabilities were discomfort in sitting (N = 323, 64.6%) and lifting (N = 318, 63.6%). The highest priority symptom was back pain (N = 242, 48.4%). A satisfactory degree of symptom improvement was a decrease of at least 3 points on the numeric rating scale. The majority of respondents preferred improvement in disability over pain (N = 270, 55.8%), a stable effect over a rapid effect (N = 391, 78.2%), and safety over treatment efficacy (N = 282, 56.4%). Safety (N = 129, 25.8%) and cost (N = 111, 22.2%) were the most important treatment factors. Improvements in back pain, leg pain, sitting, and sleeping were prioritized, and safety, stable treatment effect, and functional recovery were desired. Clinical trials for LDH should be designed to reflect this real-world patient need. Further study to examine the patients' symptoms and needs in details is needed.

[Comparison of effectiveness between unilateral biportal endoscopic lumbar interbody fusion and endoscopic transforaminal lumbar interbody fusion for lumbar spinal stenosis combined with intervertebral disc herniation]

Objective

To compare the effectiveness between unilateral biportal endoscopic lumbar interbody fusion (ULIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in treatment of lumbar spinal stenosis combined with intervertebral disc herniation.

Methods

A clinical data of 64 patients with lumbar spinal stenosis and intervertebral disc herniation, who were admitted between April 2020 and November 2021 and met the selection criteria, was retrospectively analyzed. Among them, 30 patients were treated with ULIF (ULIF group) and 34 patients with Endo-TLIF (Endo-TLIF group). There was no significant difference in baseline data such as gender, age, disease duration, lesion segment, preoperative visual analogue scale (VAS) score of low back pain and leg pain, Oswestry disability index (ODI), spinal canal area, and intervertebral space height between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospital stays, and postoperative complications were compared between the two groups, as well as the VAS scores of low back pain and leg pain, ODI, and imaging measurement indicators (spinal canal area, intervertebral bone graft area, intervertebral space height, and degree of intervertebral fusion according to modified Brantigan score).

Results

Compared with the Endo-TLIF group, the ULIF group had shorter operation time, but had more intraoperative blood loss and longer hospital stays, with significant differences ( P<0.05). The cerebrospinal fluid leakage occurred in 2 cases of Endo-TLIF group and 1 case of ULIF group, and no other complication occurred. There was no significant difference in the incidence of complications between the two groups ( P>0.05). All patients in the two groups were followed up 12 months. The VAS scores of lower back pain and leg pain and ODI in the two groups significantly improved when compared with those before operation ( P<0.05), and there was no significant difference between different time points after operation ( P>0.05). And there was no significant difference between the two groups at each time point after operation ( P>0.05). Imaging examination showed that there was no significant difference between the two groups in the change of spinal canal area, the change of intervertebral space height, and intervertebral fusion rate at 6 and 12 months ( P>0.05). The intervertebral bone graft area in the ULIF group was significantly larger than that in the Endo-TLIF group ( P<0.05).

Conclusion

For the patients with lumbar spinal stenosis combined with intervertebral disc herniation, ULIF not only achieves similar effectiveness as Endo-TLIF, but also has advantages such as higher decompression efficiency, flexible surgical instrument operation, more thorough intraoperative intervertebral space management, and shorter operation time.

Forecast of pain degree of lumbar disc herniation based on back propagation neural network

To further explore the pathogenic mechanism of lumbar disc herniation (LDH) pain, this study screens important imaging features that are significantly correlated with the pain score of LDH. The features with significant correlation imaging were included into a back propagation (BP) neural network model for training, including Pfirrmann classification, Michigan State University (MSU) regional localization (MSU protrusion size classification and MSU protrusion location classification), sagittal diameter index, sagittal diameter/transverse diameter index, transverse diameter index, and AN angle (angle between nerve root and protrusion). The BP neural network training model results showed that the specificity was 95 ± 2%, sensitivity was 91 ± 2%, and accuracy was 91 ± 2% of the model. The results show that the degree of intraspinal occupation of the intervertebral disc herniation and the degree of intervertebral disc degeneration are related to LDH pain. The innovation of this study is that the BP neural network model constructed in this study shows good performance in the accuracy experiment and receiver operating characteristic experiment, which completes the prediction task of lumbar Magnetic Resonance Imaging features for the pain degree of LDH for the first time, and provides a basis for subsequent clinical diagnosis.

A Case-Control Study of the Fokl Polymorphism of the Vitamin D Receptor Gene in Bulgarians With Lumbar Disc Herniation

BACKGROUND

The present study investigates whether vitamin D receptor (VDR) gene polymorphisms play a role in intervertebral disc degeneration (IDD), a common cause of low back pain (LBP) and reduced quality of life. Specifically, we examined the FokI VDR polymorphism and its potential association with lumbar disc herniation (LDH) in patients from Bulgaria. Previous studies have suggested a link between mutations in the VDR gene and IDD.

METHODS

We investigated whether a potential connection between VDR polymorphisms and LDH was present by comparing the FokI polymorphism of 60 selected patients (25 to 60) with LDH and 60 healthy volunteers within the same age range. We used polymerase chain reaction to assess the phenotype of the examined subjects and statistical tests to evaluate whether the obtained results were statistically significant.

RESULTS

The performed genetic and statistical analyses reviewed significant differences in genotypic frequencies between the patient group and healthy volunteers. The frequency of the F allele is notably higher in patients with LDH (80%) compared to volunteers (52%), while the f allele is more common among patients (86.6%) than volunteers (100%).

CONCLUSION

This study strongly suggests that expression of the F allele of the VDR gene may increase the susceptibility of developing LDH, while having the f allele could potentially have a protective effect. Our results shed light on the underlying complex mechanisms contributing to the development of LDH.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD).

METHODS

Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12 months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2 days and at 3, 6, and 12 months. Postoperative complications were noted.

RESULTS

Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1).

CONCLUSION

BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

Long-Term Radiographic and Clinical Outcomes in Patients Undergoing Transforaminal Endoscopic Lumbar Discectomy: A Propensity Score Matching Study

Background

Our study aims to investigate the long-term clinical and radiographic effects of transforaminal endoscopic lumbar discectomy (TELD) on lumbar disc herniation.

Patients and Methods

Radiographic and clinical data of patients undergoing TELD in our institution from January 2015 to January 2019 were retrospectively collected. LDH outpatients who had not received surgical treatment during the same period were 1:1 matched by propensity score matching as the conservative group. The radiographic parameters of the two groups at baseline and at the last follow-up (≥24 months) were analyzed.

Results

The study included 47 patients in the TELD group, matched with 47 patients in the conservative group. The disc height of the TELD group at the last follow-up was lower than that at the baseline (P < 0.001), and lower than that of the conservative group at the last follow-up (P < 0.05). The disc degeneration grade of the TELD group at the last follow-up was greater than that at the baseline, and greater than that of the conservative group at the last follow-up. There was no significant difference in the facet joint degeneration in the TELD group between the baseline and the last follow-up, and between the TELD group and the conservative group at the last follow-up (P > 0.05). The pain intensity and disability score in the TELD group at 3-month follow-up and at the last follow-up were significantly lower than those at the baseline (P < 0.001). Six patients in the TELD group required additional surgery during the follow-up period.

Conclusion

Our long-term follow-up data shows that the disc height of the operated level was significantly reduced and the disc degeneration was significantly aggravated in TELD-treated patients; in contrast, the facet joint degeneration did not show significant aggravation.

Deep learning-based detection and classification of lumbar disc herniation on magnetic resonance images

Background

The severity assessment of lumbar disc herniation (LDH) on MR images is crucial for selecting suitable surgical candidates. However, the interpretation of MR images is time-consuming and requires repetitive work. This study aims to develop and evaluate a deep learning-based diagnostic model for automated LDH detection and classification on lumbar axial T2-weighted MR images.

Methods

A total of 1115 patients were analyzed in this retrospective study; both a development dataset (1015 patients, 15 249 images) and an external test dataset (100 patients, 1273 images) were utilized. According to the Michigan State University (MSU) classification criterion, experts labeled all images with consensus, and the final labeled results were regarded as the reference standard. The automated diagnostic model comprised Faster R-CNN and ResNeXt101 as the detection and classification network, respectively. The deep learning-based diagnostic performance was evaluated by calculating mean intersection over union (IoU), accuracy, precision, sensitivity, specificity, F1 score, the area under the receiver operating characteristics curve (AUC), and intraclass correlation coefficient (ICC) with 95% confidence intervals (CIs).

Results

High detection consistency was obtained in the internal test dataset (mean IoU = 0.82, precision = 98.4%, sensitivity = 99.4%) and external test dataset (mean IoU = 0.70, precision = 96.3%, sensitivity = 97.8%). Overall accuracy for LDH classification was 87.70% (95% CI: 86.59%-88.86%) and 74.23% (95% CI: 71.83%-76.75%) in the internal and external test datasets, respectively. For internal testing, the proposed model achieved a high agreement in classification (ICC = 0.87, 95% CI: 0.86-0.88, P < 0.001), which was higher than that of external testing (ICC = 0.79, 95% CI: 0.76-0.81, P < 0.001). The AUC for model classification was 0.965 (95% CI: 0.962-0.968) and 0.916 (95% CI: 0.908-0.925) in the internal and external test datasets, respectively.

Conclusions

The automated diagnostic model achieved high performance in detecting and classifying LDH and exhibited considerable consistency with experts' classification.

Patient-Reported Outcomes Following Surgery for Lumbar Disc Herniation: Comparison of a Universal and Multitier Health Care System

STUDY DESIGN

Ambispective cohort study.

OBJECTIVE

Canada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system.

METHODS

Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively.

RESULTS

The CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P < .001) and were more likely to be employed (69.5% vs 60.3%, P = .003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (87.2% vs 64.8%, P < .0001) and 1 year (85.6% vs 69.6%, P < .0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P < .01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P < .001).

CONCLUSIONS

Despite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to patients enrolled within a multitier health system.

The efficacy and safety of condoliase for lumbar disc herniation: a systematic review and meta-analysis

Background: Chemonucleolysis is a minimally invasive treatment of lumbar disc herniation (LDH). However, the low specificity of the enzyme and the existence of serious adverse events limit the application of chemonucleolysis. Clinical studies in recent years have shown that Chondroitin sulfate ABC endolyase (condoliase) is a potential therapeutic enzyme for LDH. Aim. A meta-analysis was conducted to determine the efficacy and safety of condoliase in LDH treatment. Methods: We searched Web of Science, Embase, PubMed, and Cochrane Library databases. Two reviewers independently screened articles, extracted data, and assessed the risk of bias. The outcomes were the total effective rate, Oswestry Disability Index (ODI) score change, the proportion of lumbar surgery after condoliase treatment, herniated mass volume change, Pfirrmann grade change, and adverse events. Review Manager 5.3 and Stata 12.0 were used for meta-, sensitivity, and bias analysis. Results: Ten studies were included. A single-arm meta-analysis showed that the total effective rate was 78% [95% confidence interval (CI) 75%-81%], the proportion of surgery was 9% (95% CI 7%-12%), the proportion of Pfirrmann grade change was 43% (95%CI 38%-47%), and the adverse events were 4% (95% CI 2%-6%) after condoliase treatment. The two-arm meta-analysis showed that the ODI score change [standardized mean difference (SMD) -2.46, 95% CI -3.30 to -1.63] and the herniated mass volume change (SMD -16.97, 95% CI -23.92 to -10.03) of the condoliase treatment group were greater than those of the placebo control group, and there was no difference in adverse events between the two groups (OR 1.52, 95% CI 0.60-3.85). The results of sensitivity and publication bias analyses showed that the results were robust. Conclusion: Condoliase intradiscal injection has excellent eutherapeutic and safety for LDH, thus, has considerable potential as a treatment option besides conservative treatment and surgical intervention for LDH. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022375492, PROSPERO (CRD42022375492).