Atypical presentation of tight filum terminale with thoracic disc herniation: a case report

BACKGROUND

Tight filum terminale is a rare and challenging condition to diagnose because it presents with nonspecific symptoms and unclear imaging findings. This report documents an atypical case of tight filum terminale.

CASE PRESENTATION

The patient was a previously healthy Asian 18-year-old male presenting with recurrent upper extremity and back pain, initially treated as nonspecific musculoskeletal pain. Notably, the patient's symptoms were inconsistent with the dermatome, showing no correlation with his skin's sensory innervation areas. In contrast to typical tight filum terminale presentations focused on lower extremity and lumbar region disturbances, this patient experienced pain and weakness predominantly in the upper extremities and back, hypothesized to result from traction myelopathy exacerbated by thoracic disc herniation. Investigations including blood and nerve function tests were inconclusive. However, a magnetic resonance imaging scan revealed a combination of tight filum terminale and tiny thoracic disc herniation. A diagnosis of tethered spinal cord syndrome was confirmed following further tests and imaging. The filum terminale was surgically removed, resolving the symptoms at a 7-month follow-up.

CONCLUSIONS

This case underlines the importance of including tight filum terminale as a differential diagnosis in cases of unexplained upper or lower extremity pain. Primary care practitioners, particularly those managing undefined symptoms, should consider tight filum terminale in their diagnostic approach.

Lumbar degeneration and quality of life in patients with lumbar disc herniation: a case-control long-term follow-up study

BACKGROUND AND PURPOSE

Adults treated surgically for lumbar disc herniation in adolescence have a higher degree of lumbar disc degeneration than controls. We aimed to establish whether the degree of lumbar degeneration differs at diagnosis or at follow-up between surgically and non-surgically treated individuals.

METHODS

We identified individuals with a lumbar disc herniation in adolescence diagnosed with magnetic resonance imaging (MRI) and contacted them for follow-up MRI. Lumbar degeneration was assessed according to Pfirrmann, Modic, and total end plate score (TEP score). Patient-reported outcome measures at follow-up comprised the Oswestry Disability Index (ODI), EQ-5D-3-level version, 36-Item Short Form Health Survey (SF-36), and Visual Analogue Scale (VAS) for back and leg pain. Fisher's exact test, Mann-Whitney U tests, Wilcoxon tests, and logistic regression were used for statistical analysis.

RESULTS

MRIs were available at diagnosis and after a mean of 11.9 years in 17 surgically treated individuals and 14 non-surgically treated individuals. Lumbar degeneration was similar at diagnosis (P = 0.2) and at follow-up, with the exception of higher TEP scores in surgically treated individuals at levels L4-L5 and L5-S1 at follow-up (P ≤ 0.03), but this difference did not remain after adjustment for age and sex (P ≥ 0.8). There were no significant differences in patient-reported outcome measures between the groups at follow-up (all P ≥ 0.2).

CONCLUSION

Adolescents with a lumbar disc herniation have, irrespective of treatment, a similar degree of lumbar degeneration at the time of diagnosis, and similar lumbar degeneration and patient-reported outcomes at long-term follow-up.

Pediatrics severe low back pain by disc herniation: an uncommon entity

BACKGROUND

Common severe back pain due to disc herniation is rare in the paediatric population which involves children under eighteen years of age. Paediatric lumbar disc herniation (LDH) cannot be considered the same disease as in adults, as it has potentially different natural and clinical backgrounds. The treatment of pediatric LDH is the other particularity of this condition. Indeed, in children, delaying surgery for a conservative treatment is justified. We report 3 cases treated in 8 years.

CASE PRESENTATION

Three patients, two of whom were 14 years of age and one 17 years of age, were admitted for L5 or S1 lumbosciatica. A CT scan showed a lumbar disc herniation L5S1 associated with bi-isthmic lysis (and a transitional abnormality in 1 case or spina bifida occulta in 1 other case). The last patient had an magnetic resonance imaging (MRI) that showed a herniated L4L5 disc. The diagnosis of low back pain disc herniation was retained in two patients and that of disabling low back disc in one patient. Percutaneous discolysis in the two hyperalgesic cases and epidural corticosteroid infiltration in the disabling case were effective on lumbosciatica.

CONCLUSION

Paediatric common lomw back pain caused by a disc herniation with a hyperalgic or disabling character posed a therapeutic problem which were solved by the invasive approaches that must be given priority nowadays with children.

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.

Intramuscular paravertebral oxygen-ozone therapy for chronic neck pain and low back pain: evaluation of 6-month clinical outcomes

Spinal pain is recognized as the most common cause of disability, work absenteeism and need of healthcare services worldwide. Although many strategies have been developed for conservative treatment of spinal pain, its increasing prevalence diagnosis highlights the need for new treatments. Oxygen-ozone (O2-O3) therapy is considered to be an alternative therapy due to its analgesic and anti-inflammatory effects. This retrospective study evaluated the effects of O2-O3 intramuscular paravertebral injections in 76 patients with chronic neck pain or low back pain, in terms of pain and disability reduction, quality of life improvement, and analgesic drug intake. Patients were evaluated before, at the end of the treatment, and at 1, 3 and 6 months after the last treatment, using Numeric Rating Scale, Neck Disability Index or Oswestry Disability Index, and Short Form-12 Health Survey. There were significant beneficial effects of O2-O3 therapy in reducing pain and disability reduction and improving quality of life during the 6-month follow-up period. O2-O3 therapy was associated with a reduction in analgesic drug intake at each assessment. Our results allow us not only to support treatment with O2-O3 intramuscular paravertebral injections as a safe and beneficial treatment for chronic low back pain, but also to consider it as a valuable conservative therapy for patients with chronic neck pain.

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.

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.

A Method of Predicting Posture-related Pain Using Biomechanical Parameters for Patients with Lumbar Spinal Disc Herniation

Lumbar spinal disc herniation is a disease in which the protruding nucleus pulposus presses on the nerve due to actions that place loads on the disc, causing pain in the lower back and lower limbs. About 80% of treatments of disc herniation are conservative treatments, and although it is necessary to live with pain for a long time, there have been no studies that clearly define the relationship between pain and biomechanical parameters. In this study, we proposed a method of identifying biomechanical parameters that predict posture-related pain in patients with lumbar spinal disc herniation. The pain values were quantitatively evaluated by the Numerical Rating Scale (NRS) and the biomechanical parameters were analyzed by OpenSim. Lasso regression was performed to narrow down the biomechanical parameters that were related to pain and derive the mathematical model of the relationship. Therefore, many of the parameters of the obtained mathematical model were related to the lumbar spine and were consistent with areas that be related to lumbar spinal disc herniation.

N-Acetyl Cysteine as an Add-on Therapy is Useful in Treating Acute Lumbar Radiculopathy Caused by Disc Herniation: Results of a Randomized, Controlled Clinical Trial

BACKGROUND

Available experimental and clinical evidence indicates that N-Acetyl cysteine (NAC) may have an analgesic role in specific pain conditions, particularly neuropathic pain. Thus, we hypothesized that NAC supplementation might be also helpful in decreasing pain and improving pain-related disability in patients with acute radiculopathy. We designed this study to investigate the potential use of NAC-adjunctive treatment to Nonsteroidal Anti- Inflammatory Drugs (NSAIDs) in patients with acute radiculopathy secondary to lumbar intervertebral disc herniation.

METHODS

Sixty-two patients diagnosed with acute lumbar radiculopathy associated with disc herniation were randomly allocated to the NAC or the placebo groups. Besides naproxen at a dose of 500 mg twice a day, participants based on their allocation group started with NAC or matched placebo at a dose of 600 mg twice a day for eight weeks. The pain severity, measured by the Visual Analog Scale (VAS), and pain-related disability measured by the Oswestry Disability Index (ODI) were measured at baseline and weeks 2, 4, and 8 of treatment. Global improvement of symptoms rated by Patient and Clinical Global Impressions of Change (PGIC and CGIC) was also recorded at the end of week 8. All analyses were conducted on an Intentionto- Treat (ITT) analysis data set.

RESULTS

A comparison of the VAS and ODI scores at weeks 2 and 4 of the treatment between the two groups did not show a significant difference. In contrast, from week 4 to week 8, we noticed a significantly greater reduction in the mean VAS and ODI scores in the NAC group compared to the placebo group (p-value <0.001 for both variables). In parallel with these results, also, more NAC-treated than placebo-treated patients achieved treatment success defined as ''very much'' or ''much improved'' on CGIC and PGIC scales, and these differences reached a significant level (p-value = .011 and p-value = .043).

CONCLUSIONS

This study suggested that NAC might be a relevant candidate for adjunct therapy in managing acute lumbar radiculopathy. Additional clinical trials are needed to validate these findings.

Reliability and validity of Turkish versions of Sciatica Bothersomeness and Sciatica Frequency Index

BACKGROUND

The Sciatica Frequency Index (SFI) and Sciatica Bothersomeness Index (SBI) are two separate indices scored for both the bothersomeness and frequency of radiating symptoms. There is no Turkish scale used specifically for sciatica.

OBJECTIVE

We aimed to translate SBI and SBI in Turkish and investigate the reliability and validity of these indices.

METHODS

A total of 80 patients with lumbar disc herniation (LDH) were prospectively included. Construct validity was assessed by comparing the SBI and SFI with subscales of Short Form 36 (SF-36), back and leg Numeric Rating Scale (NRS) and Roland Morris Disability Questionnaire (RMDQ). Reliability was assessed by internal consistency (Cronbach's alpha) and test-retest reliability.

RESULTS

A weak correlation was found between SBI/SFI, back NRS and SF-36 subgroups while a moderate correlation was found between SBI/SFI, RMDQ and leg NRS. The SBI and SFI had high internal consistency measured by Cronbach's alpha (0.76 and 0.73). Test-retest reliability of the SBI and SFI were 0.95 (95% CI: 0.92-0.97) and 0.95 (95% CI: 0.92-0.97) respectively, indicating excellent reliability.

CONCLUSION

The Turkish versions of the SFI/SBI are a valid and reliable tool supporting their usability in patients with LDH-induced sciatica.

[Study on diagnosis and treatment of lumbar disc herniation and related factors based on dynamic electromyography]

OBJECTIVE

To analyze dynamic electromyography characteristics and related factors of lumbar back muscle activity in patients with lumbar disc herniation, and to clarify the clinical significance of dynamic electromyography in the diagnosis and treatment of patients with lumbar disc herniation(LDH).

METHODS

From September 2014 to March 2021, 40 patients with lumbar disc herniation(LDH group) were detected by surface electromyography telemeter. There were 14 males and 26 females, aged from 20 to 61 years old, with an average of(40.68±10.56) years old, the course of illness was from 1 to 120 months, with an average of (17.75±27.56) months. In addition, 12 normal people were recruited as the control group. There were 2 males and 10 females. The age ranged from 24 to 53 years old, with an average of(36.50±10.30) years old. All subjects were subjected to dynamic electromyographic tests of the subthoracic erector spinae, lumbar erector spinae, and multifidus muscles during static standing and trunk flexion and extension. Compare the EMG activity data (average EMG amplitude, median frequency, original EMG graph) of the tested muscles between patients with lumbar disc herniation and normal people, and analyze the correlation between the general data of patients with lumbar disc herniation and the tested muscle EMG data.

RESULTS

When standing still, the average electromyographic amplitude of the erector spinal muscle of the right and left thoracic segments of the subjects in the LDH group increased compared with the control group, and the difference was significant(P<0.05). In the trunk flexion and extension, the average electromyographic amplitude of the right and left proximal thoracic erector spinae, the right left lumbar erector spinae, and the right left multifidus muscle of the subjects in the LDH group are all larger than the control group, and the difference was significant(P<0.05). In the trunk flexion and extension, the median frequencies of the right left proximal thoracic erector spinae、the right left lumbar erector spinae, and the right left multifidus muscle of the subjects in the LDH group were all larger than the normal control group, and the difference was significant (P<0.05). During trunk flexion and extension, the original electromyographic patterns of subjects in the LDH group were significantly different from those in the control group. During the maintenance of the maximum trunk flexion of the subjects in the LDH group, there was a high level of electromyographic activity of the lower back muscles, and the electromyographic static signals that should appear regularly in the original signal could not be distinguished. When the trunk was flexed and extended, had gender, age, weight and height of subjects in the LDH group were not significantly correlated with the average EMG amplitude and median frequency of bilateral proximal thoracic, lumbar erector spinae and bilateral multifidus muscles respectively(P>0.05).

CONCLUSION

Patients with lumbar disc herniation have characteristic surface EMG changes in the back muscles that are different from those of normal people. These features can more objectively reflect the patient's muscle condition and can be an effective indicator for the diagnosis and treatment effect evaluation of patients with lumbar disc herniation. It can be seen that surface electromyography is not only a detection method, it can be considered in the routine diagnosis and treatment plan of LDH to guide clinical work.

Perimedullary arteriovenous fistula was misdiagnosed as intervertebral disc herniation: A case report

INTRODUCTION

Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction.

PATIENT CONCERNS

The patient was a 58-year-old male who presented with both lower limbs numb with intermittent walking weakness, obvious at both ankles, and no obvious inducing and relieving factors. The local hospital considered the diagnosis of lumbar disc herniation after MR examination; he was treated with lumbar fixation and fusion.

DIAGNOSIS

After admission, a ce-MRA examination showed that the left spinal artery at the T10 level showed small branch blood vessels in the local area. The distal end was unclear, which seemed to be connected with the drainage vein of the spinal cord. The digital subtraction angiography (DSA) result indicated that the left intercostal artery of T10 sent the Adamkiewicz artery down to the level of L4, and an arteriovenous fistula was seen. The fistula was located at the lower edge of the L4 level and then drained to the upper premedullary vein to the level of T4 after a short descending. It was finally diagnosed as a perimedullary arteriovenous fistula.

INTERVENTIONS

It was cured by cutting the arteriovenous fistula in the spinal canal by indocyanine green-assisted angiography.

OUTCOMES

we report a case of PMAVFS misdiagnosed as lumbar disc herniation with resection and internal fixation. In our hospital, the final diagnosis was a perimedullary arteriovenous fistula, which was cured by cutting off the arteriovenous fistula within the spinal canthus.

CONCLUSION

Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction. It is hoped that this can provide warnings to more neurosurgeons and reduce the occurrence of misdiagnosis.

Study on Intelligent Traditional Chinese Medicine Fumigation for Treating Lumbar Intervertebral Disc Herniation Based on Medical Big Data Mining

With the improvement of the traditional Chinese medicine fumigation (TCMF), more and more people are studying lumbar intervertebral disc herniation (LIDH) by TCMF. In order to clarify the thermodynamic mechanism of TCMF to LIDH and provide a model reference for individualized diagnosis, the lower control system is compiled by the microprocessor, and the upper control system is compiled by computer technology of VB. In this new system, the medical information of patients is recorded in the databases by the upper control system, and clinical diagnosis and treatment experience are packaged in the lower control system. The simulation results and clinical examples show that the new control system of TCMF has better clinical efficacy for LIDH patients, which not only effectively improves the pain symptoms of LIDH patients but is also economical and safe.

Unusual presentations of thoracic disc herniation treated by thoracic epidural block: Case reports

RATIONALE

Herniation of the thoracic intervertebral disc (HTD) is a rare disease that accounts for <1% of all disc herniations. Physicians may make diagnostic errors due to the variable clinical features and limited experience of HTD. In this report, we present 2 unusual cases of HTD.

PATIENT CONCERNS

A 72-year-old woman (case 1) visited our pain clinic because of chronic abdominal discomfort with visible bulging on the left side. Atrophy of the abdominal wall muscle and quadratus lumborum was observed. The therapeutic effect of interfascial plane block to exclude the possibility of truncal neuropathy following muscular atrophy was temporary. The other patient, a 75-year-old man (case 2) complained of aggravation of previously diagnosed postherpetic neuralgia. An extension of the previously symptomatic area of the forward upper dermatome was observed. Radiofrequency treatment on the symptomatic dorsal root ganglion failed to relieve symptoms.

DIAGNOSES

Two patients underwent magnetic resonance imaging of the spine for further evaluation. The patients were diagnosed with multilevel HTD and foraminal herniated disc, compatible with their symptoms and without myelopathy.

INTERVENTIONS

Two patients were conservatively treated with a fluoroscopy-guided transforaminal epidural block.

OUTCOMES

The 2 patients experienced significant pain reduction up to 50% on a numeric rating scale after repeated treatment.

LESSONS

Multilevel HTD of the mid- to lower-thoracic spine may present as abdominal bulging with atrophy of the abdominal wall muscles. We also report another case of concomitant symptomatic thoracic radiculopathy from HTD and postherpetic neuralgia at the adjacent level. Thoracic transforaminal epidural block may be considered a conservative therapeutic approach for HTD.

Diagnostic approach, therapeutic strategies, and surgical indications in intradural thoracic disc herniation associated with CSF leak, intracranial hypotension, and CNS superficial siderosis

Background and purpose

Intradural disc herniation (IDH) can manifest with radicular or medullary syndrome. In about 15% of cases, IDH may be responsible, through a dural laceration, for a CSF leak, determining spontaneous intracranial hypotension (SIH) and CNS superficial siderosis (CNSss). This paper attempts to present an overview on IDH as the cause for both CSF leak, and subsequent SIH, and CNSss, and to describe a peculiar clinical and neuroradiological scenario related to this condition.

Methods

A search on the PUBMED database was performed. Although the investigation did not rigorously follow the criteria for a systematic review (we consider only articles about thoracic IDH), nonetheless, the best quality evidence was pursued. Furthermore, an illustrative case was presented.

Results

A 69-year-old woman was referred to our hospital for slowly progressive gait disturbances and hearing impairment. Brain imaging revealed diffuse bilateral supratentorial and infratentorial superficial siderosis, mostly of the cerebellum, the eighth cranial nerves, and the brainstem. Spinal imaging disclosed a posterior disc herniation determining a dural tear at D6-D7. Lumbar puncture revealed low opening pressure and hemorrhagic CSF with siderophages. A posterior transdural herniectomy and dural sealing determined a stabilization of hearing and a significant improvement in both gait and balance.

Conclusions

The diagnostic workup of CNSss with suspected CNS leak demands whole neuraxis imaging, especially in cases presenting SIH or myelopathic symptoms. This may avoid delays in detection of IDH and spinal dural leaks. The different forms of treatment available depend on the type and severity of the clinical picture.

[Guideline for diagnosis, treatment and rehabilitation of lumbar disc herniation]

Recent years,the incidence of lumbar disc herniation is increasing annually,trending to younger age.There is a lack of clinical guideline for the management of lumbar disc herniation.Considering various problems in the management of lumbar disc herniation under different occasions,based on a systematic literature review,Basic Research and Transformation Society,Professional Committee of Spine and Spinal Cord organized experts to make this consensus jointly.This guideline aims to provide a standardized management of lumbar disc herniation with scientific principle and practical feasibility.Evidence-based medicine,and scientific suggestions are put forward specially for the management of lumbar disc herniation to standardize the diagnosis and treatment,promote the prognosis as well as improve the quality of life of patients.

Preoperative Transvenous Liquid Embolization for a Symptomatic Lumbar Spinal Epidural Varix Mimicking Radiculopathy

BACKGROUND

Symptomatic spinal epidural veins (SEV) are a rare cause of neurologic dysfunction. Treatment is centered upon addressing the underlying venous pathology to relieve mechanical compression of the neurologic structures. However, open surgical ligation is often associated with considerable blood loss.

OBJECTIVE

We discuss a unique case of a large symptomatic epidural venous varix and potential treatment strategy.

METHODS AND MATERIALS

A 15-year-old female presented with a 1-year history of left L5 radicular pain and weakness. Lumbar MRI demonstrated a central L5/S1 herniated disc and a large extradural anomalous SEV compressing the exiting left L5 nerve root at the L5/S1 neuroformina. The SEV was treated using a transvenous liquid embolic agent providing symptomatic relief. At 16-months follow-up, she reported recurrent symptoms. She ultimately underwent a left L5/S1 MIS decompression without complication.

CONCLUSION

Transvenous liquid embolization of large symptomatic SEV may provide temporary neurologic relief and decrease morbidity associated with open surgical treatment options.

Team Approach: Management of an Acute L4-L5 Disc Herniation

»

Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life.

»

The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation.

»

Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy.

»

The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers.

»

This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

[Intervertebral disc-related occupational diseases of the lumbar and cervical spines]

Intervertebral disc-related diseases of the cervical and lumbar spine are considered to be occupational diseases, if the occupational and medical prerequisites are fulfilled and the causal connection between the prerequisites is likely. The working conditions include occupational burdens with long-term lifting and carrying of heavy loads or long-term activities in an extremely bent position of the torso, long-term carrying of heavy loads on the shoulders and long-term effects of whole-body vibration in a sitting position. A medical prerequisite is fulfilled by a damage pattern with chronic lower back or neck pain and damage of the cervical or lumbar vertebrae in a conform manner.In the legal assessment the occupational conditions are examined by the preventive services of the statutory accident insurance and the medical conditions by the medical expert. Furthermore, the medical expert examines the causal connection between the fulfilled prerequisites, whereby the temporal connection (reaching the minimum load dose before realization of the conform damage pattern) and by exclusion of other competing factors are essential. As of 1 January 2021 the necessity to quit the burdening occupation has been omitted by law.

One-year clinical outcome after full-endoscopic interlaminar lumbar discectomy for isthmic lumbar spondylolisthesis: Two case reports

RATIONALE

For isthmic lumbar spondylolisthesis (ILS) associated with the removal of herniation, it remains challenging to perform less invasive and minimally disruptive procedures. Good results could potentially be obtained by further preserving the posterior elements in full-endoscopic lumbar discectomy (FESS), which is less invasive than microenscopic surgery (MES).

PATIENT CONCERNS

One patient complained of left leg pain, and another patient complained of right leg pain and low back pain.

DIAGNOSES

Two patients with ILS and Meyerding Grade 1 lumbar spondylolisthesis.

INTERVENTIONS

We performed a full-endoscopic lumbar discectomy via the interlaminar space (FESS-IL) for L5/S1 lumbar disc herniation (LDH) accompanied by isthmic lumbar spondylolisthesis. FESS-IL was performed in 2 patients with radiculopathy caused by different types of LDH using a full endoscopic system with a 4.1 mm working channel and 6.9 mm outer diameter. A 3.5-mm diameter high-speed drill was used in one patient for an upward-migrated LDH in the inner-rim of the infravertebral border. The other patient underwent minimal resection without bone resection.

OUTCOMES

The one-year clinical outcome included confirmation of pain relief and evacuation of migrated LDH on magnetic resonance imaging in all patients. There was no progression of slippage on radiography. The mean operative time was 82 min, and no complication was observed. The one-year clinical outcome demonstrated sufficient pain relief.

LESSONS THE Y

ear postoperative outcome showed improvement. We believe that FESS-IL is a viable alternative operative approach for LDH for ILS.

A convenient and stable vertebrae instance segmentation method for transforaminal endoscopic surgery planning

PURPOSE

Transforaminal endoscopic surgery (TES) is effective for treatment of intervertebral disc-related diseases. To avoid injury to the critical structures, preoperative planning is required to find a safe working channel. Therefore, accurate patient-specific vertebral segmentation is important. The purpose of this work is to develop a convenient, stable and feasible lumbar vertebrae segmentation method for TES planning.

METHODS

Based on the chain structure of the spine, an interactive dual-output vertebrae instance segmentation network was designed to segment the specific vertebrae in CT images. First, an initialization locator module was set up to provide an initial locating box. Then the dual-output network was designed to segment two adjacent vertebrae inside the locating box. Finally, iteration was performed until all the expected vertebrae were segmented.

RESULTS

Verification on reconstructed public dataset showed that the vertebral segmentation Dice coefficient was 96.8 ± 1.2% and average surface distance (ASD) was 0.25 ± 0.10 mm. For intervertebral foramen (IVF) region, the Dice coefficient was 96.1 ± 1.5% and ASD was 0.29 ± 0.10 mm. For IVF forming region, the Dice coefficient was 93.4 ± 3.1% and ASD was 0.28 ± 0.13 mm. The evaluation on private dataset showed that more than 90% of the segmentation were suitable for TES planning. For IVF region, the Dice coefficient was 94.4 ± 1.8% and ASD was 0.71 ± 0.49 mm.

CONCLUSION

This work provides a convenient, stable and feasible segmentation method for lumbar vertebrae, IVF region, and IVF forming region. The segmentation can meet the requirement for TES planning.

Axial Low Back Pain in Elite Athletes

Back pain in sport is a common complaint and seen by athletes, trainers, and treating physicians. Although there are a multitude of pain generators, mechanical sources are most common. Certain sports can lead to increased mechanical and axial loading, such as competitive weightlifting and football. Common mechanical causes of pain include disk herniation and spondylolysis. Patients typically respond to early identification and conservative treatment. In others, surgical intervention is required to provide stability and prevent long-term sequelae.

Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH).

SUMMARY OF BACKGROUND DATA

The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM.

METHODS

Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months).

RESULTS

We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24).

CONCLUSION

There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.

Greater Socioeconomic Disadvantage Is Associated with Worse Symptom Severity at Initial Presentation in Patients Seeking Care for Lumbar Disc Herniation

STUDY DESIGN

Retrospective, observational study.

OBJECTIVE

To determine the association of patient socioeconomic disadvantage, insurance type, and other characteristics on presenting symptom severity in patients with isolated lumbar disc herniation.

SUMMARY OF BACKGROUND DATA

Little is known of the impact of socioeconomic disadvantage and other patient characteristics on the level of self-reported symptom severity when patients first seek care for lumbar disc herniation.

METHODS

Between April 2015 and December 2018, 734 patients newly presenting for isolated lumbar disc herniation who completed the Patient-Reported Outcomes Measurement Information System Physical Function (PF), Pain Interference (PI), and Depression Computer Adaptive Tests (CATs) were identified. Socioeconomic disadvantage was determined using the Area Deprivation Index, a validated measure of socioeconomic disadvantage at the census block group level (0-100, 100 = highest socioeconomic disadvantage). Bivariate analyses were used. Multivariable linear regression was used to determine if there was an association between socioeconomic disadvantage, insurance type, and other patient factors and presenting patient-reported health status.

RESULTS

Significant differences in age, insurance type, self-reported race, marital status, and county of residence were appreciated when comparing patient characteristics by socioeconomic disadvantage levels (all comparisons, P < 0.01). In addition, significant differences in age, insurance type, marital status, and county of residence were appreciated when comparing patient characteristics by self-reported race (all comparisons, P < 0.01). Being in the most socioeconomically disadvantaged cohort was associated with worse presenting Patient-Reported Outcomes Measurement Information System scores (Physical Function: β = -3.27 (95% confidence interval [CI]: -4.89 to -1.45), P < 0.001; Pain Interference: β = 3.20 (95% CI: 1.58-4.83), P < 0.001; Depression: β = 3.31 (95% CI: 1.08-5.55), P = 0.004.

CONCLUSION

The most socioeconomically disadvantaged patients with symptomatic lumbar disc herniations present with worse functional limitations, pain levels, and depressive symptoms as compared to patients from the least socioeconomically disadvantaged cohort when accounting for other key patient factors.Level of Evidence: 3.

Pinprick and Light Touch Are Adequate to Establish Sensory Dysfunction in Patients with Lumbar Radicular Pain and Disc Herniation

BACKGROUND

The frequency with which sensory disturbances occur in patients with radicular leg pain and disc herniation is not well known, and the efficacy of tests to identify such changes are not firmly established. The presence of sensory disturbances is a key sign of nerve root involvement and may contribute to the diagnosis of a lumbar disc herniation, identify patients for referral to spinal imaging and surgery, and improve disease classification.

QUESTIONS/PURPOSES

In this study, we sought: (1) to determine the frequency with which abnormal sensory findings occur in patients with lumbar disc herniation-related radicular pain, using a standard neurological sensory examination; (2) to determine what particular standard sensory test or combination of tests is most effective in establishing sensory dysfunction; and (3) to determine whether a more detailed in-depth sensory examination results in more patients being identified as having abnormal sensory findings.

METHODS

Between October 2013 and April 2016, 115 patients aged 18 to 65 years referred to secondary health care with radicular leg pain and disc herniation were considered potentially eligible for inclusion in the study. Based on these inclusion criteria, 79% (91) were found eligible. Ten percent (11) were excluded because of other illness that interfered with the study purpose, 3% (3) because of cauda equina syndrome, 2% (2) because of spinal stenosis, 2% (2) because of prior surgery at the same disc level, and 2% (2) because of poor Norwegian language skills. Three percent (4) of the patients did not want to participate in the study. Of the 91 eligible patients, 56% (51) consented to undergo a comprehensive clinical examination and were used for analysis here. The sample for the purposes of the present study was predetermined at 50. These patients were first examined by a standard procedure, including sensory assessment of light touch, pinprick, vibration, and warmth and cold over the back and legs. Second, an in-depth semiquantitative sensory testing procedure was performed in the main pain area to assess sensory dysfunction and improve the detection of potential positive sensory signs, or sensory gain of function more precisely. Sensory loss was defined as sensations experienced as distinctly reduced in the painful side compared with the contralateral reference side. In contrast, sensory gain was defined as sensations experienced as abnormally strong, unpleasant, or painful and distinctly stronger than the contralateral side. Ambiguous test results were coded as a normal response to avoid inflating the findings. The proportions of abnormal findings were calculated for each sensory modality and for all combinations of the standard examination tests.

RESULTS

The standard examination identified at least one abnormal finding in 88% (45 of 51) of patients. Sensory loss was present in 80% (41), while sensory gain was present in 35% (18). The combination of pinprick and light touch identified all patients who were classified as having abnormal findings by the full standard examination. The semiquantitative procedure identified an additional three patients with an abnormal finding.

CONCLUSION

We suggest that the combination of pinprick and light touch assessment is an adequate minimal approach for diagnostic and classification purposes in patients with lumbar radicular pain.

LEVEL OF EVIDENCE

Level I, diagnostic study.

Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States

BACKGROUND

There is a lack of consensus for optimal management of patients with foot drop due to acute lumbar disc herniation (LDH) with lumbar radiculopathy (LR), which is a clinical scenario that may be encountered by physical therapists. Consequently, it is important to explore physical therapists' referral practice patterns for surgical consult. Currently, physical therapist referral patterns for surgical consult in this patient population are unknown.

OBJECTIVES

To describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to suspected acute LDH with LR.

DESIGN

Cross-sectional descriptive research design using an electronic, internet-based survey that utilized two clinical vignettes.

METHOD

An electronic survey was developed by an expert peer review panel. Survey participants were licensed physical therapists in the United States and members of the Orthopedic Section of the American Physical Therapy Association.

RESULTS

Of the individuals receiving the survey invitation, 2172 completed the survey. Depending on the severity of foot drop, 34-61% were likely to refer for immediate neurosurgical consult. Presence of imaging to confirm suspected clinical diagnosis slightly affected the likelihood of referral (4-12% increase) for immediate neurosurgical consult.

CONCLUSION

In patients with foot drop due to suspected acute LDH with LR, this study found that physical therapist referral patterns for immediate neurosurgical consult varied and are likely influenced by the severity of weakness and availability of MRI findings. Further research regarding the optimal management of this patient population and potential reasons for variation in practice is warranted.

Does the presence of neuropathic pain affect the outcomes of the interlaminar epidural steroid injection for cervical disc herniation?: A prospective clinical study

Epidural steroid injections (ESI) are commonly performed for the treatment of chronic cervical disc herniation (CDH). Although they are considered to be effective for both nociceptive and neuropathic types of pain, there is a lack of data regarding the impact of neuropathic pain (NP) and nociceptive pain components on treatment outcomes. The aim of this study is to compare the effectiveness of interlaminar epidural steroid injection (ILESI) between patients with predominantly NP and nociceptive pain due to CDH.Sixty five participants were initially included in the study and assessed by numeric rating scale (NRS), neck pain and disability scale (NPDS), short form-12 (SF-12), and self-reported Leeds assessment of neuropathic symptoms and signs (S-LANSS) pain scale at baseline and 1 month, 3 months, 6 months after ILESI.All patients were evaluated at 1st month and 3rd month follow-up periods while 54 of patients achieved to complete 6th month follow-up. There were significant improvements in all outcome measures for all time periods when compared with the pre-intervention scores. At baseline 24 (36.9%) of patients had predominantly NP in accordance with S-LANSS pain scale. The ratio of NP predominant patients reduced to 7.6% at 1st month, 12.3% at 3rd month, and 12.9% at 6th month with a significant difference for each follow-up period when compared with the baseline. Although all NRS and NPDS scores at baseline were significantly higher in patients with NP, improvement was significant at all follow-up periods in both groups. Minimal clinically important change in NRS was observed in >75% of patients at 1st, 3rd, and 6th month in both groups.The results of this study showed that NP is present in one-third of the patients suffering from neck and radiating arm pain due to CDH and cervical ILESI is an effective treatment approach for both neuropathic and nociceptive components of pain.Clinical Trials Registration Number: NCT04235478.

Percutaneous cervical coblation as therapeutic technique in the treatment of algo-dysfunctional pain of discal herniation

OBJECTIVE

To confirm the validity of coblation nucleoplasty in reduction of cervical discogenic nature.

STUDY DESIGN

In a monocentric prospective clinical observational study recruiting 20 patients, treated with percutaneous coblation for cervical discogenic pain in 16 months in our hospital, we have clinically evaluated 18 patients. The pain was scored with the Visual Analogic Scale (VAS) in a pre-procedural questionary, 3/4 monthly follow-up from treatment and, finally, in a long-term follow-up 2 years after procedure.

RESULTS

The mean pre-procedural VAS score was 7.9 ± 1.6 (95%-Confidence Interval 7.198-8.634), while the mean post-procedural score after 3-4 months has been 2.5 ± 3.1 (95%-Confidence Interval 1.089-3.965) and 2.5 ± 2.5 (95%-Confidence Interval 1.367-3.687) after 2 years. Among 18 patients, in the shortly post-treatment follow-up, nine had a complete pain relief, four had a > 50% VAS reduction, two hada < 50% VAS reduction, three did not have any variation of VAS; after 2 years, six patients had a total pain resolution, eight had a > 50% VAS reduction, two hada < 50% VAS reduction, two did not have any benefit. No peri- and post-procedural complication has been observed.

CONCLUSIONS

In a spite of a little sample, our results showed coblation as a valid therapeutic option to reduce cervical discogenic pain in medicine-refractory patients, as an alternative or a previous choice before a more invasive surgical treatment.

Examination of the regression model to quantify the degree of low back pain and lower limb symptoms in patients with lumbar disc herniation by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ)

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was created to evaluate specific treatment outcomes in terms of physical functioning, social ability, and mental health in patients with back pain-related diseases. In this study, we investigated whether the JOABPEQ could be used to construct a regression model to quantify low back pain and lower limb symptoms in patients with lumbar disc herniation (LDH). We reviewed 114 patients with LDH scheduled to undergo surgery at our hospital. We measured the degrees of 1) lower back pain, 2) lower limb pain, and 3) lower limb numbness using the visual analog scale before the surgery. All answers and physical function data were subjected to partial least squares regression analysis. The degrees of lower back and lower limb pain could be used as a regression model from the JOABPEQ and had a significant causal relationship with them. However, the degree of lower limb numbness could not be used for the same. Based on our results, the questions of the JOABPEQ can be used to multilaterally understand the degree of lower back pain and lower limb pain in patients with LDH. However, the degree of lower limb numbness has no causal relationship, so actual measurement is essential.

Histological demonstration of the gas precursor in a symptomatic L5-S1 disc herniation containing gas: A case report

Vacuum phenomenon is a commonly observed radiological entity in the degenerated intervertebral discs of the lumbar spine in the elderly population. The entity is frequently asymptomatic. Although disc herniation containing gas (DH-CoG) is commonly associated with the vacuum phenomenon, DH-CoG associated with clinical symptoms is a rare condition. There are very few reports which have histologically demonstrated the existence of the gas itself within DH-CoG. Herein, we report a rare case of a 65-year-old female with symptomatic DH-CoG at L5/S1. The patient was admitted to our hospital with a one-month history of pain in the left buttock and leg in addition to neurogenic claudication. Roentgenograms illustrated a degenerative lumbar spine with the vacuum phenomenon at the L5/S1 disc space. Computed tomography showed a round and low-density lesion within the spinal canal at left L5/S1. Additionally, a lesion characterized by an iso- and partially hypointense signal on T1 and hypointense signal on T2 was detected in magnetic resonance imaging (MRI) by the spin-echo method. The decision for posterior lumbar interbody fusion surgery using pedicle screws was made as the symptoms had not responded to the conservative treatment. After a degenerated prolapsed nucleus was carefully extracted, the specimen was sent to the laboratory for histopathological analysis. The prolapsed nucleus of DH-CoG histologically showed many small vacuoles containing degenerated mucopolysaccharides. The left leg pain drastically resolved on the first post-operative day, and no recurrence had been observed. Degenerated mucopolysaccharide may be a precursor of nitrogen or "the gas itself" in DH-CoG. Surgical intervention for DH-CoG should be considered if conservative treatment fails.

A Historical Review of Endoscopic Spinal Discectomy

As an essential component of minimally invasive spine surgery, endoscopic spine surgery (ESS) has continuously evolved and has been accepted as a practical procedure by the worldwide spine community. Especially for lumbar disc herniation (LDH), the percutaneous endoscopic or full-endoscopic discectomy technique has been scientifically proven through randomized controlled trials and meta-analyses to be a good alternative to open discectomy. The initial concept of endoscopic spine discectomy was concerned with indirect disc decompression using various instruments such as blind forceps, a nucleotome, laser, radiofrequency coblation, and some chemical agents. The main surgical field has been shifted from the intradiscal space to the epidural space. Precise and selective discectomy for extruded LDH in the epidural space under high-quality endoscopic visualization is now feasible. Furthermore, the medical applications of ESS is broadening to include spinal stenosis, segmental instability, infection, and even intradural lesions. In this review article, I describe the history of endoscopic spine discectomy and decompression techniques, as well as evolution of the paradigm. This history may help indicate the future of practical ESS.

Long-Term Outcomes of Epidurals with Lidocaine With or Without Steroids for Lumbar Disc Herniation and Spinal Stenosis: A Meta-Analysis

BACKGROUND

Previous meta-analyses examined only the short-term differences between lidocaine and steroids vs lidocaine alone in treating lumbar degenerative diseases. Long-term outcomes (1-2 years) in patients with lumbar disc herniation (LDH) and lumbar central spinal stenosis (LCSS) have not yet been systematically evaluated.

OBJECTIVE

The objective of our study was to assess quantitatively the difference in efficacy at 1 to 2 years between lidocaine alone vs lidocaine and steroids for the management of LDH or LCSS.

STUDY DESIGN

We conducted a meta-analysis.

METHODS

PubMed, EMBASE, and the Cochrane library were electronically searched up to July 22, 2016, for randomized controlled trials comparing lidocaine alone vs in combination with steroids for the treatment of LDH and LCSS. Effective pain relief (EPR), Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), opioid intake (OI), and total employed increased rate (TEIR) were the endpoints. Risk ratios (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated, and the pooled analysis was conducted using RevMan 5.2.

RESULTS

Seven trials were included. EPR was not significantly different at 1 and 2 years, with RR = 1.08 (95% CI, 0.90-1.30; P = .39) and RR = 1.04 (95% CI, 0.92-1.18; P = .51), respectively, in patients treated with lidocaine alone vs in combination with steroids. The NRS-11 was also similar at 1 and 2 years. ODI and OI were not significantly different at 1 and 2 years. A similar TEIR effect was also observed for the 2 treatments.

LIMITATIONS

This meta-analysis relied on a small sample size of trials. Significant heterogeneity among studies was observed. Several significant differences in terms of age of the patients were reported in one included trial.

CONCLUSION

This meta-analysis confirmed the similar effects associated with lidocaine alone vs in combination with steroids for the management of LDH and LCSS. Studies with longer follow-up periods are still recommended.

KEY WORDS

Effective pain relief, lidocaine, long-term, lumbar central spinal stenosis, lumbar disc herniation, Numeric Rating Scale, opioid intake, Oswestry Disability Index, steroids, total employed increased rate.

Clinical efficacy of targeted injection of drugs in combination with ozone in treatment of lumbar disc protrusion

To investigate the clinical efficacy of targeted injection of drugs surrounding the protruded lumbar disc in combination with the ozone in treatment of lumbar disc protrusion. Between January 2017 and January 2019, a total of 120 patients with lumbar disc protrusion were recruited in this study and divided into the control group and observation group, with 60 patients in each group. Patients in the control group received the ozone treatment, while those in the observation group additionally took the targeted injection of betamethasone surrounding the protruded lumbar disc. Following one month of treatment, we compared the short-term efficacy, joint range of motion in bending forward or backward of the lumbar disc, limb function, life quality and functional disturbance before and after treatment. In the observation group, the short-term effectiveness rate was higher than that in the control group (P<0.05), while after treatment, the joint range of motion in bending forward or backward of lumbar disc in the observation group was improved when comparing to the control group (P<0.05). After treatment, BI and Fugl-Meyer scale were all higher in the observation than those in the control group (P<0.05), with a lower Oswestry score (P<0.05). Targeted injection of betamethasone surrounding the protruded lumbar disc in combination with the ozone performs well in short-term efficacy, conducive to the improvement of the lumbar disc function and limb function and alleviation in function disturbance. Thus, this strategy is worthy of being promoted in clinical practice.

The effect of bone mineral density on development of Schmorl's nodes in young patients

OBJECTIVE

The aim of this study was to detect the relationship between the development of Schmorl's nodes (SNs) and bone mineral density (BMD) in young patients.

METHODS

Computerized tomography (CT) images of the thoracolumbar vertebral column were retrospectively examined by two experienced radiologists for SNs. The diagnostic criterion for SN was defined as a node size larger than one-third but not more than two-thirds of the relevant vertebral endplate. Considering the eligibility criteria, a total of 74 individuals (60 males and 14 females; mean age: 24.3 years; age range: 18-40 years) with SN at the thoracolumbar vertebrae were included in the patient group, and a total of 38 age- and gender-matched individuals (30 males and 8 females; mean age: 25 years) with no evidence of SN were included in the control group. All these individuals were younger than 40 years. In the patient group, SNs were assessed in terms of the distribution of the thoracolumbar vertebrae, the location of the upper and lower endplates, and the total number of lesions. In all individuals included in the study, BMD was measured from the axial CT sections by quantitative CT and then compared between the two groups.

RESULTS

The distribution of age and gender was comparable between the two groups (p=0.438). A total of 208 SNs were identified in the patient group. Of these, 92 (44%) were located at the thoracic vertebrae and 116 (56%) at the lumbar vertebrae. The mean BMD was 131.6 g/cm3 in the patient group and 140.7 g/cm3 in the control group (p=0.03). There was no significant relationship between the total number of SNs per patient and the mean BMD (p=0.156).

CONCLUSION

Evidence from this study revealed that low BMD may be a predisposing factor for the development of SNs in patients younger than 40 years.

LEVEL OF EVIDENCE

Level III, Diagnostic Study.

Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation

BACKGROUND

The purpose of our study is to compare the outcomes and effectiveness of MED vs OLD for lumbar disc herniation.

OBJECTIVES

To identify the functional outcomes in terms of ODI score, VAS score complications in terms of intraoperative blood loss, use of general anesthesia, and morbidity in terms of total hospital stay between MED and OLD.

METHODS

In our randomized prospective study we analyzed 60 patients with clinical signs and symptoms with 2 weeks of failed conservative treatment plus MRI or CT scan findings of lumbar disc herniation who underwent MED and OLD. The study was undertaken from November 2017 to January 2019 at Guangzhou Medical University of Second Affiliated Hospital, department of orthopedic surgery in spinal Unit, Guangzhou, China. Patients were divided into 2 groups i.e. who underwent MED group and the OLD group then we compared the preoperative and postoperative ODI and VAS score, duration of total hospital stay, intraoperative blood loss, and operation time.

RESULTS

We evaluated 60 patients. Among them, 30 underwent MED (15 female and 15 male) and 30 underwent OLD 14 male 16 female. Surgical and anesthesia time was significantly shorter, blood loss and hospital stay were significantly reduced in patients having MED than OLD (<0.005). The improvement in the ODI in both groups was clinically significant and statistically (P < .005) at postoperative 1st day (with greater improvement in the MED group), at 6 weeks (P > .005), month 6 (>0.005) statistically no significant. The clinical improvement was similar in both groups. VAS and ODI scores improved significantly postoperatively in both groups. However, the MED group was superior to the OLD group with less time in bed, shorter operation time, less blood loss which is clinically and statistically significant (P < .05).

CONCLUSIONS

The standard surgical treatment of lumbar disc herniation has been open discectomy but there has been a trend towards minimally invasive procedures. MED for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. The success rate of MED is about approximately 90%. Both methods are equally effective in relieving radicular pain. MED was superior in terms of total hospital stay, morbidity, and earlier return to work and anesthetic exposure, blood loss, intra-op time comparing to OLD. MED is a safe and effective alternative to conventional OLD for patients with lumbar disc herniation.

An unexpected etiology of lumbosciatica

Lumbosciatica is a frequent symptom. When it is hyperalgic and/or deficient, it requires urgent exploration and an eventual surgical procedure. In most of the cases, medullary lumbar (instead of medullary) MRI is required looking in the first place at an intervertebral disc herniation. Other etiologies are rare but must be kept in mind. We report a case of a 37-year-old man with left L5 hyperalgic and deficient lumbosciatica. The conclusion of the etiological research led to pseudoaneurysm of the internal iliac artery compressing the ipsilateral sciatic nerve. The patient was operated on with a good clinical course.

Cauda equina syndrome without motor dysfunction following lumbar spinal stenosis surgery: A case report

RATIONALE

Cauda equina syndrome (CES) refers to a group of symptoms that occur when the nerves in the cauda equina become compressed or damaged. The most common etiology of CES is lumbar intervertebral disc herniation, but CES following lumbar spinal surgery is rare, especially without motor dysfunction. Herein, we illustrate a case of CES that developed as a complication of spinal surgery and to deduce its possible underlying cause.

PATIENT CONCERNS

A 46-year-old man experienced lumbago, bilateral shank pain, and numbness with neurogenic claudication for 3 years due to degenerative lumbar disc herniation and spinal cord stenosis. After a thorough examination to diagnose lumbar spinal stenosis, the patient underwent bilateral decompression and pedicle screw system internal fixation with bone graft. Postoperatively, the patient showed regained strength in his bilateral shanks, and he did not complain of lumbago and shank pain, but CES occurred, which manifested as underpants-type numbness in the perineum without bladder, anal, and motor dysfunction.

DIAGNOSES

CES as a postoperative complication of lumbar stenosis.

INTERVENTIONS

The patient underwent bilateral laminectomies, partial facetectomies, and pedicle screw system internal fixation and fusion with bone graft. Postoperatively, the patient performed adequate rehabilitation exercises and was expected to recover spontaneously.

OUTCOMES

The symptoms of pain and claudication resolved after 3 weeks in the hospital, but an underpants-type hypoesthesia in the perineum without motor dysfunction developed. The patient experienced full recovery from CES 6 months after surgery.

LESSONS

CES as a complication of lumbar spinal surgery is very rare. Excessive sensitivity to the traction of the dural sac was, in our opinion, the most possible cause of postoperative CES in this case. When the nerve root is pulled intraoperatively, it is best not to cross the central line of the spinous process. The plane of the nerve retractor needs to be parallel to the dural sac at the pulling point to reduce the formation of shear force. Most importantly, gentle maneuver is required because sensitivity to the traction of the dural sac varies individually.

Traumatic lumbar disc herniation mimicking epidural hematoma: A case report and literature review

RATIONALE

We report a rare case of traumatic lumbar disc herniation mimicking epidural hematoma.

PATIENT CONCERNS

A 39-year old man presented with acute bilateral leg and back pain, following a crushing injury caused by a crane collapse.

DIAGNOSIS

A computed tomography scan revealed multiple compression fractures of the thoracolumbar spine, including a burst fracture of the L4 vertebral body. Magnetic resonance imaging (MRI) showed an epidural mass, extending longitudinally and causing dural sac compression behind the L3 vertebra. The mass had isosignal intensity on T1-weighted imaging and showed mixed high and low signals on T2-weighted imaging. On the basis of the patient's clinical history and imaging findings, our provisional diagnosis was an epidural hematoma following major trauma.

INTERVENTIONS

An emergency L3 laminectomy was performed with percutaneous screw fixation of L3-5. Intraoperatively, 3 large herniated disc fragments were found at L3 with no evidence of hematoma.

OUTCOMES

The patient recovered normal motor function after surgery. At the last follow-up, 3 years after surgery, there was no residual neurological deficit apart from intermittent lower back pain.

LESSONS

In cases where MRI findings reveal an epidural lesion with a longitudinal shape, similar to an epidural hematoma, with mixed signal intensity on T2-weighted images and high peripheral signal intensity on T1-weighted images, traumatic disc herniation should be included in the differential diagnosis.

Middle cluneal nerve entrapment mimics sacroiliac joint pain

BACKGROUND

Sacroiliac joint (SIJ)-related pain is associated with low back- and buttock pain and the SIJ score is diagnostically useful because it helps to differentiate between SIJ-related pain and pain due to other factors such as lumbar disc herniation and lumbar spinal canal stenosis. Middle cluneal nerve (MCN) entrapment (MCN-E) can produce pain involving the lower back and buttocks. Therefore, the origin of the pain must be identified. We successfully treated patients with a high SIJ score whose pain was attributable to MCN-E.

METHODS

Between August 2016 and June 2017, we treated 40 patients with non-specific low back pain. Among them, 18 (45%) presented with a positive SIJ score. Although SIJ treatment was unsuccessful in 4 of these patients, they responded to MCN-E treatment.

RESULTS

All 4 patients reported tenderness at the site of the sacrotuberous ligament (STL); 3 were positive for the one-finger test and experienced pain while sitting in a chair. The effect of SIJ block was inadequate in the 4 patients. As they reported severe pain at the trigger point in the area of the MCN, we performed MCN blockage. It resulted in pain control. However, in 1 patient, the effect of MCN block was transient and required MCN neurolysis. At the last visit, our patients' symptoms were significantly improved; their average numerical rating scale score fell from 8.3 to 1.0, their Roland-Morris Disability Questionnaire score fell from 12.8 to 0.3, and their average Japanese Orthopaedic Association score rose from 12.5 to 19.5.

CONCLUSIONS

In patients with suspected SIJ-related pain, the presence of MCN-E must be considered when the effect of SIJ block is unsatisfactory.

Percutaneous transforaminal endoscopic decompression in the treatment of spinal metastases: A case report

RATIONALE

Spinal metastases are always associated with specific pain of back and limbs caused by nerve root compression. Although percutaneous endoscopic lumbar discectomy (PELD) has been widely performed on patients with back and radicular pain originating from lumbar disc herniation, this minimally invasive surgery is rarely used for the treatment of spinal metastases.

PATIENT CONCERNS

A 71-year-old woman with colon cancer and a known L3 vertebral body metastasis presented with significant progressive pain of low back and limbs.

DIAGNOSES

Magnetic resonance imaging (MRI) showed the L3 vertebral body had been involved by osteolytic vertebral metastasis, which extended into spinal canal and compressed the dural sac and nerve root.

INTERVENTIONS

The patient was treated with percutaneous transforaminal endoscopic decompression and palliative resection of metastases was performed twice on both sides, respectively. After the minimally invasive procedure, the decompression of the dural sac and nerve root was ideal.

OUTCOMES

No complications during the procedure were reported. The minimally invasive surgery resulted in prompt and permanent pain relief until the patient died 6 months later.

LESSONS

Percutaneous transforaminal endoscopic decompression could be an appropriate treatment option for the patients who suffer neurologic deficits that result from the spinal metastases.

An Early Disc Herniation Identification System for Advancement in the Standard Medical Screening Procedure Based on Bayes Theorem

The aim of this research was to analyze objectively the process of disc herniation identification using Bayes Theorem. One of the symptoms of discus hernia is muscle weakness on the foot that is caused by displaced discs in the space of two vertebrae. This fact is used by experts in initial diagnosis of herniated discs and we used it to create non-invasive platform for the same purposes by measuring force values from four sensors placed on both feet (first, second, and fourth metatarsal head as well as the heel). Dataset consisted of several minute force recordings of 56 subjects with discus hernia and 15 healthy individuals during normal standing, standing on forefeet and heels. The subjects were diagnosed by a specialist with either L4/L5 or L5/S1 discus hernia. Collected recordings were processed in several steps including filtering, extraction of forefeet and heel recordings, classification of average values for forefeet, and heel sensors to the groups with or without foot muscle weakness. Application of Bayes Theorem on the attributes of interest showed average 78.3% accuracy with 62.6% sensitivity and 80.9% specificity, while application of naive Bayes Network showed average 83.1% accuracy with 57.6% sensitivity and 88.2% specificity. Very weak or no correlation was observed between gender and disc hernia diagnosis (or obesity type and disc hernia diagnosis). Obtained results show that this method can be used in initial screening of patients and be a supportive tool to doctors to send the same patients for further examination.

Spontaneous regression of herniated nucleus pulposus: The clinical findings of 76 patients

Lumbar disc hernia is common disease, affecting about 5% of the population. Many studies to date reported regression of disc herniation without surgical intervention.Medical records of the patients who applied to the spine clinic in an outpatient setting were retrospectively reviewed. Age, sex, radiological findings, neurological examinations, and medical treatments of the patients were evaluated.Male patients constituted 52.6% of the cases (n = 40) and 47.4% (n = 36) were female. The ages of the patients ranged from 25 to 82 years, with a mean of 48.5 ± 12.1 years. Visual analog scale (VAS) measurements ranged from 0 to 8 and the mean was determined as 2.65 ± 1.98. The VAS score of pain severity of 12 (15.78%) cases was 0, VAS score of 39 (51.31%) cases was 1 to 3, VAS score of 20 (26.31%) cases was 4 to 6, VAS score of 5 (6.57%) cases was 7 to 10. Eighteen (23.68%) of the cases underwent neuropathic pain treatment for more than 6 months. Fifteen (19.7%) patients also developed permanent motor deficits.Findings of our study show that there was no direct association between radiological improvement and clinical improvement. Indication for surgery still existed in a high number of patients, substantial of which developed permanent motor deficits. Current results suggest that we need to advise our patients in favor of early surgery as soon as indication for surgery is established upon neurological and radiological examination.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Combining YESS and TESSYS techniques during percutaneous transforaminal endoscopic discectomy for multilevel lumbar disc herniation

The authors retrospectively characterized the clinical outcomes of combining the Yeung endoscopic spine system (YESS) and transforaminal endoscopic surgical system (TESSYS) techniques during percutaneous transforaminal endoscopic discectomy (PTED) to treat multilevel lumbar disc herniation.PTED using both YESS and TESSYS was performed on 52 patients with multilevel lumbar disc herniations who had shown no apparent response to previous conservative treatments. Postsurgical follow-ups were conducted at weeks 1, 26, and 48. Patients' preoperative and postoperative performances were assessed by modified MacNab classification, Japanese Orthopedic Association (JOA) scores, Oswestry disability index (ODI), and visual analog scale (VAS), and compared with 34 and 45 patients who were treated only by YESS and TESSYS, respectively.The postsurgery surgeon-performed assessment showed satisfactory results in 98% of the YESS + TESSYS-treated cases. The average operative time was 116 ± 23 minutes, intraoperative bleeding was 19 ± 12 mL, and bed stay was 3 days. No complications occurred, including infection, nerve injury, or spinal canal hematoma. One week after surgery, the modified MacNab classifications of the patients were excellent in 45, good in 6, fair in 1, and poor in 0 (98% were excellent or good). JOA, ODI, and VAS scores for low back pain significantly improved relative to the preoperative assessment (P < .01) and had remained stable at 26 and 48 weeks.PTED that combined YESS and TESSYS techniques, depending on the predominant type of lumbar disc herniation at individual levels, is safe, minimally invasive, and effective.

Comparison of Multilevel Cervical Disc Replacement and Multilevel Anterior Discectomy and Fusion: A Systematic Review of Biomechanical and Clinical Evidence

OBJECTIVE

The aim of this study was to comprehensively compare the clinical and biomechanical efficiency of anterior cervical discectomy and fusion (ACDF) with anterior cervical disc replacement (ACDR) for treatment of multilevel cervical disc disease using a meta-analysis and systematical review.

METHODS

A literature search was performed using PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published between January 1960 and December 2017. Both clinical and biomechanical parameters were analyzed. Statistical tests were conducted by Revman 5.3. Nineteen studies including 10 clinical studies and 9 biomechanical studies were filtered out.

RESULTS

The pooled results for clinical efficiency showed that no significant difference was observed in blood loss (P = 0.09; mean difference [MD], 7.38; confidence interval [CI], -1.16 to 15.91), hospital stay (P = 0.33; MD, -0.25; CI, -0.76 to 0.26), Japanese Orthopaedic Association scores (P = 0.63; MD, -0.11; CI, -0.57 to 0.34), visual analog scale (P = 0.08; MD, -0.50; CI, -1.06 to 0.05), and Neck Disability Index (P = 0.33; MD, -0.55; CI, -1.65 to 0.56) between the 2 groups. Compared with ACDF, ACDR did show increased surgical time (P = 0.03; MD, 31.42; CI, 2.71-60.14). On the other hand, ACDR showed increased index range of motion (ROM) (P < 0.00001; MD, 13.83; CI, 9.28-18.39), lower rates of adjacent segment disease (ASD) (P = 0.001; odds ratio [OR], 0.27; CI, 0.13-0.59), complications (P = 0.006; OR, 0.62; CI, 0.45-0.87), and rate of subsequent surgery (P < 0.00001; OR, 0.25; CI, 0.14-0.44). As for biomechanical performance, ACDR maintained index ROM and avoided compensation in adjacent ROM and tissue pressure.

CONCLUSIONS

Multilevel ACDR may be an effective and safe alternative to ACDF in terms of clinical and biomechanical performance. However, further multicenter and prospective studies should be conducted to obtain a stronger and more reliable conclusion.

Contralateral radiculopathy after transforaminal lumbar interbody fusion in the treatment of lumbar degenerative diseases: A Case Series

RATIONALE

Transforaminal lumbar interbody fusion (TLIF) is an effective treatment for patients with degenerative lumbar disc disorder. Contralateral radiculopathy, as a complication of TLIF, has been recognized in this institution, but is rarely reported in the literature.

PATIENT CONCERNS

In this article, we report 2 cases of contralateral radiculopathy after TLIF in our institution and its associated complications.

DIAGNOSES

In the 2 cases, the postoperative computed tomography (CT) and magnetic resonance image (MRI) showed obvious upward movement of the superior articular process, leading to contralateral foraminal stenosis.

INTERVENTIONS

Revision surgery was done at once to partially resect the opposite superior facet and to relieve nerve root compression.

OUTCOMES

After revision surgery, the contralateral radiculopathy disappeared.

LESSONS

Contralateral radiculopathy is an avoidable potential complication. It is very important to create careful preoperative plans and to conscientiously plan the use of intraoperative techniques. In case of postoperative contralateral leg pain, the patients should be examined by CT and MRI. If CT and MRI show that the superior articular process significantly migrated upwards, which leads to contralateral foraminal stenosis, revision surgery should be done at once to partially resect the contralateral superior facet so as to relieve nerve root compression and avoid possible long-term impairment.