Relationship between annular tear and presence of Propionibacterium acnes in lumbar intervertebral disc.

PURPOSE: Propionibacterium acnes (P. acnes) in the intervertebral disc may result in low back pain. The purpose of this study was to determine how P. acnes accesses the disc. METHODS: Patients with low back pain and/or sciatica were examined using X-ray and MRI before surgery. The intervertebral disc space height was measured on X-ray image. Disc and muscle samples were obtained from 46 patients undergoing discectomy at the lumbar spine. The tear of annulus was inspected before discectomy. In the disc and muscle tissue cultures, 16S rDNA gene specific for P. acnes was examined using PCR. RESULTS: The discs from 11 (23.9 %) patients were identified as 16S rDNA positive, in which two patients also had 16S rDNA in their muscles. 16S rDNA gene was significantly more likely to appear in the discs with annular tear than those without tear (P < 0.05). The disc space height was significantly decreased when the disc contained P. acnes. CONCLUSION: P. acnes is significantly more likely to be present in herniated discs with an annular tear than in herniated discs without such a tear. Since in the vast majority of these cases, no P. acnes was found in control muscle samples, a true infection with P. acnes is far more likely than a contamination.

Partial annular cervical tear: A case report.

BACKGROUND: Intrapartum annular cervical tears are a rare pregnancy complication. The mechanisms underpinning these tears remain to be elucidated and currently the optimal management and future pregnancy implications remain unknown. CASE PRESENTATION: We present the case of a 35-year-old nulliparous woman who was diagnosed with a partial annular cervical tear following induction of labour. Her intrapartum course was also complicated by an intrapartum fever, prolonged labour induction and an antepartum haemorrhage. During the second stage of labour, a band of cervical tissue could be seen at the introitus and abutting the fetal head. Following normal vaginal delivery, a portion of cervical tissue was visualised, 2 cm thick by 5 cm long, avulsed at the lateral edge at 9 o'clock and extending in an annular anti-clockwise fashion towards 1 o'clock. She underwent surgical repair of the cervical tear and had an uneventful postnatal course. At 6 weeks post-partum her cervix appeared to be healing well with 2 cm length palpable on vaginal examination. CONCLUSION: To the best of our knowledge, this case is the first report of a partial annular cervical tear to present in this manner. While the optimal management and outcomes for tears of this nature remain unknown, we recommend prenatal ultrasound cervical length screening with consideration of a cervical cerclage and elective caesarean section, which could avoid pre-term birth or the recurrence of this type of tear in future pregnancies.

Could the Splitting of the Annulus During Percutaneous Endoscopic Lumbar Diskectomy (PELD) Be a Culprit for Recurrent Disk Herniation?: An Analysis of the Reherniation Pattern After PELD.

OBJECTIVE: To explore which preoperative radiologic variables have propensity for reherniation and to evaluate whether the inherent annulus splitting procedure during percutaneous endoscopic lumbar diskectomy (PELD) could prompt reherniation, we assessed the correlation between the anatomic location of annular penetration and reherniation. METHODS: Three hundred and fifty patients who underwent PELD for central or subarticular disk herniation through a transforaminal approach were followed-up for at least 24 months. Fifty-four subjects that were reoperated for recurrent herniation were allocated as the reherniation group and the other 296 subjects were allocated as the non-reherniation group. The numerical rating scale score, another lumbosacral disk herniation (LDH) lesion in addition to the PELD level (another LDH), location (central or subarticular) and severity of LDH (protrusion or extrusion), and tear of the posterior longitudinal ligament (PLL) were compared between the 2 groups to identify which variables could be predictive factors for reherniation. To assess the influences of PELD on reherniation, location and severity of reherniation were compared with those of initial herniation. RESULTS: The location at the subarticular region and the existence of a concomitant PLL tear during initial LDH were significantly related to subsequent reherniation. The location and severity of these reherniations were significantly retained when compared with those of primary herniation. CONCLUSIONS: PLL tear and subarticular herniation were significantly related to recurrent disk herniation. Reherniation patterns after PELD generally matched those of primary herniation. The annulus penetrating step during PELD did not increase the risk of reherniation.

Treatment of Low Back Pain by Treating the Annular High Intensity Zone (HIZ) Lesions Using Percutaneous Transforaminal Endoscopic Disc Surgery.

BACKGROUND: The study design was a retrospective case series. The objective was to find the clinical success rate of percutaneous transforaminal endoscopic disc surgery in patients suffering from discogenic chronic low back pain who were showing high intensity zone (HIZ) with degenerated disc as the only abnormality in the magnetic resonance imaging (MRI). The HIZ in the posterior annulus in degenerated disc is recognized as a pain generator. There are only a few studies available in the literature addressing the effect of identification and treatment of HIZ in the chronic low back pain patient. METHODS: We retrospectively evaluated the case records of all the patients who were treated by percutaneous endoscopic disc surgery for relief of symptoms as determined by visual analog scale (VAS) score, Oswestry Disability Index (ODI), Mac Nab criteria, and the consumption of analgesics, who had the predominant symptom of chronic low back pain, and whose lumbar spine MRI showed degenerated disc with HIZ and no other cause of back pain, like facet joint arthritis or sacroiliac joint arthritis. RESULTS: A total of 23 patients were identified to include in the study. Mean preoperative duration of low back pain was 13.1 months. Mean follow up after the procedure was 29 months. At final follow up, 69.6% of the patients were not taking any pain medicines, 17.36% were on frequent analgesic medicines, 13.04% were on occasional analgesics. There was statistically significant reduction in VAS at 6 weeks postop and final follow up after surgery and the ODI at final follow up; 82.6% of patients had an excellent/good outcome as per Mac Nab criteria. There were no complications or reoperations in any of the patients. CONCLUSIONS: Visualization and ablation of the chronic annular pathology in HIZ may give an effective and minimally invasive treatment for one of the back pain causes.

Using Provocative Discography and Computed Tomography to Select Patients with Refractory Discogenic Low Back Pain for Lumbar Fusion Surgery.

Background Context Controversy remains over the use of provocative discography in conjunction with computed tomography (CT) to locate symptomatic intervertebral discs in patients with chronic, low back pain (LBP). The current study explores the relationship between discogenic pain and disc morphology using discography and CT, respectively, and investigates the efficacy of this combined method in identifying surgical candidates for lumbar fusion by evaluating outcomes. Methods 43 consecutive patients between 2006 and 2013 who presented with refractory low back pain and underwent discography and CT were enrolled in the study. For this study, "refractory LBP" was defined as pain symptoms that persisted or worsened after 6 months of non-operative treatments. Concordant pain was defined as discography-provoked LBP of similar character and location with an intensity of ≥ 8/10. Fusion candidates demonstrated positive-level discography and concordant annular tears on CT at no more than two contiguous levels, and at least one negative control disc with intact annulus. Surgical outcomes were statistically analyzed using Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) for back-related pain and disability preoperatively, and 2 weeks, 3, 6, 12, and 24 months postoperatively. Results Annular tears were found in 87 discs. Concordant pain was reported by 9 (20.9%) patients at L3-L4, 21 (50.0%) at L4-L5, and 34 (82.9%) at L5-S1; pain occurred significantly more often in discs with annular tears than those without (p<0.001). Painless discs were independent of annulus status (p=0.90). 18 (42%) of the original 43 patients underwent lumbar fusion at L3-L4 (n=1(6%)), L4-L5 (n=6 (33%)), L5-S1 (n=5 (28%)), and two-level L4-S1 (n=6 (33%)) via a minimally invasive transforaminal lumbar interbody fusion (MITLIF) approach with the aim to replace the nucleus pulposus with bone graft material. Median follow-up time was 18 months (range: 12-78 months). VAS, ODI, and SF-36 scores demonstrated significant improvements at 10 out of 12 postoperative time points compared with preoperative baseline. Conclusions Lumbar discography with post-discography CT can be an effective method to evaluate patients with discogenic back pain refractory to non-operative treatments. Those patients with one- or two-level high concordant pain scores with associated annular tears and negative control disc represent good surgical candidates for lumbar interbody spinal fusion.

Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology.

BACKGROUND CONTEXT: The paper ''Nomenclature and classification of lumbar disc pathology, recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology,'' was published in 2001 in Spine (© Lippincott, Williams & Wilkins). It was authored by David Fardon, MD, and Pierre Milette, MD, and formally endorsed by the American Society of Spine Radiology (ASSR), American Society of Neuroradiology (ASNR), and North American Spine Society (NASS). Its purpose was to promote greater clarity and consistency of usage of spinal terminology, and it has served this purpose well for over a decade. Since 2001, there has been sufficient evolution in our understanding of the lumbar disc to suggest the need for revision and updating of the original document. The revised document is presented here, and it represents the consensus recommendations of contemporary combined task forces of the ASSR, ASNR, and NASS. This article reflects changes consistent with current concepts in radiologic and clinical care. PURPOSE: To provide a resource that promotes a clear understanding of lumbar disc terminology amongst clinicians, radiologists, and researchers. All the concerned need standard terms for the normal and pathologic conditions of lumbar discs that can be used accurately and consistently and thus best serve patients with disc disorders. STUDY DESIGN: This article comprises a review of the literature. METHODS: A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. The revised document was then submitted for review to the governing boards of the ASSR, ASNR, and NASS. After further revision based on the feedback from the governing boards, the article was approved for publication by the governing boards of the three societies, as representative of the consensus recommendations of the societies. RESULTS: The article provides a discussion of the recommended diagnostic categories pertaining to the lumbar disc: normal; congenital/developmental variation; degeneration; trauma; infection/inflammation; neoplasia; and/or morphologic variant of uncertain significance. The article provides a glossary of terms pertaining to the lumbar disc, a detailed discussion of these terms, and their recommended usage. Terms are described as preferred, nonpreferred, nonstandard, and colloquial. Updated illustrations pictorially portray certain key terms. Literature references that provided the basis for the task force recommendations are included. CONCLUSIONS: We have revised and updated a document that, since 2001, has provided a widely acceptable nomenclature that helps maintain consistency and accuracy in the description of the anatomic and physiologic properties of the normal and abnormal lumbar disc and that serves as a system for classification and reporting built upon that nomenclature.

Discogenic low back pain.

Most lumbar disk herniations improve over time with or without medical treatment. Disk herniations and annular tears may not be symptomatic and are shown to exist in patients without any symptoms. In some patients, chronic low back pain may result from the syndrome of internal disk disruption. Treatment of chronic pain of diskal cause can be challenging and have varying results in terms of success. The diagnosis, cause, and treatment options are reviewed in this article.

Do presence and location of annular tear influence clinical outcome after lumbar total disc arthroplasty? A prospective 1-year follow-up study.

BACKGROUND: Lumbar total disc arthroplasty is often performed in patients with axial back pain. There are multiple etiologies for axial back pain, including disc degeneration and annular tears. The location of these annular tears can vary, producing differing preoperative symptomatology. Intraoperatively, disruptions in the annulus are identifiable, and it has been suggested that patients with discrete annular tears may have better clinical outcomes after surgery. The purpose of this study was to investigate whether the presence and location of annular tears have an effect on clinical outcomes after lumbar total disc arthroplasty. METHODS: Patients undergoing a single-level anterior disc replacement from L3-S1 at a single site by a single surgeon were evaluated preoperatively for the presence or absence of annular tears with magnetic resonance imaging. All patients were part of either the ProDisc (n = 41) (Synthes, Paoli, Pennsylvania) or Activ-L (n = 19) (Aesculap [B. Braun Melsungen AG], Tuttlingen, Germany) lumbar prospective clinical trials. In those patients with annular tears, the location of the tear (central, paracentral, or lateral) was documented. Patients were assessed at 6 and 12 months after lumbar total disc arthroplasty with the Oswestry Disability Index (ODI), visual analog scale (VAS) score for back pain, VAS score for leg pain, and radiographic imaging. All radiographic evaluations were conducted by an attending neuroradiologist and an attending spinal surgeon, and reliability testing was performed. An analysis of variance was performed among the 3 anatomic locations of annular tears. RESULTS: A total of 60 patients were included and had complete 12-month follow-up. The prevalence of annular tears among all patients was 42% (n = 25). Outcome data in patients without annular tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 8.0 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 2.9 preoperatively and 1.2 postoperatively. Among those patients with tears, the prevalence of central tears was 80%, the prevalence of paracentral tears was 12%, and the prevalence of lateral tears was 8%. Outcome data in patients with central tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 7.8 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 5.2 preoperatively and 0.5 postoperatively. Outcome data in patients with paracentral tears were as follows: ODI, 86% preoperatively and 59% postoperatively; VAS score for back pain, 8.8 preoperatively and 3.3 postoperatively; and VAS score for leg pain, 5.0 preoperatively and 5.4 postoperatively. Outcome data in patients with lateral tears were as follows: ODI, 6.5 preoperatively and 2.6 postoperatively; VAS score for back pain, 9.2 preoperatively and 0.2 postoperatively; and VAS score for leg pain, 1.4 preoperatively and 0.7 postoperatively. In those patients with paracentral tears, there was a significantly higher incidence of postoperative radicular symptoms both from an intensity standpoint and from a duration standpoint. Other complications did not vary among those patients with or without annular tears. CONCLUSIONS: Although patients with annular tears and patients without annular tears improve after lumbar artificial disc replacement, those with central annular tears or without tears have significantly lower disability scores than those with paracentral tears or lateral tears, whose outcome scores showed significantly less improvement (P ≤ .03). In particular, patients with central tears have less postoperative leg pain than those with paracentral annular tears. In this study the presence or absence of an annular tear on magnetic resonance imaging was not a significant predictive factor for clinical outcome. Further investigation regarding the effects of paracentral annular tears and surgical techniques should be explored.

Disc disease: a summary and review.

A review of the etiology, clinical, radiological and laboratory presentation, differential diagnosis and management goals of disc disease is presented.