Role of the Lumbosacral Transition Vertebra and Vertebral Lamina in the Pathogenesis of Lumbar Disc Herniation.

OBJECTIVE: To investigate the prevalence of lumbosacral transition vertebrae (LSTVs) in both the normal population and the lumbar disc herniation (LDH) population and to determine the risk factors for LDH. METHODS: Between January 2019 and September 2020, all patients aged 18-39 years and underwent an anteroposterior (AP) X-ray of the lumbar vertebrae were retrospective reviewed in our institution. Those patients who were diagnosed with LDH were eligible for inclusion in the LDH group. During the same period, those patients admitted to our hospital who underwent an anteroposterior X-ray of the lumbar spine and had not been diagnosed with LDH were included in the control group. Those patients with disease that might affect the lumbar anatomy were excluded from both groups. The type of LSTV was classified according to the Castellvi classification. The height of the lumbar vertebral lamina was evaluated through the h/H index. The inter- and intra-observer reliability was evaluated by one senior radiologist and one senior orthopedist using intraclass correlation coefficient (ICC). The association between the LSTV and the herniation level was also investigated. Binary logistic regression was used to explore the association of different factors between the LDH group and the control group. RESULTS: Two hundred LDH patients (115 male and 85 female) and 200 individuals (108 male and 92 female) were investigated retrospectively. The prevalence of LSTVs was 71.5% (n = 143) in the LDH group and 34.0% (n = 68) in the control group. The most frequent LSTV types were type Ib and type IIa. The inter- and intra-observer ICCs of the measurement of "h/H" index and the classification of LSTV were all "excellent" (ICC > 0.90). The median h/H index in the control group was significantly higher than that in the LDH group (0.28 (0.26, 0.31) vs 0.34 (0.31, 0.37), P = 0.000). The distribution of the Castellvi classification in the L4/5 and L5/S1 herniation patients was significantly different (P = 0.048). LSTVs, BMI and the h/H index were closely associated with LDH, with odds ratios of 3.06 (95% CI: 2.12-4.43), 1.23 (95% CI: 1.13-1.33) and 0.09 (95% CI: 0.05-0.15), respectively. The incidence of L4/5 disc herniation in patients with an LSTV was significantly more common than that in patients with L5/S1 disc herniation (P = 0.048). CONCLUSION: The prevalence of LSTVs was 34.0% in the control group and 71.5% in the LDH group; LSTVs and BMI were positively correlated with LDH, and h/H was negatively correlated with LDH.

Solitary bone plasmacytoma of spine with involvement of adjacent disc space: A case report.

RATIONALE: Solitary bone plasmacytoma (SBP) is a rare manifestation of plasma cell tumor. Although axial skeleton is the most frequently affected site of SBP, adjacent disc space involvement is rare. Herein we report a case of SBP in thoracic vertebra with involvement of adjacent disc space. PATIENT CONCERNS: A 57-year-old male presented with a 2-year history of intermittent back pain with activity. The patient's back pain intensity with activity was a score of 5 of the 10-point visual analog scale). DIAGNOSES AND INTERVENTION: The patient underwent a posterior fusion procedure from T6 to T10, and an open biopsy of the vertebral lesion confirmed that final diagnosis of SBP. The patient received postoperative radiotherapy with a total of 4000 Gy to the T7-T9 vertebral levels over a 20-day period. OUTCOMES: Following radiotherapy, the patient's pain intensity was reduced to the visual analog scale score of 1 at the 6-month follow-up. LESSONS: SBP lacks typical clinical symptoms, and the accurate diagnosis before clinical intervention remains challenging. Due to the disc involvement, SBP often manifests as spinal infection. Hence, differential diagnosis in spinal lesions involving the disc should include SBP.

Impact of lumbar fusion on sitting spinopelvic balance: Multisegmental versus monosegmental.

OBJECTIVES: To compare the differences in sagittal spinopelvic parameters between patients receiving monosegmental or multisegmental lumbar fusion and to assess the impact of fusion length on sitting balance. METHODS: The current study recruited 41 patients who had undergone lumbar fusion, consisting of 18 in the monosegmental group and 23 in the multisegmental group. And the control group included 50 lumbar degenerative patients who had no previous spinal fusion surgery. Spinopelvic parameters of patients were assessed: sagittal vertical axis, pelvic tilt, sacral slope, pelvic incidence, thoracic kyphosis, lumbar lordosis, and proximal femur angles. RESULTS: We observed significant differences in sitting TK (P = 0.031), LL (P = 0.012), PT (P = 0.009) and SVA (P = 0.009) among the three groups. When transitioning from standing to sitting, the multisegmental group had the least change in SVA (P = 0.016), PT (P = 0.043), and LL (P = 0.009), with a compensatory increase in TK (P = 0.021). Moderate to strong correlations were found between the change in the LL and those in the SVA (r = -0.548, P = 0.001), PT (r = -0.600, P = 0.001), and SS (r = 0.623, P = 0.001). CONCLUSION: Multisegmental lumbar fusion significantly limits the lumbar mobility and affects the ability to compensate postural changes. Reducing the fusion segments as much as possible is of particular value in preserving lumbar mobility and maintaining the compensatory mechanism of spinopelvis.

Hemoglobin and adult height loss among Japanese workers: A retrospective study.

Height loss starting in middle age is reported to be associated with increased all-cause and cardiovascular mortality later in life. However, the mechanisms underlying this association are unclear. Hypoxia and oxidative stress, which are known causes of cardiovascular disease, could be reduced by hemoglobin. Therefore, hemoglobin could be inversely associated with height loss. However, high body mass index (BMI) is a known risk factor for intervertebral disc disorder, a known cause of height loss in adults. High BMI might confound the association between hemoglobin and height loss. Therefore, we performed analyses stratified by BMI status. To clarify the association between hemoglobin and height loss, we conducted a retrospective study of Japanese workers (6,471 men and 3,180 women) aged 40-74 years. Height loss was defined as being in the highest quintile of height decrease per year. In men overall and men with BMI <25 kg/m2, hemoglobin was significantly inversely associated with height loss; but no association was observed for men with high BMI (BMI ≥25 kg/m2) and for women. For men, after adjusting for known cardiovascular risk factors, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for height loss with each 1 standard deviation (SD) increase in hemoglobin (1.0 g/dL for men and 0.8g/dL for women) were 0.89 (0.83, 0.95) for men overall, 0.82 (0.75, 0.89) for men who do not have high BMI, and 1.01 (0.92, 1.12) for men with high BMI. For women, the corresponding values were 0.97 (0.89, 1.06), 0.98 (0.89, 1.09), and 0.93 (0.75, 1.15) respectively. Hemoglobin is significantly inversely associated with height loss in men who do not have high BMI, but not in men with high BMI or women. These results help clarify the mechanisms underlying height loss, which has been reported to be associated with a higher risk of mortality in adults.

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.

Pulsed Electromagnetic Fields Accelerate Sensorimotor Recovery Following Experimental Disc Herniation.

STUDY DESIGN: An experimental animal study. OBJECTIVE: The aim of this study was to investigate the effect of pulsed electromagnetic fields (PEMF) on recovery of sensorimotor function in a rodent model of disc herniation (DH). SUMMARY OF BACKGROUND DATA: Radiculopathy associated with DH is mediated by proinflammatory cytokines. Although we have demonstrated the anti-inflammatory effects of PEMF on various tissues, we have not investigated the potential therapeutic effect of PEMF on radiculopathy resulting from DH. METHODS: Nineteen rats were divided into three groups: positive control (PC; left L4 nerve ligation) (n = 6), DH alone (DH; exposure of left L4 dorsal root ganglion [DRG] to harvested nucleus pulposus and DRG displacement) (n = 6), and DH + PEMF (n = 7). Rodents from the DH + PEMF group were exposed to PEMF immediately postoperatively and for 3 hours/day until the end of the study. Sensory function was assessed via paw withdrawal thresholds to non-noxious stimuli preoperatively and 1 and 3 days postoperatively, and every 7 days thereafter until 7 weeks after surgery. Motor function was assessed via DigiGait treadmill analysis preoperatively and weekly starting 7 days following surgery until 7 weeks following surgery. RESULTS: All groups demonstrated marked increases in the left hindlimb response threshold postoperatively. However, 1 week following surgery, there was a significant effect of condition on left hindlimb withdrawal thresholds (one-way analysis of variance: F = 3.82, df = 2, P = 0.044) where a more rapid recovery to baseline threshold was evident for DH + PEMF compared to PC and DH alone. All groups demonstrated gait disturbance postoperatively. However, DH + PEMF rodents were able to regain baseline gait speeds before DH and PC rodents. When comparing gait parameters, DH + PEMF showed consistently less impairment postoperatively suggesting that PEMF treatment was associated with less severe gait disturbance. CONCLUSION: These data demonstrate that PEMF accelerates sensorimotor recovery in a rodent model of DH, suggesting that PEMF may be reasonable to evaluate for the clinical management of patients with herniation-associated radiculopathy.Level of Evidence: N/A.

The role of structure and function changes of sensory nervous system in intervertebral disc-related low back pain.

Low back pain (LBP) is a common musculoskeletal symptom, which can be developed in multiple clinical diseases. It is widely recognized that intervertebral disc (IVD) degeneration (IVDD) is one of the leading causes of LBP. However, the pathogenesis of IVD-related LBP is still controversial, and the treatment means are also insufficient to date. In recent decades, the role of structure and function changes of sensory nervous system in the induction and the maintenance of LBP is drawing more and more attention. With the progress of IVDD, IVD cell exhaustion and extracellular matrix degradation result in IVD structural damage, while neovascularization, innervation and inflammatory activation further deteriorate the microenvironment of IVD. New nerve ingrowth into degenerated IVD amplifies the impacts of IVD-derived nociceptive molecules on sensory endings. Moreover, IVDD is usually accompanied with disc herniation, which could injure and inflame affected nerves. Under mechanical and pro-inflammatory stimulation, the pain-transmitting pathway exhibits a sensitized function state and ultimately leads to LBP. Hence, relevant pathogenic factors, such as neurotrophins, ion channels, inflammatory factors, etc., are supposed to serve as promising therapeutic targets for LBP. The purpose of this review is to comprehensively summarize the current evidence on 1) the pathological changes of sensory nervous system during IVDD and their association with LBP, and 2) potential therapeutic strategies for LBP targeting relevant pathogenic factors.

Outcome of Osteophytes After Only-Fixation as Treatment for Multilevel Cervical Spondylosis-A Minimum of 12 Months Follow-Up.

OBJECTIVE: This report analyzes the significance of osteophytes in the overall pathologic scheme in patients with single-level or multilevel cervical spinal degeneration. METHODS: From January 2010 to December 2018, 249 patients with cervical spondylosis were surgically treated. The alterations in ventral compression caused by disc bulges, osteophytes, and ligament buckling (disc-osteophye-ligament [DOL] complex) at single or multiple levels were evaluated after surgical treatment that involved only spinal fixation and did not involve any kind of bone or soft tissue decompression. Delayed (≥1 year after surgery) postoperative imaging was available in 165 patients and these patients formed the study group. Forty-five patients underwent facet distraction arthrodesis (group A), 106 patients underwent only-fixation involving transarticular screw insertion (group B), and 14 patients underwent hybrid fixation that involved both intra-articular spacers and transarticular fixation techniques (group C) as the surgical treatment. RESULTS: The size of the DOL complex at the segments that underwent fixation was reduced in 136 patients. The size of the DOL complex or its related dural or neural compression did not increase in any of the cases evaluated. Reduction in the size of DOL was more pronounced in patients in group A in both immediate postoperative and delayed images and in patients in group C at spinal levels at which facet distraction was performed using facet distraction spacers. CONCLUSIONS: Spinal stabilization reduces the size of osteophytes. Facet distraction spacers are more effective in reduction of the size of DOL in both immediate and delayed postoperative periods.

Hernia del disco intervetebral lumbar: revisión narrativa de clínica y manejo / Lumbar herniated disc: narrative review on clinical management

Los cuadros de lumbociática secundarios a hernia del disco intervertebral (hdi) son frecuentes y causantes de importante morbilidad. En esta revisión narrativa, nos enfocaremos en los aspectos clínicos y de manejo de esta frecuente patología. Se tiene que mantener un algo grado de sospecha, pues no siempre los cuadros clínicos son similares a lo descrito clásicamente. Los signos radiculares irritativos y un examen neurológico exhaustivo son fundamentales, asimismo la correlación entre este cuadro y las imágenes. El curso natural de la hdi es en general hacia la resolución y, por lo tanto, el tratamiento de elección es inicialmente conservador. La cirugía tiene un rol generalmente en pacientes que han fracasado con el manejo conservador. Esta tiene mejores resultados en el corto plazo que el tratamiento conservador continuo, pero en el largo plazo son equivalentes. Es fundamental discutir estos aspectos con el paciente, para lograr una elección informada del tratamiento, de acuerdo a sus preferencias

Sciatic pain caused by a herniated disk (ldh) is frequent and cause of significant morbidity. In this narrative review, we will discuss the clinical aspects and management of ldh diagnosis and management. High suspicion for ldh diagnosis must be kept, since its clinical picture is not always classical. Tension signs and neurological examination are key, along with correlation with images. Ldh natural history is generally towards resolution and therefore, conservative treatment is the first choice. Surgery has its role for patients who have failed conservative treatment. Surgery achieves a faster pain alleviation than conservative treatment, but on the long-term results tend to become equivalent. Ample and detailed discussion of these aspects with the patient are clue for an informed consent and satisfactory results.

The effectiveness of high intensity laser therapy in the patients with lumbar disc herniation: A protocol of randomized placebo-controlled trial.

BACKGROUND: There is no consensus in existing literature on the pulse power, application time, frequency and the dose of energy of laser therapy for the patients. Therefore, we conducted this research for the assessment of safety and efficiency of ultrasound and high-intensity laser therapy (HILT) in the lumbar disc herniation (LDH) patients. METHODS: Our present research was approved by the institutional review board in the West China-Guangan Hospital. All the participants would acquire the written informed consent. From December 2020 to December 2021, we will conduct a prospective evaluation via a senior surgeon for 1 hundred LDH patients who plan to undergo the conservative treatment at our hospital. In this research, the inclusion criteria contained: the patients with lumbar disc herniation diagnosed by lumbar MRI; the patients with no history of trauma or congenital abnormalities; and the patients with sufficient psychological ability to understand and then answer the questions raised in assessment scale. The participants were randomly divided into the control group or HILT group after performing the examination of baseline. The main outcome was the pain score of visual analog scale. The other results contained the adverse effects, back range of motion as well as functional scores. CONCLUSIONS: We assumed that the HILT is as effective as the ultrasound therapy in treating pain for LDH. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5975).

Frailty and Post-Operative Outcomes in the Older Patients Undergoing Elective Posterior Thoracolumbar Fusion Surgery.

BACKGROUND AND AIM: Frailty is an independent predictor of mortality and adverse events (AEs) in patients undergoing surgery. This study aimed to quantify the ability of Modified Frailty Index (mFI) to predict AEs in older patients undergoing elective posterior thoracolumbar fusion surgery. METHODS: We retrospectively reviewed the results of 426 patients with the following diagnoses and follow-up evaluations of at least 12 months duration: lumbar disc herniation, 125; degenerative spondylolisthesis, 81; lumbar spinal canal stenosis, 187; and adult spinal deformities, 33. The cases were divided into two groups. The long spinal fusion (LSF) group was defined as ≥3 spinal levels with segmental pedicle-screw fixation. Short spinal fusion (SSF) were defined with at most two levels. The mFI used in the present study is an 11-variable assessment. The association of frailty with AEs was determined after adjusting for known and suspected confounders. RESULTS: Frailty was presented in 66 patients (15.5%) within the total population (LSF, 21.9% and SSF, 11.8%). Rates of AEs assessed in the study increased stepwise with an increase in the mFI for the two groups. The severity of frailty was an independent predictor of any, major, and minor complications in the LSF group and any, minor complication in the SSF group (P<0.05). A comparison of post-operative clinical outcomes showed that the ODI and SF-36 scores deteriorated as the mFI increased. CONCLUSION: Frailty was shown to be an independent predictor of AEs in older patients undergoing elective posterior thoracolumbar fusion surgery, especially for patients undergoing LSF.

Neck-Related Headache in Patients With Cervical Disc Disease After Surgery and Physiotherapy: A 1-Year Follow-up of a Prospective Randomized Study.

STUDY DESIGN: A prospective randomized multicenter trial. OBJECTIVE: To investigate the effects of surgery with either structured postoperative physiotherapy or standard postoperative approach on neck-related headache in patients with cervical radiculopathy. Secondary, to investigate associations between change in neck-related headache and change in neck muscle endurance, neck mobility, or neck pain. SUMMARY OF BACKGROUND DATA: The effect of physiotherapy on individuals with neck-related headache after surgery for cervical radiculopathy due to magnetic resonance imaging-verified disc disease is unknown. METHODS: One hundred six patients with neck-related headache and participating in a randomized controlled trial evaluating the additional effects of physiotherapy after surgery for cervical radiculopathy were included. Patients were randomized preoperatively to structured postoperative physiotherapy (n = 51) or the standard postoperative approach (n = 55). Outcome measures were headache intensity and neck pain intensity, neck muscle endurance, and neck mobility. Measures were obtained preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS: Headache intensity significantly changed from baseline to 1 year postoperatively (P < 0.001) in both groups. Post-hoc tests showed a significant difference between baseline and 6 weeks (P ≤ 0.05). No significant differences were found between groups (P > 0.05) or between-group differences in changes over time (P > 0.05). The change in current headache intensity over time was associated with a change in current neck pain intensity over time (P = 0.003, ß = 0.40). CONCLUSION: There was a significant improvement in headache intensity 1 year postoperatively in patients with cervical radiculopathy and neck-related headache, but there were no differences between groups over time. Change in current headache intensity was only associated with a change in current neck pain intensity. LEVEL OF EVIDENCE: 2.

Low Back Pain Induced by Posterior Longitudinal Ligament Incision in Percutaneous Transforaminal Endoscopic Lumbar Discectomy.

OBJECTIVE: To illustrate the posterior longitudinal ligament is one of the tissue candidates who can contribute to low back pain (LBP). METHODS: This is a retrospective study. A series of 72 patients who underwent single-level percutaneous endoscopic lumbar discectomy performed for lumbar disc herniation with LBP from June 2014 to June 2016 were examined. There are 42 males and 30 females. The ages of patients were 40 to 57 years, and the mean age was 49.8 years. The symptomatic disc level was at L4-5 in 43 patients and L5 S1 in 29 patients. Thirty-two patients (19 patients in L4-5 disc level, 13 patients in L5 S1 disc level) had LBP (which was limited to the lower back and buttock area) before the operation. All of the operative approaches were performed under local anesthesia. A posterior body diagram (15 cm × 10 cm) was made for this study to record the pain distribution. The centered foci of low back pain were subjectively recorded before, during, and after the operation. The transforaminal endoscopic spine system technology was used in this study. Radiological examinations (X-ray, computed tomography, and magnetic resonance imaging) were performed prior to and after surgery. The Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) scores were taken before and after the surgery to observe the degree of pain. The VSA and ODI score before and after operation were expressed as mean ± SD, and compared by t-test for statistical analysis. RESULTS: When inciting the posterior longitudinal ligament during the operation, all 72 patients had provoked low back pain. Forty-three patients with symptomatic discs at L4-5 had pain foci in the lower back and upper gluteal region under the L4 spinous process. Twenty-nine patients with symptomatic discs at L5 S1 had pain foci in the gluteal region under the S1 spinous process. The pain localizations of L4-5 and L5 S1 were different. After the surgery, the provoked low back pain disappeared, and had not returned in any of the patients at the 6-month follow-up. After the operation, one patient suffered from lower limb pain that he did not have before the operation, and the lower limb pain abated a few days later. Three patients had cerebrospinal fluid leakage and were treated with higher pressure applied on the incision and bed rest for 10 days. During the 6-months follow-up period, the mean VAS decreased from 5.97 ± 1.10 to 2.13 ± 0.78. The mean ODI score decreased from 23.14 ± 3.28 to 7.92 ± 1.85. CONCLUSIONS: The intervertebral posterior longitudinal ligament may be one of the tissues from which low back pain originates.

Severity of intervertebral disc herniation regulates cytokine and chemokine levels in patients with chronic radicular back pain.

OBJECTIVE: The contributions of intervertebral disc disease and subject-specific covariates to systemic inflammation in low back pain are unknown. We examined the effects of symptomatic disc herniation (DH) and MRI herniation severity on serum cytokine levels in clinical subjects. DESIGN: Cytokine levels from lumbar DH subjects (N = 78) were compared to control subjects (N = 57) accounting for effects of DH, age, body mass index (BMI) and gender. Effect of DH severity on cytokine levels was analyzed on subsets of subjects with acute or chronic pain. Serum cytokines were also analyzed in a subset of patients between pre- and 3 months post-surgery. RESULTS: Cytokine levels were elevated in the serum of patients with symptomatic DH, and the covariates age, BMI and gender significantly contributed to levels of some cytokines. Severity of herniation was a significant contributor to pain intensity (VAS), serum levels of HMGB1, PDGFbb, and IL-9. The relationship between DH severity and cytokine levels was confirmed in subjects with chronic, but not acute symptoms. Serum levels of macrophage migration inhibitory factor (MIF) decreased, whereas levels of CCL3, CCL11, CXCL1, and CXCL10 were significantly elevated post surgery. CONCLUSIONS: This study is the first to show that DH severity is coordinately associated with changes in serum levels of inflammatory cytokines in chronic pain subjects. HMGB1, PDGFbb and IL-9 are novel mediators of increasing DH severity, indicative of cellular damage, neuro-inflammation and angiogenesis. Resolution of inflammation was observed with decrease in MIF post surgery. However, elevated chemokine levels indicate ongoing remodeling and wound healing at 3-month time point.

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

OBJECTIVE: Surgery for lumbar disk herniation (LDH) presents an option for patients when conservative measures fail. The objective of this clinical study is to investigate a novel, objective outcome measure in patients undergoing lumbar microdiscectomy. METHODS: Twenty-four patients were evaluated pre- and postoperatively using the Oswestry Disability Index (ODI), and a novel objective scoring tool, the Gait Posture index (GPi). The score is calculated from 4 key physical health metrics: daily step count, walking speed, step length, and walking posture. The GPi ranges from 0 (nonambulant) to 100 (excellent walking performance). Wearable accelerometers and observational recordings were used to evaluate the components of the GPi. The GPi was calculated and compared with the ODI, pre- and postintervention. The study was designed as a proof of concept and confirmation of validity for use of the GPi in LDH. RESULTS: At follow-up (average 66 ± 36 days), 23 of 24 patients had an improvement in their GPi after surgery. The average GPi of the cohort improved from 59.33 ± 16.06 to 85.75 ± 9.22 with P < 0.001, with significant changes in all 4 components. The average preoperative ODI was 54.54 ± 20.70, improving to 16.33 ± 14.095 with P < 0.001. The Pearson correlation coefficient was r = 0.56, indicating a correlation between change in ODI and change in GPi. CONCLUSIONS: The GPi score is a new, objective descriptor of mobility in spinal surgery which can be used to augment traditional subjective outcome scoring surveys such as the ODI. Significant changes are seen in the GPi and its constituent metrics in patients undergoing surgery for LDH.

Association of Modic change types and their short tau inversion recovery signals with clinical characteristics- a cross sectional study of chronic low back pain patients in the AIM-study.

BACKGROUND: Modic Changes (MCs, magnetic resonance imaging (MRI) signal changes in the vertebral bone marrow extending from the vertebral endplate) may represent a subgroup of nonspecific chronic low back pain that could benefit from a specific management. The primary aim was to compare clinical characteristics between patients with type 1 versus type 2 MCs. The secondary aim was to explore associations between clinical characteristics and MC related short tau inversion recovery (STIR) signals. METHODS: This cross-sectional study used baseline data prospectively collected between 2015 and 2017 on the 180 patients included in the AIM-study (Antibiotics In Modic changes), a randomized controlled trial in a Norwegian hospital out-patient setting of patients with chronic low back pain, a lumbar disc herniation within the last 2 years, low back pain intensity score ≥ 5 (on a 0-10 scale) and current type 1 or type 2 MCs at the previously herniated lumbar disc level. We used prespecified clinical characteristics including self-report measures, physiologic measures and functional measures from clinical history and examination. The diagnostic accuracy of various clinical characteristics to discriminate between patients with type 1 MCs (with or without additional type 2 MCs) and patents with type 2 MCs only (not type 1) were assessed by calculating the area under the receiver-operating curve. We assessed the correlations of clinical characteristics with details of MC related STIR signal increase. RESULTS: No clinical characteristic differed between patients with type 1 (n = 118) versus type 2 (but not type 1) (n = 62) MCs. The clinical characteristics showed no/minor differences or no/weak correlations with MC related STIR signal increase. Patients with a positive Springing test (at any lumbar level) had slightly less volume of STIR signal increase than those with a negative test (mean difference 1.3 on a 0-48 scale, 95% CI 0.3 to 2.3). CONCLUSION: Clinical characteristics were similar for patients with type 1 MCs and patients with type 2 MCs, and showed no clinically relevant correlations with MC related STIR signal increase. TRIAL REGISTRATION: ClinicalTrials.gov NCT02323412, First registered 23 December 2014.

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

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

A Noninvasive Assistant System in Diagnosis of Lumbar Disc Herniation.

The purpose of this study is the application of pressure sensors in diagnostics and evaluation of the accuracy diagnostics of lumbar disc herniation at levels L4/L5 and L5/S1 using the aforementioned platform. The motivation behind the idea to apply the pressure measurement platform is the fact that the motor weakness of plantar and dorsal flexia of the feet is one of the absolute indications for the operative treatment of patients with lumbar disc herniation at the indicated levels. In patients, MRI diagnosis of the lumbosacral spine served as the ground truth in the diagnosis of herniation at L4/L5 and L5/S1 levels. The inclusive criteria for the study were the proven muscle weakness based on manual muscle tests performed prior to surgery, after seven days of surgery and after physical therapy. The results obtained with the manual muscular test were compared with the results obtained using our platform. The study included 33 patients who met the inclusion criteria. The results of the measurements indicate that the application of our platform with pressure sensors has the same sensitivity diagnostics as a manual muscle test, when done preoperatively and postoperatively. After physical therapy, pressure sensors show statistically significantly better sensitivity compared to the clinical manual muscle test. The obtained results are encouraging in the sense that the pressure platform can be an additional diagnostic method for lumbar disc herniation detection and can indicate the effectiveness of operative treatment and physical therapy after operation. The main advantage of the system is the cost; the whole system with platform and sensors is not expensive.

Risk Factors for Recurrent L5-S1 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Study.

BACKGROUND This retrospective study aimed to investigate the risk factors associated with the recurrence of L5-S1 disc herniation after percutaneous endoscopic transforaminal discectomy (PETD). MATERIAL AND METHODS There were 484 patients L5-S1 disc herniation who underwent PETD who were divided into the recurrence group (n=46) and the non-recurrence group (n=438). Transforaminal endoscopic approaches included modifications of the Yeung endoscopy spine system (YESS) (the intraforaminal intradiscal approach) and the transforaminal endoscopic spine system (TESSYS) (intraforaminal extradiscal approach). Demographic and clinical characteristics and imaging data were analyzed. The two study groups were compared to determine the factors associated with the recurrence of L5-S1 disc herniation. The patients underwent postoperative follow-up for between one and four years. RESULTS At follow-up, 9.504% of patients (46/484) with the recurrence of L5-S1 disc herniation following PETD when compared with the non-recurrence group showed no significant difference for time to return to work, gender, history of diabetes mellitus, trauma, duration of symptoms, smoking and alcohol history, hypertension, location of disc herniation, transverse process length, intervertebral space height, and pelvic incidence angle (P>0.05). However, age, body mass index (BMI), the degree of disc degeneration, sagittal range of motion, lumbar lordosis angle, and sacral slope were significantly associated with the recurrence of L5-S1 disc herniation following PETD (P<0.05). Logistic regression analysis supported these main associations. CONCLUSIONS The recurrence of L5-S1 disc herniation following PETD was significantly associated with increased age and BMI, more severe disc degeneration, increased sagittal range of motion, increased lumbar lordosis, and sacral slope.