Spinal fusion surgery use among adults with low back pain enrolled in a digital musculoskeletal program: an observational study.

OBJECTIVES: To compare 12-month spinal fusion surgery rates in the setting of low back pain among digital musculoskeletal (MSK) program participants versus a comparison cohort who only received usual care. STUDY DESIGN: Retrospective cohort study with propensity score matched comparison cohort using commercial medical claims data representing over 100 million commercially insured lives. METHODS: All study subjects experienced low back pain between January 2020 and December 2021. Digital MSK participants enrolled in the digital MSK low back program between January 2020 and December 2021. Non-participants had low back pain related physical therapy (PT) between January 2020 and December 2021. Digital MSK participants were matched to non-participants with similar demographics, comorbidities and baseline MSK-related medical care use. Spinal fusion surgery rates at 12 months post participation were compared. RESULTS: Compared to non-participants, digital MSK participants had lower rates of spinal fusion surgery in the post-period (0.7% versus 1.6%; p < 0.001). Additionally, in the augmented inverse probability weighting (AIPW) model, digital MSK participants were found to have decreased odds of undergoing spinal fusion surgery (adjusted odds ratio: 0.64, 95% CI: 0.51-0.81). CONCLUSIONS: This study provides evidence that participation in a digital MSK program is associated with a lower rate of spinal fusion surgery.

[Short-term effectiveness of unilateral biportal endoscopy technique in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach].

Objective: To investigate the short-term effectiveness of unilateral biportal endoscopy (UBE) in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach. Methods: A clinical data of 15 patients with lumbar lateral saphenous fossa combined with intervertebral foramina stenosis, who were admitted between September 2021 and December 2023 and met selective criteria, was retrospectively analyzed. There were 5 males and 10 females with an average age of 70.3 years (range, 46-83 years). Surgical segment was L 4, 5 in 12 cases and L 5, S 1 in 3 cases. The disease duration was 12-30 months (mean, 18.7 months). All patients were treated by UBE via contralateral sublaminar approach. The operation time, intraoperative blood loss, postoperative hospital stay, and the occurrence of complications were recorded. The visual analogue scale (VAS) score was used to evaluate the degree of lower back and leg pain before and after operation; the Japanese Orthopaedic Association (JOA) score and the Oswestry disability index (ODI) were used to evaluate the lumbar function; and the clinical outcome was evaluated using the MacNab criteria at 6 months after operation. Postoperative MRI and CT were taken to observe whether the lateral saphenous fossa and intervertebral foramen stenosis were removed or not, and the cross-sectional area of the spinal canal (CSA-SC), cross-sectional area of the intervertebral foramen (CSA-IVF), and cross-sectional area of the facet joint (CSA-FJ) were measured. Results: The operation time was 55-200 minutes (mean, 127.5 minutes); the intraoperative blood loss was 10-50 mL (mean, 27.3 mL); the length of postoperative hospital stay was 3-12 days (mean, 6.8 days). All patients were followed up 6-12 months (mean, 8.9 months). At 1 day, 1 month, 3 months, and 6 months after operation, the VAS scores of low back and leg pain and ODI scores after operation were significantly lower than preoperative scores and showed a gradual decrease with time; the JOA scores showed a gradual increase with time; the differences in the above indexes between different time points were significant ( P<0.05). The clinical outcome was rated as excellent in 10 cases, good in 4 cases, and poor in 1 case according to the MacNab criteria at 6 months after operation, with an excellent and good rate of 93.33%. Imaging review showed that the compression on the lateral saphenous fossa and intervertebral foramina had been significantly relieved, and the affected articular process joint was preserved to the maximum extent; the CSA-SC and CSA-IVF at 3 days after operation significantly increased compared to the preoperative values ( P<0.05), and the CSA-FJ significantly reduced ( P<0.05). Conclusion: The UBE via contralateral sublaminar approach can effectively reduce pressure in the lateral saphenous fossa and the intervertebral foramina of the same segment while preserving the bilateral articular process joints. The short-term effectiveness is good and it is expected to avoid fusion surgery caused by iatrogenic instability of the lumbar spine. However, further follow-up is needed to clarify the mid- and long-term effectiveness.

A new technique for low back pain in lumbar disc herniation: percutaneous endoscopic lumbar discectomy combined with sinuvertebral nerve ablation.

BACKGROUND: Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated efficacy in alleviating leg pain among patients with lumbar disc herniation. Nonetheless, residual back pain persists as a troubling issue for surgeons following the procedure. In the treatment of discogenic back pain, sinuvertebral nerve radiofrequency ablation has shown promising results. Nevertheless, the potential benefit of simultaneously implementing sinuvertebral nerve radiofrequency ablation during PELD surgery to address residual back pain has not been thoroughly investigated in current literature. METHODS: This retrospective study reviewed Lumbar disc herniation (LDH) patients with low back pain who underwent combined PELD and sinuvertebral nerve ablation in our department between January 2021 and September 2023. Residual low back pain post-surgery was assessed and compared with existing literature. RESULTS: A total of 80 patients, including 53 males and 27 females, were included in the study. Following surgical intervention, patients demonstrated remarkable improvements in pain and functional parameters. One month post-operatively, the VAS score for low back pain exhibited a 75% reduction (6.45 ± 1.3 to 1.61 ± 1.67), while the VAS score for leg pain decreased by 85% (7.89 ± 1.15 to 1.18 ± 1.26). Notably, the JOA score increased from 12.89 ± 5.48 to 25.35 ± 4.96, and the ODI score decreased form 59.48 ± 9.58 to 20.3 ± 5.37. These improvements were sustained at three months post-operatively. According to the modified Mac Nab criteria, the excellent and good rate was 88.75%. Residual low back pain is observed to be comparatively reduced compared to the findings documented in earlier literature. CONCLUSION: The combination of percutaneous endoscopic lumbar discectomy and sinuvertebral nerve ablation demonstrates effective improvement in low back pain for LDH patients.

Buck technique supplemented by temporary intersegmental pedicle screw fixation to repair lumbar spondylolysis in youth.

BACKGROUND: Lumbar spondylolysis is a bone defect in the pars interarticularis of the lumbar vertebral, which is a common cause of low back pain in youth. Although non-surgical treatment is a mainstream option, surgery is necessary for patients with persistent symptoms. Buck technique is widely used as a classical direct repair technique, but it cannot achieve reduction of low-grade spondylolisthesis and reconstruction of lumbosacral sagittal balance. We have described a novel surgical procedure based on Buck technique with temporary intersegmental pedicle screw fixation, and report a series of clinical outcomes in 5 patients to provide a reference for the clinical treatment of young lumbar spondylolysis. METHODS: Five young patients with symptomatic lumbar spondylolysis with a mean age of 19.20 ± 5.41 years underwent surgical treatment after an average of 7.60 ± 1.52 months of failure to respond to conservative treatment, using a new surgical procedure based on Buck technique combined with temporary intersegmental pedicle screw fixation. RESULTS: Five patients were successfully operated without serious complications such as nerve and vascular injury. The average operation time was 109.00 ± 7.42 min, the interpretative average blood loss was 148.00 ± 31.14 ml, and the average fusion time was 11.20 ± 1.64 months. All patients were followed up for 2 years after surgery, and the visual analogue score (VAS) of low back pain and Oswestry disability index (ODI) scores were significantly improved compared with those before surgery, and the Henderson's evaluation were rated excellent or good. After the removal of the internal fixation, it was observed that temporary intersegmental fixation could repair the isthmus, reduce lumbar spondylolisthesis, and reconstruct the sagittal balance of the lumbosacral vertebrae while preserving lumbar motion and preventing intervertebral disc degeneration. Postoperative MRI indicated the Pfirrmann classification of the affected discs: 1 case from grade III to grade II, 3 cases from grade II to grade I, and 1 case remained grade II. CONCLUSIONS: Buck technique supplemented by temporary intersegmental pedicle screw fixation is a highly applicable and effective method for the treatment of adolescent lumbar spondylolysis. The isthmic fusion is accurate, and temporary intersegmental fixation can effectively prevent disc degeneration and reconstruct the sagittal balance of lumbosacral vertebra.

Basivertebral Nerve Radiofrequency Ablation (Intracept): Procedural Technique.

Intraosseous basivertebral nerve ablation is indicated for the treatment of chronic vertebrogenic low back pain with failure of at least 6 months of conservative treatment. This article details patient positioning and setup, step-by-step instructions for the procedure, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper and can be found online (at https://vimeo.com/791578426/de0e90cfbe).

The effects of a prehabilitation programme based on therapeutic exercise, back care education, and pain neuroscience education in patients scheduled for lumbar radiculopathy surgery: A study protocol for a randomised controlled trial.

The aim of this present clinical trial is to evaluate the effectiveness of a multicomponent prehabilitation programme administered through educational videos versus another programme based on written exercise recommendations, in patients scheduled for lumbar radiculopathy surgery. This study will be a multicentre, controlled, randomised, parallel clinical trial. One hundred participants undergoing lumbar radiculopathy surgery who meet the established inclusion criteria will be recruited at different Spanish hospitals. The experimental group will follow a 4-week prehabilitation programme combining therapeutic exercise, back care education, and pain neuroscience education delivered through videos designed for consumption at home. The control group will be provided with written instructions to perform therapeutic exercises during the same prehabilitation time period. The primary outcome of the study will be disability, assessed using the Spanish version of the Oswestry Disability Index. The secondary outcomes will be pain perception, health-related quality of life, fear avoidance, kinesiophobia, catastrophising, anxiety, depression, physical activity, and the treatment satisfaction of the patients. This study will provide evidence for the effectiveness of a home-based multicomponent prehabilitation programme that addresses some already identified barriers to patient attendance in face-to-face programmes. Understanding the medium and long-term effects of pre-surgery lumbar muscle training and pain neuroscience education administered via instructional videos watched by patients at home, will help improve the design of prehabilitation programmes in this population while also improving the cost-effectiveness of such interventions.

Patient-reported outcomes after minimally invasive sacro-iliac joint surgery: a cohort study based on the Swedish Spine Registry.

BACKGROUND AND PURPOSE: There is conflicting evidence regarding treatment outcomes after minimally invasive sacroiliac joint fusion for long-lasting severe sacroiliac joint pain. The primary aim of our cohort study was to investigate change in patient-reported outcome measures (PROMs) after minimally invasive sacroiliac joint surgery in daily practice in the Swedish Spine Registry. Secondary aims were to explore the proportion of patients reaching a patient acceptable symptom score (PASS) and the minimal clinically important difference (MCID) for pain scores, physical function, and health-related quality of life outcomes; furthermore, to evaluate self-reported satisfaction, walking distance, and changes in proportions of patients on full sick leave/disability leave and report complications and reoperations. METHODS: Data from the Swedish Spine Registry was collected for patients with first-time sacroiliac joint fusion, aged 21 to 70 years, with PROMs available preoperatively, at 1 or 2 years after last surgery. PROMs included Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for low back pain (LBP) and leg pain, and EQ-VAS, in addition to demographic variables. We calculated mean change from pre- to postoperative and the proportion of patients achieving MCID and PASS. RESULTS: 68 patients had available pre- and postoperative data, with a mean age of 45 years (range 25-70) and 59 (87%) were female. At follow-up the mean reduction was 2.3 NRS points (95% confidence interval [CI] 1.6-2.9; P < 0.001) for LBP and 14.8 points (CI 10.6-18.9; P < 0.001) for ODI. EQ-VAS improved by 22 points (CI 15.4-30.3, P < 0.001) at follow-up. Approximately half of the patients achieved MCID and PASS for pain (MCID NRS LBP: 38/65 [59%] and PASS NRS LBP: 32/66 [49%]) and physical function (MCID ODI: 27/67 [40%] and PASS ODI: 24/67 [36%]). The odds for increasing the patient's walking distance to over 1 km at follow-up were 3.5 (CI 1.8-7.0; P < 0.0001), and of getting off full sick leave or full disability leave was 0.57 (CI 0.4-0.8; P = 0.001). In the first 3 months after surgery 3 complications were reported, and in the follow-up period 2 reoperations. CONCLUSION: We found moderate treatment outcomes after minimally invasive sacroiliac joint fusion when applied in daily practice with moderate pain relief and small improvements in physical function.

Coccygectomy for refractory coccydynia, old-fashioned but effective procedure: A retrospective analysis.

PURPOSE: Coccydynia, characterized by persistent pain in the coccygeal region, significantly impacts patients' quality of life. While various treatment modalities exist, including conservative measures and surgical interventions like coccygectomy, optimal management remains unclear. This retrospective cohort study aimed to compare the clinical outcomes, functional improvements, and quality of life in patients with chronic coccydynia undergoing either infiltrative treatment or coccygectomy. METHODS: Data from patients treated at our institution from January 2018 to December 2022 were analyzed. Participants meeting inclusion criteria were divided into two groups: Group A underwent coccygectomy, while Group B received conservative therapy. Clinical assessments, radiographic evaluations, and patient-reported outcomes were collected preoperatively and at follow-up intervals. RESULTS: Of the 223 initially examined patients, 55 met inclusion criteria. Group A (n = 21) underwent coccygectomy, while Group B (n = 34) received conservative therapy. Both groups showed significant pain reduction post-intervention, with sustained improvement in Group A. Functional outcomes favoured Group A, with significant improvements in disability and quality of life measures. Complications were minimal, with only one case of superficial wound infection in Group A. CONCLUSION: Our findings suggest that coccygectomy provides superior and lasting pain relief, functional improvement, and quality of life improvement compared to conservative therapy. While complications were minimal, further research with larger cohorts is warranted to validate these results and explore long-term outcomes. Despite its historical association with complications, advancements in surgical techniques and perioperative care have led to improved outcomes and reduced complication rates. Thus, coccygectomy should be considered in the treatment algorithm for patients with debilitating coccydynia.

A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up.

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Association between physical measures of spinopelvic alignment and physical functioning with patient reported outcome measures (PROMs) after total hip arthroplasty: Protocol for systematic review and meta-analysis.

INTRODUCTION: Prevalence of total hip arthroplasty (THA) has trended upwards over past decades and is projected to increase further. Optimizing outcomes after surgery is essential to avoid surgical revision and maximize outcomes. Low back pain is reported as a problem post THA. Patient-reported outcome measures (PROMs) are commonly used to evaluate THA outcomes but have limitations (e.g., ceiling effects). It is therefore important to assess a comprehensive range of outcomes. Physical outcome measures of spinopelvic alignment and physical functioning demonstrate potential value, but no evidence synthesis has investigated their association with PROMs. The objectives of this systematic review are to evaluate the association between spinopelvic alignment and physical outcome measures of physical functioning with PROMs and characteristics of low back pain after THA. METHODS AND ANALYSIS: This protocol is aligned with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Cross-sectional and longitudinal cohort studies evaluating the association between the physical outcome measures and PROMs (any outcome measures reported) following THA by any approach/implant will be included except surface replacement and revision THA. Studies investigating THA for developmental pathology and inflammatory conditions will be excluded. A systematic search in MEDLINE (Ovid), Embase (Ovid), Scopus, Web of Science, CINAHL, and the grey literature will be carried out from inception to July 31, 2023. Two independent reviewers will evaluate eligibility of retrieved articles, extract data and assess risk of bias (NIH quality assessment tool) of included studies. A third reviewer will mediate disagreements. Random-effects meta-analyses will be conducted if studies are sufficiently homogeneous in design, population, physical measures and PROMs; reporting odds ratios and 95% confidence intervals. Where meta-analyses are not possible, a narrative synthesis will be conducted. Confidence in cumulative evidence will be assessed using a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation). PROSPERO REGISTRATION NUMBER: PROSPERO Registration number CRD42023412744.

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

OBJECTIVE: Tubular microdiskectomy (tMD) is one of the most commonly used for treating lumbar disk herniation. However, there still patients still complain of persistent postoperative residual low back pain (rLBP) postoperatively. This study attempts to develop a nomogram to predict the risk of rLBP after tMD. METHODS: The patients were divided into non-rLBP (LBP VAS score < 2) and rLBP (LBP VAS score ≥ 2) group. The correlation between rLBP and these factors were analyzed by multivariate logistic analysis. Then, a nomogram prediction model of rLBP was developed based on the risk factors screened by multivariate analysis. The samples in the model are randomly divided into training and validation sets in a 7:3 ratio. The Receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the diskrimination, calibration and clinical value of the model, respectively. RESULTS: A total of 14.3% (47/329) of patients have persistent rLBP. The multivariate analysis suggests that higher preoperative LBP visual analog scale (VAS) score, lower facet orientation (FO), grade 2-3 facet joint degeneration (FJD) and moderate-severe multifidus fat atrophy (MFA) are risk factors for postoperative rLBP. In the training and validation sets, the ROC curves, calibration curves, and DCAs suggested the good diskrimination, predictive accuracy between the predicted probability and actual probability, and clinical value of the model, respectively. CONCLUSION: This nomogram including preoperative LBP VAS score, FO, FJD and MFA can serve a promising prediction model, which will provide a reference for clinicians to predict the rLBP after tMD.

Basivertebral nerve ablation with concurrent lumbar laminotomy.

Lumbar radiculopathy due to impingement of nerve roots from facet hypertrophy and/or disc herniation can often coincide with vertebrogenic low back pain. This is demonstrated on MRI with foraminal stenosis and Modic changes. We examine the potential of using a combination of basivertebral nerve ablation (BVNA) and lumbar laminotomy as an alternative to traditional spinal fusion in specific patient populations. This unique combination of surgical techniques has not been previously reported in the medical literature. We report a man in his late 30s with chronic low back pain and lumbar radiculopathy, treated with BVNA and concurrent laminotomy. The patient reported progressive improvements in his mobility and pain over the next 2 years. We discuss the advantages of using this technique for lumbar radiculopathy and Modic changes compared with conventional surgical modalities.

Impact of bilateral facet joint violation on radiographic degeneration of superior adjacent segments and clinical outcomes.

OBJECTIVE: Facet joint violation (FJV) is associated with postoperative low-back pain and is a confirmed risk factor for adjacent-segment degeneration, a long-term complication of lumbar fusion surgery. The authors' knowledge of its mechanisms comes from in vitro biomechanical research only; there is a lack of radiographic evidence of the effects of violation on the superior adjacent-segment facet joint, intervertebral disc, and other local radiographic parameters. Furthermore, any differences between unilateral and bilateral violation remain relatively unclear. The authors therefore aimed to explore the effects of nonviolation and unilateral and bilateral violation on radiographic degeneration of the facet joint and intervertebral disc at the fusion and superior adjacent segment. Patient-reported clinical outcomes were compared at the 2-year follow-up. METHODS: The authors retrospectively analyzed data from 148 patients with lumbar degenerative diseases who underwent single-segment minimally invasive transforaminal lumbar interbody fusion between 2016 and 2020. FJV and facet joint degeneration were evaluated and graded using Shah's method and Pathria's standard, respectively. Radiographic parameters, including disc height and intervertebral Cobb angle at the fusion and superior adjacent segment, were measured. Clinical outcomes were evaluated using visual analog scale (VAS) and Japanese Orthopaedic Association scores. RESULTS: Preoperative data were comparable among the 3 groups (nonviolation, unilateral violation, and bilateral violation) (p > 0.05). Patient-reported clinical outcomes were followed up for at least 2 years (average duration 28.17 ± 6.17 months). At the last follow-up, facet joint degeneration grades were sequentially increased in the nonviolation, unilateral violation, and bilateral violation groups (p = 0.006). The unilateral (2.45 ± 2.17 mm) and bilateral (2.70 ± 1.94 mm) violation groups had more severe losses of disc height in the superior adjacent segment than did the nonviolation group (1.31 ± 2.01 mm). The VAS low-back pain and Japanese Orthopaedic Association scores in the bilateral (2.57 ± 1.44 and 19.83 ± 2.84, respectively) and unilateral (2.26 ± 0.79 and 20.43 ± 3.85, respectively) violation groups were significantly worse than in the nonviolation group (1.69 ± 1.12 and 21.80 ± 3.36, respectively) (p < 0.05). By contrast, there were no significant between-group differences in disc height, intervertebral Cobb angle in the fusion segment, or VAS leg pain scores (p > 0.05). CONCLUSIONS: FJV was associated with postoperative low-back pain and worse functional outcomes. It also aggravated facet joint and intervertebral disc changes in the superior adjacent segment, especially when bilateral violation occurred; this may be part of the mechanisms of adjacent-segment degeneration.

[Progress of intraosseous basivertebral nerve ablation for symptomatic Modic alterations].

Chronic lumbar and back pain caused by degenerative vertebral endplates presents a challenging issue for patients and clinicians. As a new minimally invasive spinal treatment method, radiofrequency ablation of vertebral basal nerve in bone can denature the corresponding vertebral basal nerve through radiofrequency ablation of degenerative vertebral endplate. It blocks the nociceptive signal transmission of the vertebral base nerve, thereby alleviating the symptoms of low back pain caused by the degenerative vertebral endplate. At present, many foreign articles have reported the operation principle, operation method, clinical efficacy and related complications of radiofrequency ablation of the vertebral basal nerve. The main purpose of this paper is to conduct a comprehensive analysis of the current relevant research, and provide a reference for the follow-up clinical research.

Confirmatory study of the usefulness of quantum molecular resonance and microdissectomy for the treatment of lumbar radiculopathy in a prospective cohort at 6 months follow-up.

OBJECTIVES: Low back pain is a common musculoskeletal complaint and while prognosis is usually favorable, some patients experience persistent pain despite conservative treatment and invasive treatment to target the root cause of the pain may be necessary. The aim of this study is to evaluate patient outcomes after treatment of lumbar radiculopathy (LR) with quantum molecular resonance radiofrequency coblation disc decompression and percutaneous microdiscectomy with grasper forceps (QMRG). METHODS: This prospective cohort study was carried out in two Spanish hospitals on 58 patients with LR secondary to a contained hydrated lumbar disc hernia or lumbar disc protrusion of more than 6 months of evolution, which persisted despite conservative treatment with analgesia, rehabilitation, and physiotherapy, and/or epidural block, in the previous 2 years. Patients were treated with QMRG and the outcomes were measured mainly using the Douleur Neuropathique en 4 Questions, Numeric Rating Scale, Oswestry Disability Index, SF12: Short Form 12 Health Survey, Patient Global Impression of Improvement, Clinical Global Impression of Improvement, and Medical Outcomes Study Sleep Scale. RESULTS: Patients who received QMRG showed significant improvement in their baseline scores at 6 months post-treatment. The minimal clinically important difference (MCID) threshold was met by 26-98% of patients, depending on the outcome measure, for non-sleep-related outcomes, and between 17 and 62% for sleep-related outcome measures. Of the 14 outcome measures studied, at least 50% of the patients met the MCID threshold in 8 of them. CONCLUSION: Treatment of LR with QMRG appears to be effective at 6 months post-intervention.

Conjoined lumbosacral nerve root: a case report.

BACKGROUND: In patients with conjoined nerve roots, hemilaminectomy with sufficient exposure of the intervertebral foramen or lateral recess is required to prevent destabilization and ensure correct mobility of the lumbosacral spine. To the best of our knowledge, no case reports have detailed the long-term course of conjoined nerve roots after surgery. CASE PRESENTATION: We report the case of a 51-year-old Japanese man with a conjoined nerve root. The main symptoms were acute low back pain, radiating pain, and right leg muscle weakness. Partial laminectomy was performed with adequate exposure to the conjoined nerve root. The symptoms completely resolved immediately after surgery. However, the same symptoms recurred 7 years postoperatively. The nerve root was compressed because of foraminal stenosis resulting from L5-S disc degeneration. L5-S transforaminal lumbar interbody fusion was performed on the contralateral side because of an immobile conjoined nerve root. At 44 months after the second surgery, the patient had no low back pain or radiating pain, and the muscle weakness in the right leg had improved. CONCLUSIONS: This is the first report of the long-term course of conjoined nerve root after partial laminectomy. When foraminal stenosis occurs after partial laminectomy, transforaminal lumbar interbody fusion from the contralateral side may be required because of an immobile conjoined nerve root.

Disc herniation associated with butterfly vertebra anomaly.

Butterfly vertebra anomaly is a rare condition where the vertebral body fails to fuse during embryogenesis. In this case report, we present a 32-year-old male with progressive lower back pain and paralysis in both lower extremities. CT- and MR-scan showed an isolated L3 butterfly vertebra with a fusion of L2 and L3 discus through the defect and a discus prolapse compressing the spinal canal. The patient underwent successful decompressive surgery and experienced relief in symptoms post-operatively.

Multifidus lesions: A possible pathological component in patients with low back pain after posterior lumbar surgery.

There are few histological studies on multifidus after lumbar surgery, and it is not clear whether multifidus changes affect the clinical outcome after lumbar surgery. The aim of this study was to investigate the relationship between multifidus changes and clinical outcomes after lumbar surgery. Patients underwent internal fixation removal after lumbar posterior surgery were enrolled. Patients were divided into a low back pain (LBP) group (n = 15) and a non-low back pain (non-LBP) group (n = 10).The Oswestry disability index (ODI) and visual analog scale (VAS) were completed. 18 patients with lumbar fracture surgery were included as the control group. Multifidus morphological changes were observed by hematoxylin and eosin and Masson staining. The expression of TGF-ß1 was observed by immunohistochemistry, immunofluorescence and Western blot. The cross-sectional area (CSA) of the multifidus in the non-LBP group and the control group were greater than those in the LBP group. TGF-ß1 expression and gray value ratio in the non-LBP group and the control group were lower than those in the LBP group. The multifidus CSA and TGF-ß1 expression in multifidus were strongly correlated with ODI and VAS. Patients with LBP after posterior lumbar surgery suffered from atrophy and fibrosis lesions in the multifidus, and the degree of multifidus lesions was closely related to dysfunction and pain, which might be one of the causes of LBP after posterior lumbar surgery.

Middle cluneal nerve entrapment sites in the surgical field.

INTRODUCTION: Middle cluneal nerve (MCN) entrapment around the sacroiliac joint elicits low back pain (LBP). For surgical decompression to be successful, the course of the MCN must be known. We retrospectively studied the MCN course in 15 patients who had undergone MCN neurolysis. METHODS: Enrolled in this retrospective study were 15 patients (18 sides). We inspected their surgical records and videos to determine the course of the entrapped MCN. The area between the posterior superior- and the posterior inferior iliac spine was divided into areas A-D from the rostral side. The MCN transit points were identified at the midline and the lateral edge connecting the posterior superior- and posterior inferior iliac spine. Before and 6 months after surgery, the patients recorded the degree of LBP on the numerical rating scale and the Roland-Morris Disability Questionnaire. RESULTS: We decompressed 24 MCNs. The mean number was 1.3 nerves per patient (range 1-2). The MCN course was oblique in the cranio-caudal direction; the nerve tended to be observed in areas C and D. In six patients (40%), we detected two MCN branches, they were in the same area and adjacent. Postoperatively, LBP was improved significantly in all patients. CONCLUSION: Between the posterior superior- and the posterior inferior iliac spine, the MCN ran obliquely in the cranio-caudal direction; it was prominent in areas on the caudal side. In six (40%) patients, we decompressed two adjacent MCNs. Our findings are useful for MCN decompression surgery.