Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study.

Background: Chronic low back pain (CLBP) arising from degenerative disc disease continues to be a challenging clinical and diagnostic problem whether treated with nonsurgical, pain intervention, or motion-preserving stabilization and arthrodesis. Methods: Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnab's criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval. Results: The mean age was 46 ± 9.95 years. The mean symptoms duration was 21.21 ± 21.87 months. The mean follow-up was 15.3 ± 2.67 months. The preoperative VAS score of 7.79 ± 0.97 changed to 1.92 ± 1.38, postoperatively (P < 0.01). As per Macnab's criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes. Conclusion: The transforaminal epiduroscopic basivertebral nerve laser ablation (TEBLA) appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes.

Full Endoscopic Lumbar Discectomy using the Calcification Floating Technique for Symptomatic Partially Calcified Lumbar Herniated Nucleus Pulposus.

BACKGROUND: Partially calcified lumbar herniated nucleus pulposus (HNP) can cause severe radiating pain and neurologic symptoms requiring surgical treatment. As it is not safe to enforce conventional endoscopic lumbar discectomy using trephine or burr to remove the partially calcified disc, we report a calcification floating technique using a working channel for the treatment of these cases. METHODS: We retrospectively analyzed 31 patients who underwent full endoscopic discectomy using this technique for partially calcified lumbar HNP between April 2009 and June 2013. Calcification floating technique was performed by inserting the working channel around the partially calcified HNP and then rotating the working channel around it to remove the lesion. We analyzed the outcomes with a Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and complication rate. RESULTS: The mean follow-up period was 26.58 ± 11.2 months. The interlaminar approach was used in 15 cases, and the transforaminal approach was used in 16 cases. The mean VAS of 8.19 ± 0.65 before surgery was decreased to 1.29 ± 0.69 at the last follow-up. The mean ODI score before surgery was decreased at the last follow-up, from 41.32 ± 2.87 to 9.87 ± 3.47. Mean operative duration was 45 ± 12 minutes per level. None of the patients required revision surgery or developed any major complication. CONCLUSIONS: Calcification floating technique is a safe and effective method for the treatment of partially calcified lumbar HNP.

Percutaneous Endoscopic Interlaminar Unilateral Ventral Dural Approach for Symptomatic Bilateral L5-S1 Herniated Nucleus Pulposus: Technical Note.

BACKGROUND: Percutaneous endoscopic lumbar diskectomy is a good treatment modality for lumbar disk herniation. However, when a patient complains of bilateral lower limb radicular pain with severe disk protrusion at the L5-S1 level, the transforaminal approach is often unable to resolve both lesions owing to anatomical limitations. It is also very difficult to resolve both lesions in an ipsilateral direction using the percutaneous interlaminar approach. We report our surgical technique and clinical results using a ventral dural approach of percutaneous endoscopic interlaminar lumbar diskectomy for L5-S1 herniated nucleus pulposus (HNP) in patients with bilateral radiculopathy due to a severe disk protrusion. METHODS: Twenty-seven patients with severe L5-S1 HNP complaining of back pain and bilateral lower limb pain were included in the study. The unilateral ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy technique was used. The visual analog scale (VAS) and Macnab criteria were used for clinical evaluation. All assessments were completed 1 day before surgery, 1 week after surgery, 6 months after surgery, and at final follow-up after surgery. RESULTS: The mean preoperative back and leg pain VAS scores decreased from 5.67 ± 0.78 and 7.81 ± 0.83 to 2.44 ± 0.58 and 2.26 ± 0.53 at 1 week, 1.78 ± 0.51 and 1.52 ± 0.58 at 6 months, and 1.56 ± 0.70 and 1.67 ± 0.96, respectively, at the final follow-up after surgery. With respect to the Macnab criteria, 51.85% of the results were excellent, 44.44% were good, and 3.70% were fair. Four cases recurred: three patients underwent conservative treatment and one patient operated with percutaneous endoscopic interlaminar lumbar diskectomy. CONCLUSION: According to the results of this study, the ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy in patients with L5-S1 HNP associated with bilateral lower limb pain due to a severely protruded HNP is a good option for a minimally invasive surgical approach.

Suprapedicular Circumferential Opening Technique of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for High Grade Inferiorly Migrated Lumbar Disc Herniation.

PURPOSE: To evaluate the efficacy of suprapedicular circumferential opening technique (SCOT) of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) for high grade inferiorly migrated lumbar disc herniation. MATERIAL AND METHODS: Eighteen consecutive patients who presented with back and leg pain with a single-level high grade inferiorly migrated lumbar disc herniation were included. High grade inferiorly migrated disc was removed by the SCOT through PETLD approach. Outcome evaluation was done with visual analog scale (VAS) and Mac Nab's criteria. RESULT: There were 14 males and 4 females. The mean age of patients was 53.3 ± 14.12 years. One, 4, and 13 patients had disc herniation at L1-2, L3-4, and L4-5 levels, respectively, on MRI, which correlated with clinical findings. The mean follow-up duration was 8.4 ± 4.31 months. According to Mac Nab's criteria, 9 patients (50%) reported excellent and the remaining 9 patients (50%) reported good outcomes. The mean preoperative and postoperative VAS for leg pain were 7.36 ± 0.73 and 1.45 ± 0.60, respectively (p < 0.001). Improvement in outcomes was maintained even at final follow-up. There was no complication. CONCLUSION: In this preliminary study we achieved good to excellent clinical results using the SCOT of PETLD for high grade inferiorly migrated lumbar disc herniation.

Lumbar chronic subdural hematoma mimicking an intradural extramedullary tumor: A case report.

BACKGROUND: Chronic spinal subdural hematomas are extremely rare with only 28 cases reported in the literature. Nevertheless, they should be considered among the differential diagnoses for spinal intradural/extramedullary lesions. CASE REPORT: A 65-year-old male presented with progressive back pain and right S1 radiculopathy. Magnetic resonance imaging scan revealed a right-sided posterolateral intradural/extramedullary lesion at the L5-S1 level. It was hyperintense on T1 and hypointense on T2-weighted images; on the short TI inversion recovery sequence it was hyperintense. The lesion was excised through a right L5 hemilaminectomy, and the patient was neurologically intact postoperatively. Histopathology revealed a chronic subdural hematoma. CONCLUSION: Chronic spinal subdural hematoma can mimic intradural extramedullary spinal tumors even in the absence of trauma and/or coagulopathies.

Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk.

OBJECTIVE: Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) can be performed by using foraminal, intervertebral, and suprapedicular routes. The aim of this study was to assess clinical results of three different routes of PETLD. METHODS: One hundred eleven patients who underwent PETLD between January 2016 and October 2016 were included in this study. PETLD was performed using the foraminal (group A), intervertebral (group B), and suprapedicular (group C) routes in 32, 46, and 33 patients, respectively. Outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria. RESULTS: Seventy-one men and 40 were women (mean age 53.33 ± 14.12 years). The mean follow-up period was 6.44 ± 3.26 months. The preoperative VAS score decreased significantly (P < 0.01) in all 3 groups, but the postoperative VAS score was higher for the foraminal route than for the intervertebral (P = 0.001) and suprapedicular routes (P < 0.001). Excellent outcome grade according to MacNab criteria was less in foraminal route (18.7%) than in intervertebral (52.2%) and suprapedicular (56.7%) routes. ODI improved significantly (P < 0.01) in all 3 groups. CONCLUSION: All 3 routes of PETLD resulted in good to excellent clinical results. Nevertheless, the postoperative VAS score was higher for the foraminal route than for the intervertebral and suprapedicular routes, probably not because of the surgery but because of the neurologic characteristics of the disk location. The surgeon should consider this problem to alleviate pain postoperatively and counsel to patient well before surgery.

Percutaneous Full Endoscopic Treatment of Bertolotti Syndrome: A Report of Three Cases with Technical Note.

Background Bertolotti syndrome is characterized by an abnormal enlargement of the transverse process of the most caudal lumbar vertebra. Most of the time it is asymptomatic, but when it is symptomatic it is associated with low back pain, radiating leg pain, or both. There is no consensus regarding management of this pathology. Open to minimal invasive tubular resection techniques are described in the literature, but a full endoscopic resection technique has not yet been described. Endoscopic technique is a less invasive target-oriented iliolumbar ligament preserving technique. We report our percutaneous full endoscopic technique for the treatment of symptomatic Bertolotti syndrome. Method We have treated three symptomatic cases of Bertolotti syndrome with the percutaneous endoscopic technique. We review the feasibility of this technique and the outcomes. Result Full endoscopic resection of Bertolotti syndrome is feasible and safe with comparable good outcomes and the added benefits of minimal invasive surgery. Conclusion We believe this novel percutaneous full endoscopic technique will yield good results in the hands of expert endoscopic spine surgeons and can be an alternative treatment method in cases of symptomatic Bertolotti syndrome. To our knowledge this is the first report of percutaneous full endoscopic treatment of Bertolotti syndrome in the world.

Mutan: A mixed linkage α-[(1,3)- and (1,6)]-d-glucan from Streptococcus mutans, that induces osteoclast differentiation and promotes alveolar bone loss.

Mutan is an extracellular polysaccharide of Streptococcus mutans (S. mutans) that consists of α-(1,3)-linked glucose residues in main chains and α-(1,6) bonds in side chains. In the present study, mutan was isolated from S. mutans, and its structural characteristics were determined using Fourier-transform infrared spectroscopy (FT-IR) and (13)C nuclear magnetic resonance (NMR) spectroscopy. The effects of mutan on RANKL-induced osteoclast differentiation in RAW 264.7 cells were examined. Furthermore, microCT and morphometric analyses were used to determine the contribution of mutan to alveolar bone loss in the maxilla of a rat periodontitis model. Mutan increased (more than 2-fold) RANKL-induced osteoclast differentiation in a dose-dependent manner. Mutan also enhanced the alveolar bone loss in the rat maxilla 2.3-fold. In mutan-treated rats, the bone mineral density, bone volume, trabecular number, and trabecular thickness decreased, whereas trabecular separation significantly increased. In addition, mutan and lipopolysaccharide (LPS) induced similar microarray profiles in RAW 264.7 cells. A total of 43 genes related to osteoclastogenesis were differentially expressed after either mutan or LPS treatment. Five-fold increases in the expression of several genes, including IL-1ß, IL-1α, IL-6, and chemokine ligands, were observed in mutan-treated RAW 264.7 cells. These results suggest a molecular mechanism for the inflammation induced by S. mutans during the establishment of periodontal disease.

Lactobacillus plantarum lipoteichoic acid alleviates TNF-α-induced inflammation in the HT-29 intestinal epithelial cell line.

We recently observed that lipoteichoic acid (LTA) isolated from Lactobacillus plantarum inhibited endotoxin-mediated inflammation of the immune cells and septic shock in a mouse model. Here, we examined the inhibitory role of L. plantarum LTA (pLTA) on the inflammatory responses of intestinal epithelial cells (IEC). The human colon cell line, HT-29, increased interleukin (IL)-8 expression in response to recombinant human tumor necrosis factor (TNF)-alpha, but not in response to bacterial ligands and interferon (IFN)-gamma. TNF-α also increased the production of inducible nitric oxide synthase (iNOS), nitric oxide (NO), and intercellular adhesion molecule 1 (ICAM-1) through activation of p38 mitogen-activated protein kinase (MAPK) from HT-29 cells. However, the inflammatory response of HT-29 on TNF-α stimulation was significantly inhibited by pLTA treatment. This pLTA-mediated inhibition accompanied the inhibition of nuclear factor (NF)-kappa B and MAPKs. Our data suggest that pLTA regulates cytokine-mediated immune responses and may be a good candidate for maintaining intestinal homeostasis against excessive inflammation.

Capillary hemangioma of the thoracic spinal cord.

Capillary hemangiomas are common soft tissue tumors on the skin or mucosa of the head and neck in the early childhood, but very rare in the neuraxis. A 47-year-old man presented with one month history of back pain on the lower thoracic area, radiating pain to both legs, and hypesthesia below T7 dermatome. Thoracic spine MRI showed 1×1.3×1.5 cm, well-defined intradural mass at T6-7 disc space level, which showed isointensity to spinal cord on T1, heterogeneous isointensity on T2-weighted images, and homogeneous strong enhancement. The patient underwent T6-7 total laminotomy, complete tumor removal and laminoplasty. Histologically, the mass showed a capsulated nodular lesion composed of capillary-sized vascular channels, which were tightly packed into nodules separated by fibrous septa. These features were consistent with capillary hemangioma.

Inhibitory effects of Lactobacillus plantarum lipoteichoic acid (LTA) on Staphylococcus aureus LTA-induced tumor necrosis factor-alpha production.

Staphylococcus aureus is a common etiologic agent for Gram-positive sepsis, and its lipoteichoic acid (LTA) may be important in causing Gram-positive bacterial septic shock. Here, we demonstrate that highly purified LTA (pLTA) isolated from Lactobacillus plantarum inhibited aureus LTA (aLTA)-induced TNF-alpha production in THP- cells. Whereas pLTA scarcely induced TNF-alpha production, aLTA induced excessive TNF-alpha production. Interestingly, aLTA-induced TNF-alpha production was inhibited by pLTA pretreatment. Compared with pLTA, aLTA induced strong signal transduction through the MyD88, NF-kappaB, and MAP kinases. This signaling, however, was reduced by a pLTA pretreatment, and resulted in the inhibition of aLTA-induced TNF-alpha production. Whereas dealanylated LTAs, as well as native LTAs, contributed to TNF- induction or TNF-alpha reduction, deacylated LTAs did not, indicating that the acyl chain of LTA played an important role in the LTA-mediated immune regulation. These results suggest that pLTA may act as an antagonist for aLTA, and that an antagonistic pLTA may be a useful agent for suppressing the septic shock caused by Gram-positive bacteria.

Development of a monitoring vector for Leuconostoc mesenteroides using the green fluorescent protein gene.

The vector pCW5 with plasmid pC7, originally isolated in Lactobacillus paraplantarum C7 derived from kimchi, was constructed using a p32 strong promoter, the pC7 replicon, and green fluorescent protein (GFP) as the reporter. The constructed vector was transformed into E. coli and Leuconostoc mesenteroides, and GFP expression detected using a Western blot analysis. GFP fluorescence was recognized in E. coli and Leuconostoc mesenteroides using a confocal microscope. In addition, GFP fluorescence was also clearly detected in several industrially important lactic acid bacteria (LAB), including Lactobacillus bulgaricus, Lactobacillus paraplantarum, and Lactobacillus plantarum. Thus, pCW5 was shown to be effective for Leuconostoc mesenteroides when using GFP as the reporter, and it can also be used as a broad-host-range vector for other lactic acid bacteria.

Construction of a pTOC-T vector using GST-ParE toxin for direct cloning and selection of PCR products.

Using linker insertion mutations, we determined the most stable region of the parE gene which encodes a toxic protein (ParE) that inhibits growth of Escherichia coli. The toxicity of ParE was sustained until a 144 bp linker was inserted into this region. We have developed a 3' T-overhang vector based on these characteristics of the GST-ParE toxin, and named pTOC-T. Because pTOC-T uses a post-segregational killing system, all transformants grown up on the plates can be considered as recombinants containing foreign DNA. pTOC-T not require X-Gal, IPTG or other substrates for selection. This T-vector using a positive selection system can be applied to various E. coli strains such as XL1-Blue, BL21, DH5alpha, JM109, and JM110.

New integration vector using a cellulase gene as a screening marker for Lactobacillus.

The new integration vector for Lactobacillus, pJC4, was developed using the extracellular endoglucanase A gene (celA) of Clostridium thermocellum as a screening marker. pJC4 was transformed into four Lactobacillus species, Lb. johnsonii, Lb. gasseri, Lb. bulgaricus, and Lb. plantarum. In each species, the pJC4 integrants were easily and accurately detected by the appearance of a clear halo on a cellulase screening plate without any false transformants. Polymerase chain reaction and Southern hybridization indicated that all transformants with clear halos contained pJC4 in their chromosomal DNAs. The celA gene could be a useful screening marker for other lactic acid bacteria.