Clinical Outcome for Lumbar Disc Herniation Treatment with Intradiscal Oxygen-ozone Therapy.

BACKGROUND: Low back pain due to disc herniation is a common problem causing frequent hospital visits and loss of working days with major socio-economic impact. Conservative treatments like analgesics, physiotherapy do not work in all patients. Surgical treatment has been the mainstay of treatment when indicated but is associated with anesthetic and surgical complications. Intradiscal oxygen-ozone chemonucleolysis is a minimally invasive procedure done under local anesthesia and has promising role in shrinking the bulged disc and reducing nerve root compression and related symptoms. This retrospective study was done to see how intradiscal oxygen-ozone chemonucleolysis reduces pain severity in patients with discogenic low back pain. METHODS: Retrospective data were retrieved of those patients who underwent fluoroscopy guided intradiscal oxygen-ozone chemonucleolysis with 5-6 ml of an O2-O3 mixture (concentration of 30 microgram/ml) during a period of two years in Nepal pain care and research center. Numerical pain scale (NRS) at various follow ups were compared to preprocedural NRS. RESULTS: Preprocedural NRS was 8± 13. NRS at three hours, one week, one month, three months and six months were 2± 13 (73 percent reduction), 2± 53 (68 percent reduction), 2± 27 (72 percent reduction), 1± 08 (77 percent reduction) and 1± 67 (79 percent reduction) respectively. CONCLUSIONS: Intradiscal oxygen-ozone chemonucleolysis can be a useful modality of treatment for discogenic low back pain in patients who fail to respond to conservative management and in whom surgery is not indicated.

Predictive value of S100B and brain derived neurotrophic factor for radiofrequency treatment of lumbar disc prolapse.

BACKGROUND: This work aimed to analyze serum S100B levels and brain-derived neurotrophic factor (BDNF) in patients with lumbar disc prolapse to test their predictive values concerning the therapeutic efficacy of pulsed radiofrequency. METHODS: This prospective interventional study was carried out on 50 patients candidates for radiofrequency for treating symptomatic lumbar disc prolapse. Pain severity and functional disability were assessed using the Numeric Rating Scale (NRS) and Functional rating index (FRI) before as well as two weeks, 1, 3, and 6 months after the radiofrequency. Quantitative assessment of serum S100B level and BDNF was done for all the included patients one day before radiofrequency. RESULTS: The scores of NRS and FRI were significantly improved at two weeks, 1, 3, and 6 months following radiofrequency (P-value < 0.001 in all comparisons). Statistically significant positive correlations were found between duration of pain, NRS, and S100B serum level before radiofrequency, and both NRS (P-value = 0.001, 0.035, < 0.001 respectively) and FRI (P-value = < 0.001, 0.009, 0.001 respectively) 6 months following radiofrequency. Whereas there were statistically significant negative correlations between BDNF serum level before radiofrequency and both NRS and FRI 6 months following radiofrequency (P-value = 0.022, 0.041 respectively). NRS and S100B serum levels before radiofrequency were found to be independent predictors of NRS 6 months following radiofrequency (P-value = 0.040. <0.001, respectively). CONCLUSION: Serum level of S100B is a promising biomarker that can predict functional outcomes after pulsed radiofrequency in patients with lumbar disc prolapse.

Alkaptonuria Presenting With Lumbar Disc Herniation: A Case Report.

Alkaptonuria is a rare autosomal recessive trait. Symptomatic lumbar disc herniation warranting surgical intervention is a rare scenario in alkaptonuria and only a few cases have been described in the literature. We present one such rare case of alkaptonuria in a 31-year-old female presenting with low back pain and left leg radiculopathy not relieved with conservative management. Roentgenograms of the lumbar spine revealed wafer-like disc calcifications and MRI showed a herniated disc at the L4-L5 level with deeply hypointense disc spaces in T2 suggestive of disc calcification and associated modic type 2 changes. During the surgery, the disc material removed was black in color, which raised a clinical suspicion of alkaptonuria. Postoperatively, the patient was re-examined and urine homogentisic acid was found to be raised. This, along with a histopathological examination, was diagnostic of alkaptonuria. The patient had excellent relief of symptoms postoperatively. In conclusion, if a 'black disc' is found during surgery, retrospective analysis and re-examination of patient clinical features and urine examination have to be done to diagnose alkaptonuria. While making a differential diagnosis of degenerative disc disease in patients with a calcified disc seen on radiography, a high index of suspicion for alkaptonuria has to be maintained.

Effect of Radiofrequency on Dorsal Root Ganglion Versus Transforaminal Steroids Injection on Tumor Necrosis Factor-Alpha Level in Lumbar Radicular Pain.

BACKGROUND: The mechanism of pain control with pulsed radiofrequency (PRF) is unclear. OBJECTIVES: We aimed to compare the efficacy of combined PRF on dorsal root ganglion (DRG) with transforaminal epidural steroid injection (TFESI) vs TFESI-alone on pain improvement and serum tumor necrosis factor-alpha (TNF-a) level in lumbar disc-related radicular pain. STUDY DESIGN: Prospective, randomized, controlled trial. SETTING: Neurology and Pain Management clinics. METHODS: A total of 80 patients with lumbar disc prolapse were divided into 2 groups: combined PRF on DRG with TFESI group and TFESI-alone group. The Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), and Functional Rating Index (FRI) before intervention and at 2 weeks, 1 month, and 3 months after the intervention were observed. Serum TNF-a level was assessed pre- and post-intervention at 3 months. RESULTS: The scores of NRS-11, ODI, and FRI showed a significant improvement at 2 weeks, 1 month, and 3 months following intervention in both combined PRF & TFESI group and TFESI-alone group (P < 0.001 in all comparisons), with no significant difference between the 2 groups. Serum TNF-a levels showed a statistically significant reduction, 3 months following intervention in the combined PRF & TFESI group (P < 0.001), but not in the TFESI-alone group (P = 0.297) (P between groups < 0.001). LIMITATIONS: The main limitation of this study is that TNF-a level was not assessed earlier to see how long the steroids might reduce TNF-a. On the other hand, further study with extended follow-up periods is needed to confirm the long-term lowering effect of TNF-a provided by PRF. CONCLUSIONS: Combined PRF on DRG with TFESI showed similar outcomes to TFESI-alone in relieving pain in patients with lumbar disc prolapse. However, PRF on DRG caused a significant decrease in TNF-a serum levels at 3 months.

Outcome of Transforaminal Endoscopic Discectomy in Rural India in a Single-Level Lumbar Disc Prolapse Under Local Anesthesia.

Aim The aim of this study was to undertake a clinical study to evaluate the outcomes of transforaminal endoscopic discectomy under local anesthesia and to study the complication rate. Study Design It is a prospective study. Methods We prospectively analyzed outcomes of 60 patients with a single-level lumbar disc prolapse in rural India from December 2018 to April 2020 who underwent endoscopic discectomy under local anesthesia. Follow-up was done using the visual analogue score (VAS) and Oswestry Disability Index (ODI) scoring systems with a minimum follow-up up to 1 year postoperatively. Results In our study of 60 patients, there was 38 cases of L4-L5 disc pathology, 13 L5-S1 discs, and 9 L3-L4 discs. Our study showed a significant clinical reduction in mean VAS score that was 7.07/10 preoperatively and reduced to 3.88/10 at the third month and 3.64/10 at 1 year of follow-up ( p -value < 0.05) showing clinical significance. The ODI scoring done preoperatively was an average mean of 57.37% pointing to how crippled the patients were with lumbar disc prolapse and showed a significant reduction to 29.32% postoperatively at 1 year ( p -value < 0.05) showing clinical significance. This reduction in ODI directly corelates to how almost all patients returned to normal life coping to all activities and were completely pain free at 1 year of follow-up. Conclusion Endoscopic spine surgery in lumbar disc prolapse is highly effective and can deliver a good functional outcome if done with correct preoperative planning and approach.

Pediatric lumbar disc herniation: A case series on diagnosis and management.

Pediatric disc herniation is an uncommon but significant illness in children that can cause debilitating symptoms. The prevalence rate of lumbar disc herniation in this group is unknown. We present 4 rare cases of lumbar disc herniation in children. All patients complained from low back pain with radiation to the corresponding leg along with other neurological manifestations. Trauma and family history for all patients were negative. Magnetic Resonance Imaging (MRI) was performed for all patients and confirmed the diagnosis in all cases. All patients were treated conservatively without any improvement, thus surgical intervention (minimally invasive discectomy with foraminotomy) was performed. The importance of early identification and adequate care in pediatric patients with lumbar disc herniation cannot be overstated. More study is needed to better understand the risk factors, pathophysiology, and best treatments for this illness in children and adolescents.

Novel technique to reduce prolapsed device in atrial septal defect closure.

Objective: Transcatheter closure of atrial septal defect (ASD) has become an alternative treatment to surgical repair. One of the challenges is the prolapse of the left atrial disc during the procedure. Many techniques have been developed to prevent the prolapse but not reduce it. In this study, we present a novel technique, termed push back technique, that help reduce the prolapsed device. Methods: We enrolled 24 patients (8 males, 16 females) between May 2008 and January 2023 who underwent the push back technique during transcatheter closure of ASD in Taichung Veterans General Hospital. We recorded the hemodynamic data, success rate and complications including device embolization/migration, valvular regurgitation, pericardial effusion, and residual shunt. Results: The median age was 6.3 years (1.2-70.5 years) and the median weight was 19.1 kg (7.8-90 kg). Fifteen (62.5%) patients had mild pulmonary hypertension. The median Qp/Qs was 2.54 (1.5-8.8). The median ASD stretched size was 21.2 mm (7.7-35.3 mm). The median device size was 22 mm (8-40 mm). The median fluoroscopy time was 14 min (5-23 min) and median procedure time was 47 min (25-78 min). The push back technique successfully reduced the prolapsed device in 21 (87.5%) patients. There was no complication in all patients. Conclusion: We present a novel push back technique that can successfully reduce the prolapsed device in 87.5% (21/24) patients without complications. It is feasible, safe and effective.

Full endoscopic spine surgery.

Background: With a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries. Purpose: Full endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives. Conclusion: Full endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

A Severe Disc Herniation Mimics Spinal Tumor.

Lumbar disc herniation (LDH) is prevalent among adults aged 25-55 years who spend a considerable proportion of their time sitting or standing with heavy workloads. We report the case of a 33-year-old male waiter with severe LDH, causing compression of the nerve roots and spinal cord with neurological dysfunction, who presented to a chiropractic clinic. Magnetic resonance imaging (MRI) revealed a radiological differential diagnosis comprising LDH and an epidural mass lesion. To rule out serious pathology, a second MRI with contrast was ordered, which confirmed the diagnosis of severe LDH. Diagnosing large LDH may be challenging, and severe disc herniation often mimics spinal tumors. This study offers insights into the differential diagnosis of LDH and spinal tumors, as well as the design of a treatment strategy for severe LDH in the chiropractic clinic.

Non-iatrogenic spontaneous acute spinal subdural haematoma after transforaminal lumbar interbody fusion.

PURPOSE: Reporting a rare case of a non-iatrogenic spontaneously resolved spinal subdural haematoma (SSDH) following revision of transforaminal lumbar interbody fusion (TLIF) and its possible explanation. METHODS: Case report of a 40-year-old man with a history of persistent lower back and left lower extremity radicular pain, secondary to recurrent disc prolapse, lumbar spondylosis with foraminal stenosis. He underwent an L5/S1 transforaminal interbody fusion via a right sided approach (through previous lumbar microdiscectomy incision). On post-operative day two, the patient developed headache and photophobia that were discovered to be secondary to an acute thoracolumbar subdural haematoma with no objective neurological deficit. RESULTS: After close observation of his neurological status and conservative management of the subdural haematoma, the patient fully recovered from his symptoms and remained problem-free at 2-year follow-up. CONCLUSIONS: Although the occurrence of acute spinal subdural haematoma after spinal surgery is a rare complication following spinal surgery, its appropriate management relies on early recognition if significant morbidity is to be avoided.

Functional Outcomes and Successful Predictors of Lumbar Transforaminal Epidural Steroid Injections (LTFESIs) for Lumbar Radiculopathy Under Fluoroscopic Guidance: A Prospective Study.

BACKGROUND: Lumbar radiculopathy, a common and debilitating condition, often necessitates a multimodal approach for effective management. Lumbar transforaminal epidural steroid injection (LTFESI) has emerged as a valuable therapeutic option when conservative measures fall short. Recent interest in long-acting and non-particulate steroids prompts a critical examination of their impact on LTFESI outcomes. This prospective study aims to evaluate the efficacy of LTFESI in improving pain and functional outcomes in patients with lumbar radiculopathy, focusing on long-acting and non-particulate steroids, and analyse the associated economic burden. METHODS: The study, conducted from October 2017 to April 2019, involved 52 patients with lumbar radiculopathy meeting specific criteria. LTFESI was administered using a hospital-based prospective design. Functional outcomes were assessed using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) scores at various intervals. Statistical analyses were performed to identify predictors of successful outcomes. RESULTS: Participants (average age 43.22 years, 27 (51.92%) male) exhibited diverse Michigan State University (MSU) grade profiles and predominantly had pathology at the L4-5 level. The study demonstrated a significant and lasting functional improvement in 43 (82.69%) of patients after LTFESI. Patients with 2AB-type intervertebral disc prolapse (IVDP) showed lower response rates, emphasizing subtype influence. The efficacy of LTFESI was sustained for up to six months in almost 82.69% of patients, highlighting its potential for long-lasting benefits. The difference in the mean ODI score pre-injection and six months post-injection is statistically significant (p<0.0001). A total of four patients (7.69%) underwent surgical treatment for lumbar radiculopathy as their symptoms did not improve after injection. For all four patients (7.69%), surgery was done one month after injection. Five patients (9.61%) had ODI scores of more than 40, indicating severe disability at the end of six months. So, in nine patients (17.3%), the injection given was not effective at the end of six months, four (7.69%) of whom were operated on and five (9.61%) patients received conservative treatment. Thus, 43 (82.69%) of patients had a good outcome. DISCUSSION: The study reinforces LTFESI as an effective and safe intervention, providing substantial and lasting benefits for lumbar radiculopathy. The majority experienced immediate relief, supporting its role as an intermediate option between conservative management and surgery. Identified predictors of decreased success underscore the importance of early intervention and tailored treatment plans. The study emphasizes LTFESI's diagnostic and therapeutic potential, with economic benefits and safety highlighted. CONCLUSION: LTFESI emerges as a safe and effective intervention for lumbar radiculopathy, offering substantial and enduring pain relief. The study contributes valuable insights into the nuanced outcomes of LTFESI, including the impact of IVDP subtypes, factors influencing success, and the procedure's cost-effectiveness. While acknowledging limitations, this work adds to the growing evidence supporting LTFESI as a crucial component in the management of lumbar radiculopathy.

Relationship between Facet Joint Tropism with Lumbar Disc Herniation at A Particular Motion Segment.

BACKGROUND: Lumbar disc herniation is one of the important and common causes of low back pain. There are various modifiable and non-modifiable risk factors for the development of lumbar disc herniation. Any change in the orientation or asymmetry of the facet joint i.e. facet tropism may lead to abnormal shearing stress on the intervertebral disc and may lead to development of disc herniation. METHODS: This is a cross-sectional observational study of 46 patients aged 18-40 years with clinical features of Prolapsed Intervertebral Disc and Magnetic Resonance Imaging evidence of single level prolapsed disc who presented to Tribhuvan University Teaching Hospital from December 2019 to June 2021. MRI measurement of facet tropism of normal level (L4-L5 or L5-S1) adjacent to herniated level was used for comparison. The p - value ≤ 0.05 was considered statistically significant. Overall association of tropism with lumbar disc herniation in affected and normal level combined and at each individual level was studied using McNemar Test. RESULTS: We found a highly significant association of facet tropism with lumbar disc herniation (p-value <0.001). Considering the individual levels, at L4-L5 level, the association between facet tropism and lumbar disc herniation was highly significant (p-value <0.001). However, at L5-S1 level the association was not significant (p-value <0.388). CONCLUSIONS: The results of our study show strong association between FT and lumbar disc herniation at a particular motion segment.

Full-endoscopic versus conventional microsurgical therapy of lumbar disc herniation: a prospective, controlled, single-center, comprehensive cohort trial (FEMT-LDH trial).

BACKGROUND: Lumbar disc herniation is one of the leading causes of chronic low back pain. Surgery remains the therapy of choice when conservative approaches fail. Full-endoscopic approaches represent a promising alternative to the well-established microsurgical technique. However, high-grade evidence comparing these techniques is still scarce. METHODS: Patients presenting with lumbar disc herniation will be included. The intervention group will obtain full-endoscopic disc decompression, whereas the control group will be treated by microsurgical disc decompression. We will apply a comprehensive cohort study design involving a randomized and a prospective non-randomized study arm. Patients who do not consent to be randomized will be assigned to the non-randomized arm. The primary outcome will be the Oswestry Disability Index (ODI). Secondary outcomes involve the visual analog scale (VAS) of pain and the SF-36 health questionnaire. Furthermore, clinical characteristics including duration of hospital stay, operation time, and complications as well as laboratory markers, such as C-reactive protein, white blood cell counts, and interleukin 6 will be determined and compared. DISCUSSION: This study will significantly contribute to the current evidence available in the literature by evaluating the outcome of the full-endoscopic technique against the gold standard for lumbar disc herniation in a clinically relevant study setup. Additionally, the study design allows us to include patients not willing to be randomized in a prospective parallel study arm and to evaluate the impact of randomization on outcomes and include. The results could help to improve the future therapy in patients suffering from lumbar disc herniation. TRIAL REGISTRATION: This study was prospectively registered in The German Clinical Trials Register (DRKS), a German WHO primary registry, under the registration number: DRKS00025786. Registered on July 7, 2021.

'White Cord Syndrome': A Rare Catastrophic Complication Following Anterior Cervical Discectomy and Fusion.

Background: 'White-cord syndrome' is an extremely rare entity following decompression of cervical cord in which post-operative reperfusion injury results in worsening of patient's neurology and MRI reveals signal changes in spinal cord in absence of cord compression. We wish to report a case of 'white-cord syndrome' following a 'routine' ACDF. Case Description: A 39-year-old woman with paresthesias and spastic quadriparesis was found to have C5-C6 PIVD on MRI. ACDF was performed at C5-C6, after which worsening of quadriparesis was noted, for which intravenous high-dose steroids were started. An urgent MRI was done, which revealed findings of white-cord syndrome, without compression on underlying cord. With conservative management, her ASIA grade improved from C to D and the features of white-cord syndrome disappeared on follow-up imaging. Conclusion: It is important for surgeons and patients to be aware of this rare but potentially catastrophic entity as this needs to be discussed while taking consent for surgery.

Horner's syndrome secondary to T1-T2 intervertebral disc prolapse.

Background: T1-T2 intervertebral disc prolapse (IVDP) is a rare clinical condition. Horner's syndrome is an extremely rare clinical finding in these patients. Case Description: A 56-year-old man presented with the left C8 T1 radiculopathy, left hand grip weakness, and ipsilateral Horner's syndrome. Magnetic resonance imaging of the spine showed a contrast-enhancing lesion in the left T1 foramen compressing the left T1 nerve root. He underwent left T1 hemilaminectomy, upper half of left T2 hemilaminectomy and removal of the left foraminal lesion. A biopsy of the lesion was sent for histopathological diagnosis which revealed tissue consistent with disc material. Postoperatively, he had near-complete recovery with residual minimal Horner's syndrome. Conclusion: T1-T2 IVDP should be considered in the differential diagnosis when a patient presents with C8 T1 radiculopathy and Horner's syndrome.

Comparative effect of transforaminal injection of Magnesium sulphate versus Ozone on oxidative stress biomarkers in lumbar disc related radicular pain.

BACKGROUND: We aimed to investigate the effect of transforaminal injection of Magnesium sulphate versus Ozone on pain intensity, functional disability and the oxidative stress biomarkers; superoxide dismutase (SOD) and Glutathione (GSH) in patients with lumbar disc prolapse. METHODS: This randomized controlled trial was conducted on 135 patients having symptomatic lumbar disc prolapse, received either transforaminal injection of Magnesium sulphate with steroids, Ozone with steroids, or steroids alone. Assessment of pain severity and functional disability were done before intervention, 2 weeks, 1, 3, and 6 months after intervention. Serum SOD and GSH were measured for all included patients before and 2 weeks after intervention. RESULTS: There was a statistically significant improvement in pain intensity and functional disability 2 weeks after intervention in the three groups, but at 1-month and 3-months after intervention, the significant improvement was in Mg sulphate and Ozone groups only. At 6-months follow up, Mg sulphate group only showed a significant improvement. There was a statistically significant increase in SOD and GSH serum levels, 2-weeks after intervention in both Magnesium sulphate (P-value = 0.002, 0.005 respectively) and ozone groups (P-value < 0.001, < 0.001), but there was no statistically significant change in SOD and GSH serum levels in control group. CONCLUSION: Transforaminal injection of Mg sulphate in patients with lumbar disc prolapse causes significant long-term improvement (up to 6 months) in pain intensity and functional disability. The serum levels of SOD and GSH were significantly increased at 2 weeks following both transforaminal injection of Mg sulphate and ozone.

Cervical spine and muscle adaptation after spaceflight and relationship to herniation risk: protocol from 'Cervical in Space' trial.

BACKGROUND: Astronauts have a higher risk of cervical intervertebral disc herniation. Several mechanisms have been attributed as causative factors for this increased risk. However, most of the previous studies have examined potential causal factors for lumbar intervertebral disc herniation only. Hence, we aim to conduct a study to identify the various changes in the cervical spine that lead to an increased risk of cervical disc herniation after spaceflight. METHODS: A cohort study with astronauts will be conducted. The data collection will involve four main components: a) Magnetic resonance imaging (MRI); b) cervical 3D kinematics; c) an Integrated Protocol consisting of maximal and submaximal voluntary contractions of the neck muscles, endurance testing of the neck muscles, neck muscle fatigue testing and questionnaires; and d) dual energy X-ray absorptiometry (DXA) examination. Measurements will be conducted at several time points before and after astronauts visit the International Space Station. The main outcomes of interest are adaptations in the cervical discs, muscles and bones. DISCUSSION: Astronauts are at higher risk of cervical disc herniation, but contributing factors remain unclear. The results of this study will inform future preventive measures for astronauts and will also contribute to the understanding of intervertebral disc herniation risk in the cervical spine for people on Earth. In addition, we anticipate deeper insight into the aetiology of neck pain with this research project. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00026777. Registered on 08 October 2021.

How annulus defects can act as initiation sites for herniation.

PURPOSE: Both posture and loading rate are key factors in the herniation process and can determine the mechanism of disc failure. The aim of this study was to test the hypothesis that disruption visible with HR-MRI post-testing corresponds with microstructural features and further elucidate the mechanism by which this disruption weakens the disc. This will enable us to gain new insights into the herniation process. METHODS: Thirty ovine lumbar spinal segments were subjected to combinations of four loading conditions (0-12° flexion, 0-9° lateral bending, 0-4° axial rotation, 0-1500 N axial compression) for 1000 loading cycles at 2 Hz in a dynamic disc loading simulator. The discs were scanned in an ultra-high field MRI (11.7 T) then examined using brightfield microscopy to examine their microstructure. RESULTS: Four discs herniated and seven discs suffered nucleus displacement. These discs contained pre-existing defects in the central posterior annulus. Generally, following testing discs contained more posterior annulus disruption, Microstructural investigation revealed there was clear correspondence between HR-MRI and microstructural observations, and that the mid-outer annular-endplate junction had failed in all discs examined in this study. CONCLUSIONS: While all discs suffered outer annulus damage, only the discs containing pre-existing defects herniated. These pre-existing defects weakened the inner and mid annulus, allowing herniation to occur once the mid and outer annular wall was compromised. We propose this can occur during the degenerative cascade.

Spontaneous Recovery in Complete Foot Drop in a Case of Lumbar Disc Herniation: A Neurological Surprise.

Lumbar intervertebral disc prolapse has been associated with radiculopathy and the sensory and motor changes that occur as the result of neural compression. The most important motor symptom is foot drop. Occurrence of foot drop in lumber protrusion of intervertebral disc prompts for the surgical treatment of the condition. Here, we report a case of a 32-year-male presented with unilateral foot drop, diagnosed as lumbar protrusion of intervertebral disc and recovered significantly without surgery. The good neurological outcome of the conservative management, in this case, puts the surgeon in a quandary whether to offer surgical management or not. A clinician should always remember this outcome before choosing the management plan for lumbar protrusion of intervertebral disc although rare.

Extra-laminar microscopic-assisted percutaneous nucleotomy (EL-MAPN) for the treatment of foraminal lumbar disc prolapse, a modified minimally invasive approach.

PURPOSE: In this work, a modification of the percutaneous surgical approach for removing the lumbar foraminal disc prolapse is introduced. MATERIAL AND METHODS: A prospective study was performed. The indication for surgery was foraminal disc prolapse presenting with acute motor or persistent sensory radiculopathy. MRI and X-ray of the lumbar spine were performed. VAS and ODI were recorded. The operation was done under general anesthesia. A needle was inserted for level-localization using C-arm. A 1.5 cm para-median skin incision was performed. A gradual dilatation using trocars was followed by the insertion of a tubular system. Under direct vision using the operative microscope, the lateral edge of the lamina was identified. A small, hooked probe was inserted in the foramen, and its position was documented fluoroscopically. With the help of the microscope, the triad consisting of Pedicle, Nerve root, and Prolapse "PNP" was identified. The nerve root was mobilized, and the prolapsed disc was removed. RESULTS: The study included 50 patients, 26 females, and 24 males. The mean follow-up was 18 months. The mean operative time was 65 min. The mean blood loss was 105 ml. The mean VAS improved from 7.8 ± 2.3 preoperatively to 0.8 ± 0.3 after one year (p = 0.001). Mean ODI improved from 28 ± 10.4 to 4 ± 2.3 after one year (p = 0.02). A recurrent disc occurred in 2 patients and was revised in the same technique. CONCLUSION: EL-MAPN represents a minimally invasive approach for foraminal disc prolapse removal under direct visual control avoiding injury to the facet joint or pars interarticularis.