Diagnostic accuracy of color-coded virtual noncalcium reconstructions derived from portal venous phase dual-energy CT in the assessment of lumbar disk herniation.

OBJECTIVES: To investigate the diagnostic accuracy of color-coded contrast-enhanced dual-energy CT virtual noncalcium (VNCa) reconstructions for the assessment of lumbar disk herniation compared to unenhanced VNCa imaging. METHODS: A total of 91 patients were retrospectively evaluated (65 years ± 16; 43 women) who had undergone third-generation dual-source dual-energy CT and 3.0-T MRI within an examination interval up to 3 weeks between November 2019 and December 2020. Eight weeks after assessing unenhanced color-coded VNCa reconstructions for the presence and degree of lumbar disk herniation, corresponding contrast-enhanced portal venous phase color-coded VNCa reconstructions were independently analyzed by the same five radiologists. MRI series were additionally analyzed by one highly experienced musculoskeletal radiologist and served as reference standard. RESULTS: MRI depicted 210 herniated lumbar disks in 91 patients. VNCa reconstructions derived from contrast-enhanced CT scans showed similar high overall sensitivity (93% vs 95%), specificity (94% vs 95%), and accuracy (94% vs 95%) for the assessment of lumbar disk herniation compared to unenhanced VNCa images (all p > .05). Interrater agreement in VNCa imaging was excellent for both, unenhanced and contrast-enhanced CT (κ = 0.84 vs κ = 0.86; p > .05). Moreover, ratings for diagnostic confidence, image quality, and noise differed not significantly between unenhanced and contrast-enhanced VNCa series (all p > .05). CONCLUSIONS: Color-coded VNCa reconstructions derived from contrast-enhanced dual-energy CT yield similar diagnostic accuracy for the depiction of lumbar disk herniation compared to unenhanced VNCa imaging and therefore may improve opportunistic retrospective lumbar disk herniation assessment, particularly in case of staging CT examinations. KEY POINTS: • Color-coded dual-source dual-energy CT virtual noncalcium (VNCa) reconstructions derived from portal venous phase yield similar high diagnostic accuracy for the assessment of lumbar disk herniation compared to unenhanced VNCa CT series (94% vs 95%) with MRI serving as a standard of reference. • Diagnostic confidence, image quality, and noise levels differ not significantly between unenhanced and contrast-enhanced portal venous phase VNCa dual-energy CT series. • Dual-source dual-energy CT might have the potential to improve opportunistic retrospective lumbar disk herniation assessment in CT examinations performed for other indications through reconstruction of VNCa images.

A transfacet approach to the lumbar nerve root canal: technical note.

BACKGROUND: Intraforaminal and extraforaminal nerve root compressions caused by disk herniation or stenosis are relatively common causes of lumbar radiculopathy. Currently, the two available surgical treatment methods are decompression from the spinal canal or lateral decompression via the Wiltse approach. OBJECTIVE: To describe a novel transosseous approach to the lumbar nerve root canal. METHODS: Transfacet foraminotomy was performed in 11 patients with intraforaminal or extraforaminal disk herniation. The outcome was measured using the Patient Satisfaction Index (PSI), need for reoperation, radiographic criteria, and finite element analysis. RESULTS: We noted that at the time of dismissal, PSI scores of 1 and 3 were reported by 10 and one patients, respectively. At the last follow-up, 10 patients reported a PSI score of 1 or 2. Two patients required reoperation because of recurrent disk herniation. Two patients underwent computed tomography (CT) postoperatively, which showed the transfacet approach. Intriguingly, a second postoperative CT after one month showed that the hole through the facet joint had shrunk significantly. CONCLUSION: A posterior-anterior transfacet approach for intraforaminal or extraforaminal disk herniations using an ellipsoid facetectomy is safe and allows for fast and comfortable decompression of the nerve root without compromising the long-term strength of the facet joint.

Clinical and imaging selection for CT guided - fluoroscopy 0203 disk treatment.

Low Back Pain (LBP) is the most common spine disease and it is the most common cause of absence from work in developed countries. At lumbar level, the natural history of herniated disc is characterized by a disappearance of clinical symptoms in up to 60% with conservative treatment through simple rest for about 6 weeks and reduction of the disk heniation revealed by CT or MR scans within eight to nine months after the onset of back pain. Surgery is considered the treatment of choice for extruded, migrated and free fragment herniated disk associated to clinical symptomatology of cono-cauda syndrome, progressive foot droop and hyperalgic radiculopathy. patients with a small or contained herniated disk, without any benefit from conservative medical treatment, can be candidates for one of minimally invasive percutaneous techniques, whose outcome, though, depends on the characteristics of hernia itself and on the chosen technique. The aim of this paper is to discuss about O2-O3 treatment for symptomatic not extruded herniated disk at lumbar level, highlighting about indication inclusion exclusion criteria and our results.

Current evidence of percutaneous nucleoplasty for the cervical herniated disk: a systematic review.

BACKGROUND: Although percutaneous cervical nucleoplasty (PCN) has been shown to be both safe and effective, its application is still debated. PCN applied in disk herniation has not been systematically reviewed before, resulting in a limited insight into its effectiveness and safety, and the quality of available evidence. Therefore, we systematically reviewed the evidence on the efficacy and safety of PCN in patients with a (contained) herniated disk. METHODS: MEDLINE, EMBASE, and the Cochrane Library (Central Register of Controlled Trials) were searched for randomized controlled trials (RCTs) and nonrandomized studies using the following keywords: "Nucleoplasty," "Cervical," "Hernia," "Herniation," "Prolapse," "Protrusion," "Intervertebral disk," and "Percutaneous disk decompression." First, all articles were appraised for methodological quality, and then, RCTs were graded for the level of evidence according a best-evidence synthesis, because a meta-analysis was not possible. Finally, the RCTs' applicability and clinical relevance also was assessed. RESULTS: Of 75 identified abstracts, 10 full-text articles were included (3 RCTs and 7 nonrandomized studies). These studies represented a total of 1021 patients: 823 patients (≥ 892 disks) were treated by PCN. All studies showed low methodological quality, except for two. The level of evidence of the RCTs was graded as moderate, with low to moderate applicability and clinical relevance. CONCLUSION: All included studies showed PCN to be an effective and safe procedure in the treatment of (contained) herniated disks at short-, mid-, and long-term follow-up. However, the level of evidence is moderate and shows only low to moderate applicability and clinical relevance.

Three-level thoracic disc herniation: transthoracic decompression without fixation.

Thoracic disc herniation is a rare pathology compared to the rest of the herniated discs. Due to their difficult access to the area of compromise and proximity to the spinal cord they represent a real challenge for the spine surgeon. The objective is to report an atypical case with three symptomatic dorsal disc herniations which required surgical treatment. Surgery was performed in two times with a lapse of 12 months between interventions. It was done a minimally invasive transthoracic decompression and intersomatic arthrodesis without instrumentation. The patient presented good neurological recovery without any serious sequelae.

La hernia de disco dorsal es una afección poco frecuente en comparación con el resto de las hernias discales. Por su difícil acceso a la zona de compromiso y cercanía de la médula espinal representan un verdadero desafío para el cirujano de columna. El objetivo del trabajo es presentar un caso atípico con tres hernias de disco dorsales sintomáticas en forma sincrónica que requirió tratamiento quirúrgico. La cirugía se hizo en dos tiempos con un lapso de 12 meses entre las intervenciones. Se realizó descompresión transtorácica mínimamente invasiva y artrodesis intersomática sin instrumentación en cada nivel. El paciente presentó buena recuperación neurológica sin ninguna secuela grave.

Biomechanical comparison of spinal cord compression types occurring in Degenerative Cervical Myelopathy.

BACKGROUND: Degenerative Cervical Myelopathy results from spine degenerations narrowing the spinal canal and inducing cord compressions. Prognosis is challenging. This study aimed at simulating typical spinal cord compressions observed in patients with a realistic model to better understand pathogenesis for later prediction of patients' evolution. METHODS: A 30% reduction in cord cross-sectional area at C5-C6 was defined as myelopathy threshold based on Degenerative Cervical Myelopathy features from literature and MRI measurements in 20 patients. Four main compression types were extracted from MRIs and simulated with a comprehensive three-dimensional finite element spine model. Median diffuse, median focal and lateral types were modelled as disk herniation while circumferential type additionally involved ligamentum flavum hypertrophy. All stresses were quantified along inferior-superior axis, compression development and across atlas-defined spinal cord regions. FINDINGS: Anterior gray and white matter globally received the highest stress while lateral pathways were the least affected. Median diffuse compression induced the highest stresses. Circumferential type focused stresses in posterior gray matter. Along inferior-superior axis, those two types showed a peak of constraints at compression site while median focal and lateral types showed lower values but extending further. INTERPRETATION: Median diffuse type would be the most detrimental based on stress amplitude. Anterior regions would be the most at risk, except for circumferential type where posterior regions would be equally affected. In addition to applying constraints, ischemia could be a significant component explaining the early demyelination reported in lateral pathways. Moving towards patient-specific simulations, biomechanical models could become strong predictors for degenerative changes.

Evidence Supporting the Management of Medical Conditions During Long-Duration Spaceflight: Protocol for a Scoping Review.

BACKGROUND: Future long-duration space exploration missions, such as traveling to Mars, will create an increase in communication time delays and disruptions and remove the viability of emergency returns to Earth for timely medical treatment. Thus, higher levels of medical autonomy are necessary. Crew selection is proposed as the first line of defense to minimize medical risk for future missions; however, the second proposed line of defense is medical preparedness and crew member autonomy. In an effort to develop a decision support system, the Canadian Space Agency mandated a team of scientists from Thales Research and Technology Canada (Québec, QC) and Université Laval (Québec, QC) to create an evidence-based medical condition database linking mission-critical human conditions with key causal factors, diagnostic and treatment information, and probable outcomes. OBJECTIVE: To complement this database, we are currently conducting a scoping review to better understand the depth and breadth of evidence about managing medical conditions in space. METHODS: This scoping review will adhere to quality standards for scoping reviews, employing Levac, Colquhoun, and O'Brien's 6-stage methodology; the reported results will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. In stage 1, we identified the research question in collaboration with the Canadian Space Agency (CSA), the main knowledge user. We prioritized 10 medical conditions: (1) acute coronary syndrome, (2) atrial fibrillation, (3) eye penetration, (4) herniated disk, (5) nephrolithiasis, (6) pulmonary embolism, (7) retinal detachment, (8) sepsis, (9) stroke, and (10) spaceflight associated neuro-ocular syndrome. In stage 2, with the help of an information specialist from Cochrane Canada Francophone, papers were identified through searches of the following databases: ARC, Embase, IeeeXplore, Medline Ovid, PsychINFO, and Web of Science. In stage 3, studies will be selected and assessed using a 3-step process and emerging, refined exclusion criteria. In stage 4, the data will be charted in a table based on parameters required by the CSA and developed using Google spreadsheets for shared access. In stage 5, evidence-based descriptive summaries will be produced for each condition, as well as descriptive analyses of collected data. Finally, in stage 6, the findings will be shared with the CSA to guide the completion of this project. RESULTS: This study was planned in December 2018. Stage 1 has been completed. The initial database search strategy with all target conditions combined identified a total of 10,403 citations to review through title and abstract screening and after duplicate removal. We plan to complete stages 2-6 by the beginning of 2021. CONCLUSIONS: This scoping review will map the literature on the management of 10 priority medical conditions in space. It will also enable us to identify knowledge gaps that must be addressed in future research, ensuring successful and medically safe future missions as humankind embarks upon new frontiers of space exploration. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24323.

The Cervical Radiculopathy Impact Scale: development and evaluation of a new functional outcome measure for cervical radicular syndrome.

Objective: To develop and validate an outcome scale for the cervical radicular syndrome and to build a mapping, predicting EQ-5D utility from the new scale.Study design and setting: An item pool was developed based on literature and patient and clinician interviews. Item selection was based on symptomatology, factor analysis, and internal consistency. We assessed: (a) test-retest reliability by standard error of measurement and intraclass correlation coefficients; (b) construct validity by testing 22 hypotheses on relationships with existing measures and known-group differences. For the mapping, performance was assessed by mean absolute error and root mean squared error.Results: A total of 254 patients with cervical radicular syndrome completed the first questionnaire, 61 stable patients a retest. Item selection led to a 21-item questionnaire consisting of three subscales: Symptoms, Energy and postures, and Actions and activities. Standard error of measurement values ranged from 6.7 to 11.2 on a 0 to 100 scale. All subscales showed good reliability (intraclass correlation coefficients: 0.84, 0.87, and 0.94). All hypotheses for construct validity were confirmed. A linear utility mapping was preferred, with reasonable statistical performance.Conclusion: We developed a reliable and valid cervical radicular syndrome specific outcome scale, called the Cervical Radiculopathy Impact Scale (CRIS). This new questionnaire may facilitate (cost-)effectiveness studies in this field.Implications for RehabilitationThe cervical radicular syndrome is a frequently occurring and invalidating health problem, which causes severe radiating pain in the arm and/or hand, which can be accompanied by motor and/or sensory deficits.The Cervical Radiculopathy Impact Scale (CRIS) is a newly developed self-report questionnaire which covers measurement of symptoms and limitations in patients with cervical radiculopathy due to irradiating pain, tingling sensations and sensory loss in the arm in combination with neck disability.The CRIS consists of 21 items divided over three subscales: (i) symptoms, (ii) energy and postures, and (iii) actions and activities.The CRIS shows good content validity, test-retest reliability, construct validity and is able to discriminate between groups.The CRIS predicts EQ-5D utility and is therefore useful for (cost)effectiveness studies in this field.

Epidural Anesthesia With Low Concentration Ropivacaine and Sufentanil for Percutaneous Transforaminal Endoscopic Discectomy: A Randomized Controlled Trial.

Introduction: Percutaneous transforaminal endoscopic discectomy is a simple and effective treatment for lumbar intervertebral disc herniation, and local anesthesia is often applied in this kind of surgery in many developing countries, including China. However, many patients still feel excruciating pain under this condition. Epidural anesthesia with low-concentration ropivacaine has no impact on muscle strength, and patients might follow the surgeon well during operation. We hypothesize that epidural anesthesia is feasible for percutaneous transforaminal endoscopic discectomy. Methods: Two hundred patients with disc herniation who underwent percutaneous transforaminal endoscopic discectomy were randomized to receive either epidural anesthesia or local infiltration anesthesia. Primary outcome measures included the pain score, the cooperation degree, and patients' satisfaction. Mean arterial pressure and heart rate were also recorded. Results: Compared with the local anesthesia group, visual analog scale scores, mean arterial pressure, and heart rate were significantly lower in the epidural anesthesia group (P < 0.05), and patients' satisfaction was higher. There were no significant differences in the total operation time or blood loss between two groups. Conclusions: Epidural anesthesia with low-concentration ropivacaine and sufentanil is safe and effective for percutaneous transforaminal endoscopic discectomy. Clinical Trial Registration: ClinicalTrials.gov, identifier: ChiCTR-IOR-17011768.

Micro-anatomical structures of the lumbar intervertebral foramen for full-endoscopic spine surgery: review of the literatures.

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal surgical technique. PELD can be performed via 2 routes, transforaminal (TF) or interlaminar. The TF approach is a well-established modality in the treatment of patients with herniated lumbar discs. This technique makes the most of the space within the intervertebral foramen where, as Kambin claimed, the safe approach to the lesion is possible. Knowledge of the lumbar artery with its branches and various ligaments of anatomies of the intervertebral foramen are needed to perform successful surgeries and to reduce complications.

Lumbar Disc Herniation Presented with Contralateral Symptoms.

OBJECTIVE: This study aimed to unravel the putative mechanism underlying the neurologic deficits contralateral to the side with lumbar disc herniation (LDH) and to elucidate the treatment for this condition. METHODS: From January 2009 to June 2015, 8 patients with LDH with predominantly contralateral neurologic deficits underwent surgical treatment on the side with LDH with or without decompressing the symptomatic side. A retrospective review of charts and radiological records of these 8 patients was performed. The putative mechanisms underlying the associated contralateral neurological deficits, magnetic resonance imaging (MRI), electromyography (EMG), and the adequate surgical approach are discussed here. RESULTS: MRI revealed a similar laterally skewed paramedian disc herniation, with the apex deviated from the symptomatic side rather than directly compressing the nerve root; this condition may generate a contralateral traction force. EMG revealed radiculopathies in both sides of 6 patients and in the herniated side of 2 patients. Based on EMG findings and the existence of suspicious lateral recess stenosis of the symptomatic side, 6 patients underwent bilateral decompression of nerve roots and 2 were subjected to a microscopic discectomy to treat the asymptomatic disc herniation. No specific conditions such as venous congestion, nerve root anomaly or epidural lipomatosis were observed, which may be considered the putative pathomechanism causing the contralateral neurological deficits. The symptoms resolved significantly after surgery. CONCLUSION: The traction force generated on the contralateral side and lateral recess stenosis, rather than direct compression, may cause the contralateral neurologic deficits observed in LDH.

Massive Lumbar Disk Herniation Following "Therapeutic" Water Boiling of the Lower Extremities: Case Report and Literature Review.

BACKGROUND: Legs burning for treating lumbar radicular pain are still in use nowadays in low socioeconomical environments. They are dangerous as the case we report shows clearly. CLINICAL CASE: A 49-year-old man came to our attention with severe flaccid paraparesis occurred 10 days before, almost immediately after he had immersed his legs in boiling water to treat his severe left lumbocrural pain. This was known to be due to a right L3/4 herniated disk diagnosed by magnetic resonance imaging. At the examination he showed severe motor paresis and absent reflexes of his lower limbs, while crural pain was mild and sensation and urinary function were unaffected. The results of his neurologic examination led us to suspect an acute motor axon degeneration related to thermal shock. Lumbar magnetic resonance imaging, performed before the planned electromyogram as an exception to the established routine, showed instead a giant 5- × 5.5-cm, herniated disk compressing the dural sac at L3. CONCLUSIONS: Prompt surgical decompression led to rapid improvement. We discuss here the pathophysiology of this unusual case and point out how medieval practices for treating sciatica-like pain are not only unjustified from a medical viewpoint but also potentially dangerous.

Regresión espontánea de la hernia discal lumbar de dos féminas / Spontaneous regression of the lumbar herniated disk in two women

Se describen los casos clínicos de dos féminas que habían padecido lumbociatalgias durante varios meses, por lo cual acudieron al Hospital Provincial Docente Dr. Joaquín Castillo Duany de Santiago de Cuba, donde se les diagnosticó hernia discal lumbar y recibieron seguimiento médico en la consulta de Neurocirugía por más de un año. Ante la negativa de ser intervenidas quirúrgicamente, se prescribieron esquemas terapéuticos convencionales y alternativos, así como fisioterapia. En ambas pacientes se evidenció regresión espontánea de la discopatía, lo que se confirmó mediante estudios evolutivos de resonancia magnética. Dicha correlación entre la mejoría clínica y la recuperación imagenológica del disco intervertebral no siempre sucede en la evolución de estos casos.

The case reports of two women that had suffered from lumbar sciatic pain during several months are described, reason why they went to Dr. Joaquín Castillo Duany Teaching Provincial Hospital in Santiago de Cuba, where they were diagnosed lumbar herniated disk and received medical follow up in the Neurosurgery Service for more than a year. Before the negative of being surgically intervened, conservative and alternative therapeutic outlines were prescribed, as well as physiotherapy. In both patients spontaneous regression of the lumbar herniated disk was evidenced, which was confirmed by means of evolutionary studies of magnetic resonance. This correlation between the clinical improvement and the imaging recovery of the intervertebral disk doesn't always happen in the clinical course of these cases.

Prospective Comparison of Microsurgical, Tubular-Based Endoscopic, and Endoscopically Assisted Diskectomies: Clinical Effectiveness and Complications in Railway Workers.

OBJECTIVE: Although endoscopic diskectomy is superior to microsurgical diskectomy in terms of incision size, postoperative pain, and cosmetic appeal, the effectiveness and indications for endoscopic versus microsurgical diskectomy remain active discussion topics. Because of the increasing incidence of diskectomies being performed in Russia, further assessment of these techniques is needed. We performed a comparative analysis of 1-year clinical results and complications of microsurgical, tubular-based interlaminar endoscopic, and endoscopically assisted microsurgical diskectomies for patients with herniated lumbar disks. METHODS: The patient cohort included 131 patients who were enrolled in a prospective, randomized controlled study and 617 patients for whom data were gathered retrospectively. The quality of life was assessed using the Oswestry Disability Index (version 2.1a) and pain severity was analyzed using the visual analog scale for pain preoperatively, at discharge, and at 3, 6, and 12 months postoperatively. RESULTS: Microsurgical, tubular-based endoscopic, and endoscopically assisted microsurgical diskectomies were all effective in relieving acute radicular symptoms. Recurrent disk herniation occurred more frequently after tubular-based endoscopic diskectomy than after the other approaches. CONCLUSIONS: Our findings indicate that these 3 surgical techniques are highly effective and have similar clinical results at 1-year follow-up. Although this study points to differences in complications resulting from the 3 techniques, larger prospective studies are needed to more definitively assess possible surgical differences, complications, and outcomes. The endoscopically assisted diskectomy technique allows for minimally invasive surgery and offers enhanced visualization of the anatomy that is hidden from view in microscopic procedures.

Evaluation of low back pain with low field open magnetic resonance imaging scanner in rural hospital of Southern India.

BACKGROUND: Low back pain (LBP) is the most common symptom which is associated with limitation of normal activities and work-related disability. Imaging techniques are often essential in making the correct diagnosis for prompt management. Plain Radiography though remain a first imaging modality, magnetic resonance imaging (MRI) due to its inherent softtissue contrast resolution and lack of ionizing radiation remains invaluable modality in the evaluation of LBP. AIM: To find the common causes of LBP in different age groups and the role of MRI in detecting the spectrum of various pathological findings. MATERIALS AND METHODS: This is a prospective study done in the Department of Radiodiagnosis during a period of 2 years from July 2013 to July 2015. The study population includes all the cases referred to our department with complaints of LBP. Patients with ferromagnetic metallic implants and uncooperative cases were excluded. HITACHI 0.4 Tesla open MRI machine was used for imaging. RESULTS AND CONCLUSION: This study involved a total of 235 cases. There were 121 males and 114 females. The age of the patient ranged from 21 to 68 years with an average of 41.3 years. Back pain was commonly observed in the third to fifth decade. The common causes for back pain are disc herniations (disc bulge - 35.3%, disc protrusion - 39.6%, disc extrusion - 7.2%) accounting to 82.1%, followed by normal study (10.2%), vertebral collapse (traumatic - 2.1%, osteoporotic - 1.7%), infections (2.1%), and neoplasm (1.7%). MRI provides valuable information regarding the underlying causes of LBP, especially in disc and marrow pathology.

Rational approach, technique and selection criteria treating lumbar disk herniations by oxygen-ozone therapy.

Radicular lumbar back pain is an important public health problem not yet benefiting from a unequivocal treatment approach. Medical and physical therapies represent the first solution; however, when these fail, the second therapeutic step is still controversial and mini-invasive treatments may play an important role. In these cases oxygen-ozone therapy has been proved to be a very safe and effective option that is widely used with different modalities. This paper, by reviewing oxygen-ozone therapy literature data, aims to describe the rationale of oxygen-ozone therapy for the treatment of lumbar disk herniations, propose an effective procedural technique and clarify patient selection criteria; furthermore, complications and follow-up management are also considered.

Acute Cervical Disk Herniation Resulting in Sudden and Severe Neurologic Deterioration: A Case Series.

Objective Nontraumatic acute cervical disk herniation resulting in acute severe neurologic deficit is a rare entity described in a limited number of case reports. We describe the management and outcome in patients presenting with severe neurologic deterioration caused by acutely herniated cervical disks. Methods Four patients (mean age 39.5 years) presented to our tertiary care academic medical center from September 2012 to September 2013 with severe progressive neurologic deficits due to cervical disk herniation and were included in the series. Patients' surgical, medical, and imaging records were retrospectively reviewed under an Institutional Review Board waiver of informed consent. Results Patients in the series presented with acute neurologic deterioration, including paraparesis, Brown-Séquard syndrome, or quadriparesis deteriorating to quadriplegia. Emergent magnetic resonance imaging (MRI) scans and emergent decompression and fusion for acute soft disk herniation were performed in all cases. All patients recovered to excellent functional status with Frankel score improvement from B (one patient)/C (three patients) to E (three patients)/D (one patient). Conclusions Acute cervical disk herniation with acute neurologic deterioration is a medical emergency necessitating emergent MRI and surgical decompression. Clinical presentation varies. In patients with rapid-onset neurologic deterioration, a high level of suspicion for this rare entity is indicated.

Importance of IL-6, MMP-1, IGF-1, and BAX Levels in Lumbar Herniated Disks and Posterior Longitudinal Ligament in Patients with Sciatic Pain.

PURPOSE: The aim of this study was to evaluate prognostic importance of interleukin-6 (IL-6), matrix metalloproteinase (MMP)-1, insulin-like growth factor (IGF)-1, and Bcl-2-associated X protein (BAX) levels in biopsy specimens taken from the intervertebral disk specimens and the posterior longitudinal ligaments of patients with sciatic pain. METHODS: The specimens of the intervertebral disk and the posterior longitudinal ligament were obtained from 52 patients undergoing herniectomy and diskectomy at the Neurosurgery Department of the Abant Izzet Baysal University Izzet Baysal Training and Research Hospital between April 2012 and February 2014. The immunohistochemical expressions of IL-6, MMP-1, IGF-1, and BAX were evaluated in three categories: mild, moderate, and intense. RESULTS: The IL-6 expression in the intervertebral disk specimens was intense in the sequestration group when compared with that of the "protrusion" and "extrusion" groups. The intervertebral disk specimens in "extrusion" and "sequestration" groups were stained intensely for MMP-1. The IGF-1 expression was stained intensely in the intervertebral disk tissue of the extrude group patients. For the "extrusion" and "sequestration" groups, the intervertebral disk specimens were stained intensely for BAX compared with the protrude group. The IL-6 expression in the posterior longitudinal ligament specimens was more intense in the "sequestration" and "extrusion" groups when compared with that of the protrude group. The MMP-1 expressions were milder in the sequestration group when compared with that of the "extrusion" and "protrusion" groups. CONCLUSIONS: Our findings suggest that the cytokines, enzymes, growth factors, and proapoptotic proteins, such as IL-6, MMP-1, IGF-1, and BAX, may be critical factors in the pathophysiology of the degeneration of the intervertebral disks in patients with symptomatic degenerative disk disease.

Expression of the JAK/STAT3/SOCS3 signaling pathway in herniated lumbar discs.

The inflammatory cytokine interleukin-6 (IL-6) plays an important role in causing symptoms of lumbar disk herniation. The present study clarifies the expression of the signaling pathway of IL-6 in herniated discs. Homogenates prepared from lumbar herniated discs from 10 patients were assessed. The expression of janus kinase 1 (JAK1), signal transducer and activator of transcription 3 (STAT3), phosphorylated (p)-STAT3 at Tyr(705), suppressor of cytokine signaling 3 (SOCS3) and actin was examined by Western blot analysis. The expression of JAK1, STAT3, and p-STAT3 at Tyr(705) was also examined by immunostaining. JAK1, STAT3, p-STAT3 at Tyr(705) and SOCS3 were detected in almost all cases. Immunoreactivity against JAK1 and STAT3 was observed mainly in chondrocytes, whereas immunoreactivity against p-STAT3 at Tyr(705) was observed in the nuclei of chondrocytes. The JAK/STAT signaling pathway might be activated by IL-6 and transmit messages from the cell surface to the nucleus, and the pathway is negatively regulated by SOCS3. These JAK1, STAT3 and SOCS3 molecules might tightly regulate and play a role in the degeneration of chondrocytes within herniated discs.

[Financial expenses incurred by herniated disk in health professionals]. / Costo del subsidio por diagnóstico de hernia de disco en trabajadores del Instituto Mexicano del Seguro Social.

BACKGROUND: Long-term sick leave by illeness is cause of financial expences and worker's loss of productivity. OBJECTIVE: To evaluate the financial expense incurred by spinal disk herniation in health professionals. METHODS: 3000 health professionals of the Instituto Mexicano del Seguro Social work in Tecate, Tijuana and Rosarito, cities of Baja California, Mexico. During 2009-2011, 1070 health professionals had long sick leave certificates and 48 had a cervical or lumbar disk herniation. We evaluated the total days of absenteeism in comparison with the absenteeism days suggested by the Medical Disability Advisor. RESULTS: Of the 48 spinal herniated disks, 54% were cervical and 65% had surgical management. The mean (± SD) days of absence was 125 ± 84 and 24 (50%) of the spinal herniated disks exceeded the Medical Disability Advisor disability duration parameters, in 6 (26%), 12 (52%), and 5 (22%) patients due to no diagnostic concordance, diagnosis delay and residual pain, respectively. The total cost of the spinal herniated disks that extended outside of the Medical Disability Advisor disability duration parameters was 683,026 pesos versus 367,081 pesos of the spinal herniated disks that did not exceed the Medical Disability Advisor disability duration parameters. After 12 months of follow-up, 9 (18.8%) continue with sick leave and 2 (4%) had permanent disability. CONCLUSIONS: In patients with a spinal herniated disk, the costs of subsidies were two-fold more due principally to a not diagnostic agreement.

Antecedentes: las incapacidades prolongadas no sólo tienen un alto costo económico sino también repercusiones en la productividad debido a la ausencia del trabajador. Objetivo: evaluar el costo del subsidio pagado por el Instituto Mexicano Seguro Social (IMSS) a los trabajadores que incapacita por hernia de disco. Material y métodos: estudio observacional, descriptivo, transversal y retrospectivo efectuado con trabajadores del IMSS a quienes se incapacita para no laborar por más de 14 días. El estudio se efectuó mediante la revisión de los registros asentados entre 2009-2011 de 1,070 trabajadores con incapacidad prolongada de los que 48 tuvieron diagnóstico de hernia de disco. Se cuantificaron los días totales de incapacidad, días subsidiados por incapacidad versus los días sugeridos por el consejero médico de incapacidades. Resultados: de los 48 pacientes con hernias de disco, 54% fueron cervicales y 65% recibieron tratamiento uirúrgico. Los días totales promedio de incapacidad por hernias de disco fueron 125 ± 84 y 24 (50%), respectivamente. De las que rebasaron las recomendadas por el consejero médico, 6 (26%) fueron por concordancia diagnóstica, 12 (52%) por diferimiento en el diagnóstico y 5 (22%) por dolor residual. El costo de las incapacidades laborales originadas por hernias de disco que rebasaron las sugeridas por el consejero médico fue de 683,026 pesos en comparación con 367,081 pesos que no rebasaron la recomendación de éste. Después de 12 meses de seguimiento, 9 casos (18.8%) seguían con incapacidad y 2 (4%) tuvieron pensión por invalidez. Conclusiones: el costo en subsidio por incapacidades a pacientes con hernia de disco se duplicó principalmente por diferimiento en el diagnóstico.