Medicine Pathology and Forensic Medicine

Spine and Intervertebral Disc Pathology

Description

This cluster of papers focuses on the pathophysiology, treatment, and outcomes related to lumbar disc degeneration, including topics such as intervertebral disc biology, surgical interventions, low back pain, spinal fusion, and biological aging of the discs. It covers a wide range of research from clinical studies to basic science investigations.

Keywords

Lumbar Disc Degeneration; Intervertebral Disc; Spinal Surgery; Low Back Pain; Surgical Treatment; Nucleus Pulposus; Degenerative Disc Disease; Biological Aging; Spinal Fusion; Clinical Outcomes

Human intervertebral discs undergo age-related da-generative changes that contribute to some of the most common causes of impairment and disability for middle aged and older persons: spine stiffness, neck pain, … Human intervertebral discs undergo age-related da-generative changes that contribute to some of the most common causes of impairment and disability for middle aged and older persons: spine stiffness, neck pain, and back pain. Potential causes of the age-related degeneration of intervertebral discs Includo declining nutrition, loss of viable cells, cell senescence, past-tranalational, modification of matrix proteins, accumulation of degraded matrix molecules, and fatigue failure of the matrix. The most important of these mechanisms appears to be decreasing nutrition of the central disc that allows accumulation of cell waste products and degraded matrix molecules, impairs cell nutrition, and causes a fail in pH levels that further compromises cell function and may cause cell death. Although aging changes of the disc appear to be inevitable, identification of activities and agents that accelerate these changes may help decrease the rate and severity of disc degeneration; and recent work suggests that methods can be developed that will regenerate disc tissue.
Fifty patients who had spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied clinically and radiographically to determine if concomitant intertransverse-process arthrodesis provided better results than decompressive laminectomy alone. … Fifty patients who had spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied clinically and radiographically to determine if concomitant intertransverse-process arthrodesis provided better results than decompressive laminectomy alone. There were thirty-six women and fourteen men. The mean age of the twenty-five patients who had had an arthrodesis was 63.5 years and that of the twenty-five patients who had not had an arthrodesis, sixty-five years. The level of the operation was between the fourth and fifth lumbar vertebrae in forty-one patients and between the third and fourth lumbar vertebrae in nine patients. The patients were followed for a mean of three years (range, 2.4 to four years). In the patients who had had a concomitant arthrodesis, the results were significantly better with respect to relief of pain in the back and lower limbs.
Summary The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column. Several studies—in vitro cadaveric, in vivo … Summary The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column. Several studies—in vitro cadaveric, in vivo animal, and mathematical simulations—have shown that the neutral zone is a parameter that correlates well with other parameters indicative of instability of the spinal system. It has been found to increase with injury, and possibly with degeneration, to decrease with muscle force increase across the spanned level, and also to decrease with instrumented spinal fixation. In most of these studies, the change in the neutral zone was found to be more sensitive than the change in the corresponding range of motion. The neutral zone appears to be a clinically important measure of spinal stability function. It may increase with injury to the spinal column or with weakness of the muscles, which in turn may result in spinal instability or a low-back problem. It may decrease, and may be brought within the physiological limits, by osteophyte formation, surgical fixation/fusion, and muscle strengthening. The spinal stabilizing system adjusts so that the neutral zone remains within certain physiological thresholds to avoid clinical instability.
Study Design. A reliability study was conducted. Objectives. To develop a classification system for lumbar disc degeneration based on routine magnetic resonance imaging, to investigate the applicability of a simple … Study Design. A reliability study was conducted. Objectives. To develop a classification system for lumbar disc degeneration based on routine magnetic resonance imaging, to investigate the applicability of a simple algorithm, and to assess the reliability of this classification system. Summary of Background Data. A standardized nomenclature in the assessment of disc abnormalities is a prerequisite for a comparison of data from different investigations. The reliability of the assessment has a crucial influence on the validity of the data. Grading systems of disc degeneration based on state of the art magnetic resonance imaging and corresponding reproducibility studies currently are sparse. Methods. A grading system for lumbar disc degeneration was developed on the basis of the literature. An algorithm to assess the grading was developed and optimized by reviewing lumbar magnetic resonance examinations. The reliability of the algorithm in depicting intervertebral disc alterations was tested on the magnetic resonance images of 300 lumbar intervertebral discs in 60 patients (33 men and 27 women) with a mean age of 40 years (range, 10–83 years). All scans were analyzed independently by three observers. Intra- and interobserver reliabilities were assessed by calculating kappa statistics. Results. There were 14 Grade I, 82 Grade II, 72 Grade III, 68 Grade IV, and 64 Grade V discs. The kappa coefficients for intra- and interobserver agreement were substantial to excellent: intraobserver (kappa range, 0.84–0.90) and interobserver (kappa range, 0.69–0.81). Complete agreement was obtained, on the average, in 83.8% of all the discs. A difference of one grade occurred in 15.9% and a difference of two or more grades in 1.3% of all the cases. Conclusion. Disc degeneration can be graded reliably on routine T2-weighted magnetic resonance images using the grading system and algorithm presented in this investigation.
One hundred, twenty-four patients undergoing lumbar or lumbosacral for degenerative conditions were entered into a prospective study. The patients were randomly assigned to one of three treatment groups. Group I … One hundred, twenty-four patients undergoing lumbar or lumbosacral for degenerative conditions were entered into a prospective study. The patients were randomly assigned to one of three treatment groups. Group I underwent posterolateral fusion using autogenous bone graft. Group II had autogenous posterolateral fusions supplemented by a semi-rigid pedicle screw/plate fixation system (Luque II; Danek Medical, Memphis, Tannessee). Group III patients underwant posterolateral autogenous fusion with a rigid pedicle screw/rod fixation system (Texas Scottish Rite Hospital [TSRH]-Danek Medical, Memphis, Tennessee). All the patients were operated on by the same surgeon, Identical bone grafting technique was used in all, and all were treated in an identical fashion postoparatively. Fusion status was determined from the anteroposterior, oblique, and flexion-extension radiographs obtained at 1 year. Clinical results were rated as excellent if the patients were pain-free and had returned to work; good if the patients had mild backache requiring non-narcotic analgesics and had returned to work; fair if continuing back pain prevented a return to work; or poor if the pain was worse than that which the patient experienced preoperatively or the patient required revision surgery. Nine patients who were originally assigned to Group II or Group III were placed in Group I intraoperatively. This change was due to the identification of severe osteopenia and the determination that pedicle screw purchase was poor. One patient was lost to follow-up. Thus, 51 patients were in Group I, 35 in Group II, and 37 in Group III. Follow-up ranged from 9 to 28 months, averaging 16 months. The overall fusion rate for Group I was 65%; for Group II, 77%; and for Group III, 95%. The increased fusion rate in the rigidly instrumented pedicle screw group (Group III) was significant when compared to that of Group I (P = 0.002) or to Group II (P = 0.034). Clinical results in Group I included 71% good or excellent results, with 8% requiring revision surgery. In Group II, 89% had good or excellent results, with two additional surgeries. Group III had 95% good or excellent results, with no additional surgeries. Group III had 95% good or excellent results, with no additional surgeries. No infections or neurologic deficits occurred. No screws broke, although two Luque screws backed out, and one TSRH linkage loosened. Three screws were misplaced laterally to the pedicle (1.1% of screws) without negative sequelae. In all three groups, the fusion rates were lower for smokers than nonsmokers, and lower for revision surgery thanprimary surgery. The lowest fusion rates were seen in revision surgery without instrumentation (48%), degenerative spondylalisthesis without instrumentation (45%). Pseudarthrosis repair was successful in 20% of patients in Group I, and 100% of patients in Groups II and III. Rigid pedicle screw/rod fixation led to a significantly higher percentage of fusions in degenerative lumbar disease than did fusion without instrumentation. The fusion rate was also higher with rigid instrumentation than with semirigid plate/screw flaxation, although clinical results were improved with both fixation systems. I recommend the use of a rigid pedicle screw instrumentation system in patients undergoing fusion for degenerative disc disease or degenerative spondylolisthesis, and in revision surgery.
Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective … Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decreased with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.
Cross-sectional magnetic resonance imaging (MRI) study.To study the relation of low back pain (LBP) to disc degeneration in the lumbar spine.Controversy still prevails about the relationship between disc degeneration and … Cross-sectional magnetic resonance imaging (MRI) study.To study the relation of low back pain (LBP) to disc degeneration in the lumbar spine.Controversy still prevails about the relationship between disc degeneration and LBP. Classification of disc degeneration and symptoms varies, hampering comparison of study results.Subjects comprised 164 men aged 40-45 years-53 machine drivers, 51 construction carpenters, and 60 office workers. The data of different types of LBP, individual characteristics, and lifestyle factors were obtained from a questionnaire and a structured interview. Degeneration of discs L2/L3-L5/S1 (dark nucleus pulposus and posterior and anterior bulge) was assessed with MRI.An increased risk of LBP (including all types) was found in relation to all signs of disc degeneration. An increased risk of sciatic pain was found in relation to posterior bulges, but local LBP was not related to disc degeneration. The risks of LBP and sciatic pain were strongly affected by occupation.Low back pain is associated with signs of disc degeneration and sciatic pain with posterior disc bulges. Low back pain is strongly associated with occupation.
BACK pain ranks second only to upper respiratory illness as a symptomatic reason for office visits to physicians.<sup>1</sup>About 70% of adults have low back pain at some time, but only … BACK pain ranks second only to upper respiratory illness as a symptomatic reason for office visits to physicians.<sup>1</sup>About 70% of adults have low back pain at some time, but only 14% have an episode that lasts more than 2 weeks. About 1.5% have such episodes with features of sciatica.<sup>2,3</sup>Most causes of back pain respond to symptomatic and physical measures, but some are surgically remediable and some are systemic diseases (cancer or disseminated infection) requiring specific therapy, so careful diagnostic evaluation is important. Features of the clinical history and physical examination influence not only therapeutic choices but also decisions about diagnostic imaging, laboratory testing, and specialist referral. <h3>ANATOMIC/PHYSIOLOGIC ORIGINS OF FINDINGS IN THE LOW BACK</h3> Low back pain may arise from several structures in the lumbar spine, including the ligaments that interconnect vertebrae, outer fibers of the annulus fibrosus, facet joints, vertebral periosteum, paravertebral musculature and fascia,
In Brief Study Design. Epidemiological study using national administrative data. Objective. To provide a complete analysis of national trends in spinal fusion from 1998 to 2008 and compare with trends … In Brief Study Design. Epidemiological study using national administrative data. Objective. To provide a complete analysis of national trends in spinal fusion from 1998 to 2008 and compare with trends in laminectomy, hip replacement, knee arthroplasty, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft. Summary of Background Data. Previous studies have reported a rapid increase in volume of spinal fusions in the United States prior to 2001, but limited reports exist beyond this point, analyzing all spinal fusion procedures collectively. Methods. Data were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for the years 1998 to 2008. Discharges were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for the following procedures: spinal fusion, laminectomy, hip replacement, knee arthroplasty, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft. Population-based utilization rates were calculated from the US census data. Results. Between 1998 and 2008, the annual number of spinal fusion discharges increased 2.4-fold (137%) from 174,223 to 413,171 (P < 0.001). In contrast, during the same time period, laminectomy, hip replacement, knee arthroplasty, and percutaneous coronary angioplasty yielded relative increases of only 11.3%, 49.1%, 126.8%, and 38.8% in discharges, while coronary artery bypass graft experienced a decrease of 40.1%. Between 1998 and 2008, mean age for spinal fusion increased from 48.8 to 54.2 years (P < 0.001), in-hospital mortality rate decreased from 0.29% to 0.25% (P < 0.01), and mean total hospital charges associated with spinal fusion increased 3.3-fold (P < 0.001). The national bill for spinal fusion increased 7.9-fold (P < 0.001). Conclusion. Frequency, utilization, and hospital charges of spinal fusion have increased at a higher rate than other notable inpatient procedures, as seen in this study from 1998 to 2008. In addition, patient demographics and hospital characteristics changed significantly; in particular, whereas the average age for spinal fusion increased, the in-hospital mortality rate decreased. This study provided an analysis of trends in patient- and health care system-related characteristics for spinal fusion in the United States between 1998 and 2008. For comparison, we reported on trends of laminectomy, hip replacement, knee arthroplasty, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft procedures.
An epidemiological survey of cervical radiculopathy in Rochester, Minnesota, 1976–90, through the records-linkage system of the Mayo Clinic ascertained 561 patients (332 males and 229 females). Ages ranged from 13 … An epidemiological survey of cervical radiculopathy in Rochester, Minnesota, 1976–90, through the records-linkage system of the Mayo Clinic ascertained 561 patients (332 males and 229 females). Ages ranged from 13 to 91 years; the mean age ±SD was 47.6±13.1 years for males and 48.2±13.8 years for females. A history of physical exertion or trauma preceding the onset of symptoms occurred in only 14.8% of cases. A past history of lumbar radiculopathy was present in 41%. The median duration of symptoms prior to diagnosis was 15 days. A monoradiculopathy involving C7 nerve root was the most frequent, followed by C6. A confirmed disc protrusion was responsible for cervical radiculopathy in 21.9% of patients; 68.4% were related to spondylosis, disc or both. During the median duration of follow-up of 4.9 years, recurrence of the condition occurred in 31.7%, and 26% underwent surgery for cervical radiculopathy. A combination of radicular pain and sensory deficit, and objective muscle weakness were predictors of a decision to operate. At last follow-up 90% of our population-based patients were asymptomatic or only mildly incapacitated due to cervical radiculopathy. The average annual age-adjusted incidence rates per 100 000 population for cervical radiculopathy in Rochester were 83.2 for the total, 107.3 for males and 63.5 for females. The age-specific annual incidence rate per 100 000 population reached a peak of 202.9 for the age group 50–54 years.
Very little is known about the turnover of extracellular matrix in the human intervertebral disc. We measured concentrations of specific molecules reflecting matrix synthesis and degradation in predetermined regions of … Very little is known about the turnover of extracellular matrix in the human intervertebral disc. We measured concentrations of specific molecules reflecting matrix synthesis and degradation in predetermined regions of 121 human lumbar intervertebral discs and correlated them with ageing and Thompson grade of degeneration. Synthesis in intervertebral discs, measured by immunoassay of the content of a putative aggrecan biosynthesis marker (846) and the content of types I and II procollagen markers, is highest in the neonatal and 2-5-yr age groups. The contents of these epitopes/molecules progressively diminished with increasing age. However, in the oldest age group (60-80 yr) and in highly degenerated discs, the type I procollagen epitope level increased significantly. The percentage of denatured type II collagen, assessed by the presence of an epitope that is exposed with cleavage of type II collagen, increased twofold from the neonatal discs to the young 2-5-yr age group. Thereafter, the percentage progressively decreased with increasing age; however, it increased significantly in the oldest group and in highly degenerate discs. We identified three matrix turnover phases. Phase I (growth) is characterized by active synthesis of matrix molecules and active denaturation of type II collagen. Phase II (maturation and ageing) is distinguished by a progressive drop in synthetic activity and a progressive reduction in denaturation of type 11 collagen. Phase III (degeneration and fibrotic) is illustrated by evidence for a lack of increased synthesis of aggrecan and type II procollagen, but also by an increase in collagen type II denaturation and type I procollagen synthesis, both dependent on age and grade of tissue degeneration.
LOW back pain is usually a self-limiting symptom, but it costs at least $16 billion each year1 , 2 and disables 5.4 million Americans.3 The fact that a benign physical … LOW back pain is usually a self-limiting symptom, but it costs at least $16 billion each year1 , 2 and disables 5.4 million Americans.3 The fact that a benign physical condition has such an important socioeconomic effect can probably be explained by complex psychological, societal, and legal factors. This article emphasizes that simple treatment is sufficient for most patients with low back pain and sciatica. Timely surgical intervention for the minority of patients with sciatica and neurologic claudication who do not respond to conservative care, and aggressive rehabilitation for those disabled by chronic low back pain, will favorably influence the outcome in . . .
A retrospective review involving 307 consecutive cases of lumbar disc herniation managed by posterolateral endoscopic discectomy was conducted.To describe a contemporary posterolateral endoscopic decompression technique for radiculopathy secondary to lumbar … A retrospective review involving 307 consecutive cases of lumbar disc herniation managed by posterolateral endoscopic discectomy was conducted.To describe a contemporary posterolateral endoscopic decompression technique for radiculopathy secondary to lumbar disc herniation; to evaluate the efficacy of the technique as it is applied to lumbar disc herniation including primary herniation, reherniation, intracanal herniation, and extracanal herniation; and to report outcome and complications.The concept of percutaneous posterolateral nucleotomy was introduced in 1973. The development of the related equipment and technique had witnessed a slow and lengthy evolution.A retrospective assessment of 307 patients was performed at least 1 year after their index operation. The outcome was graded according to a modified MacNab method. A patient-based outcome questionnaire also was incorporated into the study.The surgeon-performed assessment showed satisfactory results in 89.3% of the cases. The rate of response to the questionnaire was 91%. The responses indicated that 90.7% of the respondents were satisfied with their surgical outcome and would undergo the same endoscopic procedure again if faced with a similar herniation in the future. The poor outcome occurred in 10.7% of the primary group and 9.7% of the questionnaire group. The combined major and minor complication rate was 3.5%.The surgical outcome of posterolateral endoscopic discectomy for lumbar disc herniation is comparable with that for the traditional open transcanal microdiscectomy. Intracanal and extracanal herniations, reherniations, and incidental lateral recess stenosis can be addressed by the same approach.
Study Design. This prospective study analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. Objectives. To determine whether the addition of … Study Design. This prospective study analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. Objectives. To determine whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative spondylolisthesis. Summary of Background Data. Decompression is often necessary in the treatment of symptomatic patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate, although the effect on clinical outcome remains uncertain. Methods. Seventy-six patients who had symptomatic spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients were randomized to a segmental transpedicular instrumented or noninstrumented group. Results. Sixty-seven patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45). Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435). Conclusions. In patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and lower limbs
In Brief Study Design. Prospective, randomized, controlled study of patients with lumbar disc herniations, operated either in a full-endoscopic or microsurgical technique. Objective. Comparison of results of lumbar discectomies in … In Brief Study Design. Prospective, randomized, controlled study of patients with lumbar disc herniations, operated either in a full-endoscopic or microsurgical technique. Objective. Comparison of results of lumbar discectomies in full-endoscopic interlaminar and transforaminal technique with the conventional microsurgical technique. Summary of Background Data. Even with good results, conventional disc operations may result in subsequent damage due to trauma. Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and after surgery. With the transforaminal and interlaminar techniques, 2 full-endoscopic procedures are available for lumbar disc operations. Methods. One hundred seventy-eight patients with full-endoscopic or microsurgical discectomy underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: VAS, German version North American Spine Society Instrument, Oswestry Low-Back Pain Disability Questionnaire. Results. After surgery 82% of the patients no longer had leg pain, and 14% had occasional pain. The clinical results were the same in both groups. The recurrence rate was 6.2% with no difference between the groups. The full-endoscopic techniques brought significant advantages in the following areas: back pain, rehabilitation, complications, and traumatization. Conclusion. The clinical results of the full-endoscopic technique are equal to those of the microsurgical technique. At the same time, there are advantages in the operation technique and reduced traumatization. With the surgical devices and the possibility of selecting an interlaminar or posterolateral to lateral transforaminal procedure, lumbar disc herniations outside and insidethe spinal canal can be sufficiently removed using the full-endoscopic technique, when taking the appropriate criteria into account. Full-endoscopic surgery is a sufficient and safe supplementation and alternative to microsurgical procedures. The prospective, randomized, controlled study compares the results of lumbar discectomies in full-endoscopic and microsurgical techniques. The clinical results of both techniques were equal in 178 patients, with advantages in operation technique and reduced traumatization in the full-endoscopic procedure.
Study Design. A histologic study on age-related changes of the human lumbar intervertebral disc was conducted. Objectives. To investigate comprehensively age-related temporospatial histologic changes in human lumbar intervertebral disc, and … Study Design. A histologic study on age-related changes of the human lumbar intervertebral disc was conducted. Objectives. To investigate comprehensively age-related temporospatial histologic changes in human lumbar intervertebral disc, and to develop a practicable and reliable classification system for age-related histologic disc alteration. Summary of the Background Data. No comprehensive microscopic analysis of age-related disc changes is available. There is no conceptual morphologic framework for classifying age-related disc changes as a reference basis for more sophisticated molecular biologic analyses of the causative factors of disc aging or premature aging (degeneration). Methods. A total of 180 complete sagittal lumbar motion segment slices obtained from 44 deceased individuals (fetal to 88 years of age) were analyzed with regard to 11 histologic variables for the intervertebral disc and endplate, respectively. In addition, 30 surgical specimens (3 regions each) were investigated with regard to five histologic variables. Based on the semiquantitative analyses of 20,250 histologic variable assessments, a classification system was developed and tested in terms of validity, practicability, and reliability. The classification system was applied to cadaveric and surgical disc specimens not included in the development of the classification system, and the scores were assessed by two additional independent raters. Results. A semiquantitative analyses provided clear histologic evidence for the detrimental effect of a diminished blood supply on the endplate, resulting in the tissue breakdown beginning in the nucleus pulposus and starting in the second life decade. Significant temporospatial variations in the presence and abundance of histologic disc alterations were observed across levels, regions, macroscopic degeneration grades, and age groups. A practicable classification system for age-related histologic disc alterations was developed, resulting in moderate to excellent reliability (κ values, 0.49–0.98) depending on the histologic variable. Application of the classification system to cadaveric and surgical specimens demonstrated a significant correlation with age (P < 0.0001) and macroscopic grade of degeneration (P < 0001). However, substantial data scatter caution against reliance on traditional macroscopic disc grading and favor a histology-based classification system as a reference standard. Conclusions. Histologic disc alterations can reliably be graded based on the proposed classification system providing a morphologic framework for more sophisticated molecular biologic analyses of factors leading to age-related disc changes. Diminished blood supply to the intervertebral disc in the first half of the second life decade appears to initiate tissue breakdown.
Repeated cross-sectional analysis using national Medicare data from the Dartmouth Atlas Project.To describe recent trends and geographic variation in population-based rates of lumbar fusion spine surgery.Lumbar fusion rates have increased … Repeated cross-sectional analysis using national Medicare data from the Dartmouth Atlas Project.To describe recent trends and geographic variation in population-based rates of lumbar fusion spine surgery.Lumbar fusion rates have increased dramatically during the 1980s and even more so in the 1990s. The most rapid increase appeared to follow the approval of a new surgical implant device.Medicare claims and enrollment data were used to calculate age, sex, and race-adjusted rates of lumbar laminectomy/discectomy and lumbar fusion for fee-for-service Medicare beneficiaries over age 65 in each of the 306 US Hospital Referral Regions between 1992 and 2003.Lumbar fusion rates have increased steadily since 1992 (0.3 per 1000 enrollees in 1992 to 1.1 per 1000 enrollees in 2003). Regional rates of lumbar discectomy, laminectomy, and fusion in 1992-1993 were highly correlated to rates of discectomy, laminectomy (R2 = 0.44), and fusion (R2 = 0.28) in 2002-2003. There was a nearly 8-fold variation in regional rates of lumbar discectomy and laminectomy in 2002 and 2003. In the case of lumbar fusion, there was nearly a 20-fold range in rates among Medicare enrollees in 2002 and 2003. This represents the largest coefficient of variation seen with any surgical procedure. Medicare spending for inpatient back surgery more than doubled over the decade. Spending for lumbar fusion increased more than 500%, from 75 million dollars to 482 million dollars. In 1992, lumbar fusion represented 14% of total spending for back surgery; by 2003, lumbar fusion accounted for 47% of spending.The rate of specific procedures within a region or "surgical signature" is remarkably stable over time. However, there has been a marked increase in rates of fusion, and a coincident shift and increase in cost. Rates of back surgery were not correlated with the per-capita supply of orthopedic and neurosurgeons.
In 842 patients, with the clinical diagnosis of root compression due to a disc herniation, laminectomy failed to reveal any lesion of the intervertebral disc in sixty-eight patients. In nine, … In 842 patients, with the clinical diagnosis of root compression due to a disc herniation, laminectomy failed to reveal any lesion of the intervertebral disc in sixty-eight patients. In nine, the source of the root compression was found to be foraminal migration of a sequestrated portion of the intervertebral disc; in twelve, pedicular kinking; in nineteen, articular-process impingement; in eight, segmental spinal stenosis; and in two, a lateral disc protrusion. In eighteen explorations, performed early in the series, no cause could be found for the root compression, and it is suggested that the lack of findings in these cases was due to inadequate exploration of the nerve root. The series analyzed is too small to make any dogmatic statements. However, a plea is entered for a careful appraisal of the level of root involvement preoperatively, using all ancillary methods available—myelography, discography root-sleeve injection, electromyography, diagnostic differential epidural injections—in patients without objective signs of the site of root involvement. Armed with such evidence, it is suggested that a radical exposure of the nerve root should be undertaken in all patients in whom the intervertebral disc fails to reveal pathological changes of sufficient degree to account for the nerve-root compression or tautness demonstrated.
Autologous bone grafts harvested from the iliac crest are commonly used in reconstructive orthopaedic surgery. Autologous bone is used to help promote bone healing in fractures and to provide structural … Autologous bone grafts harvested from the iliac crest are commonly used in reconstructive orthopaedic surgery. Autologous bone is used to help promote bone healing in fractures and to provide structural support for reconstructive surgery. The results of autologous bone grafting are more predictable than the use of xenografts, cadaveric allografts, or synthetic bone substitutes because autologous bone grafts provide osteoinductive and osteoconductive properties, are not immunogenic, and are usually well incorporated into the graft site. In a retrospective review of 414 consecutive cases of iliac crest bone graft procedures performed at Brooke Army Medical Center from 1983 to 1993, 41 (10%) minor and 24 (5.8%) major complications were identified. Minor complications included superficial infections, superficial seromas, and minor hematomas. Major complications included herniation of abdominal contents through massive bone graft donor sites, vascular injuries, deep infections at the donor site, neurologic injuries, deep hematoma formation requiring surgical intervention, and iliac wing fractures. Harvesting of iliac crest bone graft can be associated with significant morbidity. However, with adequate preoperative planning and proper surgical technique, the incidence of these complications can be reduced.
Retrospective cohort study using national sample administrative data.To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures.Previous … Retrospective cohort study using national sample administrative data.To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures.Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery.We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection.In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses.Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.
Two hundred eighty patients with herniated lumbar discs, verified by radiculography, were divided into three groups. One group, which mainly will be dealt with in this paper, consisted of 126 … Two hundred eighty patients with herniated lumbar discs, verified by radiculography, were divided into three groups. One group, which mainly will be dealt with in this paper, consisted of 126 patients with uncertain indication for surgical treatment, who had their therapy decided by randomization which permitted comparison between the results of surgical and conservative treatment. Another group comprising 67 patients had symptoms and signs that beyond doubt, required surgical therapy. The third group of 87 patients was treated conservatively because there was no indication for operative intervention. Follow-up examinations in the first group were performed after one, four, and ten years. The controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant. Only minor changes took place during the last six years of observation.
In Brief Study Design. A cross-sectional population study of magnetic resonance imaging (MRI) changes. Objective. To examine the pattern and prevalence of lumbar spine MRI changes within a southern Chinese … In Brief Study Design. A cross-sectional population study of magnetic resonance imaging (MRI) changes. Objective. To examine the pattern and prevalence of lumbar spine MRI changes within a southern Chinese population and their relationship with back pain. Summary of Background Data. Previous studies on MRI changes and back pain have used populations of asymptomatic individuals or patients presenting with back pain and sciatica. Thus, the prevalence and pattern of intervertebral disc degeneration within the population is not known. Methods. Lumbar spine MRIs were obtained in 1043 volunteers between 18 to 55 years of age. MRI changes including disc degeneration, herniation, anular tears (HIZ), and Schmorl's nodes were noted by 2 independent observers. Differences were settled by consensus. Disc degeneration was graded using Schneiderman's classification, and a total score (DDD score) was calculated by the summation of the Schneiderman's score for each lumbar level. A K-mean clustering program was used to group individuals into different patterns of degeneration. Results. Forty percent of individuals under 30 years of age had lumbar intervertebral disc degeneration (LDD), the prevalence of LDD increasing progressively to over 90% by 50 to 55 years of age. There was a positive correlation between the DDD score and low back pain. L5–S1 and L4–L5 were the most commonly affected levels. Apart from the usual patterns of degeneration, some uncommon patternsof degeneration were identified, comprising of subjects with skip level lesions (intervening normal levels) and isolated upper or mid lumbar degeneration. Conclusion. LDD is common, and its incidence increases with age. In a population setting, there is a significant association of LDD on MRI with back pain. This large scale population study of magnetic resonance imaging changes of the lumbar spine between the ages of 18 and 55 years showed that lumbar intervertebral disc degeneration was found to be common and age dependent. Magnetic resonance imaging changes of degeneration are associated with low back pain. Some unusual patterns of degeneration were identified.
A five-category grading scheme for assessing the gross morphology of midsagittal sections of the human lumbar intervertebral disc was developed. The ability of three observers to categorize a series of … A five-category grading scheme for assessing the gross morphology of midsagittal sections of the human lumbar intervertebral disc was developed. The ability of three observers to categorize a series of 68 discs with a wide spectrum of morphologies established the comprehensiveness of the classification. Three independent observers tested the reproducibility of the procedure by assignment of grades blindly to duplicate images of 68 discs taken from 15 spines. The intraobserver agreement ranged from 87 to 91%. The interobserver agreement was 61, 64, and 88% for the three pairs, the two low values being attributable to the bias of one observer. The agreement between the assigned and average grades was 85, 92, 68, 90, and 75% for Grades I through V, respectively. Except for Grade III, the disagreements were attributable mainly to the bias of one observer. Both the increase in the grade with age and the finding that all the discs within 14 of 15 spines had a narrow range of grades demonstrated the biologic credibility of the scheme.
The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion GEORGE SMITH;ROBERT ROBINSON; The Journal of Bone & Joint Surgery The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion GEORGE SMITH;ROBERT ROBINSON; The Journal of Bone & Joint Surgery
Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials.Surgical … Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials.Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years.We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and -16.7 for the Oswestry Disability Index (95% CI, -19.5 to -13.9). There was little evidence of harm from either treatment.In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409 [ClinicalTrials.gov].).
Study Design. Mechanical testing of cadaveric lumbar motion segments. Objectives. To test the hypothesis that minor damage to a vertebral body can lead to progressive disruption of the adjacent intervertebral … Study Design. Mechanical testing of cadaveric lumbar motion segments. Objectives. To test the hypothesis that minor damage to a vertebral body can lead to progressive disruption of the adjacent intervertebral disc. Summary of Background Data. Disc degeneration involves gross structural disruption as well as cell-mediated changes in matrix composition, but there is little evidence concerning which comes first. Comparatively minor damage to a vertebral body is known to decompress the adjacent discs, and this may adversely affect both structure and cell function in the disc. Methods. In this study, 38 cadaveric lumbar motion segments (mean age, 51 years) were subjected to complex mechanical loading to simulate typical activities in vivo while the distribution of compressive stress in the disc matrix was measured using a pressure transducer mounted in a needle 1.3 mm in diameter. "Stress profiles" were repeated after a controlled compressive overload injury had reduced motion segment height by approximately 1%. Moderate repetitive loading, appropriate for the simulation of light manual labor, then was applied to the damaged specimens for approximately 4 hours, and stress profilometry was repeated a third time. Discs then were sectioned and photographed. Results. Endplate damage reduced pressure in the adjacent nucleus pulposus by 25% ± 27% and generated peaks of compressive stress in the anulus, usually posteriorly to the nucleus. Discs 50 to 70 years of age were affected the most. Repetitive loading further decompressed the nucleus and intensified stress concentrations in the anulus, especially in simulated lordotic postures. Sagittal plane sections of 15 of the discs showed an inwardly collapsing anulus in 9 discs, extreme outward bulging of the anulus in 11 discs, and complete radial fissures in 2 discs, 1 of which allowed posterior migration of nucleus pulposus. Comparisons with the results from tissue culture experiments indicated that the observed changes in matrix compressive stress would inhibit disc cell metabolism throughout the disc, and could lead to progressive deterioration of the matrix. Conclusions. Minor damage to a vertebral body endplate leads to progressive structural changes in the adjacent intervertebral discs.
The intervertebral disc is a cartilaginous structure that resembles articular cartilage in its biochemistry, but morphologically it is clearly different. It shows degenerative and ageing changes earlier than does any … The intervertebral disc is a cartilaginous structure that resembles articular cartilage in its biochemistry, but morphologically it is clearly different. It shows degenerative and ageing changes earlier than does any other connective tissue in the body. It is believed to be important clinically because there is an association of disc degeneration with back pain. Current treatments are predominantly conservative or, less commonly, surgical; in many cases there is no clear diagnosis and therapy is considered inadequate. New developments, such as genetic and biological approaches, may allow better diagnosis and treatments in the future.
We performed a prospective roentgenographic study to determine the incidence of spondylolysis, spondylolisthesis, or both, in 500 unselected first-grade children from 1955 through 1957. The families of the children with … We performed a prospective roentgenographic study to determine the incidence of spondylolysis, spondylolisthesis, or both, in 500 unselected first-grade children from 1955 through 1957. The families of the children with spondylolysis were followed in a similar manner. The incidence of spondylolysis at the age of six years was 4.4 per cent and increased to 6 per cent in adulthood. The degree of spondylolisthesis was as much as 28 per cent, and progression of the olisthesis was unusual. The data support the hypothesis that the spondylolytic defect is the result of a defect in the cartilaginous anlage of a vertebra. There is a hereditary pre-disposition to the defect and a strong association with spina bifida occulta. Progression of a slip was unlikely after adolescence and the slip was never symptomatic in the population that we studied.
<h3>BACKGROUND AND PURPOSE:</h3> Degenerative changes are commonly found in spine imaging but often occur in pain-free individuals as well as those with back pain. We sought to estimate the prevalence, … <h3>BACKGROUND AND PURPOSE:</h3> Degenerative changes are commonly found in spine imaging but often occur in pain-free individuals as well as those with back pain. We sought to estimate the prevalence, by age, of common degenerative spine conditions by performing a systematic review studying the prevalence of spine degeneration on imaging in asymptomatic individuals. <h3>MATERIALS AND METHODS:</h3> We performed a systematic review of articles reporting the prevalence of imaging findings (CT or MR imaging) in asymptomatic individuals from published English literature through April 2014. Two reviewers evaluated each manuscript. We selected age groupings by decade (20, 30, 40, 50, 60, 70, 80 years), determining age-specific prevalence estimates. For each imaging finding, we fit a generalized linear mixed-effects model for the age-specific prevalence estimate clustering in the study, adjusting for the midpoint of the reported age interval. <h3>RESULTS:</h3> Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. <h3>CONCLUSIONS:</h3> Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient9s clinical condition.
Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials. Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials.
Review and reinterpretation of existing literature.To suggest how intervertebral disc degeneration might be distinguished from the physiologic processes of growth, aging, healing, and adaptive remodeling.The research literature concerning disc degeneration … Review and reinterpretation of existing literature.To suggest how intervertebral disc degeneration might be distinguished from the physiologic processes of growth, aging, healing, and adaptive remodeling.The research literature concerning disc degeneration is particularly diverse, and there are no accepted definitions to guide biomedical research, or medicolegal practice.The process of disc degeneration is an aberrant, cell-mediated response to progressive structural failure. A degenerate disc is one with structural failure combined with accelerated or advanced signs of aging. Early degenerative changes should refer to accelerated age-related changes in a structurally intact disc. Degenerative disc disease should be applied to a degenerate disc that is also painful.Structural defects such as endplate fracture, radial fissures, and herniation are easily detected, unambiguous markers of impaired disc function. They are not inevitable with age and are more closely related to pain than any other feature of aging discs. Structural failure is irreversible because adult discs have limited healing potential. It also progresses by physical and biologic mechanisms, and, therefore, is a suitable marker for a degenerative process. Biologic progression occurs because structural failure uncouples the local mechanical environment of disc cells from the overall loading of the disc, so that disc cell responses can be inappropriate or "aberrant." Animal models confirm that cell-mediated changes always follow structural failure caused by trauma. This definition of disc degeneration simplifies the issue of causality: excessive mechanical loading disrupts a disc's structure and precipitates a cascade of cell-mediated responses, leading to further disruption. Underlying causes of disc degeneration include genetic inheritance, age, inadequate metabolite transport, and loading history, all of which can weaken discs to such an extent that structural failure occurs during the activities of daily living. The other closely related definitions help to distinguish between degenerate and injured discs, and between discs that are and are not painful.
geons have wide discretion.For pain-related surgery, consensus on indications for specific procedures (eg, decompression alone or decompression plus fusion) is generally lacking 1-3 despite randomized trials for some condition and … geons have wide discretion.For pain-related surgery, consensus on indications for specific procedures (eg, decompression alone or decompression plus fusion) is generally lacking 1-3 despite randomized trials for some condition and procedure combinations. 4-10Furthermore, individual surgeon preferences may outweigh patient and disease characteristics in choosing procedures. 3[10]12 Risks of spine surgery are particularly important in older adults, for whom stenosis is the most common surgical indication.Symptomatic lumbar stenosis results from progressive degenerative changes in intervertebral joints and ligamentous structures, leading to spinal canal and neural foraminal narrowing.Diagnosis and treatment require complex judgments integrating data from imaging, clini-
Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.We randomly assigned 283 patients … Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).
ContextLumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.ObjectiveTo assess … ContextLumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.ObjectiveTo assess the efficacy of surgery for lumbar intervertebral disk herniation.Design, Setting, and PatientsThe Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.InterventionsStandard open diskectomy vs nonoperative treatment individualized to the patient.Main Outcome MeasuresPrimary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.ResultsAdherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.ConclusionsPatients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.Trial Registrationclinicaltrials.gov Identifier: NCT00000410
The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar … The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain.
Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. Lumbar spondylosis may result … Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity. The surgical options for interbody fusion of the lumbar spine include: posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF). The indications may include: discogenic/facetogenic low back pain, neurogenic claudication, radiculopathy due to foraminal stenosis, lumbar degenerative spinal deformity including symptomatic spondylolisthesis and degenerative scoliosis. In general, traditional posterior approaches are frequently used with acceptable fusion rates and low complication rates, however they are limited by thecal sac and nerve root retraction, along with iatrogenic injury to the paraspinal musculature and disruption of the posterior tension band. Minimally invasive (MIS) posterior approaches have evolved in an attempt to reduce approach related complications. Anterior approaches avoid the spinal canal, cauda equina and nerve roots, however have issues with approach related abdominal and vascular complications. In addition, lateral and OLIF techniques have potential risks to the lumbar plexus and psoas muscle. The present study aims firstly to comprehensively review the available literature and evidence for different lumbar interbody fusion (LIF) techniques. Secondly, we propose a set of recommendations and guidelines for the indications for interbody fusion options. Thirdly, this article provides a description of each approach, and illustrates the potential benefits and disadvantages of each technique with reference to indication and spine level performed.
We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge … We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects. In view of these findings in asymptomatic subjects, we concluded that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.
URBAN, J. P. G.; HOLM, S.; MAROUDAS, A.; NACHEMSON, A.Editor(s): CRACCHIOLO, ANDREA III M.D. Author Information URBAN, J. P. G.; HOLM, S.; MAROUDAS, A.; NACHEMSON, A.Editor(s): CRACCHIOLO, ANDREA III M.D. Author Information
Summary Pathological conditions of the cervical vertebral column cause combinations of pain, neurologic deficits and behavioural issues that affect welfare and performance in the horse. A diagnosis of cervical vertebral … Summary Pathological conditions of the cervical vertebral column cause combinations of pain, neurologic deficits and behavioural issues that affect welfare and performance in the horse. A diagnosis of cervical vertebral malformation is associated with a high mortality rate, especially when identified in young animals. Surgical treatment offers the potential for long‐term improvement or resolution of clinical signs, at the cost of the potential for complications and an initial increased financial outlay. There are difficulties with extrapolating published outcomes to the individual case; however, representative reported outcomes following cervical vertebral interbody fusion show an improvement in ataxia of 1 grade in 60%–86% of horses, 2 grades in 7%–74% of horses and 3 grades in 1%–13% of horses, with a fatal complication rate of 6%–18%. Multiple factors, such as lesion location, cause of stenosis and duration of compression affect surgical outcome. Case selection should take into account factors such as severity of initial presentation, temperament, intended use and owner attitudes. Uniportal endoscopic foraminotomy is in its infancy but shows great promise as a minimally invasive procedure able to relieve clinical signs associated with spinal nerve impingement in the cervical vertebral column. This condition is being increasingly recognised, particularly in Warmblood sport horses. Details of greater case numbers and longer‐term follow‐up are required, but 74% of the first operated cases returned to work. Cervical articular process joint arthroscopy/arthrotomy is uncommonly indicated but offers a low risk and successful treatment option for horses diagnosed with clinically relevant and surgically accessible intra‐articular fragments or loose bodies within these joints. In all cases a clear understanding of the goals of surgery and careful discussion of the process, the risks and the anticipated outcome helps an owner and their clinical team make the most appropriate decision for their animal, in a veterinary field which still contains many unknowns for the individual patient. Research in this field is very active, with much new information forthcoming.
Background Intervertebral disc degeneration (IVDD) is a major global cause of disability, and mesenchymal stem cell (MSC) therapy offers a promising regenerative solution by targeting the root causes of degeneration, … Background Intervertebral disc degeneration (IVDD) is a major global cause of disability, and mesenchymal stem cell (MSC) therapy offers a promising regenerative solution by targeting the root causes of degeneration, unlike conventional symptom-focused treatments. This bibliometric analysis explores trends and emerging research areas in MSC applications for IVDD. Methods A comprehensive literature search was conducted in the Web of Science Core Collection database, covering publications from 2000 to 2024. Bibliometric and visualized analysis was performed using VOSviewers, CiteSpace and the R package “Bibliometrix.” Results This bibliometric analysis reviewed 931 articles, revealing an overall upward trend in publication activity. Leading authors included Sakai Daisuke, Grad Sibylle, and Alini Mauro. China and the USA led in publication volume and citation counts, while the United Kingdom achieved the highest average citations per publication. The University of Pennsylvania and Zhejiang University were the most productive institutions. Key journals included Biomaterials , Spine , and Tissue Engineering Part A . Earlier core keywords primarily focused on foundational concepts such as “gene expression,” “articular cartilage,” “anulus fibrosus” and “extracellular matrix.” Recent keyword bursts include “activation,” “autophagy,” “extracellular vesicles,” “apoptosis,” “exosome,” and “oxidative stress.” Conclusion This bibliometric analysis revealed key research focuses on foundational biological mechanisms, translational applications, and addressing specific challenges in the use of MSC for IVDD. Future research is likely to focus on optimizing MSC functionality, developing cell-free therapies such as extracellular vesicles, and targeting the molecular mechanisms involved in disc degeneration and regeneration.
S. Prakash | International Journal of Oral and Maxillofacial Surgery
Retrospective observational study. This study investigated the impact of long-segment and short-segment pedicle screw fixation on degeneration indicators, particularly stable osteophytes, in the treatment of single-segment lumbar burst fractures. Current … Retrospective observational study. This study investigated the impact of long-segment and short-segment pedicle screw fixation on degeneration indicators, particularly stable osteophytes, in the treatment of single-segment lumbar burst fractures. Current research mainly focuses on clinical indicators such as operation time, Visual Analog Scale (VAS) pain scores, and imaging indicators like the Cobb angle correction rate. However, there is a paucity of research on the indicators of intervertebral disc degeneration at fixed segments (such as bone spur formation, vacuum phenomenon in the disc, and Modic changes). As the health status of the intervertebral disc is closely related to spinal stability, this study provides a comprehensive evaluation of the efficacy of two surgical techniques, providing a more precise basis for clinical treatment. This was a retrospective analysis of a cohort of 64 patients with single-segment lumbar burst fractures. Among them, 38 patients underwent posterior long-segment pedicle screw-rod fixation (long-segment group), while 26 cases received posterior shortsegment pedicle screw fixation (short-segment group). Changes in degeneration indicators within the fixation area, including osteophyte formation, intervertebral disc vacuum sign, and intervertebral height, were examined. All 64 patients completed surgery and were followed up for at least 24 months. At the final follow-up at 24 months, the shortsegment fixation group exhibited a higher osteophyte formation score than the long-segment fixation group. However, no significant between-group differences were observed in the incidence of intervertebral disc vacuum sign or intervertebral height loss rate. After a 2-year follow-up, the short-segment fixation group demonstrated a similar intervertebral height loss rate and intervertebral disc vacuum sign incidence compared to the long-segment fixation group, but a higher rate of stable osteophyte formation.
A retrospective cohort study. To determine whether the preoperative pars defect length predicts bone union following the modified smiley face rod (mSFR) technique for lumbar spondylolysis and to identify a … A retrospective cohort study. To determine whether the preoperative pars defect length predicts bone union following the modified smiley face rod (mSFR) technique for lumbar spondylolysis and to identify a threshold for clinical decision-making. Lumbar spondylolysis is a common cause of low back pain in young athletes, often leading to pseudarthrosis that requires surgical intervention. Various techniques, including mSFR, address pseudarthrosis; however, the effect of preoperative pars defect length on bone union remains unclear. This study analyzed 75 pars defects in 38 patients treated with mSFR between 2014 and 2022. Pre- and postoperative pars defect lengths were measured using computed tomography (CT). Patients were categorized into bone union and nonunion groups based on CT findings up to 24 months postoperatively. Group comparisons of defect lengths were performed using the Mann-Whitney U test. Logistic regression was used to examine the association between preoperative defect length and nonunion. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal threshold for preoperative defect length. Bone union was achieved in 65 of 75 defects (87%). The preoperative pars defect length was significantly shorter in the bone union group than in the nonunion group (3.0 mm vs. 5.6 mm, p <0.001). A strong correlation was observed between pre- and postoperative pars defect lengths (Spearman's rho=0.76). Logistic regression analysis revealed a significant association between a longer preoperative defect and nonunion (odds ratio, 1.89; 95% confidence interval, 1.29-2.72; p =0.001). ROC analysis revealed a cut-off value of 3.8 mm (sensitivity, 89%; specificity, 75%; area under the curve=0.86). Bone union following the mSFR technique may be influenced by the pars defect length, with larger preoperative defects potentially hindering bone union. The technique is most effective when the preoperative defect length is ≤3.8 mm.
A cross-sectional study. To evaluate the diagnostic performance of a novel 3-kg weight-lifting flexion radiograph for detecting lumbar instability. Conventional flexion-extension radiographs have limited sensitivity for detecting lumbar instability, while … A cross-sectional study. To evaluate the diagnostic performance of a novel 3-kg weight-lifting flexion radiograph for detecting lumbar instability. Conventional flexion-extension radiographs have limited sensitivity for detecting lumbar instability, while magnetic resonance imaging (MRI) is a reliable standard. This study compares the performance of a novel weight-lifting radiograph to conventional flexion radiographs, using MRI as the reference standard. Forty-six patients with a diagnosis of lumbar instability were enrolled. Participants underwent lateral flexion, lateral extension, and 3-kg weight-lifting flexion lumbosacral spine radiographs. MRI was also performed on all participants. Diagnostic parameters, including sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and likelihood ratios, were calculated for each lumbar level. Reliability was assessed using intraclass correlation coefficients (ICCs). The 3-kg weight-lifting flexion radiograph showed higher sensitivity for detecting spinal instability at the L3/4 and L4/5 levels (88% vs. 36% and 83.3% vs. 44.44%, respectively) but lower specificity (61.9% vs. 76.19% and 70% vs. 80%, respectively) compared to the conventional flexion radiograph. McNemar tests revealed no significant differences between the 3-kg weight-lifting flexion radiograph and MRI at these levels (p >0.05). Reliability assessments demonstrated excellent intra- and interobserver agreement (ICC ≥0.99). Furthermore, this technique was safe, with no adverse effects reported. The 3-kg weight-lifting flexion radiograph enhances diagnostic sensitivity and accuracy for lumbar instability, particularly at the L3/4 and L4/5 levels, offering a reliable screening alternative.
A retrospective cohort study. This study aimed to compare the efficacy and safety of topical and relatively high-dose intravenous tranexamic acid (TXA) in minimizing postoperative blood loss in patients undergoing … A retrospective cohort study. This study aimed to compare the efficacy and safety of topical and relatively high-dose intravenous tranexamic acid (TXA) in minimizing postoperative blood loss in patients undergoing single-level posterior lumbar interbody fusion (PLIF). Topical TXA demonstrates a similar hemostatic efficacy to intravenous TXA. However, whether intravenous or topical TXA is more effective in minimizing postoperative bleeding in spine surgery remains unclear. In total, 140 patients who underwent single-level PLIF were retrospectively enrolled and assigned to the (1) control group (n=58), which did not receive TXA; (2) TXA (iv) group (n=39), which was administered intravenously with a relatively high-dose (2 g) of TXA immediately before wound closure; and (3) TXA (t) group (n=43), which received topical application of TXA (1 g in 100 mL of saline solution) to the wound immediately before wound closure. No significant differences in age, body mass index, sex, preoperative hematological parameters, or intraoperative blood loss were found among the three groups. The total postoperative blood loss was significantly lower in the TXA (t) group than in the TXA (iv) and control groups (389.6±137.5 vs. 543.6±175.4 vs. 700.3±231.4, respectively; both p<0.01). Analysis of blood loss over time revealed significantly less blood loss throughout the postoperative period in the TXA (t) group than in the control group (p<0.01). In contrast, the TXA (iv) group showed less blood loss than the control group in 2-6 hours and 6-12 hours postoperatively (p<0.05). No complications, such as thromboembolic events, were associated with the use of either TXA formulation. Following single-level PLIF, topical TXA exerts rapid and long-lasting effects on minimizing postoperative blood loss compared with twice the amount of intravenous TXA.
The unspecific description and definition of Cauda Equina syndrome (CES) in literature gives rise to a quantum of doubts regarding its decision making and management in clinical practice. Prospective analysis … The unspecific description and definition of Cauda Equina syndrome (CES) in literature gives rise to a quantum of doubts regarding its decision making and management in clinical practice. Prospective analysis of 11 cases of CES, between Jan 2015 and Sep 2017, who had been treated with Decompression and Transforaminal Lumbar Interbody Fusion, was done. The varied presentations were studied and the following parameters were assessed in the evaluation of the functional outcome of each patient: Pain (assessed by the VAS-Visual Analogue Scale), Motor status (assessed by the MRC grading), Bladder recovery (graded as per Gleave and Macfarlane) and the Oswestry Disability Index. Our analysis of the results supported the following points: Increased duration of symptoms had a negative effect on the ODI at 3 months and 1 year, the denser the neurological deficit, the worse was the ODI score at 3 months and 1 year; age&gt;60 years had a negative effect on the ODI score at 3 months and 1 year, time to surgery since presentation had no significant effect on the overall functional outcome and ODI at 1 year, the mean VAS (Visual Analogue Scale) was drastically low at the end of 1 year with most of the patients almost free of back pain at the end of 1 year, bladder recovery was also related to the duration of symptoms and the age of the patient, as increasing age and longer duration of the deficits had a negative impact on the bladder recovery ultimately.
Study Design Retrospective comparative study. Objectives Optimal surgical treatment for low-grade L5-S1 isthmic spondylolisthesis (IS) is still subject of debate. While various surgical approaches exist, anchored stand-alone (SA) ALIF has … Study Design Retrospective comparative study. Objectives Optimal surgical treatment for low-grade L5-S1 isthmic spondylolisthesis (IS) is still subject of debate. While various surgical approaches exist, anchored stand-alone (SA) ALIF has emerged as a promising alternative technique. This study aimed to compare the efficacy, as well as the clinical and radiological outcomes of anchored SA-ALIF and posterior lumbar interbody fusion in the management of low-grade L5-S1 IS. Methods A total of 53 patients, 26 from the anterior group and 27 from the posterior group, met the inclusion criteria. Intraoperative blood loss, operative time, radiation exposure and postoperative length of hospitalization were retrospectively evaluated. Clinical outcomes were assessed using the ODI and VAS scales. Upright lumbosacral X-ray and lumbosacral CT scan were used to evaluate spinopelvic parameters and intersomatic fusion according to Brantigan-Steffee-Fraser (BSF) scale, respectively. Results The mean postoperative follow-up was 39 months. Intraoperative blood loss, radiation exposure, operative time, and postoperative length of hospitalization were significantly lower in the anterior group. Effective ODI and VAS improvement was achieved in both anterior and posterior groups. No significant differences were observed between the two groups in postoperative spinopelvic parameters assessment. Effective spinal fusion was achieved in 23 patients (88.4%) in the anterior group, and in 21 patients (77.8%) in the posterior group. Conclusion While both techniques effectively achieve spinal fusion and symptom relief, anchored SA-ALIF offers significant advantages over posterior fusion techniques in terms of intraoperative blood loss, radiation exposure, operative time, and postoperative length of hospitalization.
Background/Objectives: There exists a need to capture the current landscape of the literature for lumbar decompression on muscle strength, as measured by manual muscle testing (MMT), in cohorts with foot … Background/Objectives: There exists a need to capture the current landscape of the literature for lumbar decompression on muscle strength, as measured by manual muscle testing (MMT), in cohorts with foot drop secondary to lumbar degenerative disease (LDD). Methods: A literature search of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from each database’s inception to 21 March 2025. Eligible studies reported patients with LDD-related foot drop treated surgically. This review was registered in PROSPERO (ID: CRD42024550980). Results: A total of 20 studies comprising 918 patients met the eligibility criteria, with most cases attributable to lumbar disc herniation (79% of patients, 95% CI: 0.72–0.85, I2 = 96%) or spinal stenosis (22% of patients, 95% CI: 0.15–0.30, I2 = 96%). Following surgery, 60% of patients (95% CI: 0.44–0.75, I2 = 97%) achieved an MMT score of 4–5, indicating recovery, while 82% (95% CI: 0.76–0.88, I2 = 89%) demonstrated an improvement of at least one MMT grade. No improvement was seen in 18% of patients (95% CI: 0.12–0.24, I2 = 89%). For pain, the preoperative VAS mean was 5.91 (95% CI: 4.21–7.60, I2 = 99%), while the postoperative mean was 1.00 (95% CI: −0.05–2.06, I2 = 99%). Overall complications were reported at 1% (95% CI: −0.00–0.02, I2 = 0%). Conclusions: Lumbar decompression achieves clinically meaningful recovery of LDD-induced foot drop. However, this meta-analysis highlights the overlooked portion of patients who will not respond, providing a sequential approach for future investigation of these cohorts through foundational evidence of the present literature base.
Background/Objectives: Lumbar disc herniation (LDH) is the most common condition associated with low back pain, and it adversely impacts individuals’ health. The interplay between energy metabolism and apoptosis is critical, … Background/Objectives: Lumbar disc herniation (LDH) is the most common condition associated with low back pain, and it adversely impacts individuals’ health. The interplay between energy metabolism and apoptosis is critical, as the loss of viable cells in the intervertebral disc (IVD) can lead to a cascade of degenerative changes. Efferocytosis is a key biological process that maintains homeostasis by removing apoptotic cells, resolving inflammation, and promoting tissue repair. Therefore, enhancing mitochondrial energy metabolism and efferocytosis function in IVD cells holds great promise as a potential therapeutic approach for LDH. Methods: In this study, energy metabolism and efferocytosis-related differentially expressed genes (EMERDEGs) were identified from the transcriptomic datasets of LDH. Machine learning approaches were used to identify key genes. Functional enrichment analyses were performed to elucidate the biological roles of these genes. The functions of the hub genes were validated by RT-qPCR. The CIBERSORT algorithm was used to compare immune infiltration between LDH and Control groups. Additionally, we used single-cell RNA sequencing dataset to analyze cell-specific expression of the hub genes. Results: By using bioinformatics methods, we identified six EMERDEGs hub genes (IL6R, TNF, MAPK13, ELANE, PLAUR, ABCA1) and verified them using RT-qPCR. Functional enrichment analysis revealed that these genes were primarily associated with inflammatory response, chemokine production, and cellular energy metabolism. Further, we identified candidate drugs as potential treatments for LDH. Additionally, in immune infiltration analysis, the abundance of activated dendritic cells, neutrophils, and gamma delta T cells varied significantly between the LDH group and Control group. The scRNA-seq analysis showed that these hub genes were mainly expressed in chondrocyte-like cells. Conclusions: The identified EMERDEG hub genes and pathways offer novel insights into the molecular mechanisms underlying LDH and suggest potential therapeutic targets.
Background/Objectives: Degenerative spinal conditions, such as degenerative stenosis, have been linked to metabolic and lifestyle factors, including obesity, smoking, and diabetes. Glial cell line-derived neurotrophic factor (GDNF) plays a crucial … Background/Objectives: Degenerative spinal conditions, such as degenerative stenosis, have been linked to metabolic and lifestyle factors, including obesity, smoking, and diabetes. Glial cell line-derived neurotrophic factor (GDNF) plays a crucial role in neuroprotection, but its relationship with these risk factors remains unclear. Methods: This study aims to evaluate the relationship between body mass index (BMI), smoking, diabetes, and GDNF levels in patients with degenerative spine conditions. We measured the GDNF levels in patients with degenerative stenosis and assessed the impact of BMI, smoking status, and the presence of diabetes. Comparisons were made using appropriate statistical analyses to determine the significance of these factors on GDNF levels. Results: A significant inverse relationship was observed between the BMI and GDNF levels (p &lt; 0.01). Patients with a higher BMI exhibited lower GDNF concentrations. Additionally, patients who smoked or had diabetes showed significantly lower GDNF levels compared to non-smokers and those without diabetes (p = 0.03 and p = 0.02, respectively). These findings suggest that both metabolic and lifestyle factors are associated with decreased GDNF, which may accelerate neurodegenerative processes in the spine. Conclusions: Our study demonstrates that increased BMI, smoking, and diabetes are linked to reduced GDNF levels, potentially contributing to the progression of degenerative spine conditions such as stenosis. These findings highlight the need for targeted clinical interventions to manage these risk factors, aiming to preserve GDNF levels and slow the degenerative processes in the spine. Future research should explore therapeutic approaches to modulate GDNF in affected populations.
Background/Objectives: Degenerative lumbar spinal stenosis (LSS) is a prevalent cause of disability in elderly populations, often treated with decompressive surgery. However, postoperative functional outcomes are variable and influenced by factors … Background/Objectives: Degenerative lumbar spinal stenosis (LSS) is a prevalent cause of disability in elderly populations, often treated with decompressive surgery. However, postoperative functional outcomes are variable and influenced by factors beyond neural compression alone. This study aimed to investigate the prognostic significance of the Goutallier Classification System (GS), a radiological index of paravertebral muscle fatty degeneration, in predicting long-term postoperative disability and pain in elderly patients undergoing decompression for LSS. Methods: A retrospective cohort study was conducted on 100 elderly patients who underwent primary lumbar decompression surgery for LSS between January 2020 and July 2022, with a minimum two-year follow-up. Patients were stratified according to their preoperative GS grades assessed via MRI. The Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for pain were collected preoperatively and at follow-up. Changes in the ODI and VAS (ΔODI and ΔVAS) were analyzed to evaluate associations between GS grades and functional outcomes. Results: Significant improvements in the ODI (from 41.0 ± 17.5 to 16.9 ± 8.2) and VAS (from 6.23 ± 2.52 to 3.75 ± 2.38) were observed postoperatively (p &lt; 0.01). However, higher GS grades were associated with greater residual disability and pain at follow-up, as well as with smaller postoperative improvements in these scores (p &lt; 0.01 for ODI; p = 0.01 for VAS). Gender differences were noted, with females predominating in higher GS grades. No significant differences in comorbidities or complication rates were identified across GS subgroups. Conclusions: Preoperative paravertebral muscle degeneration, as measured by the GS, emerged as a significant predictor of postoperative disability and pain in elderly LSS patients. Incorporating GS assessment into preoperative planning may refine surgical risk stratification and inform shared decision-making to optimize long-term functional recovery.
Background: Lumbar disc herniation (LDH) is uncommon in the pediatric population but can cause significant low-back or radicular pain and, at times, neurological deficits. We aimed to study discectomy operations … Background: Lumbar disc herniation (LDH) is uncommon in the pediatric population but can cause significant low-back or radicular pain and, at times, neurological deficits. We aimed to study discectomy operations in pediatric patients to provide insight into surgical outcomes that may inform clinical decision-making and patient counseling. Methods: A national insurance claims database (PearlDiver) was queried to identify pediatric patients (&lt;21 y old) who underwent discectomy. Procedures were characterized by demographics features, including age of patient, year, and location. Reoperations was defined as discectomy, re-exploration discectomy, fusion, or laminectomy occurring within 5 years of the initial discectomy. A subsequent parallel analysis looked at reoperations following re-exploration discectomies. Kaplan-Meier survival and cox proportional regression analyzed factors impacting survival postprimary discectomy. Results: A total of 4410 primary discectomy patients were identified, with an overall 12% reoperation rate within 5 years of the initial discectomy. Specifically, patients under 18 and between the ages of 18 and 21 having a reoperation rate of 7% (115 patients) and 15% (406 patients), respectively. The incidence of discectomy operations increased with patient age. 78% of pediatric cases were performed on an outpatient basis compared with 75% of adult cases. The rate of reoperation was highest within the first year postdiscectomy, with nearly half of reoperations occurring in this time. Specifically, reoperation rates were 2.3% at 3 months, 4% at 6 months, 6% at 1 year, 7% at 2 years, and 12% at 5 years. The most common reoperation procedure was another discectomy. The reoperation rates following these revision operations were 2% at 3 months, 4% at 6 months, 6% at 1 year, 10% at 2 years, and 14% by 5 years. Fusion was the most common procedure following a failed revision discectomy (42% at 5 y). The Kaplan-Meier survival analysis similarly showed most procedures occurred in the first 3 years, with obesity and Elixhauser Comorbidity Index inversely correlated with survival. Conclusions: Overall, pediatric reoperation rates following discectomy are 11.8%. Obesity and Elixhauser Comorbidity Index significantly increased risk of reoperation. This study provides real-world, large-scale data that may guide surgeons caring for pediatric patients undergoing microdiscectomy. Level of Evidence: Level III.
Lumbar spinal stenosis is a common degenerative condition in elderly patients that often requires surgical intervention. Minimally invasive techniques combined with spinal anesthesia (SA) can reduce patient complications and improve … Lumbar spinal stenosis is a common degenerative condition in elderly patients that often requires surgical intervention. Minimally invasive techniques combined with spinal anesthesia (SA) can reduce patient complications and improve outcomes. Here the authors present the case of an elderly patient who underwent minimally invasive surgery, using dual tubular retractors and SA to address severe lumbar stenosis. A 93-year-old female presented with severe back pain radiating bilaterally to her lower extremities. MRI demonstrated severe central canal stenosis at L4-5 and severe left lateral recess stenosis at L5-S1. Under SA, the patient underwent both L4 and L5 laminectomies simultaneously with two surgeons using dual tubular retractors. The patient was ambulatory within 4 hours of surgery with complete symptom resolution. SA can be utilized safely during spinal surgery in the geriatric population. The use of dual tubular retractors by two surgeons working simultaneously allows for a safe and efficient decompression of stenosis at multiple levels. Dual tubular retractors can safely be used in conjunction with SA to achieve maximal benefit to the patient and surgical efficiency. https://thejns.org/doi/10.3171/CASE2521.
This study aimed to investigate and compare the short-term and long-term clinical outcomes of extracorporeal collagenase chemonucleolysis(ECCNL) and intradiscal-extracorporeal collagenase chemonucleolysis(IECCNL) via FLEX electrode in patients with lumbar disc herniation … This study aimed to investigate and compare the short-term and long-term clinical outcomes of extracorporeal collagenase chemonucleolysis(ECCNL) and intradiscal-extracorporeal collagenase chemonucleolysis(IECCNL) via FLEX electrode in patients with lumbar disc herniation (LDH). A retrospective analysis was performed on 65 patients diagnosed with LDH who met the inclusion criteria between April 2021 and April 2022. Patients were divided into two groups: 30 received ECCNL via FLEX electrodes (Group A) and 35 received IECCNL via FLEX electrode (Group B). Clinical outcomes were evaluated using the modified MacNab criteria, Numerical Rating Scale (NRS), and Japanese Orthopaedic Association (JOA) scores to assess the excellent/good rate, excellent rate, pain severity, and neurological function at specified intervals (3, 6, 12, and 24 months for clinical outcomes; 3 days, 1, 3, 6, 12, and 24 months for pain/neurological status). Perioperative complications, recurrence rates, and reoperation rates were systematically documented. A total of 58 patients were included. At 1 month postoperatively, Group A showed significantly lower NRS scores compared to Group B (P < 0.05) and a higher pain relief rate (P < 0.05). Although Group A had higher JOA scores than Group B at 3 days postoperatively (P < 0.05), Group B showed higher JOA scores than Group A at 24 months postoperatively (P < 0.05). The excellent-good rate between the two groups at any postoperative time point, Group B demonstrated a significantly higher excellent rate than Group A at both 3 months and 24 months postoperatively (P < 0.05). In Group A, there was 1 case of recurrence and 2 reoperations, with a recurrence rate of 3.45% [95% CI: 0.09%, 17.7%] and reoperation rate of 6.90% [95% CI: 0.84%, 22.8%]. Group B showed no recurrences or reoperations [95% CI: 0%, 9.7%] for both outcomes. No statistically significant differences were observed between the two groups. During the 24-month follow-up period, no severe complications were observed in Group A. However, one case of nerve root injury occurred in Group B. FLEX electrode application in conjunction with two collagenase injection strategies enhances therapeutic outcomes. Short-term results favor ECCNL alone, whereas long-term benefits are more pronounced with the intradiscal-extracorporeal therapy.
Background: Intervertebral disc degeneration is driven by the decline of nucleus pulposus (NP) cells and oxidative stress plays a key role in extracellular matrix disruption and progression of the condition. … Background: Intervertebral disc degeneration is driven by the decline of nucleus pulposus (NP) cells and oxidative stress plays a key role in extracellular matrix disruption and progression of the condition. Apamin, a bioactive peptide derived from bee venom is neuroprotective and anti-inflammatory, but its effect on NP cells under oxidative stress is unknown.Methods: Human NP cells were cultured, pretreated with apamin, and exposed to 200 μM H2O2 (causing oxidative stress). Reactive oxygen species (ROS) levels, disc degeneration markers, and the regulation of nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1) signaling pathways were assessed using immunocytochemistry and fluorescence-activated cell sorting analysis.Results: Apamin protected NP cell viability under oxidative stress at the optimal concentrations between 10-50 μg/mL. As a percentage relative to untreated control, apamin significantly inhibited the production of ROS (induced by H2O2) and the expression of Nrf2 and HO-1 (key regulators of the antioxidant response) was higher relative to the control. The expression of aggrecan and collagen Type 2 alpha 1 (essential components of the extracellular matrix) was higher relative to the control, while the expression of disc degeneration-related markers, including matrix metalloproteinases (MMPs) and a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) was lower compared with the control.Conclusion: In vitro, apamin protects human NP cells from oxidative stress-induced death by inhibiting levels of ROS and activating the Nrf2 and HO-1 pathways. These results suggest potential for apamin as a therapeutic antioxidant agent for intervertebral disc degeneration.
Mục tiêu: (1) Mô tả đặc điểm lâm sàng và cận lâm sàng ở bệnh nhân đứt kín gân gót. (2) Đánh giá kết quả phẫu thuật điều trị đứt … Mục tiêu: (1) Mô tả đặc điểm lâm sàng và cận lâm sàng ở bệnh nhân đứt kín gân gót. (2) Đánh giá kết quả phẫu thuật điều trị đứt kín gân gót. Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang, can thiệp lâm sàng không đối chứng, được thực hiện trên 30 bệnh nhân từ tháng 3 năm 2023 đến tháng 9 năm 2024 tại Bệnh viện Đa khoa Trung ương Cần Thơ và Bệnh viện Trường Đại học Y Dược Cần Thơ. Kết quả: Đứt kín gân gót gặp ở cả hai giới, nhưng chủ yếu xảy ra ở nam giới trong độ tuổi từ 30 đến 49. Nguyên nhân phổ biến nhất là chấn thương, chiếm 73,3%. Tỷ lệ tổn thương giữa hai chân tương đương nhau. Các dấu hiệu lâm sàng bao gồm mất liên tục gân gót (86,7%), nghiệm pháp Thompson dương tính (96,7%) và hình ảnh đứt hoàn toàn gân gót trên siêu âm (93,3%). Nghiên cứu ghi nhận mối liên quan có ý nghĩa thống kê giữa chỉ số khối cơ thể (BMI) với bệnh lý gân (p = 0,007, kiểm định Fisher) và khoảng cách vị trí đứt từ điểm bám tận (p &lt; 0,001, kiểm định Wilcoxon). Biến chứng sau phẫu thuật có liên quan đến khoảng cách vị trí đứt từ điểm bám tận, đặc biệt ở nhóm đứt đầu gần (p = 0,048). Điểm phục hồi chức năng (PHCN) ATRS không liên quan đến khoảng cách vị trí đứt từ điểm bám tận (p = 0,287). Kết luận: Phẫu thuật điều trị đứt kín gân gót giúp phục hồi chức năng sớm và mang lại hiệu quả cao.
Abstract Degenerative cervical myelopathy (DCM), encompassing cervical spondylotic myelopathy and posterior longitudinal ligament ossification, is now being documented frequently and significantly burdening the health care systems. The pathogenesis of DCM … Abstract Degenerative cervical myelopathy (DCM), encompassing cervical spondylotic myelopathy and posterior longitudinal ligament ossification, is now being documented frequently and significantly burdening the health care systems. The pathogenesis of DCM remains somewhat obscure, and the focus is now on identifying the role of genetic risk factors. Identifying these risk factors is essential for formulating future studies for novel preventive and therapeutic measures. In a cohort study, we evaluated the genetic association of two genes involved in the pathophysiology of DCM, that is, COL11A1 (single-nucleotide polymorphism [SNP] rs1337185) and ADAMTS5 (SNP rs162509). A total of 60 subjects (27 with DCM and 33 without DCM) were included. The primary and minor allelic frequencies were evaluated and compared between the cohorts. Significant association was found for SNP rs162509 of gene ADAMTS5 for DCM (odds ratio [OR] 2.5375, 95% confidence interval [CI] 0.655–9.89, p = 0.177), whereas no conclusive relation was found for SNP rs1337185 of the COL11A1 gene (OR 0.93, 95% CI 0.24–3.68, p = 0.91). Preliminary data from our study identify a probable association of two candidate genes, which play a pivotal role in the matrix synthesis and degradation. The complex etiopathogenesis of DCM may be guided by alterations in these genes and mediated through the altered gene products. Further studies are needed to substantiate and validate this.
Study DesignA retrospective comparative study.ObjectiveThis study explored the factors influencing L5-S1 fusion success following posterior lumbar interbody fusion (PLIF) and identified risk factors for symptomatic nonunion.MethodsThe cohort comprised 134 patients … Study DesignA retrospective comparative study.ObjectiveThis study explored the factors influencing L5-S1 fusion success following posterior lumbar interbody fusion (PLIF) and identified risk factors for symptomatic nonunion.MethodsThe cohort comprised 134 patients who underwent single- or multiple-level lumbar fusion, including PLIF at L5-S1, due to degenerative spine disease. Radiographic fusion was assessed using 1-year postoperative CT scans. Demographic, clinical (VAS, ODI, and EQ-5D), and radiological data were compared based on fusion status using univariate and multivariate logistic regression analyses. Subgroup analysis was performed in patients exhibiting nonunion with or without symptoms.ResultsFusion was achieved in 98 (73.1%) out of 134 patients, whereas 36 (26.9%) patients exhibited nonunion at the 1-year follow-up. Factors associated with nonunion included a higher body mass index [BMI; P = .020; 95% confidence interval (CI): .702, .971] and longer fusion levels (P = .032; 95% CI: .345, .952). Bilateral bicortical purchase of S1 pedicle screws significantly improved fusion outcomes (P = .014; 95% CI: 1.281, 9.047). Among the 36 nonunion cases, symptomatic patients showed significantly worse clinical assessment in terms of VAS, ODI, and every domain of EQ-5D. However, radiological parameters exhibited no differences based on the presence of symptoms.ConclusionThe radiological nonunion rate at L5-S1 was 27%. Higher BMI and longer fusion levels were identified as risk factors, whereas bicortical screw placement at S1 emerged as a protective factor against L5-S1 nonunion. Therefore, bilateral anterior cortical purchase of S1 pedicle screws is recommended, particularly in patients undergoing longer fusion procedures.
Hẹp ống sống gây chèn ép rễ thần kinh, khi tổn thương rễ thần kinh điều trị nội khoa thất bại thì điều trị phẫu thuật được đề ra. Trước … Hẹp ống sống gây chèn ép rễ thần kinh, khi tổn thương rễ thần kinh điều trị nội khoa thất bại thì điều trị phẫu thuật được đề ra. Trước đây, các phương pháp mổ giải ép trực tiếp cả mổ mở lẫn ít xâm lấn đều đã đem lại những hiệu quả nhất định tuy nhiên sau mổ người bệnh vẫn gặp các biến chứng thần kinh hay viêm rễ thần kinh do quá trình vén rễ trong mổ, tổn thương cơ cạnh sống… gây ảnh hưởng đến kết quả sau mổ. Phẫu thuật lấy đĩa đệm lối bên, giải ép gián tiếp và ghép xương liên thân đốt đã giải quyết được đáng kể những hạn chế của phương pháp giải ép trực tiếp, người bệnh hồi phục nhanh và ra viện sớm hơn2. Để đánh giá hiệu quả mở rộng kích thước ống sống và độ ưỡn cột sống, chúng tôi tiến hành nghiên cứu trên 21 người bệnh hẹp ống sống bằng kỹ thuật XLIF trong thời gian 4/2029-5/2024 thu được kết quả: Đường kính trước sau tăng lên từ 7.45±1.86 (mm) lên 10.23±2.61 (mm), Đường kính bên tăng lên từ 13.01±2.99 (mm) lên 16.38±2.88 (mm), Diện tích ống sống tăng từ 84.63±33.15 (mm2) lên 114.11±42.65 (mm2), Chiều sâu ngách bên tăng lên từ 1.84±1.36 (mm) lên 3.32±1.05 (mm), Kích thước lỗ liên hợp tăng lên từ 16.11±4.06 (mm) lên 20.04±2.65 (mm),Chiều cao đĩa đệm tăng lên từ 9.06±2.23 (mm) lên 11.33±2.00 (mm), Góc ưỡn đĩa tăng lên từ 3.44±4.41º lên 7.53±2.99º, Góc ưỡn thắt lưng tăng lên từ 25.55±14.85º lên 31.50±12.77º, sự cải thiện này có ý nghĩa thống kê (P&lt;0.05).
To translate AO Spine PROST (Patient Reported Outcome Spine Trauma) into Finnish and explore its psychometric properties in a Finnish spine trauma population. Patients were enrolled at an academic level-I … To translate AO Spine PROST (Patient Reported Outcome Spine Trauma) into Finnish and explore its psychometric properties in a Finnish spine trauma population. Patients were enrolled at an academic level-I trauma center. Score distribution, floor and ceiling effects, and missing items were explored for content validity. Internal consistency, concurrent validity, and reproducibility were explored with Cronbach's α, exploratory factor analysis, Spearman correlation tests, and Intraclass Correlation Coefficients (ICCs). Translation was performed using established guidelines. A sample of 110 patients was enrolled. Score distribution skewed toward higher values, but no floor and ceiling effects were present. Response rates were excellent for all items except for Work/study (60%). Factor analysis indicated two possible dimensions in PROST, explaining 75.3% of the total variance. For PROST total score, correlations were strong with EQ-5D-3 L (r = 0.77 [95% confidence interval: 0.69-0.84]) and ODI (r=-0.89 [0.92-0.84]). Test-retest reliability was excellent with ICC = 0.86 (0.76-0.91). Calculation of the PROST score without the Work/study item appeared valid (ICC 0.99 [0.98 to 1.00]). The Finnish version of AO Spine PROST is a reliable and valid measure for spine trauma outcomes. We recommend it for clinical practice and research to reduce the current controversies in spine trauma care.
Introduction Prolonged anterior shear loading may contribute to disc degeneration by damaging the annulus fibrosus. To address this, annular mechanical properties were quantified following static shear loading using a porcine … Introduction Prolonged anterior shear loading may contribute to disc degeneration by damaging the annulus fibrosus. To address this, annular mechanical properties were quantified following static shear loading using a porcine model. Methods Twelve porcine cervical FSUs were dissected, with posterior bony elements removed to isolate shear to the intervertebral disc. Specimens were randomized into two conditions: (1) Shear-loaded (100 N static anterior shear applied to C3/C4, n=6) or (2) Control (0 N, n=6). Shear force was applied via a pin through C4, secured to a testing system to prevent rotation while C3 was clamped such that anterior shear of C3 with respect to C4 resulted. Following 1 hour of loading, two anterior annulus samples were extracted per specimen. The first samples underwent circumferential tensile testing, while the other was prepared for a peel test to assess interlamellar adhesion. Results Tensile properties in the circumferential direction remained unchanged after shear loading. However, interlamellar adhesive stiffness decreased by 52% (p=0.02), and adhesive strength dropped by 46% (p=0.02) in shear-loaded specimens compared to controls. Discussion Shear loading weakened the interlamellar matrix, reducing resistance to delamination and compromising disc integrity. These findings suggest that prolonged shear loading may contribute to early-stage disc damage.
Objective: To compare biomechanical effects of full-endoscopic laminectomy (Endo-LOVE) versus continuous-endoscopic technique (C-Endo LFD) in normal and osteoporotic cervical spines. Methods: Four C2-C7 finite element models simulated daily activities: normal/osteoporotic … Objective: To compare biomechanical effects of full-endoscopic laminectomy (Endo-LOVE) versus continuous-endoscopic technique (C-Endo LFD) in normal and osteoporotic cervical spines. Methods: Four C2-C7 finite element models simulated daily activities: normal/osteoporotic bone density treated with Endo-LOVE or C-Endo LFD. Range of motion (ROM), endplate/facet joint stress, and disc pressure (IDP) were quantified. Results: Both techniques showed comparable biomechanical effects. Osteoporotic models demonstrated greater ROM increases (18.3% vs normal), elevated facet joint stress (24.6% increase), and higher endplate stress (22.1% increase). IDP remained unchanged between groups. Conclusion: C-Endo LFD does not increase cervical instability risk. However, in osteoporosis it elevates surgical segment ROM and joint/endplate stresses, potentially affecting postoperative stability.
Abstract Ferroptosis is a major contributor to intervertebral disc degeneration (IVDD) and represents a promising therapeutic target; however, effective medications that specifically target ferroptosis are still lacking. Consequently, strategies aimed … Abstract Ferroptosis is a major contributor to intervertebral disc degeneration (IVDD) and represents a promising therapeutic target; however, effective medications that specifically target ferroptosis are still lacking. Consequently, strategies aimed at suppressing the expression of ferroptosis‐related genes, such as small interfering RNA (siRNA) targeting activating transcription factor 3 (ATF3), appear to be a feasible therapeutic approach for IVDD. Zeolitic imidazolate framework‐8 (ZIF‐8) exhibits exceptionally high binding affinity for nucleic acids, including siRNA. Nevertheless, its practical application is hindered by challenges such as limited siRNA encapsulation and potential toxicity arising from Zn 2 ⁺ ion release during degradation. In the current study, a novel siRNA delivery system is designed with low toxicity, high encapsulation efficiency, and sustained release by hybridizing classical ZIF‐8 with histidine (H‐ZIF‐8) through defect engineering. In vitro functional studies demonstrated that H‐ZIF‐8 significantly enhances the delivery efficiency of siATF3 in nucleus pulposus cells (NPCs), and effectively suppresses ferroptosis and extracellular matrix (ECM) degradation. Furthermore, the incorporation of histidine into ZIF‐8 may improve its biocompatibility by reducing the proportion of Zn 2 ⁺ ions present. In vivo, siATF3@H‐ZIF‐8 significantly inhibited ferroptosis and alleviated intervertebral disc degeneration (IVDD) in a rat model through sustaining ATF3 knockdown. This research suggests that histidine‐modified ZIF‐8 may serve as a novel system for siRNA delivery and an effective gene therapy method for diseases, including IVDD.
Bone screws are used in orthopaedic surgery for fracture fixation. Correctly torquing the screws is important for fixation quality. Over-tightening may strip the threads, while under-tightening may result in loosening … Bone screws are used in orthopaedic surgery for fracture fixation. Correctly torquing the screws is important for fixation quality. Over-tightening may strip the threads, while under-tightening may result in loosening over time. This paper focuses on testing an approach where strength is estimated using screw insertion data from torque and rotation sensors, and stripping torque is predicted based on this strength. A common type of bone screw was inserted until stripping 10 times each into 8 types of polyurethane surrogate for bone. The torque–rotation data from the insertion was used to identify the material strength and estimate the stripping torque and compared with the experimental maximum torque. A good relationship was found between the estimated/predicted and true stripping torques (r = 0.926, 95% confidence interval (C.I.) [0.886, 0.952]), with a mean error of 18%. Additionally, the intermediate identified strength values were found to be highly correlated with the data-sheet values for the materials (r = 0.977, 95% C.I. [0.964, 0.985]). These outcomes demonstrate the viability and significance of this concept in general, although more development and testing is required for broad clinical applicability; such tests would be extended for more types of bone screws and use a large set of human bone samples to better reflect the natural variability.
Lumbar disc herniation (LDH) is a prevalent condition affecting the spine. In recent years, a growing body of observational research has explored the influence of metabolites found in blood and … Lumbar disc herniation (LDH) is a prevalent condition affecting the spine. In recent years, a growing body of observational research has explored the influence of metabolites found in blood and urine on the development of LDH. By applying Mendelian randomization techniques to these metabolic markers, it becomes possible to uncover potential causal links with LDH, offering novel perspectives for its prevention and therapeutic intervention. This research employed a two-sample Mendelian randomization (MR) approach to explore the association between 35 metabolites found in blood and urine and the occurrence of LDH, utilizing datasets from 2 independent sources. The most notable findings from the MR analysis, particularly those obtained through the inverse variance weighted method, were further evaluated via meta-analysis. To enhance result reliability, multiple correction methods were applied to adjust the significance thresholds. Lastly, a reverse MR analysis was carried out to confirm the directional causal influence of the selected metabolites on LDH. MR analysis was performed to investigate the relationship between 35 blood and urine metabolites and LDH using data from the Finngen R10 and UK Biobank databases. The most significant results from both sets of MR analyses, derived using the inverse variance weighted method, were then subjected to a meta-analysis. Multiple corrections were applied to the significance thresholds in the meta-analysis, resulting in an odds ratio of 0.860 (95% confidence interval: 0.795-0.930, P = .0052). Additionally, the identified positive metabolites did not exhibit reverse causality with LDH in either dataset. Apolipoprotein acts as a protective factor against LDH, potentially reducing the risk of developing the condition and slowing its progression.