To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse. Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise. 80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is. the crossed straight leg raise. The straight leg raise has not been shown to have high validity

Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases. Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined. Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007). Procedures were bilateral, left or right. 126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected. There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse

This is a study on the results of fifty consecutive patients who underwent endoscopic removal of herniated lumbar disc by interlaminar extra-dural approach. The indication for surgery was unrelenting, single level, unilateral sciatic pain not relieved by conservative treatment, with supportive evidence of disc herniation in MRI. Surgery was carried out in the lateral position. After localizing the disc space by X-ray, two 5 mm portals were made, one for an arthroscope and the other for working instruments. The spinal canal was entered through the inter-laminar route and under direct vision the herniated lumbar disc was removed. The duration of study is from February 1998 to July 1999 with an average follow-up of 14.58 months. There were 31 herniated, 9 extruded and 10 sequestrated discs. All patients were mobilized the same day and 42 were discharged the next day. There were two patients who suffered partial but permanent nerve root damage, 4 had post-operative headache and one developed transient extra-pyramidal symptoms. Modified McNab criteria were applied to study the results by an independent observer. 40 patients (80%) had a very good outcome (i.e. fully functional with occasional discomfort); 5 patients were considered to have a good outcome (i.e. normal function with some restriction to strenuous activity); 2 patients who had partial nerve root damage were considered as fair results though their final outcome was good. 3 patients suffered recurrent disc herniation and were operated by open surgery. These were classified as failures. We conclude that this technique is a minimally invasive procedure with results comparable to conventional disc surgery. The advantages to the surgeon are the excellent illumination, magnification and visualization. The advantages to the patient are minimal surgical trauma and speedy recovery

Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively. Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively. Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery. Outcome Measures: Spontaneous reduction of disc herniation on MRI scans. Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain. Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases

Purpose and Background:. Clinical interpretations of Degenerative Lumbar Disc Disease are not described in the literature. The purpose of this study was to establish a consensus of expert clinical opinion in order to fuel further research. Methods:. A reliable and valid electronic survey was designed to include theoretical constructs relating to training and education, general knowledge, assessment and management practices. Clinicians from the Society of Back Pain Research U.K. were invited to take part. Quantitative data was collated and coded using Bristol on-line survey software, and content analysis was used to systematically code and categorize qualitative data. Results:. Respondents represented a wide range of clinical specialties. The majority graduated in the U.K. (87%), were clinically active and had greater than 9 years postgraduate clinical experience (84%). MRI (36%) and physical assessment (21%) were cited as the most important clinical assessment tools. Reduction in disc height (92%) and disc dehydration (90%) were reported as the most important variables with respect to DLDD diagnosis. The most effective treatment approaches varied from education and reassurance, pain management, cognitive behavioural approaches to core stability training and group activity. Health professionals viewed the future of care advancement in terms of improvements in patient communication (35%) and education (38%). Treatment stratification (24%) and advancing evidence based management practices through research were also regarded as essential (27%). Conclusion:. Spinal clinical experts have clear views on DLDD assessment. In terms of management the results are varied suggesting inconsistency and uncertainty

Background. The majority of adults will experience an episode of low back pain during their life. Patients with non-specific low back pain and lumbar disc degeneration (LDD) may experience spinal pain and morning stiffness because of a comparable inflammatory process as in patients with osteoarthritis of the knee and/or hip. Therefore, this study assessed the association between spinal morning stiffness, LDD and systemic inflammation in middle aged and elderly patients with low back pain. Methods. This cross-sectional study used the baseline data of the BACE study, including patients aged ≥55 years visiting a general practitioner with a new episode of back pain. The association between spinal morning stiffness, the radiographic features of lumbar disc degeneration and systemic inflammation measured with serum C-reactive protein was assessed with multivariable logistic regression models. Results. At baseline, a total of 661 back pain patients were included. Mean age was 66 years (SD 8), 416 (63%) reported spinal morning stiffness and 108 (16%) showed signs of systemic inflammation measured with CRP. Both LDD definitions were significantly associated with spinal morning stiffness (osteophytes OR=1.5 95% CI 1.1–2.1, narrowing OR=1.7 95% CI 1.2–2.4) and spinal morning stiffness >30 minutes (osteophytes OR=1.9 95% CI 1.2–3.0, narrowing OR=3.0 95% CI 1.7–5.2) For severity of disc space narrowing we found a clear dose response relationship with spinal morning stiffness. We found no associations between spinal morning stiffness and the features of LDD with systemic inflammation. Conclusions. This study demonstrated an association between the presence and duration of spinal morning stiffness and radiographic LDD features. No conflicts of interest. No funding obtained

Abstract: The importance of nerve root inflammation accompanying disc herniation and its contribution to symptomatology was first proposed in the 1950’s. This encouraged the widespread administration of (percutaneous) epidural steroid injections in the non-surgical treatment of acute and chronic lumbar Radicular pain. It also prompted the local application of steroid preparations directly onto the nerve root at the time of disc compression. The literature supporting this latter practice however, is scant and equivocal. A randomised double blind prospective study was therefore carried out to evaluate the benefits of epidural steroid application at the time of lumbar disc decompression. 50 consecutive patients undergoing elective lumbar discectomy were enrolled. Patients in the study group (n=25) received 20mg of tri-amcinolone acetonide, applied directly to the decompressed nerve root. The control group (n=25) received an equal volume of saline. Intraoperative analgesia was standardised and postoperative pain was measured by a 10cm visual analog pain scale at 2, 6, 12, 25 and 72 hours. Standardised post-operative analgesic protocols were established and the amounts of consumed analgesics were determined. Statistical analysis was performed using the Mann-Whitney test. No statistically significant difference was noted in either pain score, analgesic consumption at 24, 38 or 72 hours or length of hospital stay, between the steroid treatment or control groups. This suggests that local epidural steroid administration after lumbar disc decompression offers no therapeutic advantage over mechanical decompression alone

Introduction. The usefulness of markers of non-specific low back pain (NSLBP), including MRI derived measurements of cross-sectional area (CSA) and functional CSA (FCSA, fat free muscle area) of the lumbar musculature, is in doubt. To our knowledge, such markers remain unexplored in Lumbar Disc Degeneration (LDD), which is significantly associated with NSLBP, Modic change and symptom recurrence. This exploratory 3.0-T MRI study addresses this shortfall by comparing asymmetry and composition in asymptomatic older adults with and without Modic change. Methods. A sample of 21 healthy, asymptomatic subjects participated (mean age 56.9 years). T2-weighted axial lumbar images were obtained (L3/L4 to L5/S1), with slices oriented through the centre of each disc. Scans were examined by a Consultant MRI specialist and divided into 2 groups dependent on Modic presence (M) or absence (NM). Bilateral measurements of the CSA and FCSA of the erector spinae, multifidus, psoas major and quadratus lumborum were made using Image-J software. Muscle composition was determined using the equation [(FCSA/CSA)*100] and asymmetry using the equation [(Largest FCSA-smallest FCSA)/largest FCSA*100]. Data were analysed using Mann-Whitney U tests (p value set at). Intrarater reliability was examined using Intraclass Correlations (ICCs). Results. ICCs ranged between 0.74 and 0.96 for all area measurements, indicating excellent reliability. There was no significant difference in TCSA and FCSA asymmetry (P=0.1–1.0) and muscle composition (P=0.1–1.0) between M and NM groups. Conclusion. Modic change in the absence of pain does not appear to influence cross-sectional asymmetry or composition of the lumbar musculature. CSA remains a controversial marker. No conflicts of interest. Funding: This work is funded by an Allied Health Professional Doctoral Fellowship awarded to Janet Deane by Arthritis Research U.K

Introduction: The artificial disc consists of proprietary polyolefin rubber core bonded between two titanium endplates. It has been developed for the treatment of symptomatic disc degeneration with the aim of providing segmental stability and motion following wide disc space clearance. It was designed to have similar properties to a normal adult human intervertebral disc when working in conjunction with the retained anulo-vertebral tissues and the supporting musculoligamentous system. Methods: Over 120 discs were used to biomechanically characterize the Device. Range of motion tests were designed and performed to measure the axial compression, torsional, and shear stiffness of the artificial disc and to compare this with the known values for the human lumbar disc. Pullout test was performed to evaluate the immediate and short-term stability of the inserted device by assessing the mechanical resistance to pullout or expulsion. To assess the ability of the implant to withstand average daily living loads throughout its predicted life, compression and compressive shear fatigue testing were performed. Discussion: The device was found to replicate many of the physiologic characteristics of the in-vivo FSU. The quasi-static testing showed the device to have higher strength values than the highest in-vivo loads and displacements. Fatigue testing showed the smallest device endurance limit of 3,500N at ten million cycles. The results demonstrate that the failure modes of the device contain sufficient safety margins to support the use of the device in a prospective clinical study

As part of a 10 year follow-up study investigating the relationship between MRI-diagnosed disc disease and low back pain (LBP), a comparison of MRI image acquisition protocols was conducted. The aim was to establish whether the modern protocol produced improved diagnoses of lumbar disc disease. This is of significance when attempting to determine links between lumbar disc disease and LBP. The proposed hypothesis was that little difference in the pathology reported of MRI lumbar spines between the surface coil acquired images (Coil-MRI) and phased-array acquired images (Phased-MRI) would be found. Methods: Local ethics committee approval was granted for this study. 31 male subjects (aged 35–71 years) were recruited and underwent two subsequent scans. For both Coil-MRI and Phased-MRI scans sagittal dual echo, T1, axial T1 and T2 images were acquired. A Consultant Radiologist blindly reviewed the 62 scans continuously and reported on the pathology. Disease pathology assessment consisted of disc degeneration, disc herniation (based on 5-grade classification systems), facet hypertrophy (FH) and nerve root compression (NRC). Results: A wide range of pathology was reported at all disc levels, particularly with regard to disc degeneration and herniation. Kappa agreement statistics were computed for each pathological feature at all disc levels. Disc degeneration and herniation reports were statistically consistent for all disc levels (kappa range: 0.6–0.8, p< 0.05 for degeneration & 0.5–0.7, p< 0.05 for herniation). The results show that at the L4/L5 disc level, 1 in 10 discs were reported as ‘moderately degenerate’ (an increase of 1 grade) in Phased-MRI scans. At the same disc level, 1 in 6 discs were reported as ‘moderately herniated’ in Phased-MRI scans compared to ‘bulging’ in Coil-MRI scans, indicating that Phased-MRI coil scans may improve clarity in particular for herniation diagnosis. Pathology for FH and NRC were limited, with the majority of subjects (over 91% for FH and NRC irrespective of protocol) presenting with normal features. Conclusion: The statistical results indicate that few differences in pathological diagnosis of lumbar disc disease occurred, however Phased-MRI appears to increase confidence in diagnosing more severe features at some disc levels

Introduction: Disc degeneration is consistent with advancing age and in many cases is associated with back pain and restricted mobility. The traditional surgical treatment for chronic back pain has been spinal fusion to immobilize the painful level. Long-term studies, however, suggest that fusion actually promotes degeneration at adjacent levels. One of the hallmarks of disc degeneration is aggregation of chondrocytes in the nucleus of chondrones, and more recently apoptosis has been implicated as a factor controlling the longevity of the cells. Recent research suggests that it may be possible to restore normal function to degenerate discs by introducing a fresh population of cells. This study investigated the potential for autologous costal chondrocyte implantation to prevent lumbar disc degeneration after annular injury in the sheep. Methods: the lumbar spines of eight adult sheep were exposed. In four animals, full thickness annular incisions were made in three alternate discs. No annular incisions were made in the other four sheep. A minimum of 500 mg of cartilaginous tissue was harvested from the twelfth rib of all animals. Tissue was cultured in vitro and the chondrocytes were labelled with a fluorescent marker for retrospective identification. After six weeks the chondrocytes were injected into the lower two alternate discs of all animals, leaving the uppermost discs and those untouched as internal controls. The animals were killed at intervals from three to twenty-four weeks and MRI, plain x-ray, histology and immunocytochemistry were evaluated. Results: MRI at twelve and twenty-four weeks showed apparent preservation of all incised discs that had been transplanted with autologous chondrocytes. Histology revealed clusters of viable chondrocytes of normal appearance within the nucleus. These cells stained positive for the fluorescent label. The same cells and the surrounding matrix were also positive for collagen type II. Serial X-ray measurements suggested that progressive disc degeneration was arrested in the discs that received autologous costal chondrocytes. Discussion: This pilot study showed evidence that cultured autologous costal chondrocytes remained viable and produced extracellular matrix following transplantation into normal and degenerate discs. In contrast to other studies that have used mesenchymal stem cells or chondrocytes harvested directly from discs, this study demonstrated success with cells from a source other than the disc. Costal cartilage is a convenient source of cells for transplantation and this technique warrants further investigation as a potential treatment for degenerative disc disease

Introduction: Lumbar disc disease comprises of a heavy portion of the workload in spinal as well as general orthopaedic clinic. It is well accepted that nerve root tension signs such as straight leg raise (SLR) & Lasegue’s test are sensitive at diagnosing nerve root impingement secondary to lumbar disc degeneration. In isolation, however, they lack specificity & have a poor positive predictive value (PPV). This can lead to uncertainty in clinical diagnosis. Our study proves that a structured approach to clinical examination with cumulative nerve root tension signs (RTS) significantly increases the tests’ specificity and PPV, therefore giving clinicians more confidence in their diagnosis. Methods: Prospective review of 1303 patients seen in one Orthopaedic consultant’s spinal clinic from 2004 until 2008. Data was collected using a standardized proforma. Pattern of pain as well as RTS (SLR, Lasegue, bowstring and crossover) were recorded and cross-referenced with subsequent MRI findings. In our dataset a positive MRI result was one in which the demonstrated disc lesion and nerve impingement corresponded with patient symptoms. Patients included were all those presenting with lower back and/or neuropathic leg pain. Patients had to be excluded from series due to incomplete datasets & missing MRI scans. Results: N = 858. Our results showed that as we progressed from 1 RTS up to 4 RTS there was a significant increase in the PPV : 1RTS PPV = 0.333 (CI 0.25 – 0.43), 2RTS PPV = 0.78 (CI 0.69 – 0.86), 3RTS PPV 0.87 (CI 0.81 – 0.91), 4RTS PPV 0.93 (CI 0.66 – 0.99). There was also significant increases in specificity compared with 1RTS: 1RTS 0.75 (CI 0.70 – 0.8), 2RTS 0.94 (CI 0.91 – 0.96), 3RTS 0.92 (CI 0.89 – 0.95), 4RTS 0.99 (CI 0.98 – 0.99). Discussion: This study shows that combining root tension signs as part of a structured assessment leads to a significant cumulative increase in the PPV and specificity of the diagnosis of nerve root impingement. Hence proving the importance of clinical examination. This method of sequential, cumulative RTS has not previously been documented in the literature

The reported results for primary lumbar disc surgery in open standard technique are succesful in 80–95% of patients, while after repeated surgery range from 28 to 81%. The best clinical results occur when there is an indication of neurological impairment, nerve root compression and radiological confirmation. We report the results of a retrospective study on 54 patients, aged 30 – 65 years, who were presented with recurrence of symptoms and operated on for a 2nd or 3rd time after a previous discectomy, between the period 1990 to 2001. Objective: The aim of the study is to determine the factors that influence the results after repeated surgery and to analyse those that lead to failure. Material and Methods: The 54 patients were submitted in a detailed clinical and radiological examination (CT-scan, MRI, EMG) in an attempt to determine the exact indication for re-operation. The preoperative findings for the revision surgery were: Radiculopathy secondary to a new herniation, 14 patients. Due to recurrent disc prolapse at the same level, 9 patients. Due to lateral recess stenosis, 12 patients. Instability secondary to a previous wide laminectomy, 4 patients. No obvious cause, probably due to fibrosis, 5 patients. Multiple root syndrome due to a tumor, 1 patient. Cauda equina syndrome due to an hematoma 1 patient. The follow-up of the patients ranges between 1–12 years and the results of the revision surgery are classified according to Finnegan’s classification. Results: From the 54 patients, 30 had a good result (56.6%), 16 fair (29.4%) and 8 poor (15%). Forty-six patients rated the revision surgery worthwhile (85%). Conclusions: The factors with good prediction of the results were:. Relief of pain more than 6 months after the previous surgery. Sciatica > Low back pain. Nerve root compression from a new herniation in another level or recurrence at the same. Lateral recess stenosis. Good correlation of the clinical and radiological findings. The factors with bad prediction were. The intra-operative fibrosis. Pain relief less than 6 months. The bad psychological condition of the patients

Purpose: The objective of this study was to examine the shock absorption capacity of two currently marketed lumbar disc prostheses, a metal-polyethylene prosthesis and a metal-metal prosthesis. Shock absorption capacity, which could be a useful parameter for choosing between implants, has not been examined in the literature. Material and methods: Two types of implants were tested: the Maverick prosthesis marketed by Medtronic, and the Prodic proposed by Spine Solution. Five implants of each type were tested. The disc prostheses were mounted on a testing device designed to analyse shock transmission by application of a constant force. Force captors were positioned on the upper and lower parts of the implant being tested. The force delivered and the force perceived on the opposite side of the implant were recorded simultaneously. The implant was submitted to a static loading force of 350 N to which was added a 100 N oscillating vibration force delivered at a frequency varying from 0 to 100 Hz. A supplementary 250 N shock was also applied every 10 s. The spectrum and frequency of each input and output were recorded. Vibration and transmission of the shock though the implant were defined as the ratio of the output over input spectra. Measurements were taken for all frequencies between 0 and 100 Hz. Phase deviation was calculated to characterise the shock absorption effect. Results: The phase deviation between the input and the output signal was less than 10 for both prostheses. Under loaded oscillating vibration, shock transmission was greater than 99.8% for both implants. In the 1–100 Hz frequency interval, the difference in shock transmission was less than 0.3±0.1% between the two implants. More than 98% of the supplementary 250 N shocks were transmitted by both implants. The difference between the two implants was thus less than 0.8% and can be considered negligible since the machine’s test sensitivity was 0.5%. Conclusion: The two implants tested exhibited the same capacity to absorb and transmit vibration and shocks. Shock absorption capacity was close to zero or at least less than the sensitivity threshold of the testing device. This degree of freedom is not sufficient to use shock absorption capacity as an argument for choosing between the two implants currently available

Purpose of the study: The theoretical usefulness of a disc prosthesis in comparison with arthrodesis would be to restore physiological segmental motion without perturbing the kinematics of the adjacent levels. The purpose of this study was to determine the rotation centers of the lumbar segments before and after implantation of a disc prosthesis with a mobile insert (Mobidisc™). Material and methods: Lateral flexion and extension views in the sitting position with a stabilized pelvis were obtained before and after implantation of the lumbar disc prosthesis in 32 patients. Spineview™ was applied to the digitalized images for semi-automatic recognition of the vertebral body contours and calculation of the rotation centers. The detection threshold for this automatic system was 5° motion. Results: Rotation centers were difficult to determine preoperatively because of the absence of mobility. A pathological position was found for three patients. Postoperatively, at three and twelve months, the position was «physiological» in 13 patients, in the posterior half of the disc or inferior body near the vertebral end plate. IN 14 patients, the center could not be determined because motion measured 5° or less. For three patients, the center was too anterior on a prosthesis implanted to anteriorly. There were no changes in the rotation centers for the adjacent levels. Discussion: Demonstration of an abnormal rotation center could be an additional indication of presumed instability. In certain cases, a disc prosthesis appears to restore the physiological rotation center. But the position and the thickness of the implant can influence their localization. Conclusion: Restoration of a physiological rotation center for the instrumented intervertebral segment and the absence of change in the rotation centers for the adjacent centers are arguments in favor of disc prosthesis for reducing the incidence of osteoarthritic degradation of adjacent discs in comparison with fusion, under the condition that the implantation and the size are correctly adapted

Purpose of the study: The endoscopic transforaminal approach to the lumbar disc proposed by A.T. Yeung has achieved world-wide acceptance. The Yeung endoscopic spinal system (YESS) used with a specific instrument set enables direct magnified optical control of discectomy performed under local anesthesia and neurolepanalgesia in the outpatient setting. We began our experience in 2003 and report here the results obtained in a consecutive series of 100 patients reviewed retrospectively. Material and methods: The inclusion criteria were patients with lumbar disc herniation-related lumbosciatic or crural pain non-responsive to well conducted medical care (including epidural or periradicular injections) for at least three months. The patients also had to display a concordant clinical and radiographic picture with confirmation of the symptomatic level by discography. Exclusion criteria were: excluded herniation with a fragment which had migrated into the canal; caudia equina syndrome; lower limb paralysis with muscle force scored less than 3; advanced-stage degernerative central bony stenosis affecting the clinical expression; pregnancy. The levels treated were: L3–L4 (n=6), L4–L5 (n=72), and L5–S1 (n=22). Herniation was forminal and extraforaminal in 53 cases, posterolateral in 31, and median in 16. There was an associated constitutional central stenosis in ten cases and in thirteen others, herniation was a recurrence after conventional surgery. Results: One hundred patients were reviewed at mean 18 months (range 12–34 months) follow-up. There were no serious neurological, vascular, or infectious complications. According to the McNab criteria outcome was good for 71 cases, fair for 16 and poor for 13 with 11 requiring revision with conventional surgery. Patients with foraminal and extraforminal herniation accounted for more than half of our series and responded best to treatment (84.9% good outcome) compared with posterolateral herniation (48%) (p< 0.05). Patients with median herniation had an intermediary outcome (68% good results). The least satisfactory outcome was observed at the L5–S1 level (63% fair and poor outcome), but the difference did not reach statistical significance compared with the higher levels. In patients with recurrent herniation after conventional surgery, there were four cases of failure. Discussion: These results are less satisfactory than those found in the literature. This might be explained by the less satisfactory outcome obtained with posterolateral herniations, probably because more than halve had migrated, generally above the plane of the disc, which in our experience cannot be accessed via the transforaminal approach. In addition, comparison of our first 50 cases with the last 50 showed an improvement in outcome to a mean 82%, expressing a learning curve for this type of technique. The most frequent error early in our experience was to insert the working endoscopic canula too anteriorly compared with the disc. The point of insertion must be very lateral determined by the discography in order to enter at least 30° posterior to the posterior part of the disc. Progressive fine-tuning of patient selection also helped improve outcome. YESS improves the work of the intradiscal instruments which can be control by direct view, explaining the the better results compared with the older mechanical or automatic (blind) methods. YESS is a very effective alternative to chemonucleolysis since papaine is no longer available. Compared with other endoscopic techniques for disectomy via an interlaminar approach, YESS offers the possibility of treatment patients in an outpatient setting with a local anesthesia. In addition the quality of the visual control of the foramen is better. These methods can be used in association with intradiscal Holmium-Yag laser which can also be applied to the bony walls of the foramen for a widening foraminoplasty. This transformainal endoscopic approach also offers a way to perform an exclusively foraminoscopic spondylodesis using an intersomatic cage. Conclusion: YESS is an excellent technique for non-migrated subligament posterolateral foraminal and extraforaminal herniations where conventional access to the foramen is known to be very difficult

Several surgical options have been utilised to treat patients with back dominant lumbar disc disease. The purpose of our study was to compare the outcomes in patients who underwent lumbar fusion with an expandable interbody device (B-TWIN) using different surgical techniques (PLIF, TLIF or posterolateral screws alone). Observational study, retrospective analysis of prospectively collected data. Patients underwent a single level lumbar fusion. Group A: PLIF with B-Twin cage; Group B: TLIF with B-Twin cage and unilateral pedicle screw fixation and Group C: bilateral posterolateral screw fixation alone. Functional outcomes were assessed using: SF-36, Oswestry Disability Index (ODI), Distress and Risk Assessment Method scores (DRAM) and the visual analogue pain scores (VAS). There were 32 patients, 24 female and 8 male. Average age was 45 (range 33-63). Average follow up was12 months (range 2-36). Level of spinal fusion was 2 L3/4, 11 L4/5 and 13 L5/S1. Mean hospital stay was 5.8 days. VAS improved in all 3 groups A 5.83 – 5; B 8 – 4.83; C 5.71 – 2.3. ODI improved in all 3 groups A 0.5 – 0.35; B 0.51 – 0.44, C 0.42 – 0.16. There was no statistical difference on comparison of the three groups. There were no operative complications. One patient broke her interdody device during a all in the first post-operative week requiring a subsequent procedure. Lumbar interbody fusions can safely be performed using an expandable interbody device. Good functional outcomes can be achieved in the majority of well selected patients

Introduction. Patients with recurrent low back pain (LBP) exhibit changes in postural control. Stereotypical muscle activations resulting from external perturbations include anticipatory (APAs) and compensatory (CPAs) postural adjustments. This study aimed to determine differences in postural control strategies (APAs and CPAs) between those with and without lumbar disc degeneration (LDD) and LBP. Methods. Ninety-seven subjects participated in the study (mean age 50 years (SD 12)). 3T MRI was used to acquire T2 weighted images (L1-S1). LDD was determined using Pfirrmann grading and LBP using the numerical rating scale (NRS). A bespoke perturbation platform was designed to deliver postural perturbations. Electrical activity was analysed from 16 trunk and lower limb muscles during four typical APA and CPA epochs. A Kruskal-Wallis H test with Bonferroni correction for multiple comparisons was conducted. Results. Four groups were identified; ‘no LDD no pain’ (n = 19), ‘LDD no pain’ (n =38), ‘LDD pain’ (n =35) and ‘no LDD pain’ (n = 5). There was no significant difference in age or gender between groups. Although, increased BMI was associated with LBP it did not correlate with significant findings. Significant differences in APAs and CPAs were observed between ‘LDD pain’ and ‘LDD no pain’ groups during predicted and unpredicted perturbations (p=0.009–0.049, r=0.31–0.43). Significant CPAs correlated with LBP (p=0.001–0.03) but did not correlate with LDD (p=0.22–0.94). Conclusion. Postural control strategies are different between those with LDD and pain and those without. Differences in compensatory strategy are associated with the presence of pain and not LDD. No conflicts of interest. Sources of Funding: Janet Deane is funded by an Allied Health Professional Doctoral Fellowship awarded by Arthritis Research U.K. (ARUK)

Introduction: The effect of facet tropism on the development of lumbar disc diseases has been investigated but is still controversy; moreover, there has been no study to be done on far lateral lumbar disc herniation (LDH). In the current study, the authors attempted to determine the differences of the degree of facet tropism and the degree of disc degeneration between far lateral and posterolateral LDHs. In addition, the effect of the difference of degree of facet tropism and the degree of disc degeneration on the development of far lateral LDH was investigated compared with posterolateral LDH. Methods: 38 LDHs (far lateral, n = 19; posterolateral, n = 19) who underwent posterior open discectomy or paraspinal approach were included in this study. The mean age was 52.3 years in far lateral LDH and 45.3 years in posterolateral LDH. The degrees of facet tropism and disc degeneration were measured at herniated disc level using MRI, and compared for the two different types of LDHs. Mann-Whitney U test and Spearman test were used for analysis. Results: There were significant statistical differences in the degree of facet tropism and the degree of disc degeneration. There was no significant correlation between the degree of facet tropism and the degree of disc degeneration in far lateral LDH. Discussion: The current study suggests that the differences of the degree of facet tropism and the degree of disc degeneration might be considered as the key factors to determine the development of far lateral LDH compared with posterolateral LDH

To evaluate prognostic factors that influence outcome particularly those related to duration of symptoms in surgery for lumbar radiculopathy, #2. In primary care 75% of patients are pain free after the onset of sciatica within 28 days. The optimum timing of surgery for unresolved leg pain secondary to herniated lumbar disc is unclear. #2 We prospectively recruited 113 patients in this study and at one year, the follow up was available on 103 (91%). We investigated the prognostic value of a number of variables. These included the duration of sciatic symptoms, age at operation, Modified Zung Depression Score (MZD) and Modified Somatic Perception Score (MSP) using multiple regression analysis. The outcome was measured by the change of the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS) and of the Visual Analogue Scale (VAS). Patients with contained and non-contained herniated disc were compared. The change in ODI is statistically significantly associated with the duration of sciatica symptoms (p=0.05) with a one-month increase in the duration of symptoms being associated with a decrease in the change of ODI of 0.6% (95% CI, −1.014 to −0.187). The duration of sciatica and the MZD are associated with significant reduction in LBOS (p=0.034 and 0.028 respectively). VAS was not significantly associated with all the prognostic factors investigated. A shorter duration of sciatic symptoms was associated with a greater degree of patients’ outcome satisfaction. Non-contained herniated disc had a shorter duration of symptoms and a better functional outcome compared to contained herniated disc. Unemployment and smoking were not risk factors for poor surgical outcome. Conclusion: Our study indicates that the duration of radicular pain of more than 12 months has a less favourable outcome. Patient’s satisfaction is greatest if surgery occurs within one year