Objective: To asses the outcome of hermivertebrectomy and fusion for symptomatic thoracic disc herniation. Design: A retrospective case analysis. Subjects: Between 1993 and 1999, ten patients (M5, F5) were treated surgically for thoracic disc herniation by the two senior authors (JKW & SHM). The average age of patients at presentation was 5Oyears (range 32–77years). Two patients had two level disc herniations (total 12 disc herniation). The most common sites of disc herniation were at T10/11(4 patients). Duration of diffuse mid thoracic hock pain in eight patients varied from one week to six months. The initial neurological evaluation demonstrated weakness and spasticity of varying grades in eight patients, of which five had paraplegia and three had monoparesis. Sensory changes below the level of the lesion were found in eight patients. Sphincter dysfunction was noted in seven patients. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and only bone grafting in two patients. Spinal cord monitoring was used in all cases. Outcome Measures: The average follow up was 24 months (range 13–36 months). Pre-operative and postoperative neurological grading was done using MRC grading for motor and sensory deficit. Asymptomatic patients with full activity were regarded as a successful outcome. Results: Three patients had excellent, three had good, three had fair and one had poor outcome. Seven out of eight patients with cages had radiological fusion. The cage stabilises the segment and maintains the spinal height till bony fusion takes place. One patient with hone graft alone had recurrence of symptoms and had a re-surgery with a poor outcome. Six patients had residual back pain of varying degrees. One patient had atelectasis, which recovered within two days of surgery. One patient had suffered from complete paraplegia immediately after surgery detected by SSEPs. She underwent a MRI scan within the hour and was reoperated. She had complete corpectomy and instrumented fusion. At two years she was walking with a support. Conclusion: Exposure of the norrnal tissue above and below herniated disc by hemivertebrectomy facilitates the safe removal of the disc and reduces the risk of further neurological damage. Cages were found to have advantages over autogenous strut only grafts. However, persistent back pain in some cases remains an unsolved problem

Aims. The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral discogenic pain through the analysis of clinical data and finite element modelling (FEM). Methods. Retrospective analysis was conducted on clinical data, with a specific focus on the spinal units displaying facet tropism, utilizing FEM analysis for motion simulation. We studied 318 intervertebral levels in 156 patients who had undergone provocation discography. Significant predictors of clinical findings were identified by univariate and multivariate analyses. Loading conditions were applied in FEM simulations to mimic biomechanical effects on intervertebral discs, focusing on maximal displacement and intradiscal pressures, gauged through alterations in disc morphology and physical stress. Results. A total of 144 discs were categorized as ‘positive’ and 174 discs as ‘negative’ by the results of provocation discography. The presence of defined facet tropism (OR 3.451, 95% CI 1.944 to 6.126) and higher Adams classification (OR 2.172, 95% CI 1.523 to 3.097) were important predictive parameters for discography-‘positive’ discs. FEM simulations showcased uneven stress distribution and significant disc displacement in tropism-affected discs, where loading exacerbated stress on facets with greater angles. During varied positions, notably increased stress and displacement were observed in discs with tropism compared to those with normal facet structure. Conclusion. Our findings indicate that facet tropism can contribute to disc herniation and changes in intradiscal pressure, potentially exacerbating disc degeneration due to altered force distribution and increased mechanical stress. Cite this article: Bone Joint Res 2024;13(9):452–461

Introduction and Aims: Recurrent disc herniation or sciatica is one of the major complications of discectomy, often leading to a cascade of surgical procedures of increasing magnitude, but decreasing surgical outcome. We undertook a study to see if prolapsed disc fragment type can predict the possibility of recurrence of disc herniation or sciatica. Method: We looked at the records of patients who had a discectomy operation during a 10-year period from 1992–2002. We excluded from the study patients who had a concomitant fusion operation, patients with multiple level disc operations and those who have diabetes. We went through the operation records, looking for the type of the disc fragment, i.e. whether it was contained, extruded or sequestrated disc. In the follow-up notes we recorded the patients that complained of leg pain, starting three months after the operation and continuing despite treatment. We recorded the length of follow-up. Results: Sixty-five patients were entered for the study. There were 31 males and 34 females. The age range at surgery was 16–61 years (average 42.1 year). The follow-up ranged from 18 months to 10 years (average 30 months). We divided the patients into two groups. Group A, those patients with recurrent leg pain; and group B, those patients with no leg pain. There were 18 patients in group A – they were all subjected to further examination with MRI scan. In five of the patients, the scan showed recurrence of disc herniation. It was an ipsilateral reherniation in four patients and contralateral in one patient. Eight of these 18 patients required repeat surgery. In the five patients with reherniation (7.69% of whole series), the repeat surgery was a discectomy. In another three patients the surgery was a wide decompression and fusion. On further analysing the pathology found at the initial discectomy, in the group A patients, six (33%) had extruded discs and 12 (66%) had contained discs. In group B, 34 (72%) had extruded discs and 13 (27%) had contained discs. The statistical significance in this small series is debatable. Conclusion: Patients with extruded discs do much better than those with contained discs. Recurrent disc herniation is more common in contained discs and less common in extruded discs. If we could select pre-operatively those patients with contained disc herniations, we could elect to persist with conservative treatment for longer in this group

Background: Many studies have examined magnetic resonance images (MRI) with a view to the anatomy and signaling properties of the intervertebral disc and adjacent tissues in asymptomatic populations. In this study we have examined MRIs of a discrete population of patients undergoing surgery for symptomatic disc herniations. Methods: Sixty patients (aged 23–66 years, mean 41.5±8.4) had sagittal T1 and T2- weighted turbo spin echo imaging of the lumbar spine prior to surgery. One disc was herniated at L2-3, 3 at L3-4, 22 at L4-5 and 31 at L5-S1; 3 patients had herniations at both L4-5 and L5-S1. The images were scored for disc narrowing and signal, degree of anterior and posterior bulging and herniation, and assessed for Modic I and II endplate changes and fatty degeneration within the vertebrae. These were carried out for each of 6 discs (T12-S1) for all patients (ie 360 discs and 720 endplates). Results: There were trends of increasing disc narrowing, disc bulging and fatty degeneration with increasing age in these patients. 83% of patients had disc bulging, 53% had endplate irregularities and 44% had fatty degeneration. There was a significant correlation between patient weight and fatty degeneration. 7.5% of vertebrae (in 22% of patients) demonstrated Modic I changes whilst Modic II changes were seen in 14% of vertebrae (40% of patients). This is considerably higher than the incidence reported in asymptomatic individuals where Modic I changes were seen in 0.7% of vertebrae (3% of individuals) and Modic II changes in 1.9% of vertebrae (10% of individuals). Conclusion: There is a higher incidence of Modic I and II changes in disc herniation patients than in asymptomatic individuals

Background: The dermatomal drawings used in clinical practice are based on questionable experiments performed in the 1930s. Though widely used in the clinical practice to identify the level of nerve root irritation, this may not be a reliable practise. Purpose: To identify the pain distribution and overlap of single level L4, L5 and S1nerve root irritation. Methods: 187 patients with radicular pain to or below the knee made a precise drawing of their pain distribution and then underwent a MRI scan. Only patients identified as having a single level disc herniation were included in this study. Using computer software, the pain distribution of all people who had the same level nerve root irritation was made by layering their pain drawings. The darkest parts of these compound drawings was where most patients experienced pain. Results: 89 patients were excluded due to tumour, depression or disc lesions on several levels. 98 patients with single level disc herniation were included. There was wide overlap in the pain from each nerve root level, and these areas were much wider than shown on dermatome charts. In general, L4 nerve root pain tended to be anterior on the leg, L5 and S1 nerve root pain was on the posterior leg, with L5 root pain tending to be more lateral. Conclusion: Pain distribution from the L4, L5, S1 nerve roots is not concordant with the sensory distribution of common dermatome charts. This might be due to the methods by which these dermatomes were constructed, or because sciatica is a complex pain experience

The purpose of this study was to highlight uncommon and confusing clinical problem of unilateral prolapsed intervertebral disc (PIVD) producing contralateral symptoms based on case reports and literature review. Four cases of patients with disc prolapse contralateral to the symptomatic limb are presented. Two patients had cervical disc herniations, and one patient had a lumbar disc prolapse. All three patients had resolution of their contralateral radicular pain following discectomy. Few reports have been published of patients with unilateral sciatica following contralateral lumbar disc herniation. The authors described the unique features of their patients’ anatomy and related this to their respective pathology. Coexistence of lumbar spondylosis and lateral recess stenosis, as well as the unique features of the attachments of the dural sac and nerve root sleeves to the surrounding osseous structures serve to provide an explanation for contralateral symptoms. The cervical spine is quite different from the lumbar spine. Here the spinal cord rather than the more flexible cauda equina fills most of the spinal canal. A number of reports can be found describing Brown-Sequard syndrome as a consequence of cervical disc herniation. The two cases presented are in our opinion also the consequence of direct pressure on the spinal cord. We suggest that pressure on the ascending spinothalamic tracts leads to contralateral pain without other neurological symptoms

The aim of this study was to assess whether the pro-lapsed disc fragment type was predictive of recurrent disc herniation or sciatica after discectomy. The records of 39 patients treated by lumbar discectomy only were reviewed. Within two months of surgery, the type of disc fragment prolapse and state of the annulus were assessed on CT scans or MRI. Patients who presented later with recurrent sciatica or disc prolapse were reviewed with MRI. All other patients were contacted and asked whether they had had recurrent sciatica or had undergone repeat surgery elsewhere. The follow-up period was three years. The results suggest that patients in whom discs required annulotomy at surgery had poorer results than those with extrusion through an annular fissure. The degree of annular competence can be used to assess the risk of recurrence of herniation or sciatica

Introduction: The purpose of this case report is to highlight an unusual presentation of a well-described but rare condition (idiopathic spinal epidural lipomatosis) in association with a commonly presenting problem (far-lateral disc herniation). Methods: Retrospective case report and review of the literature. Results: A 46-year-old Caucasian male presented with right L5 radiculopathy secondary to a far-lateral lumbosacral disc protrusion, confirmed on MRI scanning. Treatment consisted of a right L5 foraminal steroid injection with a 50% improvement in symptoms. This was soon followed by symptoms of spinal stenosis, and repeat MRI showed worsening of idiopathic spinal epidural lipomatosis seen on the initial scan. Over this period the patient had been unable to exercise regularly and had gained 10 kg of weight. Nonoperative treatment, including a supervised Xenical weight-reduction program (which was unsuccessful), failed to alleviate his symptoms so operative decompression was performed, with satisfactory resolution of the stenotic symptoms. Discussion: Spinal epidural lipomatosis may be idiopathic or secondary to excess steroids (endogenous or exogenous). It affects either the thoracic or lumbar spine. Treatment options are withdrawal of exogenous steroids, weight reduction or decompressive surgery. In this case, disability associated with a far-lateral disc herniation resulted in weight gain, and subsequent stenotic symptoms from previously asymptomatic lumbar idiopathic spinal epidural lipomatosis

Thirteen patients with symptomatic disc herniation in the cervical spine were treated with percutaneous laser disc decompression (PLDD). Patients included 10 males and 3 females with a mean age of 41.4 (range, 24–60) years old. Preoperative symptom was divided into 2 types; myelopathy in 8 and radiculopathy in 5 patients. The level of the treated disc, which was diagnosed from the provoked cervicobrachial neuralgia during discography, distributed to C4/5 in 1, C5/6 in 8, C6/7 in 4 patients. The Nd:YAG laser (1064 nm) was percutaneously irradiated to the involved disc through a needle of 1.5 mm with a mean energy of 600 joules. Clinical evaluations were assessed with modified Macnab`s criteria at a mean follow-up period of 3 years (range, 0.5–5.7 years) excluding one patient who received open surgery 3 weeks after PLDD. Six patients (46.2%) showed good to excellent results without any significant complications. Four patients of 7 with unsuccessful results received a subsequent open surgery. There was no significant difference between successful and unsuccessful group in gender, disc level, preoperative duration of symptoms, positive provocation during discography, and the total amount of irradiated energy. Patients with successful results tended to be younger with a mean age of 35.7 years compared to those with unsuccessful results with a mean of 46.3 (p=0.053). Clinical outcome in two patients with radiculopathy were judged as excellent. Although postoperative MRI revealed few morphological changes on the disc in 2–3 weeks after PLDD, MRI at the final follow-up showed remarkable decrease of signal intensity in the disc. On postoperative radiographs, the disc height and the range of motion during flexion to extension in the treated discs significantly decreased, indicating the acceleration of disc degeneration and the resultant stabilization of the segment

Aim: To investigate the effectiveness of Adcon-L in re-discectomy and/or surgical neurolysis compared to autologous fat graft. Methods: A total of 50 patients with recurrent disc herniation (n=30) and/or epidural þbrosis (n=20) were included. All had failed in conservative treatment and suffered from predominantly radicular pain. MRI scans proofed the re-herniation (same segment, same side) and/or epidural þbrosis. Standard preoperative and follow-up examinations were carried out. Follow-up examination was performed by an independend investigator. Data were analysed using the intention-to-treat principle. Result: The clinical outcome showed no statistically difference between both groups one year after revision surgery. Conclusion: Due to our results, and as we know that the rate of clinically relevant cerebrospinal ßuid leakage is increased after the application of Adcon-L, we prefer the use of autologous graft as an antiadhesive in revision surgery of the spinal canal

Introduction: Discectomy for herniation of the nucleus pulposus is an effective procedure when conservative treatment has failed. However, a number of patients rapidly progress to symptomatic instability after discectomy. Those most likely to develop instability have central and multi-regional herniations. Therefore, primary posterior lumbar interbody fusion (PLIF) may be a better option than discectomy alone in this group. This paper presents the clinical and radiological outcome of a consecutive group of such patients treated in one centre by PLIF, but recognises that newer technologies may make such destructive spinal surgery unnecessary in the future. Methods: Between June 1997 and December 2000, PLIF for central disc herniation presenting with acute, subacute and chronic back and leg pain, with or without neurological loss, using Diapason pedicle screw instrumentation and Ogival PEEK (Polyether-ether-ketone) Interbody Fusion cages was performed on 41 patients. Eight patients presented acutely with cauda equina symptoms and 33 patients had sub-acute or chronic symptoms. Formal clinic follow-up was continued for at least two years post-surgery and the final outcome at 2 to 5 years after operation was assessed using the Low Back Outcome Score (LBOS). Two independent orthopaedic surgeons assessed the radiological evidence of fusion on X-rays taken at least two years after surgery. Results: 39 of the 41 patients completed the LBOS questionnaire (95%). One patient had died from an unrelated cause and the other could not be contacted having moved away. 34 (87%) of these had an excellent or good outcome according to the LBOS criteria. However, every patient who returned the questionnaire stated that they would undergo the operation again if guaranteed the same surgical result and all would recommend it to a friend for similar trouble. Four patients (9.7%) were dissatisfied with the process of care they experienced. Analysis of radiographs taken between two and four years post-operatively revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in 38 cases (92.7%). None of the patients with a non-union radiologically had a poor outcome. Conclusions: Post-discectomy instability causing disabling low back and leg pain is more likely to occur in patients with an incompetent annulus than those with a largely intact annulus. The patients in this series all had good evidence on MRI of complete (pan-annular) failure. The decision to perform an acute single level PLIF was taken after discussion with the patients, presenting them with the option of having only a central discectomy and a later fusion if needed or of dealing with the problem at one operation. The outcomes described in this study show that this condition is a good indication for PLIF. However, newer technologies such as disc arthroplasty may be a better option for this group of patients in the future

INTRODUCTION: Discectomy for herniation of the nucleus pulposus is an effective procedure when conservative treatment has failed. However, a number of patients rapidly progress to symptomatic instability after discectomy. Those most likely to develop instability have central and multi-regional herniations. Therefore, primary posterior lumbar interbody fusion (PLIF) may be a better option than discectomy alone in this group. This paper presents the clinical and radiological outcome of a consecutive group of such patients treated in one centre by PLIF, but recognises that newer technologies may make such destructive spinal surgery unnecessary in the future. METHODS: Between June 1997 and December 2000, PLIF for central disc herniation presenting with acute, sub-acute and chronic back and leg pain, with or without neurological loss, using Diapason pedicle screw instrumentation and Ogival PEEK (Poly-ether-ether-ketone) Interbody Fusion cages was performed on 41 patients. Eight patients presented acutely with cauda equina symptoms and 33 patients had sub-acute or chronic symptoms. Formal clinic follow-up was continued for at least two years post-surgery and the final outcome at two to five years after operation was assessed using the Low Back Outcome Score (LBOS). Two independent orthopaedic surgeons assessed the radiological evidence of fusion on X-rays taken at least two years after surgery. RESULTS: 39 of the 41 patients completed the LBOS questionnaire (95%). One patient had died from an unrelated cause and the other could not be contacted having moved away. 34 (87%) of these had an excellent or good outcome according to the LBOS criteria. However, every patient who returned the questionnaire stated that they would undergo the operation again if guaranteed the same surgical result and all would recommend it to a friend for similar trouble. Four patients (9.7%) were dissatisfied with the process of care they experienced. Analysis of radiographs taken between two and four years post-operatively revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in 38 cases (92.7%). None of the patients with a non-union radiologically had a poor outcome. CONCLUSIONS: Post-discectomy instability causing disabling low back and leg pain is more likely to occur in patients with an incompetent annulus than those with a largely intact annulus. The patients in this series all had good evidence on MRI of complete (pan-annular) failure. The decision to perform an acute single level PLIF was taken after discussion with the patients, presenting them with the option of having only a central discectomy and a later fusion if needed or of dealing with the problem at one operation. The outcomes described in this study show that this condition is a good indication for PLIF. However, newer technologies such as disc arthroplasty may be a better option for this group of patients in the future

Introduction Symptomatic Thoracic disc prolapse (TDH) is a rare condition, with approximately 1 case per million population presenting per year. There are not many Spinal surgeons with a significant experience in the management of these lesions which necessitate a familiarity with the anatomy of the thorax and thoracic spinal cord. TDH is often diagnosed on modern imaging, but the indications for surgery in asymptomatic cases or in patients with spinal pain only, remain undefined. The natural history of TDH is not known and there is a poor correlation between the radiological and clinical presentation. The advent of newer minimally invasive endoscopic techniques for TDH may have reduced the incidence of open procedures for this condition, but may lead to an increase in operations performed for TDH, especially in cases where the surgical indications remain uncertain. In a small country like New Zealand it is especially difficult to build up a large series and to become very familiar with what remains a difficult operation

Methods The Neurosurgical experience with this condition in Auckland over the last ten years was reviewed. Clinical presentation, diagnostic imaging, surgical management and patient outcome were analyzed.

Results Twenty-one patients were treated over the last 10 years. All had symptomatic TDH. Most operations were performed by the senior author. Patient age varied between 30 and 80, with mean age 50.8 years. There was a slight female preponderance (n=14). Most patients were of European ethnicity. Most patients had spinal cord or nerve root dysfunction, but local pain and sensation change were also noted. MRI was the mainstay in diagnosis, and CT scan was often also used. Surgical exposure was aimed at avoiding spinal cord manipulation and will be discussed. The surgical approach was via thoracotomy in most cases, costotransversectomy, pediculectomy and laminectomy. One case was treated conservatively. There was one case of postoperative paraplegia which will be discussed. There were no other permanent major neurological complications. Patient outcomes will be discussed in detail. Patients with motor weakness showed post operative improvement or full recovery. Pain and sensory loss symptoms were less likely to resolve. Complications that warrant discussion included temporary cranial nerve palsy, thoracic empyema, and long-term opioid addiction for pain.

Discussion Over the past 10 years, a reasonable number of patients with TDH have been treated surgically without major incident. The surgical management of this condition remains a challenge. Younger spinal surgeons may not have the training to deal with these cases, which should be addressed. Endoscopic treatment has a steep learning curve, and may not be well suited to larger symptomatic TDH.

Background: Publications concerning recurrent disc disease quote percentage recurrence without regard to the times of recurrence and the influence of longer follow-up.

Objective: To assess the use of survival analysis to measure revision rate after lumbar microdiscectomy.

Design: A retrospective analysis of the hospital records of all patients undergoing lumbar microdiscectomy over a nine-year period was undertaken. Patients who had a repeat microdiscectomy at the same level as the index procedure were designated ‘revisions’. The overall revision rate was calculated for the average length of follow-up. A survival analysis was then carried out using the life table method, as described by Murray et al for follow-up of hip arthroplasty.

Subjects: Seven hundred and twenty-nine patients underwent primary microdiscectomy during this time period, average age 40 years.

Results: Twenty-seven patients had a revision microdiscectomy during the study period. This gave an overall revision rate of 3.7% at average follow up of five years, one month. Using survival analysis the revision rate was 5.5% at eight years of follow up, number at risk 51.

Conclusions: Survival analysis gives a more accurate estimation of the true recurrence rate for patients undergoing lumbar microdiscectomy. The method would allow better comparison between different interventions for intervertebral disc herniation.

Purpose: In this study, we evaluated AGEs(advanced glycation end products) based on the following points. In routine clinical practice, some patients with intervertebral disc hernia show or previously showed a high blood glucose level, similar to the state in cataract patients. This study is significant for hernia therapy in the near future in context of an approach from sugar(cause),not aging(result).

Materials and Methods: Herniated intervertebral discs were obtained during surgery. We obtained human fetal (aborted) tissue and immunohistologically stained.

Results: AGEs were already exposed during histogenesis, suggesting a relation to apoptosis.

Discussion: In this study, a relationship between programmed cell death and AGEs was suggested. During the early step of glycosylation, the reaction progresses in a manner dependent on saccharide concentration and reaction time. In patients in whom the blood glucose level had been high in the past, the incidence remained high even though the blood glucose level is currently controlled, suggesting that AGEs affect a gene and the effect is memorized.

Despite the clinical relevance of back pain and intervertebral disc herniation, the lack of reliable models has strained their molecular understanding. We characterized the lumbar spinal phenotype of C57BL/6 and SM/J mice during aging. Interestingly, old SM/J lumbar discs evidenced accelerated degeneration, associated with high rates of disc herniation. SM/J AF's and degenerative human's AF transcriptomic profiles showed altered immune cell, inflammation, and p53 pathways. Old SM/J mice presented increased neuronal markers in herniated discs, thicker subchondral bone, and higher sensitization to pain. Dorsal root ganglia transcriptomic studies and spinal cord analysis exhibited increased pain and neuroinflammatory markers associated with altered extracellular matrix regulation. Immune system single-cell and tissue level analysis showed distinctive T-cell and B-cell modulation and negative correlation between mechanical allodynia and INF-α, IL-1β, IL2, and IL4, respectively. This study underscores the multisystemic network behind back pain and highlights the role of genetic background and the immune system in disc herniation disease. Acknowledgments: This study is supported by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) R01AR055655, R01AR064733, R01AR074813 to MVR

Background. It has become increasingly important to conduct studies assessing clinical outcomes, reoperation rates, and revision rates to better define the indications and efficacy of lumbar spinal procedures and its association with symptomatic adjacent segment degeneration (sASD). Adjacent segment degeneration (ASD) is defined as the radiographic change in the intervertebral discs adjacent to the surgically treated spinal level. SASD represents adjacent segment degeneration which causes pain or numbness due to post-operative spinal instability or nerve compression at the same level. The most common reason for early reoperation and late operation is sASD, therefore is in our best interest to understand the causes of ASD and make steps to limit the occurrence. Method. A comprehensive literature search was performed selecting Randomized controlled trials (RCTs) and retrospective or prospective studies published up to December 2023. Meta-analysis was performed on 38 studies that met the inclusion criteria and included data of clinical outcomes of patients who had degenerative disc disease, disc herniation, radiculopathy, and spondylolisthesis and underwent lumbar fusion or motion-preservation device surgery; and reported on the prevalence of ASD, sASD, reoperation rate, visual analogue score (VAS), and Oswestry disability index (ODI) improvement. Results. When compared to fusion surgery, a significant reduction of ASD, sASD and reoperation was observed in the cohort of patients that underwent motion-preserving surgery. Conclusion. Dynamic fusion constructs are treatment options that may help to prevent sASD. Conflicts of interest. This research was funded by Paradigm Spine. Sources of funding. Paradigm Spine

Abstract. Objectives. There is still controversy in the literature over whether Cervical Foraminotomy or Anterior Cervical discectomy and fusion (ACDF) is best for treating cervical Radiculopathy. Numerous studies have focused on the respective complication rates of these procedures and outcome measures with a lack of due consideration to preoperative MRI findings. Proximal foraminal stenosis can theoretically be accessed via either approach. We aimed to investigate whether patient reported outcome measures (PROMs) favoured one approach over the other in patients with proximal foraminal stenosis. Methods. A single centre retrospective review of patients undergoing either ACDF or Cervical foraminotomy over the period 2012 to 2022. VAS, Neck disability index (NDI), EQ5DL and Patient Satisfaction on a Five Point Likert scale were obtained. Patients who had both an ACDF and a Foraminotomy were excluded. Axial MRI images were analysed and the location of the worst clinically relevant disc herniation stratified as follows: Central (1), Paracentral (2) and Foraminal (3). Correlations and average PROMs were analysed in SPSS. Results. PROMs scores were available for 33 ACDF patients and 37 Foraminotomy patients. Average surgery time in ACDF group was 167 minutes while Foraminotomy 142 minutes. Average Length of hospital stay was 6.24 days in the Foraminotomy group and 3.54 days in the ACDF group. 18 patients were excluded due to having both surgeries (2 of which developed CSF leaks postoperatively). Of the included patients there were no postoperative complications. 13 patients in the ACDF had Central or Paracentral stenosis in addition to proximal Foraminal stenosis, 3 patients in the Foraminotomy group had some significant Paracentral herniation just before the Proximal foramen. The majority of patients in both groups had pure proximal Foraminal stenosis (N= 17 (ACDF), 20 (Foraminotomy). The results showed no significant difference in PROMs between patients who received an ACDF or a Foraminotomy for Proximal foraminal stenosis (EQ5DL, NDI, and satisfaction, P= 0.268, 0.253 and 0.327). There was no correlation between location of the stenosis and PROM scores in either group. Conclusions. Our data suggest that Proximal foraminal stenosis can be effectively addressed by either an anterior ACDF or a Foraminotomy with no difference in complication rates. Foraminotomy has the benefit of no implant cost but longer hospital stay. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

A 980 nm Diode (Biolitec AG) Laser energy introduced via a 21G needle under C-arm or CT-Scan guidance and local anesthesia, vaporizes a small amount of nucleous polposus with a disc shrinkage and a relief of pressure on nerve root. The procedure in the disc herniation treatment over the years had several changes, not only related to the different types of lasers (Ho:YAG, Nd: YAG, Er:YAG), but also in the types of optical fibers employed and in the neuronavigation systems. In our department starting under C-arm, realized that the only way to visualize the nerve root and increase the total energy delivered in several points of disc herniation, was to use a CT-Scan guidance (Aquilion 64 Slices Toshiba). Matherial and Method: A prospective study on 350 patients (470 cases) affected by contained and non contained disc herniation was performed. The patients had a PLDD (Percutaneous Laser Disc Decompression) under CT-Scan guidance. A control group of 200 patients (350 cases) affected both by contained and noncontained disc herniation had a PLDD under C-arm. Results: The results showed a statistically significant difference (p< 0.05) in the effectiveness of the PLDD in Disc Herniation treatment. Non Contained disc herniation had a successful result in 88.5% of cases under Ct-Scan guidance vs 70% of cases under C-arm. No statistically significant (p > 0.05) difference was found in contained disc herniation group. The laser energy delivered under CT-Scan was on average 40% (S.D. 0.36) more than under C-arm, because the visualization of nerve root and the size of the disc herniation permits to apply laser energy on different points, in order to obtain a disc shrinkage over a bigger surface, without any damage on surrounding tissues. In conclusion, CT-Scan guidance appear to be the best way to practice PLDD not only in terms of resolution, treating succesfully non contained disc herniation, but also because the visualization of the nerve root permits a safe application of the laser energy and the effectiveness of the procedure give a faster return to normal life