Aims. Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. Methods. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. Results. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. Conclusion. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery. Cite this article: Bone Joint J 2023;105-B(4):422–430

Aims

The aim of this study was to evaluate the time course of changes in parameters of diffusion tensor imaging (DTI) such as fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in patients with symptomatic lumbar disc herniation. We also investigated the correlation between the severity of neurological symptoms and these parameters.

Aims. The purpose of this study was to investigate the risk of additional surgery in the lumbar spine and to describe long-term changes in patient-reported outcomes after surgery for lumbar disc herniation in adolescents and young adults. Patients and Methods. We conducted a retrospective study design on prospectively collected data from a national quality register. The 4537 patients were divided into two groups: adolescents (≤ 18 years old, n = 151) and young adults (19 to 39 years old, n = 4386). The risk of additional lumbar spine surgery was surveyed for a mean of 11.4 years (6.0 to 19.3) in all 4537 patients. Long-term patient-reported outcomes were available at a mean of 7.2 years (5.0 to 10.0) in up to 2716 patients and included satisfaction, global assessment for leg and back pain, Oswestry Disability Index, visual analogue scale for leg and back pain, EuroQol five-dimension questionnaire (EQ-5D), and 36-Item Short-Form Health Survey (SF-36) Mental Component Summary and Physical Component Summary scores. Statistical analyses were performed with Cox proportional hazard regression, chi-squared test, McNemar’s test, Welch–Satterthwaite t-test, and Wilcoxon’s signed-rank test. Results. Any type of additional lumbar spine surgery was seen in 796 patients (18%). Surgery for lumbar disc herniation accounted for more than half of the additional surgeries. The risk of any additional surgery was 0.9 (95% confidence interval (CI) 0.6 to 1.4) and the risk of additional lumbar disc herniation surgery was 1.0 (0.6 to 1.7) in adolescents compared with the young adult group. Both age groups improved their patient-reported outcome data after surgery (all p < 0.001). Changes between short- (mean 1.9 years (1.0 to 2.0)) and long-term follow-up (mean 7.2 years (5.0 to 10.0)) were small. Conclusion. The risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults. All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. Cite this article: Bone Joint J 2019;101-B:1534–1541

Purpose: In recent years, many reports have described spontaneous resorption of lumbar disc herniation evaluated with Gd-enhanced MRI. We also found retrospectively that sequestrated lumbar disc herniation with Gd-enhanced MRI would disappear, and that patient with this type of lumbar disc herniation would improve clinically. But there is a question that Gd-enhanced MRI is really needed to speculate the prognosis of sequestrated lumbar disc herniation. The purpose of this study is to clarify the prognostic value of Gd-enhanced MRI for sequestrated lumber disc herniation. Materials and methods: Since Nov. 1995, 22 patients of sequestrated lumber disc herniation were treated non-operatively under the speculation of getting good clinical result prospectively. From Nov. 1995 to Oct. 1997, 9 patients with sequestrated lumbar disc herniation with ring-enhancement on Gd-enhanced MRI were treated non-operatively (Group A). From Nov. 1997 to July 2000, 13 patients with sequestrated lumbar disc herniation were treated non-operatively without Gd-enhanced MRI examination (Group B). Clinical results and the last MRI findings of Group A were compared with that of Group B. Results: In Group A, all cases were treated non-operatively and all of them improved clinically within a month of the first MRI examinations. Mean period of NSAID administration was 37 days (range 14–67 days), and the last MRI examinations revealed that the herniated masses disappeared in 5 cases and that the size of herniations diminished in 4 cases. All of 9 cases obtained good clinical results. In Group B, all cases were treated non-operatively but one, whose clinical symptoms were not improved within a month of the first MRI examination. Mean period of NSAID administration was 38 days (range 7–110 days), and the last MRI examinations revealed that the herniated masses disappeared in 5 cases and that the size of herniations diminished in 5 cases. Remaining 2 cases, the second MRI was not examined for some reasons. All of 12 cases obtained good clinical results. There were no differences between Group A and Group B by means of clinical results. Conclusions: Gd-enhanced MRI is not needed to speculate the prognosis of sequestrated lumbar disc herniation. In the case of sequestrated lumbar disc herniation, good clinical result could be obtained without Gd-enhanced MRI examination at the first MRI examination

We have treated 15 patients with massive lumbar disc herniations non-operatively. Repeat MR scanning after a mean 24 months (5 to 56) showed a dramatic resolution of the herniation in 14 patients. No patient developed a cauda equina syndrome. We suggest that this condition may be more benign than previously thought

Introduction: Operations inside the spinal canal are afflicted with a certain number of iatrogenic dural lesions. Incidence figures in the literature vary from 1 to 17% and are mainly based on retrospective studies. The Swedish Spine Register, SweSpine, provides a good possibility to study the incidence in a prospective patient material. Patients and Methods: During 5 years more than 9 000 patients had surgical treatment for lumbar disc herniation or lumbar spinal stenosis and were registered according to the protocol of the Swedish Spine Register. One year follow-up data were present for 74 % of the patients. Pre- and postoperative data are entirely based on questionnaires answered by the patient whereas surgical data are completed by the surgeon. Complication and re-operation registration is included. Mean patient age for LDH was 45 (12–88) years, for spinal stenosis 68 (27–93) years and 56% of the disc herniation patients and 43% of the spinal stenosis patients were males. Most common level for LDH operation was L5/S1 followed by L4/L5 and for spinal stenosis L4/L5 followed by L3/L4. The one-year result was studied. Results: The incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in spinal stenosis decompression 7.3%. The risk for dural lesion was more than doubled in patients with previous surgery which, thus, was a significant but also the only risk factor. At one year after surgery the result was similar for patients with and without dural lesion when VAS pain, ODI, SF-36 and patient graded global assessment were studied. Correlation between previous surgery and inferior outcome was seen but was not affected by the dural lesion as such. Three and 5% respectively in the groups were subjected to repeat surgery before discharge from the hospital. The lost-to follow-up group (26%) had similar pre-operative demographics and the same incidence of dural lesion as those followed-up. Conclusion: In a large prospectively studied material, the incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in decompressive spinal stenosis surgery 7.3%. Previous surgery was a significant risk factor for dural lesion. The dural lesion as such did not negatively influence the one-year outcome

We present our four-year experience with a new minimally invasive method for ambulatory treatment of lumbar discal herniation: micro video endoscopic dissectomy. Video endoscopic surgery associates microsurgical procedures similar to those used in conventional surgery with a very precise technique. This method was used for 50 patients presenting lumbar disc herniation diagnosed with magnetic resonance imaging using the MacNab criteria, placing priority on the neurological risk of sensorimotor deficit. Clinical outcome was also evaluated with the MacNab criteria. These patients were able to walk early, resumed work rapidly, and had little lumbar pain and few complications

Introduction Minimally invasive lumbar discectomy using the METRx™ System (MAST discectomy) has been advocated as an alternative to open microdiscectomy for symptomatic posterolateral lumbar disc herniation. This paper presents a quality assurance dual surgeon retrospective study with independent observer minimum twelve month follow-up. Methods This study was approved by the Ethics Committee of the Princess Alexandra Hospital prior to commencement. All patients who underwent MAST discectomy using the METRx™ System for the management of radiculopathy caused by posterolateral lumbar disc herniation under the care of two surgeons (AN and RK) more than twelve months prior to the commencement of assessment were included in the study. The patient demographic data was collected contemporaneously, operation performance data was collected retrospectively from hospital databases and outcome data was collected by telephone interview by independent observers (PL, SO and JP) a minimum of twelve months after discharge from hospital. Results 101 patients (53 males, 48 females) (average age 43 years, range 17 to 83 years) underwent 102 procedures between July 2001 and December 2004. Surgery was performed on the right side in 63 cases and was either at L4/5 (30%) or more commonly L5/S1 (70%). 21 were public patients and 80 private patients with 59 episodes of surgery occurring in a public hospital. 46 operations were performed with the METRx™ MED System and 56 with the METRx™ MD System. The average duration of surgery for patients at the Princess Alexandra Hospital (n = 48) was 88 minutes with an average length of post-operative hospital stay of 22 hrs 35 mins. 16 of these cases were performed as day surgery. Perioperative complications were: conversion to open (3), urine retention (7), nausea and vomiting (3), durotomy (5), wound haematoma not requiring surgery (1) and incorrect level surgery identified and rectified during surgery (1). The average length of time from surgery to independent follow-up was 679 days (range: 382 to 1055) with 78% successful contact. On the Modified McNabb Outcome Scale, 83% reported an excellent or good outcome, 9% reported a fair outcome and 8% a poor outcome. The time until return to work was identified as less than two weeks in 28% and between 2 weeks and 3 months in 39%. Patients whose surgery was funded by Workers Compensation were over-represented in both the poor outcomes and delayed return to work. 4 patients reported progressive severe low back pain, 10 patients reported ongoing lower limb pain (severe in 1 and mild in 9) and 1 patient underwent surgery for a recurrent disc prolapse. Further disc prolapse at different sites was identified in five patients. Discussion The retrospective data in this study forms class IV evidence for efficacy. As a quality assurance exercise it suggests an acceptable level of safety and efficacy to allow further technique development and study. A prospective randomized controlled study is proposed. The high incidence of urine retention early in the series of one surgeon is considered to be related to the practice of placing depot morphine in the operative bed. The reduction in complications in general and the improvement in duration of surgery over the series is evidence of the learning curve for this procedure

Background. Recently, some studies have focused attention on the possibility that anaerobic pathogens of low virulence could constitute an etiological factor in disc herniation. There have been isolated such strains, predominantly Propionibacterium acne, between 7 and 53% of patients undergoing surgery for disc pathology. According to these studies, patients with anaerobic infections of the disc are more likely to develop Modic changes in the adjacent vertebrae. The aim of this work was to test this hypothesis by growing in specific media the disc material extracted in a series of lumbar discectomy and relating this factor with the presence of pre-intervention Modic changes. Methods. A total of 22 consecutive patients undergoing primary unisegmental discectomy for lumbar disc herniation (77.2% male, mean age 40.1 ± 9.1 years) were included. All patients were immunocompetent and none had previously received an epidural steroid injection prior surgery. MRI study confirmed the disc herniation. Following strict antiseptic protocols, the extracted disc material was sent for slow-growth anaerobic enriched culture (>10 days). Results. In total, anaerobic cultures were positive in 7 cases (31.8%) all men. In 5 of these cases, the symptoms developed with an acute onset. The isolated germs were always unique: Propionibacterium acne (3), Streptococcus parasanguinis (1), Actinomyces naeslundii (1), Actinomyces meyeri (1) and methicillin sensitive Staphylococcus epidermidis. Only two (28.6%) of these 7 patients had Modic changes on MRI prior surgery (one type I, one type 2). None of the patients with negative cultures had Modic changes. Conclusions. These findings support the theory that anaerobic infections of low virulence and slow growth may contribute to the pathogenesis of herniated discs. However, these cases do not necessarily develop type 1 Modic changes as previously speculated. Level of evidence. Level IV

Introduction and Objectives: Indications for surgery in the treatment of lumbar disc herniation are still the subject of some controversy, in spite of previous systematic studies demonstrating its effectiveness. Many believe that this treatment should be avoided in working patients, in whom results of vertebral surgery tend to be poorer. Health-related quality of life indicators permit the objective measurement of the degree to which the health of the patient is improved by a particular type of procedure. They also permit a comparision of health improvement for patients with various types of treatment interventions. The goal of this study is to evaluate the impact of lumbar microdiscectomy on health-related quality of life in working patients. Materials and Methods: A total of 105 patients of working age who underwent surgery at the Vertebral Surgery Unit of an On-the-Job Accident Cooperative were evaluated prospectively. Of these patients, 89 (84.8%) were male, and 51% were working in jobs that involved heavy lifting; 68.6% had high-school or less education or no education. Patients were evaluated before and 3 months after surgical intervention using a validated Spanish version of a questionnaire on the following clinical dimensions: Health-Related Quality of Life (SF-36), Lumbar Spine Function (Oswestry’s questionnaire), Lumbar and Radicular Pain (Visual Analogue Scale). Unvalidated versions of Work Situation and Satisfaction with results (GEER scales) were used. Results: Statistically significant and clinically relevant improvement was observed in the following parameters: Intensity of lumbar pain (preoperative: 61.7; postoperative: 33.5; p< 0.001) and radicular pain (preoperative: 76.1; postoperative: 28.4; p< 0.001), specific lumbar spine function (preoperative: 44.3; postoperative, 18.3; p< 0.001), patient satisfaction and the SF 36 Physical Function items (preoperative: 38.1373; postoperative, 71.152; p< 0.001), physical role (preoperative,6.2092;postoperative,24.8366; p< 0.001), bodily pain (preoperative, 24.5196; postoperative, 51.0882; p< 0.001), general health (preoperative, 59.2607; postoperative, 62,901; p< 0.044), vitality (preoperative, 45.8333; postoperative, 58.2843; p< 0.001), social function (preoperative: 55.6373; postoperative: 73.8971; p< 0.001), and mental health (preoperative: 61.9706; postoperative, 70.9706; p< 0.001). A statistically significant improvement was not found in emotional role (preoperative: 65.6766; postoperative, 72.9373; p=0.182). Discussion and Conclusions: Apart from the impact on their work situation, working patients who underwent microdiscetomy for lumbar disc herniation enjoyed significant short-term clinical improvement in multiple areas of their health

Between 1995 and 1999, 12 patients aged 65 years or more (mean 70.2) with lumbar disc herniation, underwent partial laminectomy and nucleotomy. The results were compared with those of 25 younger patients aged between 20 and 40 years (mean 30.1), who underwent the same surgical procedure. The Japanese Orthopedic Association (JOA) score was used to assess the clinical outcome. The minimum follow-up was 12 months. The pre- and post-operative total JOA scores and the rate of improvement of the JOA score were not significantly different between the elderly (11.1, 24.3 points, and 74.1%), and the younger group (11.6, 26.4 points and 84.5%). The results of this study indicate that the outcome of lumbar discectomy in elderly patients is as good as in younger patients

The purpose of this study is to call attention to the diagnosis of spinal cyst caused by lumbar disc herniation. Reviewing a total of 11 cases of lumbar spinal cyst that have been encountered in our spinal practice, we propose our views concerning the pathology of this lesion. The clinical findings of lumbar spinal cyst are identical to those in acute disc herniation such as low back pain and radiculopathy. The characteristics of imaging study are as follows; The magnetic resonance imaging (MRI) demonstrates a relatively large, rounded mass postero-laterally to the vertebral body. These lesions are isointense relative to the intervertebral disc on T1-weighted images and homogeneously hyperintense on T2. A gadolinium -DTPA-enhanced MRI shows a rim-enhancing lesion. A discogram reveals leakage of the contrast medium into the mass. The operative findings demonstrated encapsulated soft tissue masses which contained bloody fluid and small fragments of herniated disc tissue. The pathologic examinations revealed fibrous tissue with hemosiderin deposit in cyst wall and degenerative disc materials with inflammatory cell infiltration. This type of lumbar spinal cyst has been recognized as spinal epidural hematoma in recent years. Wiltse suggested that epidural hematoma may result from tearing of fragile epidural veins due to acute disc disruption. However, MRI characteristics of hematoma are not identical with those with lumbar spinal cyst. It is more likely that the lesions showing the pattern of changes are herniated disc tissue accompanied by hemorrhage and inflammation. If hernial tissue is covered with some membranous susbtance, formation of cystic lesions is understandable. Hence, we hypothesize that lesions, in which lysis liquefaction and absorption of the herniated disc tissue associated with inflammatory response have progressed, and the herniated disc tissue has completely disappeared, may be filled solely with bloody fluid, showing an appearance like cysts

Percutaneous nucleotomy is a relatively new technique for treating lumbar disc herniation. There is no agreement as to the volume of disc material to be removed. A long-term study of clinical and radiological data from patients treated by percutaneous nucleotomy was designed to identify the factors associated with favourable and unfavourable outcomes. We studied 42 patients for at least ten years; the mean follow-up was 10.9 years. They were divided into two subgroups to assess the value of preserving the nucleus pulposus in the central area of the disc. The overall success rate for both subgroups was 50%. A decrease in disc height on plain radiography and a decrease in signal intensity on MRI were observed more infrequently in patients in whom the nucleus pulposus in the central area of the disc had been preserved, than in those in whom it had been extensively removed. These adverse radiological findings correlated closely with increased low back pain during the first one to two years after operation and a poorer overall outcome. We conclude that percutaneous nucleotomy is most likely to be successful when the central area of the disc is preserved

In this retrospective study 27 patients who had undergone revision discectomies for recurrent lumbar disc herniations were surveyed to assess their clinical outcomes. The patients chosen for the study were compared to a control group of 30 matched patients who had undergone only a primary discectomy. The spine module of the MODEMS® outcome instrument was used to evaluate the patients’ satisfaction, their pain and functional ability following discectomy, as well as their quality of life. All patients were also asked whether they were improved or worsened with surgery. Those undergoing revision surgery were asked whether the improvement following the second surgery was more or less than the improvement following the first surgery. Differences in residual numbness/tingling in the leg and/or the foot as well as in frequency of back and/or buttock pain were identified. Nevertheless improvement due to the repeat discectomy was not statistically different from those who underwent just the primary operation. Based upon patient derived outcome data with a validated instrument, revision discectomy is as efficacious as primary discectomy in selected patients

Lumbar disc herniation (LDH) is uncommon in youth and few cases are treated surgically. Very few outcome studies exist for LDH surgery in this age group. Our aim was to explore differences in gender in pre-operative level of disability and outcome of surgery for LDH in patients aged ≤ 20 years using prospectively collected data. From the national Swedish SweSpine register we identified 180 patients with one-year and 108 with two-year follow-up data ≤ 20 years of age, who between the years 2000 and 2010 had a primary operation for LDH. Both male and female patients reported pronounced impairment before the operation in all patient reported outcome measures, with female patients experiencing significantly greater back pain, having greater analgesic requirements and reporting significantly inferior scores in EuroQol (EQ-5D-index), EQ-visual analogue scale, most aspects of Short Form-36 and Oswestry Disabilities Index, when compared with male patients. Surgery conferred a statistically significant improvement in all registered parameters, with few gender discrepancies. Quality of life at one year following surgery normalised in both males and females and only eight patients (4.5%) were dissatisfied with the outcome. Virtually all parameters were stable between the one- and two-year follow-up examination. LDH surgery leads to normal health and a favourable outcome in both male and female patients aged 20 years or younger, who failed to recover after non-operative management. Cite this article: Bone Joint J 2015;97-B:1675–82

We reviewed two comparable groups of patients who had been treated for lumbar disc herniation by chymopapain chemonucleolysis (145) or conventional surgical discectomy (91). They were reviewed 10 years after treatment by questionnaire, followed by a personal interview by an independent observer. The results of the surgically treated groups were slightly better than those treated with chymopapain. In particular, there was significantly better early relief of leg and low back pain, and fewer patients needed a second procedure. Complications were few in both groups

Background. Percutaneous endoscopic interlaminar discectomy (PEID) has achieved favorable effects in the treatment of lumbar disc herniation (LDH), as a new surgical procedure. With its wide range of applications, a series of complications related to the operation has gradually emerged. Objective. To describe the type, incidence and characteristics of the complications following PEID and to explore preventative and treatment measures. Study Design. Retrospective, observational study. Setting. A spine center affiliated with a large general hospital. Method. In total, 479 cases of patients with LDH received PEID, which was performed by an experienced spine surgeon between January 2010 and April 2013. Data concerning the complications were recorded. Result. All of the 479 cases successfully received the procedure. A total of 482 procedures were completed. The mean follow-up time was 44.3 months, ranging from 24 to 60 months. The average patient age was 47.8 years, ranging from 16 to 76 years. There were 29 (6.0%) related complications that emerged, including 3 cases (0.6%) of fragment omission, and the symptoms gradually eased following 3–6 weeks of conservative treatment; 2 cases (0.4%) of nerve root injury, and the patients recovered well following 1–3 months of taking neurotrophic drugs and functional exercise; 15 cases (3.1%) of paresthesia, and this condition gradually improved following 3–6 weeks of rehabilitation exercises and treatment with mecobalamin and pregabalin; and recurrence occurred in 9 cases (1.9%), and the condition was controlled in 4 of these cases by using a conservative method, while 5 of the cases underwent reoperation, including 3 traditional open surgeries and 2 PEID. Furthermore, the complication rate for the first 100 cases was 16%. This rate decreased to 3.4% (for cases 101–479), and the incidence of L4–5 (8.2%) was significantly higher than L5-S1 (4.5%). Limitations. This is a retrospective study, and some bias exists due to the single-center study design. Conclusion. PEID is a surgical approach, which has a low complication rate. Fragment omission, nerve root injury, paresthesia and recurrence are relatively common. Some effective measures can prevent and reduce the incidence of the complications, such as strict indications for surgery, a thorough action plan and skilled operation skills

We measured the serum concentration of C-reactive protein (CRP) by a high-sensitive method in patients with lumbar disc herniation. There were 48 patients in the study group and 53 normal controls. The level and type of herniation were evaluated. The clinical data including the neurological findings, the angle of straight leg raising and post-operative recovery as measured by the Japanese Orthopaedic Association (JOA) score, were recorded. The high-sensitive CRP (hs-CRP) was measured by an ultrasensitive latex-enhanced immunoassay. The mean hs-CRP concentration was 0.056 ± 0.076 mg/dl in the patient group and 0.017 ± 0.021 mg/dl in the control group. The difference was statistically significant (p = 0.006). There was no other correlation between the hs-CRP concentration and the level and type of herniation, or the pre-operative clinical data. A positive correlation was found between the concentration of hs-CRP before operation and the JOA score after. Those with a higher concentration of hs-CRP before operation showed a poorer recovery after. The significantly high concentration of serum hs-CRP might indicate a systemic inflammatory response to impingement of the nerve root caused by disc herniation and might be a predictor of recovery after operation

The purpose of this review is to evaluatei the clinical and surgical aspects of lumbar disc herniation in paediatric and adolescent patients. Between 1975 and 1991, a total of 5,160 lumbar disc operations were performed at the Rizzoli Orthopaedic Institutes. We included in this study only 129 patients (2.5%), aged from 9 to 18 years, with a mean age of 16.2 years (S.D. 1.7). Almost half of the patients (66 cases) ranged from 17 to 18 years of age and 49% (63 cases) from 9 to 16. Only three subjects were aged 9, 11 and 12 years. This group consisted of 84 boys and 45 girls. Eleven had noted the onset of symptoms after a trauma and 15 during athletic activities or after lifting heavy objects. Almost all of the patients (106 cases, 82%) had low-back pain with radiculopathy, 13% (17 cases) complained of lumbar pain alone, 5% (six cases) had sciatica and 16% (21 cases) presented with a radicular neurological deficit. Posterior discectomy by conventional procedure without fusion was performed in all patients, except for three cases with associated spondylolisthesis, treated by a posterolateral artrodesis, supplemented in two cases by pedicle screw fusion. Patients were followed in a short-term assessment using medical records. Long-term follow-up was conducted by a mailed, self-report questionnaire that quantified leg and back pain and scored the ability to return to normal activities and satisfaction. Short-term results were excellent for 120 patients (93%) and postoperative complications included one superficial wound infection and one discitis. A total of 98 (76%) long-term responses were obtained with a mean follow-up time of 12.4 years (range, 6-19.4 years). Mean age at long-term follow-up was 28.7 years whereas the functional outcomes were excellent in 56%, good 30% and poor 14%. Eight patients (6.2%) required additional surgical treatment at a mean interval from the first surgery of 9 years (range 2 to 16). Three of them had a re-exploration for a herniated disc at the same level, five at a different level. Our results have confirmed, as in adult patients, a negative trend between the short-term and long-term functional outcomes in young patients treated by discectomy. Furthermore, they have suggested that young individuals with lumbar Scheuermann-type changes are at great risk of experiencing herniation of intervertebral discs (10% in our series)

Aim of the present study was to investigate clinical outcomes and quality of life after standard discectomy for lumbar disc herniation on a minimum 25-year follow-up throughout validated tools. Between 1973 and 1979, a total of 343 patients underwent single or double level standard lumbar discectomy at the Orthopaedic Department of Naples Federico II University Hospital, Italy. Fifty patients died from causes unrelated to disc surgery. Out of the remnants, one hundred fifty-eight patients could be traced and contacted by mail (46.1% survey rate). All of them (100% response rate) completed and sent back three questionnaires: the official Italian version of the Short Form-36 Health Survey (SF-36), the Oswestry Disability Questionnaire, and a questionnaire ideated by the authors to evaluate the degree of satisfaction with surgery. Forty-two patients even accepted to undergo clinic examination. The study population consisted of 97 males and 61 females. The mean age at the time of surgery was 37.8 +/− 8.7 years (18–62), whereas on follow up it was 65.8 +/− 8.9 (44–89). The average follow up in the study group was 27 years (25–31). The eight SF-36 scales averaged 72.53 +/− 31.3 for physical functioning, 63.1 +/− 30.1 for bodily pain, 61.30 +/− 44.4 for role-physical, 54.57 +/− 22.2 for general health, 56.62 +/− 19.2 for vitality, 72.08 +/− 30 for social functioning, 67.56 +/− 41.4 for role-emotional, and 62.28 +/− 19 for mental health. The mean SF-36 physical composite score (PCS) and mental composite score (MCS) were 44.2 +/− 11.6 (17.3–64.5) and 45.7 +/− 9,9 (13.2–62.4), respectively. The mean Oswestry Disability Score was 16.67 +/− 22.82 (0–96). One hundred forty-two patients (89.9%) were satisfied with the results of surgery, whereas sixteen (10.1%) were dissatisfied. One hundred and one (89.2%) would have had the same operation again. Nineteen patients underwent recurrent back surgery, giving a reoperation rate of 12%. As for the objective findings, we noted slight improvement of motor disturbances, hyporeflexia, and radicular tension signs with respect to preoperative period. Lumbar alignment abnormalities and trunk mobility did not show significant changes. On multivariate analysis worst SF-36 PCS scores were associated with increasing age (P = 0.039), low educational level (P = 0.002), and reoperation (P = 0.008). Similar correlations were appreciated for the Oswestry Disability Score. Negative role of female gender (P = 0.012) in determining the score of SF-36 MCS was also detected. To the best of our knowledge, no patient-oriented evaluation of lumbar discectomy outcomes has been reported with a similar ultra-long-term follow-up. The minimum 25-year results obtained in the present study were satisfying for both general health and disability indicators. The general health scores were similar to age-adjusted normative values

We studied the use of gadolinium diethylenetriaminepentaacetic acid-enhanced MRI in the detection of pathological changes in the nerve roots of 25 patients with unilateral sciatica due to lumbar disc herniation. Enhancement was observed in the affected nerve roots within the root sleeve at the caudal edge of the herniation and was classified into three categories: grade 0, none; grade 1, enhancement restricted to a focal region within the sleeve; and grade 2, diffuse and homogeneous. The grade of enhancement correlated well with the severity of the sciatica, and was considered to be due to a disruption of the blood-nerve barrier, leading to oedema

The study was founded by The Regional Institute of Health Sciences Research. Background: There is a need for identifying specific subgroups of LBP, Modic changes might be one of these subgroups. The aim is to describe the relationship between a previous herniated disc and the following Modic changes. Methods: 181 patients with radicular pain below the knee, leg pain ≥ 3, duration of leg pain between 2 and 52 weeks, and age between 18 and 65 years were included. The patients were randomized into one of two active conservative treatment regimes lasting eight weeks. All included patients were scanned at baseline and again at 14 months follow-up. All MRI evaluation was carried out by the same experienced radiologist using a validated evaluation protocol. Results: The prevalence of Modic changes type 1 increased more than 3 fold from 9 % at baseline to 29 % at follow-up; type 2 was respectively 14 % and 13 %. In patients with Modic changes at baseline, extremely few reduced in size or disappeared, on the contrary new type 1 changes developed after the herniation. In patients with a normal disc, 0 % developed Modic changes at follow-up, whereas in those with extrusions and sequestrations 56–63%. There exist a strong association between Modic changes and LBP, 67 % of those with Modic changes had LBP compared to 21 % of the patients without, OR 6.1, (p< 0.0001). Discussion: A lumbar disc herniation is a strong risk factor for developing Modic changes (especially type 1) during the following year. Furthermore, Modic changes are strongly associated with LBP

Aims

The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events.

We analysed prospectively 26 patients who had revision operations for ipsilateral recurrent radicular pain after a period of pain relief of more than six months following primary discectomy. They were assessed before the initial operation, between the two procedures and at a minimum of two years after reoperation. MRI was performed before primary discectomy and reoperation. Fifty consecutive patients who had a disc excision during the study period but did not have recurrent radicular pain, were analysed as a control group.

Of the study group 42% related the onset of recurrent radicular pain to an isolated injury or a precipitating event, but none of the control group did so (p < 0.001). T2-weighted MRI performed before primary discectomy showed that patients in the study group had significantly more severe disc degeneration compared with the control group (p = 0.02). Intraoperative findings revealed recurrent disc herniation in 24 patients and bulging of the disc in two, one of whom also had lateral stenosis. Epidural scarring was found to be abundant, intraoperatively and on MRI, in eight and in nine patients, respectively.

At the last follow-up, the clinical outcome was satisfactory in 85% of patients in the study group and in 88% of the control group (p > 0.05). Work or daily activities had been resumed at the same level as before the onset of symptoms by 81% of the patients in the study group and 84% of the control group. No correlation was found between the amount of epidural fibrosis, as seen intraoperatively and on MRI, and the result of surgery. The recurrence of radicular pain caused no significant changes in the psychological profile compared with the assessment before the primary discectomy.

Of a total of 330 patients requiring operation on a lumbar disc, 20 (6.1%) with lateral disc prolapse had a new muscle-splitting, intertransverse approach which requires minimal resection of bone.

There were 16 men and 4 women with a mean age of 52 years. All had intense radicular pain, 15 had femoral radiculopathy and 19 a neurological deficit. Far lateral herniation of the disc had been confirmed by MRI.

At operation, excellent access was obtained to the spinal nerve, dorsal root ganglion and the disc prolapse. The posterior primary ramus was useful in locating the spinal nerve and dorsal root ganglion during dissection of the intertransverse space.

At review from six months to four years, 12 patients had excellent results with no residual pain and six had good results with mild discomfort and no functional impairment. Two had poor results. There had been neurological improvement in 17 of the 20 patients.

We report a cadaver study of the anatomy of the posterior primary ramus. It is readily identifiable through this approach and can be traced down to the spinal nerve in the intertransverse space.

We recommend the use of a muscle-splitting intertransverse approach to far lateral herniation of the disc, using the posterior primary ramus as the key to safe dissection.

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW).

Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61.

Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc.

We have studied, prospectively, 116 patients with motor deficits associated with herniation of a lumbar disc who underwent microdiscectomy. They were studied during the first six months and at a mean of 6.4 years after surgery. Before operation, muscle weakness was mild (grade 4) in 67% of patients, severe (grade 3) in 21% and very severe (grade 2 or 1) in 12%. The muscle which most frequently had severe or very severe weakness was extensor hallucis longus, followed in order by triceps surae, extensor digitorum communis, tibialis anterior, and others.

At the latest follow-up examination, 76% of patients had complete recovery of strength. Persistent weakness was found in 16% of patients who had had a mild preoperative deficit and in 39% of those with severe or very severe weakness. Muscle strength was graded 4 in all patients with persistent weakness, except for four with a very severe preoperative deficit affecting the L5 or S1 nerve root. They showed no significant recovery. Excluding this last group, the degree of recovery of motor function was inversely related to the preoperative severity and duration of muscle weakness. The patients’ subjective functional capacity was not directly related to the degree of recovery except in those with persistent severe or very severe deficit.

We made a prospective study of 43 consecutive patients treated for intraforaminal (34) or extraforaminal (9) herniations of a lumbar disc by excision through an interlaminar approach, using an operating microscope. The intraforaminal herniations were contained or extruded in 52% and sequestrated in 47%; for extraforaminal herniation the proportions were 66% and 33%, respectively. There was additional posterolateral protrusion or spinal stenosis at the level of the lateral herniation in seven and four cases, respectively. The patients were reviewed at three months and two years after surgery. Radiographs showed three grades of facetectomy: grade I, removal of 50% or less, grade II, excision of 51% to 75%, and grade III, subtotal or total facetectomy.

For intraforaminal herniations the results were excellent or good in 88% of patients when reviewed at three months and in 91% at two years. For extraforaminal herniations, there was an excellent or good outcome in 89% of patients in the short term and in all in the long term. The facetectomy had been grade I in 14 and grade II in 25; it had been grade III in four, but only one had had total facetectomy. No patient had developed vertebral hypermobility as a result of the operation.

An intralaminar approach using an operating microscope can provide adequate access to a lateral protrusion. It has the advantage of allowing the treatment of posterolateral protrusion or posterior annular bulge and of spinal stenosis at the same level.

Aims: To explore the clinical value of foot extensor digi-torum brevis (EDB) muscle in patients with unilateral lumbosacral radiculopathy. Methods: This is a prospective study of 153 patients with low back pain (LBP) and unilateral lumbosacral radiculopathy. The average duration of symptoms was 94 (1–279) days and the average age of patients was 62 (18–75) years. Twenty þve patients had disc herniation with the involvement of L4 nerve root; 32 patients with the L5, and 36 with the S1. There were 31 patients with LBP only. Patients with a history of trauma of the lower legs, repetitive mechanical irritation, or systemic diseases were excluded. In all patients full clinical and neurological examination of the spine was performed. Clinical evaluation of the EDB with resisted dorsal ßexion of the toes was also made. The size and consistency of the EDB muscle was documented and compared with that of the opposite foot. Results: Seventeen patients with L5 and S1 nerve root involvement had isolated atrophy of the EDB muscle as this was compared to the EDB of the opposite side. Conclusions: Clinical evaluation of EDB muscle in patients with unilateral lumbosacral radiculopathy may aid the examiner in understanding the nature and level of the spinal nerve root pathology.

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.

Aims. This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect. Methods. This experiment included three patients diagnosed with lumbar disc herniation who failed conservative treatment. Nucleus pulposus tissue was isolated from these patients when they underwent surgical intervention, and primary NPCs were isolated and cultured. Western blotting, reverse transcription polymerase chain reaction, fluorescence staining, and other methods were used to detect changes in related signalling pathways and the ability of cells to resist pyroptosis. Results. Western blot analysis confirmed the expression of cleaved CASP-1 and melatonin receptor (MT-1A-R) in NPCs. The cultured NPCs were identified by detecting the expression of CD24, collagen type II, and aggrecan. After treatment with hydrogen peroxide, the pyroptosis-related proteins NLR family pyrin domain containing 3 (NLRP3), cleaved CASP-1, N-terminal fragment of gasdermin D (GSDMD-N), interleukin (IL)-18, and IL-1β in NPCs were upregulated, and the number of propidium iodide (PI)-positive cells was also increased, which was able to be alleviated by pretreatment with melatonin. The protective effect of melatonin on pyroptosis was blunted by both the melatonin receptor antagonist luzindole and the nuclear factor erythroid 2–related factor 2 (Nrf2) inhibitor ML385. In addition, the expression of the transcription factor Nrf2 was up- or downregulated when the melatonin receptor was activated or blocked by melatonin or luzindole, respectively. Conclusion. Melatonin protects NPCs against reactive oxygen species-induced pyroptosis by upregulating the transcription factor Nrf2 via melatonin receptors. Cite this article: Bone Joint Res 2023;12(3):202–211

Aims. Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD. Methods. In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated. Results. Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325). Conclusion. Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392–1399

It has been proposed that intervertebral disc degeneration might be caused by low-grade infection. The purpose of the present study was to assess the incidence of herpes viruses in intervertebral disc specimens from patients with lumbar disc herniation. A polymerase chain reaction based assay was applied to screen for the DNA of eight different herpes viruses in 16 patients and two controls. DNA of at least one herpes virus was detected in 13 specimens (81.25%). Herpes Simplex Virus type-1 (HSV-1) was the most frequently detected virus (56.25%), followed by Cytomegalovirus (CMV) (37.5%). In two patients, co-infection by both HSV-1 and CMV was detected. All samples, including the control specimens, were negative for Herpes Simplex Virus type-2, Varicella Zoster Virus, Epstein Barr Virus, Human Herpes Viruses 6, 7 and 8. The absence of an acute infection was confirmed both at the serological and mRNA level. To our knowledge this is the first unequivocal evidence of the presence of herpes virus DNA in intervertebral disc specimens of patients with lumbar disc herniation suggesting the potential role of herpes viruses as a contributing factor to the pathogenesis of degenerative disc disease

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

Aims. The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results. A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days . (sd. 46.5) and 47 days . (sd. 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm . (sd. 10.3) and a mean VAS for arm pain of 6.3 mm . (. sd. 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (. sd. 12.4; p < 0.001); mean NPAD, 19.3 (. sd. 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (. sd. 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (. sd. 6.8; p = 0.103). Conclusion. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71

Purpose. To investigate sociodemographic and clinical characteristics in patients operated for lumbar disc herniation in public and private hospitals, and evaluate whether selection for surgical treatment were different across the two settings. Methods and results. A cross-sectional multicenter study of patients who underwent a total of 5308 elective surgeries for lumbar disc herniation at 41 hospitals. Data were included in the Norwegian Registry for Spine Surgery (NORspine). Of 5308 elective surgical procedures, 3628 were performed at 31 public hospitals and 1680 at 10 private clinics. Patients in the private clinics were slightly younger, more likely to be man, have higher level of education, and more likely to be employed. The proportions of disability and retirement pension were more than double in public as compared to private hospitals. Patients operated in public hospitals were older, had more obesity and co-morbidity, lower educational level, longer duration of symptoms, and sick leave and were less likely to return to work. Patients operated in public hospitals reported more disability and pain, poorer HRQol and general health status than those operated in private clinics. The differences were consistent but small and could not be attributed to less strict indications for surgical treatment in private clinics. Conclusion. Indications for surgical treatment of lumbar disc herniation appear to be similar in public and private hospitals. Patients operated in private clinics seem to be handled more effectively. They were younger, healthier and had more socioeconomic and lifestyle attributes, known to be predictors more favorable outcomes after surgery

Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for decision making, the merit of predictable outcome with THA first, leg weakness as an indication for spine surgery, the concern of THA position with spinal deformity, and the urgency of myelopathy. Conclusion. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial in certain clinical scenarios, even for experienced hip and spine surgeons. Additional outcome studies of these patients are necessary for appropriate decision making

The February 2014 Spine Roundup. 360 . looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side. A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI). There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05). Revision discectomy can give results that are as good as those seen after primary surgery. Cite this article: Bone Joint J 2013;95-B:90–4

Introduction: A far lateral access is required in fullen-doscopic operations of sequestered lumbar disc herniations to achieve a sufficient decompression of the ventral epidural space. The conventional endoscopes and instruments had very narrow limits especially in the mobility and possibility to resect hard tissue and to clean the intervertebral space sufficiently. The aim of this prospective study was to investigate the extended possibilities of the new endoscopes and instruments with regard to the efficacy of decompression, the advantages and problems of this technique in comparison to previous data. Methods: 368 patients with lumbar disc herniations have been treated in 2002 and 2003 in a full endoscopic transforaminal technique using a lateral access. A 7-mm endoscope with 4 mm-working canal and new designed instruments were used. Follow-up lasted at least 12 months. 298 patients (81%) could be followed. Results: No intraoperative complication occurred. 6 patients reported a transient dysaesthesia postoperatively. The average operation time was 28 minutes. A sufficient decompression could be achieved in all cases. 244 patients (82%) reported no more leg pain after surgery, 42 patients (14%) had transient persistence in the first 6 weeks. 8 patients (2,7%) showed a recurrent herniation, 7 of those were reoperated in the same technique. Discussion/Conclusion: As a minimally invasive technique wich efficacy of decompression is equal to an open procedure we see advantages over conventional operations of lumbar disc herniations. Within the inclusion criterias of indication this technique is sufficient and safe. The technical developments on endoscopes and instruments lead to a decrease of recurrence, increase of mobility as well as the possibility of resection of hard tissue and sufficient cleaning of the intervertebral space. The combination of a far lateral access with other approaches extends the spectrum of indications with regard to full endoscopic bony decompression and fusion

The December 2012 Spine Roundup. 360. looks at: the Japanese neck disability index; adjacent segment degeneration; sacroiliac loads determined by limb length discrepancy; whether epidural steroids improve outcome in lumbar disc herniation; spondylodiscitis in infancy; total pedicle screws; and iliac crest autograft complications

The December 2014 Spine Roundup. 360 . looks at: surgeon outcomes;. complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis

Background. Microdiscectomy involves substantial aggressive excision of disc material from the intervertebral space to prevent reherniation. However, the recent trend is towards conservative disc removal and simple fragment excision (sequestrectomy). Aim. To compare the clinical outcome of microdiscectomy and sequestrectomy. Methods. During the 2-year study period, we performed 196 lumbar microdiscectomies for disc herniation. One hundred and one patients met the inclusion criteria: unilateral single level lumbar disc herniation. Cases suitable for sequestrectomy were based on intraoperative assessment (stable fibrous ring without significant disc bulge; posterior longitudinal ligament perforation of < 5mm). Results. Five patients were lost to follow-up, 72 patients underwent conventional microdiscectomy and 24 patients were suitable for sequestrectomy and included in the final analysis. There was no significant difference in terms of age and pre-operative VAS in both groups (p >0.05, unpaired t test. In the microdiscectomy group, 17/31 patients with motor deficit and 34/66 patients with sensory deficit showed post-operative improvement, but in sequestrectomy group, only 1 of 5 patients with motor deficit and 8 of 13 with sensory deficit recovered but this was not statistically significant (p>0.05, Fisher's exact test). Conclusion. In the sequestrectomy group, patients had significantly better improvement in VAS score. There was no significant difference between either group with regards to reherniation or post-operative neurological deficit. In a selected group of patients with single level lumbar disc herniation, clinical outcome of sequestrectomy is comparable to conventional microdiscectomy

The April 2023 Spine Roundup³⁶⁰ looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

The December 2022 Spine Roundup³⁶⁰ looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making

Aims

The aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.

Lumbar disc herniations are quite common pathology in orthopedics. Percutaneous discectomy remains somewhat controvercial. It has limited indications and has not proven to be as effective as conventional or microscopic discectomy. Smith and Foley developed a new minimum invasive procedure for lumbar disc disease, Microendoscopic Discectomy (MED) in 1995. We started MED from October 1998. Besides, we started the clinical application of MED for lumbar spinal canal stenosis from February 2000. The purpose of the presentations are to present operative technique, early clinical results and complications. A) We operated upon 40 patients of MED from October 1998 to July 2000 for lumbar disc herniations. Male were 25, female were 15, and mean age was 38 years (15~64). In one patient, operated disc level was L2/3, in 21, L4/5, in 16, L5/S, and in two L4/5/S. Methods: We investigated: period of hospital stay, period of hospital stay postoperation, period to return to normal temperature, frequency of postop. NSAID, operation time, blood loss, period to begin to walk, JOA score, period to return to work or school, and complications. Results: The mean hospital stay was 17.9 days, the mean hospital stay postop. 9.7 days, period to return to normal temperature 1.3 days, frequency of postop. NSAID 1.1 times. The mean operation time was 105 ± 42 minutes, (65–180 min). The mean blood loss was 9.7 ± 18.5 Gm. (uncountable~ 120Gm.). All patients began to walk one day postoperatively. Mean JOA score was improved from 10.7 ± 3.8 preop. to 27.6 ± 0.9 4w. postop, to 28.1 ± 0.7 12w. postop., to 28.7 ± 0.6, 24w. postop. The mean period to return to work or school was 22.3 days. In one case, we had liquorrhea, and the damaged dura had to be repaired. B)We operated upon five patients of decompression by MED for lumbar spinal canal stenosis from February 2000 to July 2000. Male were one, female were four, and mean age was 72 years (65–77). In four patient, operated disc level was L4/5, in one, L5/S. We will show the operative procedures by videotape. We investigated – operation time, blood loss, period to begin to walk, JOA score, and complications. Results: The mean operation time was 128+−31 minutes, (85m–170m.). The mean blood loss was 25 ± 29 Gm. (uncountable – 70Gm.). All patients began to walk one day postoperatively. Mean JOA score was improved from 15.7 ± 3.3preop. to 27.5 ± 0.5 4w. postop, to 28.0 ± 0.7 12w. postop.. There was no complication. Discussion: The advantages of MED are small skin incision, less invasion to paravertebral muscles, short bed rest, and rapid return to work. The disadvantages are loss of deep perception and technical demands. To overcome the disadvantages, we are developping the 3D MED, and we are organizing live pig seminar biannually. Conclusion: MED has several advantages i,e, small skin incision, less invasion to paravertebral muscles, short bed rest, and rapid return to work. We need proper knowledge and technique about endoscopic surgery, and laboratory training by live pig and cadaver. MED can be applied to the decompression surgery for lumbar spinal canal stenosis

Lumbar disc herniation represents by far the most prevalent pathology, causing pain and sciatica and constitutes an important cause of disability and one of the most cost-intensive health problems. The aetiology is very complex. In recent years, it has been suggested in twin and family studies that genetic risk factors contribute to the development of LDH. Our purpose is to analyse genetic susceptibility to symptomatic LDH in Spanish surgical patients treated with different surgical techniques. Single-nucleotide polymorphisms (SNPs) in VDR, GDF5, Col1A1, THBS2 and CHST were genotyped in a case-control study with 50 symptomatic LDH in Spanish surgical patients and 50 Spanish health controls. All patients provided signed informed consent. Sampling was carried out with a puncture of the pad of a finger using a sterile, single-use lancet. SNPs were determined by real-time polymerase chain reaction (PCR) using specific, unique probes with the analysis of the melting temperature of hybrids. The X2 test compared genotypes between groups. Multivariate logistic regression analysed the significance of many covariates and the incidence of LDH. We found significant differences in age, gender and smoking status between the two groups. There were significant differences in the CC (rs2228570) genotype in VDR in patients with LDH (p<0.05). There were significant differences in the GT (rs1800012) genotype in Col1A1 in patients with LDH (p=0.001). In Col1A1, T allele was more frequent in the case group than in the control group (p<0.001). Regarding surgical techniques, of the 50 patients included in the cases group, 25 were treated with open microdiscectomy and 25 received endoscopic discectomy. Outcomes were assessed at 12 months using VAS, and NASS instrument. Postoperative pain and pain medication were significantly reduced in the endoscopic group. Patient satisfaction is greater in the endoscopic group, with shorter hospital stays and earlier return to normal activity. GT genotype in Col1A1 was more frecuent in the endoscopic group compared to the microdiscectomy group (p=0.002). CC genotype in VDR and GT genotype in Col1A1 are associated with symptomatic LDH susceptibility in Spanish surgical patients. GT genotype in Col1A1 is associated with symptomatic LDH treated with full-endoscopic discectomy

Aims

CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

Aims

This study aimed, through bioinformatics analysis and in vitro experiment validation, to identify the key extracellular proteins of intervertebral disc degeneration (IDD).

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks.

Cite this article: Bone Joint J 2021;103-B(9):1442–1448.

Purpose. A new approach to the reporting of health outcomes involves assessing the proportion of patients achieving a level of symptoms that they feel they could live with. We evaluated the acceptable level of pain in patients after surgery for lumbar disc herniation (LDH). Methods. 12 mo after first-time surgery for LDH, patients completed 0–10 scales for back pain and leg pain and a question: “if you had to spend the rest of your life with the symptoms you have now, how would feel about it?,” answered on a 5-point Likert scale from “very satisfied” to “very dissatisfied”. This was dichotomised and used as the external criterion in receiver operating characteristics (ROC) analysis to derive the cut-off score for pain that best indicated being at least “somewhat satisfied” with the symptom state. Results. 1,209 (91%) patients returned a questionnaire, of which 611 (51%) reported being at least somewhat satisfied with their symptom state. The area under the curve for the ROC analysis was 0.91 (95% CI, 0.89–0.92), indicating a good ability of the pain score to discriminate between being in a satisfactory state or not. The cut-off indicating a satisfactory symptom state was ≤2 points on the pain scale (sens, 76% and spec 89%). Conclusion. Most spine interventions are aimed at decreasing pain but only rarely do they totally eliminate it. Determination of the % patients achieving an acceptable symptom state for pain may represent a useful and more stringent target for denoting surgical success in the treatment of painful spinal disorders

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings. Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between Radiologists’ interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a pre-eminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results Reliability tests show only fair agreement (k=0.36) between the Radiologists and at best only moderate agreement (=0.41) between the Radiologists and surgical findings. Conclusion: MRI is an excellent tool for diagnosis of a disc prolapse. MRI is poor at defining the character of a disc prolapse, and does not appear to help in classifying discs suitable for percutaneous treatment

We evaluated the nerve roots of the cauda equina by CT myelography in 36 patients aged from 11 to 19 years with lumbar disc herniation. On straight-leg-raising tests, six younger patients had isolated hamstring tightness with no sciatica (group A) and 30 had sciatic pain (group B). CT myelography showed that no patient in group A had associated nerve-root swelling, and that the roots were displaced posteriorly, but not compressed. In 21 of the group-B patients, swelling of the nerve roots was confirmed, with compression between the herniated disc and the superior articular process. Our findings suggest that hamstring tightness in these patients may be caused by a different mechanism from that which causes sciatic pain

Transitional vertebrae (TV) may be one of the risk factors for lumbar disc herniation. It is not clear, however, whether the presence of TV can affect the development of nerve-root symptoms. Our aim was to clarify this relationship. A total of 501 patients with lumbar degenerative disease and nerve-root symptoms was studied in respect of their level and the presence of TV. As a control group, 508 patients without low back pain or nerve-root symptoms were studied to establish the incidence of TV. In patients with disc herniation, the incidence was statistically higher and the mean age lower in patients with TV than in those without. In most patients, the symptomatic disc level was just above the TV. Similarly, in those with stenosis of the spinal canal without spondylolisthesis, the symptomatic disc level was most commonly just above the TV

Purpose. To evaluate comorbidity and health-related quality of life in patients with idiopathic scoliosis. Patients and methods. 496 patients treated with Boston brace for idiopathic scoliosis were invited for long-term follow-up. 361 women and 29 men responded. Mean age was 39.2 (4.6) years; mean follow-up time 23.4 (4.3) years. 28 patients had been operated. All patients had radiographs at baseline, brace weaning, and follow-up, and filled in validated self-report questionnaires for evaluation of health-related quality of life. Results. 122 patients had at least one comorbid condition at follow-up. The most commonly reported diseases were: asthma, n = 14; migraine, n = 13; lower extremity disorders, n = 10; anxiety/depression, n = 9; allergy, n = 9; cardiovasular disease, n = 8; lumbar disc herniation, n = 8; neck pain or injury, n = 8; and widespread pain, n = 8. Age at bracing and at menarche, compliance, curve sizes, and the number of patients operated were not different in patients with comorbidity. Mean EQ-5D was 0.74 with comorbidity and 0.85 (normal) without (p < 0.001). Global back rating was excellent or good in 61% with comorbidity versus 78% without (p < 0.000). Fifty-seven percent versus 86% worked full-time. Those with comorbidity had lower (p < 0.001) SRS-22 scores for pain, function, self-image, and mental health, but satisfaction with bracing was not different. Final major curve size was associated only with self-image. Conclusion. Health related quality of life and work were reduced in patients with idiopathic scoliosis reporting comorbidity at long-term

Aim. To compare outcomes of revision lumbar discectomy to primary surgery in the same patient cohort. Methods. Prospective outcome data in 36 patients who underwent primary and subsequent revision surgery for lumbar disc herniation between 1995 and 2009. Outcome measures used were Visual Analogue Scores for back (VAB) and leg pain (VAL), the Oswestry Disability Index (ODI) and Low Back Outcome Score (LBO). 5 early recurrences within 3 months were excluded. Results. Complete data was available in 31 patients 13F;18M. The average age was 39 years at index and 45 years at revision. Average interval between surgery of 39 months (range 6-122). Mean Pre op ODI 54 and VAL 73 primary procedure, final follow up of primary procedure ODI 33, VAL 43; prior to revision ODI 57, VAL 75; at last FU ODI 32 and VAL 40. There was no statistical difference between outcomes. In the primary discectomy group there was a statistically significant improvement in the VAL, ODI and LBO scores (P<0.05), with no significant improvement in the VAB (P=0.67). In the revision group there was a statistical significant improvement in all the outcomes (P<0.05). Overall, 45% of patients felt their outcome from revision discectomy was better/much better with 54% of patients rating their treatment as either good/excellent. Conclusion. Primary discectomy produced significant improvement in leg pain, ODI and LBO. Revision discectomy did the same, but also a significant improvement in VAB scores. There was no statistically significant difference in comparing the preoperative and postoperative scores for both procedures. Revision discectomy is a procedure which yields clinically significant and patient perceived improvements in spinal outcome measures with an unexplained improvement in VAB scores as compared to the primary procedure. This may challenge the belief of some surgeons in the need for fusion at the time of revision

Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ

Introduction: Modic changes have recently been identified as a pain giving pathoanatomical diagnosis for a considerable percentage (20–30 %) of Low Back Pain (LBP) patients. The causes of these Modic changes have not been determined conclusively. The aim was to evaluate a possible effect of antibiotic treatment in an uncontrolled group of patients with LBP and Modic changes. Methods: A cohort of patients (n=32) participated in this study. The patients had previous sciatic mostly from lumbar disc herniation, all were treated conservatively. At the 14 month follow-up, 43 of the patients had Modic changes, six of whom did not suffer from LBP, five declined participation. The treatment consisted of amoxicillin-clavulanate (500 mg/125 mg) (Spektramox ®) three times a day for 90 days. Results: Twenty-nine patients completed the treatment, of which 15 (52 %) reported that they were much better or cured, 7 (24 %) experienced moderate improvement, and 7 (24 %) remained unchanged. None reported a worsening of symptoms. At the end of treatment and at long term follow-up (mean 10.8 months) there was both a clinically and statistically significant (p< 0.001) improvement found in all outcome parameters, namely; general health, disease and patient specific function, pain in the lumbar area, and number of days with pain. Discussion: The clinical effect of antibiotic treatment was profound in a group of patients suffering from persistent low back pain after experiencing a disc herniation. Our results support the theory that bacterial infection could play a role in LBP with Modic changes

Introduction: Etanercept is a selective competitor of TNF alpha which is a pro-inflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease. Aim: To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation. Method: Triple blind randomised controlled study. Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on MRI scan. Exclusions were previous back surgery, spinal stenosis and any contraindications to the use of etanercept such as immunosuppression. The patient, the injector and assessor were blinded to the agent being used. Follow up was at 6 weeks and 3 months post treatment. Oswestry Disability Index (ODI) and Visual analogue scores (VAS) were among the assessment criteria. Results: 15 patients were recruited in a 4 year period with a 3 month follow up of 80%. The Etanercept group had 8 patients whilst the placebo group had 7. The average ODI for the Etanercept group pre-intervention was higher than that in the placebo group (56.1 vs. 50.4) and this remained the same after 6 weeks (50.5 vs 31) and 3 months of follow up (39.2 vs. 27.3). VAS was also higher in the Etanercept group vs. placebo; pre-injection (8.5 vs. 7.4), 6 weeks (5.6 vs. 3.8), and 3 months (7.0 vs. 4.5). Conclusion: Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of Etanercept over placebo in the pharmacological treatment of sciatica

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

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

Purpose: Persistent radiculopathy secondary to lumbar disc herniation is a common problem that greatly compromises quality of life. In North America, lumbar discectomies are among the most common elective surgical procedures performed. There is still much debate about when conservative or surgical treatments should be offered to patients. Although the related literature is comprehensive, there are limited systematic reviews on the prognostic factors predicting the outcome of lumbar discectomy. The purpose of this review is to define the preoperative factors predicting clinical outcome after lumbar discectomy. Method: We conducted a computerized literature search using Ovid Medline and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials or prospective studies dealing with lumbar disc surgery. The preoperative predictors had to be clearly identified and correlated with outcome measures in terms of pain, disability, work capacity, analgesia consumption, or a combination of these measures. We assessed the articles as high or low quality studies using the Newcastle-Ottawa Quality Assessment Scale, and summarized the results of High Quality Studies. Results: A total of 39 articles were included. The two most prominent negative predictors were Workers’ Compensation status and depression according to 6 studies. Poor predictors reported in 4 articles were female gender, increasing age, and prolonged duration of leg or back pain. Lower education level, smoking, and higher levels of psychological complaints were negative predictors in 3 articles. A positive Lasègue sign was a positive predictor in 7 articles. Absence of back pain, positive patient expectations, and higher income were good prognostic factors in 3 studies. Patients with contained herniations did worse than those who had uncontained disc extrusions and sequestrations according to 4 studies. The level of herniation was not a predictive factor in 7 studies. Conclusion: Workers’ Compensation, depression, greater back versus leg pain, increasing age, female gender, contained herniations, and prolonged symptoms predict unfavourable postoperative outcomes after lumbar discectomy. Positive Lasègue sign, higher income, uncontained herniations, and positive patient expectations predict favourable postoperative outcomes. The level of herniation is not an established prognostic factor. The results of this review provide a preliminary framework for patient selection for lumbar disc surgery

Introduction: Traumatic cauda equina constitutes a significant number of presentations of spinal cord injury in the emergency setting. Cauda equina syndrome from lumbar disc herniation accounts for up to 2–3% of all disc herniation. The aim of this study was to investigate and compare the success of surgical intervention between cauda equina that results from acute versus chronic pathology. Patients and Methods: 47 patients who underwent surgery for cauda equina syndrome due to acute trauma or a herniated disc in the period between 2000 and 2006. All presented with one or more of the categorical symptoms associated with cauda equina (CE) syndrome such as sciatica, saddle hypoaesthesia, urinary incontinence and others. All patients had been catheterised at the time of admission to the National Spinal Unit. Patients presenting with acute CE underwent surgery within 24 hours. Patients presenting with chronic pathology underwent surgery within 48 hours. Differences in postoperative resolution of neurological function is compared between the two groups. The role of preoperative duration of symptoms in recovery of bladder function was examined. Results: The follow-up ranged from 12–86 months. In 33 patients (70%) excellent results were achieved, in 8 patients (18%) good results were achieved and in 6 patients (10%) poor results were achieved. There was no statistically significant difference concerning the time between the onset of symptoms and surgical decompression. Significant difference appears to exist between the neurological recovery of those patients who underwent surgery subsequent to acute trauma in comparison to those with longer standing pathology. Conclusion: Surgical intervention results in the resolution of neurological symptoms in those patients who present with symptoms consistent with cauda equina. This result is more apparent in those who presented with acute trauma

Aim: Evaluate the preoperative prognostic factors of a poor result in conventional surgery of lumbar disc herniation. Methods: From November 1995 to November 2001, we performed 113 standard discectomies (63 males/50 females) with a mean-age of 42 years (21–75). All patients had been evaluated preoperatively with X-ray and C.T. scan. Fifty-nine patients (52%) had a preoperative M.R.I., and an evaluation was made of disk degeneration degree, multilevel degeneration and bone changes in vertebral end-plates (according Modic classiþcation). The postoperative mean follow-up was 46,2 months. The outcomes were evaluated considering the reoperation rate, the intensity of pain in the Visual Analogue Score, and þnal function with the Oswestry Disability Index. The results were compared using ANOVA. Results: We have found a statistical correlation between a poor result and older age (p=0.006), diabetes (p=0.005), psychological factors (p=0.006) and preoperative X-ray changes, such as disk height loss greater than a third (p< 0.001), subcondral sclerosis (p< 0.001), segmental instability (p=0.019) and ostheo-arthritis (p< 0.001). Regarding M.R.I., the multilevel degeneration and the Modic changes (type I, II or III) have been correlated in this study with poor functional result (p=0.004 and p< 0.001 respectively). Conclusions: Our results support the concept that in patients with lumbar disk herniation and with described X-ray or M.R.I. changes, especially changes in vertebral end-plate, we should strongly consider treatment for disk degeneration and not limit the intervention to the excision of disk extrusion

Purpose of the study: Conventional treatment for recurrent lumbar disc herniation is repeated discectomy. Other methods such as fusion, ligamentoplasty or implantation of a discal prosthesis are sometimes proposed but all increase morbidity. The purpose of this work was to ascertain the efficacy of isolated repeated radicular release for the treatment of recurrent discal herniation. Material and methods: Thirty-four patients underwent surgery for recurrent discal herniation. Repeated radicular release was used in all patients included in this analysis who completed a self-administered questionnaire at last follow-up to assess the final functional outcome. Results: The cohort included 13 women and 21 men, mean age at surgery 45 years. Mean time from first discectomy to revision surgery for recurrence was 55 months. At the time of the review, four patients had died, all four from cancer. None of these patients had undergone a revision procedure on the lumbar spine. One patient was lost to follow-up so 85% of the cohort was analyzed with 60 months average follow-up. A dural tear occurred during the proscedure in six patients (17%. Five patients (14.7%) required revision surgery, one for deep infection, four for recurrent or persistent lumboradiculalgia (recurrent discal herniation, isthmic fracture, lateral stenosis associated with inflammatory discopathy). The rate of revision for painful failure was 11.4%. The final outcome could be assessed for 25 patients and was satisfactory for 22/25 (88%). The self-administered questionnaire revealed 65% average improvement with more than half of the patients reported better than 80% improvement. Ten patients (40%) complained of lumbar pain and a third had residual, generally intermittent, radiculalgia. Eighteen of 25 patients resumed their work at a comparable level after six months on average; 84% of the patient would accept the same operation again. Discussion: In terms of morbidity and rate of revision, the results are comparable to reports in the literature. Repeated release does not increase the risk of a new recurrence. Conclusion: This work enabled us to demonstrate that in the large majority of patients repeated discectomy provides satisfactory functional outcome with little morbidity

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Background: The usefulness of open (fenestration/ laminotomy) discectomy for the treatment of a herniated lumbar disc has been studied extensively. In the current prospective, randomized study, the results of this procedure were compared with those of Microendoscopic discectomy. Methods: One hundred and twelve patients who had objective evidence of a single level, central or para-central herniation of a lumbar disc caudal to the first lumbar vertebra were randomized into two groups; Group 1 (55 patients) was managed with Microendoscopic discectomy, and Group 2 (57 patients) was managed with open (fenestration/ laminotomy) discectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient’s self-evaluation before and after the operation through Oswestry scoring, the preoperative and postoperative clinical findings, and the patient’s ability to return to a functional status. The patients were followed at one week, 6 weeks, 6 months and for a minimum of one year postoperatively. Results: On the basis of the patient’s preoperative and postoperative self-evaluation, the findings on physical examination, and the patient’s ability to return to work or to normal activity, 53 patients (96 percent) in Group 1 and 54 patients (95 percent) in Group 2 were considered to have had a satisfactory outcome. The mean surgical time, mean anaesthesia time, postoperative stay, was significantly less in Group 1. The overall satisfaction score was higher after the endoscopic microdiscectomies than after the laminotomies and discectomies especially in immediate postoperative period (one and six weeks) as assessed through Oswestry scoring. Conclusions: The data from this randomized, prospective study suggest that Microendoscopic discectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, that are caused by lumbar disc herniation, provided that patients are properly selected—that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperative management and have no evidence of spinal stenosis. All the major advantages of an endoscopic procedure like less hospital stay, lesser morbidity, and early return to work can be passed on to the patients without in anyway compromising the surgical goals viz. decompression of the canal and the compressed nerve root. However, endoscopic microdiscectomy is a demanding technique and should not be attempted without specific instruction and training

Study Design: A randomised, double-blind controlled trial. Objectives: To determine the efficacy of corticosteroids in periradicular infiltration for radicular pain. We also examined prognostic factors in relation to the outcome of the procedure. Summary of background data: Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anaesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomised trial to determine the efficacy of single injection of corticosteroids. Methods: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomised for single double-blind injection with bupivicaine and methylprednisolone (b+s) or bupivicaine (b) only. Outcome measures include change in Oswestry Disability Index (ODI), change in Visual Analogue Score for back pain and leg pain (VAS), change in walking distance and patient’s subjective level of satisfaction of the outcome. Objective successful clinical outcome is defined as a change in 10% of ODI. Results: We recruited 37 patients in the b+s group and 38 patients in the b only group. The follow up rate is 100%. 4 patients had early termination of the trial for discectomy and further rootblock. There is no statistically significant difference in the outcome measure between the groups at 3 months (change of the ODI [p=0.6], change in VAS [back pain, p=0.28, leg pain, p=0.95], change in walking distance [p=0.9]). 35% of patients in the b+s group and 55% in the b only group had a successful clinical outcome. Duration of symptoms has a statistically significant negative association with the change in ODI (p=0.03). No prognostic value is found in age, gender, pre-operative Modified Somatic Perception and Modified Zung Depression score. Conclusion: Clinical improvement occurs in both groups of patients. However, corticosteroids do not provide additional benefit

Massive disc herniations after surgical decompression develop secondary back pain due to important loss of nucleus material with instability. No earlier proposed method to restore disc function was biological. Chondrocyte culturing allows living repair of lost disc tissue. The contained disc space appears particularly suitable for receiving those tissue cultures. Surprisingly disc replantations had not been attempted before. In 1996 two women and one man (aged 38-55) underwent open resection of a massive disc herniation by hemi-laminotomy, twice at L5-S1, once at L4/5. All the excised disc tissue was given to tissue culture in an identical protocol as in autologous chondrocyte transplantation (ACT) for articular cartilage repair. After sufficient cell multiplication (11.5-23 millions living cells in 750 μl) four weeks later the engineered autolo-gous disc tissue was injected in suspension through a contra-lateral puncture under local anaesthesia. In prospective follow up a simplified Oswestry Disability Index was recorded and functional radiographs and NMR were taken after one, three, six and nine years. All three patients remained freed from radicular pain and vertebral symptoms over the whole follow up period. Two patients never had functional restrictions nor loss of working capacity (Oswestry 1 and 6), one after retirement at 5 years developed rheumatoid disease but is still unchanged at the lumbar spine. The third patient partially recovered from preoperative radiculop-athy (slight loss of strength and sensitivity S1) but still works, with minor adaptations to his original professional activity (Oswestry 18). Functional radiographs up to the last follow up didn’t show vertebral instability. In all cases the replanted intervertebral disc space remained unchanged with minimal widening in one case. In NMR all three discs had partial signal recovery. Twice during the first year a new outgrowth of disc tissue was observed at the site of the primary disc herniation opposite to the replanting injection, without any clinical correlation. Three cases with massive lumbar disc herniations showed good clinical and large anatomical recovery persisting nine years after reimplantation of engineered autologous disc tissue. The encouraging results of this small pilot study led to further closely monitored clinical applications before wider propagation of biological disc repair surgery

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

It is frequently difficult to diagnose and treat of malignant sacral bone tumors. This tumor is diagnosed with lumbar disc hernia, instability coccygitis, hemorrhoids. We reviewed the surgical treatment of primary malignant (14) and secondary (metastatic) sacral tumors (11) in 25 patients from 1983 to 2000. Primary tumors consisted of chordoma in 11 patients, chordoma with spindle cell sarcoma, malignant peripheral nerve sheath tumor (MPNST), giant cell tumor of bone in 1 patient each. The secondary tumors consisted of invading carcinoma in 7 patients, metastatic carcinoma in 4 patients. Location of the sacral tumor was showed total sacrum in 2 patients, below S2 in 18, S3 in 2 and S4 in 3. Preserving nerves were L5 in 1 patient, S1 in 17, S2 in 2, S3 in 3, and 2 performed curettage. Posterior approach was used in 8 patients, and an anterior and posterior combined approach in 17. Sacrectomy only in 7 patients, and sacrectomy and colostomy in 8, including with rectum was performed in 8, and 2 patients had extensive curettage and bone graft or hydroxyapatite (HA) transplantation. Six tumor excisions were used modified T-saw which pass through the sacral canal preserving nerve roots. Surgical margin of chordoma in primary sacral tumors had wide in 10, wide excision with partial contamination in 2, except curettage in 1. MPNST had curettage and giant cell tumor of bone had marginal in 1 each. Secondary sacral tumors had wide in 9, marginal in 2. Adjuvant therapy was used radiation therapy in 3 patients and chemotherapy in 2 and ethanol in 1. Musculocutaneous flap was reconstracted tensor fascia lata flap and gluteal muscle flap in 2 patients. Interval between initial chief complaints and diagnosis of chordoma detected from 6 months to 10 years, avarage 5 years 3 months by rectal examination, radiogram, genital ultra echo and MRI; invading carcinoma from 2 months to 3 years, avarage 8 months, and metastatic carcinoma from 2 months to 4 months, average 3 months. Six of 12 patients of chordoma in primary sacral tumors are alive from 6 months to 18 years, average 4 years 6 months; remaining patients were died 6 month to 8 years, average 3 years 2 months, except 2 patient died with infection. The patient with a MPNST died after 2 years 6 months, and a giant cell tumor of bone had no recurrence or lung metastases in 10 years. One of 11 patients of secondary sacral tumor (initial surgery) is alive in 14 years 6 months, remaining 10 patients died 3 months to 4 years 6 months, average 1 year 10 months, except 2 patients died with infection. Complications were much bleeding, infection, skin slough, nerve injury. We recommend better surgical method that anterior and posterir approach use above S3, and posterior approach blow S4, A modified T-saw performed an osteotomy of the pars lateral of the sacrum, proved to be easier and faster than osteotomies performed using the old method

Aims

The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

Objectives

Degenerative disc disease (DDD) and osteoarthritis (OA) are relatively frequent causes of disability amongst the elderly; they constitute serious socioeconomic costs and significantly impair quality of life. Previous studies to date have found that aggrecan variable number of tandem repeats (VNTR) contributes both to DDD and OA. However, current data are not consistent across studies. The purpose of this study was to evaluate systematically the relationship between aggrecan VNTR, and DDD and/or OA.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

The indications for lumbar discectomy are pain and neurological dysfunction. This paper considers the extent and timing of neurological recovery following spinal decompression.

The October 2012 Spine Roundup³⁶⁰ looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture.

We carried out a study to determine the effect of facet tropism on the development of adolescent and adult herniation of the lumbar disc. We assessed 149 levels in 140 adolescents aged between 13 and 18 years and 119 levels in 111 adults aged between 40 and 49 years with herniation. The facet tropism of each patient was measured at the level of the herniated disc by CT.

There was no significant difference in facet tropism between the herniated and the normal discs in both the adolescent and adult groups, except at the L4-L5 level in the adults. Facet tropism did not influence the development of herniation of the lumbar disc in either adolescents or adults.

We have studied 180 patients (128 men and 52 women) who had undergone lumbar discectomy at a mean of 25.4 years (20 to 32) after operation. Pre-operatively, most patients (70 patients; 38.9%) had abnormal reflexes and/or muscle weakness in the leg (96 patients; 53.3%). At follow-up 42 patients (60%) with abnormal reflexes pre-operatively had fully recovered and 72 (75%) with pre-operative muscle impairment had normal muscle strength. When we looked at patient-reported outcomes, we found that the Short form-36 summary scores were similar to the aged-matched normative values. No disability or minimum disability on the Oswestry disability index was reported by 136 patients (75.6%), and 162 (90%) were satisfied with their operation. The most important predictors of patients’ self-reported positive outcome were male gender and higher educational level. No association was detected between muscle recovery and outcome.

Most patients who had undergone lumbar discectomy had long-lasting neurological recovery. If the motor deficit persists after operation, patients can still expect a long-term satisfactory outcome, provided that they have relief from pain immediately after surgery.

We performed a prospective study to examine the influence of the patient’s position on the location of the abdominal organs, to investigate the possibility of a true lateral approach for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy. Axial images in parallel planes of each intervertebral disc from L1 to L5 were achieved in both supine and prone positions. The most horizontal approach angles possible to avoid injury to the abdominal organs were measured. The results demonstrated that the safe approach angles were significantly less (i.e., more horizontal) in the prone than in the supine position. Obstacles to a more lateral approach were mainly the liver, the spleen and the kidneys at L1/2 (39 of 40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4 (33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach from each side was possible for 30 of the 40 discs at L3/4 (75%) and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more horizontal approach for transforaminal endoscopic lumbar discectomy is possible in the prone position but not in the supine. Prone abdominal CT is more helpful in determining the trajectory of the endoscope. While a true lateral approach is feasible in many patients, our study shows it is not universally applicable.

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Hypovitaminosis D has been identified as a common risk factor for fragility fractures and poor fracture healing. Epidemiological data on vitamin D deficiency have been gathered in various populations, but the association between vertebral fragility fractures and hypovitaminosis D, especially in males, remains unclear. The purpose of this study was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in patients presenting with vertebral fragility fractures and to determine whether patients with a vertebral fracture were at greater risk of hypovitaminosis D than a control population. Furthermore, we studied the seasonal variations in the serum vitamin D levels of tested patients in order to clarify the relationship between other known risk factors for osteoporosis and vitamin D levels. We measured the serum 25-OH D levels of 246 patients admitted with vertebral fractures (105 men, 141 female, mean age 69 years, sd 8.5), and in 392 orthopaedic patients with back pain and no fractures (219 men, 173 female, mean age 63 years, sd 11) to evaluate the prevalence of vitamin D insufficiency. Statistical analysis found a significant difference in vitamin D levels between patients with vertebral fragility fracture and the control group (p = 0.036). In addition, there was a significant main effect of the tested variables: obesity (p < 0.001), nicotine abuse (p = 0.002) and diabetes mellitus (p < 0.001). No statistical difference was found between vitamin D levels and gender (p = 0.34). Vitamin D insufficiency was shown to be a risk factor for vertebral fragility fractures in both men and women.

Cite this article: Bone Joint J 2015;97-B:89–93.