Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Aims. The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment. Methods. The type and extent of disc herniation at the time of presentation in 108 patients who underwent anterior discectomy for cervical radiculopathy were analyzed on MRI, using a four-point scale. These were dichotomized into disc bulge and disc herniation groups. Clinical outcomes were evaluated using the Neck Disability Index (NDI), 36-Item Short Form Survey (SF-36), and a visual analogue scale (VAS) for pain in the neck and arm at baseline and two years postoperatively. The perceived recovery was also assessed at this time. Results. At baseline, 46 patients had a disc bulge and 62 had a herniation. There was no significant difference in the mean NDI and SF-36 between the two groups at baseline. Those in the disc bulge group had a mean NDI of 44.6 (SD 15.2) compared with 43.8 (SD 16.0) in the herniation group (p = 0.799), and a mean SF-36 of 59.2 (SD 6.9) compared with 59.4 (SD 7.7) (p = 0.895). Likewise, there was no significant difference in the incidence of disabling arm pain in the disc bulge and herniation groups (84% vs 73%; p = 0.163), and no significant difference in the incidence of disabling neck pain in the two groups (70.5% (n = 31) vs 63% (n = 39); p = 0.491). At two years after surgery, no significant difference was found in any of the clinical parameters between the two groups. Conclusion. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(11):1242–1248

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

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% ± 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results

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

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

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

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

Studies on recurrent disc herniation quote rates of recurrence without regard to the times of recurrence and the influence of longer follow-up. Our objective was to assess the use of survival analysis to measure the rate of revision after lumbar microdiscectomy. We undertook a retrospective analysis of the hospital records of 993 patients who underwent lumbar microdiscectomy over a period of ten years. After calculating the overall rate of revision for the mean length of follow-up, we carried out a survival analysis using the life-table method. During the study period 49 patients had a revision microdiscectomy. This gave an overall rate of revision of 4.9% at a mean follow-up of 5.25 years. Using survival analysis, the rate of revision was 7.9% at a follow-up of ten years when the number at risk was 84. Survival analysis gives a more accurate estimation of the true rate of recurrence for patients undergoing lumbar microdiscectomy. The method allows better comparison between different interventions for disc herniation

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

Magnetic resonance imaging (MRI) was used to compare the appearance of the spine in 20 adolescents with proven symptomatic intervertebral disc herniations with that in 20 asymptomatic patients who acted as controls. Abnormality in the signal from the nucleus pulposus of one or more discs was present in all patients, while only four of the 20 controls had any abnormal signals. In all the patients the symptomatic disc produced an abnormal signal and in most a herniated fragment of the nucleus pulposus was identified. Fifteen of the 20 patients had multiple-disc abnormality: six had three abnormal discs and nine had two. This suggests there was an underlying diathesis in patients who later developed disc herniation

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

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

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

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

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

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

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

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

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

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

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

We describe a rare herniation of the disc at the C2/C3 level in a 73-year-old woman. It caused hemicompression of the spinal cord and led to the Brown-Sequard syndrome. The condition was diagnosed clinically and by MRI six months after onset. Discectomy and fusion gave complete neurological resolution.

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.

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

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

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

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

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

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

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

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

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

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

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

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. Methods. Patients were asked to prospectively complete visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores on the day of their MRI scan. All patients with primary disc herniation were included. Exclusion criteria included recurrent disc herniation, cauda equina syndrome, or any other associated spinal pathology. T2 weighted MRI scans were reviewed on picture archiving and communications software. The T2 axial image showing the disc protrusion with the largest cross sectional area was used for measurements. The area of the disc and canal were measured at this level. The size of the disc was measured as a percentage of the cross-sectional area of the spinal canal on the chosen image. The VAS leg pain and ODI scores were each correlated with the size of the disc using the Pearson correlation coefficient (PCC). Intraobserver reliability for MRI measurement was assessed using the interclass correlation coefficient (ICC). We assessed if the position of the disc prolapse (central, lateral recess, or foraminal) altered the symptoms described by the patient. The VAS and ODI scores from central and lateral recess disc prolapses were compared. Results. A total of 56 patients (mean age 41.1 years (22.8 to 70.3)) were included. A high degree of intraobserver reliability was observed for MRI measurement: single measure ICC was 0.99 (95% confidence interval (CI) from 0.97 to 0.99 (p < 0.001)). The PCC comparing VAS leg scores with canal occupancy for herniated disc was 0.056. The PCC comparing ODI for herniated disc was 0.070. We found 13 disc prolapses centrally and 43 lateral recess prolapses. There were no foraminal prolapses in this group. The position of the prolapse was not found to be related to the mean VAS score or ODI experienced by the patients (VAS, p = 0.251; ODI, p = 0.093). Conclusion. The results of the statistical analysis show that there is no direct correlation between the size or position of the disc prolapse and a patient’s symptoms. The symptoms experienced by patients should be the primary concern in deciding to perform discectomy. Cite this article: Bone Joint J 2022;104-B(6):715–720

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

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

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

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

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

Background. FORECAST is a prospective longitudinal cohort study exploring mechanism-based prognostic factors for pain persistence in sciatica. Here, we share an update on this largest deeply-phenotyped primary care sciatica cohort. Methods/results. Our cohort includes 180 people with sciatica (score >4 on Stynes’ Sum Score), aged 18–85, within 3 months of symptom onset. Psychosocial factors, self-reported sensory profiling, clinical examination, quantitative sensory testing (QST), biological samples (blood and skin samples), and Magnetic Resonance Neurography of lumbar nerve roots were collected at baseline. Pain persistence was determined at three and twelve months with the Sciatica Bothersomeness Index (SBI) and a numeric pain rating scale (NRS) as primary outcomes. Recruitment nears completion, with 160 participants enrolled to date. 127 and 96 participants have completed 3 and 12 months follow-up respectively. Overall, 56% of our cohort are female, with a mean age (SD) of 54.14yrs (16.57). Ethnicity data approximates local populations. SBI at baseline was (median [IQR]) 13[10-17], and interim longitudinal data shows stepwise improvement at 3 and 12 months. Baseline ‘average’ pain intensity was 5.56 (2.15) for leg pain, and 4.14(2.82) for low back pain (LBP). Overall, pain scores decreased at 3 and 12 months, with greater reductions in leg pain than LBP at 12 months. However, around 55–80% and 40–65% of people reported persistent pain at 3 and 12 months respectively. Conclusion. Leg pain severity was moderate and higher than LBP at baseline. All primary outcome measures demonstrate improvement over time, however 40–65% of patients report persistent pain at 12 months. Conflicts of interest. LR: Paid facilitation of post-graduate courses internationally. SK, MT, FP, KM, WS, CP, CR, SC: No conflicts of interest. GC: Editor in Chief of Health Psychology Review. Director of board of directors, MentalCHealth Care setting NoordWestVlaanderen. JF: Copyright holder of ODI (Oswestry Disability Index). Served on a data monitoring committee for a clinical trial of 2 different surgical approaches to cervical disc herniation (FORVAD). Member of HTA Prioritisation Committee B: Inside hospital Care from 2015-February 2019. Member of HTA Interventional Procedures Panel from 2010–2015. Trustee and board member of 3 spine related charities – Back to Back; British Scoliosis Research Foundation and BackCare. Expert instructed by both claimant and defendant solicitors in negligence and person injury cases. GB: Paid consultancy (RNA-seq) with Ivy Farm and Coding.bio. ABS: Paid post-graduate lecturing internationally. Co-chair NeupSig sciatica working group (unpaid). Sources of funding. This project is funded by UKRI and Versus Arthritis as part of the UKRI Strategic Priorities Fund (SPF) Advanced Pain Discovery Platform (APDP), a co-funded initiative by UKRI (MRC, BBSRC, ESRC), Versus Arthritis, the Medical Research Foundation and Eli Lilly and Company Ltd (Grant MR/W027003/1). Additional funding has been received from the back to back charity to expand longitudinal components of the study. LR has received support with PhD fees from the CSP charitable trust. ABS is supported by a Wellcome Trust Clinical Career Development Fellowship. (222101/Z/20/Z). WS is partly funded through the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King's College London. FP is funded by a Dorothy Hodgkin Career Development Fellowship in Chemistry in association with Somerville College. GB is supported by the Wellcome Trust (223149/Z/21/Z) and Diabetes UK (19/0005984). GC and KRM are partly funded by UKRI and Versus Arthritis as part of the Advanced Pain Discovery Platform (APDP) PAINSTORM (MR/W002388/1). The UKRI and Versus Arhthritis (APDP) are the major funders of FORECAST. All other funders provided either some people support, or funded projects with legacy data that we reuse

Repetitive manual handling caused 31% of all work related musculoskeletal disorders in 2015, with the back being the site of injury 38% of the time. Despite its high resilience, studies have shown that intervertebral discs can be damaged during repetitive loading at physiological motions, causing cumulative damage and disc herniation. To understand the mechanism of disc injury resulting from repetitive lifting, it is important to measure disc deformations/strains accompanied by MRI imaging to identify disc tissue damage. Therefore, the aim of this study was to examine associations between the magnitude of 3D internal strains, tissue damage and macroscopic evidence of disc injury after simulated repetitive lifting on normal human lumbar discs. Sixteen cadaver lumbar functional spinal units (FSUs) were subjected to pre-test MRI. Eight FSUs (control) underwent 20,000 cycles or until failure (5 mm displacement) of loading under compression (1.7 MPa – to simulate lifting a 20 kg weight) + flexion (13°) + right axial rotation (2°) using a novel Hexapod Robot. The remaining eight FSUs (experimental) had a grid of tantalum wires inserted, and stereoradiographs were taken to track internal disc displacements at increasing cyclic intervals. Maximum shear strains (MSS) were calculated from the displacements using radiostereometric analysis at cycle 1 and 20,000 cycles (or failure). Post-test MRI was conducted to determine the extent of tissue damage and associated with regions of highest MSS. A repeated measures ANOVA was performed on MSS with a within–subjects factor of cycle number (cycle 1 and failure cycle) and a between subjects-factor of disc region and failure type (p < 0 .05). Pfirrmann grading revealed mostly normal discs [I (N=2), II (N=13), and III (N=1)]. No significant difference in MSS between control and experimental groups was found for number of cycles to failure (p=0.279). Pre and post-test MRI analysis revealed that 13 specimens were injured after repetitive lifting with either an endplate failure (N=9) or disc bulge (N=4), and two specimens did not fail. Failure strain was significantly greater than cycle 1 in all regions except posterior, left/right posterolateral (p>0.109). Largest MSS at failure was seen in the anterior (60%), and left/right posterolateral regions (64% and 70%, respectively). MSS at failure for the endplate failure group was significantly larger than the no injury group in all regions except right lateral and nucleus (p>0.707). Disc bulge group MSS was significantly larger than the no injury group in the anterior, right anterolateral, and left/right posterolateral regions (p < 0 .027). Simulated repetitive lifting led to largest shear strains in the anterior, left and right posterolateral regions that corresponded to annular tears or annular protrusion. The no injury group shear strain was less than 50% in all regions, indicating there may be a threshold that could be associated with tissue damage linked with injuries such as disc bulge and endplate failure. There was no evidence of disc herniation in normal discs, agreeing with current clinical knowledge. These results may be indicative of the effects of repetitive manual handling on normal discs of younger patients

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Endoscopic spine surgery is a promising and minimally invasive technique for the treatment of disc herniation and spinal stenosis. However, the literature on the outcome of interlaminar endoscopic decompression (IED) versus conventional microsurgical technique (CMT) in patients with lumbar spinal stenosis is scarce. We analyzed 88 patients (IED: 36/88, 40.9%; CMT: 52/88, 59.1%) presenting with lumbar central spinal stenosis between 2018–2020. Surgery-related (operation time, complications, time to hospital release (THR), ASA score, C-reactive protein (CRP), white blood cell count (WBC), side (unilateral/bilateral), patient-reported (ODI, NRS (leg-, back pain), eQ5D, COMI), and radiological (preoperative dural sack cross-sectional area (DSCA), Shizas score (SC), left (LRH) and right (RRH) lateral recess heights, left (LFA) and right (RFA) facet angle) parameters were extracted. Complication (most often re-stenosis due to hematoma and/or residual sensorimotor deficits) rates were higher in the endoscopic (38.9%) than microsurgical (13.5%) treatment group (p<0.01). Age, THR, SC, CRP, and DSCA revealed significant correlations with 3 weeks and 1 year postoperatively evaluated ODI, COMI, eQ5D, NRS leg, or NRS back values in our cohort. We did not observe significant differences in the endoscopic versus microsurgical group for the patient-reported outcomes. Age, THR, SC, CRP, and DSCA revealed significant correlations with patient-centered outcomes and should be considered in future studies. Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach, although it was associated with higher complication rates in our single-center study experience. This was probably because of the surgeons' lack of experience with this method and the resulting different learning curve compared with the conventional technique

Introduction. In degenerative lumbar spine, it seems possible that foraminal stenosis is over-diagnosed as axial scanning is not performed in the plane of the exiting nerve root. We carried out a two-part study to determine the true incidence of foraminal stenosis. Patients and Methods. Initially we performed a retrospective analysis of radiology reports of conventional Magnetic Resonance Imaging in 100 cases of definite spinal stenosis to determine the incidence of reported ‘foraminal stenosis’. Subsiquently we performed a prospective study of MRI including fine slice T2 and T2 STIR coronal sequences in 100 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional axial and sagittal sequences with the coronal scans. Results. The retrospective analysis found that ‘foraminal stenosis’ was reported by radiologists in 46% using conventional axial and sagittal sequences. In the prospective study of 100 patients suspected of having stenosis, spinal stenosis was reported in 40; degenerative spondylolisthesis in 14; posterolateral disc herniation in 14; normal report in 13; far lateral disc herniation in 7; isthmic (lytic) spondylolisthesis in 6; and degenerative scoliosis in 6. Conventional sequences diagnosed lateral recess stenosis reliably, but also suggested foraminal stenosis in 43%. However, coronal sequences clearly showed no foraminal nerve compression at all. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 10 of 14 cases. Coronal imaging again showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. Foraminal nerve compression was confirmed by conventional and coronal imaging only in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation. Conclusion. The addition of coronal MRI proves that foraminal stenosis is over-diagnosed. True foraminal stenosis definitely exists in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation, but we question its existence in spinal stenosis and degenerative spondylolisthesis

In a prospective, consecutive study we determined the frequency of common symptoms and signs in 300 patients with lumbar nerve-root compression syndromes. We compared 100 patients with disc herniation (mean age 43 years), 100 with lataral spinal stenosis (41 years) and 100 with central spinal stenosis (65 years), using a standard protocol of common signs and symptoms. The diagnoses were established by one or more of myelography, CT, MRI and nerve-root block, and all were confirmed at operation. The preoperative duration of symptoms was significantly shorter in patients with disc herniation. Pain at rest, at night, and on coughing was as common in lateral stenosis as in disc herniation, but regular consumption of analgesics was more common in patients with disc herniation. Positive straight-leg-raising tests were more common in disc herniation than in lateral stenosis and were uncommon in central stenosis. Motor disturbances were seen most often in central spinal stenosis, especially patellar reflex changes. Sensory disturbances were most common in patients with complete disc herniation

The volume of spinal procedures have increased over the last two decades (220% in lumbar region). A simultaneous increase in re-operation rates (up to 20%) has been reported. Our aim was to compare with literature the reoperation rates and complications for various spinal procedures from a peripheral unit and to provide this information to the patients. This was a retrospective study of all patients who underwent spinal surgery during the period 1995 to 2005 by one surgeon. Using ICDM-9 codes and private notes patients were identified and medical records were used to gather relevant data. The following information was extracted-demographics, diagnosis, ASA criteria, primary procedure, any complication/s, secondary procedures, duration of follow up and to secondary procedure. The index procedures were grouped into regional and according to indication. Both complications and reoperations were grouped into early (within three months) or delayed (after three months) from the index operation. Reoperation rates and complications were calculated and compared with literature. Four hundred and thirty-nine patients formed the study population. Five patients had inadequate data and were excluded. 23 patients have since died. Demographics showed 22% were smokers and 9% were either unemployed or sickness beneficiary. The commonest diagnosis in the lumbar spine was disc herniation (194). Stenosis and disc degeneration were the next most common surgical indications. In the cervical spine 27 patients had disc herniation and 15 patients were operated for trauma. Lumbar discectomy was the commonest procedure-191 patients with one third having microdiscectomy. Instrumented fusion was performed in 97 while 37 patients underwent decompression only. The majority of cervical spine patients (46) had discectomy and fusion. Stabilisation for trauma formed a reasonable workload in both cervical and lumbar regions. Early complications included dural tears (seven), neurological symptoms (eight), wound infections (12) and pulmonary embolism (one) and repeat disc herniation. Delayed problems included repeat disc herniation, pseudoarthrosis and implant related symptoms. Overall re-operation rate was 14.52% with 5.02% early and 9.4%delayed repeat surgery. Repeat discectomy (eight) and decompression and exploration (seven) were the common early reoperation whereas fusion post discectomy (19) and recurrent disc herniation (12) were indications for delayed intervention. Removal of metalware (8) was another large late re-operation group. Our re-operation rates fall within the quoted figures in literature. However our early re-operation rates are somewhat higher. These figures help us to inform patients better at the time of consent for the primary procedure especially lumbar disc surgery as most of the re-operation were required after discectomy

Purposes of the study and background. The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for sciatica due to disc herniation. The last search was conducted in 2011. Since then new reviews have been published or existing reviews have been updated. Summary of the methods used and results. A comprehensive search was performed in multiple databases including Cochrane database of systematic reviews (CDSR), Database of Reviews of Effectiveness (DARE) and Pubmed. Included are Cochrane and non-Cochrane systematic reviews on sciatica due to disc herniation published in peer-reviewed journals. We evaluated surgery versus conservative care and different surgical techniques compared to one another. The methodological quality of the systematic reviews was evaluated using AMSTAR by two independent reviewers. Nine, mostly high quality, systematic reviews on surgical interventions for disc herniation were included. Four reviews compared surgery with conservative treatment and concluded consistently that surgery has only short term benefits while the long term results showed no difference in effect. Four reviews compared open discectomy with micro(endo)scopic discectomy and found no significant and/or clinically relevant differences. The quality of evidence on alternative minimal invasive techniques (laser discectomy, automated percutaneous discectomy, and nucleoplasty or coblation) is consistently low in four recent reviews. Conclusion. Although the quality of the reviews was quite acceptable, the quality of the included studies was mostly poor. The choice between surgical techniques and surgery and conservative intervention should be based on surgeon and patient preferences, among other things

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

Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function. Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation. Methods: 26 consecutive patients who had undergone anterior decompression and reconstruction were evaluated for recovery. The gait pattern, hand functions and return to activities were evaluated pre and postoperatively. No specific scoring system could be used in our studies due to practical reasons. Results: 18/26 patients had CSM, 5/26 had OPLL and 3/26 soft disc herniations. Soft disc herniation were at 2 levels and all underwent discectomy, tricortical bone grafting and stabilization with ACP. Other patients had corpectomy 1 level – 4, 2 levels – 9, 3 levels – 4, 4 levels – 1. OPLL was removed in 4/5 patients. Xx/10 patients who were wheel chair bound preoperatively became ambulatory, 3/10 had decrease in spasm but still could not walk postoperatively. At 1 year follow up 9/10 patients had good gait pattern and 1 was still wheel chair bound. 18/26 had good hand function recovery with improvement in hand writing, 16/26 returned to previous activity, 1 patient expired. Conclusion: Anterior decompression for CSN is an effective surgical option. It not only prevents further detoriation, but also improvement is seen in most of the patients. Significance: Anterior decompression is indicated for all patients with CSM, OPLL and disc herniation as the pathology is anterior based

The aim of this study was to identify potential inflammatory mediators in herniated and non-herniated intervertebral disc. It has been suggested that inflammation of the nerve root is a pre-requisite for disc herniations to be symptomatic. What leads to this inflammation is a matter of conjecture; one possible cause may be inflammatory mediators released from the herniated disc tissue itself. In this study we have examined discs from individuals with and without disc herniations to determine if there is a different degree of occurrence. Twenty two discs from 21 patients with disc herniation were examined together with four discs from patients with other disc disorders and five age-matched discs from individuals obtained at autopsy. Samples were studied for the presence of blood vessels and inflammatory cytokines: IL-1α and β, IL-6, INOS, MCP1, TNFα, TSG-6 and thromboxane. Of the herniated discs 10 were protrusions, six extrusions and six sequestrations. There was less of all the cytokines in the non-herniated discs than found in the herniated, with very little immunostaining for iNOS or IL-1α in any samples. Staining was seen in all herniated samples for IL-1β, but in fewer for IL-six and MCP1 (86%), thromboxane (68%), TNFα (64%) and TSG-6 (59%). The presence of cytokines was strongly associated with the presence of blood vessels. Protruded discs had less TNFα and thromboxane than sequestrated or extruded discs. Cytokines appear to play an active role in the aetiopathogenesis of disc herniations. Some may be involved in the stimulation of degradative enzymes and hence resorption of, for example, sequestrations, whereas others may be responsible for an inflammatory response in the surrounding tissues such as nerve roots

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”. Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans. Patients with suspected spinal stenosis undergoing MRI. Incidence of “foraminal stenosis” on radiologists' reports. Diagnoses obtained by different scanning methods. Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences. Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging. Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation

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 Aims: Lower back and/or leg pain is a symptom of a number of pathological conditions involving lumbosacral nerve roots. Disc herniation is one of the most common causes of LBP (after mechanical back pain). There is controversy regarding the progression of disc degeneration and/or lower back pain to symptomatic disc prolapse over time. Method: The aim of the study was to determine the natural progression of patients with lower back pain/disc degeneration established clinically and on MRI to symptomatic disc herniation over three to six years. Total of 970 patients who had an MRI scan between January 1998 and September 2000 were included in the study. Information about disc pathology, level and number of discs involved were recorded from MRI scan reports. A short questionnaire was sent to all patients. It contained 10 questions regarding current status of pain and neurology, any treatment in form of back injection and operation, current occupation and smoking status. Results: The collected data was analysed using standard statistics software (SPSS). The results will be discussed. Conclusion: The information provided by this study will be useful in judging the natural progression of lower back pain and/or disc degeneration to a symptomatic prolapse intervertebral disc. It will also be useful in medico-legal cases where patients had pre-existing disc degeneration and subsequently developed disc herniation over time

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

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

The belief that an intervertebral disc must degenerate before it can herniate has clinical and medicolegal significance, but lacks scientific validity. We hypothesised that tissue changes in herniated discs differ from those in discs that degenerate without herniation. Tissues were obtained at surgery from 21 herniated discs and 11 non-herniated discs of similar degeneration as assessed by the Pfirrmann grade. Thin sections were graded histologically, and certain features were quantified using immunofluorescence combined with confocal microscopy and image analysis. Herniated and degenerated tissues were compared separately for each tissue type: nucleus, inner annulus and outer annulus. Herniated tissues showed significantly greater proteoglycan loss (outer annulus), neovascularisation (annulus), innervation (annulus), cellularity/inflammation (annulus) and expression of matrix-degrading enzymes (inner annulus) than degenerated discs. No significant differences were seen in the nucleus tissue from herniated and degenerated discs. Degenerative changes start in the nucleus, so it seems unlikely that advanced degeneration caused herniation in 21 of these 32 discs. On the contrary, specific changes in the annulus can be interpreted as the consequences of herniation, when disruption allows local swelling, proteoglycan loss, and the ingrowth of blood vessels, nerves and inflammatory cells. In conclusion, it should not be assumed that degenerative changes always precede disc herniation. Cite this article: Bone Joint J 2013;95-B:1127–33

Purpose of study and background. The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined. Methods and results. 68 patients underwent NRB by an ESP (Extended Scope Physiotherapist). 37 females, 31 males, mean age 75 years (range 23–87). Their stenosis was categorized as either lateral recess (n=43), foraminal (n=18), or combined (n=7) on MRI scan evaluation by 2 reviewers. Roland Morris Disability Questionnaire and Visual Analogue Scores were recorded pre-injection and 6 weeks post injection. 2 year final outcome was recorded with an ‘in-house’ questionnaire. 2 year outcome: Lateral recess stenosis: 37% had surgery, 40% required no further treatment. In foraminal stenosis: 17% had surgery, 50% required no further treatment. Combined pathology: 43% had surgery, 57% required no further treatment. Patients requiring no further treatment rated their 2 year outcome as satisfactory symptom control. Of the whole group 15% required a repeat injection, 7% were referred to pain clinic and one patient had died. Conclusion. A single NRB is an effective long term (two year) treatment for 44% of patients undergoing the procedure for radicular pain secondary to spinal stenosis. Its use should be considered as a first-line intervention in this group of patients prior to exploring surgical options. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

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.