Aims. Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse. Methods. We retrieved data from the Swedish spine register about 3,291 patients who underwent primary surgery for a lumbar disc prolapse between January 2007 and December 2008. These patients were followed until December 2020 to record all additional lumbar spine operations and the reason for them. Results. In total, 681 of the 3,291 patients (21%) needed one or more additional operations. More than three additional operations was uncommon (2%; 15/906). Overall, 906 additional operations were identified during the time period, with a mean time to the first of these of 3.7 years (SD 3.6). The most common reason for an additional operation was recurrent disc prolapse (47%; 426/906), followed by spinal stenosis or degenerative spondylolisthesis (19%; 176/906), and segmental pain (16%; 145/906). The most common surgical procedures were revision discectomy (43%; 385/906) and instrumented fusion (22%; 200/906). Degenerative spinal conditions other than disc prolapse became a more common reason for additional surgery with increasing length of follow-up. Most patients achieved the minimally important change (MIC) for the patient-reported outcomes after the index surgery. After the third additional spinal operation, only 20% (5/25) achieved the MIC in terms of leg pain, and 29% (7/24) in terms of the EuroQol five-dimension index questionnaire visual analogue scale. Conclusion. More than one in five patients operated on for a lumbar disc prolapse underwent further surgery during the 13-year follow-up period. Recurrent disc prolapse was the most common reason for additional surgery, followed by spinal stenosis and segmental pain. This study shows that additional operations after primary disc surgery are needed more frequently than previously reported, and that the outcome profoundly deteriorates after the second additional operation. The findings from this study can be used in the shared decision-making process. Cite this article: Bone Joint J 2022;104-B(5):627–632

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

1. Four cases of vascular injury during lumbar disc removal are reported, and the literature is reviewed. One of the cases is unique in that the inferior mesenteric artery was transected. 2. Clinical syndromes associated with various vascular injuries are discussed. 3. The possibility ofvascular injury should always be kept in mind during lumbar lam inectomy for disc prolapse. Unexplained hypotension is strongly suggestive of a vascular catastrophe. The advent of high output cardiac failure in the patient who has recently undergone lumbar disc removal is almost diagnostic of traumatic arteriovenous fistula

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQOL) outcome by using a Euroqol (EQ-5D) questionnaire in 263 patients who had undergone surgery for herniation of a lumbar disc. Data from the National Swedish Register for lumbar spinal surgery between 2001 and 2002 were used and, in addition, a comparison between our cohort and a Swedish EQ-5D population survey was performed. We analysed the pre- and post-operative quality of life data, age, gender, smoking habits, pain and walking capacity. The mean age of the patients was 42 years (20 to 66); 155 (59%) were men and 69 (26%) smoked. Pre-operatively, 72 (17%) could walk at least 1 km compared with 200 (76%) postoperatively. The mean EQ-5D score improved from 0.29 to 0.70, and the HRQOL improved in 195 (74%) of the patients. The pre-operative score did not influence the post-operative score. In most patients, all five EQ-5D dimensions improved, but did not reach the level reported by an age- and gender-matched population sample (mean difference 0.17). Predictors for poor outcome were smoking, a short pre-operative walking distance, and a long history of back pain

Aims. The complex relationship between acetabular component position and spinopelvic mobility in patients following total hip arthroplasty (THA) renders it difficult to optimize acetabular component positioning. Mobility of the normal lumbar spine during postural changes results in alterations in pelvic tilt (PT) to maintain the sagittal balance in each posture and, as a consequence, markedly changes the functional component anteversion (FCA). This study aimed to investigate the in vivo association of lumbar degenerative disc disease (DDD) with the PT angle and with FCA during postural changes in THA patients. Methods. A total of 50 patients with unilateral THA underwent CT imaging for radiological evaluation of presence and severity of lumbar DDD. In all, 18 patients with lumbar DDD were compared to 32 patients without lumbar DDD. In vivo PT and FCA, and the magnitudes of changes (ΔPT; ΔFCA) during supine, standing, swing-phase, and stance-phase positions were measured using a validated dual fluoroscopic imaging system. Results. PT, FCA, ΔPT, and ΔFCA were significantly correlated with the severity of lumbar DDD. Patients with severe lumbar DDD showed marked differences in PT with changes in posture; there was an anterior tilt (-16.6° vs -12.3°, p = 0.047) in the supine position, but a posterior tilt in an upright posture (1.0° vs -3.6°, p = 0.005). A significant decrease in ΔFCA during stand-to-swing (8.6° vs 12.8°, p = 0.038) and stand-to-stance (7.3° vs 10.6°,p = 0.042) was observed in the severe lumbar DDD group. Conclusion. There were marked differences in the relationship between PT and posture in patients with severe lumbar DDD compared with healthy controls. Clinical decision-making should consider the relationship between PT and FCA in order to reduce the risk of impingement at large ranges of motion in THA patients with lumbar DDD. Cite this article: Bone Joint J 2020;102-B(11):1505–1510

1. French in 1946 presented eight cases of arachnoiditis complicating a lumbar disc lesion; five further cases are reported here. 2. It is suggested that repeated minor persistent trauma produces the strictly localised changes in the arachnoid, in the same sort of way that it may produce ulnar neuritis at the elbow. 3. The various causes of arachnoiditis are discussed. 4. The place of operation has been found difficult to assess

Dorsal root ganglion neurones with dichotomising axons are present in several species and are considered to play a role in referred pain. Clinically, patients with lesions in the lower lumbar discs occasionally complain of pain in the groin. We investigated the existence of dichotomising afferent neurones projecting axons both to the lumbar disc and to the groin skin, using the double fluorescent-labelling technique in rats. We observed neurones labelled with a tracer applied at the ventral portion of the L5-L6 disc and another tracer placed on the groin skin in L1 and L2 dorsal root ganglia. Our results showed that the double-labelled neurones had peripheral axons which dichotomised into both the L5-L6 disc and the groin skin, indicating the convergence of afferent sensory information from the disc and groin skin. Our findings provide a possible neuroanatomical mechanism for referred groin pain in patients with disc lesions

1. The results of wide laminectomy of the fifth lumbar vertebra and disc excision in 132 patients are reviewed and compared with some published results of the interlaminar operation. 2. There was no significant difference in either the immediate or the long-term results of the two operations suggesting that post-operative morbidity was not related to operative technique. 3. The incidence of post-operative back pain was found to increase with age at operation, duration of pre-operative symptoms and length of follow-up, and supported the impression that backache is predominantly a feature of the underlying degenerative process rather than the incidental operation. 4. The significance of recurrent disc lesions is discussed. Recurrence usually occurred at the previously cleared disc space and was thought to indicate incomplete degeneration of the disc at the time of the original operation. 5. The place of fusion combined with disc excision is discussed. No reliable indications for coincident fusion were found in this series. 6. The value of radiography is discussed. Plain radiographs were essential before operation to exclude other causes of backache and sciatica; otherwise they were of little value. Motion radiographs were no more helpful and myelography was used only when the level of the lesion was in doubt. 7. The risk of an acute cauda equina lesion following manipulation of a prolapsed lumbar disc is noted and the danger of manipulation, unless facilities for emergency surgery are available, is stressed

The National Inpatient Register and the Swedish Death Register were linked to determine the incidence of surgical intervention, the trends and characteristics of the patients, the death rate and the pre- and post-operative admissions for herniation of a lumbar disc based on comprehensive national data between 1987 and 1999. There were 27 576 operations which were followed cumulatively for 155 249 years, with a median of 6.0 years. The mean annual rate of operation was 24 per 100 000 inhabitants, the median age of the patients was 42 years. The 30-day death rate was 0.5 per 1000 operations. The rates of re-operation at one and ten years were 5% and 10%, respectively, decreasing significantly (40%) with time. The mean length of stay decreased from nine to five days. Patients who had been in hospital because of a previous spinal disorder had a significantly higher risk of readmission

We report a patient who developed an aortic pseudoaneurysm in the L3–L4 disc space after lumbar disc surgery. The diagnosis was made by MRI and aortography, and repair using a prosthetic graft and anterior fusion was successful. We discuss the predisposing factors, the clinical picture and management of vascular injuries during disc excision

Based on a study using a retrograde neurotracer, we have previously found that the dorsal portion of the L5/6 disc in the rat is multisegmentally innervated by dorsal root ganglia (DRG) from the level of T13 to L6, and that sensory nerve fibres from DRG of T13, L1 and L2 pass through the paravertebral sympathetic trunks. In this study in newborn rats, we injected crystals of 1,1′-dioctadecyl-3,3,3′,3′-tetramethylinedocarbocyanine perchlorate (DiI) into the DRG of T13, L1 and L2 and showed DiI-labelled sensory nerve fibres in the dorsal portion of the discs from the level of T13/L1 to L5/6. Our results show that the dorsal portion of the lumbar discs is innervated by the DRG from levels T13 to L2

We carried out MRI studies of 74 patients with end-plate and vertebral bone-marrow changes associated with degenerative lumbar disc disease. Abnormalities were classified into type A, with decreased signal intensities, and type B, with increased signal intensities on T1-weighted spin-echo images. Twenty-seven (73%) of the 37 patients with type-A changes had low back pain, in contrast to only four (11%) of the 37 patients with type-B changes. Lateral flexion-extension radiographs showed hypermobility in 26 patients (70%) with type-A changes, and in only six (16%) with type-B changes. Type-A changes correlated with segmental hypermobility and low back pain, while type-B changes were more common in patients with stable degenerative disc disease

The pre-operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for prolapsed intervertebral disc were reviewed. Prolapse was recognized as bulging or sequestration of the disc with consequent root compromise. Measurement of the lumbar level of the interiliac line was shown to correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacral junction was significantly higher than normal. A pathological value for the lumbosacral angle could not be identified.

The oblique sagittal diameter of the lumbar spinal canal was measured by diagnostic ultrasound in seventy-three patients with symptomatic disc lesions, and compared with measurements from 200 asymptomatic subjects. Results suggest that the available space in the spinal canal is highly significant in the symptomatology of disc lesions, and in the patient's response to treatment.

1. Of 456 patients with features of herniated intervertebral disc eight were under twenty years of age.

2. Differences in the pattern of clinical presentation of the herniated disc syndrome in adults and in adolescents are discussed.

3. Whereas in the adult conservative treatment is usually successful, this is not so in the adolescent, in whom the symptoms and signs tend to persist for many months.

4. It is suggested that in the adolescent conservative treatment should not be prolonged despite the absence of neurological deficit; operation should be undertaken early after confirmation of the diagnosis by myelography.

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent.

2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay.

3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided.

4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence".

5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work.

6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation.

7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis.

8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes.

9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space.

1. In this investigation one was impressed by the close relationship that exists between the constituent parts of the intervertebral discs and the surrounding supporting structures. The part that is responsible for the maintenance of a co-ordinated balance between these structures, and hence for the effective mechanism of the spine, is the nucleus pulposus.

2. The cruciate arrangement of the annulus fibrosus is related to spinal function, and the angle of intersection of consecutive laminae of the annulus fibrosus is more or less constant.

3. In the Bantu it was found that the interspinous and supraspinous ligaments differ from the classical descriptions given in anatomical text-books.

4. The movements taking place between two vertebrae are comparable to those of a rocking-horse.

5. Narrowing of a disc is a progressive process which is the result of the disturbances in the balance between the components of the force to which a disc is subjected. The process is initiated by the loss of nucleus pulposus content.

6. With the approximation of two adjacent vertebrae a disturbance of the relations of the structures in the intervertebral foramen was noted. On anatomical grounds, when a disc is narrowed it appears that the most likely structures to cause pressure on the nerve root are not the disc itself, but the superior articular processes with their overlying ligamentum flavum.

We have measured the dynamic movement of the lumbar spine in 57 patients with degenerative lumbar disc disease. Each completed a questionnaire which recorded pain and subjective signs and symptoms. From plain lateral radiographs, the subjects were graded using the criteria of Kellgren and Lawrence and those of Lane et al, which are both based on the severity of degenerative changes. Measurements of the height of the disc space and the vertebral height were obtained and expressed as a ratio. We found no relationship between the characteristics of spinal movement and the overall grading of degenerative disc disease with either system. Both were influenced (p < 0.01) by age, walking distance, severity of symptoms, drug intake and frequency of pain. The present systems for grading degenerative disc disease from plain lateral radiographs have limited application

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.

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. Patients and Methods. This was a longitudinal observation study. Data from herniated lumbar disc operations were retrieved from a large medical database using a combination of procedure and diagnosis codes from all public hospitals in Norway from 1999 to 2013. The impact of age, gender, geographical affiliation, education, civil status, income, and comorbidity on unfavourable events were analyzed by logistic regression. Results. Of 34 639 operations, 2.7% (95% confidence interval (CI) 2.6 to 2.9) had a surgical complication, 2.1% (95% CI 2.0 to 2.3) had repeat surgery within 90 days, 2.4% (95% CI 2.2 to 2.5) had a non-surgical readmission within 90 days, and 6.7% (95% CI 6.4 to 6.9) experienced at least one of these unfavourable events. Unfavourable events were found to be associated with advanced age and comorbidity. Conclusion. The results suggest that surgical complications are less frequent than previously suggested. There are limited associations between sociodemographic patient characteristics and unfavourable events. Cite this article: Bone Joint J 2019;101-B:470–477

Aims. It has been well documented in the arthroplasty literature that lumbar degenerative disc disease (DDD) contributes to abnormal spinopelvic motion. However, the relationship between the severity or pattern of hip osteoarthritis (OA) as measured on an anteroposterior (AP) pelvic view and spinopelvic biomechanics has not been well investigated. Therefore, the aim of the study is to examine the association between the severity and pattern of hip OA and spinopelvic motion. Methods. A retrospective chart review was conducted to identify patients undergoing primary total hip arthroplasty (THA). Plain AP pelvic radiographs were reviewed to document the morphological characteristic of osteoarthritic hips. Lateral spine-pelvis-hip sitting and standing plain radiographs were used to measure sacral slope (SS) and pelvic femoral angle (PFA) in each position. Lumbar disc spaces were measured to determine the presence of DDD. The difference between sitting and standing SS and PFA were calculated to quantify spinopelvic motion (ΔSS) and hip motion (ΔPFA), respectively. Univariate analysis and Pearson correlation were used to identify morphological hip characteristics associated with changes in spinopelvic motion. Results. In total, 139 patients were included. Increased spinopelvic motion was observed in patients with loss of femoral head contour, cam deformity, and acetabular bone loss (all p < 0.05). Loss of hip motion was observed in patients with loss of femoral head contour, cam deformity, and acetabular bone loss (all p < 0.001). A decreased joint space was associated with a decreased ΔPFA (p = 0.040). The presence of disc space narrowing, disc space narrowing > two levels, and disc narrowing involving the L5–S1 segment were associated with decreased spinopelvic motion (all p < 0.05). Conclusion. Preoperative hip OA as assessed on an AP pelvic radiograph predicts spinopelvic motion. These data suggest that specific hip osteoarthritic morphological characteristics listed above alter spinopelvic motion to a greater extent than others. Cite this article: Bone Joint J 2023;105-B(5):496–503

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear

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. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed. Research in the 1980s suggested that pain sensation was conducted in part via the sympathetic system. These sensory pathways have now been clarified using sophisticated experimental and histochemical techniques confirming a dual pattern. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry through the thoracolumbar white rami communicantes. Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission. The nature and mechanism of discogenic pain is still speculative but there is growing evidence to support a ‘visceral pain’ hypothesis, unique in the muscloskeletal system. This mechanism is open to ‘peripheral sensitisation’ and possibly ‘central sensitisation’ as a potential cause of chronic back pain

In a study on ten fresh human cadavers we examined the change in the height of the intervertebral disc space, the angle of lordosis and the geometry of the facet joints after insertion of intervertebral total disc replacements. SB III Charité prostheses were inserted at L3-4, L4-5, and L5-S1. The changes studied were measured using computer navigation sofware applied to CT scans before and after instrumentation. After disc replacement the mean lumbar disc height was doubled (p < 0.001). The mean angle of lordosis and the facet joint space increased by a statistically significant extent (p < 0.005 and p = 0.006, respectively). By contrast, the mean facet joint overlap was significantly reduced (p < 0.001). Our study indicates that the increase in the intervertebral disc height after disc replacement changes the geometry at the facet joints. This may have clinical relevance

We studied 52 patients, each with a lumbosacral transitional vertebra. Using MRI we found that the lumbar discs immediately above the transitional vertebra were significantly more degenerative and those between the transitional vertebrae and the sacrum were significantly less degenerative compared with discs at other levels. We also performed an anatomical study using 70 cadavers. We found that the iliolumbar ligament at the level immediately above the transitional vertebra was thinner and weaker than it was in cadavers without a lumbosacral transitional vertebra. Instability of the vertebral segment above the transitional vertebra because of a weak iliolumbar ligament could lead to subsequent disc degeneration which may occur earlier than at other disc levels. Some stability between the transitional vertebra and the sacrum could be preserved by the formation of either an articulation or by bony union between the vertebra and the sacrum through its transverse process. This may protect the disc from further degeneration in the long term

Computerised tomography (CT) was performed in 30 patients with herniated lumbar discs; this was done both before chemonucleolysis and three months after. In 20 of the 28 patients who were CT positive, the compression produced by the herniated disc was eliminated or reduced. Twenty-three of the 28 patients developed diffuse bulging of the annulus. There was good correlation between the clinical results at three months and the alteration in compression as shown by the CT scan. No evidence of alteration in the bony relationship was seen in the scan and none of the patients developed epidural fibrosis. Chemonucleolysis has thus been shown to be an effective treatment of herniated lumbar discs, but it is definitely not indicated in cases where compression of the nerve root or dural sac is due to a bulging annulus

It has been suggested that matrix metalloproteinase-3 (MMP-3, stromelysin-1) has an important role in the degeneration of intervertebral discs (IVDs). A human MMP-3 promoter 5A/6A polymorphism was reported to be involved in the regulation of MMP-3 gene expression. We suggest that IVD degeneration is associated with 5A/6A polymorphism. We studied 54 young and 49 elderly Japanese subjects. Degeneration of the lumbar discs was graded using MRI in the younger group and by radiography in the elderly. 5A/6A polymorphism was determined by polymerase-chain reaction-based assays. We found that the 5A5A and 5A6A genotype in the elderly was associated with a significantly larger number of degenerative IVDs than the 6A6A (p < 0.05), but there was no significant difference in the young. In the elderly, the IVD degenerative scores were also distributed more highly in the 5A5A and 5A6A genotypes (p = 0.0029). Our findings indicate that the 5A allele is a possible risk factor for the acceleration of degenerative changes in the lumbar disc in the elderly

To clarify the pathomechanisms of discogenic low back pain, the sympathetic afferent discharge originating from the L5-L6 disc via the L2 root were investigated neurophysiologically in 31 Lewis rats. Sympathetic afferent units were recorded from the L2 root connected to the lumbar sympathetic trunk by rami communicantes. The L5-L6 discs were mechanically probed, stimulated electrically to evoke action potentials and, finally, treated with chemicals to produce an inflammatory reaction. We could not obtain a response from any units in the L5-L6 discs using mechanical stimulation, but with electrical stimulation we identified 42 units consisting mostly of A-delta fibres. In some experiments a response to mechanical probing of the L5-L6 disc was recognised after producing an inflammatory reaction. This study suggests that mechanical stimulation of the lumbar discs may not always produce pain, whereas inflammatory changes may cause the disc to become sensitive to mechanical stimuli, resulting in nociceptive information being transmitted as discogenic low back pain to the spinal cord through the lumbar sympathetic trunk. This may partly explain the variation in human symptoms of degenerate discs

Between January 1990 and December 2000 we carried out 226 SB Charité III disc replacements for lumbar disc degeneration in 160 patients. They were reviewed at a mean follow-up of 79 months (31 to 161) to determine the clinical and radiological outcome. The clinical results were collected by an independent observer, who was not involved in patient selection, treatment or follow-up, using a combination of outcome measures, including the Oswestry Disability Index. Pain was recorded using a visual analogue score, and the most recent radiographs were reviewed. Survival of the device was analysed by the Kaplan-Meier method and showed a cumulative survival of 35% at 156 months when radiological failure was taken as the endpoint. The mean improvement in the Oswestry disability index scores after disc replacement was 14% (6% to 21%) and the mean improvement in the pain score was 1.6 (0.46 to 2.73), both falling below the clinically significant threshold. Removal of the implant was required in 12 patients, four because of implant failure. These poor results indicate that further use of this implant is not justified

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):46–9

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. . Patients and Methods. A total of 13 patients with unilateral radiculopathy due to herniation of a lumbar disc were investigated with DTI on a 1.5T MR scanner and underwent micro discectomy. There were nine men and four women, with a median age of 55.5 years (19 to 79). The changes in the mean FA and ADC values and the correlation between these changes and the severity of the neurological symptoms were investigated before and at six months after surgery. . Results. The mean FA values were significantly lower (p = 0.0005) and mean ADC values were significantly higher (p = 0.0115) in compressed nerves than in intact nerves. Although the FA values increased significantly at six months after surgical treatment (p = 0.020), the ADC values decreased but not significantly (p = 0.498). There were strong correlations between the DTI parameters such as the FA value and the severity of the neurological symptoms as assessed using the Japanese Orthopaedic Association (JOA) score and the Roland-Morris Disability Questionnaire (RDQ). . Conclusion. This preliminary study suggests that it may be possible to use DTI to diagnose, quantitatively evaluate and follow-up patients with lumbar nerve entrapment. Take home message: DTI is a potential tool for functional diagnosis of lumbar nerve damage. Cite this article: Bone Joint J 2016;98-B:387–94

Aims. The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position. Patients and Methods. A total of 161 patients were considered for inclusion. Patients had a mean age of the remaining 61 years (. sd. 11) with a mean body mass index (BMI) of 28 kg/m. 2. (. sd. 6). Of the 161 patients, 82 were male (51%). We excluded 17 patients (11%) with spinal conditions known to affect lumbar mobility as well as the rotational axis of the spine. Standing and sitting spine-to-lower-limb radiographs were taken of the remaining 144 patients before and one year following THA. Spinopelvic alignment measurements, including sacral slope, lumbar lordosis, and pelvic incidence, were measured. These angles were used to calculate lumbar spine flexion and femoroacetabular hip flexion from a standing to sitting position. A radiographic scoring system was used to identify those patients in the series who had lumbar degenerative disc disease (DDD) and compare spinopelvic parameters between those patients with DDD (n = 38) and those who did not (n = 106). Results. Following THA, patients sat with more anterior pelvic tilt (mean increased sacral slope 18° preoperatively versus 23° postoperatively; p = 0.001) and more lumbar lordosis (mean 28° preoperatively versus 35° postoperatively; p = 0.001). Preoperative change in sacral slope from standing to sitting (p = 0.03) and the absence of DDD (p = 0.001) correlated to an increased change in postoperative sitting pelvic alignment. Conclusion. Sitting lumbar-pelvic-femoral alignment following THA may be driven by hip arthritis and/or spinal deformity. Patients with DDD and fixed spinopelvic alignment have a predictable pelvic position one year following THA. Patients with normal spines have less predictable postoperative pelvic position, which is likely to be driven by hip stiffness. Cite this article: Bone Joint J 2018;100-B:1289–96

A method of posterior lumbo-sacral fusion is described in which springs are used to fix the grafts and to maintain immobilisation. Fifty patients with lumbar disc degeneration or spondylolisthesis have been reviewed. The results have been assessed clinically by grading the symptoms before and after operation. Stay in hospital has been short and return to work rapid. There has been a high proportion of good results

Five patients known to be HIV (human immunodeficiency virus)-positive--that is, susceptible to AIDS--presented with symptoms initially thought to be indicative of lumbar disc lesions. Signs of nerve root or cauda equina compression were found in all five patients. Lumbar radiculography and, in one patient, computerised tomography produced no evidence of compressive pathology. We recommend that orthopaedic surgeons exercise caution in diagnosing nerve root compression in patients who may be HIV-positive

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.

The development of the iliolumbar ligament and its anatomy and histology were studied in cadavers from the newborn to the ninth decade. The structure was entirely muscular in the newborn and became ligamentous only from the second decade, being formed by metaplasia from fibres of the quadratus lumborum muscle. By the third decade, the definitive ligament was well formed; degenerative changes were noted in older specimens. The iliolumbar ligament may have an important role in maintaining lumbosacral stability in patients with lumbar disc degeneration, degenerative spondylolisthesis and pelvic obliquity secondary to neuromuscular scoliosis

We treated 137 patients with symptomatic lumbar disc prolapse by automated percutaneous lumbar discectomy (APLD). Seventeen (12%) required further operation. At a mean follow-up of 55 months, the success rate was 45%. Of those who had APLD alone, 52% were graded as either excellent or good. In this group, 76% were employed, and the mean Oswestry score was 28.2%. One-third of those patients initially rated as successful had deterioration in symptoms and increased disability from back pain. The Short Form 36 health survey questionnaire revealed that these patients had a chronic ill-health profile

Cadaveric lumbar discs were injected with chymopapain and subjected to a series of mechanical tests over a period of up to 19 hours. Discs from the same spine injected with saline were used as controls. The results showed that chymopapain had no measurable effect on the mechanical properties of the disc apart from the increased height and stiffening caused by fluid injection. Another series of tests on isolated pieces of disc material showed that chymopapain could reduce the size of prolapsed nuclear material by 24% in one hour and by 80% in 48 hours. It is concluded that, in the short-term, chymopapain has a negligible effect on the mechanics of a disc but it can reduce the size of any prolapsed nuclear material with which it comes in contact

The spinal stenosis syndrome is a potential hazard when congenital or developmental narrowing of the bony canal, particularly in its lateral recesses where it can be demonstrated by axial tomography, places the emergent nerve root and its blood supply at risk to further small compressive elements. When lumbar disc degeneration allows rotatory and lateral instability, posterolateral bulging of the annulus fibrosus into the root canal occurs when weight is taken on the ipsilateral lower limb. Symptoms of the spinal stenosis syndrome do not arise until the development of this instability. To relieve the symptoms, the nerve root must be freely mobilised and decompressed by full lateral decompression, with partial or total facetectomy if necessary, by enucleation of the intervertebral disc and by removal of the posterolateral portions of the annuli fibrosi

1. Ten patients with neurological evidence of damage to the intrathecal sacral nerve roots of the cauda equina by verified lumbar disc prolapse are described. 2. The nature of the bladder paralysis has been investigated by cystometry and the findings contrasted with published opinions. 3. The prognosis of the bladder paralysis has been established by review up to six years after removal of the disc prolapse. No evidence of recovery of complete bladder paralysis has been found, but the consequences of persistent bladder paralysis have been much less severe than previous reports have stated. Reasons have been suggested for this. 4. Principles of recognition and management of bladder paralysis due to cauda equina lesions have been stated and methods suggested

We studied 135 lumbar discs from 27 spines removed post-mortem from subjects of an average age of 31.5 years. Defects of the annulus fibrosus were classified as peripheral, circumferential or radiating; the nucleus pulposus as normal, moderately or severely degenerate. Peripheral tears were more frequent in the anterior annulus, except in the L5-S1 disc. Circumferential tears were equally distributed between the anterior and the posterior annulus. Almost all the radiating tears were in the posterior annulus, and closely related to the presence of severe nuclear degeneration. Histology suggested that peripheral tears were due to trauma rather than biochemical degradation, and that they developed independently of nuclear degeneration. The association of peripheral annular lesions with low back pain is uncertain but our study suggests that they may have a role in the pathogenesis of discogenic pain

Herniated intervertebral disc tissue has been shown to produce a number of proinflammatory mediators and cytokines, but there have been no similar studies using discs from patients with discogenic low back pain. We have compared the levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and prostaglandin E. 2. (PGE. 2. ) in disc tissue from patients undergoing discectomy for sciatica (63) with that from patients undergoing fusion for discogenic low back pain (20) using an enzyme-linked immunoabsorbent assay. There was a statistically significant difference between levels of production of IL-6 and IL-8 in the sciatica and low back pain groups (p < 0.006 and p < 0.003, respectively). The high levels of proinflammatory mediator found in disc tissue from patients undergoing fusion suggest that production of proinflammatory mediators within the nucleus pulposus may be a major factor in the genesis of a painful lumbar disc

1. Passive straight-leg raising may induce pain in the back or leg or a combination of both in patients with acute lower lumbar disc lesions. Clinical, myelographic and operative observations were carried out prospectively in fifty such cases to investigate the relation of the pattern of pain on straight-leg raising to the site of the protrusion. 2. In patients with central protrusion straight-leg raising induced mainly back pain. In patients with intermediate protrusion, lying in contact with both dura and nerve root, a combination of back and leg pain predominated. Patients with lateral protrusion usually experienced only pain in the leg. This correlation was found in 80 per cent of cases. 3. Production of pain in the leg by straight-leg raising is of practical significance in lateral protrusions where myelography may be normal. 4. Pain in the back and pain in the leg on straight-leg raising may be related respectively to dural and nerve root sensitivity

Two collagen type IX gene polymorphisms that introduce a tryptophan residue into the protein’s triple-helical domain have been linked to an increased risk of lumbar disc disease. To determine whether a particular subset of symptomatic lumbar disease is specifically associated with these polymorphisms, we performed a prospective case-control study of 107 patients who underwent surgery of the lumbar spine. Patients were assigned to one of five clinical categories (fracture, disc degeneration, disc herniation, spinal stenosis without spondylolisthesis and spinal stenosis with spondylolisthesis) based on history, imaging results, and findings during surgery. Of the 11 tryptophan-positive patients, eight had spinal stenosis with spondylolisthesis and three had disc herniation. The presence of the tryptophan allele was significantly associated with African-American or Asian designation for race (odds ratio 4.61, 95% CI 0.63 to 25.35) and with the diagnosis of spinal stenosis with spondylolisthesis (odds ratio 6.81, 95% CI 1.47 to 41.95). Our findings indicate that tryptophan polymorphisms predispose carriers to the development of symptomatic spinal stenosis associated with spondylolisthesis which requires surgery