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It is a controversial issue that the difference of the occurrence of heterotopic ossification (HO) concerning cervical prosthesis is still huge. In this study, in the two cervical disc prostheses the development of HO is independent on their architecture., Study Design. Retrospective analysis using data from randomized clinical trials. Objective. To compare the occurrence of heterotopic ossification (HO) between two cervical disc prostheses. Clinical outcome and range of motion (ROM) were also evaluated. Summary of Background Data. Cervical arthroplasty was reported to be able to maintain the segmental ROM. However, controversy exists since the difference of the occurrence of HO concerning cervical prosthesis is still huge. Methods. Patients who underwent anterior cervical discectomy with arthroplasty for a cervical radiculopathy due to a herniated disc from the The Netherlands Cervical Kinematics (NECK) trial (activC; metal endplates with a polyethylene inlay and a keel for primary stability) and the PROCON trial (Bryan; metal-on-polymer with titanium coated endplates without a keel) were analyzed for HO at 12 and 24 months postoperatively. HO was scored according to the McAfee–Mehren classification. Segmental ROM was defined by a custom developed image analysis tool, and global cervical ROM was measured by Cobb's angle. Clinical outcome was evaluated by means of the neck disability index (NDI) as well as physical-component summary (PCS) and mental-component summary (MCS). Results. At 2-year follow-up, the occurrence of HO was 68% in patients treated with the activC prosthesis (severe HO 55%), which was comparable with 85% (P = 0.12) in patients with the Bryan disc (severe HO 44%; P = 0.43). The HO progression was similar between groups. Clinically, the patients had comparable NDI, PCS, and MCS at 2-year follow-up, and comparable improvement of clinical outcomes. The global ROM in the Bryan group (56.4 ± 10.8°) was significantly higher than in the activC group (49.5 ± 14.0, P = 0.044) at 2-year follow-up. Conclusion. In comparison of two cervical disc prostheses the development of HO is independent on their architecture. Although global ROM was higher in the Bryan prosthesis group, this difference was not deemed clinically important, particularly because the clinical condition of patients with and without severe HO was comparable. Level of Evidence: 2

Study Design. Retrospective analysis was performed on data from 251 patients that were included in two randomized, double-blinded clinical trials comparing clinical results of anterior cervical discectomy and arthroplasty (ACDA) to anterior cervical discectomy and fusion (ACDF), and anterior cervical discectomy (ACD), for single-level disc herniation. Objective. This study aimed to investigate whether the ACDA procedure offers superior clinical results 2 years after surgery, to either ACDF or ACD without instrumentation, in the entire group of patients or in a particular subgroup of patients. Summary of Background Data. The cervical disc prosthesis was introduced to provide superior clinical outcomes after ACD. Methods. Neck Disability Index (NDI), and subscales of the 36-item short-form health survey (SF-36) and McGill pain score were collected at baseline, 1 year and 2 years after surgery. Reoperations and complications were also evaluated. A preliminary subgroup analysis was performed for age, disc height, body mass index (BMI), smoking, and sex. Results. The NDI decreased comparably in all treatment arms to circa 50% of the baseline value and marginal mean NDI differences varied from 0.4 to 1.1 on a 100 point NDI scale, with confidence intervals never exceeding the 20-point minimal clinical important difference (MCID). Secondary outcome parameters showed comparable results. Preliminary subgroup analysis could not demonstrate clinically relevant differences in NDI between treatments after 2 years. Conclusion. After combining data from two Randomized Controlled Trials it can be concluded that there is no clinical benefit for ACDA, when compared with ACDF or ACD 2 years after surgery. Preliminary subgroup analysis indicated outcomes were similar between treatment groups, and that no subgroup could be appointed that benefited more from either ACD, ACDF, or ACDA.

Introduction: Posterior epidural migration of lumbar disc fragment (PEMLDF) is a very rare condition that may lead to a serious neurological deficit such as cauda equina syndrome. Magnetic resonance imaging (MRI) findings can often result in cases of PEMLDF being misdiagnosed as extradural masses of other origin or epidural hematomas. In this study, we reported four additional cases of PEMLDF and reviewed the relevant literature. Patient concerns: We present four patients with PEMLDF. The mean age of the patients was 53.5 years. Two patients suffered from cauda equine syndrome, and the other two patients complained of radiculopathy. Diagnosis: The MRI findings in each case showed masses with slightly high signal intensity in T2-weighted images, as well as heterogenous and peripheral rim enhancement after contrast enhancement. In some patients there was a tract-like enhancement extending from the outer aspect of the disc to the posterolateral epidural space. A definitive diagnosis was made intraoperatively. Interventions: We performed laminectomy and discectomy in all patients. Outcomes: The PEMLDF patients with radiculopathy had no complaints of weakness or pain after surgery. Both patients with cauda equine syndrome showed a total recovery post-surgery. Conclusions: Early diagnosis and treatment via laminectomy and discectomy is critical to achieving the best postoperative outcomes. Understanding the patient's history, recognizing the similar signal intensity of the mass and intervertebral disc on MRI scans, and looking for peripheral rim enhancement, are the keys to the correct diagnosis of PEMLDF.

Introduction: Lumbar interbody fusion (LIF) is an effective treatment for lumbar degenerative diseases. Cage subsidence (CS) contitutes one of the most common postoperative complications. Many risk factors for CS after LIF have been reported in some studies. However, controversies still exist. The objective of this study will be to summarize data on the prevalence and risk factors of CS after LIF. Methods and analysis: Our study present a protocol that conducted a systematic review and meta-analysis of prevalence and risk factors for CS after LIF. Two reviewers retrieved the relevant articles using the 5 databases (PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science) from inception to May 31st, 2021. Primary outcome will be the prevalence of CS after LIF. Second outcomes include the risk factors associated with postoperative CS and clinical outcomes associated with postoperative CS. Three reviewers will screen citation titles and abstracts and evaluated full-text of each potentially relevant citation, and then extracted the data using a data extraction form. Any discrepancies in decisions between reviewers will be resolved through discussion. We assessed the methodological quality and risk of bias of the included studies based on the Newcastle–Ottawa Quality Assessment Scale (NOS). The aim of the extra analysis is to explore the explanations of the heterogeneity (age, gender, race, year of publication, type of study and surgical procedure). Publication bias will be assessed by Begg test, Egger test and funnel plots. Ethics and dissemination: No primary data will be collected and individual patient information and endangering participant rights, thus ethics approval is not required. Findings will be reported through publication and media. Protocol registration number: PROSPERO CRD42021257981 (https://www.crd.york.ac.uk/PROSPERO/#joinuppage).

Background: Microendoscopic discectomy (MED) and percutaneous transforaminal endoscopic discectomy (PTED), as two alternative surgical techniques in minimally invasive spine surgery (MISS), are widely conducted in the treatment of upper lumbar disc herniation (ULDH). This study will systematically assess and compare the clinical outcomes of MED and PTED in treating ULDH combining with the meta-analysis. Methods: All the randomized controlled trials (RCTs) will be searched at the databases including PubMed, EMBASE, Cochrane Library and Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP), and WANFANG Database from inception to December 2025. The primary outcome will involve Japanese Orthopedic Association (JOA), Oswestry disability index (ODI), and visual analog scale (VAS) scores. The secondary outcomes will be the short-form 36-item (SF-36) health survey questionnaire and the modified MacNab criterion. We will perform data synthesis, subgroup analysis, sensitivity analysis, meta-regression analysis, and the assessment of reporting bias using RevMan 5.3 software. Results: This systematic review will comprehensively evaluate the clinical outcomes of comparison of MED and PTED in the treatment of ULDH and provide a reliable and high-quality evidence. Conclusion: The conclusion of this study will elucidate the clinical outcomes of MED compared with PTED and clarify whether PTED generates better clinical effects than MED in treating ULDH. PROSPERO registration number: CRD 42021244204

Background: Patients with lumbar disc herniation, who undergo spine surgery, occasionally complain of pain and functional disability. Fortunately, the concept of enhanced recovery after surgery has emerged recently. As a result, patients seek traditional Chinese medicine after spine surgery. This systematic review will thoroughly analyze and synthesize evidence on integrative traditional Chinese medicine therapy for lumbar disc herniation after surgery. Methods: The following databases will be utilized to search for pertinent studies: the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, Chinese National Knowledge Infrastructure, Japan Medical Abstracts Society, and 7 Korean databases (the Korean Studies Information Service System, Korean Association of Medical Journal Editors, National Digital Science Library, Database Periodical Information Academic Korean Traditional Knowledge Portal, Oriental Medicine Advanced Searching Integrated System, and Korean National Assembly Digital Library). The risk of bias of the selected studies will be assessed according to the Cochrane assessment tool for risk of bias. For articles that used the same measurements, a meta-analysis will be conducted to synthesize the results of each trial. Pain severity will be the primary outcome, while the results of functional questionnaires and range of motion, etc, will be the secondary outcomes. Results and conclusion: Since this protocol does not include any data from patients, ethics approval is not required. The results of this review will be disseminated through a peer-reviewed journal. Registration number: DOI 10.17605/OSF.IO/KP47A (https://osf.io/kp47a)

Rationale: For isthmic lumbar spondylolisthesis (ILS) associated with the removal of herniation, it remains challenging to perform less invasive and minimally disruptive procedures. Good results could potentially be obtained by further preserving the posterior elements in full-endoscopic lumbar discectomy (FESS), which is less invasive than microenscopic surgery (MES). Patient concerns: One patient complained of left leg pain, and another patient complained of right leg pain and low back pain. Diagnoses: Two patients with ILS and Meyerding Grade 1 lumbar spondylolisthesis. Interventions: We performed a full-endoscopic lumbar discectomy via the interlaminar space (FESS-IL) for L5/S1 lumbar disc herniation (LDH) accompanied by isthmic lumbar spondylolisthesis. FESS-IL was performed in 2 patients with radiculopathy caused by different types of LDH using a full endoscopic system with a 4.1 mm working channel and 6.9 mm outer diameter. A 3.5-mm diameter high-speed drill was used in one patient for an upward-migrated LDH in the inner-rim of the infravertebral border. The other patient underwent minimal resection without bone resection. Outcomes: The one-year clinical outcome included confirmation of pain relief and evacuation of migrated LDH on magnetic resonance imaging in all patients. There was no progression of slippage on radiography. The mean operative time was 82 min, and no complication was observed. The one-year clinical outcome demonstrated sufficient pain relief. Lessons: The 1-y ear postoperative outcome showed improvement. We believe that FESS-IL is a viable alternative operative approach for LDH for ILS.

Rationale: Diffuse idiopathic skeletal hyperostosis (DISH) is a skeletal disease characterized by calcification of anterolateral ligaments of the spine and the rest of the body. DISH combined with disc herniation induces complex symptoms and is more difficult to treat. Here, we describe a complicated case of a patient diagnosed with DISH as well as cervical disc herniation that was successfully treated using anterior cervical surgery. Patients concern: A 69-year-old Asian male experienced dysphagia and weakness in his left limbs. He also experienced a stiff neck and right slant over a 6-month period. Diagnosis: An X-ray revealed calcification of the C4-7 vertebral front edge and a narrowed intervertebral space between C5/6. Coronal and sagittal computerized tomography (CT) and magnetic resonance imaging (MRI) both showed compression of the spinal cord at the cervical 5/6. Esophagography revealed that osteophytes in the anterior margin of vertebral body (C4-C7) oppressed the esophagus. Interventions: An operation focused on anterior cervical C5/6 disc fusion and anterior vertebral C4-7 osteophyte removal was performed. Outcomes: After the operation, X-ray and CT showed that most osteophytes were removed and spinal cord compression was relieved. One day following the operation, both dysphagia and numbness in limbs were improved. Strong recovery was observed at the three-month follow-up exam. Lessons: This complex DISH combined with disc herniation case is rarely observed in patients. Anterior cervical disc fusion and anterior vertebral osteophyte removal were effective treatment measures. This case study provides insight into treating cases presented with cervical spine complications associated with DISH combined with other ailments.

Background: The effect of adding alpha lipoic acid (ALA) to pulsed radiofrequency (PRF) for treatment of lumbar-sacral pain was evaluated. Objective: to evaluate the effect of using ALA as an adjuvant therapy with PRF for treatment of chronic lumbosacral radicular pain caused by herniated disc. Methods: One hundred twenty patients with lumbo-sacral radicular pain allocated into 2 groups. Group I: treated with PRF at 42°C for 120 seconds. Group II: treated as in group I, plus oral ALA 600 mg (Thiotacid 600 mg, EVA PHARMA, Egypt) three times per day (1800 mg/day) for 3 weeks then 600 mg once daily for 2 weeks. The lumbo-sacral radicular pain evaluated using the numerical rating pain score and Oswestry Disability Index. Results: Success rate was significantly higher in group II at 3 and 6 months after intervention. The median values of the numerical rating pain score and the Oswestry Disability Index were significantly lower in group II with no significant difference in Epworth Sleepiness Scale. No major complications were reported in both groups. Conclusion: The current study supports the use of ALA with PRF on the dorsal root ganglion for treating lumbosacral radicular pain.

This study explored the effect of percutaneous intervertebral foraminoscopic discectomy (PIFD) in the treatment of lumbar disc herniation (LDH). This retrospective study collected a total of 88 patient cases for inclusion. Epidemiological and clinical data of patients with LDH at the First Affiliated Hospital of Jiamusi University between May 2017 and January 2020 were retrospectively analyzed. Of those, 44 patients received PIFD and were allocated to an intervention group. The other 44 patients administrated fenestration discectomy (FD), and were assigned to a control group. We compared surgery time (minute), incision length (cm), duration of hospital stay after surgery (day), pain intensity (as checked by Visual Analogue Scale (VAS), health-related quality of life (as examined by Oswestry Disability Index, ODI), and complications between 2 groups. There were not significant differences in surgery time (minute) (P = .56), VAS (P = .33) and ODI (P = .46) after surgery between 2 groups. However, there were significant differences in incision size (cm) (P .05). The findings of this study showed that both PIFD and FD benefit patients with LDH. However, PIFD can benefit patients more than FD in the incision size and duration of hospital stay after surgery.

Supplemental Digital Content is available in the text It is unclear if percutaneous transforaminal endoscopic discectomy (PTED) has comparable outcomes compared with open microdiscectomy (OM). Multiple online databases were systematically searched up to April 2020 for prospective studies. There is moderate quality evidence suggesting no difference in leg pain or functionality at intermediate and long-term follow-up between PTED and OM in the treatment of lumbar disk herniation., Study Design. Systematic review and meta-analysis. Objective. To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). Summary of Background Data. The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM. Methods. Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3–6 months), and long-term (12 months). Results. We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI –0.10–0.21) and long-term follow-up (SMD 0.11, 95% CI –0.30–0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD –0.09, 95% CI –0.24–0.07) and long-term (SMD –0.11, 95% CI –0.45–0.24). Conclusion. There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking. Level of Evidence: 2

Background: Lumbar herniated intervertebral disc (LHIVD) is a common disease that causes low back pain. Traditional Chinese medicine (TCM) with conservative conventional treatment is known to be effective at treating LHIVD, but evidence for complex TCM therapies with conventional intervention has not been sufficiently collected to facilitate quality assessment and synthesis of data. Methods and analysis: Studies were retrieved from the following databases: the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE/PubMed, 7 Korean databases (Korean Studies Information Service System, Korean Traditional Knowledge Portal, Oriental Medicine Advanced Searching Integrated System, Korean National Assembly Digital Library, Korean Association of Medical Journal Editors, National Digital Science Library, and Database Periodical Information Academic), Japan Medical Abstracts Society, and Chinese National Knowledge Infrastructure. The risk of bias of the included studies will be assessed using the Cochrane Assessment Tool for Risk of Bias. Eligible studies were quantitatively synthesized through a meta-analysis. The primary outcome will be pain scales, and the secondary outcomes will include range of motion, questionnaires for lumbar function, questionnaire for quality of life, etc. Ethics and dissemination: Ethical approval was waived for this study protocol because it does not provide any patient data. The results of this review will be disseminated through peer-reviewed publications. Registration number: DOI 10.17605/OSF.IO/K7NJ8 (https://osf.io/k7nj8).

Epidural steroid injections (ESI) are commonly performed for the treatment of chronic cervical disc herniation (CDH). Although they are considered to be effective for both nociceptive and neuropathic types of pain, there is a lack of data regarding the impact of neuropathic pain (NP) and nociceptive pain components on treatment outcomes. The aim of this study is to compare the effectiveness of interlaminar epidural steroid injection (ILESI) between patients with predominantly NP and nociceptive pain due to CDH. Sixty five participants were initially included in the study and assessed by numeric rating scale (NRS), neck pain and disability scale (NPDS), short form-12 (SF-12), and self-reported Leeds assessment of neuropathic symptoms and signs (S-LANSS) pain scale at baseline and 1 month, 3 months, 6 months after ILESI. All patients were evaluated at 1st month and 3rd month follow-up periods while 54 of patients achieved to complete 6th month follow-up. There were significant improvements in all outcome measures for all time periods when compared with the pre-intervention scores. At baseline 24 (36.9%) of patients had predominantly NP in accordance with S-LANSS pain scale. The ratio of NP predominant patients reduced to 7.6% at 1st month, 12.3% at 3rd month, and 12.9% at 6th month with a significant difference for each follow-up period when compared with the baseline. Although all NRS and NPDS scores at baseline were significantly higher in patients with NP, improvement was significant at all follow-up periods in both groups. Minimal clinically important change in NRS was observed in >75% of patients at 1st, 3rd, and 6th month in both groups. The results of this study showed that NP is present in one-third of the patients suffering from neck and radiating arm pain due to CDH and cervical ILESI is an effective treatment approach for both neuropathic and nociceptive components of pain. Clinical Trials Registration Number: NCT04235478

Background: Lumbar disc herniation (LDH) is an important factor of causing leg pain and numbness. As a secondary discipline of Traditional Chinese Medicine, tuina is widely used for the treatment of LDH in China even in other nations while its clinical value is not acknowledged universally. So, we focus on this article aims to evaluate its efficacy and safety of LDH. Methods: Electronic databases involving Cochrane Library, PubMed, Web of Science, EMBASE, China Science and Technology Journal, China National Knowledge Infrastructure, Wanfang and Chinese Biomedical Literature Database will be pertained with appropriate search strategy. And RevMan V.5.3.5 software will be conducted as the assessment tool for bias risk, data synthesis, subgroup analysis as well as meta-analyses. Results: This systematic review will provide a high-quality synthesis of current evidence of tuina for LDH. Conclusion: This protocol will determine whether Tuina is an effective and safe treatment method for LDH.

Background: A very large acceleration in clinical studies on the efficacy of fire needle to treat lumbar disc herniation (LDH) are increasing, while studies on the assessment of its efficacy are still lacking. Therefore, this study will demonstrate the efficacy of fire needle in the treatment of LDH combining with the meta-analysis. Methods: The studies on randomized controlled trials (RCTs) will be searched at the databases of China National Knowledge Infrastructure (CNKI), WANFANG database (Chinese Medicine Premier), Chinese Scientific Journal Database (VIP), Chinese Biomedical Literature database (CBM), PubMed, EMBASE, and Cochrane Library from their inception to May 1, 2020. Results: This authentic and multi-dimensional study will shed light on the referable information for the treatment of LDH with fire needle. Conclusion: This study will evaluate the efficacy of fire needle in the treatment of LDH. Registration: PROSPERO (registration number CRD42020158596).

Background: Both acupoint injection and sacral canal injection are widely adopted in the treatment of lumbar disc herniation (LDH), but there are still doubts about the effectiveness and safety of the 2 methods. Therefore, the objective of the randomized controlled trial is to evaluate the effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH. Method: This is a prospective randomized controlled trial to study the effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH. With the approval by the clinical research ethics committee of our hospital, patients were randomly included into 1 of 2 treatment protocols: (1) acupoint injection group and (2) sacral canal injection group. Patients, doctors, nurses, and research assistants responsible for collecting data were blinded to group allocation. Main outcome observation indicator: visual analogue scale; secondary outcome observation indicator: Oswestry disability index scores; paresthesia score; adverse reactions. Data were analyzed using the statistical software package SPSS version 25.0 (Chicago, IL). Discussion: The effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH were evaluated in this study, and the results of this trial would establish clinical evidence for the adoption of acupoint injection or sacral canal injection to treat LDH. Trial registration number: DOI 10.17605 / OSF.IO / VTFUD

Rationale: We report a case of Schmorl node induced multiple radiculopathy. Patient concerns: A 70-year-old female patient complained of lower back pain in the left leg accompanied by numbness and weakness. Diagnosis: Radiographs showed obvious osteoporosis in the lumbar vertebrae. Computed tomography demonstrated a hole in the upper posterior half of the L2 vertebral body. Magnetic resonance imaging of the lumbar spine revealed a herniated disc involving a protrusion at the posterior wall of the L2 vertebral body, which was present in the left lateral and dorsal epidural spaces. There was significant lumbar stenosis at the L2 vertebral body secondary to dural sac compression due to the mass. Intervention: Left-sided hemilaminectomy was performed at L2 with screw fixation at L1–3. Intraoperatively, the severely ruptured disc compression in the dural sac and nerve root was removed. Outcomes: The patient's leg pain was immediately resolved, and her back pain was reduced. The patient recovered normal motor function at 20 days after surgery. Lessons: A Schmorl node can progress and break through the lumbar vertebral body, resulting in nerve compression. A large proximal herniated mass can cause distal multiple radiculopathy. Therefore, this special case of Schmorl node with multiple radiculopathy should be treated by removing the proximal herniated nucleus pulposus from the vertebral body.

Background: Despite some researchers have compared the safety and effectiveness of percutaneous endoscopic discectomy (PED) and microendoscopic discectomy (MD) for the lumbar disc herniation; however, they got conflicting outcomes in several variables. Therefore, our aim was to clarify whether PED produces less surgical trauma and better clinical results than MD. Methods: A single-center, retrospective cohort trial was conducted for the comparison of the safety and effectiveness between the MD and PED in the patients with lumbar disc herniation who received surgery from May 2016 to July 2018 in our hospital. The inclusion criteria for our investigation included: 1. age of 30 to 60 years; 2. preoperative CT and MRI scans revealed disc herniation; 3. conservative treatment was unsuccessful for at least 6 weeks; 4. patients with no former lumbar surgery history at same level. The follow-ups were performed 6 weeks, 3, 6, 12 and 24 months after the surgery. Numeric Rating Scale, Short-form 36, and Oswestry Disability Index, as well as complications were evaluated in our study. The software of SPSS Version 22.0 (IBM Corporation, Armonk, NY) was applied to analyze all the statistical data. When P is less than .05, the difference is significant in statistics. Results: This protocol will provide a solid theoretical basis for exploring which technique is better in treatment of lumbar disc herniation. Trial registration: This protocol was registered in Research Registry (researchregistry6005).

Study designA biomechanical analysis correlating internal disc strains and tissue damage during simulated repetitive lifting.ObjectiveTo understand the failure modes during simulated safe and unsafe repetitive lifting.Summary of background dataRepetitive lifting has been shown to lead to lumbar disc herniation (LDH). In vitro studies have developed a qualitative understanding of the effect of repetitive loading on LDH. However, no studies have measured internal disc strains and subsequently correlated these with disc damage.MethodsThirty human cadaver lumbar functional spinal units were subjected to an equivalent of 1 year of simulated repetitive lifting under safe and unsafe levels of compression, in combination with flexion (13-15°), and right axial rotation (2°) for 20,000 cycles or until failure. Safe or unsafe lifting were applied as a compressive load to mimic holding a 20 kg weight either close to, or at arm's length, from the body, respectively. Maximum shear strains (MSS) were measured, and disc damage scores were determined in nine regions from axial post-test magnetic resonance imaging (MRI) and macroscopic images.ResultsTwenty percent of specimens in the safe lifting group failed before 20,000 cycles due to endplate failure, compared with 67% in the unsafe group. Over half of the specimens in the safe lifting group failed via either disc protrusion or LDH, compared with only 20% via protrusion in the unsafe group. Significant positive correlations were found between MRI and macroscopic damage scores in all regions (rs > 0.385, P ConclusionIncreased shear strains were observed in the contralateral side to the applied rotation as disc injury progressed from protrusion to LDH. Larger compressive loads applied to simulate unsafe lifting led to frequent early failure of the endplate, however, smaller compressive loads at similar flexion angles applied under safe lifting led to more loading cycles before failure, where the site of failure was more likely to be the disc. Our study demonstrated that unsafe lifting leads to greater risk of injury compared with safe lifting, and LDH and disc protrusion were more common in the posterior/posterolateral regions.Level of evidenceN/A.

Study Design. Systematic review and meta-analysis of comparative studies. Objective. To characterize the association of annular defect width after lumbar discectomy with the risk of symptom recurrence and reoperation. Summary of Background Data. Large annular defect width after lumbar discectomy has been reported to increase risk of symptom recurrence. However, this association has not been evaluated in a systematic manner. Methods. A systematic literature search of MEDLINE and EMBASE was performed to identify comparative studies of large versus small annular defects following lumbar discectomy that reported symptom recurrence or reoperation rates. Main outcomes were reported with pooled odds ratios (OR) and 95% confidence intervals (CIs). Sensitivity analyses were performed to assess the robustness of the meta-analysis findings. Results. After screening 696 records, we included data from 7 comparative studies involving 1653 lumbar discectomy patients, of whom 499 (30%) had large annular defects and 1154 (70%) had small annular defects. Methodological quality of studies was good overall. The median follow-up period was 2.9 years. The risk of symptom recurrence (OR = 2.5, 95% CI = 1.3–4.5, P = 0.004) and reoperation (OR = 2.3, 95% CI = 1.5–3.7, P

Study design Patients scheduled for spinal surgery were screened prospectively for a microbial presence associated with intervertebral disc specimens. Inclusion was limited to patients requiring surgery for any of five conditions: study patients with cervical spine intervertebral herniation (IVH), lumbar spine IVH, lumbar spine discogenic pain, and control patients with idiopathic scoliosis/Scheurermann's kyphosis or trauma/neuromuscular deformity. Exclusion criteria included ongoing systemic infection, abnormal pre-operative white cell counts, documented or suspected spinal infection, or previous surgery to the involved disc. Objective The aim of this study was to test for an association between the presence of a bacterial entity in operated discs and a diagnosis of pathologic disc disease. Summary of background data An association has been described between microbial colonization and progressive intervertebral disc degeneration in 36 herniation patients undergoing microdiscectomies. A total of 19 patients had positive cultures on long-term incubation, with Propionibacterium acnes present in 84% of discs. Materials and methods Discs were harvested during surgery, using strict sterile technique. Each disc was divided, with half the sample sealed in a sterile, commercially prepared anaerobic culture transport container, and half fixed in formalin. Live specimens were cultured for bacteria at a university-affiliated laboratory in a blinded fashion. Fixed pathologic specimens were gram-stained and read by a board-certified pathologist. Results A total of 169 intervertebral discs from 87 patients were evaluated (46 males, 41 females). Positive cultures were noted in 76 of 169 discs (45%), with 34 discs positive for P. acnes and 30 discs positive for Staphylococcus. No pathologic evidence was seen of microorganisms, acute or chronic inflammation, or infection. Pooling the IVH and discogenic pain patients and contrasting them with control patients showed a significant association of IVH with positive bacterial cultures (χ = 15.37; P = 0.000088). Conclusion Endemic bacterial biofilms are significantly associated with IVH and discogenic pain. Level of evidence N/A.

Supplemental Digital Content is available in the text., Cervical radiculopathy is characterized by compression of the roots of the nerve. When conservative treatment fails and symptoms persist or increase in severity, surgical treatment is considered. Anterior cervical discectomy with or without fusion is regarded as the standard treatment for cervical disk herniation. Recently, there is an evolving trend in spinal surgery towards less invasive techniques. Nucleoplasty is a minimally invasive technique in which radiofrequency technology is used for percutaneous decompression. During the last years nucleoplasty has been proven to be a safe and effective treatment to alleviate radiculopathy, caused by a contained disk herniation. Nucleoplasty is usually performed on an outpatient basis and is associated with a fast recovery time. This paper will describe the preoperative and postoperative management of cervical nucleoplasty as well as the surgical technique, accompanied by a video.

Study Design. Multicenter randomized, double-blind, simulated therapy-controlled trial in a cohort of patients with acute low back pain (LBP) due to lumbar disc herniation (LDH). Objective. To assess the benefit of intramuscular-paravertebral injections of an oxygen-ozone (O 2 O 3 ) mixture. Summary of Background Data. Recent findings have shown that O 2 O 3 therapy can be used to treat LDH that fails to respond to conservative management. However, these findings are based on intradiscal/intraforaminal O 2 O 3 injection, whereas intramuscular-paravertebral injection is the technique used most in clinical practice in Italy and other Western countries. Methods. Sixty patients suffering from acute LBP caused by LDH was randomized to an intramuscular O 2 O 3 or control group. Patients were observed up to assess pain intensity, LBP-related disability, and drug intake (15 [V2] and 30 [V3] days after treatment started, and 2 weeks [V4], and 3 [V5] and 6 [V6] months after treatment ended). Results. A significant difference between the 2 groups in the percentage of cases who had become pain-free (61 % vs. 33%, P < 0.05) was observed at V6. Patients who received O 2 O 3 had a lower mean pain score than patients who received simulated therapy throughout the observation period. A significant improvement was observed in LBP-related disability in the study group patients when compared with the control group patients. Active O 2 O 3 therapy was followed by a significantly lower number of days on nonsteroidal anti-inflammatory drugs at V2 and V3 and by a lower number of days at V4. No adverse events were reported. Conclusion. Treatment of LBP and sciatica is a major concern. Although the natural history of acute LBP is often self-limiting, conservative therapies are not always effective; in such cases, 0 2 0 3 intramuscular lumbar paravertebral injections, which are minimally invasive, seem to safely and effectively relieve pain, as well as reduce both disability and the intake of analgesic drugs.