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This study aims to compare the clinical effectiveness of transforaminal endoscopic spine system (TESSYS) technique combined with selective nerve root block (SNRB) in treating patients with far lateral lumbar disc herniation (FLDH) and patients with central or paracentral herniation (C/PDH).Between June 2015 and June 2019, a total of 204 patients (80 males, 124 females; mean age: 62.3±5.4 years; range, 51 to 66 years) with a herniated disc were included. Of these, 22 consecutive adult patients with FLDH formed the FLDH group, while 182 patients with C/PDH formed the C/PDH group. Considering that FLDH was a rare type of LDH and occurred outside the spinal canal, the patients with LDH in the spinal canal (C/PDH) were selected as the controls in our study. All cases received ultrasound-guided SNRB to identify the diseased disc and treated by the TESSYS technique. Data including demographics, duration of operation, duration of hospital stay, surgical cost, complications, Visual Analog Scale (VAS) scores for the back and leg, and Oswestry Disability Index (ODI) scores and the modified MacNab criteria were analyzed.The FLDH group presented the similar clinical outcomes and costs with the C/PDH group. No significant differences in the VAS score, ODI score, and Macnab score were observed between the groups (p0.05 for all). Both groups showed the significantly improved postoperative VAS scores on Day 3, at 1, 3, 6, and 12 months compared to baseline. The postoperative ODI scores at 6 and 12 months were also significantly improved (p0.05). At the final follow-up at 12 months, the FLDH group showed the MacNab criteria rating excellent and good of 81.8% and C/PDH group showed 84.62%.The FLDH patients presented the comparable clinical effectiveness with C/PDH patients. Based on these findings, the TESSYS technique combined with ultrasound-guided SNRB for FLDH is safe and feasible with caution, although the risk of nerve root injury may be worried.

To evaluate lumbosacral transitional vertebrae (LSTV) frequency in patients with low back pain and lumbar disc herniation (LDH) and to analyze correlations between LSTV presence and intervertebral disc degeneration.This retrospective study included patients with low back pain applying between January 2021 and August 2021. Inclusion criteria were age of 18-65, presence of a standing lumbosacral Xray and a lumbar MRI taken within 2 weeks of the indexed symptoms. Patients with a history of spondylolisthesis, spondylodiscitis, scoliosis and vertebral neoplasia were excluded. A total of 1821 patients met the inclusion criteria. Radiographs and MRIs were evaluated by 2 radiologists.Of all patients, 61.4% were female and the mean age was 43.2 ± 12.2. LDH was detected in 57.7% of patients while a LSTV was present in 43.3%. Sacralization and LSTV were significantly different between the patients with and without an LDH. Patients with LSTV had a higher incidence of a LDH affecting 3 or more intervertebral disc levels (p 0.001). There was a significant difference in-between LSTV and non-LSTV groups regarding the M1 and M2 intervertebral disc degeneration levels.A LDH is more common in the presence of a LSTV. Female sex is highly correlated with herniation. Three or more intervertebral disc levels are affected in the presence of an LSTV. Significantly higher degeneration incurs at the M1 and M2 intervertebral levels. Sacralization is a risk factors for a lumbar disc herniation.

There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion.Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36.Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution.Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

We present the largest series of tubular assisted minimally invasive extraforaminal L5/S1 microdiskectomy and describe the operative nuances. An extraforaminal L5/S1 disk herniation poses a surgical challenge as a result of limited access from a high iliac crest, the sacral ala, and the large transverse process of L5 necessitating oblique working angles.This is a case series of 28 consecutive patients who underwent tubular retractor-assisted minimally invasive extraforaminal L5/S1 microdiskectomy between 2017 and 2020 for L5 radiculopathy. Preoperative variables include demographics (age, gender); imaging characteristics (presence of spondylolisthesis, grade and presence of dynamic instability); and patient-reported measures of pain and function. Postoperatively, any complications, pain, and function were documented at 1-day, 3-month, and 12-months follow-up. Statistical analysis involved descriptive analysis of measured variables.Patients (13 females and 15 males) had a median age of 62 years (range: 32-92). One patient demonstrated grade I spondylolisthesis with no dynamic instability. Twenty-six patients (93%) achieved complete pain resolution during the follow-up period. Two patients had persistent or recurrent radicular pain, 1 of whom resolved completely with a redo tubular retractor-assisted minimally invasive microdiskectomy. No other complications were noted during the postoperative follow-up.Tubular retractor-assisted minimally invasive extraforaminal L5/S1 microdiskectomy is an effective approach. Good surgical outcomes are achieved while avoiding the complications associated with more invasive options such as open surgery or fusion.

Giant thoracic disk herniations are calcified hernias that fill40% of the spinal canal and result in myelopathy with associated neurologic symptoms. This is a fairly rare abnormality that requires surgical treatment. Currently, there is no unambiguous opinion about the surgical approach to the treatment for this pathology. It is believed that the most effective method is the anterior approach (minithoracotomy or thoracoscopic approach), which reduces the risks of spinal cord injury but is associated with the risks of damage to the lungs, pleura, and major vessels. A giant thoracic disk herniation is also quite large.We describe the case of a 60-year-old female patient with a giant thoracic disk herniation. Complete removal of the hernia through a minimally invasive dorsal approach was performed, followed by stabilization. In this case, we used 3-dimensional planning with the help of Surgical Theater, as well as intraoperative neuromonitoring. We also used the ZEISS QEVO, a microinspection tool to aid in resection.No complications have been registered after the surgery. In this case, surgery resulted in a curative treatment outcome for the patient.The minimally invasive dorsal approach in the surgery of giant thoracic herniated disks can be successfully used in neurosurgical practice. With this approach, it may be possible to avoid dorsal stabilization, but this requires additional research.

The vacuum phenomenon is often observed in degenerative disc disease, whereas gas-containing disc herniation is relatively rare. Full-endoscopic discectomy at the lumbar spine level via a transforaminal approach, which was established and subsequently refined over the last two decades, requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles. Foraminoplasty, performed with a high-speed drill, is a useful technique to enlarge the foramen, especially when applied at the L5-S1 level, where the trajectory is limited because of anatomical structures such as the iliac crest. Here, we report a case of gas-containing lumbar disc herniation at L5-S1 that was successfully treated by transforaminal full-endoscopic discectomy. The patient was a 62-year-old man with low back pain and pain in the plantar aspect of the right great toe. Magnetic resonance and computed tomography scans demonstrated gas-containing lumbar disc herniation at L5-S1 on the right. Following foraminoplasty, transforaminal full-endoscopic lumbar discectomy was successfully performed under local anesthesia. The patient's symptoms improved immediately after the surgery. Transforaminal full-endoscopic surgery can be effective and minimally invasive even when performed for gas-containing disc herniation. J. Med. Invest. 69 : 328-331, August, 2022.

Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020).The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured.We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.

BACKGROUND: Due to the anatomical characteristics of the anterior epidural space, dorsal migration of material from herniated lumbar disc is quite rare. Also, bilateral foot drop due to unilateral dorsal migration of disc herniation is extremely rare. This report presents a case of sudden bilateral foot drop caused by the unilateral dorsal migration of material from a herniated lumbar disc. CASE DESCRIPTION: A 51-year-old male presented with sudden onset severe leg pain with bilateral foot drop. The patient was referred to our emergency department by a local clinic. Neurological examination showed bilateral ankle and big toe dorsiflexion weakness grade 1. There was no perianal anesthesia, anal sphincter weaknesses, or voiding difficulty. Apart from essential hypertension, this patient’s medical history was unremarkable. Magnetic resonance imaging showed that intervertebral disc material in the dorsal extradural space at the L3-4 level had compressed the dural sac from the left side to the center. We performed an emergency operation. The pathologic result revealed fibrous cartilaginous materials. After the operation, the leg pain was markedly resolved. At postoperative three months, the patient showed improvement of foot drop. CONCLUSION: We recommended emergent mass removal, which produced a favorable outcome.

Background Condoliase-induced chemonucleolysis is a less-invasive alternative treatment for lumbar disc herniation (LDH); however, its long-term clinical outcome is still unclear. This study aimed to investigate 1-year clinical outcomes and assess radiographs after chemonucleolysis with condoliase. Methods We enrolled patients with LDH who received condoliase injection with a follow-up period of >1 year. Sixty patients (37 men, 23 women; mean age, 44.5 ± 18.9 years; mean follow-up period, 22.0 ± 6.0 months) were analyzed. Changes in disc height and degeneration were evaluated using magnetic resonance imaging. Visual analog scale (VAS) scores for leg and back pain and the Oswestry disability index (ODI) were obtained. All data were assessed at baseline, 1-month, 3-month, and 1-year follow-up. Results Surgical treatment was subsequently required in 8 patients (12.5%) after condoliase therapy. Their ODI and VAS scores for leg pain and back pain significantly improved at 1 year, as in those who received condoliase therapy only. On MRI, progression of Pfirrmann grade was observed in 23 patients (44.2%) at 3 months; however, 8 patients recovered to baseline at 1 year. The mean disc height decreased at 3 months; however, it recovered at 1 year. Disc height recovery (disc recovery rate >50%) was observed in 30.8% of the patients. Patients with disc height recovery were significantly younger than those without. Patients with longer symptom duration (≥1 year) showed significantly lower rates of effectiveness compared with those with shorter symptom durations ( Conclusions Chemonucleolysis with condoliase is a safe and minimally invasive treatment. Disc degeneration induced by chemonucleolysis could be recovered, particularly in younger patients. Prolonged symptom duration had adverse effects on outcome; thus, therapeutic intervention at the optimal time is needed.

Background Nowadays, percutaneous endoscopic lumbar discectomy (PELD) has become a popular surgical option for the management of LDH, On the basis of the approach to the herniation disc materials, PELD could be classified into percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). During PETD procedure, especially in in-and-out approach, accurate determination of whether the posterior longitudinal ligament is needed resection seems particularly important.In the study, we tried assessing comparative clinical outcome, surgical duration and complications between the two different surgical methods of LDH treated by PETD via inside-and-out approach. Methods A total of 135 symptomatic LDH patients who were treated by PETD resecting the posterior longitudinal ligament (68 patients) or remaining the posterior longitudinal ligament (67 patients) during the surgery were included in the study. Visual analog scale (VAS) score, Oswestry disability index (ODI) and modified MacNab criteria were used to evaluate clinical outcomes. Operation time, blood loss, recurrence of LDH and other complication such as dural tear, nerve injury, intervertebral infection, etc. of these two groups were recorded. Clinical evaluation was performed preoperatively, immediately postoperatively, and at each follow-up visit (1 month, 3 months, and final follow-up). Results There were 38 males and 30 females in the group A that resecting the posterior longitudinal ligament (mean age = 52.40 ± 8.73 years) and 35 males and 32 females in the group B that remaining the posterior longitudinal ligament (mean age = 53.50 ± 9.24 years). The mean operation time of the group A and the group B respectively, were 82.7 ± 18.5 min and 115.6 ± 24.6 min (P 0.05). There was no significant difference in the complication rate, the excellent/good ratio and the recurrence rate between the two groups (P > 0.05). Conclusion Whether the posterior longitudinal ligament is resected do not make any difference on curative effect in PETD via inside-and-out approach, and remaining the ligament when it’s intact is preferred because of its shorter operation time.

Purpose: It remains unclear whether the long-term results of RCTs regarding the outcome of microdiscectomy for lumbosacral radicular syndrome (LSRS) are generalizable. The purpose of this study was to determine the external validity of the outcome preseneted in RCTs after microdicectomy for LSRS in a patient cohort from a high-volume spine center. Methods: Between 2007 and 2010, 539 patients had a single level microdiscectomy for MRI disk-related LSRS of whom 246 agreed to participate. Questionnaires included visual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36 and Likert scores for recovery, leg and back pain. Lumbar re-operation(s) were registered. Results: Mean age was 51.3, and median time of follow-up was 8.0 years. Re-operation occurred in 64 (26%) patients. Unfavorable perceived recovery was noted in 85 (35%) patients, and they had worse leg and back pain than the 161 (65%) patients with a favorable recovery: median VAS for leg pain 28/100 mm versus 2/100 mm and median VAS for back pain 9/100 mm versus 3/100 mm, respectively. In addition, the median RDQ and OLBD scores differed significantly: 9 vs 3 for RDQ and 26 vs 4 for OLBD, respectively (p < 0.001). Conclusion: In this cohort study, the long-term results after microdiscectomy for LSRS were less favorable than those obtained in RCTs, possibly caused by less strict patient selection than in RCTs. Our findings emphasize that patients, who do not meet the same inclusion criteria for surgery as in RCTs, should be informed about the chances of a less favorable result.

Background The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. Methods A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. Results Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. Conclusions Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.

To evaluate the association between smoking status and patient characteristics and to identify risk factors associated with recurrence in patients who underwent surgery for lumbar disc herniation (LDH). This retrospective study was carried out at Lokman Hekim University, Ankara, Turkey between January 1, 2021 and January 1, 2022. The medical data of patients who underwent microsurgical discectomy for LDH were retrospectively recorded. Patients with any reemergence of LDH within a 6-month period after surgery were defined as having recurrent LDH. A total of 1109 patients were included in the study and mean age was 50.7 ± 14.3 years. The frequency of hernia at L2-L3 and L3-L4 levels was higher in the nonsmoker group (P .001). The frequency of cases with Pfirrmann Grade 4 degeneration was higher in the nonsmoker group than in smokers and ex-smokers (P .001). Protrusion-type hernias were more common in nonsmokers (P = .014), whereas paracentral hernias were more common in smokers (P .001). The overall frequency of recurrence was 20.4%, and was higher in smokers than in non-smokers and ex-smokers (P .001). Multivariable logistic regression revealed that current smoking (OR: 2.778, 95% CI [confidence interval]: 1.939-3.980, P .001), presence of Pfirrmann Grade 45 disc degeneration (OR: 4.217, 95% CI: 2.966-5.996, P .001), and paracentral herniation (OR: 5.040, 95% CI: 2.266-11,207, P .001) were associated with higher risk of recurrence, whereas presence of sequestrated disc was associated with lower risk of recurrence (OR: 2.262, 95% CI:0.272-0.717, P = .001). Taken together, our data show that smoking, increased degree of degeneration and paracentral hernia increase the risk of LDH recurrence, while sequestrated disc appears to decrease risk. Taking steps to combat smoking in individuals followed for LDH may reduce the risk of recurrence in LDH patients.

Objectives The objective is to determine whether the preoperative duration of symptoms can affect the clinical and functional outcomes after microdiscectomy. Method This study is a single blind randomized controlled trial with level 1 evidence. From 3 January 2016 to 15 February 2017, 122 adult patients with symptomatic lumbar disc herniation were divided randomly by computer system into three groups were treated by microdiscectomy at 6 weeks, 3 months and 6 months from onset of symptoms respectively. Ninety‐seven patients, age (19–47) years, 42 males and 55 females, were analyzed at the end of this study with 3 years of follow up. Primary outcome measures are Oswestry Disability Index (ODI), Roland‐Morris Questionnaire (RMQ) and Visual Analogue Scale (VAS) for back pain and leg pain. Secondary outcome measures are post‐operative complications, length of hospital stay and time of return to daily activities. Results There was significant difference in VAS for back pain among study groups (P = 0.002) at 2 weeks). There were significant differences in VAS for leg pain among study groups (P, Patients, with symptomatic lumbar disc herniation and failure of conservative management for 6 weeks, will have better clinical and functional outcomes when surgical treatment of microdiscectomy was done as early as possible.

INTRODUCTION We aimed to identify imaging-based findings that can differentiate between spinal subchondral bone metastasis with focal pathologic endplate fracture and oedematous Schmorl's nodes that have been histopathologically confirmed. METHODS Between March 2010 and April 2016, 11 patients who had undergone spinal magnetic resonance (MR) imaging or computed tomography (CT) with final radiologic reports that included 'subchondral bone metastasis with focal pathologic endplate fracture' or 'edematous Schmorl's node' and had also undergone percutaneous imaging-guided spinal biopsies were included. Two radiologists retrospectively evaluated the following imaging features in consensus: size, location, presence of sclerotic margin, presence of intralesional or perilesional enhancement and opposite endplate enhancement of the involved disc, presence of disc height loss and presence of metabolic uptake at a corresponding lesion on nuclear medicine imaging. RESULTS A total of 11 patients, including six patients with spinal subchondral bone metastasis with focal pathologic endplate fracture and five patients with oedematous Schmorl's nodes, were included in this study (median age, 58 years; range, 50-63 years; six men). Sclerotic margin (P = 0.002) and enhancement on the opposite endplate of the involved disc (P = 0.047) were significantly different between oedematous Schmorl's node and subchondral bone metastasis with focal pathologic endplate fracture. CONCLUSION Sclerotic margin and enhancement on the opposite endplate of the involved disc suggest oedematous Schmorl's node rather than subchondral bone metastasis with focal pathologic endplate fracture. Decreased disc height is likely to be an oedematous Schmorl's node rather than subchondral bone metastasis with focal pathologic endplate fracture.

Objective After percutaneous endoscopic lumbar discectomy (PELD), most patients with lumbar disc herniation (LDH) experience relief from the typical symptoms of low back and leg pain. However, for a small number of patients, these symptoms are relieved immediately after surgery but aggravated soon after, and then relieved after short‐term full rest or conservative treatment. The aim of the study was to demonstrate this short‐term recurrent phenomenon, termed rebound pain. Methods A retrospective study was conducted on 144 patients who underwent single‐segment PELD from May 2017 to June 2020. Postoperative patients were divided into a rebound pain group and a non‐rebound pain group. For the former group, general information, symptom characteristics and visual analogue score (VAS) changes in rebound pain were summarized. For both groups, postoperative efficacy was evaluated by recent VAS of low back and leg pain in the remission stage, the Oswestry disability index (ODI) and the modified MacNab criteria at the last follow‐up. Logistic regression analysis was used to identify predictors for rebound pain. Results The VAS and ODI exhibited significant improvements at the last follow‐up of average 15.4 months (P 45 days was found as a protective factor for rebound pain (p = 0.031). Conclusion Although rebound pain with multiple characteristics and a short duration had no significant effect on long‐term postoperative efficacy, its high incidence often caused unnecessary concern in both patients and doctors. As a result, careful differentiation of rebound pain from other postoperative complications is needed., For patients with lumbar disc herniation, most received relief from low back and leg pain after percutaneous endoscopic lumbar discectomy (PELD). However, 10.4% of patients had short‐term pain recurrence after PELD, termed rebound pain, which could be alleviated by adequate rest and conservative treatment.

Objective To investigate the feasibility and efficacy of percutaneous transforaminal endoscopic discectomy (PTED) with three‐step maneuver for puncture (TSMP) for lumbar herniated disc (LDH). Methods We performed a retrospective review of 30 patients who underwent PTED using TSMP for LDH and met inclusion criteria from January 2018 to September 2018. The primary outcome, leg or back pain, was assessed using Visual Analogue Scale (VAS). Patient surgical satisfaction was measured at 12 months post surgery using a five‐point Likert scale. Potential prognostic factors measured were demographic characteristics, duration of symptom (DOS), and involved levels. Statistical analysis was performed using Fisher exact test and t‐test. TSMP is a three‐step maneuver that builds on the concept of needle puncture site and trajectory determination based on the principles of Kambin's triangle. First, accurate direction of the puncture is confirmed by inserting the needle horizontally. Then by gradually raising the needle tail in the manner described, the superior articular facet and the intervertebral foramen are sequentially located. Finally, the needle tip slides into the intervertebral foramen to reach the target superior articular facet. Results Preoperative mean VAS was 7.6 ± 1.19, which decreased to 1.4 ± 0.97 at 12 months following treatment (P, Three‐step maneuver for puncture (TSMP). Step 1 (A and B): needle is inserted through appropriate entry point and advanced toward spinous process slowly. Step 2 (C and D): needle is pulled out to appropriate length (arrow a). Then, after raising needle tail properly (arrow b), needle will be advanced toward superior articular facet (arrow c). Step 3 (E and F): needle is pulled out to appropriate length again (arrow d). Then, after raising needle tail properly, needle is advanced toward the target (arrow e), and needle tip will slide into the intervertebral foramen along superior articular facet (arrow f).

Background Various surgical techniques have been described to address intraforaminal/extraforaminal lumbar lesions. They vary from the classic posterior open approaches to minimally invasive techniques with tubular retractors and even endoscopy. These lesions have been approached from either an ipsilateral or a contralateral approach. Only a few reports have described a contralateral minimally invasive tubular approach to address these lesions. However, none of them have been able to address calcified pathologies. Method We used a contralateral tubular approach to remove the calcified disc herniations in 2 patients presenting with radiculopathy secondary to a calcified intraforaminal L5-S1 disc herniation. Results Early clinical and radiological outcomes were positive. No perioperative complications occurred. Conclusions To our knowledge, this is the first report of the expanded use of fixed tubular retractors to address calcified lumbar intraforaminal disc herniations. This approach allows a satisfactory access and view of the contralateral foramen and offending lesion. It permits a wide decompression while preserving the facet joint and thus prevents iatrogenic instability. It can also avoid the iliac crest, which does not allow an ipsilateral extraforaminal approach at the L5-S1 level. This approach is a safe and effective way to treat this specific pathology.

OBJECTIVE Although several reports have described adjacent-segment disease (ASD) after posterior lumbar interbody fusion (PLIF), there have been only a few reports focusing on early-onset ASD occurring within 3 years after primary PLIF. The purpose of this study was to investigate the prevalence and postoperative pathologies of early-onset ASD and its relation with radiological parameters such as segmental lordosis (SL). METHODS The authors reviewed a total of 256 patients who underwent single-segment PLIF at L4–5 for degenerative lumbar spondylolisthesis (DLS) and were followed up for at least 5 years. The definition of ASD was a symptomatic condition requiring an additional operation at the adjacent fusion segment in patients who had undergone PLIF. ASD occurring within 3 years after primary PLIF was categorized as early-onset ASD. As a control group, 54 age- and sex-matched patients who had not suffered from ASD for more than 10 years were selected from this series. RESULTS There were 42 patients with ASD at the final follow-up. ASD prevalence rates at 3, 5, and 10 years postoperatively and at the final follow-up were 5.0%, 8.2%, 14.1%, and 16.4%, respectively. With respect to ASD pathologies, lumbar disc herniation (LDH) was significantly more common in early-onset ASD, while lumbar spinal stenosis and DLS occurred more frequently in late-onset ASD. Significant differences were detected in the overall postoperative range of motion (ROM) and in the changes in ROM (ΔROM) at L3–4 (the cranial adjacent fusion segment) and changes in SL (ΔSL) at L4–5 (the fused segment), while there were no significant differences in other pre- and postoperative parameters. In stepwise logistic regression analysis, ΔSL was identified as an independent variable (p = 0.008) that demonstrated significant differences, especially in early-onset ASD (control 1.1° vs overall ASD −2.4°, p = 0.002; control 1.1° vs early-onset ASD −6.6°, p = 0.00004). CONCLUSIONS The study results indicated that LDH was significantly more common as a pathology in early-onset ASD and that ΔSL was a major risk factor for ASD, especially early-onset ASD.

Objective The study introduced uniportal‐bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD). Methods This is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal‐bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement. Results PETD via lumbar foraminoplasty was successfully performed in all cases. The follow‐up points were 3 months, 6 months, and 12 months. The average follow‐up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow‐up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P, Lumbar foraminoplasty is a crucial and challenging step in PETD. In conventional TESSYS, surgeons could not get a direct view of the anatomic structure around the foramen during foraminoplasty with bone reamers or trephines, which is difficult to control the direction and may cause some unexpected complications including neural injury and bleeding. Also, the articular surface of facet joints is not in a sagittal plane or coronal plane, and oblique articular surface makes reamers and trephines easier deviated to ventral direction, which leads to unsatisfactory foraminoplasty. As an original designed technique, UBiSES allows operation with two surgical instruments simultaneously under full‐time and real‐time visualization in just one incision, which could be less invasive and more efficient. Uniportal‐bichannel foraminoplasty assisted by UBiSES could control the direction easier and get a satisfactory bone resect at the dorsal side of foramen with extensive view and space.

Background and purpose — There are several national value sets for SF-6D. For studies conducted in countries without a country-specific value set the authors may use a value set from a neighboring or culturally similar county. We evaluated the consequences of using different national value sets in SF-6D index-based outcome analyses. Patients and methods — Patients surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017 were recruited from the national Swedish spine register. 16,398 procedures were eligible for analysis. The SF-6D health states were coded to SF-6D preference indices using value sets for 9 countries. The SF-6D index distributions were then estimated with kernel density estimation. The change in SF-6D index before and after treatment was evaluated with the standardized response mean (SRM). Results — There was a marked variability in mean and shape for the resulting SF-6D index distributions. There were considerable differences in SF-6D index distribution shape before and after treatment using the same value set. The effect sizes of 2-year change (SRM) were in most cases similar when the 9 value sets were applied on pre- and post-treatment data. Interpretation — We found a marked variability in SF-6D index distributions when a single large data set was applied to 9 national SF-6D value sets. Consequently, we recommend that SF-6D index data from studies conducted in countries without country-specific SF-6D value sets is interpreted with caution.

Background A recent randomized controlled trial (RCT), performed by the authors, comparing early surgical microdiscectomy with 6 months of nonoperative care for chronic lumbar radiculopathy showed that early surgery resulted in improved outcomes. However, estimates of the incremental cost-utility ratio (ICUR), which is often expressed as the cost of gaining one quality-adjusted life year (QALY), of microdiscectomy versus nonsurgical management have varied. Radiculopathy lasting more than 4 months is less likely to improve without surgical intervention and may have a more favorable ICUR than previously reported for acute radiculopathy. Question/purpose In the setting of chronic radiculopathy caused by lumbar disc herniation, defined as symptoms and/or signs of 4 to 12 months duration, is surgical management more cost-effective than 6 months of nonoperative care from the third-party payer perspective based on a willingness to pay of less than CAD 50,000/QALY? Methods A decision analysis model served as the vehicle for the cost-utility analysis. A decision tree was parameterized using data from our single-center RCT that was augmented with institutional microcost data from the Ontario Case Costing Initiative. Bottom-up case costing methodology generates more accurate cost estimates, although institutional costs are known to vary. There were no major surgical cost drivers such as implants or bone graft substitutes, and therefore, the jurisdictional variance would be minimal for tertiary care centers. QALYs derived from the EuroQoL-5D were the health outcome and were derived exclusively from the RCT data, given the paucity of studies evaluating the surgical treatment of lumbar radiculopathy lasting 4 to 12 months. Cost-effectiveness was assessed using the ICUR and a threshold of willingness to pay CAD 50,000 (USD 41,220) per QALY in the base case. Sensitivity analyses were performed to account for the uncertainties within the estimate of cost utility, using both a probabilistic sensitivity analysis and two one-way sensitivity analyses with varying crossover rates after the 6-month nonsurgical treatment had concluded. Results Early surgical treatment of patients with chronic lumbar radiculopathy (defined as symptoms of 4 to 12 months duration) was cost-effective, in that the cost of one QALY was lower than the CAD 50,000 threshold (note: the purchasing power parity conversion factor between the Canadian dollar (CAD) and the US dollar (USD) for 2019 was 1 USD = 1.213 CAD; therefore, our threshold was USD 41,220). Patients in the early surgical treatment group had higher expected costs (CAD 4118 [95% CI 3429 to 4867]) than those with nonsurgical treatment (CAD 2377 [95% CI 1622 to 3518]), but they had better expected health outcomes (1.48 QALYs [95% CI 1.39 to 1.57] versus 1.30 [95% CI 1.22 to 1.37]). The ICUR was CAD 5822 per QALY gained (95% CI 3029 to 30,461). The 2-year probabilistic sensitivity analysis demonstrated that the likelihood that early surgical treatment was cost-effective was 0.99 at the willingness-to-pay threshold, as did the one-way sensitivity analyses. Conclusion Early surgery is cost-effective compared with nonoperative care in patients who have had chronic sciatica for 4 to 12 months. Decision-makers should ensure adequate funding to allow timely access to surgical care given that it is highly likely that early surgical intervention is potentially cost-effective in single-payer systems. Future work should focus on both the clinical effectiveness of the treatment of chronic radiculopathy and the costs of these treatments from a societal perspective to account for occupational absences and lost patient productivity. Parallel cost-utility analyses are critical so that appropriate decisions about resource allocation can be made. Level of evidence Level III, economic and decision analysis.

Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation.To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5-S1 disc herniation.A total of 32 patients (average age: 49.4 years, range: 23-78) with L5-S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical "The Medical Research Council of the United Kingdom" method.The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz-Ilbay plantar flexion test yielded the correct classification for all cases.We suggest that the proposed method "Yilmaz-Ilbay plantar flexion test" can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5-S1 herniation.

Percutaneous cervical nucleoplasty (PCN) is a minimally invasive technique used for the treatment of cervical disc herniation. However, if the lesion is located at the neural foramen, complete access and effective neural decompression are often challenging because of the special anatomical condition of the uncovertebral joint, osteophyte, and facet joint of the cervical foraminal space.To investigate the effect of PCN on radiculopathy caused by foraminal cervical disc herniation (FCDH).Retrospective case series.Single-center tertiary hospital.This study included 44 patients with radiculopathy caused by FCDH who were treated with PCN. Visual analog scale (VAS) scores, preoperative, 1 week, and 3 months postoperatively, and at the last follow-up, as well as the Macnab criteria, were used to evaluate clinical outcomes. A paired t-test was used to compare the preoperative and follow-up VAS scores. The percentage of patients with VAS scoreslt;= 3 at each follow-up time point was also investigated. Statistical significance was set at Plt; 0.05.Twenty-seven men (62.4%) and 17 women (38.6%) were enrolled in this study. The mean age was 54.5 years (range 31-81). The average follow-up period after the operation was 15.4 months (range 3.7-30.8). The mean preoperative VAS was 7.50 ± 1.21. The VAS scores at 1 week, 3 months, and the last follow-up were 4.36 ± 2.46, 3.20 ± 2.58, and 2.91 ± 2.74, respectively, showing a significant improvement in pain compared to before the operation (Plt; 0.001 for all). The number of patients (percentage) with a VAS score oflt;= 3 was 20 (45.5%), 28 (63.6%), and 31 (70.5%) of 44 patients at 1 week, 3 months, and the last follow-up, respectively. The number of patients (percentage) with excellent, good, fair, or poor satisfaction according to the Macnab criteria was 17 (38.6%), 9 (20.5%), 8 (18.2%), and 10 (22.7%) of 44, respectively. No patients experienced postoperative complications.This study was retrospective and included a small number of patients from a single center.Although PCN for radiculopathy caused by FCDH is thought to have limitations because of the surrounding bony structure, the clinical outcome seemed favorable. If PCN is not contraindicated, it may be a viable treatment option for CR due to FCDH.

To investigate the clinical application of two elastic pedicle internal fixation systems in single-segment lumbar disc herniation fenestration.A retrospective analysis of 64 patients with lumbar intervertebral disc herniation treated by surgery from June 2019 to March 2021. According to the different elastic fixation systems placed during the operation, the patients were divided into ordinary pedicle screw elastic rod link group (elastic rod group) and a special elastic pedicle screw rigid rod fixed connection group (elastic screw group). There were 33 cases in the elastic rod group, including 18 males and 15 females, aged from 30 to 69 years old with an average of(49.18±10.23) years old;and 31 cases in the elastic screw group, including 16 males and 15 females, aged from 32 to 68 with an average of (49.81±9.24) years old. The operation time, intraoperative blood loss, postoperative wound drainage, and postoperative landing time of the two groups were recorded separately. The visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) score, and Oswestry Disability Index (ODI) were compared before and 3, 12 months after operation. The height of the adjacent vertebral space on the lateral DR film before and 12 months after the operation was measured. The clinical efficacy was evaluated by Macnab standard.All the patients successfully completed the operation, and were followed up. The operation time, intraoperative blood loss, postoperative wound drainage and postoperative landing time in the elastic rod group were(63.73±12.01) min, (89.55±16.07) ml, (81.67±16.00) ml, (3.45±0.75) d , while in the elastic nail group was (62.96±11.54) min, (88.35±17.14) ml, (82.29±15.40) ml, (3.29±0.78) d, the difference was not statistically significant. The symptoms of low back pain and lower extremity numbness were significantly improved in all patients after operation. There was no significant difference in VAS, JOA score and ODI between the two groups before and after surgery (In fenestrated nucleus pulposus extraction for lumbar disc herniation, the two elastic pedicle internal fixation systems are equally effective and can be used. The elastic screw internal fixation system has certain advantages when the distance between the two vertebral bodies is short, and the elastic rod cannot be placed or is difficult to be placed, and it is more widely used.

To analyze dynamic electromyography characteristics and related factors of lumbar back muscle activity in patients with lumbar disc herniation, and to clarify the clinical significance of dynamic electromyography in the diagnosis and treatment of patients with lumbar disc herniation(LDH).From September 2014 to March 2021, 40 patients with lumbar disc herniation(LDH group) were detected by surface electromyography telemeter. There were 14 males and 26 females, aged from 20 to 61 years old, with an average of(40.68±10.56) years old, the course of illness was from 1 to 120 months, with an average of (17.75±27.56) months. In addition, 12 normal people were recruited as the control group. There were 2 males and 10 females. The age ranged from 24 to 53 years old, with an average of(36.50±10.30) years old. All subjects were subjected to dynamic electromyographic tests of the subthoracic erector spinae, lumbar erector spinae, and multifidus muscles during static standing and trunk flexion and extension. Compare the EMG activity data (average EMG amplitude, median frequency, original EMG graph) of the tested muscles between patients with lumbar disc herniation and normal people, and analyze the correlation between the general data of patients with lumbar disc herniation and the tested muscle EMG data.When standing still, the average electromyographic amplitude of the erector spinal muscle of the right and left thoracic segments of the subjects in the LDH group increased compared with the control group, and the difference was significant(Patients with lumbar disc herniation have characteristic surface EMG changes in the back muscles that are different from those of normal people. These features can more objectively reflect the patient's muscle condition and can be an effective indicator for the diagnosis and treatment effect evaluation of patients with lumbar disc herniation. It can be seen that surface electromyography is not only a detection method, it can be considered in the routine diagnosis and treatment plan of LDH to guide clinical work.

Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction.The patient was a 58-year-old male who presented with both lower limbs numb with intermittent walking weakness, obvious at both ankles, and no obvious inducing and relieving factors. The local hospital considered the diagnosis of lumbar disc herniation after MR examination; he was treated with lumbar fixation and fusion.After admission, a ce-MRA examination showed that the left spinal artery at the T10 level showed small branch blood vessels in the local area. The distal end was unclear, which seemed to be connected with the drainage vein of the spinal cord. The digital subtraction angiography (DSA) result indicated that the left intercostal artery of T10 sent the Adamkiewicz artery down to the level of L4, and an arteriovenous fistula was seen. The fistula was located at the lower edge of the L4 level and then drained to the upper premedullary vein to the level of T4 after a short descending. It was finally diagnosed as a perimedullary arteriovenous fistula.It was cured by cutting the arteriovenous fistula in the spinal canal by indocyanine green-assisted angiography.we report a case of PMAVFS misdiagnosed as lumbar disc herniation with resection and internal fixation. In our hospital, the final diagnosis was a perimedullary arteriovenous fistula, which was cured by cutting off the arteriovenous fistula within the spinal canthus.Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction. It is hoped that this can provide warnings to more neurosurgeons and reduce the occurrence of misdiagnosis.

OBJECTIVE: To investigate the relationships between the bony structures, nerve, and indentations of ligamentum flavum of the upper lumbar spine by using CT three-dimensional reconstruction technique, in order to guide the unilateral biportal endoscopy (UBE) technique via contralateral approach in the treatment of upper lumbar disc herniation (ULDH). METHODS: Twenty-one ULDH patients who were admitted between June 2019 and July 2021 and met the selection criteria were selected as the research subjects. There were 12 males and 9 females with an average age of 62.1 years (range, 55-72 years). The disease duration was 1-12 years (mean, 5.7 years). There was 1 case of L(1, 2), 4 cases of L(2, 3), and 16 cases of L(3, 4). The CT myelography data of T(12)-S(3) segment was saved in DICOM format and imported into Mimics21.0 software for three-dimensional reconstruction. The relationship between the intersection (point Q) of spinous process and the inferior margin of lamina, the indentation of superior margin of ligamentum flavum, the inferior margin of nerve root origin, intervertebral space, and foramen were observed. The Mimics21.0 software was used to create a 3-mm-diameter cylinder to simulate the UBE channel and measure its abduction angle (∠b1), as well as measure the following lumbar vertebra-related indicators: in L(1,2)-L(3,4) segments, the vertical distance from the point Q to the inferior margin of the contralateral lumbar pedicle of the same lumbar vertebra (a1), the superior margin of the contralateral pedicle of the lower lumbar vertebra (a2), the lower endplate of the same lumbar vertebra (a3), the upper endplate of the lower lumbar vertebra (a4); the vertical distance from the lower endplate of lumbar vertebra to the inferior margin of the lumbar pedicle (c1), the vertical distance from the upper endplate of the lower lumbar vertebra to the superior margin of the lumbar pedicle (c2); the vertical distance from the inferior margin of the nerve root origin to the superior margin (d1) and the inferior margin (d2) of the lumbar pedicle, respectively; the vertical distance from the intersection (point P) of the indentation of superior margin of ligamentum flavum and the medial margin of the lumbar pedicle to the superior margin (e1) and the inferior margin (e2) of the lumbar pedicle, respectively; the horizontal distance from the lateral margin of the dural mater (f1) and the narrowest part of the lumbar isthmus (f2) to the facet joint space, respectively. Thirteen of the patients included in the study chose the UBE surgery via contralateral approach. There were 8 males and 5 females with an average age of 63.3 years (range, 55-71 years). The disease duration was 2-12 years, with an average of 6.2 years. There were 3 cases of L(2, 3) and 10 cases of L(3, 4). The perioperative complications and surgical decompression were recorded. And the effectiveness were evaluated by visual analogue scale (VAS) score, Oswestry disability index (ODI), and short form-36 health survey (SF-36) score. RESULTS: The imaging results showed that there was no significant difference in a1, a3, a4, e1, e2, f1, and f2 between segments (P>0.05), and there were significant differences (P

This study aimed to investigate the long-term clinical outcomes after surgical decompression in cauda equina syndrome (CES) and see if any preoperative patient-related factors contributed to this outcome. A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Data regarding outcome parameters from eligible studies were extracted. Meta-analysis was performed using a random-effect model. A total of 852 patients (492 males and 360 females), with a mean age of 44.6 ± 5.5 years from 22 studies diagnosed with cauda equina syndrome and undergoing surgical decompression, were included in the meta-analysis; however, not all studies reported every outcome. The mean follow-up period was 39.2 months, with a minimum follow-up of 12 months in all included studies. Meta-analysis showed that on long-term follow-up, 43.3% [29.1, 57.5] (n=708) of patients had persistent bladder dysfunction. Persistent bowel dysfunction was observed in 31.1% [14.7, 47.6] (n=439) cases, sensory deficit in 53.3% [37.1, 69.6] (n=519), motor weakness in 38.4% [22.4, 54.4] (n=490), and sexual dysfunction in 40.1% [28.0, 52.1] (n=411). Decompression within 48 hours of the onset of symptoms was associated with a favourable outcome in terms of bladder function with 24.6% [1.6, 50.9] (n=75) patients having persistent dysfunction, whereas 50.3% [10.3, 90.4] (n=185) of patients in studies with a mean time to decompression after 48 hours had persistent bladder dysfunction. Other factors such as speed of onset and sex of the patients were not found to significantly impact long-term bladder outcomes. The long-term outcomes of CES after decompression are enumerated. Decompression within 48 hours of the onset of symptoms appears to result in fewer patients with persistent bladder dysfunction. However, a randomized controlled trial is required to conclusively determine whether early decompression leads to better outcomes.

INTRODUCTION The degenerative process of the intervertebral disc is a heterogeneous process that may exist in two forms, and involves dominant degenerative changes within the nucleus pulposus and the annulus fibrosus. In degenerative disc disease, the oxidative stress factor can play an important role. OBJECTIVE The aim of research was to present a new approach to understanding the role of the analyzed elements in the process of degeneration of the intervertebral disc. MATERIAL AND METHODS Selected elements from oxidative groups (Fe, Zn, Mo, As, Se), associated with enzymatic processes (Fe, Mo, Se, Zn, Ag, As, Bi), metals (Fe, Zn, Mo, Li) and metalloids (As, Bi) and their content was analyzed depending on the changes in the radiological images of the intervertebral disc. Elemental content analysis was performed by Inductively Coupled Plasma Mass Spectrometry analytical technique. RESULTS The similarity between Fe and Se has been demonstrated during different stages of the analysis of groups of patients with degenerative disc disease. There was a negative correlation between Li and degenerative disc disease. The results also suggest that Fe and Ag are involved in degenerative changes within the intervertebral disc. A potential relationship between As/Bi and Fe/Mo in the degeneration of the intervertebral disc was demonstrated. CONCLUSIONS Only some of the correlations can be explained by the metabolism of morphological elements of the intervertebral disc. The relationships indicate new directions for further studies on the degeneration process of the intervertebral disc. The presented study may reflect metabolic changes in the intervertebral disc and adjacent structures in response to the progressive degenerative process.

Background Neovasculogenesis is characteristic of herniated lumbar discs, in which extruded nucleus pulposus is prone to heme iron-induced cytotoxicity (increased oxidative stress causing ferroptosis). However, recent analyses of neovascularization are very complicated, and the mechanism of action is rarely reported. Methods Matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry (MALDI-TOF MS) was performed to analyze human herniated and nonherniated nucleus pulposus. Then, the clinical relevance of the MALDI-TOF MS results and Pfirrmann classification of the degenerative nucleus pulposus were analyzed. To explore the mechanism, the heme-induced ferroptosis effect was evaluated at both the tissue and cell levels using high-resolution MALDI-TOF MS and molecular biology methods. Results The spectra revealed that hemoglobin (Hb) and heme signals were greatly increased, thus serving as predictors of vasculogenesis in herniated nucleus pulposus. The clinical relevance analysis demonstrated that the intensity of Hb and heme peaks was closely related to the Pfirrmann classification of degenerative nucleus pulposus. Mechanistically, increased heme catabolism and downregulation of glutathione peroxidase 4 (GPX4) levels were detected in herniated nucleus pulposus, reflecting iron-dependent cell death or ferroptosis. Iron levels was also increased in herniated nucleus pulposus compared with that in nonherniated nucleus pulposus. Furthermore, accuracy mass measurements confirmed that the levels of ferroptosis-related metabolites, such as glutathione, arachidonic acid (AA), sphinganine, polyunsaturated fatty acid (PUFA), and tricarboxylic acid (TCA) cycle metabolites, were significantly different between herniated and nonherniated tissues, indicating that the interior of the herniated tissues is a pro-oxidant environment. Moreover, heme-induced ferroptosis was verified in human nucleus pulposus cells (HNPCs), and the underlying mechanism might be associated with the Notch pathway. Conclusions Neovascularization in herniated nucleus pulposus may expose tissues to high levels of heme, which can induce cytotoxicity and ferroptosis within tissues and accelerate the progressive degeneration of herniated nucleus pulposus. This study is beneficial for understanding the pathological mechanism of herniated nucleus pulposus and facilitating the development of nonoperative interventions for treating lumbar disc herniation (LDH).

Retrospective cohort study.Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs).Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined.Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge.Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P 0.01).Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4.

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

This work aimed to explore the relationship between spine surgery lumbar facet joint (LFJ) and lumbar disc herniation (LDH) via compressed sensing algorithm-based MRI images to analyze the clinical symptoms of patients with residual neurological symptoms after LDH. Under weighted BM3D denoising, Epigraph method was introduced to establish the novel CSMRI reconstruction algorithm (BEMRI). 127 patients with LDH were taken as the research objects. The BEMRI algorithm was compared with others regarding peak signal-to-noise ratio (PSNR) and structural similarity index (SSIM). Patients’ bilateral LFJ angles were compared. The relationships between LFJ angles, lumbar disc degeneration, and LFJ degeneration were analyzed. It turned out that the PSNR and SSIM of BEMRI algorithm were evidently superior to those of other algorithms. The proportion of patients with grade IV degeneration was at most 31.76%. Lumbar disc grading was positively correlated with change grading of LFJ degeneration ( P < 0.001 ). LFJ asymmetry was positively correlated with LFJ degeneration grade and LDH ( P < 0.001 ). Incidence of residual neurological symptoms in patients aged 61–70 years was as high as 63.77%. The proportion of patients with severe urinary excretion disorders was 71.96%. Therefore, the BEMRI algorithm improved the quality of MRI images. Degeneration of LDH was positively correlated with degeneration of LFJ. Asymmetry of LFJ was notably positively correlated with the degeneration of LFJ and LDH. Patients aged 61–70 years had a high incidence of residual neurological symptoms after surgery, most of which were manifested as urinary excretion disorders.

BACKGROUND: Clinical studies assessing the impacts of ozone on the musculoskeletal framework are slowly expanding. OBJECTIVE: In this study, we analyzed the impact of paravertebral ozone treatment (OT) injection treatment on distress and disability in patients with lumbar disc hernia (LDH). METHODS: The records of 432 patients with L4-5 and L5-S1 LDH were examined retrospectively. 298 patients who met the inclusion criteria and who provided written informed consent were divided into two groups. Each group received 15 sets of physiotherapy at a rate of five sets every week (study group (n= 139), control group (n= 159)). Six OT injections were applied solely to the study group, two days per week. A visual pain score (VAS) was set up for distress and the Oswestry Disability Questionnaire (ODI) for disablement was administered when the groups were called to control before treatment, towards the end of the treatment, and three months after the treatment ended. RESULTS: The groups had significantly reduced (p< 0.05) VAS and ODI scores following and three months after the treatment contrasted with their scores before the treatment. The Physiotherapy + OT group had significantly lower (p< 0.05) VAS and ODI scores than the physiotherapy group following and three months after the treatment. CONCLUSIONS: Paravertebral OT injection is quite a safe and helpful treatment technique in LDH patients. Further studies should be conducted to investigate the long-term outcomes of the paravertebral OT application.

Chemonucleolysis with condoliase, which degrades chondroitin sulfate, could be a new, minimally invasive therapeutic option for patients with lumbar disc herniation (LDH). The purpose of this study was to analyze prognostic factors for clinical outcomes in LDH patients subjected to chemonucleolysis with condoliase.Inclusion criteria for this procedure were 1) 18-70 years of age; 2) unilateral leg pain and positive straight leg raise (SLR) (70°) or femoral nerve stretching test; 3) subligamentous extrusion verified on magnetic resonance imaging; 4) neurological symptoms consistent with a compressed nerve root on magnetic resonance imaging (MRI) images; and 5) minimum six months of follow-up. In total, 82 patients (55 men, 27 women; mean age, 47.2 ± 15.5 years; mean follow-up, 9.1 ± 3.0 months) who underwent chemonucleolysis with condoliase for painful LDH were included. An improvement of 50% or more in the Visual analogue scale (VAS) of leg pain was classified as effective.Seventy patients (85.4%) were classified into the effective (E) group and 12 patients (14.6%) into the less-effective (L) group. Surgical treatment was required in four patients. No severe adverse complications were reported; 41.3% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level. Univariate analysis revealed that young age (p = 0.036), without history of epidural or nerve root block (p = 0.024), and injection into the central portion of the intervertebral disc (p = 0.014) were significantly associated with clinical effectiveness. A logistic regression analysis revealed that injection into the central portion of the intervertebral disc (p = 0.049; odds ratio, 4.913; 95% confidence interval, 1.006-26.204) was significantly associated with clinical effectiveness.Chemonucleolysis with condoliase is a safe and effective treatment for painful LDH; 85.4% of the patients showed improvement after the treatment without severe adverse events. To obtain the best outcome, condoliase should be injected into the center of the intervertebral disc.

Cervical chest pain (CCP), as 1 atypical symptom associated with cervical spondylosis, often overlaps with other chest-related diseases. CCP obviously relieved after ultrasound-guided cervical nerve root block near a herniated disc should be considered as a potential pathologic source. The purpose of this study is to investigate whether coblation discoplasty can alleviate CCP after positive ultrasound-guided nerve root block.From August 2016 to September 2019, 21 patients with high suspicion of CCP experienced over 50% pain relieve after ultrasound-guided diagnostic nerve root block. Through 12 months of follow-up, the primary efficacy was assessed with visual analogue scale (VAS) of CCP, and secondary outcomes included: neck pain VAS, neck disability index (NDI), the proportion of significant CCP relief, the rating of CCP alleviation, the patient satisfaction index (PSI), and analgesic consumption. Adverse events were recorded to evaluate safety.Following postoperative 12 months, a time-course analysis confirmed a robust decline in VAS of CCP (P0.0001), and a similar recovery trend was shown in VAS of neck pain and NDI (P0.0001). After treatment, the number of patients taking analgesics decreased (P0.0001), and around 60% of patients reported notable relief and satisfaction with treatment. No serious complications were observed.After positive ultrasound-guided nerve root block, coblation discoplasty can provide up to 12 months of relief for intractable CCP.

Neuromuscular reeducation of the muscles that stabilize the spine is the basis of conservative treatment of disc herniation. Therefore, it is important to investigate how these muscles are affected by disc herniation. The aim of this study was to investigate the effect of disc herniation, herniation severity, patient age, and biomechanics on the lumbar stabilizer muscles. A total of 330 individuals, including 261 patients with disc herniations and 69 without disc herniation participated in this study. The cross-sectional areas (CSAs) of the lumbar stabilizer muscles and the lumbar lordosis angle were evaluated by magnetic resonance imaging (MRI), according to the severity of the disc herniation and the patient's age. In the patients with disc herniation, the CSAs of the quadratus lumborum (QL) and the multifidus (MF) muscles were decreased. The psoas major (PM) muscle CSA was higher in the patients with sequestered discs than in those with protruded and extruded discs. A negative relationship between the sagittal curve and the PM muscle CSA was found. In addition, MF muscle CSA was found to decrease at age 45 years and over. Although disc herniation negatively affects muscle CSAs, no linear relationship was found between the severity of the herniation and the muscle CSA. In addition, the PM muscle was found to be a strong compensatory muscle in disc herniation.

The aim of this retrospective study is to evaluate and compare the clinical and radiological results of the use of Zero-P implant and the integrated cage-plate implant in surgical treatment of single level cervical disc disease. It includes 54 consecutive patients who underwent single level anterior cervical discectomy and fusion. The patients were divided into 2 groups. Group (A) including 28 patients operated with zero- profile implant and group (B) including 26 patients operated with integrated cage-plate implant. Mean operative time, blood loss, incidence of dysphagia and any other complications related to the procedure were recorded and compared. Patients were assessed radiologically by measuring cervical lordosis using the Cobb angle and the segmental angle. Patients were assessed clinically by the Japanese orthopedic association score and the neck disability index. These values were also compared. The mean age of the patients in group (A) was 49.5±11 years, and in group (B) it was 49.8±11.6 years. Mean blood loss and operative time in group (A) were 77.3±9.4 ml and 72.1±7.9 minutes, while in group B, they were 80.7±9.5 ml and 74.8±8.4 minutes with no statistically significant difference between both groups. There were also no statistically significant difference between both groups as regards incidence of dysphagia, clinical scores nor radiological parameters. In conclusion, both zero-profile implant and integrated cage-plate implant have comparable satisfactory clinical and radiological results in treatment of single level cervical disc diseases with little complications.

This retrospective study aimed to compare the clinical and radiological outcomes of transforaminal lumbar interbody fusion (TLIF) through the Wiltse approach (W-TLIF) vs minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion (ME-TLIF) in single-segment lumbar disc herniation (LDH).A retrospective study was conducted to study the differences in specific clinical outcomes between single-segment LDH patients receiving W-TLIF and ME-TLIF. Single-segment LDH patients admitted to the Fujian Medical University Union Hospital from March 2015 to June 2018 were included. All the participants were divided into the ME-TLIF group or the W-TLIF group according to their TLIF surgery types. Demographic characteristics, the visual analog score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scale, blood loss volume, postoperative drainage, ambulated time, initial postoperative back pain, hospitalization duration, expenses, and improvement rates of patients in the two groups were collected for analysis. Radiographic fusion was ultimately assessed via the Bridwell interbody fusion grading system. All selected patients with TLIF were followed up for 1 year.Fifty-seven patients were selected, with 26 in the ME-TLIF group and 31 in the W-TLIF group, both of whom were followed up for 1 year. The mean age of the included patients was 53.75 ± 9.313 years, and the sex ratio was indiscrimination. There was no significant difference in demographic data or operating time between the two groups prior to surgery. The blood loss volume (ME-TLIF: 228.5 vs W-TLIF: 681.3), postoperative drainage (ME-TLIF:82.1 ± 23.5 vs W-TLIF: 345.8 ± 65.2), initial postoperative back pain (ME-TLIF: VAS_3 days: 1.96 ± 0.60 VAS_7 days: 1.73 ± 0.53, W-TLIF: VAS_3 days: 2.48 ± 0.51 VAS_7 days: 1.87 ± 0.43), and hospitalization duration (ME-TLIF: 9.04 vs. W-TLIF: 11.29) were all significantly lower in the ME-TILF group (p 0.05). However, there were no statistical differences between the two groups in VAS, ODI, and JOA at 1 month, 3 months, 6 months, and 1 year postoperatively (p 0.05). The fusion rates of the two groups showed no notable difference (p 0.05), while the X-ray exposure time in the ME-TLIF group was significantly longer than in the W-TLIF group (p 0.05).ME-TLIF surgery was an effective and satisfactory surgical technique to manage LDH. Although ME-TLIF increased the operation time and intraoperative fluoroscopic irradiation volume, it could effectively relieve low back pain from early postoperative onset and promote early postoperative recovery compared with W-TLIF.

OBJECTIVE: To investigate the effectiveness of the unilateral biportal endoscopy (UBE) technique in the treatment of high-grade migrated lumbar disc herniation (LDH). METHODS: Between January 2020 and February 2021, 23 cases of high-grade migrated LDH were treated with discectomy via UBE. There were 14 males and 9 females, with a mean age of 48.7 years (range, 32-76 years). All patients had low back and leg pain. The disease duration ranged from 2 months to 7 years (median, 13 months). Lesion segments were L(3, 4) in 2 cases, L(4, 5) in 15 cases, and L(5), S(1) in 6 cases. The operation time, intraoperative blood loss, the time when the patients started to move off the floor, and postoperative complications were recorded. The effectiveness was evaluated using the visual analogue scale (VAS) score, the modified Oswestry disability index (ODI), and the modified MacNab criteria. RESULTS: All operations were completed successfully, and no complication such as dural tear, epidural hematoma, nerve injury, or vascular injury occurred. The operation time ranged from 53 to 96 minutes, with an average of 71.0 minutes. The intraoperative blood loss ranged from 32 to 56 mL, with an average of 39.3 mL. All patients were removed the drainage tube and wore a lumbar brace to move off the floor around 1 to 2 days after operation. All patients were followed up 3-12 months after operation, with an average of 5.7 months. The VAS scores of low back pain and leg pain and the modified ODI at all postoperative time points were lower than those before operation, and the differences were significant (P

BACKGROUND Pancoast tumors, also called superior sulcus tumors, are a rare type of cancer affecting the lung apex. These tumors can spread to the brachial plexus and spine and present with symptoms that appear to be of musculoskeletal origin. CASE REPORT A 59-year-old Asian man presented to a chiropractor in Hong Kong with a 1-month history of neck and shoulder pain and numbness that had been treated unsuccessfully with exercise, medications, and acupuncture. He had an active history of tuberculosis, which was currently treated with antibiotics, and a 50-pack-year history of smoking. Cervical magnetic resonance imaging (MRI) was performed urgently, revealing a small cervical disc herniation thought to correspond with radicular symptoms. However, as the patient did not respond to a brief trial of care, a thoracic MRI was urgently ordered, revealing a large superior sulcus tumor invading the upper to mid-thoracic spine. The patient was referred for medical care and received radiotherapy and chemotherapy with a positive outcome. A literature review identified 6 previously published cases in which a patient presented to a chiropractor with an undiagnosed Pancoast tumor. All patients had shoulder, spine, and/or upper extremity pain. CONCLUSIONS Patients with a previously undiagnosed Pancoast tumor can present to chiropractors given that these tumors may invade the brachial plexus and spine, causing shoulder, spine, and/or upper extremity pain. Chiropractors should be aware of the clinical features and risk factors of Pancoast tumors to readily identify them and refer such patients for medical care.

Objective The aim of the present study was to compare the clinical outcomes and quality of life following percutaneous transforaminal endoscopic discectomy (PTED) and microscope‐assisted tubular discectomy (MTD) for lumbar disc herniation (LDH). Methods This study had a retrospective design. From June 2017 to June 2018, the clinical data of 120 patients with LDH treated with PTED (60 cases, PTED group) and MTD (60 cases, MTD group) were analyzed and followed up for at least 20 months. There were 59 men and 61 women. Patients were aged between 22 and 80 years. The operation time, intraoperative blood loss, incision length, frequency of intraoperative fluoroscopy, cost, hospital stay, types of herniated discs, complications, and clinical outcomes were evaluated. Clinical outcomes were assessed using the visual analog scale (VAS), the Oswestry disability index (ODI), and the modified Macnab criteria. Short‐Form 36 (SF‐36) and the EQ‐5D‐5L were used to evaluate the quality of life of patients. The data between the two groups were compared by independent sample t‐tests. Multiple comparisons between samples were analyzed by analysis of variance. Results Compared with the MTD group, the PTED group had shorter incision length (9.20 ± 1.19 mm vs 26.38 ± 1.82 mm), less intraoperative blood loss (18.00 ± 4.97 mL vs 39.83 ± 6.51 mL), and shorter hospital stay (5.42 ± 5.08 days vs 10.58 ± 3.69 days) (P = 0.00). PTED was much more appropriate for foraminal and extraforaminal disc herniation. The incidence of paresthesia was lower in the PTED group (6.67% vs 16.67%). At each follow up, the VAS and ODI scores of all patients were significantly improved compared with those before surgery (P = 0.00). At 3 days postoperatively, the lumbar VAS score of the PTED group was significantly lower (1.58 ± 1.00 vs 2.37 ± 1.10, P = 0.00). The excellent rate of the PTED group reached 91.67%, and that of the MTD group reached 93.33%. Compared with the preoperative SF‐36 scores for physiological function, mental health, and social function, the postoperative scores were significantly improved in both groups (P = 0.00). The EQ‐5D‐5L in the PTED group increased from 0.30 ± 0.17 before the operation to 0.69 ± 0.13 after 6 months of follow up (P = 0.00) and 0.73 ± 0.14 after 20 months of follow up. The EQ‐5D‐5L in the MTD group increased from 0.28 ± 0.17 before the operation to 0.68 ± 0.13 after a 6‐month follow up (P = 0.00), and 0.73 ± 0.12 after a 20‐month follow up. Conclusion Although both PTED and MTD are effective for LDH, PTED is much more appropriate for various types of LDH and has the advantages of the low incidence of low back pain, fewer complications, and early recovery., Schematic illustration

Symptomatic lumbar disc herniation (LDH) is widely treated using percutaneous endoscopic lumbar discectomy (PELD). In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over‐invasion of the undegenerated annulus fibrosus. A wide range of intraoperative exploration also induces an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe case. Hence, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression. However, the classical disc staining technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered, even induces unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is accomplished more effectively by designing procedures that perform fully visible disc staining under spinal endoscope. There is no specific research to discuss the technique note of endoscopic staining in PELD surgery. We have come up with a new original technology of endoscopic staining with methylene blue injection in PELD for treatment of LDH., This current study is to display a series cases using a new and original endoscopic disc staining. This modified technique can fully observe the process of disc staining. It also minimizes the iatrogenic injury of the intraoperative undegenerated annulus fibrosus. In addition, the learning curve is smooth and it is easy to master this technique for experienced orthopedic and neurosurgical spine specialists.