Introduction. Herniation pits had been considered as a normal variant, a cystic lesion formed by synovial invagination. On the contrary, it was also suggested that herniation pits were one of the diagnostic findings in femoroacetabular impingement (FAI) because of the high prevalence of herniation pits in the FAI patients. To date, the exact etiology is still unknown. The purpose of this study was to evaluate whether there is an association between the presence of herniation pits and morphological indicators of FAI based on computed tomography (CT) examination. Materials and methods. We reviewed the CT scans of 245 consecutive subjects (490 hips, age: 21–89 years) who had undergone abdominal and pelvic CT for reasons unrelated to hip symptom from September, 2010 to June, 2011. These subjects were mainly examined for abdominal disorders. We confirmed by the questionnaire survey that there were no subjects who had symptoms of hip joints. We reviewed them for the presence of herniation pits and the morphological abnormalities of the femoral head and acetabulum. Herniation pits were diagnosed when they were located at the anterosuperior femoral head-neck junction with a diameter of more than 3 mm. We measured following four signs as indicators for FAI: α angle, center edge angle (CE angle), acetabular index (AI), and acetabular version. Mann-Whitney U-test was used for statistical analysis. Results. Herniation pits were identified in 61 of the 245 subjects or, with respect to individual hips, in 85 (17%) of 490 hips. The prevalence of herniation pits in younger subjects (<60 years, 240 hips) and elderly subjects (≥60 years, 250 hips) were 16.3% and 18.4%, respectively. Among 85 hips, the mean diameter of herniation pits was 5.9 ± 2.4 mm and it was significantly larger (p<0.01) in the elderly subjects (7.1 ± 2.4 mm) than in the younger subjects (4.7 ± 1.7 mm). In terms of the α angle, there were significant differences between the group with (49.8 ± 16.6°) and without herniation pits (40.7 ± 6.7°) in the elderly subjects, whereas not significantly different among the younger subjects. Measurements of the acetabular coverage (CE angle, AI) and the acetabular version showed no significant difference between the subject with and without herniation pits. Discussion. In the present study, the prevalence of herniation pits was 17% in asymptomatic Japanese general population. The fact that the size of the herniation pits enlarge with age may suggest these cystic lesions have degenerative characteristics with no association with FAI. Although large α angles have been recognized as a predictor of cam impingement especially in young population, it was impossible to show the relationship between α angle and presence of herniation pits in young population. These results suggest that the presence of the herniation pits has little relevance to FAI diagnosis

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

Purpose: Calcified thoracic discal herniation is an uncommon entity. The purpose of this study was to analyse the population concerned to search for radiological signs of sequellar Scheuermann disease and the characteristic features of hernias in this context and to compare computed tomography (CT) and magnetic resonance imaging (MRI) findings with intraoperative and histological findings. Material and methods: A retrospective series of 13 patients with symptomatic calcified thoracic discal herniation (CTDH) who underwent surgery from 1996 to 2001 was analysed. Mean age was 50.7 years. The population included ten men and three women. CT was performed in all cases, with myelography in two. MRI was performed in eleven cases with DTPA-gadolinium injection in six. Two neuroradiologists blinded to intraoperative findings reviewed the images independently to search for radiological signs predictive of dural adherence and/or penetration and the presence of Scheuermann squellae. Pathology data were available for five patients. Results: All herniations occurred in the mid to lower thoracic level in patients in their fourth or fifth decade. The disk was calcified at the zone of herniation in all cases. The hernia occupied more than half of the spinal canal in 70% of patients. The nature of the lesion was analysed on axial CT and T1/T2 weighted MRI sequences with fat suppression. Images confirmed the pathological findings: the majority of the calcified herniations were composed of mature haversian bone. In ten of the eleven cases, the radiological interpretation of the hernia/dural interface was found to correspond to the intraoperative observation. Discussion: The sensitivity and specificity of T2 weighted MRI with gadolinium injection of the hernia/dural interface is superior, enabling prediction of dural penetration. Sequellae of Scheuermann disease found in five patients confirmed a probably non-fortuitous association. Conclusion: The natural history of CTDH starts with discal calcification in a degenerative spine during posterior migration, followed by bone metaplasia which can involve neighbouring structures such as the longitudinal ligament and lead to penetration of the dura by the mature ossified lesion

Purpose of the study: Discal herniation is an exceptional cause of lumbar canal stenosis. When surgery for this disorder was first performed in the sixties, discectomy was not exceptional because discal protrusions were frequent. It was rather rapidly observed however that these protrusions were actually osteoarthitic discal rims that do not cause root compression. Discectomy was thus almost completely abandoned for lumbar stenosis surgery. Consequently, the development of true discal herniation after surgery for lumbar canal stenosis is highly exceptional. To our knowledge, this situation has not been reported in the literature. Among several hundred procedures for decompression of the lumbar canal practised in our unit over the last thirty years, we have observed seven cases. Material and methods: The patients were aged 43 to 74 years at the time of reoperation (mean 61 years). The stenosis was at the L4-L5 level in all patients and extended to L3-L4 in three and to L5-S1 in two and was bilateral in one patient. The L4-L5 disk had been removed at the prior surgery in three patients. Delay to recurrent pain was variable, from six months to eleven years. The sciatic pain was associated with motor disorders in one patient. Discal herniation was observed at the L4-L5 level in all patients and was often voluminous, excluded in three patients. Reossification was present in one patient but did not have a compressive effect. Treatment after recurrence was chemonucleolysis in three patients, with two successes and one failure. Surgical treatment by discal excision was used in four cases associated with instrumented fusion in one patient. Results: The patients were reviewed at one to ten years after the second operation. Nucleolysis was successful in two and a failure in one. The patient with failure of nucleolysis was treated by a new decompression with fusion and achieved an excellent result at ten years. Pain relief was achieved after surgery in all patients though only partial in one. Discussion and conclusion: Discal herniation is rare in elderly subjects and can cause problems late after surgical decompression of lumbar canal stenosis. It is important to search for discal herniation which is not always easy to confirm radiologically due to postoperative remodeling. Chemonucleolysis is an effective and economical solution when the disk has not been resected during the first procedure. When an operation is necessary, spinal fusion is not useful except in case of associated instability

Objective: To determine the late (2–5 years) clinical results of surgery for herniated lumbar disc (HLD) as related to duration of preoperative symptoms and type of herniation. Methods: The study was limited to 63 adult Moslem Arab residents of the hospital’s catchment area. All subjects had been scored for pre and postoperative leg pain and for related disability using a 0–11 visual analog scale and a functional grading system (Spangfort’s), respectively. Relationships between duration of preoperative symptoms and extent of disc herniation with the above scores were statistically analyzed. Results: The mean overall score for leg pain decreased from 7.2 ± 2.0 (preoperatively) to 3.4 ± 2.4, a mean reduction (ΔVAS) of 3.1 ± 2.7, a 43.3% change (P< 0.001). Patients operated upon within 4 weeks after onset of symptoms attained the highest degree of leg pain relief (ΔVAS 4.3 ± 2.6), those operated within 4–12 weeks reported the least relief of leg pain (ΔVAS 1.7 ± 2.8). Paradoxically, patients who underwent surgery after 12 weeks received better results than the 4 – 12 week group (ΔVAS 3.0 ± 1.3). Patients with non-contained herniation reported a more intense preoperative leg pain than those defined as contained (VAS 8.3 vs. 6.5), were operated earlier (7.4 vs. 15.8 weeks), and their functional outcome was graded as better (Good/Fair in 96.4% vs. 74.3%). Conclusions: Patients with incapacitating radicular pain, not responding to conservative treatments, are best operated upon within 6 weeks of onset. Surgery for non-contained herniation achieves a higher long-term success rate, probably since severe pain hastens surgical procedure, thereby preventing irreversible root damage

We estimated the long term results of the different methods in chirurgical treatment of lumbar disk herniation in consideration with the presence or absence of degenerative changes and the grade in witch these factors influence the result of this kind of treatment. Seventy eight patents with lumbar disk herniation have been submitted in partial discectomy. The men were 42 and 36 women. The patients were separated in tow groups. In the first group [48 patients, 31 of them (A1) without degenerative changes, while the 17 (A2) with degenerative changes], was applied macrodiscectomi. In the second group [30 patients, 18 of them (B1) without degenerative changes and the 12 (B2) with changes], was applied microdiscectomi with use of magnifying lenses. The mean age during operation was 44 years (18–67) and 38 years (24–62) respectively for the tow groups, and the mean time of follow-up was 7 years and 8 months (18 months-13 years). For all patients, the operation was executed from the same surgeon. The elements that were evaluated were the Visual analog scale (VAS, O-10), the Oswestry Disability Index (ODI), as well as the complications during and after the operation and the cases that required a reoperation. In the first group VAS score was improved from 9.1 to 3.1 and the ODI score was improved from 86% to 24.2%. In the second group VAS score was improved from 9 to 2.6 and the ODI score was improved from 84.2% to 19.2%. From all patients, subgroup B1 without degenerative changes, which was submitted in microdiscectomy presented the biggest improvement. We have had to reoperate 6 patients (7.8%). In cases of lumbar disk hernia both methods are appropriate and lead to a considerable improvement of the symptoms. Degenerative changes of the lumbar spine is a factor that leads in less satisfactory results

Introduction. Herniated disc tissue removed at surgery usually appears degenerated, and MRI often reveals degenerative changes in adjacent discs and vertebrae. This has fostered the belief that a disc must be degenerated before it can herniate, which has medicolegal significance. We hypothesise that degenerative changes in herniated disc tissues differ from those found in tissues that have degenerated in-situ, and are consistent with being consequences rather than causes of herniation. Methods. Surgically-removed discs were examined using histology, immunohistochemistry and confocal microscopy. 21 samples of herniated tissues were compared with age-matched tissues excised from 11 patients whose discs had reached a similar Pfirrman grade of degeneration but without herniating. Degenerative changes were assessed separately in three tissue types (where present): nucleus, inner annulus, and outer annulus. Mann-Whitney U tests were used to compare ‘herniated’ vs ‘in-situ’ tissues. Results. Herniated tissues showed significantly greater cellularity (annulus), greater proteoglycan loss (outer annulus), greater neovascularisation (annulus), greater innervation (annulus) as judged by PGP 9.5 staining, greater expression of matrix-degrading enzymes MMP1 and MMP3 (inner annulus), but less cell clustering (outer annulus). Some similar but non-significant differences were seen in nucleus tissues. Interpretation. Herniated tissues that escape the pressurised confines of the disc are free to swell, lose proteoglycans and come into contact with blood cells. These events could explain most of the differences between herniated tissues and those that degenerated ‘in situ’. Results support our hypothesis, and warn against assuming that degenerative changes always precede (or cause) disc herniation. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Summary Statement. Repetitive loading of degenerated human intervertebral discs in combined axial compression, flexion and axial rotation, typical of manual handling lifing activities, causes: an increase in intradiscal maximum shear strains, circumferential annular tears and nuclear seperation from the endplate. Introduction. Chronic low back pain (LBP) is a crippling condition that affects quality of life and is a significant burden to the health care system and the workforce. The mechanisms of LBP are poorly understood, however it is well known that loss of intervertebral disc (disc) height due to degeneration is a common cause of chronic low back and referred pain. Gross disc injury such as herniation can be caused by sudden overload or by damage accumulation via repetitive loading, which is a cause of acute LBP and an accelerant of disc degeneration. The aim of this study was to determine for the first time the relationship between combined repetitive compression, flexion and axial rotation motion of degenerated cadaver lumbar spine segments, and the progression of three-dimensional (3D) internal disc strains that may lead to disc herniation and macroscopic tissue damage. Patients & Methods. Seven degenerated human lumbar functional spinal units (FSUs) underwent pre-test MRI, had a grid of tantalum wires inserted into the mid-transverse plane of the disc and were subjected to 20,000 cycles of repetitive loading in combined compression (1.7 MPa), flexion (11–13°) and right axial rotation (2–3°) in a six degree of freedom hexapod robot. Stereoradiographs were taken at cyclic intervals (1, 500, 1000, 5000, 10000, 15000 and 20000 cycles) from which 3D intradiscal principal strains and maximum shear strains (MSS) were calculated and partitioned into nine disc anatomical regions. After testing the discs underwent post-test MRI followed by macroscopic assessment to identify tissue damage. A repeated measures ANOVA having a within-subjects factor of cycle number, and a between-subjects factor of disc region was used to examine the effects of cycle number and disc region on MSS. Results. No visible evidence of disc herniation occurred after 20,000 cycles, however circumferential annular tears and nucleus separation from the endplate were observed in all specimens in agreement with observed signal changes in post-test MRI images. There was a significant effect of both cycle number, disc region and the interaction of cycle number x disc region on MSS (p<0.001). MSS was significantly larger after 20,000 cycles compared with the first loading cycle in the anterior, left anterolateral, left lateral, and left posterolateral disc regions (p<0.037). Minor changes in MSS were seen in the posterior and nucleus regions. The largest increases were observed in the left anterolateral and left posterolateral regions after 20,000 cycles. Discussion/Conclusion. A significant increase in MSS was observed across most regions in the disc after 20,000 repetitive loading cycles, especially in the left anterolateral and left posterolateral regions. No herniation was observed, although macroscopic and MRI evidence of circumferential annular tears and nuclear separation from the endplate occurred, suggesting internal disc tissue disorganisation that may indicate a progression towards eventual herniation

Purpose of the study: Conventional treatment for recurrent lumbar disc herniation is repeated discectomy. Other methods such as fusion, ligamentoplasty or implantation of a discal prosthesis are sometimes proposed but all increase morbidity. The purpose of this work was to ascertain the efficacy of isolated repeated radicular release for the treatment of recurrent discal herniation.

Material and methods: Thirty-four patients underwent surgery for recurrent discal herniation. Repeated radicular release was used in all patients included in this analysis who completed a self-administered questionnaire at last follow-up to assess the final functional outcome.

Results: The cohort included 13 women and 21 men, mean age at surgery 45 years. Mean time from first discectomy to revision surgery for recurrence was 55 months. At the time of the review, four patients had died, all four from cancer. None of these patients had undergone a revision procedure on the lumbar spine. One patient was lost to follow-up so 85% of the cohort was analyzed with 60 months average follow-up. A dural tear occurred during the proscedure in six patients (17%. Five patients (14.7%) required revision surgery, one for deep infection, four for recurrent or persistent lumboradiculalgia (recurrent discal herniation, isthmic fracture, lateral stenosis associated with inflammatory discopathy). The rate of revision for painful failure was 11.4%. The final outcome could be assessed for 25 patients and was satisfactory for 22/25 (88%). The self-administered questionnaire revealed 65% average improvement with more than half of the patients reported better than 80% improvement. Ten patients (40%) complained of lumbar pain and a third had residual, generally intermittent, radiculalgia. Eighteen of 25 patients resumed their work at a comparable level after six months on average; 84% of the patient would accept the same operation again.

Discussion: In terms of morbidity and rate of revision, the results are comparable to reports in the literature. Repeated release does not increase the risk of a new recurrence.

Conclusion: This work enabled us to demonstrate that in the large majority of patients repeated discectomy provides satisfactory functional outcome with little morbidity.

Purpose: The purpose of this study was to assess the efficacy and safety of treating extra-foramen discal herniation via a microsurgical extra-foramen approach.

Material and methods: Fourteen patients underwent this surgical procedure which enables release of the roots outside the foramen while preserving the vertebral isthma. The technique is described in detail together with the postoperative period. All patients were reviewed clinically and radiologically at at least one year. The PROLO score was used to assess results.

Results: Among the 14 operated patients, good or excellent results were obtained in 13, fair results in one. There was no postoperative neurological deficit. The small number of cases in this series did not allow a statistical analysis of this uncommon clinical presentation.

Discussion: The extra-formamen approach is an interesting alternative to isthmic resection requiring fixation for the treatment of disc-root conflicts in the extra-foramen position. With appropriate surgical skill, the technique is safe.

Purpose

To investigate sociodemographic and clinical characteristics in patients operated for lumbar disc herniation in public and private hospitals, and evaluate whether selection for surgical treatment were different across the two settings.

Injury of the intervertebral disc (IVD) can occur for many reasons including structural weakness due to disc degeneration. A common disc injury is herniation. A herniated nucleus can compress spinal nerves, causing pain, and nucleus depressurisation changes mechanical behaviour. Many studies have investigated in vitro IVD injuries including endplate fracture, incisions, and nucleotomy. There is, however, a lack of consensus on how the biomechanical behaviour of spinal motion segments is affected. The aim of this study was to induce defined changes to IVDs of spine specimens in vitro and apply 6 degree of freedom testing to evaluate the effect of these changes. Six porcine lumbar spinal motion segments were harvested from organically farmed pigs. Posterior structures were removed to produce isolated spinal disc specimens. Specimens were potted in Wood's metal, ensuring the midplane of the IVD remained horizontal. After potting, specimens were sprayed with 0.9% saline, wrapped in saline-soaked tissue and plastic wrap to prevent dehydration. A 400N axial preload was equilibrated for 30 minutes before testing. Specimens were tested intact and after a partial nucleotomy removing ~0.34g of nuclear material with a curette through an annular incision. Stiffness tests were performed using the University of Bath's custom 6-axis spine simulator with coordinate axes and displacement amplitudes. Tests comprised five cycles with data acquired at 100Hz. Stiffness matrices were evaluated from the last three motion cycles using the linear least squares method. Stiffness matrices for intact and nucleotomy tests were compared. No significant differences in shear, axial or torsional stiffnesses were noted. Nucleotomy caused significantly higher stiffness in lateral bending and flexion-extension with increased linearity and the load-displacement behaviour in these axes displayed no neutral zone (NZ). Induced changes were designed to replicate posterolaterally herniated discs. Unaffected shear, axial and torsional stiffnesses suggest the annulus is crucial in these axes. However, reduced ROM and NZ after nucleotomy suggests bending is most affected by herniation. Increased linearity and lack of defined NZ in these axes demonstrates herniation causes major changes to the viscoelastic behaviour of spine specimens in response to loading

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

Purpose of the study: The endoscopic transforaminal approach to the lumbar disc proposed by A.T. Yeung has achieved world-wide acceptance. The Yeung endoscopic spinal system (YESS) used with a specific instrument set enables direct magnified optical control of discectomy performed under local anesthesia and neurolepanalgesia in the outpatient setting. We began our experience in 2003 and report here the results obtained in a consecutive series of 100 patients reviewed retrospectively. Material and methods: The inclusion criteria were patients with lumbar disc herniation-related lumbosciatic or crural pain non-responsive to well conducted medical care (including epidural or periradicular injections) for at least three months. The patients also had to display a concordant clinical and radiographic picture with confirmation of the symptomatic level by discography. Exclusion criteria were: excluded herniation with a fragment which had migrated into the canal; caudia equina syndrome; lower limb paralysis with muscle force scored less than 3; advanced-stage degernerative central bony stenosis affecting the clinical expression; pregnancy. The levels treated were: L3–L4 (n=6), L4–L5 (n=72), and L5–S1 (n=22). Herniation was forminal and extraforaminal in 53 cases, posterolateral in 31, and median in 16. There was an associated constitutional central stenosis in ten cases and in thirteen others, herniation was a recurrence after conventional surgery. Results: One hundred patients were reviewed at mean 18 months (range 12–34 months) follow-up. There were no serious neurological, vascular, or infectious complications. According to the McNab criteria outcome was good for 71 cases, fair for 16 and poor for 13 with 11 requiring revision with conventional surgery. Patients with foraminal and extraforminal herniation accounted for more than half of our series and responded best to treatment (84.9% good outcome) compared with posterolateral herniation (48%) (p< 0.05). Patients with median herniation had an intermediary outcome (68% good results). The least satisfactory outcome was observed at the L5–S1 level (63% fair and poor outcome), but the difference did not reach statistical significance compared with the higher levels. In patients with recurrent herniation after conventional surgery, there were four cases of failure. Discussion: These results are less satisfactory than those found in the literature. This might be explained by the less satisfactory outcome obtained with posterolateral herniations, probably because more than halve had migrated, generally above the plane of the disc, which in our experience cannot be accessed via the transforaminal approach. In addition, comparison of our first 50 cases with the last 50 showed an improvement in outcome to a mean 82%, expressing a learning curve for this type of technique. The most frequent error early in our experience was to insert the working endoscopic canula too anteriorly compared with the disc. The point of insertion must be very lateral determined by the discography in order to enter at least 30° posterior to the posterior part of the disc. Progressive fine-tuning of patient selection also helped improve outcome. YESS improves the work of the intradiscal instruments which can be control by direct view, explaining the the better results compared with the older mechanical or automatic (blind) methods. YESS is a very effective alternative to chemonucleolysis since papaine is no longer available. Compared with other endoscopic techniques for disectomy via an interlaminar approach, YESS offers the possibility of treatment patients in an outpatient setting with a local anesthesia. In addition the quality of the visual control of the foramen is better. These methods can be used in association with intradiscal Holmium-Yag laser which can also be applied to the bony walls of the foramen for a widening foraminoplasty. This transformainal endoscopic approach also offers a way to perform an exclusively foraminoscopic spondylodesis using an intersomatic cage. Conclusion: YESS is an excellent technique for non-migrated subligament posterolateral foraminal and extraforaminal herniations where conventional access to the foramen is known to be very difficult

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

The October 2013 Research Roundup. 360 . looks at: Orthopaedics: a dangerous profession?; Freezing and biomarkers for bone turnover; Herniation or degeneration first?; MARS MRI and metallosis; Programmed cell death in partial thickness cuff tears; Lead glasses for trauma surgery?; Smoking inhibits bone healing; Optimising polyethylene microstructure

Thoracic spinal cord herniation is a relatively uncommon syndrome of anterior hemi cord dysfunction. However it has been reported in literature with increasing frequency over the last decade. Since the initial description of this clinical entity by Weitzman et al. in 1974, more than 100 cases have been described. Although clinical features may vary considerably, as a clinical syndrome it is now widely recognized, and remains a potentially treatable cause of thoracic cord dysfunction. Anterior spinal or thoracic cord herniation remains an uncommon yet a potentially treatable cause of thoracic myelopathy. Patients usually present in their middle ages, and literature suggests that there is a female predominance. The presenting symptom is usually a Brown Sequard syndrome, although other symptoms suggestive of thoracic cord dysfunction may be present. Although the symptoms are insidious the condition may lead to progressive paraparesis. The herniation is usually through a dural defect, the cause of which open to speculation. Operative treatment is advised, as the outcomes are generally favourable. As part of a continued focus on this clinical syndrome we describe below a series of 4 patients with thoracic spinal cord hernias that presented to our neurosurgical service over the past 3 years and our experience in the treatment of this condition. Apart from one patient, in whom there possibly was an iatrogenic factor, the rest were all purely idiopathic. All the patients underwent surgical treatment and their outcomes were generally favorable

Introduction Literature indicates that following microdiscectomy significant loss of disc height with corresponding recurrent back and/or leg pain may occur. Loss of disc material due to herniations and/or surgery can accelerate degeneration of the disc. NuCore™ Injectable Nucleus is an in-situ curing protein polymer hydrogel which mimics the properties of the natural nucleus. It is intended as an adjunct to microdiscectomy, replacing the natural nucleus lost to herniation and discectomy. The hydrogel is injected as a fluid through the annular defect, and adheres to the surrounding discal tissue as it cures. The material is designed to immediately fill the nuclear void and seal the anulotomy; and, in the long term, prevent recurrent herniation and further degeneration of the disc. Methods Pre-clinical studies showed the device restores biomechanics, and the material is biocompatible, resistant to expulsion forces, and highly durable under simulated in vivo loading. A multi-center pilot clinical study is underway to evaluate NuCore™ Injectable Nucleus as an adjunct to microdiscectomy. At the time of this writing, the material has been implanted into thirteen patients aged between 23 and 52 years (6 females, 7 males) following a standard microdiscectomy procedure for monosegmental radicular pain non-responsive to conservative treatment. L5/S1 was treated in ten cases and L4/5 in three cases. Results All surgeries were successfully completed using between 0.3 and 2.6cc of hydrogel, with an average injection volume of 1.2cc. Six patients currently are at twelve months follow-up and four others have reached six months. In all cases, pain subsided as normally expected following standard microdiscectomy. Neurologic evaluation, Oswestry index, SF36 and VAS scores were taken pre- and post-operatively, and at six, twelve, twenty-six, and fifty-two weeks post-op. All measures showed significant improvement. Average ODI scores dropped from 44 preoperatively to less than 10 at 12-month follow-up. Leg pain dropped from an average preoperative score of 6.8 to less than 1.0 at 12-month follow-up. All categories of the SF36 showed substantial improvement over preoperative scores. No patient had any device related complication. MRI assessments confirmed stable positioning of the implants at all time-points, and no recurrent herniations. Analysis of standing plain films indicated improved disc height maintenance relative to published literature, with an average loss of disc height at completed follow-ups of 4.4%. Discussion To our knowledge, this is the first injectable nucleus replacement to have been implanted as an adjunct to microdiscectomy. Early clinical results indicate that NuCore™ Injectable Nucleus can be reliably used as a nuclear defect-filler. All patients are doing well clinically, and disc height and function appear to be maintained over the course of follow-up. Though early results indicate potential functional benefits, longer term follow-up will be necessary to fully determine the functional benefits of this treatment. Additional clinical studies have been approved to investigate the use of this hydrogel as an early intervention in degenerative disc disease

As part of a 10 year follow-up study investigating the relationship between MRI-diagnosed disc disease and low back pain (LBP), a comparison of MRI image acquisition protocols was conducted. The aim was to establish whether the modern protocol produced improved diagnoses of lumbar disc disease. This is of significance when attempting to determine links between lumbar disc disease and LBP. The proposed hypothesis was that little difference in the pathology reported of MRI lumbar spines between the surface coil acquired images (Coil-MRI) and phased-array acquired images (Phased-MRI) would be found. Methods: Local ethics committee approval was granted for this study. 31 male subjects (aged 35–71 years) were recruited and underwent two subsequent scans. For both Coil-MRI and Phased-MRI scans sagittal dual echo, T1, axial T1 and T2 images were acquired. A Consultant Radiologist blindly reviewed the 62 scans continuously and reported on the pathology. Disease pathology assessment consisted of disc degeneration, disc herniation (based on 5-grade classification systems), facet hypertrophy (FH) and nerve root compression (NRC). Results: A wide range of pathology was reported at all disc levels, particularly with regard to disc degeneration and herniation. Kappa agreement statistics were computed for each pathological feature at all disc levels. Disc degeneration and herniation reports were statistically consistent for all disc levels (kappa range: 0.6–0.8, p< 0.05 for degeneration & 0.5–0.7, p< 0.05 for herniation). The results show that at the L4/L5 disc level, 1 in 10 discs were reported as ‘moderately degenerate’ (an increase of 1 grade) in Phased-MRI scans. At the same disc level, 1 in 6 discs were reported as ‘moderately herniated’ in Phased-MRI scans compared to ‘bulging’ in Coil-MRI scans, indicating that Phased-MRI coil scans may improve clarity in particular for herniation diagnosis. Pathology for FH and NRC were limited, with the majority of subjects (over 91% for FH and NRC irrespective of protocol) presenting with normal features. Conclusion: The statistical results indicate that few differences in pathological diagnosis of lumbar disc disease occurred, however Phased-MRI appears to increase confidence in diagnosing more severe features at some disc levels

Obesity is an increasing public health concern associated with increased perioperative complications and expense in lumbar spine fusions. While open and mini-open fusions such as transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF (MIS-TLIF) are more challenging in obese patients, new MIS procedures like oblique lateral lumbar interbody fusion (OLLIF) may improve perioperative outcomes in obese patients relative to TLIF and MIS-TLIF. The purpose of this study is to determine the effects of obesity on perioperative outcomes in OLLIF, MIS-TLIF, and TLIF. This is a retrospective cohort study. We included patients who underwent OLLIF, MIS-TLIF, or TLIF on three or fewer spinal levels at a single Minnesota hospital after conservative therapy had failed. Indications included in this study were degenerative disc disease, spondylolisthesis, spondylosis, herniation, stenosis, and scoliosis. We measured demographic information, body mass index (BMI), surgery time, blood loss, and hospital stay. We performed summary statistics to compare perioperative outcomes in MIS-TLIF, OLLIF, and TLIF. We performed multivariate regression to determine the effects of BMI on perioperative outcomes controlling for demographics and number of levels on which surgeries were operated. OLLIF significantly reduces surgery time, blood loss, and hospital stay compared to MIS-TLIF, and TLIF for all levels. MIS-TLIF and TLIF do not differ significantly except for a slight reduction in hospital stay for two-level procedures. On multivariate analysis, a one-point increase in BMI increased surgery time by 0.56 ± 0.47 minutes (p = 0.24) in the OLLIF group, by 2.8 ± 1.43 minutes (p = 0.06) in the MIS-TLIF group, and by 1.7 ± 0.43 minutes (p < 0.001) in the TLIF group. BMI has positive effects on blood loss for TLIF (p < 0.001) but not for OLLIF (p = 0.68) or MIS-TLIF (p = 0.67). BMI does not have significant effects on length of hospital stay for any procedure. Obesity is associated with increased surgery time and blood loss in TLIF and with increased surgery time in MIS-TLIF. Increased surgery time may be associated with increased perioperative complications and cost. In OLLIF, BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between obese and non-obese patients