Postdural disc herniation has been documented rarely and the pathogenesis is still unknown. The average age of postdural disc herniations is between 50 and 60 years, and the sites most frequently affected by postdural lumbar disc herniations are L3–L4 and L4–L5, only less than 10 % in L5–S1. Although magnetic resonance imaging (MRI) is a useful tool in the diagnosis of this disease, the postdural disc herniation is usually misdiagnosed as extradural spine tumor preoperatively. The definitive diagnosis is made during operation or according to the postoperative pathology.
Methods
In this article, we described here a 48-year-old male patient who presented with intermittent pain in the low back and frequent urination for 4 years as well as hypesthesia and pain of the left lower extremity for 1 month.
Results
A standard total laminectomy was performed and the histopathological diagnosis was consistent with a degenerated intervertebral disc. The patient presented significant relief of the pain and of the neurological symptoms, but no improvement of frequent urination, in the postoperative period.
Conclusions
The diagnosis of postdural disc herniations is very difficult and mainly based on intraoperative and histopathological results. Early surgical intervention is important to relieve symptoms and prevent severe neurological deficits.
The minimally invasive (MI) lateral lumbar interbody fusion (LLIF) approach has become increasingly popular for the treatment of degenerative lumbar spine disease. The neural anatomy of the lumbar plexus has been studied; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the vascular structures that are relevant in relation to the MI-LLIF approach.
Methods
Anatomic dissection of the lumbar spines and associated vasculature was performed in three embalmed, adult cadavers. Right and left surgeon perspective views during LLIF were for a total of six approaches. During the dissection, all vascular elements were noted and photographed, and anatomical relationships to the vertebral bodies and disc spaces were analyzed. In addition, several axial and sagittal MRI images of the lumbar spine were analyzed to complement the cadaveric analysis.
Results
The aorta descends along the left anterior aspect of lumbar vertebra with an average distance of 2.1 cm (range 1.9–2.3 cm) to the center of each intervertebral disc. The vena cava descends along the right anterior aspect of lumbar vertebrates with average distance of 1.4 cm (range 1.3–1.6 cm) to the center of the intervertebral disc. Each vertebral body has two lumbar arteries (direct branches from the aorta); one exits to the left and one to the right side of the vertebral body. The lumbar arteries pass underneath the sympathetic trunk, run in the superior margin of the vertebral body and extend all the way across it, with average length of 3.8 cm (range 2.5–5 cm). The mean distance between the arteries and the inferior plate of the superior disc space is 4.2 mm (range 2–5 mm) and mean distance of 3.1 cm (range 2.8–3.8 cm) between two arteries in adjacent vertebrae. One of the cadavers had an expected normal anatomical variation where the left arteries at L3–L4 anastomosed dorsally of the vertebral bodies at the middle of the intervertebral disc.
Conclusions
Understanding the vascular anatomy of the lateral and anterior lumbar spine is paramount for successfully and safely executing the LLIF procedure. It is imperative to identify anatomical variations in lumbar arteries and veins with careful assessment of the preoperative imaging.
The goal of this paper was to describe how endoscope-assisted oblique lumbar interbody fusion (OLIF) could remove huge lumbar disc herniation (HLDH) manifested with cauda equina syndrome (CES).
Methods
In this study, the authors made an attempt to treat CES with a direct endoscopic decompression through the OLIF corridor and performed OLIF in two patients with HLDH.
Results
Two patients with HLDH were successfully treated using OLIF with spinal endoscopic discectomy. We achieved direct ventral decompression by removal of herniated disc fragments located beyond the posterior longitudinal ligament (PLL). All preoperative symptoms in two patients improved postoperatively.
Conclusions
Endoscope-assisted oblique lumbar interbody fusion (OLIF) could successfully achieve neural decompression without additional posterior decompression in CES and could be used as an alternative treatment in well selected cases.
To analyze the effects of mobility of degenerated disc in the lower lumbar discs (L4–5 and L5–S1) on both whole lumbar motion and adjacent segment ROM.
Methods
The kMRIs with disc degeneration at L4–5 or L5–S1 were classified into three groups: the normal group, the motion-preserved (MP) group and the motion-lost (ML) group based on range of motion (ROM) of 5° in the degenerated segment. Each segmental ROM, whole lumbar motion, and the contribution % of the upper lumbar spine (ULS: L1–2–3) and the lower lumbar spine (LLS: L4–5–S1) motion to whole lumbar motion were measured and compared with each of the other groups.
Results
There were 94, 99 and 66 patients in the normal group, MP group and ML group, respectively. The normal group showed no significant difference compared to the MP group in all ROM parameters. The ML group showed significantly less whole lumbar motion, more contribution % in the ULS and less in the LLS than the normal and the MP groups. The ROM in the superior adjacent segment in the ML group was not significantly different between that in the normal and MP group.
Conclusions
Degenerated lumbar discs did not show hypermobility within functional ROM. Loss of segmental ROM from advanced disc degeneration did not cause an increase in the ROM of the superior adjacent segment in vivo. When the LLS had motion-lost, advanced disc degeneration, whole lumbar motion was significantly decreased and compensatory increase in ROM was accomplished by the ULS.
To evaluate the results of a novel rigid–dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL).
Materials and methods
Forty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively.
Results
At 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level.
Conclusions
When properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion.
Investigation of the automation of radiological features from magnetic resonance images (MRIs) of the lumbar spine.
Objective
To automate the process of grading lumbar intervertebral discs and vertebral bodies from MRIs.
Summary of background data
MR imaging is the most common imaging technique used in investigating low back pain (LBP). Various features of degradation, based on MRIs, are commonly recorded and graded, e.g., Modic change and Pfirrmann grading of intervertebral discs. Consistent scoring and grading is important for developing robust clinical systems and research. Automation facilitates this consistency and reduces the time of radiological analysis considerably and hence the expense.
Methods
12,018 intervertebral discs, from 2009 patients, were graded by a radiologist and were then used to train: (1) a system to detect and label vertebrae and discs in a given scan, and (2) a convolutional neural network (CNN) model that predicts several radiological gradings. The performance of the model, in terms of class average accuracy, was compared with the intra-observer class average accuracy of the radiologist.
Results
The detection system achieved 95.6% accuracy in terms of disc detection and labeling. The model is able to produce predictions of multiple pathological gradings that consistently matched those of the radiologist. The model identifies ‘Evidence Hotspots’ that are the voxels that most contribute to the degradation scores.
Conclusions
Automation of radiological grading is now on par with human performance. The system can be beneficial in aiding clinical diagnoses in terms of objectivity of gradings and the speed of analysis. It can also draw the attention of a radiologist to regions of degradation. This objectivity and speed is an important stepping stone in the investigation of the relationship between MRIs and clinical diagnoses of back pain in large cohorts.Level of Evidence: Level 3.
Anterior cervical decompression and fusion (ACDF) is a widely accepted surgical procedure for the treatment of cervical degenerative disc diseases. This retrospective study was designed to analyze and compare the efficacy and outcomes of anterior cervical fusion using stand-alone polyetheretherketone (PEEK) cages and autogenous iliac crest grafts with the anterior cervical plating system.
Methods
A total of 72 consecutive patients suffering from cervical degenerative disc diseases treated with ACDF from June 2005 to Dec 2008 were enrolled in the study. Patients in group A (40 patients, 64 segments) had anterior interbody fusion with stand-alone PEEK cages and patients in group B (32 patients, 51 segments) with autogenous iliac crest graft combined with anterior plate fixation. The operative time and intraoperative blood loss were recorded. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scoring system; cervical lordosis, intervertebral height, and cervical fusion status were assessed on X-ray and computed tomography.
Findings
The mean follow-up period was 17.3 months in the stand-alone cage group and 23.2 months in the autologous iliac crest graft group. The operative time and intraoperative blood loss in group A were much less than those in group B (p?
Conclusions
The stand-alone PEEK cage is a good substitute for fusion in patients with cervical disc disease; it can effectively restore the cervical physiological curvature and the intervertebral height, facilitate radiological follow-up, cause few complications, and leads to satisfactory outcomes.
To investigate whether axial loading of the spine during MRI (alMRI) instantaneously induces changes in biochemical disc features as reflected by altered quantitative T2 values in patients with chronic low back pain (LBP).
Methods
T2 mapping was performed on 11 LBP patients (54 lumbar discs) during the conventional unloaded MRI and subsequent alMRI. Each disc was divided into five volumetric regions of interests (ROIs), anterior annulus fibrosus (AF) (ROI 1), the interface anterior AF-nucleus pulposus (NP) (ROI 2), NP (ROI 3), the interface NP-posterior AF (ROI 4), and the posterior AF (ROI 5). The mean T2 values for each ROI were compared between MRI and alMRI and correlated with degeneration grade (Pfirrmann), disc angle, and disc level.
Results
With alMRI, T2 values increased significantly in the whole disc as well as in various parts of the disc with an increase in ROI 1–3 and a decrease in ROI 5. The changes in T2 values correlated to degeneration grade, changes in disc angle, and lumbar level.
Conclusion
alMRI instantaneously induces T2-value changes in lumbar discs and is, thus, a feasible method to reveal dynamic, biochemical disc features in patients with chronic LBP.
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.
Study design
Case report.
Objective
To report a clinical case with adjacent level infection after spinal fusion.
Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.
Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.
Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.
To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.
Methods
Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5–8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.
Results
Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.
Conclusions
Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.
Expandable cages are a more recent option for maintaining or restoring disc height and segmental lordosis with transforaminal lumbar interbody fusion (TLIF). Complications associated with expandable cages have not yet been widely reported. We report a case of postoperative failure of a polyether-ether-ketone (PEEK) expandable interbody device used during TLIF.
Methods
A 50-year-old man presented with severe back and right leg pain after undergoing L4-5 and L5-S1 TLIFs with expandable cages and L3-S1 posterior instrumented fusion. Imaging showed retropulsion of a portion of the interbody cage into the spinal canal causing nerve compression. Displacement occurred in a delayed manner. In addition, pseudoarthrosis was present.
Results
The patient underwent re-exploration with removal of the retropulsed wafer and redo fusion.
Conclusions
Expandable cages are a recent innovation; as such, efficacy and complication data are limited. As with any new device, there exists potential for mechanical failure, as occurred in the case presented.
The aim was to elucidate elite swimming’s possible influence on lumbar disc degeneration (DD) and low back pain (LBP).
Methods
Lumbar spine MRI was performed on a group of elite swimmers and compared to a matched Finnish population-based no-sport group.
Results
One hundred elite swimmers and 96 no-sport adults, mean age 18.7/20.8, respectively, participated. Overall, the two groups had similar prevalence of DD. Swimmers had more DD in the upper lumbar spine but tended to have less DD at the lowest level. Prevalence of bulges and disc herniations were similar, but swimmers had significantly more bulges at L4–5. The swimmers reported less LBP, although not significantly (N.S.). If degenerative findings were present, the association between them and LBP was stronger in the no-sport group.
Conclusion
Elite swimmers and controls had similar prevalence of DD and LBP, although the pattern of DD differed between the groups. In case of DD, swimmers reported less LBP, although N.S.
The modern literature is producing a rapidly growing number of articles which highlight the relationship between infection and lumbar disc degeneration. However, the means by which samples are collected is questionable. Posterior approach surgery is not free from skin contamination. The possibility of intraoperative contamination of disc biopsies cannot be excluded.
Objective
The objective of this study was to determine if an association existed between lumbar disc degeneration and chronic infection of the intervertebral disc.
Materials and methods
313 patients (186/127, F/M) with chronic low back pain secondary to degenerative disc disease which was resistant to medical treatment were included in a single-centre prospective study. All underwent a lumbar anterior video-assisted minimally invasive fusion or disc prosthesis in L4–L5 and/or L5–S1 via an anterior retroperitoneal approach. The patients MRI scans demonstrated in Pfirrmann's classification grade IV or V disc degeneration; 385 disc drives were taken. In terms of Modic changes, 303 Modic 1, 58 Modic II and 24 absence of Modic change, respectively. All underwent intraoperative biopsy, performed according to a strict aseptic protocol. The biopsies were then cultured for 4 weeks with specialised enrichment cultures and subjected to histopathological analysis.
Results
The mean age was 47 ± 8.6 years sterile cultures were obtained in 379 samples (98.4 %) and 6 were positive (1.6 %). The cultured bacteria were: Propionibacterium acnes (n:2), Staphylococcus epidermidis (n:2), Citrobacter freundii (n:1), and Saccharopolyspora hirsuta (n:1). Histopathological analysis did not demonstrate any evidence of a neutrophilia. There were no delayed or secondary infections.
Discussion and conclusion
Unlike the posterior approach where contamination is common, the anterior video-assisted approach allows a biopsy without skin contact. This approach to the spine is the most effective way to eliminate the risk of contamination. Our results confirm the absence of any relationship between infection and disc degeneration. We suggest that the 6 positive samples in our study may be related to contamination. The absence of infection at 1-year followup is an additional argument in favour of our results. In conclusion, our study shows no association between infection and disc degeneration. The pathophysiology of disc degeneration is complex, but the current literature opens new perspectives.
Few complications have been reported for lumbar total disc replacement (TDR) and hybrid TDR fixations. This study evaluated retrieved implants and periprosthetic tissue reactions for two cases of osteolysis following disc arthroplasty with ProDisc-L prostheses.
Methods
Implants were examined for wear and surface damage, and tissues for inflammation, polyethylene wear debris (polarized light microscopy) and metal debris (energy-dispersive X-ray spectroscopy).
Results
Despite initial good surgical outcomes, osteolytic cysts were noted in both patients at vertebrae adjacent to the implants. For the hybrid TDR case, heterotopic ossification and tissue necrosis due to wear-induced inflammation were observed. In contrast, the non-hybrid implant showed signs of abrasion and impingement, and inflammation was observed in tissue regions with metal and polyethylene wear debris.
Conclusions
In both cases, wear debris and inflammation may have contributed to osteolysis. Surgeons using ProDisc prostheses should be aware of these rare complications.
To investigate the prevalence of low virulence disc infection and its associations with characteristics of patients or discs in the cervical spine.
Background
Low virulence bacterial infections could be a possible cause of intervertebral disc degeneration and/or back pain. Controversies are continuing over whether these bacteria, predominantly Propionibacterium acnes (P. acnes), represent infection or contamination. However, the current studies mainly focus on the lumbar spine, with very limited data on the cervical spine.
Methods
Thirty-two patients (20 men and 12 women) who underwent anterior cervical fusion for degenerative cervical spondylosis or traumatic cervical cord injury were enrolled. Radiological assessments included X-ray, CT, and MRI of the cervical spine. Endplate Modic changes, intervertebral range of motion, and disc herniation type were evaluated. Disc and muscle tissues were collected under strict sterile conditions. Samples were enriched in tryptone soy broth and subcultured under anaerobic conditions, followed by identification of the resulting colonies by the PCR method.
Results
Sixty-six intervertebral discs were excised from thirty-two patients. Positive disc cultures were noted in eight patients (25%) and in nine discs (13.6%). The muscle biopsy (control) cultures were negative in 28 patients and positive in 4 patients (12.5%); three of whom had a negative disc culture. Seven discs (10.6%) were positive for coagulase-negative Staphylococci (CNS) and two discs were positive for P. acnes (3.0%). A younger patient age and the extrusion or sequestration type of disc herniation, which represented a complete annulus fibrous failure, were associated with positive disc culture.
Conclusions
Our data show that CNS is more prevalent than P. acnes in degenerative cervical discs. The infection route in cervical discs may be predominantly through an annulus fissure. Correlation between these infections and clinical symptoms is uncertain; therefore, their clinical significance needs to be investigated in the future.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Restoring sagittal alignment is an important factor in the treatment of spinal deformities. Recent investigations have determined that releasing the anterior longitudinal ligament (ALL) and placing hyperlordotic cages can increase lordosis, while minimizing need for 3 column osteotomies. The influences of parameters such as cage height and angle have not been determined. Finite element analysis was employed to assess the extent of lordosis achievable after placement of different sized lordotic cages.
Methods
A 3-dimensional model of a L3–4 segment was used. Disc distraction was simulated by inserting interbody cages mid-body in the disc space. Analyses were performed in the following conditions: (1) intact, (2) ALL release, (3) ALL release + facetectomy, and (4) ALL release + posterior column osteotomy. Changes in segmental lordosis, disc height, foraminal height, and foraminal area were measured.
Results
After ALL resection and insertion of hyperlordotic cages, lordosis was increased in all cases. The lordosis achieved by the shorter cages was less due to posterior disc height maintained by the facet joints. A facetectomy increased segmental lordosis, but led to contact between the spinous processes. For some configurations, a posterior column osteotomy was required if the end goal was to match cage angle to intradiscal angle.
Conclusion
Increased segmental lumbar lordosis is achievable with hyperlordotic cages after ALL resection. Increased cage height tended to increase the amount of lordosis achieved, although in some cases additional posterior bone resection was required to maximize lordosis. Further studies are needed to evaluate the impact on regional lumbar lordosis.
Cervical and back pains are important clinical problems affecting human populations globally. It is suggested that Propionibacterium acnes (P. acnes) is associated with disc herniation. The aim of this study is to evaluate the distribution of P. acnes infection in the cervical and lumbar disc material obtained from patients with disc herniation.
Methods and material
A total of 145 patients with mean age of 45.21 ± 11.24 years who underwent micro-discectomy in cervical and lumbar regions were enrolled into the study. The samples were excited during the operation and then cultured in the anaerobic incubations. The cultured P. acnes were detected by 16S rRNA-based polymerase chain reaction.
Results
In this study, 145 patients including 25 cases with cervical and 120 cases with lumbar disc herniation were enrolled to the study. There was no significant difference in the age of male and female patients (p = 0.123). P. acnes infection was detected in nine patients (36%) with cervical disc herniation and 46 patients (38.3%) with lumbar disc herniation and no significant differences were reported in P. acnes presence according to the disc regions (p = 0.508.). Moreover, there was a significant difference in the presence of P. acnes infection according to the level of lumbar disc herniation (p = 0.028).
Conclusion
According to the results, the presence of P. acnes is equal in patients with cervical and lumbar disc herniation. There was a significant difference in the distribution of P. acnes infection according to level of lumbar disc herniation.
To determine whether the presence of intervertebral bridging ossifications is associated with intravertebral cleft (IVC) formation following a vertebral compression fracture (VCF).
Methods
Patients with a VCF who received conservative treatment for a minimum of 3 months were recruited over a 3-year period. Baseline radiographs obtained within a month of onset were compared between 50 patients who developed an IVC at 3-month follow-up (IVC group) and 100 patients without an IVC (control group). Intervertebral bridging ossification was defined as complete bridging of the intervertebral space by ossification. The presence of bridging ossification was assessed at each intervertebral level from T9/10 to L5/S. In addition to the absolute levels of bridging ossifications, the level relative to a fresh VCF was recorded.
Result
The incidence of bridging ossification at levels T9/10 and T10/11 was significantly higher in the IVC group than in the control group. IVC group patients showed a significantly higher incidence of bridging ossification at the second proximal intervertebral segment than those in the control group. IVC group patients also had a significantly greater sagittal wedge angle and a greater local kyphosis angle than control group patients.
Conclusion
A fresh VCF with bridging ossification at the second proximal intervertebral level is associated with increased risk of IVC formation. Careful observation and strict conservative treatment are recommended in such cases.
The aims of this study were to assess lumbar multifidus fatigue (LM) and transversus abdominis activation (TrA) in individuals with lumbar disc herniation associated with low back pain.
Methods
Sixty individuals were divided into the lumbar herniation (LHG, n = 30) and control groups (CG, n = 30). Fatigue of the LM was assessed using surface electromyography during the Sorensen effort test, and activation of the TrA with a pressure biofeedback unit. Pain intensity was determined using a visual analog scale and the McGill pain questionnaire. The Oswestry disability questionnaire and the Borg scale for self-evaluating exertion were used to assess functional disability.
Results
Fatigue was significantly more intense and the TrA activation was insufficient (p < 0.01) in individuals with disc herniation relative to the control group. The LHG had mild functional disability and moderate pain. There were differences in the initial exertion self-evaluation between groups, which were not observed in the final exertion evaluation.
Conclusion
Individuals with lumbar disc herniation associated with low back pain have increased fatigue of the LM and decreased activation of the TrA, when compared to the control group.
