The delayed OP--indications for surgery of lumbar disc herniations

In Germany, lumbar disc herniations require surgical treatment in about 50,000 patients/year. The clinical and socio-economical results are determined by the preoperative duration of symptoms and preoperative time out of work (highly predictive). Other parameters such as severity of neurological deficits, morphology of disc herniation, age, associated diseases, type of surgery, working conditions or litigation processes are only weak predictors of outcome. Postoperative improvement of clinical symptoms as well as professional reintegration is strongly determined by the time period between onset of symptoms and surgery. Surgery performed "too early" diminishes the chance for improvement by conservative therapy. If surgery is performed "too late" the risk of a bad result is high, and the reintegration of the patient into his preoperative social and professional activities may be prevented. The duration of conservative therapy including so-called semi-invasive procedures is critical in this sense. If a therapeutic success (= professional and social reintegration) cannot be achieved by conservative measures and if there is a clear morphological correlate (= disc herniations with corresponding clinical symptoms) of the clinical symptoms an early change of the strategy towards surgical therapy is recommended.     

Endogenous-lesioned cervical disc herniation: a retrospective review of 9 cases

The purpose of this study was to analyze the pathogenic mechanisms, clinical presentation, and surgical treatment of cervical disc herniation without external trauma. Between 2004 and 2008, 9 patients with cervical disc herniation and no antecedent history of trauma were diagnosed with cervical disc herniation and underwent surgical decompression. Pathogenic mechanisms, clinical presentation, surgical treatment, and prognosis were analyzed retrospectively. In 6 patients, herniation resulted from excessive neck motion rather than from external trauma. An injury from this source is termed an endogenous-lesioned injury. Patients exhibited neurologic symptoms of compression of the cervical spinal cord or nerve roots. In the other 3 patients, no clear cause for the herniation was recorded, but all patients had a desk job with long periods of head-down neck flexion posture. After surgery, all patients experienced a reduction in their symptoms and an uneventful recovery. Cervical disc herniation can occur in the absence of trauma. Surgical decompression is effective at reducing symptoms in these patients, similar to other patients with cervical disc herniation. Surgical treatment may be considered for this disorder when the herniation becomes symptomatic.     

Types of lumbar herniated disc and clinical course

STUDY DESIGN: A retrospective study of different types of herniated discs and duration of symptoms in patients with lumbar disc herniation, and a trial of longer conservative treatment to reduce the number of operations. OBJECTIVE: To determine whether noncontained and contained herniated discs have different clinical courses and to evaluate the results of the clinical trial of longer and vigorous conservative treatment. SUMMARY OF BACKGROUND DATA: The possibility of a difference in clinical features between contained and noncontained disc herniation has been suggested previously. METHODS: In the first study, the medical history and intraoperative findings of 156 patients who had undergone herniotomy were reviewed. In the second study, conservative treatment of at least 2 months' duration was recommended for all patients with lumbar disc herniation. RESULTS: In the first study, patients with noncontained disc herniation had a shorter preoperative clinical course than those with contained disc herniation. It was rare for noncontained herniation to require surgery 4 months or more after the onset of symptoms. In the second study, the authors' protocol reduced the number of herniotomies required, especially the number of operations for the patients with noncontained disc herniation. CONCLUSIONS: The authors believe that patients with noncontained lumbar disc herniation can be treated without surgery, if these patients can tolerate the symptoms for the first 2 months.     

Giant ganglionic cyst of the hip as a rare cause of sciatica

Although ganglionic cysts located at the hip joint are described infrequently, those found in this region are usually small, deep-seated, and asymptomatic. Occasionally, however, a large ganglionic cyst of the hip area is observed that becomes symptomatic following compression of adjacent neurovascular bundles. In this report, the authors describe a 51-year-old man with symptoms of sciatica caused by a giant ganglionic cyst of the posterior hip joint. Because of its intermuscular location, the cyst was not palpable, and was probably misdiagnosed previously as a herniated disc of the lumbar spine. After resection of the cyst, the patient's symptoms resolved completely. This case highlights the importance of a detailed clinical examination for patients with multiple degenerative joint diseases.     

Translational research of herniated discs: current status of diagnosis and treatment

Lumbar herniated discs commonly occur in patients 20–40 years of age, and result in acute symptoms of shooting and intractable pain in the low back and/or lower extremities. However, the prognosis of these patients is considered to be very good. Moreover, 70 % of these patients have been reported to be free from sciatica at approximately 6 months after the first onset. Magnetic resonance imaging (MRI) studies have described the spontaneous resorption process of herniated discs, which is a major cause of the reduction of symptoms in patients. New advancements in MRI have recently been developed that have facilitated the examination of nerve tract fibers and identification of symptomatic nerve tissue. Furthermore, the mechanism underlying the resorption process of a herniated disc has been determined. Inflammatory cytokines such as TNF (tumor necrosis factor)-α, angiogenic factors such as vascular endothelial growth factor, and enzymes such as matrix metalloproteinases are intricately related to each other. In our previous studies, matrix metalloproteinase-7 (MMP-7) has been shown to play a crucial role in the initiation of herniated disc resorption. Therefore, we developed recombinant human MMP-7 for intradiscal therapy through an industry–university joint research program. We have already performed in vitro and in vivo experiments to confirm its efficacy; this therapy avoids the side effects associated with surgery, such as nerve tissue damage. Moreover, the phase 1/2 studies of recombinant human (rh) MMP-7 are currently ongoing in the United States, and careful monitoring is required for these clinical trials. In conclusion, patients with lumbar herniated discs may benefit from the development of a less invasive treatment for disc herniation, which can be applied even immediately after the onset of disease symptoms.     

Articular disc position in association with mandibular setback surgery.

OBJECTIVE: The purpose of this study was to evaluate the influence of orthognathic surgery on articular disc position and temporomandibular disorder symptoms of skeletal class III patients by means of clinical and radiographic evaluation of the temporomandibular joint. STUDY DESIGN: Thirty-six patients with skeletal class III malocclusion, who were treated at Kangnam St. Mary's Hospital between January 2005 and January 2006, were evaluated by clinical examination and pre- and postoperative magnetic resonance imaging. RESULTS: The change of articular disc position after mandibular setback surgery by means of sagittal split ramus osteotomy was not statistically significant, but it tended to be positioned posteriorly. CONCLUSION: It can be suggested that orthognathic surgery does not significantly change the position of the articular disc.     

Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36–96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.     

椎间孔镜治疗有典型根性症状的腰椎手术失败综合征

目的：评价椎间孔镜治疗有典型根性症状的腰椎手术失败综合征（failedbacksurgerysyndrome,FBSS）的临床效果。方法选择2012年11月～2013年6月12例有典型根性症状的FBSS,其中腰椎间盘突出单纯开窗髓核摘除术后复发5例,腰椎管狭窄髓核摘除并神经根管减压术后复发3例,腰椎间盘突出椎间孔镜髓核摘除术后复发4例。均采用椎间孔镜治疗。结果12例术后患肢直腿抬高试验阴性,神经根刺激所致的患肢疼痛症状均明显缓解,患肢疼痛评分依据视觉模拟评分法（visualanaloguescore,VAS）,术前8．3±1．9,术后1个月2．6±1．1（t＝16．301,P＝0．000）。结论椎间孔镜是治疗有典型根性症状的FBSS安全和有效的微创手术,合理选择手术适应证和成熟的椎间孔镜手术经验是保证手术成功的关键。     

Epidural injections for the treatment of symptomatic lumbar herniated discs

Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer.     

单节段腰椎退变不稳并神经根管狭窄手术治疗的初步报告

目的 探讨应用腰椎侧后方斜向单枚ＢＡＫ椎间融合器椎间融合及小关节螺钉固定术治疗单节段腰椎退变不稳并神经根和狭窄的治疗效果。方法 采用后路腰椎侧后方对神经根管彻底减压,由侧后方斜向植入单枚ＢＡＫ椎间植骨融合器,再经棘突根部向对侧未减压的小关节植入１枚小关节螺钉固定的方法,治疗单节段腰椎退变不稳并神经根管狭窄患者３０例,男３０例,女１７例,平均年龄４６．５岁;其中融合节段为Ｌ３～４者４例,Ｌ４－５者１     

When should conservative treatment for lumbar disc herniation be ceased and surgery considered?

Different authors recommend different time spans for conservative treatment before considering surgery in patients suffering from lumbar disc herniation. We analyzed the time of onset of symptoms such as pain, sensory deficit, and motor deficit in a surgically treated group in comparison to outcome after surgery in order to define a time threshold when surgical results deteriorate and operation should therefore be considered. General data, symptoms, signs, and neurological findings of 219 patients were preoperatively recorded. The outcome was evaluated according to the Prolo scale after a mean of 9.9 months. In the statistical workup, we calculated the duration of symptoms, sensory deficits, and motor deficit as continuous variables. Additionally, the population was divided into three groups of duration of symptoms, sensory deficit, or motor deficit for ≤30 days, 30–60 days, and >60 days. Statistically significant predictors for unfavourable outcome were, for example, a longer duration of preoperative pain and motor and sensory deficit. Patients suffering for more than 60 days from disc herniation were found to have statistically worse outcome than patients suffering for 60 days or less. Findings were similar for the different time groups concerning the duration of sensory deficit but not for duration of motor deficit. The overall outcome seems to be better when patients are operated on for lumbar disc herniations within 2 months after onset of symptoms and sensory deficits. Due to these findings, we recommend conservative treatment up to 2 months and, if conservative management does not succeed, consideration of surgery. Electronic Publication     

Cell therapy for disc degeneration--potentials and pitfalls

Disc degeneration is considered a major source of pain in patients with chronic low back pain. Novel strategies to cure or decrease the symptoms and increase the patient's quality of life and function are under development. Until recently conservative treatment and fusion surgery were the main therapeutic options. Disc prostheses are undergoing clinical evaluation. The potential for cell transplantation to the intervertebral disc with mature autologous disc cells, chondrocytes, or stem cells is in early stages of investigation. Cell transplantation potentially can increase proteoglycan production and induce disc regeneration or slow down the degeneration process. In animal models, transplantation of autologous disc cells and chondrocytes (derived from costal cartilage) has been demonstrated to be feasible and may slow disc degeneration.     

新型冠状病毒肺炎疫情期间关节外科疾病诊疗思考

目前,中国上下都积极投身于新型冠状病毒肺炎(COVID-19)的疫情防控,其致病体为2019新型冠状病毒(SARS-CoV-2)。关节外科疾病与人们日常生活紧密相关,亦属于高发疾病,有些患者需要急诊手术。COVID-19疫情期间,关节外科医师应按照相关指南和诊疗常规,并着眼于当前形势,做好关节外科疾病的分类诊疗,选择适当的治疗方式;同时优化诊治流程,根据不同的风险等级做好自身防护措施。建议关节外科疾病患者尽量通过电话或者网络进行就诊、随诊,需要手术的患者按照流程就诊,并配合治疗。     

Alkaptonuria with lumbar disc herniation: a report of two cases

STUDY DESIGN: Two cases of lumbar disc herniation with alkaptonuria are presented. OBJECTIVES: To present a probable clinical course of lumbar disc herniation with alkaptonuria, a rare metabolic disease. SUMMARY OF BACKGROUND DATA: Although lumbar disc disease is a common clinical occurrence in alkaptonuria, lumbar disc surgery is needed rarely in this disease. A patient with alkaptonuria without ochronotic signs is also rarely seen. METHODS: The cause, clinical presentation, diagnostic techniques and treatment of alkaptonuria with lumbar disc disease are reviewed. RESULTS: The symptoms of the patients disappeared after surgery, and there were no symptoms on follow-up. CONCLUSION: Alkaptonuria frequently occurs in association with lumbar disc disease. In patients with no other signs of alkaptonuria or ochronosis, early detection of the disease is important to treat involvement of other systems (e.g., cardiovascular and urinary).     

Microsurgery of the cervical spine in elderly patients Part 1: Surgery of degenerative disease

Summary The results of microsurgery for degenerative disease of the cervical spine are reported in 84 consecutive patients being 65 years of age or older at the time of surgery. Patients were suffering from either soft or hard disc disease or from advanced forms of cervical myelopathy. In 60 patients microsurgical resection of the involved cervical disc and posterior osteophytes was performed followed by anterior fusion. Spondylectomy, microsurgical decompression and osteosynthesis was performed in 24 patients with multi-level cervical stenosis. A multitude of accompanying systemic diseases was present in almost all patients. Evaluation of the peri-operative risk profile of the patients was performed using the American Society of Anesthesiology (ASA) Grading of Physical Status Score.In 82 patients a complete follow-up was available. Two patients died within seven days after surgery from heart attack and pulmonary embolism. Three patients died during the observation period from causes unrelated to their cervical disease or to surgery. Overall surgical results were as follows: 66 patients (79%) were improved by surgery. 14 patients (17%) were unchanged, two patients (2%) became worse, and two patients (2%) died. Postoperative recovery was significantly correlated to the pre-operative neurological status. Neither age, nor the pre-operative ASA score had a significant influence on the postoperative outcome. The incidence of peri-operative systemic complications was significantly correlated to the pre-operative physical status of the patients according to the ASA score. No significant correlation towards an increase of peri-operative complications with higher grades of pre-operative neurological deficits or with increasing age of the patients could be found.It is concluded, that surgery of degenerative disease of the cervical spine, even in advanced cases, and with aggressive forms of surgical treatment, can be performed in a safe and effective manner in elderly patients, resulting in a significant relief of pre-operative clinical symptoms and signs in the majority of patients.     

Cervical epidural steroid injections for symptomatic disc herniations

OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.     

Disc replacement with the SB Charité endoposthesis - experience,preliminary results and comments after 35 prospectively performed operations

Aim of this prospective study was an investigation concerning the indication for the implantation of an artificial disc endoprosthesis and the rating of this operation. METHOD: 35 patients with 11 bi- and 24 monosegmental implanted disc endoprosthesis were observed over an average follow-up of 14.7 months. Indications for the operation were: unsuccessful, orthopedic conservative treatment > 6 months, segmental pain, age < 45 years, evidence of a radiologic (MRI) demonstrable mono- or bisegmental disc degeneration with or without disc prolabation, exclusion of psychogenic disease and positive preoperative, diagnostic measures. RESULTS: The average stay in the hospital was 16.8 days (preoperative: 4.3 days), the average operation time 85.5 minutes, the average blood loss was 125 ccm. 23 patients were operated in L 5 / S 1, 20 in L 4 / 5 and 2 in L 3 / 4. NSAR was given in 33 patients preoperatively, opiates in 2 further patients, postoperatively NSAR was necessary in 5 patients, opiates in 2 patients. The preoperative angle of lordosis (L 1 - S 1, n = 25) was changed from 35.6 degrees to 42.6 degrees (20,2 %), the segmental angle from 19 degrees to 30 degrees (57.5 %). CONCLUSION: The implantation of the artificial disc was followed by a good pain relief in patients suffering from a mono- or bisegmental disc degeneration. In patients with a facett joint arthrosis and elderly patients > 45 years this method cannot be used, the indication in patients with failed back surgery syndrome cannot be estimated yet. Improvements of the instrumentation and the discussion in the case of revisional operations are mandatory.     

An overview of underlying causes and animal models for the study of age‐related degenerative disorders of the spine and synovial joints

As human lifespan increases so does the incidence of age‐associated degenerative joint diseases, resulting in significant negative socioeconomic consequences. Osteoarthritis (OA) and intervertebral disc degeneration (IDD) are the most common underlying causes of joint‐related chronic disability and debilitating pain in the elderly. Current treatment methods are generally not effective and involve either symptomatic relief with non‐steroidal anti‐inflammatory drugs and physical therapy or surgery when conservative treatments fail. The limitation in treatment options is due to our incomplete knowledge of the molecular mechanism of degeneration of articular cartilage and disc tissue. Basic understanding of the age‐related changes in joint tissue is thus needed to combat the adverse effects of aging on joint health. Aging is caused at least in part by time‐dependent accumulation of damaged organelles and macromolecules, leading to cell death and senescence and the eventual loss of multipotent stem cells and tissue regenerative capacity. Studies over the past decades have uncovered a number of important molecular and cellular changes in joint tissues with age. However, the precise causes of damage, cellular targets of damage, and cellular responses to damage remain poorly understood. The objectives of this review are to provide an overview of the current knowledge about the sources of endogenous and exogenous damaging agents and how they contribute to age‐dependent degenerative joint disease, and highlight animal models of accelerated aging that could potentially be useful for identifying causes of and therapies for degenerative joint diseases. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 831–837, 2013     

Risk management in posterior spinal endoscopic surgery in lumbar diseases

Background

Minimally invasive posterior spinal endoscopic surgery has increased in popularity. However, a steep learning curve may result in a high frequency of complications. Additionally, device failure may occur during routine use. We retrospectively investigated the incidence of such safety issues in a population of patients undergoing endoscopic spinal surgery at our institution.

Patients/materials and methods

A total of 611 cases were included. Underlying diseases that required endoscopic surgery were lumbar disc herniation in 382 patients, lumbar spinal stenosis in 123 patients, lumbar degenerated spondylolisthesis in 100 patients, and lumbar facet joint cysts in 6 patients. Surgical complications, anatomic abnormality, and mechanical failure and/or damage of surgical instruments were considered adverse events associated with the surgery. The time period was divided into first and second halves in order to investigate the effects of the learning curve.

Results and conclusion

Complications were divided into perioperative and postoperative complications. Due to operator inexperience, complications such as intraoperative dural tear, wrong disc level surgery, and contralateral symptoms due to lack of nerve decompression were more common during the first 5 years. In contrast, no improvement was seen in the frequency of epidural hematoma in the late phase. This report indicates that during endoscopic spinal surgery, some safety issues and surgical complications are independent of surgeon experience, and may include radicular anomaly, postoperative hematoma, and mechanical damage of instruments.     

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases

Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.