The effect of laser irradiation for nucleus pulposus: an experimental study

BACKGROUND: The radicular pain caused by disc herniation can be explained by two mechanisms: the compression of the nerve root by the herniated disc or the irritation of the nerve root due to chemical factors. Percutaneous laser disc decompression (PLDD) was introduced for the treatment of lumbar disc hernias in the 1980s. Decompression of the nerve root is assumed to be an effective therapeutic mechanism for PLDD. However, laser irradiation might reduce the chemical factors that cause nerve root irritation by altering intra-disc proteins. We used nerve conduction velocities (NCV) and levels of two chemical factors to evaluate the differences between the two groups in this in vivo study. METHODS: All rabbits had the nerve root in contact with the leakage from the nucleus pulposus. One group underwent laser irradiation for the leaking nucleus pulposus including the incision site of the disc and nucleus pulposus itself. The levels of two chemical factors, prostaglandin E2 and phospholipase E2, in the intervertebral disc were measured before and after laser irradiation. RESULTS: NCV in the laser-irradiated group was significantly faster than in the non-laser-irradiated group. The levels of chemical factors were significantly reduced after laser irradiation. CONCLUSIONS: One of the mechanisms thought to be responsible for PLDD's effectiveness is a decrease in the chemical factors through protein alteration in the intervertebral disc by laser irradiation.     

The Effect of Laser Irradiation for Nucleus Pulposus: an Experimental Study

Abstract

Background: The radicular pain caused by disc herniation can be explained by two mechanisms: the compression of the nerve root by the herniated disc or the irritation of the nerve root due to chemical factors. Percutaneous laser disc decompression (PLDD) was introduced for the treatment of lumbar disc hernias in the 1980s. Decompression of the nerve root is assumed to be an effective therapeutic mechanism for PLDD. However, laser irradiation might reduce the chemical factors that cause nerve root irritation by altering intra–disc proteins. We used nerve conduction velocities (NCV) and levels of two chemical factors to evaluate the differences between the two groups in this in vivo study.

Methods: All rabbits had the nerve root in contact with the leakage from the nucleus pulposus. One group underwent laser irradiation for the leaking nucleus pulposus including the incision site of the disc and nucleus pulposus itself. The levels of two chemical factors, prostaglandin E2 and phospholipase E2, in the intervertebral disc were measured before and after laser irradiation.

Results: NCV in the laser–irradiated group was significantly faster than in the non–laser–irradiated group. The levels of chemical factors were significantly reduced after laser irradiation.

Conclusions: One of the mechanisms thought to be responsible for PLDD's effectiveness is a decrease in the chemical factors through protein alteration in the intervertebral disc by laser irradiation.     

经皮髓核钳夹术联合臭氧治疗腰椎间盘突出症的应用研究

目的 探讨经皮髓核钳夹术(PLD)联合医用臭氧(O3)注射治疗腰椎间盘突出症后O3在椎间盘内外弥散、突出物回缩情况以及临床效果、不良反应、并发症等.方法 选择通过影像检查(CT或MR)结合临床确诊为腰椎间盘突出症的120例患者,按随机数字表法分为3组(PLD组、O3注射组、PLD+O3注射组),每组各40例,分别按方案实施治疗.结果 PLD+O3注射组腰痛发生率最低,O3在椎间盘内外弥散最好;突出物回缩率3组间无明显差异;PLD+O3注射组术后立即有效率为86%,PLD组为83%,O3注射组为35%;随访6～18个月,PLD+O3注射组总有效率为92.5%,PLD组为87.5%,O3注射组为77.5%;3组均未发生并发症.结论 PLD联合O3注射治疗腰椎间盘突出症是一种较好的综合治疗方案,安全、有效,可提高治疗效果,减少不良反应.     

Lumbar disc herniation in early childhood: case report and literature review

INTRODUCTION: Lumbar disc herniation is a common condition in adults, uncommon in adolescents and exceptional below the age of 10 years. CASE REPORT: We report on a 6-year-old boy who presented with low-back pain and sciatica after having sustained an injury in a rear-end automobile accident. Due to our limited experience with protruded discs in this age group, we decided to be conservative initially. However, the persistence of incapacitating pain prompted surgical treatment. Operative findings consisted of a torn annulus, attached at one end to the cartilaginous plate, which formed a major portion of the extruded L5-S1 disc. DISCUSSION: A search of the literature yielded only four cases of lumbar disc (L4-5) protrusions in patients aged 9 years or younger. The child described here is one of the youngest patients with a lumbar disc rupture to be reported in the literature, and the first with an L5-S1 traumatic herniation.     

Spontaneous epidural hematoma as a cause of sciatic pain in a schoolboy

A previously healthy 13-year-old boy began to manifest radiating pain in his left leg after heavy physical exertion during judo training. He also had a sensation of numbness in his left buttock and leg. Initially, the patient was treated conservatively with a clinical diagnosis of disc herniation. However, following 3 months of conservative treatment, there was no relief of pain. Magnetic resonance imaging of the lumbar spine demonstrated an epidural mass causing compression of the dural sac at the L4-L5 disc level. During surgery, the L5 nerve root was found to be severely compressed in the spinal canal because of a chronic epidural hematoma. Following microsurgical removal of this hematoid mass, the patient had a good recovery. Spontaneous epidural hematomas in the lumbar region are rare, and only a few cases presenting with features simulating those caused by a disc herniation have been reported. Our patient represents the first such case described in a child.     

Lumbar Disc Herniation in Tae Kwon Do Athletic Child

Lumbar disc herniation is extremely uncommon in children below 10 years of age. A 7-year-old boy is reported who presented with low back pain and left leg radiating pain. The pain started seven days prior to presentation and was attributed to performing the jumping kick without any previous warm-up. Magnetic resonance imaging revealed a posterolateral disc herniation at the L3-4 level and multiple degenerative changes. The patient received conservative treatment including limitation of sports activities, anti-inflammatory and muscle relaxant medications as well as physical therapy. After three months of the aggressive treatment the child was symptom free. We present here a lumbar disc herniation in one of the youngest patient.     

局部生物力学因素在L5/S1椎间盘突出症发病中的作用

背景：近年来,有关生物力学因素与腰背痛关系的报道大多集中在腰椎整体生物力学与腰背痛的研究上,而针对局部生物力学特点与单纯腰椎间盘突出的研究则较少。 目的：探讨局部生物力学因素在L5/S1椎间盘突出症发病中的作用。 方法：共纳入对象124例,包括椎间盘突出症组和对照组,62例/组。椎间盘突出症组为2008-06/2009-07于青岛大学医学院附属医院诊断明确并行手术治疗的L5/S1椎间盘突出症患者;对照组为健康体检人员。在腰椎正侧位X射线片上测量和观察各组L5椎体相对深度、腰骶移行椎、L5/S1椎间盘相对高度、腰骶角、骶骨水平角和骶骨垂直角的变化。 结果与结论：与对照组比较,椎间盘突出症组L5椎体相对深度明显增加(P < 0.01),椎间盘突出症组腰骶移行椎数目明显降低(P < 0.01),说明相对位置较深的L5椎体及腰骶移形椎可能对L5/S1椎间盘具有保护作用,可降低L5/S1椎间盘突出症的发生率。椎间盘突出症组腰骶角和骶骨水平角明显减小(P < 0.01);但L5/S1骶骨垂直角和椎间盘相对高度在椎间盘突出症组与对照组之间差别无显著性意义(P > 0.05),可见,L5/S1椎间盘相对高度、腰骶角、骶骨水平角和骶骨垂直角与椎间盘突出的关系仍不明确,需进一步探讨。     

Dermatomal somatosensory evoked potential demonstration of nerve root decompression after VAX-D therapy

Abstract

Reductions in low back pain and referred leg pain associated with a diagnosis of herniated disc, degenerative disc disease or facet syndrome have previously been reported after treatment with a VAX-D table, which intermittently distracts the spine. The object of this study was to use dermatomal somatosensory evoked potentials (DSSEPs) to demonstrate lumbar root decompression following VAX-D therapy. Seven consecutive patients with a diagnosis of low back pain and unilateral or bilateral L5 or S1 radiculopathy were studied at our center. Disc herniation at the L5-S1 level was documented by MRI or CT in all patients. All patients were studied bilaterally by DSSEPs at L5 and S1 before and after VAX-D therapy. All patients had at least 50% improvement in radicular symptoms and low back pain and three of them experienced complete resolution of all symptoms. The average pain reduction was 77%. The number of treatment sessions varied from 12 to 35. DSSEPs were considered to show improvement if triphasic characteristics returned or a 50% or greater increase in the P1-P2 amplitude was seen. All patients showed improvement in DSSEPs after VAX-D therapy either ipsilateral or contralateral to the symptomatic leg. Two patients showed deterioration in DSSEPs in the symptomatic leg despite clinically significant improvement in pain and radicular symptoms. Overall, 28 nerve roots were studied before and after VAX-D therapy. Seventeen nerve root responses were improved, eight remained unchanged and three deteriorated. The significance of DSSEP improvement contralateral to the symptomatic leg is emphasized. Direct compression of a nerve root by a disc herniation is probably not the sole explanation for referred leg pain. [Neurol Res 2001; 23: 706-714]     

Microdecompression for Extraforaminal L5-S1 Disc Herniation; The Significance of Concomitant Foraminal Disc Herniation for Postoperative Leg Pain

Objective

To analyze the relationship of concomitant foraminal lumbar disc herniation (FLDH) with postoperative leg pain after microdecompression for extraforaminal lumbar disc herniation (EFLDH) at the L5-S1 level.

Methods

Sixty-five patients who underwent microdecompression for symptomatic EFLDH at the L5-S1 level were enrolled. According to the severity of accompanying FLDH, EFLDH was classified into four categories (Class I : no FLDH; Class II : mild to moderate FLDH confined within a lateral foraminal zone; Class III : severe FLDH extending to a medial foraminal zone; Class IV : Class III with intracanalicular disc herniation). The incidence of postoperative leg pain, dysesthesia, analgesic medication, epidural block, and requirement for revision surgery due to leg pain were evaluated and compared at three months after initial surgery.

Results

The incidences of postoperative leg pain and dysesthesia were 36.9% and 26.1%, respectively. Pain medication and epidural block was performed on 40% and 41.5%, respectively. Revision surgery was recommended in six patients (9.2%) due to persistent leg pain. The incidences of leg pain, dysesthesia, and requirement for epidural block were higher in Class III/IV, compared with Class I/II. The incidence of requirement for analgesic medication was significantly higher in Class III/IV, compared with Class I/II (p=0.02, odds ratio=9.82). All patients who required revision surgery due to persistent leg pain were included in Class III/IV.

Conclusion

Concomitant FLDH seems related to postoperative residual leg pain after microdecompression for EFLDH at the L5-S1 level.     

Dermatomal somatosensory evoked potential demonstration of nerve root decompression after VAX-D therapy.

Reductions in low back pain and referred leg pain associated with a diagnosis of herniated disc, degenerative disc disease or facet syndrome have previously been reported after treatment with a VAX-D table, which intermittently distracts the spine. The object of this study was to use dermatomal somatosensory evoked potentials (DSSEPs) to demonstrate lumbar root decompression following VAX-D therapy. Seven consecutive patients with a diagnosis of low back pain and unilateral or bilateral L5 or S1 radiculopathy were studied at our center. Disc herniation at the L5-S1 level was documented by MRI or CT in all patients. All patients were studied bilaterally by DSSEPs at L5 and S1 before and after VAX-D therapy. All patients had at least 50% improvement in radicular symptoms and low back pain and three of them experienced complete resolution of all symptoms. The average pain reduction was 77%. The number of treatment sessions varied from 12 to 35. DSSEPs were considered to show improvement if triphasic characteristics returned or a 50% or greater increase in the P1-P2 amplitude was seen. All patients showed improvement in DSSEPs after VAX-D therapy either ipsilateral or contralateral to the symptomatic leg. Two patients showed deterioration in DSSEPs in the symptomatic leg despite clinically significant improvement in pain and radicular symptoms. Overall, 28 nerve roots were studied before and after VAX-D therapy. Seventeen nerve root responses were improved, eight remained unchanged and three deteriorated. The significance of DSSEP improvement contralateral to the symptomatic leg is emphasized. Direct compression of a nerve root by a disc herniation is probably not the sole explanation for referred leg pain.     

Intradiscal oxygen-ozone therapy for the treatment of symptomatic lumbar disc herniation: A preliminary study

PurposeTo assess safety and effectiveness of computed tomography (CT)-guided intradiscal oxygen-ozone therapy (O₂-O₃ therapy) for the treatment of symptomatic lumbar disc herniation and radiological changes.Materials and MethodsThis study was conducted in twenty patients presenting lumbar disc herniation with resistant lumbar or lumbar radicular pain They underwent intradiscal oxygen-ozone therapy under CT guidance. They were treated at one- or two-disc levels, representing a total of 24 discs treated. MR imaging examinations were obtained before treatment and 2 months post-procedure to analyse treatment-related disc modifications including modification of the surfaces of the disc and of the herniated disc, and the variations in disc height according to the disc height index. Clinical outcomes were assessed using the visual analogue scale (VAS) to evaluate the severity of pain before the procedure, at primary (2 months) and at secondary (12 months) follow-ups.ResultsAll the procedures were technically successful. The median VAS scores were 7.95 before the procedure, 3.9 at 2 months and 2.95 at 12 months. MRI analysis showed a significant decrease in herniation size at 2 months (-20%, p = 0.008). No immediate or late complications were observed. Only three patients (13.6%) underwent lumbar spine microdiscectomy in the year following ozone therapy. The treatment appeared to be more effective in cases of nerve root symptomatology.ConclusionThis study suggests that intradiscal O₂-O₃ therapy is safe and effective for the treatment of lumbar disc herniation associated with resistant lumbar or lumbar radicular pain.     

Lumbar Epidural Varix Mimicking Disc Herniation

Lumbar radiculopathy is generally caused by such well-recognized entity as lumbar disc herniation in neurosurgical practice; however rare pathologies such as thrombosed epidural varix may mimic them by causing radicular symptoms. In this case report, we present a 26-year-old man with the complaint of back and right leg pain who was operated for right L4–5 disc herniation. The lesion interpreted as an extruded disc herniation preoperatively was found to be a thrombosed epidural varix compressing the nerve root preoperatively. The nerve root was decompressed by shrinking the lesion with bipolar thermocoagulation and excision. The patient''s complaints disappeared in the postoperative period. Thrombosed lumbar epidural varices may mimic lumbar disc herniations both radiologically and clinically. Therefore, must be kept in mind in the differential diagnosis of lumbar disc herniations. Microsurgical techniques are mandatory for the treatment of these pathologies and decompression with thermocoagulation and excision is an efficient method.     

Endoscopic Discectomy for the Cauda Equina Syndrome During Third Trimester of Pregnancy

Low back pain is common during pregnancy. However, the prevalence of symtomatic lumbar disc herniation is rare, and cauda equina syndrome due to disc herniation during pregnancy is even rarer. We report a rare case of lumbar disc herniation causing cauda equina syndrome during third trimester of pregnancy which successfully treated by endoscopic discectomy. This case shows that endoscopic discectomy can be the treatment option for the lumbar disc herniation during pregnancy.     

A patient with thoracic intradural disc herniation

Intradural disc herniation is a rare disease that occurs most commonly in the lumbar region, while fewer than 5% occur in the thoracic and cervical regions. We report a patient with thoracic intradural disc herniation at T12-L1 who presented with radiculopathy and motor weakness. The preoperative MRI did not demonstrate an intradural lesion, and it was identified intraoperatively by inspection and palpation of the thecal sac. The disc was removed, and the patient experienced good neurological recovery and remains pain free 1 year after surgery.     

外周血T淋巴细胞与腰椎间盘突出类型及直腿抬高试验的相关性

的：观察腰椎间盘突出症患者外周血T淋巴细胞变化水平,探讨患者外周血T淋巴细胞水平变化与其突出类型、体征的关系。 方法：收集2008-01/10在天津医科大学总医院需外科治疗的49例单阶段腰椎间盘突出症患者外周血,男 26例,女23例。发病部位：L4~5 22例,L5S1 27例。治疗前直腿抬高试验阳性34例,阴性15例。根据术中所见腰椎间盘位置分为破碎疝出组30例和退变突出组19例。以同期健康献血者20名为对照组。采用流式细胞仪检测外周血T淋巴细胞分类。 结果：破碎疝出组CD3+、CD4+、CD4+/CD8+水平较对照组高(P < 0.05),CD8+低于对照组(P < 0.05);直腿抬高试验阳性组CD4+、CD4+/CD8+水平较阴性组高,阳性组CD8+水平较阴性组低,差异有显著性意义(P < 0.05)。破碎疝出组直腿抬高试验试验阳性率高于退变突出组直腿抬高试验阳性率。 结论：腰椎间盘疝出后出现外周血T淋巴细胞免疫变化,且其不同病理类型也存在差异,T细胞介导免疫反应在患者体征发生、发展中起重要的作用。直腿抬高试验可能有助于证实突出间盘对神经根的损伤及治疗方式的选择。     

医用臭氧治疗腰椎间盘突出症长期疗效分析

目的 评价经皮椎间盘内臭氧注射治疗腰椎间盘突出症的长期疗效. 方法回顾性分析南方医科大学珠江医院影像中心及南方医院介入治疗科自2002年7月至2004年3月应用臭氧治疗的324例腰椎间盘突出症患者的临床资料.所有患者均随访≥3年,比较术前和最后随访时日本骨科学会(JOA)评分及下肢根性痛的视觉模拟评分(VAS);运用改良的MacNab分级法记录最后随访的临床效果并评价患者年龄、病史长短、突出程度及类型等因素对治疗效果的影响. 结果本组患者JOA评分、下肢根性痛VAS术前及术后终末随访时比较差异均有统计学意义(6.3±1.4 vs 13.1±1.2,P=0.018;7.5±0.8 vs 2.1±0.3,P=0.039),JOA评分、VAS改善率分别为78.2%和70.4%;改良的MacNab分级法记录到最后随访时疗效优良率为77.5%(251/324),患者年龄、病程及椎间盘突出程度对疗效有明显影响;部分(33.8%)包含型突出患者治疗后近期可有症状"反跳".结论 臭氧治疗腰椎间盘突出症术后3年以上随访结果显示疗效令人满意,患者年龄、病程和椎间盘突出程度能影响患者疗效.     

Retrograde Horseradish Peroxidase Transport in Motor Axons after Nd:YAG Laser Irradiation of the Tibial Nerve in Rats

We have recently demonstrated that the number of small sensory neurons of the A-δ- and C-fiber group in lumbar dorsal root ganglia labeled with horseradish peroxidase (HRP) is selectively decreased 7 days after Nd:YAG laser irradiation of the tibial nerve in the rat. In contrast, the number of large diameter sensory neurons was not affected by laser application. In an attempt to clarify the fate of motoneurons after laser irradiation of their peripheral axons, the numbers of lumbar motoneurons retrogradely labeled with HRP 7 days after Nd:YAG laser irradiation of the tibial nerve have been determined in rats. Our results show that the number of HRP-labeled motoneurons in lumbar segments L6 to L3 is not altered to a significant extent after laser irradiation of their peripheral axons (laser-treated side, 767 ± 10 cells vs control side, 808 ± 19; n = 5, mean ± SEM). In addition, no difference was detected in the mean value or the distribution of soma cross-sectional areas of labeled motoneurons on the laser-treated side and the control side. Specifically, the numbers of HRP-labeled small diameter motoneurons, which are presumably γ in type and have a conduction velocity similar to sensory neurons of the A-δ group, were not affected by laser application. Possible mechanisms of the differential vulnerability of sensory neurons as compared to motoneurons of similar size are discussed.     

Magnetic resonance image findings and surgical considerations in T1-2 disc herniation

OBJECTIVE: To report a case of disc herniation at T1-2. CLINICAL PRESENTATION: A 57-year-old man presented with hand weakness, Horner's syndrome, and pain radiating along the medial aspect of one upper extremity. Magnetic resonance imaging demonstrated extruded T1-2 disc herniation with upward herniation of a sequestrated fragment. INTERVENTION: An anterior approach was used to excise the disc, that was compressing the spinal cord and the T1 nerve root. All the patient's symptoms resolved completely, including Horner's syndrome. CONCLUSION: Anterior discectomy may be the simplest and most effective method for disc excision and relief of spinal cord and T1 nerve root compression.     

锦州地区青少年椎间盘突出危险因素的logistic回归分析

背景：成人与青少年椎间盘突出的发病机制和危险因素差别很大,国内应用logistic回归分析青少年椎间盘突出危险因素的研究较少。 目的：多因素非条件Logistic回归分析锦州地区青少年椎间盘突出发病的危险因素。 方法：选择青少年椎间盘突出患者94例作为实验组,男56例,女38例;年龄9~18岁。居住地为锦州市。对照组患者选自同期因其他非椎间盘突出疾病入院的同年龄组同居住地患者共100例。采用多因素非条件Logistic回归分析对椎间盘突出发病的可能相关因素进行分析,以OR > 1为椎间盘突出发生的危险因素：OR < 1为椎间盘突出发生的保护因素。 结果与结论：194例患者均进入结果分析。多因素非条件Logistic回归分析显示：与对照组相比,椎间盘突出患者家族遗传OR =6.427,P=0.015;创伤因素OR=17.196,P=0.011;先天畸型 OR=31.429,P=0.002;运动过量OR=12.644,P=0.027。结果表明,家族遗传、创伤、先天畸型和运动过量是锦州地区青少年椎间盘突出发病的危险因素。以此为依据制定相应的预防方案十分必要。     

Percutaneous automated lumbar nucleotomy

The results of percutaneous automated lumbar nucleotomy in the treatment of lumbar disc herniation were assessed in a series of 39 patients. The technique consists of mechanical decompression of the herniated intervertebral disc without total excision. Only one-space discs were treated by this method. Sciatica was the predominant clinical symptom in 30 cases, and lumbar pain in 9 cases. Good to very good results were obtained in 70% of patients with sciatica and in 55% of patients with lumbar pain. After 4 cases of nucleotomy performed after failure of nucleolysis were excluded, the proportion of very good results rose to 77% in sciatica. Conversely, it seems that a number of failed nucleotomies can be treated by nucleolysis. Nucleotomy is very well tolerated and deserves to be used as first-line treatment of single and radiologically well documented lumbar disc herniations.