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Background: Low back pain (LBP) is a highly prevalent condition that comprise a large portion of outpatient practice, challenging the diagnosis and treatment. However, the diagnostic tools are limited to clinical history, physical examination and imaging. Degenerative disc disease (DDD) is a significant cause of LBP, and emerging literature confirms the elevated levels of biomarkers in the discs. These biomarkers may serve as a tool for diagnosis, but may also be useful in predicting the treatment outcome. Here, we examine the expression of various cytokines on 1-year recovery from patients with LBP., Methods: Patient-reported outcome (PRO) in terms of pain intensity (VAS), disability (ODI), and quality of life (Eq-5D) is collected from 44 patients at baseline and 12 months after surgery to study the influence of baseline TNF-α, IL-1β, and IL-6 mRNA expression in both annulus fibrosus (AF) and nucleus pulposus (NP)., Results: Between baseline and follow-up, our cohort showed improvement in VAS back pain (p < 0.001), VAS leg pain (p < 0.001), ODI (p = 0.02), and Eq-5D (p = 0.01). Baseline levels of IL-1 β was positively correlated with VAS back pain scores in AF (p = 0.05) and NP (p = 0.01) at 1-year follow-up. TNF-α expression at baseline was also positively correlated to ODI scores (p = 0.01) at follow-up and inversely correlated to improvements in ODI score between baseline and follow-up, suggesting that high TNF-α expression at baseline is associated with poor outcomes from surgery., Conclusion: The results from our study support that TNF-α expression at baseline can serve as a very important predictor of treatment response from lumbar fusion surgery., (© 2024 World Institute of Pain.)

Background: The fusion rate, clinical efficacy, and complications of minimally invasive fusion surgery and open fusion surgery in the treatment of lumbar degenerative disease are still unclear., Methods: We conducted a literature search using PubMed, Embase, Cochrane Library, CNKI, and WANFANG databases., Results: This study included 38 retrospective studies involving 3097 patients. Five intervention modalities were considered: unilateral biportal endoscopic-lumbar interbody fusion (UBE-LIF), percutaneous endoscopic-lumbar interbody fusion (PE-LIF), minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF). Quality assessment indicated that each study met acceptable quality standards. PE-LIF demonstrated reduced low back pain (Odds Ratio = 0.50, Confidence Interval: 0.38-0.65) and lower complication rate (Odds Ratio = 0.46, Confidence Interval: 0.25-0.87) compared to PLIF. However, in indirect comparisons, PE-LIF showed the lowest fusion rates, with the ranking as follows: UBE-LIF (83.2%) > MIS-TLIF (59.6%) > TLIF (44.3%) > PLIF (39.8%) > PE-LIF (23.1%). With respect to low back pain relief, PE-LIF yielded the best results, with the order of relief as follows: PE-LIF (96.4%) > MIS-TLIF (64.8%) > UBE-LIF (62.6%) > TLIF (23.0%) > PLIF (3.2%). Global and local consistency tests showed satisfactory results, and heterogeneity tests indicated good stability., Conclusions: Compared to conventional open surgery, minimally invasive fusion surgery offered better scores for low back pain and Oswestry Disability Index, lower complication rates, reduced bleeding, and shorter hospital stays. However, minimally invasive fusion surgery did not show a significant advantage in terms of fusion rate and had a longer operative time., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Facet joint violation (FJV) is associated with postoperative low-back pain and is a confirmed risk factor for adjacent-segment degeneration, a long-term complication of lumbar fusion surgery. The authors' knowledge of its mechanisms comes from in vitro biomechanical research only; there is a lack of radiographic evidence of the effects of violation on the superior adjacent-segment facet joint, intervertebral disc, and other local radiographic parameters. Furthermore, any differences between unilateral and bilateral violation remain relatively unclear. The authors therefore aimed to explore the effects of nonviolation and unilateral and bilateral violation on radiographic degeneration of the facet joint and intervertebral disc at the fusion and superior adjacent segment. Patient-reported clinical outcomes were compared at the 2-year follow-up., Methods: The authors retrospectively analyzed data from 148 patients with lumbar degenerative diseases who underwent single-segment minimally invasive transforaminal lumbar interbody fusion between 2016 and 2020. FJV and facet joint degeneration were evaluated and graded using Shah's method and Pathria's standard, respectively. Radiographic parameters, including disc height and intervertebral Cobb angle at the fusion and superior adjacent segment, were measured. Clinical outcomes were evaluated using visual analog scale (VAS) and Japanese Orthopaedic Association scores., Results: Preoperative data were comparable among the 3 groups (nonviolation, unilateral violation, and bilateral violation) (p > 0.05). Patient-reported clinical outcomes were followed up for at least 2 years (average duration 28.17 ± 6.17 months). At the last follow-up, facet joint degeneration grades were sequentially increased in the nonviolation, unilateral violation, and bilateral violation groups (p = 0.006). The unilateral (2.45 ± 2.17 mm) and bilateral (2.70 ± 1.94 mm) violation groups had more severe losses of disc height in the superior adjacent segment than did the nonviolation group (1.31 ± 2.01 mm). The VAS low-back pain and Japanese Orthopaedic Association scores in the bilateral (2.57 ± 1.44 and 19.83 ± 2.84, respectively) and unilateral (2.26 ± 0.79 and 20.43 ± 3.85, respectively) violation groups were significantly worse than in the nonviolation group (1.69 ± 1.12 and 21.80 ± 3.36, respectively) (p < 0.05). By contrast, there were no significant between-group differences in disc height, intervertebral Cobb angle in the fusion segment, or VAS leg pain scores (p > 0.05)., Conclusions: FJV was associated with postoperative low-back pain and worse functional outcomes. It also aggravated facet joint and intervertebral disc changes in the superior adjacent segment, especially when bilateral violation occurred; this may be part of the mechanisms of adjacent-segment degeneration.

Objectives: Low back pain is an important public health problem that impairs quality of life and causes limitations in both social and working life. It is attempted to be treated with conservative or surgical procedures. However, how wise is it to plan surgery with a high complication rate when conservative treatment fails to respond?, Methods: In this study, it was planned to investigate the effectiveness of the Disc-Fx procedure, which is one of the minimally invasive techniques for low back pain. Patients who underwent the Disc-Fx procedure were included. After consent was obtained, questions were asked before and after the procedure. The data of the patients were obtained by telephone and hospital database. Data of 40 patients older than 18 years of age were collected and analyzed retrospectively according to the established protocol. Then, the data were subjected to statistical calculation and the results were obtained., Results: Similar to the literature, there was a significant difference between preoperative and postoperative 1st, 6th, and 12th months of VAS, ODI, and MacNab values. In fact, a significant difference was found between the VAS, ODI, and MacNab values in each postoperative period compared to the preoperative period. In addition, factors that may be important in the etiology of low back pain were also evaluated., Conclusion: The Disc-Fx procedure is thought to be a promising procedure for carefully selected patients due to its low complication rates. It has been concluded that more precise results can be obtained as a result of randomized controlled studies with a larger number of patients and longer follow-up of patients.

Purpose: Low back pain is a significant socio-economic problem which is expected to deepen. Degenerative disc disease is considered to be one of its main causes. Unsuccessful conservative treatments usually lead to surgical treatments, including methods providing pain relief by vertebral fusion in the affected segment. However, this leads to changes in biomechanics, which is why approximately 30 years ago total disc replacements appeared. This work aims at determining the current state of treatments with this kind of replacement, comparing the results with those of fusion methods and assessing why fusion continues to dominate. Current treatments of degenerative disc disease by advanced procedures (regenerative and gene therapy, 3D printing) is also examined and evaluated, and future developments are considered., Methods: A critical review based on available scientific articles from online databases. The main keywords used were "lumbar", "total", "disc" and "replacement", supplemented according to the individual, monitored areas ("follow-up", "fusion", "future" etc.). For the articles found through database search (n = 895), narrower selection was made and the result was 33 articles included in review., Review: Total disc replacements have not yet satisfactorily demonstrated that they are superior to fusion methods in long term follow-up. Advanced methods are in their infancy., Conclusions: Additional research and development of total disc replacements is still necessary. For implants, the 3D scan - 3D model - 3D printing chain and its related technologies are increasingly important. The development of regenerative procedures using induced pluripotent stem cells and gene therapies is important, but conservative treatments and primary prevention should also be developed because regenerative procedures and gene therapies apparently will not be used routinely until the future.

Introduction and Purpose: With current imaging modalities and diagnostic tests, identifying pain generators in patients with non-specific chronic low back pain (CLBP) is difficult. There is growing evidence of the effectiveness of SPECT/CT examination in diagnosing the source of pain in the spine. The study aims to investigate the effect of posterior interbody fusion on a single-level SPECT/CT positive lumbar degenerative disc disease (DDD)., Material and Methods: This is a prospective study of patients with chronic low back pain (CLBP) operated on for a single-level SPECT/CT positive DDD. Primary outcomes were changes in visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). Secondary outcomes were complications, return to work, satisfaction and willingness to re-undergo surgery., Results: During a 3-year period, 38 patients underwent single-level fusion surgery. The mean preoperative VAS score of 8.4 (± 1.1) decreased to 3.2 (± 2.5, p < 0.001) and the mean preoperative ODI of 51.5 (± 7.3) improved to 20.7 (± 14.68, p < 0.001) at a 2-year follow-up. A minimum clinically important difference (30% reduction in VAS and ODI) was achieved in 84.2% of patients. Some 71% of patients were satisfied with the surgery results and 89.4% would undergo surgery again. There were four complications, and two patients underwent revision surgery. Some 82.9% of patients returned to work., Conclusion: Fusion for one-level SPECT/CT positive lumbar DDD resulted in substantial clinical improvement and satisfaction with surgical treatment. Therefore, SPECT/CT imaging could be useful in assessing patients with CLBP, especially those with unclear MRI findings., Trial Registration: ClinicalTrials.gov Identifier: NCT04876586., (© 2023. The Author(s).)

Objective: This study aimed to examine whether preoperative severity and location of lumbar intervertebral disc vacuum phenomenon (VP) influence surgical outcomes after single-level transforaminal lumbar interbody fusion., Methods: We included 106 patients (age, 67.4 ± 10.4 years; 51 male/55 female) with lumbar degenerative diseases, who were treated with single-level transforaminal lumbar interbody fusion. Severity of VP (SVP) score was measured preoperatively. SVP score at fused disc was used as SVP (FS) score and at nonfused discs was used as SVP (non-FS) score. Surgical outcomes were assessed using the Oswestry Disability Index (ODI) and visual analog scale (VAS; low back pain (LBP), lower extremity pain, numbness, LBP in motion, in standing, and in sitting). The patients were divided into severe VP (FS or non-FS) and mild VP (FS or non-FS) groups, and surgical outcomes were compared between the 2 groups. Correlations between each SVP score and surgical outcomes were analyzed., Results: There were no differences in surgical outcomes between the severe VP (FS) and mild VP (FS) groups. Postoperative ODI, VAS score for LBP, lower extremity pain, numbness, and LBP in standing were significantly worse in the severe VP (non-FS) group than in the mild VP (non-FS) group. SVP (non-FS) scores significantly correlated with postoperative ODI, VAS score for LBP, lower extremity pain, numbness, and LBP in standing; however, SVP (FS) scores did not correlate with any surgical outcomes., Conclusions: Preoperative SVP at fused disc is not associated with surgical outcomes; however, SVP at nonfused discs is correlated with clinical outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This study aimed to assess the quality of life of 113 Caucasian patients with intervertebral disc (IVD) degeneration of the lumbosacral (L/S) spine who qualified for microdiscectomy during a 12-month period after surgery. Based on magnetic resonance imaging before the surgery, the degree of radiological advancement of the degenerative changes was determined according to the Pfirrmann grading scale from 1 to 5. To assess pain intensity, the Visual Analog Scale (VAS) was used; the Satisfaction with Life Scale (SWLS) was used to evaluate quality of life; and to assess the degree of ability, the Oswestry Low Back Pain Disability Questionnaire (ODI) was employed. The level of pain, assessed using the VAS, significantly changed in the months following the surgery, with the highest values noted before surgery and the lowest a year after. In turn, the results of the SWLS questionnaire revealed a significant increase in satisfaction with life in the subsequent stages of the study. The conducted correlation analysis revealed significant dependencies in terms of quality of life in regard to pain as well as degree of disability. The level of pain and degree of disability were closely related to the degree of radiological advancement of degenerative changes according to the Pfirrmann grading scale., (© 2023. The Author(s).)

Low back pain is associated with degenerative disc diseases of the spine. Surgical treatment includes fusion and non-fusion types. The gold standard is fusion surgery, wherein the affected vertebral segment is fused. The common complication of fusion surgery is adjacent segment degeneration (ASD). The ASD often leads to revision surgery, calling for a further fusion of adjacent segments. The existing designs of nonfusion type implants are associated with clinical problems such as subsidence, difficulty in implantation, and the requirement of revision surgeries. Various surgical approaches have been adopted by the surgeons to insert the spinal implants into the affected segment. Over the years, extensive biomechanical investigations have been reported on various surgical approaches and prostheses to predict the outcomes of lumbar spine implantations. Computer models have been proven to be very effective in identifying the best prosthesis and surgical procedure. The objective of the study was to review the literature on biomechanical studies for the treatment of lumbar spinal degenerative diseases. A critical review of the clinical and biomechanical studies on fusion spine surgeries was undertaken. The important modeling parameters, challenges, and limitations of the current studies were identified, showing the future research directions., (© 2023. International Federation for Medical and Biological Engineering.)

Background and Objectives: The impact of the duration of symptoms (DOS) on postoperative clinical outcomes of patients with degenerative lumbar spinal diseases is important for determining the optimal timing of surgical intervention; however, the timing remains controversial. This prospective case−control study aimed to investigate the influence of the preoperative DOS on surgical outcomes in minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF). Materials and Methods: Patients who underwent single-level TLIF for lumbar degenerative diseases between 2017 and 2018 were reviewed. Only patients with full clinical data during the 1-year follow-up period were included. The patients were divided into two groups (DOS < 12 months, group S; DOS ≥ 12 months, group L). The clinical outcomes, including the Oswestry disability index (ODI) and visual analog scale (VAS) for lower back pain, leg pain, and numbness, were investigated preoperatively and at 1, 3, and 6 months, as well as 1 year, after surgery. Furthermore, postoperative patient satisfaction 1 year after surgery was also surveyed. Results: A total of 163 patients were assessed: 60 in group S and 103 in group L. No differences in baseline characteristics and clinical outcomes were found. The ODI and VAS significantly improved from the baseline to each follow-up period (all p < 0.01). Group S had significantly lower ODI scores at 3 months (p = 0.019) and 6 months (p = 0.022). In addition, group S had significantly lower VAS scores for leg pain at 3 months (p = 0.027). In a comparison between both groups, only the patients with cauda equina symptoms showed that ODI and leg pain VAS scores at 3 months after surgery were significantly lower in group S (19.9 ± 9.1 vs. 14.1 ± 12.5; p = 0.037, 7.4 ± 13.9 vs. 14.7 ± 23.1; p = 0.032, respectively). However, the clinical outcomes were not significantly different between both groups 1 year after surgery. Patient satisfaction was also not significantly different between both groups. Conclusions: Patients with a shorter DOS tended to have a significantly slower recovery; however, clinical outcomes 1 year after surgery were good, regardless of the DOS.

Objective: We compared the clinical outcomes of minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF)., Methods: We retrospectively analyzed the clinical data of patients who underwent single-segment Mis-TLIF or Endo-TLIF between June 2016 and June 2019 at our hospital. The patients in each treatment group were matched 1:1 for sex, age, and type of lumbar degenerative disease, and their clinical outcomes were compared at discharge and at 1 and 2 years postoperatively., Results: Our study included 64 patients, with 32 patients in each treatment group. Operative time and fluoroscopy time were significantly higher in the Endo-TLIF versus Mis-TLIF groups, whereas estimated blood loss, postoperative drainage volume, and the low back pain visual analog scale score at discharge were significantly lower. Both treatments achieved exact interbody fusion at the final-follow up. There was no significant difference in the visual analog scale score or Oswestry Disability Index between the groups at 1 and 2 years postoperatively. Complication rates were higher in the Endo-TLIF group (21.9%) than in the Mis-TLIF group (6.2%), although the difference was not significant., Conclusions: Although there was no difference in the long-term outcomes between the treatments, Endo-TLIF had less blood loss and a lower postoperative drainage volume and low back pain visual analog scale score at discharge than Mis-TLIF. However, the longer operative time and potentially higher complication rate of Endo-TLIF suggest that surgeons may need to overcome the steeper learning curve than the procedure of Mis-TLIF., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Degenerative disc disease is a major health concern in spine surgery. The aim of this systematic review was to summarize the current knowledge about injectable regenerative therapies (mesenchymal stem cells [MSC] or platelet rich plasma [PRP]) in degenerative disc disease., Evidence Acquisition: A research and analysis of the literature on Pubmed, Medscape, Medline, Google Scholar and Cochrane databases was performed, in accordance with the Preferential Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart. Only peer-reviewed randomized controlled trials (RCTs), prospective single-arm trials, case series, and cohort studies were included., Evidence Synthesis: A total of 17 studies were included. All were homogeneous regarding indications to the procedure: discogenic low-back pain for at least 3-6 months, failure of conservative treatment, MRI evidence of disc degeneration. A total of 182 patients were treated with MSC and 198 patients were treated with PRP. Considering the efficacy, the studies were heterogeneous in clinical evaluation systems; however, they all reported significant improvement in clinical and functional scores. Neither major complications nor adverse effects were reported by any author. As for radiographical outcome none of the studies reported a disc height improvement after treatment., Conclusions: Degenerative disc disease is a major health concern. Regenerative therapies could play a role in the treatment of its symptoms, as they have been proven to be clinically effective, cheap, and safe. Nevertheless, further studies are needed, in order to establish evidence based standardized treatments.

Discogenic low back pain is a common musculoskeletal complaint in patients presenting to orthopaedic surgeons. In addition to surgical options, there are several nonsurgical intradiscal treatments that have gained interest, ranging from biologic, nonbiologic, cell-based, and molecular therapies. However, there is limited evidence for many of these techniques, and some are still in the clinical trial stage. We describe a broad overview of these intradiscal therapies, the mechanism of action, and the evidence behind them., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Objective: The purpose of this study was to analyze whether the type of preoperative pain affects the improvement in postoperative pain intensity in patients with a lumbar degenerative disease (LDD)., Methods: We retrospectively reviewed 93 patients who underwent lateral lumbar interbody fusion (LLIF) without direct decompression. All patients were evaluated using Numeric Rating Scale (NRS) scores for low back pain (NRS LBP ), leg pain (NRS LP ), and leg numbness (NRS LN ) and imaging data before and after LLIF surgery. Based on the Japanese version of the painDETECT scores, patients were classified into 3 groups: a neuropathic pain (NeP) group, a nociceptive pain (NocP) group, and an intermediate mixed pain group., Results: The Japanese version of the painDETECT identified NeP in 20.4% of patients with LDD prior to LLIF. Preoperative NRS LBP , NRS LP , and NRS LN scores were higher in the NeP group than those in the NocP group. All types of pain improved after LLIF surgery. The NRS LBP score 12 months after surgery was higher in the NeP group (3.8 ± 2.8) than that in the NocP group (1.9 ± 2.2) (P = 0.008). Similar results were obtained with NRS LP (NeP group = 3.1 ± 2.8, NocP group = 1.5 ± 2.0, P = 0.010)., Conclusions: Although LLIF was useful for relieving all types of preoperative pain in LDD patients, the NRS scores for preoperative pain were higher in the NeP group than those in the NocP group, and the postoperative NRS LBP and NRS LP score was significantly higher in the NeP group. Thus, controlling preoperative NeP may improve therapeutic efficacy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP)., Design: Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials., Methods: Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA., Results: The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success., Conclusions: In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Introduction: There is a growing number of publications highlighting sarcopenia and myosteatosis as poor prognosic factors for treatment results in oncological patients. The decrease in the cross-sectional area (CSA) of the multifidus muscle and muscle steatosis is associated with lumbar disc herniation and low back/limb pain. Nevertheless, no studies have analyzed the influence of the above parameters on patient satisfaction, pain decrease and return to daily activities. The aim of the study was to verify whether decreased preoperative CSA of the paraspinal and psoas major muscles and their fatty degeneration (myosteatosis) may influence the outcome of surgical treatment of lumbar disc disease (LDD)., Materials and Methods: One hundred and one patients with LDD undergoing open microdiscectomy were enrolled in the analysis. Relative cross-sectional areas (rCSA) of the paraspinal and psoas major muscles as well as their fatty degeneration were measured. Patients were assessed according to the validated Polish versions of the EURO EQ-5D, Core Outcome Measure Index (COMI), Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) 1 and 6 months postoperatively. The association between the variables was calculated using Pearson r and Spearman rank correlation. The Kruskal-Wallis test was used to compare the results between the groups with different rCSA of paraspinal and psoas major muscles and a different degree of paraspinal muscle myosteatosis., Results: Fatty degeneration of the paraspinal muscles correlated with better outcomes 1 and 6 months postoperatively according to ODI (P = 0.003 and P = 0.027, respectively). Patients with higher rCSA of the paraspinal and psoas major muscles achieved better results on the EURO EQ-5D scale (P = 0.0289 and P = 0.0089, respectively). Higher rCSA of the paraspinal and psoas major muscles did not correlate with better outcomes measured using ODI, COMI and VAS scales (P ≥ 0.072)., Conclusion: The degree of fatty degeneration of the paraspinal muscles correlates with better outcomes 1 and 6 months after microdiscectomy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Aim:  To explore the effects of viable allogeneic disc tissue supplementation in younger patients with discogenic chronic low back pain (CLBP). Patients & methods: VAST was a randomized placebo-controlled trial of disc allograft supplementation in 218 patients with discogenic CLBP. We conducted a post hoc analysis of change from baseline to 12 months in Oswestry Disability Index (ODI) and visual analog scale for pain intensity scores stratified by patient age. Results: Patients aged <42 years receiving allograft experienced greater improvement in ODI (p = 0.042) and a higher ODI response rate (≥10-, ≥15- and ≥20-point reductions in ODI) than those receiving saline (p = 0.001, p = 0.002 and p = 0.021, respectively). Conclusion: Young patients with discogenic CLBP may have significant functional improvement following nonsurgical disc allograft supplementation.

Purpose: Back pain is a major problem worldwide and is linked to intervertebral disc degeneration and Modic change. Several studies report growth of bacteria following extraction of degenerate discs at spine surgery. A pathophysiological role for infection in back pain has been proposed., Method: We conducted a PRISMA systematic review. MEDLINE, PubMed, Scopus and Web of Science were searched with the terms Modic change, intervertebral dis*, bacteria, microb*, and infect*. Date limits of 2001-2021 were set. Human studies investigating the role of bacteria in disc degeneration or Modic change in vertebrae were included., Results: Thirty-six articles from 34 research investigations relating to bacteria in human degenerate discs were found. Cutibacterium acnes was identified in pathological disc material. A 'candidate bacterium' approach has been repeatedly adopted which may have biased results to find species a priori, with disc microbial evidence heavily weighted to find C. acnes., Conclusion: Evidence to date implicates C. acnes identified through culture, microscopy and sequencing, with some suggestion of diverse bacterial colonisation in the disc. This review found studies which used culture methods and conventional PCR for bacterial detection. Further agnostic investigation using newer methods should be undertaken., (© 2021. The Author(s).)

Background: To report clinical results after percutaneous cement discoplasty (PCD) in a multicentric case series with a minimum of 2 years of follow-up., Methods: Between December 2014 and January 2019, 180 patients with low back pain and advanced degeneration were treated with percutaneous discoplasty in 2 centers. The inclusion criteria were as follows: patients 65 years or older, with mechanical low back pain with or without spinal stenosis, who did not respond to conservative management. Patients were divided into 3 groups: group 1: patients without previous spine surgeries who underwent PCD, group 2: patients with previous spine surgeries who underwent PCD, and group 3: patients with/without previous surgery who underwent PCD plus decompression surgery. Clinical and radiological analyses were performed as well as complication and readmission rates., Results: A total of 156 patients (74% female; mean age, 75.8 ± 5.7 years; mean body mass index, 29.9 ± 5.2) were included in our study. Overall preoperative visual analog score (VAS) and Oswestry Disability Index (ODI) were 7.8 ± 0.9 and 68.1 ± 9.6, respectively. At 2 years of follow-up, mean VAS improvement was 3.56 (95% confidence interval: 3.92-3.20; P < 0.0001) and mean ODI improvement was 17.18 (95% confidence interval: 19.52-14.85; P < 0.0001), showing a significant and sustained improvement in both scores. In addition, 84% of patients reached both VAS and ODI minimum important clinical difference at the final follow-up. Finally, 5.7% of patients suffered major complications 30 days postoperatively., Conclusions: PCD showed significant improvement of VAS and ODI scores at 2 years of follow-up with relatively low rate of complications., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Low back pain is the leading cause of disability worldwide in industrialized nations. The pathology underlying chronic low back pain is associated with numerous factors. Lumbar degenerative disc disease is a potential major source of low back pain. There are numerous treatment modalities and options. Nonsurgical treatment options exist in the form of pain management through a combination of anti-inflammatory medications and steroid injections, physical therapy and lifestyle modifications. This article reviews the history and current trends in use for lumbar toral disc arthroplasty for degenerative disc disease treatment. Furthermore, indications, contraindications, and complications management are discussed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: Cohort study.This study aimed to determine the effectiveness of the universal approach of full endoscopy and percutaneous transpedicular fixation via a medial central approach (ACM) performed to surgically treat patients with lumbar degenerative surgical pathologies.Alternatives to interventionist treatments available to patients with lumbar degenerative surgical pathologies are related to recovery from minimally invasive surgery. Considering this, full endoscopic spinal decompression (full endoscopy) and percutaneous transpedicular fixation via an ACM represent advances in neurosurgical procedures, in particular, spinal surgery. Thus, the introduction of endoscopic and minimally invasive surgeries for the lumbar region has become 1 of the most important advances in modern surgery.A cohort of 79 patients undergoing full endoscopy and percutaneous transpedicular fixation was evaluated 6 times in 1 year. Pain intensity was measured using the visual analog scale (VAS), and lumbar functionality was measured using the Oswestry Disability Index (ODI). Six evaluations were performed: before surgery and on discharge after surgery as well as at 1, 3, 6, and 12 months after surgery.Before the ACM was applied, the VAS pain score was 8.52. At 11 hours post-surgery, the pain score reduced to 2.59 points (a difference of 5.73 points; P = 0.001). Of the 10 ODI domains evaluated, a difference was found between the period prior to surgery and 1 month later (P < 0.01).The universal approach to full endoscopy and lumbar percutaneous transpedicular fixation via an ACM is highly effective for patients with lumbar surgical degenerative pathologies., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

This study aimed to compare the clinical outcomes of endoscopic spinal surgery (ESS) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative lumbar disease (DLD) through meta-analysis. The Medline (via PubMed), Cochrane, Scopus, and Embase databases were searched for studies that evaluated the outcomes of ESS and MIS-TLIF in DLD, including visual analog scale (VAS) score for low back pain, VAS score for leg pain, Oswestry Disability Index (ODI), and complications published between January 2000 and August 2020. Two authors extracted the data independently. Any discrepancies were resolved by a consensus. Four comparative studies were identified. No significant differences were found between the ESS and MIS-TLIF groups in terms of VAS score for back pain, VAS score for leg pain, and ODI, except for complication rate. The complication rate was higher in the ESS than in the MIS-TLIF group. A literature review identified four comparative studies reporting the clinical outcomes of ESS and MIS-TLIF for DLD. Despite the heterogeneity, a limited number of meta-analyses showed that the clinical outcomes between the two groups were not significantly different except for complication rate. Hence, further large-scale multicenter studies are required to validate our results., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To investigate and compare the clinical and radiological outcomes of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) for lumbar spinal stenosis (LSS) patients with and without degenerative spondylolisthesis (DS)., Methods: A total of 129 patients who underwent LE-ULBD for single-level LSS were retrospectively reviewed. The patients were classified into 2 groups based on the presence of DS. Clinical outcomes were assessed with the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and numeric rating scale (NRS) for low back pain, lower limb pain, and lower limb numbness. Scores were obtained at baseline and final follow-up (mean follow-up, 28.6 months [range, 24-63 months])., Results: The follow-up rate was 77.5% (103 patients). All domains of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and NRS evaluations significantly improved during the follow-up period in both groups; group differences were not significant except for the postoperative NRS limb numbness score, which was higher in patients with DS. The Macnab outcome classification was excellent or good in 80% of patients without DS and 77.1% of patients with DS. During the follow-up period, the increase of vertebral slip was observed in 31% of the patients with DS that includes vertebral slip progression defined as percent slip >5% in 4% of the patients. The increase of vertebral slip was not related to a clinical outcome. Segmental motion of the affected intervertebral disc did not increase after surgery., Conclusions: LE-ULBD provides a comparably favorable outcome in LSS patients with and without DS. Postoperative segmental instability did not occur in patients with DS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We sought to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease., Methods: A comprehensive duplicate electronic database search including PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure was conducted to identify relevant prospective studies published up to June 30, 2020. The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short- (<2 years) and long-term (≥2 years) follow-up results. Analyses were performed in Review Manager software 5.3., Results: Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included. The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, except that lumbar fusion might bring about lower additional surgery rate (risk ratio, 0.40; 95% confidence interval, 0.17 to 0.98; P = 0.04), and higher complication rate (risk ratio, 21.46; 95% confidence interval, 4.34 to 106.04; P = 0.0002) in the long term., Conclusions: The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The development of adjacent segment degeneration (ASD) is a major concern after lumbar spinal fusion surgery, but the causative mechanisms remain unclear. This study used a combined in vivo and in silico method to investigate the changes of anatomical dimensions and biomechanical responses of the adjacent segment (L3-4) after spinal fusion (L4-S1) in five patients under weight-bearing upright standing conditions. The in vivo adjacent disc height changes before and after fusion were measured using a dual fluoroscopic imaging system (DFIS), and the measured in vivo intervertebral positions and orientations were used as displacement boundary conditions of the patient-specific three-dimensional (3D) finite element (FE) disc models to simulate the biomechanical responses of adjacent discs to fusion of the diseased segments. Our data (represented by medians and 95% confidence intervals) showed that a significant decrease by - 0.8 (- 1.2, - 0.4) mm (p < 0.05) in the adjacent disc heights occurred at the posterior region after fusion. The significant increases in disc tissue strains and stresses, 0.32 (0.21, 0.43) mm/mm (p < 0.05) and 1.70 (1.07, 3.60) MPa (p < 0.05), respectively, after fusion were found in the posterolateral portions of the outermost annular lamella. The intradiscal pressure of the adjacent disc was significantly increased by 0.29 (0.13, 0.47) MPa after fusion (p < 0.05). This study demonstrated that fusion could cause alterations in adjacent disc biomechanics, and the combined in vivo and in silico method could be a valuable tool for the quantitative assessment of ASD after fusion.

It has been reported that Modic change of the lumbar spine endplate includes three types: i.e. . edema or inflammation for type 1, fatty marrow change for type 2 and sclerotic change for type 3. Basically, type 1 Modic change may be related to the chronic low back pain. There are two kinds of the treatment for the type 1 Modic change to heal the pain : the anti-inflammatory drugs, and intra-discal injection of steroid. When the inflammatory change would be intractable, surgical intervention is needed. The gold standard for the surgical intervention is the segmental fusion of the affected level. The fusion surgery may cause the adjacent degeneration ; thus, motion preservation surgery is better, if possible. Our department started the motion preservation full-endoscopic intradiscal debridement surgery for this pathology, since some of the type 1 Modic change may be chronic discitis by P. Acnes. In this paper, we describe the first patient of type 1 Modic change who was successfully treated by the full-endoscopic intra-discal debridement and drainage under the local anesthesia. We named this procedure as transforaminal full-endoscopic disc cleaning surgery (FEDC). Finally, pathology, conservative and surgical intervention of Modic change was discussed. J. Med. Invest. 68 : 1-5, February, 2021.

Aim: To evaluate the option of lumbar transpedicular fixation at the index level in patients who did not achieve adequate pain relief after lumbar total disc replacement (TDR) without evidence of device failure., Material and Methods: Four patients (mean age, 47 years) presented with persistent low back pain following lumbar TDR for 12-24 months (mean, 16.3). No device failures were observed. All patients underwent transpedicular fixation at the index level. Clinical outcome was assessed via the Oswestry disability index, a visual analog scale, and recording of the consumption of analgesics., Results: No postoperative complications were observed. The average follow-up after lumbar transpedicular fixation was 53.5 months (range, 43-80). Two patients considered the outcome as excellent, one as good, and one as poor. The mean visual analog scale pain score decreased from 7.8 (range, 7-8) to 4.3 (range, 2-8). The mean Oswestry disability index decreased from 43.5 (range, 39?47) to 27.5 (range, 14-47). At the last follow-up, one patient was without analgesic medication and substitution of opiates with non-opioid analgesics was possible in two patients., Conclusion: In patients with persistent low back pain after TDR without device failure or adjacent segment pathologies, lumbar transpedicular fixation without removal of the disc prosthesis may be a useful therapeutic option.

Background: The impact of symptom characteristics on outcomes of spine surgery remains elusive., Objective: To determine the impact of symptom location, severity, and duration on outcomes following lumbar spine surgery., Methods: We queried the Quality Outcomes Database (QOD) for patients undergoing elective lumbar spine surgery for lumbar degenerative spine disease. Multivariable regression was utilized to determine the impact of preoperative symptom characteristics (location, severity, and duration) on improvement in disability, quality of life, return to work, and patient satisfaction at 1 yr. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom., Results: A total of 22 022 subjects were analyzed. On adjusted analysis, we found patients with predominant leg pain were more likely to be satisfied (P < .0001), achieve minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) (P = .002), and return to work (P = .03) at 1 yr following surgery without significant difference in Euro-QoL-5D (EQ-5D) (P = .09) [ref = predominant back pain]. Patients with equal leg and back pain were more likely to be satisfied (P < .0001), but showed no significant difference in achieving MCID (P = .22) or return to work (P = .07). Baseline numeric rating scale-leg pain and symptom duration were most important predictors of achieving MCID and change in EQ-5D. Predominant symptom was not found to be an important determinant of return to work. Worker's compensation was found to be most important determinant of satisfaction and return to work., Conclusion: Predominant symptom location is a significant determinant of functional outcomes following spine surgery. However, pain severity and duration have higher predictive importance. Return to work is more dependent on sociodemographic features as compared to symptom characteristics., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Study Design: Prospective experimental uncontrolled trial., Background: Lumbar microinstability (MI) is a common cause of lower back pain (LBP) and is related to intervertebral disc degeneration that leads to inability to adequately absorb applied loads. The term "microinstability" has recently been introduced to denote a specific syndrome of biomechanical dysfunction with minimal anatomical change. Trans-facet fixation (TFF) is a minimally invasive technique that involves the placement of screws across the facet joint and into the pedicle, to attain improved stability in the spine., Purpose: In this study, we aimed to evaluate the effectiveness, in terms of pain and disability reduction, of a stand-alone TFF in treatment of patients with chronic low back pain (LBP) due to MI. Moreover, as a secondary endpoint, the purpose was to assess the feasibility and safety of a novel percutaneous CT-guided technique., Methods: We performed percutaneous CT-guided TFF in 84 consecutive patients presenting with chronic LBP attributable to MI at a single lumbar level without spondylolysis. Pre- and post-procedure pain and disability levels were measured using the visual analogue scale (VAS) and Oswestry Disability Index (ODI)., Results: At 2 years, TFF resulted in significant reductions in both VAS and ODI scores. CT-guided procedures were tolerated well by all patients under light sedation with a mean procedural time of 45 min, and there were no reported immediate or delayed procedural complications., Conclusion: TFF seems to be a powerful technique for lumbar spine stabilization in patients with chronic mechanical LBP related to lumbar MI. CT-guided technique is fast, precise, and safe and can be performed in simple analgo-sedation.

Purpose: To report clinical and radiographic outcomes, rate of complications and influence on spinal alignment on long-term follow-up (FU) of patients who underwent lumbar total disc arthroplasty (TDR), bringing some evidence to determine the profile of the most well-suited patients for TDR., Methods: A retrospective review of patients underwent TDR for low back pain from degenerative disc disease (DDD) resistant to conservative treatment was performed. Demographic features, surgical data, clinical and radiographic outcomes, complications and spinopelvic parameters were evaluated., Results: Thirty patients (32 TDR) were included with a mean FU of 164 ± 36.5 months. The clinical outcomes measured by visual analogue scale and Oswestry Disability Index showed a significant improvement between preoperative and 1-year FU (p < 0.01). No significant temporal variance has been identified between 1-year and long-term follow-up (p > 0.05). The surgical revision rate was 10%. The overall rate of complications was 20%. At final follow-up, the mobility of the prosthesis was preserved in 68.75% of the cases, and 73.3% of the patients were globally well aligned., Conclusion: The optimal surgical indication is crucial to achieve excellent clinical and radiological outcomes. According to the literature and to our experience, we underline the importance of a coronal deformity < 15° Cobb angle and a Roussouly type 1 or 2 as the profile of the most well-suited patient for TDR. Our long-term results confirm the existing evidence about efficacy and safety of TDR as a reliable option, in optimal surgery indication, to treat DDD. These slides can be retrieved under Electronic Supplementary Material.

Purpose: To compare the long-term clinical results and complications of two revision strategies for patients with failed total disc replacements (TDRs)., Methods: In 19 patients, the TDR was removed and the intervertebral defect was filled with a femoral head bone strut graft. In addition, instrumented posterolateral fusion was performed (removal group). In 36 patients, only a posterolateral instrumented fusion was performed (fusion group). Visual analogue scale (VAS) for pain and Oswestry Disability Index (ODI) were completed pre- and post-revision surgery. Intra- and post-operative complications of both revision strategies were assessed., Results: The median follow-up was 12.3 years (range 5.3-24.3). In both the removal and fusion group, a similar (p = 0.515 and p = 0419, respectively) but significant decrease in VAS- (p = 0.001 and p = 0.001, respectively) and ODI-score (p = 0.033 and p = 0.013, respectively) at post-revision surgery compared to pre-revision surgery was seen. A clinically relevant improvement in VAS- and ODI-score was found in 62.5% and 43.8% in the removal group and in 43.5% and 39.1% in the fusion group (p = 0.242 and p = 0.773, respectively). Removal of the TDR was associated with substantial intra-operative complications such as major vessel bleeding and ureter lesion. The percentage of late reoperations for complications such as pseudarthrosis was comparable for both revision strategies., Conclusions: Revision of a failed TDR is clinically beneficial in about half of the patients. No clear benefits for additional TDR removal as compared to posterolateral instrumented fusion alone could be identified. Particularly, when considering the substantial risks and complications, great caution is warranted with removal of the TDR. These slides can be retrieved under Electronic Supplementary Material.

Background: The aim of this study is to compare intraoperative cultural examination in patients undergoing elective surgery for low-back pain with Modic 2 changes to patients without Modic signs. The aim of this study is to compare intraoperative cultural examination in patients undergoing elective surgery for low-back pain with Modic 2 changes to patients without Modic signs., Methods: Sixteen patients with Modic 2 changes were compared with 23 patients without Modic signs. Preoperative laboratory tests and intraoperative tissue cultures were performed, according to a standardized procedure., Results: While no difference was found in preoperative laboratory tests, intraoperative cultural examination showed positive results in six of 16 (37.5%) Modic 2 patients versus one of 23 (4.3%) in patients without Modic changes (P=0.012)., Conclusions: Although performed in a limited series of patients, this study supports the hypothesis that some cases of Modic 2 changes might be associated with the presence of low virulent bacteria.

Study Design: Prospective cohort study., Objective: The aims of this study were to evaluate the outcome of surgical and nonsurgical treatment for patients with lumbar herniated disc (LHD) or lumbar spinal stenosis (LSS) after 2 years and to identify predictors for nonsuccess., Summary of Background Data: Studies regarding the clinician's ability to identify patients with a poor prognosis are not in concurrence and further studies are warranted., Methods: This study included 390 patients with LHD or LSS referred for surgical evaluation after unsuccessful conservative treatment. Nonsuccess was defined as a Roland-Morris Disability score above 4 (0-23) or a Numeric Rating Scale back and leg pain score above 20 (0-60). Uni- and multivariate logistic regression analyses were used to investigate potential predictive factors including sociodemographic characteristics, history findings, levels of pain and disability, and magnetic resonance imaging findings., Results: Rates of nonsuccess at 2 years were approximately 30% in surgically treated patients with LHD, approximately about 60% in patients with LSS for disability, and 30% and 40%, respectively for pain. For the main outcome variable, disability, in the final multiple logistic regression model, nonsuccess after surgery was associated with male sex (odds ratio [OR] 2.04, 95% confidence interval [CI]: 1.02-4.11, P = 0.04), low level of education (OR 2.60, 95% CI: 1.28-5.29, P = 0.01), high pain intensity (OR 3.06, 95% CI: 1.51-6.21, P < 0.01), and widespread pain (OR 3.59, 95% CI: 1.36-9.46, P = 0.01)., Conclusion: The results indicate that the prognosis for patients referred for surgery with persistent LHD or LSS and unsuccessful conservative treatment is substantially better when surgery is performed as opposed to not performed. The predictive value of the variables male sex, low level of education, high pain intensity, and widespread pain location found in our study are partly in accordance with results of previous studies. Thus, our results warrant further investigation until firm conclusions can be made., Level of Evidence: 3.

Lumbar fusion is a mainstay in the treatment of low back pain resulting from degenerative disc disease. Anterior lumbar interbody fusion (ALIF) has become a reasonable treatment technique to achieve indirect foraminal decompression with high fusion rates. The aim of the study was to analyse the biometrical parameters of the lumbar spine and the clinical outcome. The medical records of 51 patients treated with ALIF between 2012 and 2016 were retrospectively reviewed. Anterior and posterior disc height (DH), lumbar lordosis (LL), local disc angle (LDA) and foraminal dimensions were obtained on pre- and postoperative plain radiographs and computed tomography scans using ImageJ and Surgimap software according to the pedicle-pedicle technique. To evaluate the interbody fusion status on the last follow-up CT scans, we used Bridwell criteria. Preoperative and 12 months postoperative Oswestry Disability Index (ODI) scores were determined for all patients. The average length of hospitalisation was 4 days. Most of the patients had degenerative disc disease with foraminal stenosis. Five patients had early complications like paresthesia of lower limbs, sympathetic dysfunction or wound infections, but there were no major complications. Statistically significant (P < .01) improvement was observed in foraminal dimensions (area = 49%, height = 33% and width = 19%), anterior DH (49%), posterior DH (69%), LDA (47%) and LL (17.5%). Posterior DH correlated significantly with foramen height improvement. Radiographic evidence of fusion according to the modified Bridwell criteria (grade I and grade II) was observed in 96% (49/51) of the patients in the last CT of the lumbar spine. We also observed significant improvement in functional recovery in 94% of patients. The mini-open ALIF approach is a reasonable alternative to the more extensive posterior approaches. ALIF significantly restores the height of the intervertebral disc, indirectly increases foraminal dimensions, increases lordosis angle with significant short and long-term pain relief and functional recovery.

Background: Lumbar degenerative disease (LDD) is a very common disease. And decompression alone, posterior lumbar interbody fusion (PLIF), and interspinous device (Coflex) are generally accepted surgical techniques. However, the effectiveness and safety of the above techniques are still not clear. Network meta-analysis a comprehensive technique can compare multiple treatments based on indirect dates and all interventions are evaluated and ranked simultaneously. To figure out this problem and offer a better choice for LDD, we performed this network meta-analysis., Methods: PubMed and WanFang databases were searched based on the following key words, "Coflex," "decompression," "PLIF," "Posterior Lumbar Interbody Fusion," "Coflex" "Lumbar interbody Fusion." Then the studies were sorted out on the basis of inclusion criteria and exclusion criteria. A network meta-analysis was performed using The University of Auckland, Auckland city, New Zealand R 3.5.3 software., Results: A total of 10 eligible literatures were finally screened, including 946 patients. All studies were randomized controlled trials (RCTs). Compared with decompression alone group, there were no significant differences of Oswestry Disability Index (ODI) in Coflex and lumbar interbody fusion groups after surgery. However, Coflex and PLIF were better in decreasing Visual Analogue Scale (VAS) score compared with decompression alone. Furthermore, we found Coflex have a less complication incidence rate., Conclusion: Compared with decompression alone, Coflex and lumbar interbody fusion had the similar effectiveness in improving lumbar function and quality of life. However, the latter 2 techniques were better in relieving pain. Furthermore, Coflex included a lower complication incidence rate. So we suggested that Coflex technique was a better choice to cue lumbar spinal stenosis (LSS)., Level of Evidence: Systematic review and meta-analysis, level I.

Background: Lumbar spinal disease causes disabilities in performing daily activities. Operative treatments are aimed at pain relief and rapid return to routine activity. Patient-based outcome measures are used to evaluate pathologies and therapeutic effects associated with lumbar spinal disease. Nevertheless, it remains unknown as to how much such treatment improves activity levels. The purpose of the current study was to measure changes in activity levels before and after lumbar spinal surgery using a wearable activity tracker and to analyze the differences between results and patient-based outcomes., Methods: Sixty patients who underwent lumbar surgery were studied. The physical activity of participants was objectively evaluated using a wearable Micro-Motion logger system (Actigraph). We measured the amount of activity before and at 1, 3, 6, and 12 months after the surgery to evaluate postoperative changes. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, Oswestry Disability Index, Roland-Morris Disability Questionnaire and visual analog scale were used to assess patient-based outcomes of pain and activities of daily living-related scores; we analyzed the relationships between scores and actual activity levels., Results: The amount of actual activity decreased significantly 1 month after the surgery compared to that during the preoperative period, which then improved after 3 months postoperatively (p < 0.01). Furthermore, there was a significant improvement 6 months after the surgery compared to that during the preoperative period (p < 0.05). The changes in activity for each period were strongly correlated, regardless of the period. In contrast, a significant improvement was observed at 1 month after the surgery in almost all items of the patient-based questionnaires (p < 0.05)., Conclusions: The objective activity tracker demonstrated that lumbar surgery results in the amount of activity decreasing 1 month just after surgery followed by gradual postoperative recovery within 3 months. By contrast, patient-based outcomes showed improvement in 1 month that was significantly different from the change in actual activity, indicating a gap between patient-oriented clinical scores and their actual activities.

Objective: To determine the efficacy of OLIF in the treatment of reoccurring discogenic low back pain (LBP) after discoblock METHODS: We included 108 patients with LBP that was suspected to be discogenic (such as high intensity zone, Schmorl's nodes, Modic changes Type I, etc.), from August 2015 to August 2017. All patients underwent discography, and patients whose LBP was confirmed to be discogenic received discoblock. Patients who had reoccurring pain after discoblock underwent OLIF. Perioperative parameters and complications were recorded. The VAS and Oswestry Disability Index (ODI) were assessed at preoperation, and 1 week and 1, 3, 6, and 12 months after the surgery. The fusion rate was evaluated., Results: Of 108 patients, 89 were confirmed to have discogenic LBP, and 32/89 patients with reoccurring LBP pain after discoblock underwent OLIF. Twenty-eight patients were followed up for ≥ 1 year. The OLIF operation lasted for 92 ± 34 min. Blood loss during the operation was 48 ± 15 ml. The mean incision length was 3.0 ± 0.6 cm. The average length of stay was 4.8 ± 1.9 days. The VAS and ODI scores decreased from 8.1 ± 1.7 preoperatively to 0.9 ± 0.4, and from 71.2 ± 11.3 to 9.3 ± 3.1, 12 months postoperatively, respectively. The total incidence of complications was 15.6%, including 2 cases of cage subsidence, 2 cases of ipsilateral hip flexor weakness, and 1 case of ipsilateral anterior thigh pain. All symptoms relieved or disappeared during follow-up. The fusion rate was 96.9%., Conclusions: Reoccurring discogenic LBP after discoblock should be considered as a suitable group for treatment by OLIF.

Background: In the current surgical therapeutic regimen for the degenerative lumbar disease, both oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) are gradually accepted. Thus, the objective of this study is to compare the radiographic and clinical outcomes of OLIF and LLIF for the degenerative lumbar disease., Methods: We conducted an exhaustive literature search of MEDLINE, EMBASE, and the Cochrane Library to find the relevant studies about OLIF and LLIF for the degenerative lumbar disease. Random-effects model was performed to pool the outcomes about disc height (DH), fusion, operative blood loss, operative time, length of hospital stays, complications, visual analog scale (VAS), and Oswestry disability index (ODI)., Results: 56 studies were included in this study. The two groups of patients had similar changes in terms of DH, operative blood loss, operative time, hospital stay and the fusion rate (over 90%). The OLIF group showed slightly better VAS and ODI scores improvement. The incidence of perioperative complications of OLIF and LLIF was 26.7 and 27.8% respectively. Higher rates of nerve injury and psoas weakness (21.2%) were reported for LLIF, while higher rates of cage subsidence (5.1%), endplate damage (5.2%) and vascular injury (1.7%) were reported for OLIF., Conclusions: The two groups are similar in terms of radiographic outcomes, operative blood loss, operative time and the length of hospital stay. The OLIF group shows advantages in VAS and ODI scores improvement. Though the incidence of perioperative complications of OLIF and LLIF is similar, the incidence of main complications is significantly different.

Objective: The aim of this study is to compare the clinical outcomes of two-level percutaneous endoscopic lumbar discectomy (PELD) and foraminoplasty PELD in treating highly migrated lumbar disc herniations., Methods: Patients with highly migrated lumbar disc herniations were enrolled from May 2014 to June 2016. Low back pain and leg pain were evaluated by the Visual Analog Scale (VAS), and functional outcomes were assessed with the Oswestry Disability Index (ODI). The satisfaction rate of clinical outcomes was assessed according to the modified MacNab criteria. In addition, the intraoperative duration and postoperative complications were also recorded., Results: Forty patients, 14 cases in two-level PELD group and 26 cases in foraminoplasty PELD group, were included. The VAS scores of low back pain ( P =0.67) and leg pain ( P =0.86), as well as the ODI scores ( P =0.87), were comparative between two-level PELD and foraminoplasty PELD groups. The satisfaction rate of clinical outcomes based on the modified MacNab criteria in the two-level PELD group was equivalent to that in foraminoplasty PELD group (92.9% versus 92.3%, P =0.92). In addition, the intraoperative duration of two-level PELD group was longer than that of foraminoplasty PELD group (80.2 ± 6.6 min versus 64.1 ± 7.3 min, P < 0.01). The postoperative complications in the two-level PELD group (postoperative dysesthesia: N  = 1) were relatively fewer as compared to those in the foraminoplasty PELD group (postoperative dysesthesia: N  = 1; recurrence: N  = 1; nucleus pulposus residues: N  = 1)., Conclusions: Both two-level PELD and foraminoplasty PELD are safe and effective surgical procedures for the patients with highly migrated lumbar disc herniations. Moreover, the two-level PELD technique has merits in reducing the incidence of postoperative nucleus pulposus residue., Competing Interests: The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper., (Copyright © 2019 Xinbo Wu et al.)

Background: The local infectious origin and the putative role of Cutibacterium acnes (CA) of a particular subtype of discopathy (Modic 1) are still debated., Purpose: To establish the association of CA in intervertebral disc (IVD) and Modic 1 discopathy in patients with low back pain., Methods: The prevalence of bacteria in IVD samples obtained by anterior approach in patient with chronic low back pain harboring Modic type 1, 2 or no Modic changes was compared to that measured in IVD samples obtained by posterior approach for sciatica. From 45 patients included in the study, 77 discs samples were obtained: 58 by anterior approach (32 Modic 1/2 changes, 26 without Modic change) and 19 by posterior approach. Conventional microbial cultures, universal 16S rRNA molecular detection and a CA specific PCR were performed., Results: 12 /77 (15.6%) disc samples were culture positive. Among the 10 CA positive cultures, 5 out of 58 (8.6%) were identified from specimens obtained by anterior approach and 5/19 (26.3%) from posterior approach (p = 0.046). Moreover, the percentage of CA culture positive sample was statistically no different between the patient with or without Modic changes. The CA prevalence was lower through molecular, culture-free approaches: the universal 16S rRNA PCR was positive for 6 specimens, including one CA positive sample and the CA specific PCR was positive for one specimen obtained by posterior approach., Conclusions: In spine surgery the prevalence of CA in culture was significantly higher in IVD samples collected through a posterior approach compared to an anterior approach, suggesting a contamination process. This study did not support the CA related local infectious origin of Modic 1 discopathy., Competing Interests: The authors have declared that no competing interests exist.

Purpose: The endplate defects (EDs), Modic changes (MCs), disc degeneration (DD), facet orientation (FO), and facet tropism (FT) were demonstrated to be related to the low back pain (LBP). The aim of this study was to investigate possible correlations between them., Methods: 75 patients were reviewed to evaluate the degenerative change in vertebral bodies (EDs and MCs), intervertebral discs (DD), and facet joint degeneration (FO and FT). All patients were categorized into four groups based on the grade of EDs. Clinical outcomes were evaluated with the visual analog scale (VAS) and Oswestry disability index (ODI) before and after surgery., Results: There was no difference between the four groups in baseline characteristics except for gender and weight. FT is positively correlated with FO. The same rule exists between EDs, the size of MCs II, FO (left) and FO (right), and VAS and ODI. The grade of EDs is positively correlated with the grade of DD. L4-L5 can bear more load than other levels; thus, the grade of EDs is higher than that of other lumbar levels. The preoperative LBP was relieved in all groups in varying degrees. The change of pain and dysfunction is inversely proportional to the grade of EDs in the general trend., Conclusion: The relationship between weight, gender, and disc degeneration provided a mechanism by which increasing weight can predispose to DD. Different grades of EDs had different effects on patients with LBP. There was a significant correlation between EDs, MCs II, DD, FT, and FO.

Objective: The pathomechanism and factors influencing hypertrophy of the Ligamentum flavum in the lumbar spine still requires a confident specificity. We aimed to analyse the association between various factors and Ligamentum Flavum Thickness (LFT) and also to investigate the major contributor for Ligamentum Flavum Hypertrophy (LFH) at various levels in the lumbar spine., Patients and Methods: The following were evaluated at L1-L2,L2-L3,L3-L4,L4-L5 and L5-S1 levels in MRI of 1070 lumbar disc levels of 214 subjects: Pfirrmann's grade of the disc, anterior and posterior disc height, disc volume, facet tropism and LFT. LFT > 0.4 cm was considered as hypertrophy.Correlation between LFT and other parameters was done and values with p < 0.05 was considered statistically significant., Results: 112 male and 102 female were included. There was an increase in the anterior disc height (0.98 cm to 1.50 cm), posterior disc height (0.84 cm to 0.96 cm), disc volume (7.17cm 3 to 14.6cm 3 ), facetal angle and LFT on both sides from L1-2 to L5-S1 levels. Highest frequency of LFT was seen at L4-5.Pfirrmann's grade of the disc and anterior disc height had a statistically significant positive correlation with LFT at L1-L2,L2-L3,L3-L4,L4-L5 levels whereas facet tropism was strongly associated with LFT at L5-S1 level., Conclusion: Higher Pfirrmann's grade and decreased anterior disc height can lead to ligamentum flavum hypertrophy at L1-L2, L2-L3,L3-L4,L4-L5 levels.Whereas at L5-S1 level, it is the presence of facet tropism which can cause LFH. Hence, patients with the presence of above mentioned factors at those respective levels have higher preponderance to develop Lumbar canal stenosis., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To evaluate effects of holmium:yttrium-aluminum-garnet (Ho:YAG) laser ablation on postoperative low back pain and improving functional status in patients with lumbar disc herniation undergoing transforaminal endoscopic lumbar discectomy (TELD)., Methods: The study enrolled 220 patients with lumbar disc herniation who underwent TELD or TELD with Ho:YAG laser from August 2015 to September 2016. Parameters including operative time, hospitalization, complications, and recurrence were recorded. Clinical outcomes were assessed according to visual analog scale for back pain and leg pain, Oswestry Disability Index for functional status, and modified MacNab criteria for patient satisfaction., Results: Minimal 2-year follow-up was completed by 186 patients: 76 patients who underwent TELD and 110 patients who underwent TELD with Ho:YAG laser. In the group undergoing TELD, clinical outcomes of back pain and functional status exhibited a V-shaped upward trend after surgery; there were no statistically significant differences in visual analog scale for back pain and Oswestry Disability Index scores at final follow-up compared with preoperatively (P > 0.05). In the group undergoing TELD with Ho:YAG laser, postoperative visual analog scale for back pain and Oswestry Disability Index scores significantly improved compared with preoperatively (P < 0.05) exhibiting relatively consistent improvement after surgery. The only laser-related complication was a burning sensation in the ipsilateral lower limb during the thermal procedure in 2 cases., Conclusions: Performing Ho:YAG laser ablation with TELD prolonged low back pain relief and improved functional outcome during 2-year follow-up compared with TELD alone in patients with symptomatic lumbar disc herniation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Endoscopic partial facetectomy (EPF) is an effective option for decompressing the lumbar exiting root without causing spinal instabilities in the treatment of patients with degenerative lumbar foraminal stenosis. The aim of the present study was to identify the preoperative risk factors of poor clinical outcomes after EPF in patients with degenerative lumbar foraminal stenosis., Methods: A total of 51 consecutive patients who had undergone EPF from 2012 to 2015 were included in the present study. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry disability index (ODI), and Short-Form 36-item (SF-36) outcome questionnaires. The preoperative radiological risk factors were measured using the lumbar Cobb's angle, disc wedging angle, lumbar lordosis (LL), segmental lordosis, disc height index, presence of spondylolisthesis, and morphological changes (no change, horizontal collapse, vertical collapse) of the exiting root within the most stenotic level on preoperative magnetic resonance imaging., Results: The VAS, ODI, and SF-36 scores had significantly improved at the 1-month follow-up visit compared with the baseline mean values and were maintained within the 2-year follow-up period. A correlation analysis revealed significant relationships between various preoperative factors and clinical outcomes. On multiple regression analysis, the morphological change of vertical collapse significantly predicted the VAS, ODI, and SF-36 scores, and LL significantly predicted the ODI and SF-36 scores., Conclusions: A morphological change in vertical collapse found on preoperative magnetic resonance imaging and decreased LL were significant predictors of poor clinical outcomes after EPF in the treatment of lumbar foraminal stenosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Percutaneous cement discoplasty (PCD) is a minimally invasive surgical procedure, that can provide a segmental stabilizing and indirect decompression effect in case of severely degenerated discs characterized by vacuum phenomenon. The objective of this study was to evaluate the effects of PCD on spinopelvic radiological parameters and their associations with the clinical outcome., Methods: Retrospective analysis of prospectively collected dataset of 28 patients (112 lumbar segments) who underwent single- or multilevel PCD was performed. Spinopelvic, intrasegmental and intersegmental parameters were measured on lumbar X-rays pre-, postoperatively and 6 months after the surgery. Correlations between radiological parameters and clinical outcome data were determined., Results: Sacral slope significantly increased (p < .001), and pelvic tilt (p < .05) was decreased after the PCD procedure. Segmental and total lordosis (p < .05, p < .05) disc and foraminal height showed significantly increase (p < .001, p < .001) after procedure. Pain and disability (ODI) significantly decreased due to PCD. An association was found between postoperative increase in SS and improvement in ODI (r = 0.39, p < .05). The change in low back pain was correlated with segmental scoliosis correction (p < .001). Moderate correlation was detected between the increase in disc height and ODI (p < .05) as well as leg pain (p < .01)., Conclusion: PCD is an effective minimally invasive technique to treat axial pain and disability related to severe lumbar disc degeneration. Our study shows that an improvement in lumbar alignment and a significant indirect foraminal decompression could be achieved with the procedure. These changes can significantly contribute to the pain relief and increase in the patients' functional capacity. These slides can be retrieved under Electronic Supplementary Material.

Background: Sacroiliac joint (SIJ)-related pain is associated with low back- and buttock pain and the SIJ score is diagnostically useful because it helps to differentiate between SIJ-related pain and pain due to other factors such as lumbar disc herniation and lumbar spinal canal stenosis. Middle cluneal nerve (MCN) entrapment (MCN-E) can produce pain involving the lower back and buttocks. Therefore, the origin of the pain must be identified. We successfully treated patients with a high SIJ score whose pain was attributable to MCN-E., Methods: Between August 2016 and June 2017, we treated 40 patients with non-specific low back pain. Among them, 18 (45%) presented with a positive SIJ score. Although SIJ treatment was unsuccessful in 4 of these patients, they responded to MCN-E treatment., Results: All 4 patients reported tenderness at the site of the sacrotuberous ligament (STL); 3 were positive for the one-finger test and experienced pain while sitting in a chair. The effect of SIJ block was inadequate in the 4 patients. As they reported severe pain at the trigger point in the area of the MCN, we performed MCN blockage. It resulted in pain control. However, in 1 patient, the effect of MCN block was transient and required MCN neurolysis. At the last visit, our patients' symptoms were significantly improved; their average numerical rating scale score fell from 8.3 to 1.0, their Roland-Morris Disability Questionnaire score fell from 12.8 to 0.3, and their average Japanese Orthopaedic Association score rose from 12.5 to 19.5., Conclusions: In patients with suspected SIJ-related pain, the presence of MCN-E must be considered when the effect of SIJ block is unsatisfactory.

Purpose: The aim of this study is to report our experiences on managing large lumbar disc herniations with several symptoms by surgery with transforaminal lumbar interbody fusion (TLIF) and to shed light for spine surgeons about TLIF surgery., Methods: We retrospectively evaluated our database of patients with various lumbar spine pathologies who underwent TLIF surgery from 2014 to 2017. We separated 18 patients who had been operated on for extruded disc herniation, which causes severe pain and radicular symptoms. The pain was quantified by visual analog scores (VAS). The disability status were pre-operatively and post-operatively evaluated by the Oswestry Disability Index (ODI). We evaluated the patients for at least two years. Interbody fusion was detected by routine radiographs at six, 12, and 24 months after surgery., Results: An ODI outcomes analysis demonstrated a statistically significant improvement in the six and 24-month mean scores compared with the pre-operative scores on the same scales. Patients' mobility improved significantly after surgery, as indicated by the decrease in the Oswestry Disability Index from 72 to 23 over two years (p < 0.001). Pain rapidly decreased in all patients and continued to decrease at the time of the latest follow-up. The mean pre-operative VAS scores for pain was 8.8; it had improved to 2.4 after surgery (p < 0.05). Within the follow-up period of two years, the ascertained mean VAS declined from 8.8 to 1.4 (p < 0.001). The average disc space height at the herniated levels was fairly well maintained. No patient had evidence of implant failure. Interbody fusion was graded as definitely solid in 100% of cases two years post-operatively. One patient displayed a superficial wound infection. Following appropriate debridement and antibiotics, the wound healed without sequelae. No major complications were observed, including permanent neurological deficit, pulmonary embolism, peri-operative cardiac event, or death., Conclusions: The findings of our study and those in the literature showed that primary herniated disc patients with radicular and chronic low back pain, degenerative changes, bi-radicular symptoms, and instability are required to have fusion after a discectomy. Being a heavy-duty worker is also a criterion for fusion surgery. TLIF is performed by a unilateral approach preserving the interlaminar surface on the contralateral side, which can be used as a site for additional fusion. As an effective results TLIF procedure should be chosen for fusion surgery.

Background: The objectives of this study were to define the role for surgery in the treatment of chronic low back pain (cLBP) and to develop a new classification of cLBP based on the pattern of injury., Hypothesis: Surgery may benefit patients with cLBP, and a new classification based on the injury pattern may be of interest., Method: A systematic literature review was performed by searching Medline, the Cochrane Library, the French public health database (Banque de Données en Santé Publique), Science Direct, and the National Guideline Clearinghouse. The main search terms were "back pain" OR "lumbar" OR "intervertebral disc replacement" OR "vertebrae" OR "spinal" AND "surgery" OR "surgical" OR "fusion" OR "laminectomy" OR "discectomy"., Results: Surgical techniques available for treating cLBP consist of fusion, disc replacement, dynamic stabilisation, and inter-spinous posterior devices. Compared to non-operative management including intensive rehabilitation therapy and cognitive behavioural therapy, fusion is not better in terms of either function (evaluated using the Oswestry Disability Index [ODI]) or pain (level 2). Fusion is better than non-operative management without intensive rehabilitation therapy (level 2). There is no evidence to date that one fusion technique is superior over the others regarding the clinical outcomes (assessed using the ODI). Compared to fusion or multidisciplinary rehabilitation therapy, disc replacement can produce better function and less pain, although the differences are not clinically significant (level 2). The available evidence does not support the use of dynamic stabilisation or interspinous posterior devices to treat cLBP due to degenerative disease (professional consensus within the French Society for Spinal Surgery). The following recommendations can be made: non-operative treatment must be provided for at least 1 year before considering surgery in patients with cLBP due to degenerative disease; patients must be fully informed about alternative treatment options and the risks associated with surgery; standing radiographs must be obtained to assess sagittal spinal alignment and a magnetic resonance imaging scan to determine the mechanism of injury; and, if fusion is performed, the lumbar lordotic curvature must be restored., Discussion: This work establishes the need for a new classification of cLBP based on the presumptive mechanism responsible for the pain. Three categories should be distinguished: non-degenerative cLBP (previously known as symptomatic cLBP), in which the cause of pain is a trauma, spondylolysis, a tumour, an infection, or an inflammatory process; degenerative cLBP (previously known as non-specific cLBP) characterised by variable combinations of degenerative alterations in one or more discs, facet joints, and/or ligaments, with or without regional and/or global alterations in spinal alignment (which must be assessed using specific parameters); and cLBP of unknown mechanism, in which the pain seems to bear no relation to the anatomical abnormalities (and the Fear-Avoidance Beliefs Questionnaire and Hospital Anxiety and Depression Scale may be helpful in this situation). This classification should prove useful in the future for constituting well-defined patient groups, thereby improving the assessment of treatment options., Level of Evidence: II, systematic review of level II studies., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)