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While abnormal loading is widely believed to cause cervical spine disc diseases, in vivo cervical disc deformation during dynamic neck motion has not been well delineated. This study investigated the range of cervical disc deformation during an in vivo functional flexion-extension of the neck. Ten asymptomatic human subjects were tested using a combined dual fluoroscopic imaging system (DFIS) and magnetic resonance imaging (MRI)-based three-dimensional (3D) modeling technique. Overall disc deformation was determined using the changes of the space geometry between upper and lower endplates of each intervertebral segment (C3/4, C4/5, C5/6, and C6/7). Five points (anterior, center, posterior, left, and right) of each disc were analyzed to examine the disc deformation distributions. The data indicated that between the functional maximum flexion and extension of the neck, the anterior points of the discs experienced large changes of distraction/compression deformation and shear deformation. The higher level discs experienced higher ranges of disc deformation. No significant difference was found in deformation ranges at posterior points of all the discs. The data indicated that the range of disc deformation is disc level dependent and the anterior region experienced larger changes of deformation than the center and posterior regions, except for the C6/7 disc. The data obtained from this study could serve as baseline knowledge for the understanding of the cervical spine disc biomechanics and for investigation of the biomechanical etiology of disc diseases. These data could also provide insights for development of motion preservation surgeries for cervical spine.

To observe the morphology character of the anterior epidural space at the L 4-5 disc level and to provide an anatomical basis for safely and accurately performing a percutaneous endoscopic lumbar discectomy (PELD). Fifty-five cases with L 5 S 1 lumbar disc herniation were included in this study, and cases with L 4-5 disease were excluded. When the puncture needle reached the epidural space at the L 5 S 1 level, iohexol was injected at the pressure of 50 cm H 2 O during the PELD, then C-Arm fluoroscopy was used to obtain standard lumbar frontal and lateral images. The widths of epidural space at the level of the L 4 lower endplate, the L 5 upper endplate, as well as the middle point of the L 4-5 disc were measured from the lumbar lateral X-ray film. Epidural space at the L 4-5 disc plane performs like a trapezium chart with a short side at the head end and a long side at the tail end in the lumbar lateral X-ray radiograph, while the average widths of epidural space were 10.2 ± 2.5, 12.3 ± 2.3, and 13.8 ± 2.6 mm at the upper, middle, and lower level of the L 4-5 disc. Understanding the morphological characteristics of epidural space will contribute to improving the safety of the tranforaminal percutaneous endoscopy technique., (© 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

A 10-year-old girl with a 2-week history of atraumatic back pain presented to the emergency department with difficulty ambulating and a history of 2 episodes of urinary incontinence in the past week. Her examination was significant for pain with movement, tenderness to palpation in the lower thoracic spine, and no neurological deficits. In this case, the child was found to have a Schmorl node at T8 in the superior aspect of the vertebral body. Schmorl nodes are protrusions of the cartilage of the intervertebral disc through the vertebral body endplate and into the adjacent that is more commonly reported in the adult population. In this child, radiographic findings were normal, with no evidence of the Schmorl node. The diagnosis was made by magnetic resonance imaging. The child's symptoms significantly resolved with ibuprofen anti-inflammatory therapy. In children with atraumatic back pain lasting greater than 2 weeks with a sudden increase in severity and associated with a neurological deficit, advanced imaging is strongly recommended.

Background: Previous findings have demonstrated that lumbar radicular pain after disc herniation may be associated with up-regulation of inflammatory mediators. In the present study we examined the possible role of extracellular microRNAs (miRs) in this process., Methods: Single unit recordings, isolation of exosome-like vesicles, electron microscopy, nanoparticle tracking analysis, western blot analysis and qPCR were used in rats to demonstrate the effect of nucleus pulposus (NP) applied onto the dorsal nerve roots. ELISA and qPCR were used to measure the level of circulating IL-6 and miRs in a 1-year observational study in patients after disc herniation., Results: In the rats, enhanced spinal cord nociceptive responses were displayed after NP applied onto the dorsal nerve roots. An increased release of small non-coding RNAs, including miR-223, miR-760 and miR-145, from NP in exosome-like vesicles was demonstrated. In particular, the NP expression of miR-223, which inhibited the nociceptive spinal signalling, was increased. In the patients, increased extracellular miR-223 was also verified in the acute phase after disc herniation. The increased miR-223 expression was, however, only observed in those who recovered (sex, age and smoking were included as covariates)., Conclusions: Our findings suggest that miR-223, which can be released from the NP after disc herniation, attenuates the neuronal activity in the pain pathways. Dysregulation of miR-223 may predict chronic lumbar radicular pain. Trial registration/ethics REK 2014/1725.

The intervertebral disc (IVD) is noted for its low cell content, and being the largest avascular structure of human body. The low amount of cells in the disc have to adapt to an anaerobic metabolism with low oxygen pressure and acidic pH. Apart from surviving in an adverse microenvironment, they are exposed to a high level of mechanical stress. The biological adaptation of cells to acidosis and hyperosmolarity conditions are regulated by mechanoproteins, which are responsible for converting a mechanical signal into a cellular response, thus modifying its gene expression. Mechanobiology helps us to better understand the pathophysiology of IVD and its potential biological repair., (Copyright © 2016 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Cauda equina syndrome (CES) is a rare neurologic complication of lumbar herniated disc for which emergency surgical decompression should be undertaken. Despite the common belief that the restoration of functions that are affected by CES can take several years postoperatively, follow up seldom exceeds the first year after surgery. Long term outcome of especially micturition, defecation and sexual function-which are by definition affected in CES-are unknown. The aim of this study is to evaluate 1) postoperative long term outcome of micturition, defecation and sexual function in CES patients 2) attitude of patients towards received hospital care with regard to (recovery of) these functions., Methods: CES patients were selected by screening the records of all patients operated on lumbar herniated disc in our university hospital between 1995-2010. A questionnaire was sent to the selected CES patients evaluating current complaints of micturition, defecation and sexual function and attitude towards delivered care with focus on micturition, defecation and sexual function., Results: Thirty-seven of 66 eligible CES patients were included (response rate 71%, inclusion rate 56%). Median time after surgery was 13.8 years (range 5.8-21.8 years). Dysfunction at follow up was highly prevalent: 38% micturition dysfunction, 43% defecation dysfunction and 54% sexual dysfunction. Younger age at presentation was associated with sexual dysfunction at follow up: for every year younger at presentation, odds ratio for sexual dysfunction at follow up was 1.11 (p = 0.035). Other associations with outcome were not identified. Two-third of the CES patients wished their neurosurgeon had given them more prognostic information about micturition, defecation and sexual function., Conclusion: The presented data demonstrate that dysfunction of micturition, defecation and sexual function are still highly prevalent in a large number of CES patients even years postoperatively. These alarming follow up data probably have a devastating effect on personal perceived quality of life, which should be studied in more detail. CES patients communicate a clear demand for more prognostic information. The presented figures enable clinicians to inform their CES patients more realistically about long term postoperative outcome of micturition, defecation and sexual function after surgical intervention.

The involvement of growth factors (GFs) in the pathogenesis of lumbar intervertebral disc (ID) herniation and the spontaneous resorption of herniated ID fragments remains only partially elucidated. A simultaneous assessment of the transcript levels of numerous GFs and their association with clinical and epidemiological profiles of human ID herniation would provide valuable insight into the biology and clinical course of the disease. In the present study, we examined simultaneously the transcript levels of vascular endothelial growth factor (VEGF), transforming growth factor β1 (TGF‑β1), basic fibroblast growth factor 2 (bFGF2), platelet derived growth factor (PDGF) isoforms and receptors, epidermal growth factor (EGF) and insulin growth factor‑1 (IGF‑1) in herniated and control ID specimens and investigated their correlation with the clinicopathological profiles of patients suffering from symptomatic lumbar ID herniation. GF mRNA expression levels were determined by RT-qPCR in 63 surgical specimens from lumbar herniated discs and 10 control ID specimens. Multiple positive correlations were observed between the transcript levels of the GFs examined in the ID herniation group. VEGF mRNA expression was significantly increased in the protruding compared with the extruded discs. Intense and acute pain significantly upregulated the PDGF transcript levels. Significant negative correlations were observed between the patient body mass index and the transcript levels of VEGF and PDGF receptors. Our findings support the hypothesis of the involvement of GFs in the natural history of ID herniation. GFs synergistically act in herniated IDs. Increased VEGF expression possibly induces the neovascularization process in the earliest stages of ID herniation. PDGF‑C and ‑D play a role in the acute phase of radiculopathy in a metabolic response for tissue healing. A molecular effect, in addition to the biomechanical effect of obesity in the pathogenesis of ID herniation is also implied.

Background: The relationship of exiting root and Kambin's triangle is discussed in this article. Transforaminal endoscopic surgery as the gold standard of less invasive lumbar disc surgeries is performed through Kambin's triangle. Existing root damage is one of the most important complication for this type of surgery. Anatomic variations in Kambin's triangle may be the main reason for nerve root damage during endoscopic lumbar disc surgery., Methods: Kambin's triangle was investigated with surgical views and cadaver studies. Thirty-four patients with far lateral disc herniation were treated with an extraforaminal approach under the microscope. On the other hand, 48 Kambin's triangles were dissected on 8 cadavers. Three main types of triangle were identified, and patients were grouped according to these 3 types of the triangle., Results: Only 6 of the 34 patients had type 3 triangles, which is the wide classical triangle described by Kambin; however, 17 patients had type 2, with a narrow space in the triangle, and 11 patients had type 1, with no space inside the triangle. Cadaver results were similar; only 10 of the 48 specimens had the type 3 classical triangle, whereas 23 specimens had type 2, and 15 specimens had type 1 triangles. Our results disclosed narrowed or no space in 82.4% of the patients and 79.2% of the cadavers., Conclusion: We observed that a wide and safe room of the triangle may not be exist in some patients. Therefore, more care must be taken during endoscopic lumbar disc surgery to avoid nerve damage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Percutaneous endoscopic lumbar discectomy (PELD) with remarkable advancements has led to successful results comparable with open discectomy; however, its application in herniated disc (HD) with migration is still challenging and technically demanding. The purpose of this study is to propose various strategies for PELD according to HD with migration., Methods: A retrospective review was performed on 434 consecutive patients who had undergone PELD. HD with migration was classified into 4 zones: low-grade up/down and high-grade up/down based on the extent and direction of migration. Clinical outcomes were assessed by visual analogue scale score for back and leg pain, Oswestry Disability Index, and modified Macnab criteria. Endoscopic approaches and techniques were analyzed depending on HD with migration., Results: A total of 149 patients underwent PELD for HD with migration. There were 93 low-grade down HD patients, 13 high-grade down, 11 low-grade up, and 32 high-grade up. High-grade up HDs were removed with the outside or outside-in techniques from L1-2 to L4-5. High-grade down HDs were removed via the outside technique with additional foraminoplasty. Low-grade up/down HDs with disc space continuity were removed with the inside-out technique. Meanwhile, at the L5-S1 level, interlaminar PELD was used to treat high-grade up/down HD with migration. The mean visual analogue scale score for back pain, leg pain, and Oswestry Disability Index were significantly improved after PELD. Favorable outcome was achieved in 90.6% of cases., Conclusions: An appropriate strategy for PELD is important for successful removal of HD considering the extent of migration and direction., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Intervertebral disc (IVD) degeneration is responsible for various spine pathologies and present clinical treatments are insufficient. Concurrently, the mechanisms behind IVD degeneration are still not completely understood, so as to allow development of efficient tissue engineering approaches. A model of rat IVD degeneration directly coupled to herniation is here proposed in a pilot study. Disc injury is induced by needle puncture, using two different needles gauges: a low caliber 25-G needle and a high caliber 21-G needle. Histological, biochemical, and radiographic degeneration was evaluated at 2 and 6 weeks post-injury. We show that the larger caliber needle results in a more extended histological and radiographic degeneration within the IVD, compared to the smaller one. TUNEL quantification indicates also increased cell death in the 21-G group. Analyses of collagen type I (Picrosirius red staining), collagen type II (immunofluorescence), and GAG content (Blyscan assay) indicate that degeneration features spontaneously recover from 2 to 6 weeks, for both needle types. Moreover, we show the occurrence of hernia proportional to the needle gauge. The number of CD68+ macrophages present, as well as cell apoptosis within the herniated tissue are both proportional to hernia volume. Moreover, hernias formed after lesion tend to spontaneously diminish in volume after 6 weeks. Finally, MMP3 is increased in the hernia in the 21-G group at 2 weeks. This model, by uniquely combining IVD degeneration and IVD herniation in the same animal, may help to understand mechanisms behind IVD pathophysiology, such as hernia formation and spontaneous regression. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:258-268, 2017., (© 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

IL-1β has been reported highly expressed in degenerative intervertebral disc, and our previous study indicated IL-1β facilitates apoptosis of human degenerative nucleus pulposus (NP) cell. However, the underlying molecular mechanism remains unclear. We here demonstrate that IL-1β played a significantly pro-apoptotic effect under serum deprivation. IL-1β decreased Bcl-2/Bax ratio and enhanced cytochrome C released from mitochondria to cytosol, which proved mitochondria-meidated apoptosis was induced. Subsequently, mitochondria damage was detected under IL-1β stimualtion. In addition, IL-1β-mediated injuried mitochondria contributes to activate autophagy. However, pretreatment with the autophagy inhibitor 3-methyladenine showed the potential in further elevating the apoptosis rate induced by IL-1β in NP cells. Our results indicated that the mitochondrial pathway was involved in IL-1β-induced apoptosis of NP cells. Meanwhile, the damaged mitochondria-induced autophagy played a protective role against apoptosis, suggesting a postive feedback mechanism under inflammatory stress.

Study Design: High resolution imaging investigation of the failure of ovine lumbar intervertebral discs under complex loading., Objective: To investigate how different loading combinations influence the mechanism and extent of intervertebral disc failure., Summary of Background Data: Even though there has been extensive research on how an intervertebral disc fails under various conditions, failure mechanisms remain unclear. In addition, the influence of different loading directions on the mode and extent of failure under complex loading was never systematically investigated., Methods: Thirty ovine lumbar spinal segments were loaded in a newly developed, dynamic, 6-degree-of-freedom (6-DOF) disc loading simulator under five combinations of the following loading parameters: 0°-13° flexion, 0°-10° lateral bending, 0°-4° axial rotation, 0-800 N axial compression. A total of 1000 cycles at 2 Hz were done. After testing, imaging of the discs was performed in an ultra-high field magnetic resonance imaging (11.7 T) scanner and with a micro-computed tomography scanner., Results: A total of 13 large endplate junction failures (EPJFs) occurred, of which all but one maintained an intact cartilaginous endplate. Ten out of 13 EPJFs occurred caudally. Four solely annulus failures occurred affecting only the outer posterior annulus. A herniation was not observed. The maximum moments measured in any group (median) were 52.5 N · m flexion, 16.5 N · m lateral bending, and 14.0 N · m axial rotation., Conclusion: Complex loading protocols could lead to EPJFs (76%) and annulus failures (24%) in vitro. The combination of flexion, lateral bending, axial rotation, and axial compression bears the highest risk for caudal EPJF. Flexion without lateral bending and vice versa has the lowest risk for failure. Both axial compression and axial rotation seem to have a smaller influence than flexion and lateral bending. It seems that a herniation requires an additional failure of the cartilaginous endplate, likely initiated by further axial compressive load., Level of Evidence: 4.

Background: Osteoblastoma is rare and accounts for 3% of all benign tumors and 1% of all bone tumors. The spine is the most common site of occurrence, constituting 32% to 45% of all osteoblastomas. It has a strong predilection for the posterior elements, most often occurring in the lumbar spine., Method: In this case report, we describe an unusual presentation of spinal osteoblastoma presenting as thoracic T9 vertebra plana in a 20-year-old female. She presented with discomfort over the midback with unsteadiness of gait. The patient underwent detailed investigations including computed tomography (CT), magnetic resonance imaging, and CT-guided biopsy. To our knowledge, this is the first case report of vertebra plana due to spinal osteoblastoma in the English literature., Result: The patient successfully underwent posterior decompression of T9 with laminectomy followed by minimally invasive surgery posterior instrumentation from T7 to T11. Histopathology of the intraoperative specimen was consistent with osteoblastoma. The patient had an uneventful postoperative recovery and no evidence of tumor recurrence could be demonstrated on positron emission tomography scan at 15 months' follow-up., Conclusion: In conclusion, the differential diagnosis for vertebra plana is extensive and we add spinal osteoblastoma as another etiology to the existing list. Diagnosis and treatment of vertebra plana involve multimodality radiological imaging, and careful histological and surgical evaluation to identify the underlying etiology., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The formation of connective tissue changes in the spinal canal of rats, caused by the method of intervertebral disc ruptures, in association with a mixture of epidural injection of longidaza and diprospan has been researched. Simultaneous injection of hialuronidase and betamethasone in composition of diprospan and longidaza, revealed a high synergistic effect and anti-fibrotic activity. Combined antifibrosis action of these two drugs is stronger than the sum of the actions of the two drugs in their separate use. Reducion of the maximum thickness of the fibrous layer was 49%, compared with the reference value and reduction of the total area of the fibrous formation was 46%. In our opinion, due to anti-inflammatory effects and the ability to reduce epidural scar adhesion, this complex is promising for its therapeutic use in treatment of spinal epidural fibrosis.

Background: Lumbar disc herniation (LDH), a common disease, is often treated conservatively, frequently resulting in spontaneous resorption of the herniated disc. The incidence of this phenomenon, however, remains unknown., Objective: To analyze the incidence of spontaneous resorption after conservative treatment of LDH using computed tomography and magnetic resonance imaging., Study Design: Meta-analysis and systematic review of cohort studies., Setting: The work was performed at The Suzhou Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine., Methods: We initiated a search for the period from January 1990 to December 2015 using PubMed, Embase, and the Cochrane Library. Two independent reviewers examined the relevant reports. The references from these reports were also searched for additional trials using the criteria established in the PRISMA statement., Results: Our results represent the pooled results from 11 cohort studies. The overall incidence of spontaneous resorption after LDH was 66.66% (95% CI 51% - 69%). The incidence in the United Kingdom was 82.94% (95% CI 63.77% - 102.11%). The incidence in Japan was 62.58% (95% CI 55.71% - 69.46%)., Limitations: Our study was limited because there were few sources from which to extract data, either in abstracts or published studies. There were no randomized, controlled trials that met our criteria., Conclusions: The phenomenon of LDH reabsorption is well recognized. Because its overall incidence is now 66.66% according to our results, conservative treatment may become the first choice of treatment for LDH. More large-scale, double-blinded, randomized, controlled trials are necessary to study the phenomenon of spontaneous resorption of LDH.Key words: Lumbar, disc herniation, spontaneous resorption, conservative treatment, incidence, country, meta-analysis, systematic review, observational studies, study designs.

Aim: To analyze clinical and emotional/behavioral characteristics of acute and chronic low-back pain that significantly affect quality-of-life., Material and Methods: Fifty-three patients with pain syndromes were examined using the painDETECT questionnaire, the Visual Analog Scale for Pain, The McGill Pain Questionnaire and laboratory and instrumental methods of neurological assessment., Results and Conclusion: A 'picture of the patient with acute and chronic pain' was built, a group of patients with neuropathic component of pain was described. The size of herniated discs was not correlated with VAS assessments and the neuropathic component had a mild effect on pain intensity. The significant correlation was found between the severity of pain and coping strategies for pain. The results indicate the importance of effective and safety pain stopping, in particular at the acute stage, to prevent pain chronification. A drug of choice in case of intensive pain and marked nociceptive component are highly effective and safe nonsteroidal anti-inflammatory drugs, in particular etoricoxib (Arcoxia), a selective COX-2 inhibitor.

Objective is to describe a safe and effective percutaneous endoscopic approach for removal of highly migrated and sequestrated disc herniations of the upper lumbar spine and to report the results, surgical indications, and technical considerations of the new technique. Eleven patients who had highly migrated and sequestrated disc herniations in the upper lumbar were included in this study. A retrospective study was performed for all patients after translaminar osseous channel-assisted PELD was performed. Radiologic findings were investigated, and pre-and postoperative visual analog scale (VAS) assessments for back and leg pain and Oswestry disability index (ODI) evaluations were performed. Surgical outcomes were evaluated under modified MacNab criteria. All of the patients were followed for more than 1 year. The preoperative and postoperative radiologic findings revealed that the decompression of the herniated nucleus pulposus (HNP) was complete. After surgery, the mean VAS scores for back and leg pain immediately improved from 8.64 (range, 7-10) and 8.00 (range, 6-10) to 2.91 (range, 2-4) and 2.27 (range, 1-3), respectively. The mean preoperative ODI was 65.58 (range, 52.2-86), which decreased to 7.51 (range, 1.8-18) at the 12-month postoperative follow-up. The MacNab scores at the final follow-up included nine excellent, one good, and one fair. The modified translaminar osseous channel-assisted PELD could be a safe and effective option for the treatment of highly migrated and sequestrated disc herniations of the upper lumbar.

Background: The exact location of migrated extruded lumbar disk fragments is an important consideration in selecting a treatment plan. However, few descriptive reports of the migration pattern of extruded lumbar disk fragments are available., Objective: To examine the distribution of disk fragments and possible contributing factors that affect their migration., Design: Retrospective descriptive study., Setting: Tertiary university outpatient and inpatient clinic., Patients: A total of 164 patients diagnosed with a symptomatic extruded lumbar disk from January 2011 to December 2012., Methods: Lumbar spine magnetic resonance imaging scans of patients were retrospectively reviewed. The term "migration" was defined as the horizontal and vertical displacement of extruded material away from the opening in the annulus through which the material has extruded. Migration of the disk material was recorded in both the horizontal and vertical plane. In the horizontal plane, migration was recorded as central, paracentral, subarticular, or foraminal. In the vertical plane, migration was recorded as rostral or caudal., Main Outcome Measurements: The pattern of migration and the associated factors (age and the level of herniation) were analyzed., Results: Rostral and caudal migration was observed in 27% (95% confidence interval [CI], 21%-35%) and 73% (95% CI, 66%-79%) of the patients. Central, paracentral, subarticular, and foraminal migration was observed in 6% (95% CI, 3%-11%), 67% (95% CI, 60%-74%), 18% (95% CI, 13%-25%), and 9% (95% CI, 5%-14%) of the patients, respectively. A significant increase was observed in the incidence of rostral migration with increasing age (P = .048). A significant association was also noted between migration in the horizontal plane and increasing age (P = .01). A significant increase occurred in the incidence of foraminal extrusion with increasing age (P = .01). A significant association was found between migration in the vertical plane and horizontal plane; in patients with foraminal herniations, migration was always rostral (P < .001)., Conclusion: The migration of extruded lumbar disk materials follows some general patterns. The results of this study may help spine interventionists and surgeons choose appropriate treatments for patients who have radiculopathy associated with lumbar disk extrusions., Level of Evidence: IV., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

The pathogenesis of pain in lumbar disc herniation (LDH) remains poorly understood. We have recently demonstrated that voltage-gated sodium channels (VGSCs) in dorsal root ganglion (DRG) neurons were sensitized in a rat model of LDH. However, the detailed molecular mechanism for sensitization of VGSCs remains largely unknown. This study was designed to examine roles of the endogenous hydrogen sulfide synthesizing enzyme cystathionine β-synthetase (CBS) in sensitization of VGSCs in a previously validated rat model of LDH. Here we showed that inhibition of CBS activity by O-(Carboxymethyl) hydroxylamine hemihydrochloride (AOAA) significantly attenuated pain hypersensitivity in LDH rats. Administration of AOAA also reduced neuronal hyperexcitability, suppressed the sodium current density, and right-shifted the V 1/2 of the inactivation curve, of hindpaw innervating DRG neurons, which is retrogradely labeled by DiI. In vitro incubation of AOAA did not alter the excitability of acutely isolated DRG neurons. Furthermore, CBS was colocalized with Na V 1.7 and Na V 1.8 in hindpaw-innervating DRG neurons. Treatment of AOAA markedly suppressed expression of Na V 1.7 and Na V 1.8 in DRGs of LDH rats. These data suggest that targeting the CBS-H 2 S signaling at the DRG level might represent a novel therapeutic strategy for chronic pain relief in patients with LDH.

Objective To compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF) for spinal fusion in patients previously treated by discectomy. Methods This retrospective study evaluated pre- and postoperative neurological status via Japan Orthopaedic Association (JOA) score. Surgical outcome was based on recovery rate percentage (RR%). Adverse event data were reviewed. Results Both PLIF ( n = 26) and TLIF ( n = 25) significantly improved neurological status. There were no significant between-group differences in postoperative JOA score, RR% or surgical outcome. Overall, 92.3% patients in the PLIF group and 84% in the TLIF group had an excellent or good outcome (RR ≥ 65%). No patient had a poor outcome (RR < 50%). There were six cases of dural tear in the PLIF group and two in the TLIF group. Conclusions PLIF and TLIF provided good outcomes for recurrent lumbar disc herniation. TLIF may be preferred because of its shorter operative time and fewer procedure-related complications than PLIF.

Purposes: To evaluate the usefulness of our original five questions in a medical interview for diagnosing discogenic low back pain (LBP), and to establish a support tool for diagnosing discogenic LBP., Materials and Methods: The degenerative disc disease (DDD) group (n = 42) comprised patients diagnosed with discogenic LBP associated with DDD, on the basis of magnetic resonance imaging findings and response to analgesic discography (discoblock). The control group (n = 30) comprised patients with LBP due to a reason other than DDD. We selected patients from those who had been diagnosed with lumbar spinal stenosis and had undergone decompression surgery without fusion. Of them, those whose postoperative LBP was significantly decreased were included in the control group. We asked patients in both groups whether they experienced LBP after sitting too long, while standing after sitting too long, squirming in a chair after sitting too long, while washing one's face, and in the standing position with flexion. We analyzed the usefulness of our five questions for diagnosing discogenic LBP, and performed receiver operating characteristic (ROC) curve analysis to develop a diagnostic support tool., Results: There were no significant differences in baseline characteristics, except age, between the groups. There were significant differences between the groups for all five questions. In the age-adjusted analyses, the odds ratios of LBP after sitting too long, while standing after sitting too long, squirming in a chair after sitting too long, while washing one's face, and in standing position with flexion were 10.5, 8.5, 4.0, 10.8, and 11.8, respectively. The integer scores were 11, 9, 4, 11, and 12, respectively, and the sum of the points of the five scores ranged from 0 to 47. Results of the ROC analysis were as follows: cut-off value, 31 points; area under the curve, 0.92302; sensitivity, 100%; and specificity, 71.4%., Conclusions: All five questions were useful for diagnosing discogenic LBP. We established the scoring system as a support tool for diagnosing discogenic LBP., Competing Interests: The authors have declared that no competing interests exist.

The Coflex is one of the representatives of posterior dynamic interspinous process device, but no study with the application of Coflex interlaminar stabilization in L5/S1 level has been performed. The aim of this study was to evaluate the feasibility and validity of the Coflex interlaminar stabilization in the treatment of degenerative lumbar diseases on L5/S1 level. A retrospective study was conducted for a consecutive series of 33 patients with degenerative lumbar spinal stenosis or lumbar disc herniation located in L5/S1 between November 2007 and September 2010. Subjects were all received decompressive laminectomy with implantation of Coflex device. Clinical effects were evaluated by visual analog scale and Oswestry Disability Index. Radiographs were done preoperatively, postoperatively, and at final follow-up. The Coflex devices were successfully implanted in all subjects. Fourteen cases completed the operations by inverting the prosthesis on account of too short S1 spinous processes. During the minimum 4-year follow-up period, all patients had obvious improvement in clinical effects (P < 0.05). Radiological evaluation revealed that dorsal intervertebral space height and intervertebral foramen height of target level increased significantly in all cases postoperatively and maintained well to final follow-up. In addition, the sagittal range of motion of operated level was restricted (P < 0.05), and the range of motion of adjacent segment did not change much (P > 0.05). The Coflex is an efficacious dynamic interspinous process device for the treatment of degenerative lumbar diseases that can apply to L5/S1.

Objective: The purpose of this study was to evaluate whether cervical disk herniation (CDH) location, morphology, or Modic changes (MCs) are related to treatment outcomes., Methods: Magnetic resonance imaging (MRI) and outcome data from 44 patients with CDH treated with spinal manipulative therapy were evaluated. MRI scans were assessed for CDH axial location, morphology, and MCs. Pain (0-10 for neck and arm) and Neck Disability Index (NDI) data were collected at baseline; 2 weeks; 1, 3, and 6 months; and 1 year. The Patient's Global Impression of Change data were collected at all time points and dichotomized into "improved," yes or no. Fischer's exact test compared the proportion improved with MRI abnormalities. Numerical rating scale and NDI scores were compared with MRI abnormalities at baseline and change scores at all time points using the t test or Mann-Whitney U test., Results: Patients who were Modic positive had higher baseline NDI scores (P = .02); 77.8% of patients who were Modic positive and 53.3% of patients who were Modic negative reported improvement at 2 weeks (P = .21). Fifty percent of Modic I and 83.3% of Modic II patients were improved at 2 weeks (P = .07). At 3 months and 1 year, all patients with MCs were improved. Patients who were Modic positive had higher NRS and NDI change scores. Patients with central herniations were more likely to improve only at the 2-week time point (P = .022)., Conclusions: Although patients who were Modic positive had higher baseline NDI scores, the proportion of these patients improved was higher for all time points up to 6 months. Patients with Modic I changes did worse than patients with Modic II changes at only 2 weeks., (Copyright © 2016. Published by Elsevier Inc.)

Purpose: Spinopelvic parameters can be useful in identifying risk factors for lumbar degenerative disc disease, but few studies assess patients with single-level disc herniation and most do not evaluate symptoms. This comparative retrospective study was aimed to analyse spinopelvic parameters, symptoms and MRI changes in patients with single-level lumbar disc herniation undergoing conservative or surgical treatment., Methods: Patients with clinical and radiological assessment (Japanese Orthopaedic Association Score) and an MRI evaluation of the lumbar spine were identified and divided into two groups: surgically treated (group A) and not requiring surgery (group B). Spinopelvic parameters were determined on standing profile radiographs of the lumbar spine and pelvis, and mean values were compared to those reported in the literature for normal subjects. MRI findings were graded according to the system described by Pfirrmann et al., Results: The study included 71 patients with single-level lumbar disc herniation: 26 in group A (39.4 ± 12.1 years) and 45 in group B (51.4 ± 17.2 years). The notable differences in spinopelvic parameter means between the two groups did not reach statistical significance. A positive correlations of age with pelvic tilt and Pfirrmann changes with pelvic incidence was only found in group A, while both groups showed highly significant positive correlations of pelvic incidence with the spine's conformational type (p = 0.001)., Conclusions: Characteristic changes in spinopelvic parameters identified in patients with lumbar degenerative disc disease were a reduction in pelvic incidence, sacral slope and lumbar lordosis, with an increased pelvic tilt. These were found to correlate with MRI changes in surgically treated patients.

Objectives: To study the characteristics of the relationship between injury and disease in forensic identification cases of cervical trauma with cervical vertebra degeneration, and to explore the problems about how to identify the participation rates of injury and disease using the clinical information, forensic examination and imaging examination., Methods: Seventeen forensic identification cases of cervical trauma with cervical vertebra degeneration were collected. The age distributions, injury formations, injury severities and imaging findings of these cases were analyzed and the relationship between injury and disease was evaluated comprehensively., Results: Middle-aged and elderly were common in 17 cases and every case was involved with intervertebral disc herniation. The main reasons of injuries were hyperextension. The degree of injury severity and vertebra degeneration were graded according to the imaging findings. The participation rates of injury and disease were also calculated comprehensively., Conclusions: The forensic identification cases of cervical trauma with cervical vertebra degeneration should be evaluated with clinical information, forensic examination and imaging finding., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Forensic Medicine)

The aim of this study was to identify the possible correlation between polymorphisms in matrix metalloproteinase (MMP)-1 and MMP-3 and their corresponding protein levels in disc tissues obtained from patients with lumbar disc herniation (LDH) using biochemical and immunohistochemical analyses. Blood and disc samples were obtained from 100 patients with LDH who underwent a lumbar microdiscectomy. Based on the radiological degeneration, the patients were diagnosed with grade 2, 3, or 4 LDH. MMP-1 -1607 1G/2G and MMP-3 -1171 5A/6A were analyzed by real-time polymerase chain reaction. The expressions of MMP-1 and MMP- 3 were detected by biochemical and immunohistochemical analyses. We found no association between the MMP-1 polymorphism and disc degeneration and MMP-1 expression. However, patients expressing the 6A/6A and 5A/6A alleles of MMP-3 -11715A/6A showed higher MMP-3 expression, compared to those expressing the 5A/5A genotype. Additionally, the radiological degeneration grades were correlated with the histological degeneration scoring. Protein levels and immunopositive cell rates of MMP-1 and MMP-3 were associated with disc degeneration grades. Moreover, the MMP-1 and MMP-3 expression and the histological and radiological scores were positively correlated and the MMP-3 -11715A/6A polymorphism was associated with MMP-3 expression in herniated disc tissues. This study is the first to investigate polymorphisms in MMP-1 and MMP-3, as well as their corresponding protein expressions. We also quantified an association between the radiological degeneration grades and MMP-1 and MMP- 3 expression. Further genomic studies on MMPs could focus on the utilization of MMP-1 and MMP-3 as markers for the prevention and treatment of this disease., Competing Interests: The authors declare no conflict of interest.

Purpose: The aim of this study was to compare two approaches for the delivery of biomaterials to partially nucleotomised intervertebral discs in whole organ culture under loading. Such models can help to bridge the gap between in vitro and in vivo studies by assessing (1) suitability of biomaterial delivery and defect closure methods, (2) effect of mechanical loading and (3) tissue response., Methods: Mechanical performance of bovine discs filled with a hyaluronan-based thermoreversible hydrogel delivered through the annulus fibrosus (AF) or the bony endplate (EP) was evaluated under cyclic axial loading in a bioreactor. The loading protocol was optimised to achieve physiological disc height changes in nucleotomised discs. A loading regime of 0.06 ± 0.02 MPa, 0.1 Hz, 6 h daily was applied on the nucleotomised discs. Disc height and stiffness were tracked for 5 days, followed by histological analyses., Results: Creation of a defect is less demanding for AF approach, while sealing is superior with the EP approach. Dynamic compressive stiffness is reduced following nucleotomy, with no significant difference between the two approaches. Disc height loss was higher, disc height recovery was lower and region around the defect with reduced cell viability was smaller for AF-approached than EP-approached discs., Conclusions: Two alternative methods for biomaterial testing in whole organ culture under loading were developed. Such models bring insights on the ability of the biomaterial to restore the mechanical behaviour of the discs. From a clinical perspective, the cavity models can simulate treatment of nucleotomy after disc herniation in young patients, whereby the remaining nucleus pulposus is still functional and therefore at high risk of re-herniation, though the defect may differ from the clinical situation.

Lumbar disc disease occurs mainly in the adult population. A disc prolapse in the paediatric population is very rare. Cauda equine syndrome resulting from compression of the cauda equina is a rare syndrome and is one of the few spinal surgical emergencies. Here we present a 13-year-old boy with pain in the lumbar region radiating bilaterally to the lower limbs, with asymmetrical weakness of lower the limbs, perianal hypoaesthesia and urinary retention. MRI of lumbar spine confirmed disc protrusion at the L3-L4 level with severe spinal canal stenosis. Patient was treated with microdiscectomy at the L3-L4 level. Postoperatively, his neurological deficit disappeared gradually. Although very rare, lumbar disc prolapse in the paediatric age group can lead to cauda equina syndrome. Early diagnosis and treatment can prevent life-long disability.

Purpose: To elucidate the mechanism of action of intradiscal oxygen-ozone therapy for herniated intervertebral disc therapy., Methods: Ozone's mechanism of action was investigated using 3 approaches: mathematical models of intervertebral disc space to explore the relationship between disc pressure and volume; ozonolysis experiments using glycosaminoglycans (GAGs) from a Chinese hamster ovary cell line that were similar in composition to GAGs found in human nucleus pulposus; and experiments in which live Yucatan miniature pigs received various concentrations of percutaneous, image-guided intradiscal oxygen-ozone treatment and were examined (after sacrifice) with histology and semiquantitative analysis of disc cytokine concentrations., Results: Engineering calculations support observations that a small (6%) disc volume reduction can result in considerable (9.84%) intradiscal pressure reduction. Porcine disc histology and Chinese hamster ovary GAG ozonolysis results showed that administered ozone reacted with and fragmented disc proteoglycans, reducing disc volume through disc dehydration. Cytokine analysis of porcine discs found that each of 4 cytokines measured (interleukin [IL]-1β, IL-6, IL-8, and tumor necrosis factor α) increased in concentration after 2 wt% ozone treatment., Conclusions: Oxygen-ozone therapy breaks down proteoglycan GAGs that maintain disc osmotic pressure, dehydrating the nucleus pulposus and reducing intervertebral disc volume. This is likely a primary mechanism by which ozone relieves nerve root compression and alleviates herniated disc-related pain. Additionally, 2 wt% ozone appears to interact with intradiscal cytokines, generating an antiinflammatory response that may contribute to symptom improvement., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Clinically, magnetic resonance (MR) imaging is the most effective non-invasive tool for assessing IVD degeneration. Histological examination of the IVD provides a more detailed assessment of the pathological changes at a tissue level. However, very few reports have studied the relationship between these techniques. Identifying a relationship may allow more detailed staging of IVD degeneration, of importance in targeting future regenerative therapies., Objectives: To investigate the relationship between MR and histological grading of IVD degeneration in the cervical and lumbar spine in patients undergoing discectomy., Methods: Lumbar (N = 99) and cervical (N = 106) IVD samples were obtained from adult patients undergoing discectomy surgery for symptomatic IVD herniation and graded to ascertain a histological grade of degeneration. The pre-operative MR images from these patients were graded for the degree of IVD (MR grade) and vertebral end-plate degeneration (Modic Changes, MC). The relationship between histological and MR grades of degeneration were studied., Results: In lumbar and cervical IVD the majority of samples (93%) exhibited moderate levels of degeneration (ie MR grades 3-4) on pre-operative MR scans. Histologically, most specimens displayed moderate to severe grades of degeneration in lumbar (99%) and cervical spine (93%). MR grade was weakly correlated with patient age in lumbar and cervical study groups. MR and histological grades of IVD degeneration did not correlate in lumbar or cervical study groups. MC were more common in the lumbar than cervical spine (e.g. 39 versus 20% grade 2 changes; p < 0.05), but failed to correlate with MR or histological grades for degeneration., Conclusions: In this surgical series, the resected IVD tissue displayed moderate to severe degeneration, but there is no correlation between MR and histological grades using a qualitative classification system. There remains a need for a quantitative, non-invasive, pre-clinical measure of IVD degeneration that correlates with histological changes seen in the IVD.

Objective: To explore the anatomical characteristics and surgical selections of upper lumbar disc herniation, and evaluate its clinical effects., Methods: From January 2009 to January 2013, 26 patients with upper lumbar disc herniation were treated in our department. There were 16 males and 10 females, aged from 28 to 51 years old with an average of 45.7 years, 4 cases were in L₁,₂, 9 cases in L₂,₃, and 13 cases in L₃,₄. The data was collected including distance between outer edge of lower facet and the spinous process, the outer edge of the isthmus and spinous process, the lower edge of lamina and the upper edge of the intervertebral space, nerve root arising points and lower edge of the corresponding pedicle. Transforaminal discectomy and interbody fusion combined with pedicle screw fixation was performed in patients with L₁,₂, L₂,₃ herniated disk and 5 patients with L₃,₄ herniated disk complicated with lumbar instability. However another 8 patients with L₃,₄ herniated disk were treated with posterior fenestration decompression. Clinical effects were evaluated by Japanese Orthopaedic Association(JOA). The relative height rate(R) of the intervertebral space was measured preoperatively and 1 year postoperatively. The fusion of the bone graft was also observed., Results: Intraoperative anatomical measurement was taken in all patients. All patients were followed up for more than 1 year with an average of 16 months, and all incisions got healing, JOA was improved from preoperative(10.13±1.49) points to last follow up (25.21±2.13) points with the improvement rate of 79.9%. Among the patients underwent fusion operation, 17 cases obtained bone fusion and 1 case maybe non fusion and no internal fixation failure was found;the R value was (0.231±0.056) mm preoperatively, however (0.345±0.076) mm at 1 year after operation with statistical difference( P <0.05). In the patient underwent posterior fenestration decompression, the R value was(0.243±0.036) mm preoperatively, and (0.212±0.046) mm at 1 year after operation without statistical difference ( P >0.05). No spinal instability and lumbar disc herniation recurrence were found in these patients., Conclusions: According to the anatomical characteristics of L₁,₂ and L₃,₄ herniated disk, these patients could be treated with transforaminal discectomy and interbody fusion. The anatomical characteristics and clinical manifestations of L₃,₄ herniated disk is similar with the lower lumbar disc herniation, for the patients, an appropriate surgical method should be chosen according to the lumbar stability., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Although some studies have evaluated the clinical impact of lumbosacral transitional vertebrae (LSTV), few have attempted to determine an effective conservative treatment method for lumbar disc herniation (LDH) presenting concurrently with LSTV., Methods: We prospectively enrolled 291 consecutive patients who were followed-up for at least one year after transforaminal epidural injection (TFEI) for LDH. We confirmed the presence of LSTV with Paik et al.'s method, the Castellvi classification, and the Southworth and Bersack method. Clinical outcomes were evaluated with a visual analogue scale (VAS) for pain intensity and the Oswestry Disability Index (ODI) for functional status., Results: Of the 291 patients, 47 (16.2%) had LSTV, including 33 with sacralization and 14 with lumbarization, while 244 (83.8%) did not have LSTV. Patients in both groups improved significantly after TFEI in terms of the VAS (P < 0.001) and ODI (P < 0.001) scores. However, LDH patients with LSTV had a worse clinical outcome after six months of TFEI than did those without LSTV, with a significant difference between groups for both the VAS (P < 0.01) and ODI (P = 0.01) scores. LDH patients with sacralization had worse post-treatment clinical outcomes than LDH patients with lumbarization (P < 0.001) or LDH patients without LSTV (P < 0.001)., Conclusions: Sacralization can reduce the improvement after TFEI among LDH patients, while lumbarization appears to have no direct effect on TFEI outcomes. The presence of sacralization should be identified before TFEI, and if present, patients should be informed that the outcomes of TFEI may not be as good as they would be if sacralization was not present., (© 2015 World Institute of Pain.)

Transforaminal endoscopic spine surgery has emerged internationally as a minimally invasive technique that can be performed in an awake patient in the outpatient setting. Advances in high-definition endoscopic camera technologies as well as the availability of specialty graspers, reamers, drills, and other instruments that can be used down a working channel endoscope have made a myriad of spine diseases accessible to the minimally invasive spine surgeon. The major challenge inherent in the surgical treatment of thoracic disc disease is that the disc herniation is often ventral to the spinal cord. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc disease., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Dysuria in camelids is usually associated with the presence of lower urinary tract disease such as urolithiasis. As another differential diagnosis, urine retention may be caused by neurological disturbances resulting from infections of the spinal cord, discospondylitis or trauma., Case Presentation: A 2.5-year-old male Huacaya alpaca (Vicugna pacos) presented with dysuria due to damage of the lumbosacral intumescence of the spinal cord. On presentation the alpaca was recumbent. Clinical examination revealed abdominal pain, oliguria, leucopenia with neutrophilia, and slightly elevated creatinine kinase. Ultrasonography of the abdomen showed an irregularly shaped, dilated urinary bladder with hyperechoic serosa. Magnetic resonance imaging revealed discospondylitis of the fourth and fifth lumbar vertebrae and herniation of the intervertebral disc between these vertebrae and the spinal cord. Postmortem examination confirmed severe chronic purulent discospondylitis with ventral spondylosis and narrowing of the spinal canal. Urolithiasis could not be verified., Conclusion: Although rare, diseases of the spinal cord should be considered as a differential diagnosis for impaired micturition in camelids.

Shoulder problems are common in patients with a cervical herniated intervertebral disc (HIVD). This study aimed to explore the incidence and risk of shoulder capsulitis/tendonitis following cervical HIVD surgery. We used data from the Taiwan "Longitudinal Health Insurance Database". We identified all patients who were hospitalized with a diagnosis of displacement of a cervical HIVD and who underwent cervical surgery (n = 1625). We selected 8125 patients who received cervical HIVD conservative therapy only as the comparison group matched with study patients. We individually tracked these sampled patients for 6 months to identify all patients who received a diagnosis of shoulder tendonitis/capsulitis. We found that incidence rates of shoulder tendonitis/capsulitis during the 6-month follow-up period were 3.69 (95% CI: 2.49~5.27) per 100 person-years for the study group and 2.33 (95% CI: 1.89~2.86) per 100 person-years for the comparison group. Cox proportional hazard regressions showed that the adjusted hazard ratio for shoulder tendonitis/capsulitis among patients who underwent cervical disc surgery was 1.66 (95% CI = 1.09~2.53) when compared to comparison group. We concluded that patients who underwent surgery for a cervical HIVD had a significantly higher risk of developing shoulder capsulitis/tendonitis in 6 months follow-up compared to patients who received cervical HIVD conservative therapy only.

Purpose: To investigate asymmetry in size and composition of the multifidus and erector spinae in patients with posterolateral disc herniation and concordant radicular symptoms, and determine whether symptom duration is associated with degree of asymmetry., Methods: Thirty-three patients diagnosed with posterolateral disc herniation at L4-L5 verified on imaging and concordant leg pain were included. Multifidus and erector spinae cross-sectional area (CSA), functional cross-sectional area (FCSA, fat-free area), signal intensity and ratio of FCSA to total CSA were measured bilaterally from T 2-weighted axial magnetic resonance imaging (MRI) at L3-L4, L4-L5, L5-S1 and S1 levels., Results: No side-to-side differences in multifidus CSA, FCSA, and ratio of FCSA/CSA reached statistical significance at any spinal level. The multifidus signal intensity at L5-S1 was significantly greater (more fatty infiltration) on the side of the disc herniation. The erector spinae FCSA (lean muscle mass) at L5-S1 was found to be significantly smaller on the side of the herniation and the ratio of FCSA/CSA was smaller (more fatty infiltration) on the side of the herniation at L4-L5 and L5-S1. The degree of muscle asymmetry was not associated with symptoms duration., Conclusions: There was no significant asymmetry of the multifidus at spinal level above, same or level below the disc herniation. Instead, variations in muscle composition were observed, with greater fat infiltration on the side and at spinal levels adjacent to the disc herniation. Muscle asymmetry was not correlated with symptom duration.

The present study was performed to investigate the role of p38 mitogen‑activated protein kinase (MAPK) in the resorption of herniated intervertebral discs in 30 rats. In the non‑contained and p38 MAPK inhibition (p38i) groups, two coccygeal intervertebral discs (IVDs) were removed and wounded prior to relocation into the subcutaneous space of the skin of the back. In the contained group, the cartilage endplates maintained their integrity. Furthermore, SB203580 was injected intraperitoneally into the p38i group, whereas saline was injected into the other two groups. In the non‑contained group, the weight of the relocated IVDs decreased to a greater extent over time when compared with the contained and p38i groups. Phosphorylated p38, tumor necrosis factor‑α, and interleukin‑1β were observed to exhibit higher expression levels in the non‑contained group compared with the contained and p38i groups, at weeks 1 and 4 post‑surgery. The expression level of caspase‑3 and the densities of apoptotic disc cells were significantly higher in the non‑contained group compared with the contained and p38i groups at 4 weeks post‑surgery. In conclusion, p38 MAPK induces apoptosis in IVDs, while also accelerating the resorption of the relocated IVDs. Thus, p38 MAPK may be important in spontaneous resorption of IVDs.

Background: Magnetic resonance imaging is routinely done for diagnosis of lumbar disc prolapse. Many abnormalities of disc are observed even in asymptomatic patient.This study was conducted tocorrelate these abnormalities observed on Magnetic resonance imaging and clinical features of lumbar disc prolapse., Methods: A This prospective analytical study includes 57 cases of lumbar disc prolapse presenting to Department of Orthopedics, Tribhuvan University Teaching Hospital from March 2011 to August 2012. All patientshad Magnetic resonance imaging of lumbar spine and the findings regarding type, level and position of lumbar disc prolapse, any neural canal or foraminal compromise was recorded. These imaging findings were then correlated with clinical signs and symptoms. Chi-square test was used to find out p-value for correlation between clinical features and Magnetic resonance imaging findings using SPSS 17.0., Results: This study included 57 patients, with mean age 36.8 years. Of them 41(71.9%) patients had radicular leg pain along specific dermatome. Magnetic resonance imaging showed 104 lumbar disc prolapselevel. Disc prolapse at L4-L5 and L5-S1 level constituted 85.5%.Magnetic resonance imaging findings of neural foramina compromise and nerve root compression were fairly correlated withclinical findings of radicular pain and neurological deficit., Conclusions: Clinical features and Magnetic resonance imaging findings of lumbar discprolasehad faircorrelation, but all imaging abnormalities do not have a clinical significance.

Purpose: To investigate volumetric changes in lumbar disc herniation (LDH) using three-dimensional measurements obtained by magnetic resonance imaging (MRI) and to identify possible factors affecting such changes., Methods: Between January 2004 and December 2011, 43 patients who underwent conservative treatment for LDH were enrolled. In all, 56 disc levels were investigated. MRI was performed on two or more occasions (minimally, at the initial visit and 6 months later). The volume of each herniated disc was determined. For each patient, disc migration, morphology, initial LDH size, and clinical outcome were evaluated., Results: The mean volumes of herniated discs at the initial and follow-up visits were 1,304.57 ± 837.99 and 993.84 ± 610.04 mm(3), respectively. The mean change in volume from the initial to the follow-up visit was 310.73 ± 743.60 mm(3). Volumes decreased at 35 disc levels and increased at 21 levels. The disc containment, the extent of LDH, the initial size of the herniated disc, and the degree of intactness of the posterior longitudinal ligament were significantly correlated with disc resorption and an increase in disc volume (p = 0.01, p = 0.018, p = 0.001, and p < 0.001, respectively). No significant association was evident between disc volumetric change and clinical outcome., Conclusions: We observed that LDH is a dynamic disease and that a herniated disc is not always spontaneously resorbed, in contrast to what has been reported previously. Alleviation of clinical symptoms can be achieved via conservative treatment even if the volume of the herniated disc changes. Spinal surgeons should not only present an option of initial non-surgical treatment to LDH patients but should also inform them that the LDH may change in size during daily activity or exercise.

Background: Herniated discs may exhibit calcification, and calcified discs may complicate surgical treatment. However, the osteogenic potential and expression of osteogenic markers in degenerative discs of different degenerative grades are still unclear. Our purposes are to study the differences in calcification rate and osteogenic potential of herniated discs according to different degenerative grades., Methods: Fifty-eight lumbar intervertebral discs were removed from 41 patients. After grading according to the Pfirrmann scale, calcification was analyzed by micro computed tomography (μ-CT), and expression of osteogenic markers was analyzed by immunohistochemistry and real-time quantitative polymerase chain reaction (qPCR). Data from μ-CT scans were compared with the Kruskal-Wallis test. The Mann-Whitney test was applied to compare data between any two groups. Differences in osteogenic mRNA expression in different regions of the removed discs (posterior vs. anterior) were analyzed by paired t tests. Differences in the posterior portion of removed discs of different Pfirrmann grades were analyzed by one-way analysis of variance (ANOVA), and comparisons of data between discs of any two grades were completed with least significant difference (LSD) tests., Results: Significant differences in calcification according to μ-CT scanning were observed between discs of different degenerative grades. Nearly half of the discs of Pfirrmann grade V showed the highest degree of calcification compared to Pfirrman grade II discs. Bone morphogenetic protein (BMP)-2, Osterix, and Osteocalcin were detected histologically in discs of Pfirrmann grades III-V. Alkaline phosphatase (ALP) expression was observed in discs showing evidence of calcification. The qPCR analysis showed that BMP-2, Osterix, and Osteocalcin were expressed in most degenerated discs. We also observed greater expression of these osteogenic markers in the posterior portion of removed discs than in the anterior portion., Conclusions: The osteogenic potential of degenerated intervertebral discs appears to increase with the severity of degeneration and to be greater in the tissue near the spinal canal than in tissue in the inner portion of the disc.

The aim of the current study was to examine matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-2 (TIMP-2) expression in patients with cervical disc herniation (CDH). A total of 127 specimens from CDH patients undergoing posterior spinal surgery were obtained for the case group, which was divided into three subgroups: lateral protrusion (N = 102), median protrusion (N = 18), and paramedian protrusion (N = 7). Another 55 specimens from subjects who had cervical spine trauma and underwent spinal canal decompression were obtained for the control group. Routine hematoxylin and eosin staining was performed for pathological diagnosis. Immunohistochemical (IHC) analysis was used to determine MMP-2 and TIMP-2 expression. Under light microscopy, MMP-2-positive cells presented brown-yellow or dark brown staining in the cell membrane or cytoplasm. MMP-2 expression in the case group was significantly higher than that in controls (P < 0.05). Furthermore, MMP-2 expression in the lateral and median protrusion groups was significantly higher compared to that in the paramedian protrusion group (both P < 0.05), while there was no apparent difference in MMP-2 expression between the lateral and median protrusion groups (P > 0.05). IHC results showed that TIMP-2 expression in cases was significantly lower than that in controls (P < 0.05). Spearman correlation analysis indicated that MMP- 2 was negatively correlated with TIMP-2 expression (r = -0.418, P < 0.001). In conclusion, MMP-2 expression increased, whereas TIMP- 2 expression decreased in CDH patients, suggesting that MMP-2 and TIMP-2 expression may contribute to CDH development.

Background: Lumbar intervertebral disc herniation and spinal tumor are major pathologies that may cause back pain and radiculopathy. Neurological symptoms resulting from disc herniation and intradural spinal tumor together, however, are very rare., Case Presentation: We report a case of lumbar disc herniation which coexists with intradural schwannoma at the same spinal level in a 67-year-old man. The patient presented with persistent low back pain, sciatica, and weakness of the lower limbs. Contrast lumbar spine magnetic resonance (MR) imaging clearly delineated an intradural lesion and an extradural herniated disc at L3/4 level. Using a single posterior approach, both pathologies were addressed. Pathological studies confirmed the intradural lesion was schwannoma., Conclusion: The case report highlights a rare concomitance of two symptomatic pathologies in a lumbar spine, which deserves clinical attention. Complete history, careful physical examination, and investigative measures, such as contrast MR imaging, are helpful to establish throughout diagnoses.

Purpose: Magnetic resonance imaging (MRI) can reveal a range of degenerative findings and anatomical abnormalities; however, the clinical importance of these remains uncertain and controversial. We aimed to investigate if the presence of MRI findings identifies patients with low back pain (LBP) or sciatica who respond better to particular interventions., Methods: MEDLINE, EMBASE and CENTRAL databases were searched. We included RCTs investigating MRI findings as treatment effect modifiers for patients with LBP or sciatica. We excluded studies with specific diseases as the cause of LBP. Risk of bias was assessed using the criteria of the Cochrane Back Review Group. Each MRI finding was examined for its individual capacity for effect modification., Results: Eight published trials met the inclusion criteria. The methodological quality of trials was inconsistent. Substantial variability in MRI findings, treatments and outcomes across the eight trials prevented pooling of data. Patients with Modic type 1 when compared with patients with Modic type 2 had greater improvements in function when treated by Diprospan (steroid) injection, compared with saline. Patients with central disc herniation when compared with patients without central disc herniation had greater improvements in pain when treated by surgery, compared with rehabilitation., Conclusions: Although individual trials suggested that some MRI findings might be effect modifiers for specific interventions, none of these interactions were investigated in more than a single trial. High quality, adequately powered trials investigating MRI findings as effect modifiers are essential to determine the clinical importance of MRI findings in LBP and sciatica (, Prospero: CRD42013006571).

Laser discectomy or nucleotomy is an increasingly important method for less invasive procedures of column, but the ideal kind of laser is still not established. As the wavelength is an important parameter for water absorption, this study was performed to investigate the action of the laser emission in the near infrared (808 to 1908 nm) region in the context of surgical procedures for percutaneous intervertebral disc decompression (nucleotomy). Forty intervertebral discs from pigs lumbar spines were irradiated with laser (λ = 808, 980, 1470 and 1908 nm), 1-s on/off time cycles, for 120 cycles and 10 W of power (808, 980, and 1470 nm) or 240 cycles and 5 W of power (1908 nm), with total power of 1200 J, and subjected to microscopic evaluation through hematoxylin-eosin (HE) staining in order to measure the ablation lesions and the residual thermal injury. Ten other discs were not irradiated and worked as controls. The ablation lesions were measured (in mm) at 1.08 ± 1.25, 1.70 ± 0.63, 2.23 ± 1.02, 1.37 ± 0.39, and 0.94 ± 0.41 (median ± SD) for the control, 808, 980, 1470, and 1908 nm groups, respectively. The difference between 1908 nm and all the other groups was statistically significant (p < 0.05). The residual thermal injury was less evident in 1908 nm laser and sharper in 980 nm laser wavelengths. The laser at a wavelength of 1908 nm was considered the most efficient for the vaporization of the nucleus pulposus, followed by the laser wavelengths of 1470, 808, and 980 nm, and proved to be useful for laser nucleotomy procedure.

Background: Low back pain is one of the common health problems encountered in life with intervertebral disc herniation being a common cause of its occurrence. Magnetic resonance imaging has emerged the gold standard for diagnosing a herniated disc., Aims and Objective: To assess the frequency and pattern of occurrence of disc herniation as well as evaluate the association of disc herniation on magnetic resonance imaging with clinical symptoms., Method: A total of 120 adult patients who came for magnetic resonance imaging scan of the lumbosacral spine for a period of 1year in the department of Radiology University of Port-Harcourt Teaching Hospital. The end plates of 600 lumbar interspaces were graded for type, size and site of lumbar disc herniation., Results: The age distribution of patients was from 18-80 years; mean age was 51.0.

Structural health monitoring (SHM) is an engineering technique used to identify mechanical abnormalities not readily apparent through other means. Recently, SHM has been adapted for use in biological systems, but its invasive nature limits its clinical application. As such, the purpose of this project was to determine if a non-invasive form of SHM could identify structural alterations in the spines of living human subjects. Lumbar spines of 10 twin pairs were visualized by magnetic resonance imaging then assessed by a blinded radiologist to determine whether twin pairs were structurally concordant or discordant. Vibration was then applied to each subject's spine and the resulting response recorded from sensors overlying lumbar spinous processes. The peak frequency, area under the curve and the root mean square were computed from the frequency response function of each sensor. Statistical analysis demonstrated that in twins whose structural appearance was discordant, peak frequency was significantly different between twin pairs while in concordant twins, no outcomes were significantly different. From these results, we conclude that structural changes within the spine can alter its vibration response. As such, further investigation of SHM to identify spinal abnormalities in larger human populations is warranted.

The objective of this systematic review was to identify the effectiveness of percutaneous endoscopic lumbar discectomy (PELD) in the treatment of recurrent lumbar disc herniation (rLDH) and to present its indications and techniques. We conducted a comprehensive search in MEDLINE, EMBASE, PubMed, Web of Science and Cochrane databases, searching for relevant studies of managing rLDH with PELD up to July 2015. Only papers published in English were included. Two review authors independently selected the studies, extracted relevant data and assessed their methodological quality. The Cochrane Collaboration's Revman 5.3 software was used for data analyses among the controlled studies. At last, one randomized controlled trial (RCT), two non-randomized control studies and five observational studies including a total of 579 cases were selected for this system review. The methodological quality of these studies was low to modern. The mean overall improvement of leg pain (visual analogue scale) was 66.92% (50.6%-89.87%), back pain (visual analogue scale) 54.91% (29%-67.95%), Oswestry Disability Index 60.9% (40.7%-75%), global perceived effect (MacNab/other) 75.77% (60%-95%). The mean overall of complication rate was 4.89% (0%-9.76%), dural tear rate 0.1% (0%-4.9%), recurrence rate 6.3% (4%-10%), re-operation rate 3.66% (2.33%-4.8%). We conducted a meta-analysis among the control trials. Compared with Open discectomy (OD), PELD resulted in better outcomes in terms of operative time, blood loss, lower complication rates, but with no significance differences regarding hospital stay, second recurrence rate, Macnab criteria and pain reduction. In conclusion, according to the current evidence, PELD is an effective procedure for the treatment of rLDH in terms of reducing complication and shorting hospital course, comparing with OD. Therefore, we suggested that PELD was a feasible alternative to OD in the treatment of the rLDH in the condition of proper indication. High-quality RCTs with large sample sizes are needed to further confirm these results., (Copyright © 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)