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Objectives: Symptoms associated with spinal disk herniation may heal without surgery. In some patients, imaging reveals a reduction in hernia size, too. This phenomenon is referred to as spontaneous regression of the herniated disk. It was first reported in 1984 and is widely covered in today’s research papers. Case Presentation: This paper describes a case of spontaneous regression of lumbar disk herniation at L5-S1, where another disk was herniated at L4-L5 after only 8 months. The patient (F) sought help complaining of pain in the lumbar region. An MRI scan revealed a 6.2-mm hernia at L5-S1. The patient was prescribed conservative treatment comprising non-steroidal anti-inflammatory drugs and kinesitherapy, to which she refused to adhere and decided to treat the condition on her own. Eight months later, the patient sought help again, reporting other symptoms of pronounced constant pain in the rear lateral surface of the left leg and lameness. A further MRI scan revealed spontaneous hernia resorption at L5-S1 with an emergent vacuum phenomenon and a different disk herniated at L4-L5 to 9.4 mm. Discussion: Since the symptoms were pronounced and non-steroidal anti-inflammatory drugs did not have a therapeutic effect, the patient required surgery.

STUDY DESIGN Retrospective matched cohort analysis. OBJECTIVE The aim of this study was to investigate the impact of adjacent level ossification development (ALOD) on the affected as well as the next-level discs with regards to range of motion (ROM) and degenerative changes. SUMMARY OF BACKGROUND DATA Although ALOD is not a rare condition in patients who undergo anterior cervical fusion procedures, there has been little discussion to date about its clinical implications. METHODS Patients who underwent anterior cervical instrumented fusion with a minimum 2-year follow-up were reviewed. Twelve patients with each respective ossification grade (totally 48 patients) were matched based on age, sex, and number of fusion levels. On the preoperative and final follow-up x-rays, disc height, osteophytes, ROM, and maximal listhesis were assessed at the segments which were one- (the adjacent segment) and two-level cranial (the next segment) to the uppermost fused disc. Then, the patients were divided into two groups according to ALOD degree: group 1 (grade 0-1, N = 24) versus group 2 (grade 2-3, N = 24). The changes of all variables were compared between the two groups. RESULTS The mean ROM of the adjacent segment increased by 3.6 degree in group 1 and conversely decreased by 2.8 degree in group 2 (P = 0.002). The mean ROM increase of the next segment was significantly greater in group 2 than in group 1 (4.5 vs. 1.2 degree, P = 0.016). The osteophyte growth and the progression of listhesis at the next segment were significantly greater in group 2 (P

Background The occurrence of adjacent-level disease in spinal fusion is a complex and contentious issue. Through the years, surgeons have developed various approaches to address this problem. While some have avoided fusion altogether, others have advocated for large, multilevel fusion constructs. With the advent of minimally invasive spine surgery, there are now novel approaches to the spine which allow for less onerous and morbid revision surgeries. In this paper, we present the case of a woman who previously underwent a posterior cervical fusion and presented with adjacent-level disease. Case Description A 63-year-old female who had previously undergone a cervical 5 to thoracic 1 posterior instrumented fusion presented with axial neck pain, hand numbness, and imbalance. Imaging demonstrated adjacent-level disease with anterolisthesis of cervical 4 on cervical 5. Rather than exposing her entire fusion construct, we used a new technique to link her old hardware to new instrumentation. Conclusions We believe that our case is demonstrative of a new, modularized approach to spinal fusion and suggest a way forward in the treatment of adjacent-level disease.

The goal of this study was to refine clinical MRS to optimize performance and then determine whether MRS-derived biomarkers reliably identify painful discs, quantify degeneration severity, and forecast surgical outcomes for chronic low back pain (CLBP) patients. We performed an observational diagnostic development and accuracy study. Six hundred and twenty-three (623) discs in 139 patients were scanned using MRS, with 275 discs also receiving provocative discography (PD). MRS data were used to quantify spectral features related to disc structure (collagen and proteoglycan) and acidity (lactate, alanine, propionate). Ratios of acidity to structure were used to calculate pain potential. MRS-SCOREs were compared to PD and Pfirrmann grade. Clinical utility was judged by evaluating surgical success for 75 of the subjects who underwent lumbar surgery. Two hundred and six (206) discs had both a successful MRS and independent pain diagnosis. When comparing to PD, MRS had a total accuracy of 85%, sensitivity of 82%, and specificity of 88%. These increased to 93%, 91%, and 93% respectively, in non-herniated discs. The MRS structure measures differed significantly between Pfirrmann grades, except grade I versus grade II. When all MRS positive discs were treated, surgical success was 97% versus 57% when the treated level was MRS negative, or 54% when the non-treated adjacent level was MRS positive. MRS correlates with PD and may support improved surgical outcomes for CLBP patients. Noninvasive MRS is a potentially valuable approach to clarifying pain mechanisms and designing CLBP therapies that are customized to the patient. These slides can be retrieved under Electronic Supplementary Material.

Spinal fusion in young children for treatment of early onset scoliosis is not optimal because it limits growth and contributes to long-term lung compromise. Various types of growth-friendly spinal implants and newer technologies have been introduced in the past few years. Similarly, in adolescent idiopathic scoliosis, fusion decreases spinal mobility and may lead to development of adjacent level disc degeneration. A variety of different new technologies have been developed for alternative surgical approaches that halt curve progression while maintaining spinal mobility.

The incidence of adjacent level disease, in patients who have undergone a previous open posterior pedicle screw and rod instrumented fusion, is reported to be as high as 30% at 5-year follow-up. Due to the traditional revision open posterior surgery used to manage these patients being fraught with complications, several studies have compared this to newer MIS interbody fusion techniques. While the PLIF and TLIF inter-body fusion procedures have shown promising results, nerve root tethering by scar tissue limits the amount of retraction that can be safely performed, and as such may limit access to the disc space of the adjacent level. The ALIF is an anterior alternative, however several studies note it to be characterized by a high complication rate. As such the XLIF has been evaluated as an alternative to the ALIF, PLIF, and TLIF procedures and, despite several advantages, several papers note it to have its own specific set of complications despite the mandatory utilization of intra-operative electromyographic neurophysiological monitoring. As such an attending spinal surgeon, when managing a patient with adjacent level disease, must have a through understanding of the pros and cons of each possible surgical technique that could be used to manage the adjacent level. We present a series of three patients, all of which had previously undergone an open posterior instrumented lumbar fusion, and now presented to our unit with adjacent level disease. Two patients were successfully managed with a minimally invasive XLIF procedure augmented by open posterior decompression and extension of the instrumented fusion, and one patient was successfully managed by a minimally invasive stand-alone XLIF procedure without additional open posterior surgery. Our case series serves to highlight the specific and valuable role of the MIS XLIF procedure, specifically in the context of patients presenting with adjacent level disease.

Although vertebroplasty (VP) and balloon kyphoplasty (BKP) are highly common procedures in the management of vertebral fractures, their use over the years has raised a number of questions that promoted the development of new techniques and materials. The main issues related to their application are the risk of adjacent level fracture, cement leakage, and correction of segmental kyphosis. The main augmentation techniques that are addressed in this chapter are: Elastoplasty, Vesselplasty, the Kiva System®, Spine Jack®, and Lordoplasty. Elastoplasty involves the use of VK100®, a silicone whose biomechanical properties are very similar to those of cancellous bone. Vesselplasty, the Kiva System®, and Spine Jack® have been designed to obtain a more adequate restoration of lordosis, reducing the risk of cement leakage and trying to avoid the loss of correction that kyphoplasty can show over time. Lordoplasty, instead, uses a bending moment applied to the vertebrae adjacent to the fractured one to correct the segmental kyphosis. A separate mention deserves the discoplasty which involves the application of PMMA in the intervertebral disc for the treatment of “vertical instability” in patients complaining low back pain and leg pain who are not eligible for more complex surgical treatments.

Study Design: Retrospective case control study. Objectives: Adjacent-level ossification development (ALOD) is a distinct form of adjacent segmental degeneration that has been recognized to occur after anterior cervical discectomy and fusion (ACDF). It is unclear whether ACDF with plate versus standalone has an effect on rates of ALOD. This retrospective case-control study aims to assess the rate of ALOD in a large series of patients undergoing ACDF with and without plate and factors causing ALOD. Methods: Data was collected for patients undergoing ACDF from January 2009 to July 2016. Data collected was from multiple centers and included demographic data, surgical data, radiological imaging at time of surgery, and serial follow-up imaging. The radiology for ALOD was independently reviewed. Cohorts were divided into ACDF with plate (Group P = plate) and ACDF without plate (Groups S = standalone) and outcomes were compared. Results: There were 260 patients with 138 (53%) in Group P and 122 (47%) in Group S. ALOD was observed in 15.3% of patients overall, 29% in group P and 2.8% in group S ( P < .001). Following multivariate adjustment, statistically significant association was found between use of plate and ALOD (odds ratio = 12.8, 95% confidence interval = 3.52-45.45, P < .001). Plate-to-disc distance Conclusion: The use of anterior plate with ACDF was associated with ALOD. Plate-to-disc distance

Prospective randomized, 2-center, clinical trial.To prospectively compare adjacent level degeneration between the Bryan Cervical Disc Prosthesis and anterior cervical discectomy and fusion (ACDF), and assess the reliability of our measurements utilizing a method not previously described.ACDF is a reliable and proven procedure for the treatment of radiculopathy and/or myelopathy. Despite a successful track record several limitations including adjacent segment degeneration/disease, loss of viscoelastic disc properties, perioperative immobilization, graft site morbidity, pseudarthrosis, and plating complications have been identified. An original driving force and theoretical basis for total disc arthroplasty was prevention of adjacent level degeneration.Seventy-nine patients were enrolled and followed prospectively at 2 centers in a multicenter, Food and Drug Administration Investigational Device Exemption trial for the Bryan Cervical Disc arthroplasty. Neutral lateral radiographs were obtained preoperatively and postoperatively, and at 1-, 2-, 4-, and out to 7-year follow-up after surgery. The cephalad, adjacent level above the blinded procedure level was analyzed for all patients and time points by measuring the anteroposterior distance and the vertical disc height. A ratio was created using disc height/anteroposterior distance.Seventy patients (Bryan Cervical Disc N=34 and ACDF N=36) met inclusion criteria. Both fusion and arthroplasty groups showed a significant (P=0.001) decrease in disc height over time, indicative of adjacent level degeneration. Overall change in disc height between groups was not significantly different. Using our measurement technique, the overall interreviewer reliability was good [intrareviewer correlation coefficients (95% confidence interval)=0.77 (0.55-0.85)] and intrareviewer reliability was excellent [0.93 (0.91-0.94) and 0.85 (0.81-0.87)].Adjacent level degeneration occurs in a similar manner in both the ACDF and total disc arthroplasty group. Our measurement technique is reliable and to the best of our knowledge not previously reported in the literature.

O problema da doença no nível discal adjacente após a fusão espinhal levou a um novo conceito de tratamento sem fusão, cujo alvo é manter o segmento móvel. A introdução do disco artificial nas doenças degenerativas pode resultar no alívio da dor e na manutenção da movimentação com restauração da estabilidade. Nós analisamos 12 pacientes submetidos à introdução de PDN(Prosthesis of Disc Nucleus) no Hospital Santa Rita, em São Paulo, entre dezembro de 2000 e junho de 2001. A seleção dos pacientes é muito importante. Dor discogênica em pacientes jovens com “disco preto” maiores que 5 mm é critério necessário. Dois diferentes acessos foram usados: o acesso microendoscópico posterior, com a implantação de PDN através do METRIX (Medtronic), e um outro, o acesso laparoscópico retroperitoneal transpsoas. Em quatro casos nós introduzimos dois PDN pelo acesso posterior. Em dois casos houve extrusão. Nós introduzimos em outros dois casos de acesso via posterior somente um PDN. Após esses problemas, iniciamos o uso do acesso retroperitoneal e introduzimos somente um PDN. A média de hospitalização foi de cinco dias. O paciente permanecia em repouso por 24 horas. A altura do disco foi restaurada em 4 mm. Dos pacientes, 90% dos avaliados pela escala de Oswestry referiam alívio da dor. Em dois pacientes houve extrusão: em um deles o PDN foi para o canal e o paciente foi reoperado, com remoção de uma das próteses. No outro caso, a extrusão e ambas as próteses foram para a musculatura, sem complicações clínicas. Retorno ao trabalho ocorreu em três meses. Para maiores conclusões, será necessário um acompanhamento maior

Percutaneous vertebroplasty is a minimally invasive procedure that involves filling of a fractured vertebral body with bone cement to relieve pain and to restore the vertebral height. It is a safe and effective treatment and is widely used for treating Osteoporotic Vertebral Compression Fracture. Despite of its beneficial advantages over primary conservative managements, adjacent level vertebral compression fracture remains the challenge for surgeons. Adjacent level vertebral compression fracture following percutaneous vertebroplasty using PMMA cement has been reported as a complication. Numerous risk factors have been reported for the occurrence of new adjacent VCFs after PVP. The multiple level osteoporotic vertebral compression fractures and the increasing age of the patients are directly proportional to the risk of developing new symptomatic adjacent vertebral compression fracture after PVP. Moreover, low BMD and cement leakage are other factors that directly affect the incidence of new symptomatic adjacent vertebral fractures. The aim of this review is to evaluate the adjacent level vertebral compression fracture following percutaneous vertebroplasty on the basis of radiographs, Kaplan-Meier Estimation index and also the factors that lead to adjacent level vertebral compression fractures.

The precise etiology of adjacent segment disease following cervical spine surgery is controversial. Theories for development include inevitable changes secondary to the natural progression of the degenerative cascade and changes secondary to altered biomechanics of the fused cervical spine. Motion preserving techniques, such as cervical disc arthroplasties (CDA), have been introduced with the hopes of reducing the rates of adjacent segment pathology. Recently, 7-year data from the investigational device exemption (IDE) studies have been published. The purpose of this review is to provide an update on cervical adjacent segment disease incorporating this emerging data into the analysis.Although the 7-year data for CDA has confirmed continued success, specifically regarding improved neck pain and reduced re-operation rates, the influence of CDA on reducing rates of adjacent segment pathology remains questionable. Although some studies have found more radiographic adjacent segment disease after anterior cervical discectomy and fusion (ACDF) compared to CDA, an association between these findings and clinical symptoms has not been established. Cervical disc arthroplasty continues to outperform cervical disc fusion regarding some patient specific parameters, however, whether CDA reduces rates of radiographic and clinical adjacent segment pathology remains unknown. Without studies developed specifically to address this question, the answer remains elusive.

Background Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, use of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. Here we provide the first report on the efficacy of robotic spinal surgery systems in support of the treatment of grade II spondylolisthesis. Methods Using 2 illustrative cases, we provide a technical report describing how robotic spinal surgery platform can be used to treatment grade II spondylolisthesis with a novel instrumentation strategy. Results We describe how the “reverse Bohlman” technique to achieve a large anterior fusion construct spanning the pathological level and buttressed by the adjacent level above, coupled with a novel, high-fidelity posterior fixation scheme with transdiscal S1-L5 and S2 alar iliac (S2AI) screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ. Conclusions The reverse Bohlman technique coupled with transdiscal S1-L5 and S2AI screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. The use of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.

Quantifying hydrologic alteration in the Mississippi Alluvial Plain (MAP) of the south‐central United States is particularly difficult because of the lack of current reference, or even relatively undisturbed, streams and associated streamflow data. Impacts, such as water withdrawals for agriculture, weirs, dams, channelization, and other forms of regulation, within the MAP increased substantially beginning around 1960 suggesting that streamflow has since been altered. Using historical streamflow and climate data and explanatory variables, the U.S. Geological Survey developed random forest regression models to estimate expected reference monthly streamflows (pre‐1960) at 76 sites in the MAP and two adjacent Level III Ecoregions. To compensate for the lack of current reference stream sites in the study area, the pre‐1960 streamflow data were used as a surrogate to estimate current streamflow conditions without anthropogenic influence (inferring current reference conditions). Overall, nearly every site within the study area had less zero‐flow days than what historically has been observed and there were more low‐pulse spells. However, the frequency of floods remained relatively consistent.

Aims The aim of this study was to determine the influence of developmental spinal stenosis (DSS) on the risk of re-operation at an adjacent level. Patients and Methods This was a retrospective study of 235 consecutive patients who had undergone decompression-only surgery for lumbar spinal stenosis and had a minimum five-year follow-up. There were 106 female patients (45.1%) and 129 male patients (54.9%), with a mean age at surgery of 66.8 years (sd 11.3). We excluded those with adult deformity and spondylolisthesis. Presenting symptoms, levels operated on initially and at re-operation were studied. MRI measurements included the anteroposterior diameter of the bony spinal canal, the degree of disc degeneration, and the thickness of the ligamentum flavum. DSS was defined by comparative measurements of the bony spinal canal. Risk factors for re-operation at the adjacent level were determined and included in a multivariate stepwise logistic regression for prediction modelling. Odds ratios (ORs) with 95% confidence intervals were calculated. Results Of the 235 patients, 21.7% required re-operation at an adjacent segment. Re-operation at an adjacent segment was associated with DSS (p = 0.026), the number of levels decompressed (p = 0.008), and age at surgery (p = 0.013). Multivariate regression model (p < 0.001) controlled for other confounders showed that DSS was a significant predictor of re-operation at an adjacent segment, with an adjusted OR of 3.93. Conclusion Patients with DSS who have undergone lumbar spinal decompression are 3.9 times more likely to undergo future surgery at an adjacent level. This is a poor prognostic indicator that can be identified prior to index decompression surgery.

The introduction of cervical spine total disc arthroplasty (CSTDA) in 2002 inaugurated a promise to lower the adjacent level degeneration in patients after cervical spine arthrodesis [1].

Adjacent segment disease and pseudarthrosis are common complications of cervical spine fusions. Adjacent segment disease occurs in up to 30% of patients 10 years after surgery. Pseudarthrosis rates in the cervical spine can be as high as 18% for a three level fusion. Both these incidences can be reduced with surgical techniques.

Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.

To explore the efficacy of secondary balloon kyphoplasty (BKP) for new vertebral compression fracture (NVCF) of previously non-fractured, non-treated vertebrae after previous BKP and to compare the therapeutic effect between patients with single-level adjacent NVCF and remote NVCF.We retrospectively studied patients with single-level NVCF after initial BKP in our hospital from January 2007 to August 2014. The mean follow-up time from secondary BKP was 13.78 ± 3.18 (12-24) months. Visual analog scale (VAS) and Oswestry disability index (ODI) scores were assessed prior to the initial BKP, one day after initial BKP, prior to the secondary BKP, one day after the secondary BKP, and at last follow-up. Kyphotic angle and vertebral heights were also compared for secondary BKP. Data were compared between patients with adjacent NVCF and remote NVCF.36 patients were investigated. Compared with pre-operative value of initial and secondary BKP, patients in both groups gained statistical significant improvements for VAS and ODI after initial and secondary BKP, respectively (P 0.05), and this improvement maintained at final follow-up. No statistical difference in VAS was found between the 2 groups after initial BKP and prior to the secondary BKP (P 0.05), but patients in remote NVCF group achieved better VAS score than patients in adjacent NVCF group after the secondary BKP and at the final follow-up (P 0.05). No statistical differences were detected in ODI between the 2 groups prior to the initial BKP, one day after initial BKP, prior to the secondary BKP and 1 day after the secondary BKP (P 0.05), but the ODI scores were higher in adjacent NVCF group than in remote NVCF at last follow-up (P 0.05). Kyphotic angle and vertebral heights were significantly restored and maintained after secondary BKP within groups, respectively.Secondary BKP is an effective procedure for treating NVCF after initial BKP. Patients with new fracture in remote level gain slightly better pain relief than those in the adjacent level.