Adjacent Lumbar Disc Research Articles

Comparison of multilevel low-grade techniques versus three-column osteotomies in adult spinal deformity surgery: does harmonious correction matter?

Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD. ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions [interbody fusion, thoracolumbar posterior column osteotomies, and 3CO]). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups. A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043). MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.

Topping-off Surgery Versus Transforaminal Lumbar Intervertebral Fusion for Combined One-level Spondylolisthesis and Adjacent Lumbar Disc Herniation: A Comparative Study of Clinical Efficacy and Radiographic Outcomes With a Two-year Follow-up.

To investigate the radiographic and clinical outcomes in patients diagnosed with multilevel lumbar spine degeneration, undergoing hybrid stabilization with an interspinous device (IPD) adjacent to spine fusion, as compared with those experiencing three-segment or two-segment transforaminal lumbar interbody fusion (TLIF) via minimally invasive surgery (MIS). Between 2015-2017, 51 consecutive patients who received three-segment TLIF, interspinous dynamic stabilization combined with two-segment TLIF (topping-off surgery), and two-segment TLIF coupled with adjacent level lumbar discectomy (two-segment TLIF+discectomy) were studied. These three operative procedures were performed by one neurosurgeon at the same hospital. Post-operative analysis of the two-year analysis was conducted by another neurosurgeon. Radiographic and clinical outcomes were compared among the three groups. Duration of surgery was significantly shorter in the topping-off surgery and TLIF+discectomy compared to three-segment TLIF group. Although there was no difference in hospital stay among the three groups, visual analogue scale (VAS) and Oswestry disability index (ODI) were less in the topping-off group than in the three-segment TLIF or two-segment TLIF+discectomy groups after one week and three months follow-up, respectively. Disc high index (DHI) in adjacent segment decreased from before the operation to two years follow-up postoperatively in the two-segment TLIF+discectomy group. In contrast, DHI in the segment adjacent to spondylolisthesis increased from before the operation to last follow-up post-operatively in the three-segment TLIF group. Compared with the two-segment TLIF+discectomy group, the topping-off group showed higher foramen high index at the IPD level. While there was no difference in segment range of motion among the three groups, the topping-off group showed preserved total range of motion at a two-year follow-up, as compared with the three-segment TLIF group. Under strict indications, topping-off surgery is an acceptable alternative to fusion surgery for spondylolisthesis combined with adjacent disc degeneration.

Changes in quantitative elastography assessment of the adjacent lumbar disc after segmental fixation of the spine: a case description of a burst fracture of L4.

Raphaël Pietton, Raphaël Vialle, Romain Laurent, Wafa Skalli, Claudio Vergari, Tristan Langlais

Comparing Oblique Lumbar Interbody Fusion with Lateral Screw Fixation and Transforaminal Full-Endoscopic Lumbar Discectomy (OLIF-TELD) and Posterior Lumbar Interbody Fusion (PLIF) for the Treatment of Adjacent Segment Disease.

Background A potential long-term complication of lumbar fusion is the development of adjacent segment disease (ASD), which may require surgical intervention and adversely affect outcomes. A high incidence of recurrent ASD was reported in patients who underwent the second (repeat) PLIF for symptomatic ASD. Herein, a feasible method, oblique lumbar interbody fusion combined with transforaminal endoscopic lumbar discectomy (OLIF-TELD) for dealing with adjacent lumbar disc herniation with upward or downward migration after lumbar spinal fusion, was proposed. Methods A total of 19 patients who underwent revision surgery at ASD were consecutively enrolled. Clinical efficacy analysis included operative time, intraoperative bleeding, visual analogue scale (VAS) score, Oswestry dysfunction index (ODI) score, and Japanese orthopaedic association (JOA) assessment treatment score. Results Among them, 11 patients were treated in a new surgical strategy, which is OLIF-TELD, and 8 patients underwent PLIF. There was no statistically significant difference between the two groups in terms of age, gender, and preoperative scores of VAS, ODI, and JOA. The operative duration was shorter, and intraoperative bleeding was less in the OLIF-TELD group compared with the PLIF group. PLIF had the greatest blood loss, and the OLIF-TELD group had lower VAS scores than the PLIF group postoperatively. The symptoms of all patients improved postoperatively with statistical significance. Conclusion OLIF with lateral screw fixation combined with TELD may be an alternative surgical method for the treatment of adjacent lumbar disc herniation with upward or downward migration after lumbar fusion surgery.

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Adjacent Lumbar Disc Herniation after Lumbar Posterolateral Fusion by Radiologic Evaluations

Minimally invasive percutaneous endoscopic 2 levels adjacent lumbar discectomy through 1 portal skin incision: Preliminary study.

Background:Acute lumbar disc herniation can occur in every lumbar intervertebral disc space and in multiple levels simultaneously. In the cases of 2 levels adjacent lumbar disc herniations of severe unilateral radiculopathic leg pain caused by compression of the nerve roots, respectively, multiple incision or long incision is generally needed for simultaneous removal of disc fragment in 2 levels.Objectives:We proposed the minimally invasive one portal skin incision endoscopic discectomy is effective and safe method to treat 2 levels adjacent lumbar disc herniation.Materials and Methods:We have experimented total 8 cases of 2 levels adjacent lumbar disc herniation having unilateral radiculopathic pain respectively. All cases are 2 levels adjacent lumbar disc herniation. We have tried a percutaneous endoscopic transforaminal approach through minimal one portal skin incision and remove the two herniated disc materials in the adjacent levels.Results:The L2-L3 level was involved in 2 patients, L3-L4 level in 6 patients, while the L4-L5 level was involved in 7 patients, L5-S1 level in 1 patient. The mean follow-up was 18.5 months. The mean visual analogue score (VAS) of the patients prior to surgery was 7.75, and the mean postoperative VAS was 2.375. According to Macnab's criteria, 3 patients had excellent results, 4 patients had good results, 1 patient had fair results, and no patient had a poor result; satisfactory results were obtained in 87.5% of the cases.Conclusion:The percutaneous endoscopic transforaminal approach through 1 skin portal incision could be effective surgical method in unilateral adjacent 2 levels lumbar disc herniation.

Http://www.omicsonline.org/open-access/obtaining-of-hydrogels-using-pva-and-hec-for-adipose-tissue-regeneration-2157-7552-1000152.php?aid=58212

Circumferential tears of the Annulus Fibrosus (AF) are frequently observed pathological features of degenerate lumbar discs and have been associated with vascular propagation and the generation of low back pain. In order to evaluate the potential of novel biological agents to repair annular defects and arrest disc degeneration we required an animal model that would permit injection of cells or their cryoprotectant into adjacent lumbar discs of the same animal. Three lumbar discs (L2/3, L3/4 and L4/5) of 6 sheep were subjected to a peripheral lateral annular surgical incision. The adjacent uninjured lumbar L1/2 and L5/6 discs served as uninjured controls. After three months the spines were radiographed and disc height indices (DHI) calculated and Pfirrmann disc degeneration scores determined from MRI spinal images. Isolated lumbar discs were analysed morphologically, histologically and biochemically using published procedures. Disc height index measurements of injured discs revealed an average decrease of 23.67% relative to baseline values (p<0.0001). The corresponding MRI Pfirrmann degeneration scores were significantly higher than non-injured control discs (p<0.05), as were their morphology scores (p<0.005). The sulphated - glycosaminoglycan content, of the Nucleus Pulposus (NP) and injured side of the AF of lumbar discs, were significantly lower than control discs (p<0.05 and p<0.0005) respectively. Conversely, the DNA levels of the injured side of the AF were higher than the uninjured side (p<0.05). The histological scores showed higher degenerative changes in injured than in control discs (p<0.005). For all parameters monitored in this study no statistical differences were observed between the three injured lumbar discs confirming their uniform response to injury. This study therefore confirmed the suitability of this large animal model for evaluating the potential of biologicals to reconstitute degenerate ovine lumbar discs relative to their carriers/cryoprotectant.

Immunoselected STRO-3+mesenchymal precursor cells and restoration of the extracellular matrix of degenerate intervertebral discs

Chronic low-back pain of discal origin is linked strongly to disc degeneration. Current nonsurgical treatments are palliative and fail to restore the disc extracellular matrix. In this study the authors examined the capacity of ovine mesenchymal precursor cells (MPCs) to restore the extracellular matrix of degenerate discs in an ovine model. Three adjacent lumbar discs of 24 adult male sheep were injected intradiscally with chondroitinase-ABC (cABC) to initiate disc degeneration. The remaining lumbar discs were used as normal controls. Three months after cABC injection, the L3-4 discs of all animals were injected with either a high dose (4 × 10(6) cells, in 12 sheep) or low dose (0.5 × 10(6) cells, in 12 sheep) of MPCs suspended in hyaluronic acid (HA). The adjacent L4-5 degenerate discs remained untreated; the L5-6 discs were injected with HA only. The animals were euthanized at 3 or 6 months after MPC injections (6 sheep from each group at each time point), and histological sections of the lumbar discs were prepared. Radiographs and MR images were obtained prior to cABC injection (baseline), 3 months after cABC injection (pretreatment), and just prior to necropsy (posttreatment). Injection of cABC decreased the disc height index (DHI) of target discs by 45%-50%, confirming degeneration. Some recovery in DHI was observed 6 months after treatment in all cABC-injected discs, but the DHI increased to within baseline control values only in the MPC-injected discs. This improvement was accompanied by a reduction in MRI degeneration scores. The histopathology scores observed at 3 months posttreatment for the high-dose MPC-injected discs and at 6 months posttreatment for the low-dose MPC-injected discs were significantly different from those of the noninjected and HA-injected discs (p <0.001) but not from the control disc scores. On the basis of the findings of this study, the authors conclude that the injection of MPCs into degenerate intervertebral discs can contribute to the regeneration of a new extracellular matrix.

Posterior single segment anterolateral decompression and anterior column reconstruction for type Denis B thoracolumbar burst fractures

Objective To investigate the feasibility and clinical effect of the posterior single segment anterolateral decompression and anterior column reconstruction in the treatment of thoracolumbar burst fractures. Methods A retrospective study was done on 21 patients with type Denis B thorocalumbar burst fractures who were treated by posterior approach minimal incision pedicle SCreW fixation,single segment anterolateral decompression and titanium mesh and bone graft from August 2007 to August 2009.There were 15 males and six males at mean age of 35.6 years(range,23-50 years).The involved segments included T12 in six patients,L1 in 11,L2 in three,and L3 in one.The preoperative spinal canal enemachment rate was 62.5%and the anterior-middle vertebral compression of all patients was less than 50%.CT scanning showed normal vertebral body and inferior endplate structure.The fracture reduction,graft fusion,neurological function recovery,correction loss,lumbar activities and adjacent lumbar disc degeneration were observed through preoperative,immediate postoperative and final follow up X-ray,CT and neurological examinations. Results The operation duration was 1.5-3.2 hours(average 2.1hours),with the bleeding of 350-1 000 ml(average 580 ml).All the patients were followed up for 4-26months(average 10.3 months),which showed that the vertebral fusion time was 4-6 months,with no loss of the vertebral height,implant breakage,loosening or extrusion.The nerve function was improved for 1-2 grades. Conclusions With correct selection of the indications,the posterior single segment anterolateral decompression and anterior column reconstruction is a reliable fixation,for it takes advantages of simple operation,minor trauma,less fusion segments and fast recovery. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Reconstruction

Efficacy of Linezolid Versus Vancomycin in the Treatment of Methicillin-Resistant Staphylococcus aureus Discitis

A rabbit model was used to assess the efficacy of linezolid and vancomycin for the treatment of discitis due to methicillin-resistant Staphylococcus aureus (MRSA). Nontreated controls were used for comparison. The purpose of this study was to determine if there was a therapeutic difference between using linezolid and vancomycin in the treatment of MRSA discitis. Vancomycin is currently the gold standard treatment for medical management of MRSA discitis. Linezolid is a relatively new drug that has been approved for treatment of MRSA infections, but currently there is no research demonstrating its efficacy at treating infections of the disc space. Twenty-four rabbits were inoculated with MRSA at two adjacent lumbar disc spaces via an anterior retroperitoneal approach. Six rabbits were to receive only pain medication and to serve as controls. Ten rabbits were assigned to a 5-day course of intravenous vancomycin, and 8 were assigned to a 5-day course of intravenous linezolid. Disc spaces were sent for quantitative culture after the 5-day treatment course. The mean culture growth for the disc spaces was not statistically different between the linezolid treated group and the nontreated controls. While vancomycin treatment did lead to lower bacterial loads when compared with controls, the reduction was not statistically significant. When bacterial counts for the vancomycin group and linezolid group were compared, vancomycin treatment resulted in less bacterial growth. This difference was statistically significant. Linezolid is a clinically attractive alternative to vancomycin due to its mild side effect profile and oral bioavailability. However, in this MRSA discitis model with a short treatment course, vancomycin was superior to linezolid.

INGROWTH OF NEURAL ELEMENTS INTO THE ANNULUS FIBROSUS OF OVINE INTERVERTEBRAL DISC IN AN ACUTE AND SUBACUTE EXPERIMENTAL DISC INJURY

Ingrowth of nerves and blood vessels is regarded as a part of disc degeneration. Schwann cells, which guide the development and regeneration of nerves both in the central and peripheral nervous system, have recently been located in degenerated human discs. The purpose of this study was to investigate by immunohistochemical methods, whether or not there was nerve, Schwann cell and blood vessel ingrowth in experimentally induced acute (3 weeks) and subacute (3 months) annular tears; and to study the detailed topography of such nerve ingrowth when present. Ingrowth of nerves and Schwann cells has so far not been studied in experimentally induced acute annular tears. A stab incision with a scalpel blade was made in two adjacent lumbar discs in adult sheep (n = 9). The L2–L3 discs were injured superficially, whereas in L3–L4 discs the incision reached the nucleus pulposus (full-thickness injury). The animals were sacrificed three weeks (acute injury, n = 3) or three months (subacute injury, n = 6) post-operatively. Discs were immunoassayed for general neuronal markers (protein gene product 9.5, PGP 9.5 and synaptophysin, SYN), Schwann cell marker (glial fibrillary acidic protein, GFAP) and endothelial marker (CD 31). Nerves visualized with all antibodies employed were situated inside the injured area and mainly near amd around blood vessels although free nerve endings could be seen also. PGP 9.5-immunopositive nerves were evident in every sample. Immunoreactivity to SYN and GFAP was not observed in control discs. Such immunoreactivity appeared already at 3 weeks (acute injury) in a few samples, and was present in all samples at 3 months (subacute injury). For the superficial injury, nerves did not penetrate deeper than in control discs until at 3 months. With more extensive annular injury, mean values for both nerve and Schwann cell penetration were higher. Blood capillaries were visible deeper in the inner annulus than neural tissues immunopositive to PGP 9.5, GFAP or SYN. The results suggest an ingrowth of nerves and Schwann cells with time, following an injury of the annulus fibrosus. A trend for deeper penetration already in the acute stage, but only for deep lesions reaching all the way to the nucleus pulposus, may be suggested. Such ingrowth, also previously reported in degenerated human discs, may relate to mechanisms of low back pain, originating in the intervertebral disc.

The diagnostic value of contrast-enhanced magnetic resonance imaging in the detection of experimentally induced anular tears in sheep.

An investigation of the visualization of experimental anular tears using contrast-enhanced magnetic resonance imaging. To investigate how different kinds of experimentally induced anular tears can be visualized on contrast-enhanced magnetic resonance imaging. Because the outer part of the anulus is innervated, tears of this part of disc are considered one cause for lumbar back pain. Moreover, clinical and experimental studies suggest that anular injuries may lead to a progressive degeneration of the entire disc. In the human disc, vascularized anular tears associated with disc degeneration can be visualized with contrast-enhanced magnetic resonance imaging, but acute peripheral anular injuries, probably caused by sudden trauma, have not been studied with this method. Two adjacent lumbar discs in adult sheep (n = 11) were injured with a scalpel blade. The L2-L3 discs were injured superficially, whereas in the L3-L4 discs, the incision reached the nucleus pulposus (full-thickness injury). In seven animals, only a stab incision was made to the disc, and in four animals, a small fragment (5 x 2 x 3 mm) of anulus was cut and removed. The animals were killed 3 weeks (acute injury, n = 5) and 3 months (subacute injury, n = 6) after surgery. Five minutes before death, gadolinium-diethylenetriaminepentaacetic acid was injected intravenously. After death, the whole lumbar spines were excised and 1.5-T high-field magnetic resonance imaging was immediately performed. Thereafter, the disc samples were examined histologically to determine the existence of blood capillaries. In all injured discs, the injured area was macroscopically visible. Histologically, blood capillaries, lamellar destruction, and granulation tissue were clearly seen in every injured anulus. Contrast-enhanced magnetic resonance imaging showed that the superficial injuries were only occasionally visible in magnetic resonance imaging (3 of 11), whereas the full-thickness injuries were visible in a majority of the discs (8 of 11). In magnetic resonance imaging, the size of the injury did not relate to the enhancement intensity. The subacute injuries, particularly the full-thickness injuries, were more often visualized than the acute ones. Even though macroscopically visible and histologically evident, it was not always possible to demonstrate experimental anulus injuries by contrast-enhanced magnetic resonance imaging. This experimental study shows that further research work is needed to develop more sensitive methods to detect peripheral, relatively small, but probably clinically important disc injuries.

Spinal biomechanics and aging are major determinants of the proteoglycan metabolism of intervertebral disc cells.

The proteoglycan metabolism of ovine disc nucleus pulposus and anulus fibrosus cells was investigated in relation to age, spinal level, and intrinsic spinal biomechanical properties. To evaluate the hypothesis that with aging loss of proteoglycans from the lumbosacral disc exceeds that from upper lumbar discs because of its proximity to a rigid segment, the sacrum. The proteoglycan and associated water of the disc decreases with aging. Proteoglycans were extracted directly from the disc tissues using 4 M GuHCl and examined by composite agarose polyacrylamide gel electrophoresis. Disc cells were cultured in alginate beads, and their metabolic activity was assessed by 3H-thymidine incorporation into DNA and by bioreduction of a cell proliferation dye. Newly synthesized proteoglycans were radiolabeled with 35S, and their molecular weight distributions and ability to aggregate with hyaluronan were determined by Sephacryl S1000 gel chromatography. Resident proteoglycans extracted from disc tissues with 4 M GuHCl were similarly evaluated. A group of adult animals also were studied biomechanically to evaluate the range of spinal motion (L4/L5 to L7/S1). In contrast to the neonatal proteoglycan samples, the biosynthesis of proteoglycans by nucleus pulposus cells of adult discs increased progressively toward the sacrum. This correlated with increased metabolic activity. Analysis of the resident proteoglycans by composite agarose polyacrylamide gel electrophoresis indicated that although the aggrecan-1 population was present almost exclusively in the neonatal group, it was the aggrecan-2 population that predominated in the adult discs, and it became progressively more heterogeneous with aging and proximity of the disc to the sacrum. The proteoglycans of the lumbosacral disc of adult animals turned over faster than proteoglycans of adjacent lumbar discs. The reduced proteoglycan content and ability to aggregate, particularly in the nucleus pulposus of lumbosacral discs, indicated that proteoglycan catabolism exceeded the rate of biosynthesis. These events in the lumbosacral disc are thought to be determined mechanically by its proximity to the sacrum.

An Experimental Study Comparing Percutaneous Discectomy with Chemonucleolysis

The aim of this study was to assess the macroscopic and microscopic reaction of the intervertebral disc to discectomy with the Automated Nucleotome (Surgical Dynamics, San Leandro, CA), and to compare this with simple trephining of the annulus and with chemonucleolysis. In eight adult sheep, two of four adjacent lumbar discs were randomly incised using the trephine of the Automated Nucleotome, while the remaining levels underwent nuclear excision with the Automated Nucleotome probe. Another four sheep underwent chemonucleolysis at three adjacent lumbar levels. All animals were killed at 6 weeks. The discs that had undergone trephining alone and those treated with the Automated Nucleotome probe had almost identical radiographic and macroscopic changes and showed similarities on microscopic examination. Macroscopically, these discs did not differ from control levels, whereas those treated with chymopapain showed marked changes with a reduction of both nuclear and annular volume. The results of this study suggest that any therapeutic effect of percutaneous discectomy with the Automated Nucleotome is likely to be attributable to the perforation of the annulus alone with the removal of small amounts of nuclear material contributing little, or nothing, to the claimed benefits of the procedure.

A longitudinal study of the matrix changes induced in the intervertebral disc by surgical damage to the annulus fibrosus.

A 5 x 5-mm anterolateral incision was made in the annulus fibrosus (AF) of lumbar discs of 16 sheep; four animals of similar age not operated on were used as controls. The experimental animals were sacrificed 2, 4, 6, 8, 12, and 18 months postoperatively (PO), and the incised and adjacent lumbar discs were collected. Discs were dissected into four zones: AF (zones 1 and 2) and nucleus pulposus (NP) (zones 3 and 4) corresponding to the half of the AF in which the cut was made and its opposite half, and the complementary halves of the NP. Each zone was analyzed for moisture, proteoglycan (PG), collagen, and noncollagenous protein (NCP) content. The PG extractability, aggregation, and hydrodynamic size were also examined. The NP of injured discs showed a significant loss of PGs and collagen 8 months PO, but NCP levels increased. In the incised discs, PG aggregation initially declined but recovered to within control values 6-8 months PO. The NP of discs adjacent to the incised disc also showed time-dependent changes in matrix components that included loss of collagen and PG; however, the AF matrix remained essentially uneffected. Double immunodiffusion studies indicated that a sizeable proportion of the NCPs present in the injured discs (but not the adjacent lumbar discs) were derived from serum.