Herniated Disc Material Research Articles

ANALYSIS OF LUMBO-SACRAL DISC PROLAPSE NEUROSURGICAL INTERVENTION

Background: Low back pain is a common cause of pain and there are many causes. Finding the exact cause of the pain can help guide treatment and management.
 Objective: To evaluate the clinical presentation, diagnosis and surgical outcome of the treated patients with lumbar-disc prolapse.
 Patients and Methods: Patients selection done using neuroimagings like plain radiographs and MRI Scan of lumbosacral spine. The surgical procedures applied were laminectomy, foraminatomy and evacuation of herniated disc material. Patients were analyzed postoperatively for outcome according to the symptoms resolved after surgery, objective clinical examinations and imaging studies.
 Results: Fifty five patients, 25 (45%) males and 30 (55%) females. Predominant clinical presentation were low back pain with radiation to leg 36(65.4%), neurogenic claudication in 15 patients (27%), and neurological deficit (foot drop) 4 about (7.2%). Seventy four percent (about 41) of the herniated disc were found at L4 L5 and L5 SI levels. Rate of complications were 12.7% (about 7) with 4 cases infections and 3 with dural tear repaired intraopertively being commonest. Excellent to good surgical outcome were found in 90% (about 50) of the cases.
 Conclusion: The results of the study depend mainly on selection of patients. Traditional laminectomy and discectomy still play a benefit for major group of patients. Foraminatomy, opening of roots foramen adds a benefit for the results.
 Keywords: Laminectomy, MRI, disc, prolapse.

Friday, September 28, 2018 10:45 AM–12:00 PM abstracts: how should we measure our success: 191. Correlation between Oswestry Disability Index (ODI) and Patient-Reported Outcome Measurement Information System (PROMIS) in minimally invasive microdiscectomy

BACKGROUND CONTEXT As the treatment focus for spine surgery shifts from radiographic measures of success towards patient-centric outcomes, having validated and relevant tools that assess quality of life, functional outcomes and pain is becoming increasingly important. Lumbar microdiscectomy is a procedure to remove herniated disc material that is causing compression of the spinal cord or nerve roots. PURPOSE To evaluate the correlation between Oswestry Disability Index (ODI) and Patient-Reported Outcome Measurement Information System (PROMIS) in patients undergoing minimally invasive microdiscectomy. STUDY DESIGN/SETTING Retrospective review of prospectively collected patient reported outcome measures (PROMs). PATIENT SAMPLE Patients who underwent minimally invasive lumbar decompression with PROMs data. OUTCOME MEASURES Correlation between ODI and PROMIS. METHODS PROMs data collected preoperatively and at 6 weeks, 3 months, 6 months and 1 year after surgery was analyzed using a Pearson product-moment correlation to determine the relationship between ODI and PROMIS. RESULTS The mean ODI score decreased from 45.07+17.25 preoperatively to 20.67+21.70 at 1 year. Concurrently, the PROMIS score improved from 35.59+6.43 preoperatively to 47.39+10.49 at 1 year. At all times points there was a statistically significant, negative correlation between ODI and PROMIS, which was moderate preoperatively (r=−0.58, n=180, p CONCLUSIONS A very strong correlation between ODI and PROMIS is seen in the postoperative period, especially at 3 months and longer follow-up. Thus, PROMIS is a good surrogate for ODI in assessing postoperative outcomes

Lumbar disc reherniation after transforaminal lumbar endoscopic discectomy.

Transforaminal lumbar endoscopic discectomy is a minimally invasive surgical procedure that can be performed in awake patients through an incision less than 1 cm. The procedure requires very little bony removal to access the herniated disc material because the approach is through the foramen, and only a small amount of the superior articulating process is removed to access Kambin's triangle. This study describes our experience with transforaminal endoscopic lumbar decompression (TELD) for the treatment of lumbar disc herniation. We evaluate the risk for reherniation in the first year after surgery and the characteristics of the patients who experience reherniation. We describe the technique for the transforaminal endoscopic approach to treat lumbar disc herniations. Retrospectively, a series of 141 consecutive patients, who were operated on with lumbar radiculopathy, was analyzed. We excluded patients who had previous surgery at the lumbar level, surgeries done for disease adjacent to a fusion, and surgeries done for spondylolisthesis. A total of 84 consecutive patients were included who had single level lumbar non-revision surgery and at least 1-year follow up. A series of 46 consecutive male and 38 female patients with an average age of 57.4 years (range, 28-87 years old) who underwent transforaminal endoscopic treatment for lumbar disc herniations between 2014 and 2016 is presented. Four patients required microdiscectomy due to reherniation at 5 months, 8 months, 9 months, and 10 months postoperatively. All the patients in the series improved immediately following their endoscopic procedures, and no patients presented with symptoms suggestive of reherniation until 5 months after their initial endoscopic surgery. Patients with reherniation tended to be young: 31, 45, 48, and 49 years of age: all less than the average patient age who underwent endoscopic surgery. Transforaminal endoscopic surgical access to lumbar disc herniations is an ultra-minimally invasive approach for the treatment lumbar degenerative disc disease. It allows for neural decompression by removing disc and foraminal pathology with minimal bone removal. This minimal bone removal prevents iatrogenic destabilization. However, the 1-year reherniation rate presented here is 4.7%. This suggests that the benefit of this technique may be that it is ultra-minimally invasive, but it may only be equal, not superior to microdiscectomy in its rate of reherniation.

Accuracy of the kissing sign on lumbar spine MRI in cases of axillary disc herniation and the surgical correlation: an Indian multi-center study

ObjectivesMagnetic resonance imaging has proven to be a valuable tool in the assessment of disc abnormalities. Two types of disc extrusion can be described according to the direction of herniated disc material: shoulder type and axillary type. Axillary disc herniation is described when the extruded disc fragment lies in the recess between the lateral border of cauda equina and medial to the nerve roots, while in the shoulder type the disc lies lateral to the nerve roots. It is very important to describe the type of disc herniation, as the surgical approach differs in each type. To the best of the authors’ knowledge, no definite signs have been described in literature to date. This study aimed to address the accuracy of the kissing sign on MRI for he diagnosis of axillary disc herniation. MethodsThe MRIs of 72 patients undergoing spinal surgery were prospectively evaluated for axillary disc herniation by a senior radiologist and experienced spinal surgeon using the kissing sign on MRI. The kissing sign was considered positive when the herniated disc material was in direct contact with the lamina and/or ligamentum flavum on axial images. Subsequently, all surgeries were performed by two independent surgeons and the actual type of disc herniation was documented. The accuracy of the results was statistically assessed. ResultsThe kissing sign on MRI was found to be 66.66% sensitive, 92.59% specific, and 76.38% accurate in detecting axillary disc herniation with significant correlation with the surgical findings. ConclusionThe type of disc herniation is an important parameter for patient selection in different surgical approaches. The kissing sign on MRI can be considered as an important tool for diagnosing axillary disc herniation due to its high specificity and accuracy.

Clinical and radiological outcomes of spinal endoscopic discectomy-assisted oblique lumbar interbody fusion: preliminary results.

OBJECTIVE Direct neural decompression cannot be achieved by performing lateral lumbar interbody fusion (LLIF). To overcome the indirect decompressive effect of LLIF, additional endoscopic discectomy with oblique lumbar interbody fusion (OLIF) has been attempted. The purpose of this study was to assess the clinical and radiological outcomes of patients who underwent OLIF with additional endoscopic discectomy. METHODS Spinal endoscopic discectomy-assisted OLIF was attempted to remove herniated disc material. Only patients with a follow-up time that exceeded 12 months were enrolled. Clinical parameters examined were the Oswestry Disability Index and visual analog scale scores of back and leg pain. Postoperative MRI was also performed. RESULTS Fourteen patients were enrolled. Central and foraminal disc herniations were evident in 8 and 6 patients, respectively. Concomitant central or foraminal herniated discs were removed completely after additional endoscopic discectomy, and disc removal was confirmed by postoperative MRI. Mean preoperative visual analog scale scores and Oswestry Disability Index scores improved postoperatively. CONCLUSIONS OLIF with additional endoscopic discectomy results in successful direct neural decompression without posterior decompressive procedures. Endoscopic assistance might overcome the limitations of LLIF.

Anterior lumbar discectomy and fusion for acute cauda equina syndrome caused by recurrent disc prolapse: report of 3 cases

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage. The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain. ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

Value of a new pathological classification of lumbar intervertebral disc herniation based on transforaminal endoscopic observations.

Removal of herniated disc materials based on an imaging only method may not relieve symptoms in many patients. Therefore, the aim of the present study was to develop a transforaminal endoscopic method of classifying the pathological type of lumber intervertebral disc herniation and to compare the outcomes of surgery based on the pathological type with those of conventional endoscopic disc removal. The records of patients who received endoscopic transforaminal nucleotomy with foraminoplasty for symptomatic lumbar disc herniation between 2009 and 2013 were retrospectively reviewed. Patients were then divided into two groups: Group A, which consisted of 275 patients who received conventional endoscopic transforaminal nucleotomy with foraminoplasty between 2009 and 2011 and group B, which consisted of 316 patients who received ‘targeted’ endoscopic transforaminal nucleotomy with foraminoplasty between 2011 and 2013 (based on the pathological type of disc herniation identified at surgery, including fresh, calcified and scar type based on intraoperative observations). The results showed that there were no significant differences in age, gender, body mass index, symptom duration, operated segments or previous invasive therapies between the two groups. Moreover, evaluation of visual analogue scale pain scores and Oswestry disability index scores revealed that the patients in group B had a greater improvement in symptoms than those in group A (P<0.05). In addition, an age >40 years and a longer symptom duration were associated with the calcified type, and previous invasive therapy was associated with the scar type. Therefore, specific surgical treatment based on the transforaminal endoscopic pathological type can result in better outcomes for patients with lumbar disc herniation.

120 - Further Research on the Efficacy of a New Navigable Percutaneous Disc Decompression Device (L'DISQ) in Patients with Lumbar Radicular Pain: 2-Year Follow-Up

BACKGROUND CONTEXT: Existing minimally invasive percutaneous disc decompression techniques have clinical limitations. Although the efficacy and safety of the disc ablation with radiofrequency energy has been previously demonstrated, nucleoplasty using radiofrequency ablation is restricted by the difficulty associated with focal direct removal of the herniation. To overcome this liability, we developed a navigable decompression device named L'DISQ that is designed to allow direct access to the herniated disc material by rotating a control wheel directed into the disc herniation.

CLINICAL AND MAGNETIC RESONANCE IMAGING CHARACTERISTICS OF THORACOLUMBAR INTERVERTEBRAL DISK EXTRUSIONS AND PROTRUSIONS IN LARGE BREED DOGS.

Treatment recommendations differ for dogs with intervertebral disk extrusion vs. intervertebral disk protrusion. The aim of this retrospective, cross-sectional study was to determine whether clinical and magnetic resonance imaging (MRI) variables could be used to predict a diagnosis of thoracolumbar intervertebral disk extrusion or protrusion in dogs. Dogs were included if they were large breed dogs, had an MRI study of the thoracolumbar or lumbar vertebral column, had undergone spinal surgery, and had the type of intervertebral disk herniation (intervertebral disk extrusion or protrusion) clearly stated in surgical reports. A veterinary neurologist unaware of surgical findings reviewed MRI studies and recorded number, location, degree of degeneration and morphology of intervertebral disks, presence of nuclear clefts, disk space narrowing, extent, localization and lateralization of herniated disk material, degree of spinal cord compression, intraparenchymal intensity changes, spondylosis deformans, spinal cord swelling, spinal cord atrophy, vertebral endplate changes, and presence of extradural hemorrhage. Ninety-five dogs were included in the sample. Multivariable statistical models indicated that longer duration of clinical signs (P = 0.01), midline instead of lateralized disk herniation (P = 0.007), and partial instead of complete disk degeneration (P = 0.01) were associated with a diagnosis of intervertebral disk protrusion. The presence of a single intervertebral herniation (P = 0.023) and dispersed intervertebral disk material not confined to the disk space (P = 0.06) made a diagnosis of intervertebral disk extrusion more likely. Findings from this study identified one clinical and four MRI variables that could potentially facilitate differentiating intervertebral disk extrusions from protrusions in dogs.

Reoperation Rates following Single-Level Discectomy

Introduction Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy due to lumbar disc herniation. Randomized trials have demonstrated the advantage of surgical removal of herniated disc material over non-surgical treatment options, allowing for a more rapid reduction in symptoms and return of function. Many small-size studies suggest that long-term outcomes for patients treated with discectomy and non-operative management are similar. Additionally, treatment of recurrent lumbar disc herniation is not standardized. Population-level data regarding reoperation following single level hemilaminotomy and discectomy is limited. Material and Methods Data was collected and analyzed for 13,654 patients undergoing single-level lumbar discectomy between January 2007 and December 2010 using the commercially available PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA). The nationwide Humana private insurance database was queried for patients billed with the Current Procedural Terminology (CPT) code for our index procedure, hemilaminotomy and removal of disc material (CPT-63030). Patients receiving concurrent lumbar surgeries were excluded from the index group. The index group was then followed in retrospective cohorts for 3 months, 6 months, 1 year, 2 years, and 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Results Patients received additional lumbar surgeries following single-level discectomy at a rate of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.90% (370/6274) of patients within 4 years, with interbody fusion in 75.4% (279/370) of cases and multi-level fusion in 47.0% (174/370) of cases. Reoperation for re-exploration discectomy at the same level as the index procedure with no subsequent surgeries occurred in 2.71% (170/6274) of patients followed out to 4 years. Patients who received a re-exploration discectomy at the same intervertebral level within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years following the re-exploration discectomy. Conclusion Data in our study demonstrated a reoperation rate of 12.2% after single level discectomy, a routinely performed procedure for the treatment of symptomatic lumbar disk herniation. Moreover, we show that the rate of progression to lumbar fusion after a re-exploration discectomy was 38.4% within 4 years of reoperation. These data should help surgeons in their operative decision-making and counseling recommendations to patients. To our knowledge, this is the largest population study delineating reoperation rates across the US after single-level lumbar discectomy. Further studies are needed regarding the best treatment algorithm in patients with re-herniation or iatrogenic instability following lumbar discectomy.

Revision Surgery for "Real" Recurrent Lumbar Disk Herniation: A Systematic Review.

A systematic review. To systematically review the previous literature regarding revision surgery for real recurrent lumbar disk herniation. "Real" recurrent lumbar disk herniation means the presence of herniated disk material at the same level and side as the primary disk herniation. If conservative treatment fails, revision surgery, a major concern, is indicated. It is important for both patients and spine surgeons to understand epidemiology trends and outcomes of revision surgery for real recurrent lumbar disk herniation (real-RLDH). The electronic databases PubMed, the Cochrane library, and EMBASE were queried for English articles regarding revision surgery for real-RLDH, published between January 1980 and May 2014. The incidence, interval between primary and revision surgery, risk factors, surgery type, complications, and clinical outcomes of revision surgery for real-RLDH were summarized. The reported incidence of revision surgery, specifically for real-RLDH, lies between 1.4% and 11.4%. The complication rate is reported between 0% and 34.6%, with dural tear being the most common complication. Previous studies revealed that satisfactory or successful clinical outcome was achieved in 60%-100% of patients after revision surgery for real-RLDH. Several studies reported similar clinical outcomes between primary and revision surgery. The incidence of revision surgery for real-RLDH is relatively low. It is essential to pay careful attention to prevent a dural tear. Patients may expect clinical outcomes similar to those following primary discectomy.

Obtuse-angled Laminotomy as a Modification of Multilevel Laminectomy for Spinal Cord Decompression.

The purpose of this note is to describe an obtuse-angled laminotomy of C7 during cervical decompression that aims to preserve cervicothoracic junction stability and potentially reduce pain. Cervical spondylotic myelopathy can result from degenerative cervical spinal disease including, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the posterior longitudinal ligament. Surgical intervention for multilevel myelopathy aims to decompress the spinal cord and maintain stability of the cervical spine. Multilevel laminectomy is traditionally used when degenerative changes affect 3 or more levels and when there is primarily dorsal compressive disease. Traditional laminectomy can result in instability and kyphosis. The C7 lamina can be particularly vulnerable given the location at cervicothoracic junction. We describe an obtuse-angled laminotomy for the most caudal lamina in a planned decompression. This lamina is left attached to ligamentum nuchea, adjacent fascia, and paravertebral muscles. Only the base of spinous process and ventral portion of lamina's cortical and cancellous bone are removed in an obtuse angle through the opening. This variation is aimed to preserve as much of the cervical stability while still achieving the goal of decompression.

Cervical Laminectomy for the Treatment of Chronic Caudal Cervical Spondylomyelopathy in a Dog

Background: Cervical spondylomyelopathy (CSM) is a common disease of the cervical spine, and causes neurogenic disorders commonly diagnosed in large and giant breeds dogs. There are many surgical procedures proposed for the treat­ment of CSM. Although many authors report a high success rate (between 70% and 90%) after surgical procedures, the high number of techniques described reflects the difficulty in treating this disorder. The objective of this paper is to report a case of CSM with chronic ventral compression (intervertebral disc extrusion) that was treated with dorsal decompres­sion, and to demonstrate the effectiveness of the decompressive technique through pre- and post-operative myelograms.Case: A 9-year-old Doberman Pinscher dog weighing 41.8 kg presented due to a history of tetraparesis. Neurological exami­nation did not reveal any alteration in mental status. There was absence of conscious proprioception on the four limbs; the pelvic limbs were more severely affected. Bilateral patellar hyperreflexia and normal flexor withdrawal reflex were observed on the hind limbs. There was decreased flexor withdrawal reflex and increased extensor tone on the forelimbs. The patient exhibited pain during caudal cervical palpation, and no alterations were seen on the cutaneous trunci reflex. Superficial pain was absent in the hind limbs; forelimbs exhibited presence of motor function with severe paresis. Survey radiographs revealed intervertebral disc space narrowing between C6-C7. A myelogram revealed ventral and dorsal compressions of the spinal cord in the C6-C7 area. Surgical treatment was elected, and laminectomy of the sixth and seventh cervical vertebrae was performed. Improvements were progressive on evaluations made on the seventh, eighteenth, forty-fifth, and sixtieth days after surgery. On the forty-fifth day after surgery, the patient was able to walk with the aid of a support sling, but was incapable of standing and walking without help. Muscle atrophy and paresis progressively improved up to the sixtieth day after surgery, but such improvement was not enough for the patient to get up and walk without the aid of the sling. In view of the evolution of the clinical signs during the post-operative period, another myelogram was performed to check if the extruded intervertebral disc, which was not removed during laminectomy, was still causing spinal cord compression. In comparison to the first myelogram, the compression was significantly attenuated by the surgical procedure. In this examination, the contrast medium columns were minimally compromised by the presence of herniated material; because of that, we opted not to perform a second surgical intervention for removal of herniated disc content.Discussion: Cervical laminectomy is indicated primarily for cases of dorsal compression associated with osteoarthritic changes of facet joints, malformation of the dorsal lamina, or ligamentum flavum hypertrophy however, this technique has also been used to treat ventral compressions, especially if they are multiple. There are no reports of direct comparison between laminectomy and other surgical techniques for the treatment of chronic ventral compressions; consequently, the choice of the technique depends on the surgeon’s experience and preference. Some authors argue that cervical laminec­tomy is not enough to attenuate the compression caused by the disc because this technique does not allow removal of the herniated disc material located ventrally. However, in the case reported here, a comparison between pre- and postopera­tive myelograms revealed that even though the herniated material was not removed, dorsal decompression allowed dorsal dislocation of the spinal cord and, consequently, promoted considerable attenuation of ventral compression.Keywords: Wobbler syndrome, nervous system, spinal cord, cervical vertebrae.

Painful lumbar Schmorl nodule mimicking osteoma osteoid

A 21-year-old man presented with complaints of nocturnal low back pain radiating to the right posterior thigh for 6 months. Aggravated by sitting position, the pain was alleviated by non-steroidal anti-inflammatory drug (NSAID). Computed tomography scan revealed an osteolytic lesion in the superior end plate of the L2 vertebra with sclerotic margins (Fig. 1, Top Left, Top Right, Bottom Left, Bottom Right). Magnetic resonance imaging showed low intense nodule with surrounding hyperintense rim in T2-weighted and hypointense in T1-weighted images (Fig. 2, Left, Middle). The patient was submitted to transpedicular biopsy and absolute alcohol injection with sciatic pain control (Fig. 2, Right). Pathology confirmed herniated disc material (Schmorl nodule). Low back pain was completely resolved with COX-2 non-steroidal anti-inflammatory drug for several years. Fig. 2Magnetic resonance image: (Left) pre-biopsy T1-weighted image; (Middle) pre-biopsy T2-weighted image; and (Right) post-alcohol injection showing reduction in volume. View Large Image Figure Viewer Download Hi-res image

A Randomized Controlled Trial on the Effect of Repeated Lumbar Traction By A Door-mounted Pull-up Bar on the Size and Symptoms of Herniated Lumbar Disk

Objective: Physiotherapy is one of the popular modalities in the conservative management of disk herniation; however, the costs of physiotherapy programs are high and they are time consuming. Therefore, we were curious to investigate an easy and home-based way to reduce the size of herniated lumbar disk material and its pain, “the use of a door-mounted pull-up bar.” Materials and Methods: In this prospective randomized controlled single-blind clinical trial, 50 patients with lumbar disk herniation were included, and randomized into 2 groups: the traction group (25 patients) and the control group (25 patients). The traction group experienced a program of frequent (20 times a day) suspension (each 30 s) from a door-mounted pull-up bar for 2 months. The control group was given the same medication, but without traction. Data for the pain symptoms (visual analog scale) were collected before and after the treatment together with calculation of a herniation index from MRI images that reflected the size of the herniated disk material. Data analysis and comparison followed. Results: Means comparison of the posttreatment visual analog scale in both groups showed a significant difference (P=0.0004). In the traction group, the herniation index decreased from 156.8 pretreatment value to 106.5 (P<0.01) after the exercise. In the control group, pretreatment value was 204.7, and it decreased to 194.1 after treatment (P>0.1). Conclusions: Use of a simple pull-up bar at home as a way of traction in the conservative management of lumbar disk herniation is quite effective, considering that it is very cost effective and time sparing.

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.

Clinical and Surgical Correlation with MRI Findings in Herniated Lumbar Disc: Towards Clinical and Surgical Application of the Current Classification Oriented Understanding of the Morphology of the Herniated Lumbar Disc

Background Data: Herniated lumbar discs requiring surgery are evaluated preoperatively by magnetic resonance imaging. This helps the surgeon to appreciate the size, direction and morphology of the herniated disc material and aids planningthe surgical procedure. The currently available MRI based classifications and terminology do correlate clinical, surgical and prognostic information. Purpose: Our study aims to find clinical and/or surgical correlation between the morphology of different disc herniations based on MRI findings with correlation to the clinical and surgical findings. Study Design: Retrospective analysis of 117 patients who had lumbar microdiscectomy for single level herniated lumbar discs.Patients and Methods: Preoperative MRI was thoroughly examined and the level, laterality, the presence of High Intensity Zone (HIZ) on T2 MRI and Modic changes were recorded. Furthermore, all disc levels were analyzed using theMichigan University Grading System (MSU), the Pfirmann grading for degree of disc degeneration. We subdivided the fragment according to its base diameter on sagittal MRI into: uniform, protruded, extruded and sequestrated. Noted was the fragment direction. The signal intensity of the herniated material in T2 weighted images was reported. We then correlated using statistical analysis each of the MSU Grade, Pfirmann Grade, fragment morphology, fragment signal and fragment migration with the preoperative duration of symptoms, self-reported Visual Analogue Score for leg pain (VAS), neurological deficit, sphincters dysfunction and straight leg raising, blood loss, incision length, bony work, the amount of disc material removed and the shape of the fragment, length of hospital stay, early postoperative sciatica, unintended durotomy, recurrent sciatica, redo surgery within the first year. Results: The mean age was 39.3 years, 70% were males, 47% were L4-5, and 47.9% were L5-S1. Unilateral left herniation was reported in 52.1%, right in 31.6%, central in 12%, and bilateral in 4.3%. Patients were classified as IIAB in 36, IIB in 28, III AB in 24, HIZ in 7. Caudal migration was reported in 28.2%, straight posterior in 64.1%, and cranial migration in 7.7%. The fragments were dark gray on T2WI in 66 (56.4%) patients. Fragment base was uniform in 53 (45.3%) patients. Most of our surgically treated disc prolapses were Pfirmann, Grade 3 and 4. There was no statistical significance between any of the preoperative clinical or the surgical or the postoperative parameters and Pfrimann grade, MSU grade, fragment base, fragment signal, sagittal extent(P>0.05). Except for a statistically significance between the disc size according to MSU classification and the severity of the preoperative leg pain (VAS) (P=0.01) and the preoperative SLR (P=0.005). There was also a statistically significant correlation between the operative time and the fragment base (P=0.006) Conclusion: Not all disc herniations are similar. On our first attempt to clinically and surgically correlate some of these classifications, we found few clinical and surgical correlations with herniated fragment morphology. A more surgically oriented classification scheme would be useful and applicable for surgeons to anticipate the degree of difficulty of surgery and the plan required for adequate nerve root decompression. (2015ESJ079)

Do bacteria play an important role in the pathogenesis of low back pain?

Considerable interest has been generated recently regarding an alternative hypothesis for the pathogenesis of low back pain and radiculopathy in the presence of intervertebral disc prolapse. Traditionally, back pain and radicular (sciatic) symptoms have been attributed to mechanical compression of neural tissue by herniated disc material and to inflammation caused by exposure of the nerve roots to disc tissue. Recent research however has suggested that low-grade infection within the intervertebral disc by anaerobic bacteria may be responsible. The development of Modic changes in the corresponding adjacent vertebral endplates has also been suggested as an indicator of infection. This article is a thorough review of the current literature regarding the hypothesis that low-grade anaerobic bacterial infection may be the cause of disabling low back pain and radiculopathy.

Bilateral Facet Dislocation with Neural Compression from an Avulsed Posterior Longitudinal Ligament

Background and Importance: A review of the literature failed to show evidence of normal appearing posterior longitudinal ligament avulsion as a cause of spinal cord compression after bilateral cervical facet dislocations. We report a case of the posterior longitudinal ligament (PLL) avulsion causing spinal cord compression after bilateral cervical facet dislocation. Clinical presentation: A 93 year female presented with upper extremity numbness and bilateral C5-C6 facet dislocations. The patient was immediately taken for closed reduction and anterior cervical decompression with fusion (ACDF). After awake, closed reduction, an ACDF was immediately performed. After a complete discectomy procedure, the spinal cord could be visualized secondary to an absent PLL. A nerve hook was used to explore behind the C6 vertebral body to decompress the spinal cord. A segment of normal appearing posterior longitudinal ligament, which had avulsed from the superior aspect of C5, was found folded behind the C6 vertebra causing cord compression. There was no herniated disk material discovered. Conclusion: In addition to herniated disk material, avulsed PLL is another potential source of cord compression after closed reduction of cervical facet dislocations and surgeons must be aware of this possible source of compression while exploring and decompressing the spinal canal. This case study elucidates that the PLL is a potential cause of spinal cord compression after traumatic bilateral cervical facet dislocations.

Evaluation of the Association Between Matrix Metalloproteinase 11 and Intervertebral Disc Disease.

The intervertebral disc starts to degenerate when a human being begins to stand and learn to walk. It is known that many extrinsic, intrinsic and genetic factors play a role in disc degeneration. In this study, we examined whether the matrix metalloproteinase 11 might be associated with intervertebral disc degeneration. Fifty-six patients with lumbar disc herniations who were operated at Göztepe Education and Research Hospital, Neurosurgery Clinic between September 2008 and December 2009 were prospectively reviewed. History and complaints were obtained from the case reports. Neuroradiological evaluation was performed with magnetic resonance imaging. Surgical findings of cases were reported in the operation notes. Microscopic posterior hemipartial laminectomy and discectomy were performed in all cases. Degenerated herniated disc material of all cases extracted during surgery was evaluated with immunohistochemical staining in Marmara University, Institute of Neurological Sciences, Pathology Laboratory. Comparing the immunohistochemical staining of cases who were 50 years or younger and cases who were over 50 years old, statistical significance was determined. Matrix metalloproteinase 11 has a role in degenerating intervertebral disc disease, but it is not the only factor. Matrix metalloproteinase 11 might be a genetic factor in young-middle aged patients.