Herniated Nucleus Pulposus Research Articles

A case report of Scoliosis secondary to herniated lumbar disc in an adolescent: A case report

Background: Herniated nucleus pulposus is infrequent among children and adolescents. The first case of surgical intervention for disc herniation was reported in a 12-year-old child. Since then, very few cases or series of cases have been published. The current case report is of a 15-year-old girl with no history of spinal ailment, who presented with a large disc herniation in the L4–L5 region, associated with reactive secondary scoliosis and resolved following a successful surgical intervention.
 Case Description: A 15-year-old female with a known case of scoliosis and a history of lower back pain for nine months following a fall while playing football, without any past account of the spinal disease, was presented at the outpatient clinic. After a series of proper imaging, a large L4/5 HNP with positional secondary scoliosis was diagnosed. However, due to the persistence of symptoms for more than two months in radiculopathy and reactive scoliosis, the decision was made to proceed with L4/5 microscopic discectomy. After six months, the neurological examination was normal, with a significant improvement of scoliosis with the restoration of normal spine alignment seen in plain X-ray films. The right leg radiculopathy improved as well.
 Conclusion: Lumbar disc herniation in association with scoliosis needs a vigilant evaluation of signs and symptoms and appropriate diagnostic imaging. Imaging is vital in diagnosing underlying disease states and helps in clinical management and surgical planning. The appropriate treatment is a discectomy.

Anterior Cervical Discectomy and Fusion Results in Clinically Significant Improvements in Patients With Preoperative Sleep Difficulties.

Individual items within the Patient Health Questionnaire-9 (PHQ-9) have not been assessed as predictors of postoperative outcomes. Our objective is to study the relationship between responses to individual PHQ-9 items and achievement of a minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF). A prospective surgical database was reviewed for primary, single-level ACDF procedures performed for degenerative spinal pathology. Patient demographics, preoperative spinal pathology, and perioperative characteristics were recorded. Patient-reported outcome measures (PROMs) including PHQ-9, visual analog scale (VAS) neck and arm, Neck Disability Index, 12-item Short Form physical component score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System Physical Function were administered at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. MCID achievement was determined by comparing postoperative PROM improvement from baseline to previously established values. Logistic regression assessed responses to each individual question of the preoperative PHQ-9 as predictors of MCID achievement in each other PROMs. Sixty-six ACDF patients were included with a mean age of 47.2 years. Herniated nucleus pulposus was the most common preoperative spinal diagnosis (95.6%). The mean operative duration was 50.3 minutes, the mean estimated blood loss was 27.5 mL, and most patients were discharged on postoperative day 0 (81.8%). A majority of patients achieved MCID for all measures except SF-12 PCS. PHQ-9 question 3 significantly predicted MCID achievement for VAS neck (P = 0.045), VAS arm (P = 0.049), and SF-12 PCS (P = 0.037). No other PHQ-9 items or overall PHQ-9 scores significantly predicted MCID achievement. Question 3 of the PHQ-9 regarding "trouble falling asleep, staying asleep, or sleeping too much" significantly predicted clinically meaningful improvement in neck pain, arm pain, and physical function following ACDF, although overall PHQ-9 scores did not. Providers should inform patients experiencing significant sleep-related difficulties that they may be especially likely to benefit from ACDF surgery. Evaluation of sleep from the PHQ-9 predicts clinically relevant improvement in neck pain, arm pain, and physical function in patients undergoing ACDF.

Diagnostic accuracy of contrast and non-contrast 1.5 tesla magnetic resonance imaging for lumbar herniated nucleus pulposus based on surgical findings

This study aims to provide the latest information regarding the accuracy of contrast and non-contrast 1.5 Tesla MRI in the diagnosis of lumbar Herniated Nucleus Pulposus (HNP) compared with surgical findings. We included studies with subjects diagnosed with lumbar HNP due to degenerative processes, preoperative 1.5 Tesla contrast, and non-contrast MRI and described the number of findings of MRI diagnostic tests (index test) on the actual conditions found during surgery (reference standard). We searched literature from 5 databases: ProQuest, Pubmed, Cochrane Library, Biomed Central, and ScienceDirect. The sensitivity and specificity of contrast and non-contrast 1.5 Tesla MRI ranged between 64-95% and 55-100% (95% CI) with the area under the curve above the threshold on the ROC curve. Two studies compared the accuracy of MRI and Computed Tomography (CT) myelography with a wider ROC curve on CT myelography than on MRI. The ROC curve which has a wide area under the curve above the threshold depicts the relationship between sensitivity and specificity, shows that contrast non-contrast 1.5 Tesla MRI has a good accuracy in HNP diagnostic.

Multiple suicide attempts associated with addiction to tramadol

BackgroundThe opioid tramadol is used as analgesic drug, and more recently was also proposed for the management of major depressive disorder. However, growing evidence suggests a link between opioid system dysfunction and suicidal behaviors, raising the question of tramadol use in view of the high addictive and suicidal risk. Here, we present the case of a young adult woman with multiple suicide attempts related to tramadol addiction.Case presentationA 25-year-old woman was admitted for suicide attempt by phlebotomy in the Department of Psychiatric Emergency and Acute Care, Montpellier (France), in March 2020. The suicide attempt occurred 3 days after an abrupt tramadol withdrawal. In 2018, due to spinal disc herniation, she had a first prescription of tramadol to which she became addicted. The patient described an effect on psychological pain and suicidal ideation. However, she had to increase tramadol dose to obtain the desired effects, and for several months her intake was 2 000 mg per day. When she could not obtain tramadol any longer, suicidal ideation and psychological pain increased, leading to the suicide attempt. At the time of a worldwide opioid crisis that contributes to increasing suicidal behaviors, this case raises questions about tramadol prescription (often considered to be less addictive and with lower abuse potential) to individuals at risk of suicide.

Incidental Dural Tears in Lumbar Decompressive Surgery: Incidence, Causes, Treatment, Results

Durotomy (Incidental dural tears or ID) is a very rarely occurring disorder when decompressive surgery (spinal surgery) of the patients takes place. This disorder has severe effects on patients. During different surgeries of the spinal cord, the chances of this durotomy vary greatly. Objective: The main objective of this research work is to evaluate the main reasons for the incidence of this durotomy disease. During different surgeries of the spinal cord surgeries (decompressive and compressive) within the different regions, many factors play their role in the initiation of this durotomy disease. It is the target of this work to find the initiation factors of the disease so that effective methods of treatment can also find out. Methods: It was a retrospective study with a statistical approach. This study was conducted in Neurosurgery unit, Mardan medical complex / Bacha khan medical college, Mardan for the Duration of one year August 2020 to July 2021. To proceed with this study, 30 patients were selected with posterolateral and posterior compressive and decompressive surgeries within the different regions of the spinal cord. The patients were randomly selected from December 2020 to December 2021. Results: The incidence of this durotomy disease was investigated within all groups and the probability of this disease was only 12.65%. The occurrence of this disease also depends upon the type of surgery. Patients suffering from spinal trauma, stenosis of the spinal, different tumors, and vertebral disc herniation had exaggerating role in the incidence of durotomy in patients having some spinal surgery. Conclusion: The durotomy disease should be considered a serious issue with a number of other complications. For the treatment of this disease, prevention is the best method and to know about the complications is important because all of the factors involved in the incidence of durotomy should be considered while performing any kind of surgery

Microglia and macrophages contribute to the development and maintenance of sciatica in lumbar disc herniation.

Lumbar disc herniation (LDH) is a major cause of sciatica. Emerging evidence indicated that inflammation induced by the herniated nucleus pulposus (NP) tissues plays a major role in the pathogenesis of sciatica. However, the underlying mechanisms are still elusive. Although microglia and macrophages have been implicated in nerve injury-induced neuropathic pain, their roles in LDH-induced sciatica largely remain unknown. This study successfully established and modified a mouse model of LDH. We found that nerve root compression using degenerated NP tissues can initiate remarkable and persistent sciatica, with increased and prolonged macrophage infiltration in dorsal root ganglia (DRG) and significant activation of microglia in the spinal dorsal horn. Instead, compression of the nerve root with nondegenerated NP tissues only led to transient sciatica, with transient infiltration and activation of macrophages and microglia. Moreover, continuous treatment of PLX5622, a specific colony-stimulating factor 1 receptor antagonist, ablated both macrophages and microglia, which effectively alleviated LDH-induced sciatica. However, mechanical allodynia reoccurred along with the repopulation of macrophages and microglia after the withdrawal of PLX5622. Using RNA sequencing analysis, the current study depicted transcriptional profile changes of DRG after LDH and identified several macrophage-related potential target candidates. Our results suggested that microglia and macrophages may play an essential role in the development and maintenance of LDH-induced sciatica. Targeting microglia and macrophages may be a promising treatment for chronic LDH-induced sciatica.

Clinical and pathological considerations in lumbar herniated disc associated with inflammatory lesions.

Lumbar herniated disc is the most frequent cause for lumbar pain. It is caused by degenerative, macroscopic and microscopic changes of the intervertebral discs. It is a chronic disease, with periods of exacerbation and remission under drug and physiotherapeutic treatment. When the disc lesions are large, with intense symptoms, reduced or impossible movements, with pain radiating to the sciatic nerve trajectory, a surgical treatment is required, to remove the herniated nucleus pulposus and decompress the nerve roots. Patients who present high inflammatory signs, high inflammatory serous markers, may have a longer postoperative recovery period, while the motor recovery may be late and incomplete. We analyzed a group of 24 patients with lumbar herniated disc that required discectomy, with clear inflammatory signs, together with histopathological and immunohistochemical changes present in the herniated disc.

SURGICAL TECHNIQUE AND CLINICAL BENEFITS IN FULL-ENDOSCOPIC TRANS-KAMBIN TRIANGLE LUMBAR INTERBODY FUSION (KLIF): A REVIEW

Full-endoscopic surgery started as discectomy via the transforaminal route toward the end of the 20th century. The interlaminar route was subsequently used for herniated nucleus pulposus at the L5/S1 level in patients with an anatomically high iliac crest. Thus, two full-endoscopic approaches are described in the literature. Furthermore, the surgical indications have expanded from discectomy to decompression and, most recently, to interbody fusion. The term used to describe interbody fusion surgery performed via the transforaminal route using a facet-preserving technique is trans-Kambin fusion (KLIF) and that used to describe such surgery when performed after facetectomy using the interlaminar technique is transforaminal lumbar interbody fusion (TLIF). Therefore, we have agreed the nomenclature of full-endoscopic facet-preserving KLIF and full-endoscopic facet-sacrificing TLIF. We have been performing full-endoscopic KLIF surgery since 2018. This review describes the surgical technique used for full-endoscopic KLIF, its clinical outcomes, and how it differs from full-endoscopic TLIF.

CLINICAL RESULTS OF EVOLUTIONAL CHANGE OF PRACTICE FROM OPEN TO ENDOSCOPIC SURGERY FOR CERVICAL DISC HERNIATION AND FORAMINAL STENOSIS

Objective: Limited literature on the effect on clinical and radiological outcomes in cervical endoscopic spine surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients for cervical disc herniations and foraminal pathologies. Methods: Retrospective comparative cohort study of two periods of 2015 to 2017 (first generation) is compared to 2018–2020 (second generation) on surgical treatment of degenerative cervical spinal conditions for 132 spinal cases. Basic demographics, preoperative, post-operative 1 week, 3 months and final follow-up of patients’ clinical outcomes in terms of Visual Analog Scale Pain Score, Neck Disability Index, Japanese Orthopaedic Association Score and MacNab’s Criteria were evaluated. Results: In the first generation, 50 cases of cervical disc herniation and foraminal stenosis with 70% open anterior cervical discectomy fusion or disc replacement 30% of the cases underwent posterior cervical endoscopic procedures with complication rate of 2%. In the second generation, 82 cases of cervical disc herniation and foraminal stenosis with 7% open anterior cervical discectomy fusion or disc replacement 93% of the cases underwent posterior cervical endoscopic procedures with complication rate of 6%. Compared to preoperative score, motor, JOA, VAS and NDI scores all statistically significant improved within the individual cohort. Compared to the first generation, the second generation has statistically significant improved VAS of 0.326+/−0.146 at 3 months and 0.648+/−0.163 at final follow-up and statistically significant improved NDI of 2.81+/−1.15 at final follow-up, p < 0.05. Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing good clinical outcomes.

Pentoxifylline significantly reduces radicular pain secondary to lumbar disc hernia: A prospective, randomized crossover, single-blind controlled pilot study

Background and objectivesOptimal medical treatment for low back pain, sometimes associated to radicular pain, has yet to be established. Herniated nucleus pulposus has been found to release TNFα, a pro-inflammatory cytokine involved in radiculopathy. Interestingly, Pentoxifylline (PTX), a phosphodiesterase inhibitor, blocks the activity of TNFα. The aim of this study is to assess the effectiveness of PTX when added to the treatment protocol of radiculopathy in lumbar disc herniation. MethodsFifty-eight patients with radicular pain secondary to a lumbar disc hernia were included in this prospective, randomized crossover, single-blind controlled study. PTX was added randomly to the same treatment protocol (ibuprofen + paracetamol + pregabalin) either during the first or the second 15 days of treatment. Patients’ pain was assessed at day 15 via the Numeric Rating Scale (NRS) and the Patient’s Global Impression of Change score (PGIC). D15 NRS value was considered as the primary outcome measure. ResultsMean D15 NRS score was 3.2 ± 0.84 during the 15-days treatment with PTX, and 5,1 ± 0.97 during the 15-days treatment without PTX (p < 0.0001). During the 15 days treatment period with/without PTX, PGIC score was (7) in 19/3 patients, (6) in 30/10 patients, (5) in 7/27 patients and (4) in 2/18 patients respectively, difference being highly significant (p < 0.0000). ConclusionAdjunction of PTX to the standard medical treatment of radicular pain associated with lumbar disc hernia seems to significantly decrease patients’ pain intensity in addition to improving their global satisfaction with treatment.

Development and Validation of Deep Learning-Based Algorithms for Predicting Lumbar Herniated Nucleus Pulposus Using Lumbar X-rays.

Lumbar herniated nucleus pulposus (HNP) is difficult to diagnose using lumbar radiography. HNP is typically diagnosed using magnetic resonance imaging (MRI). This study developed and validated an artificial intelligence model that predicts lumbar HNP using lumbar radiography. A total of 180,271 lumbar radiographs were obtained from 34,661 patients in the form of lumbar X-ray and MRI images, which were matched together and labeled accordingly. The data were divided into a training set (31,149 patients and 162,257 images) and a test set (3512 patients and 18,014 images). Training data were used for learning using the EfficientNet-B5 model and four-fold cross-validation. The area under the curve (AUC) of the receiver operating characteristic (ROC) for the prediction of lumbar HNP was 0.73. The AUC of the ROC for predicting lumbar HNP in L (lumbar) 1-2, L2-3, L3-4, L4-5, and L5-S (sacrum)1 levels were 0.68, 0.68, 0.63, 0.67, and 0.72, respectively. Finally, an HNP prediction model was developed, although it requires further improvements.

Characteristics of Sagittal Spinopelvic Alignment Changes After Symptom Relief After Simple Lumbar Decompression.

Sagittal spinopelvic alignment (SSPA) parameters are essential for the diagnosis of adult spinal deformities (ASDs) and their progression. Certain clinical symptoms that occur in patients with lumbar spinal stenosis (LSS) and herniated nucleus pulposus (HNP) may distort the SSPA and mimic ASD. To differentiate SSPA in symptomatic patients from asymptomatic patients within 10 minutes in the standing position. This retrospective cohort study evaluated changes in SSPA after simple lumbar decompression surgery in patients with LSS and HNP. Relative sagittal alignment (RSA), relative pelvic version, relative lumbar lordosis (RLL), Lordosis Distribution Index (LDI), and global alignment and proportion (GAP) values were calculated using the conventional Schwab classification method. First, the preoperative and postoperative SSPA parameters were compared. Second, patients were subgrouped into symptomatic within 10 minutes of standing (SP group) and other symptoms of LSS and HNP as controls. Changes in SSPA parameters after symptom relief after simple lumbar decompression surgery were compared between the two groups. Overall, all SSPA parameters improved after surgery. However, after subgrouping, patients in the control group did not show significant SSPA alterations, except for LDI, whereas patients in the SP group significantly improved in terms of their RSA, RLL, LDI, and GAP values after symptom relief after surgery. Patients with pain on standing within 10 minutes showed significant correction in RSA, RLL, and GAP values after simple lumbar decompression. Therefore, it is important to observe such clinical symptoms to avoid misdiagnosis of ASD.

Obesity and Workers’ Compensation in the Setting of Minimally Invasive Lumbar Decompression

To investigate the influence of body mass index (BMI) on perioperative outcomes, postoperative patient-reported outcome measures (PROMs), and minimal clinically important difference (MCID) achievement among workers' compensation (WC) claimants undergoing minimally invasive lumbar decompression (MIS-LD). WC patients diagnosed with herniated nucleus pulposus undergoing single-level MIS-LD were identified. Patients were divided into 3 groups: Non-obese (<30 kg/m2), Obese I (≥30 and <35 kg/m2), and Obese II/III (≥35 kg/m2). PROMs were collected preoperatively and at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years postoperatively. The predictive influence of BMI grouping on mean PROM scores was computed using simple linear regression. To compare PROMs between groups, post hoc pairwise comparisons of adjusted means were utilized. MCID achievement was compared between groups with χ2 analysis. A total of 81 patients were in the Non-obese cohort, and 43 and 45 in the Obese I and Obese II/III cohorts, respectively. Visual analog scale (VAS) leg, Oswestry Disability Index (ODI), and 12-Item Short Form Physical Composite Score (SF-12 PCS) were worse in the Obese I cohort at 12 weeks, and SF-12 PCS was lower in the Obese I vs. Obese II/III subgroup analysis (P ≤ 0.045, all). MCID achievement rates for ODI were higher for the Non-obese group at 12 weeks and overall (P ≤ 0.049, both). MCID attainment for VAS back was higher among the Non-obese cohort at 6-weeks (P= 0.022). Patients with higher levels of obesity were more likely to experience longer length of stay and delayed discharge following MIS-LD. Increasing BMI was generally not a significant predictor of postoperative pain, disability, or physical health PROMs at most timepoints. MCID achievement rates for disability relief were significantly higher for non-obese patients.

Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation With Type II Modic Changes

Percutaneous endoscopic lumbar discectomy (PELD) has become a favorable surgical approach for lumbar radiculopathy caused by intervertebral disc herniation. Studies have revealed patients with type II Modic change may suffer from unrelieved low back pain and higher lumbar disc herniation (LDH) recurrence after herniated nucleus pulposus removal. Therefore, in this study, we aim to evaluate how PELD performed in management of LDH patients with type II Modic change. We collected 267 single-level LDH cases aged 20-50 yearswho underwent PELD from December 2016 to December 2019. The mean follow-up time was 26.3 months (range: 12-48 months). The visual analog scale (VAS), Oswestry Disability Index (ODI), and MacNab scores, as well as the recurrence rate, were analyzed pre- and post-surgery, as well as at the time points of 3 months, 12 months, and the final follow-up time after surgery. The clinical outcomes in LDH patients with or without type II Modic change who underwent PELD were thoroughly analyzed. Within the 267 LDH patients enrolled, 145 cases present Modic signals, among which 3 are type I and 142 are type II. The VAS and ODI scores of the patients in the 2 groups at different follow-up times were significantly lower than those before surgery. The excellent and good MacNab scores in the control group and Modic type II change group were 87.0% and 82.1%, respectively. However, with the extension of follow-up time, the VAS and ODI scores, as well as the recurrence rate, were found to be higher in the type II Modic change group when compared with those in the non-Modic change group. PELD performed well in management of LDH patients. However, we need to pay more attention to the continuous low back pain and the recurrence possibility in the cases with type II Modic change. In these cases, longer brace support or other interventions could be applied.

Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up

Backgrounds. Microscopic decompression (MD) has been widely used as an alternative to open decompression. Lately, biportal endoscopic spinal surgery (BESS) - a new approach in minimal-invasive spinal surgery – has also been used with good results. Although both groups can achieve adequate lumbar decompression, there is still a lack of evidence regarding their comparison. We aim to compare the outcomes of both techniques in a one-year follow-up.&#x0D; Methods. This is a retrospective study in 100 consecutive patients with symptomatic lumbar spine compression due to herniated nucleus pulposus (HNP) and lumbar canal stenosis (LCS) that was treated by either BESS or MD. Clinical evaluations using Visual Analog Score (VAS), Oswestry Disability Index (ODI), and SF-36 questionnaire were obtained. Objective data such as surgery duration, amount of postoperative drain production, and hospital length of stay were collected. Complications were noted throughout the follow-up time.&#x0D; Results. The BESS group had a significantly lesser surgical duration, drain production, and length of stay. At one year follow-up, both groups achieved significant improvement in VAS, ODI, and SF-36 compared to the preoperative condition. Complications were not observed in the BESS group.&#x0D; Conclusions. Both procedures were comparably effective to treat lumbar stenosis. Although this study shows superiority with BESS technique in immediate and long-term follow-up, the final choice may depend on the surgeon's preference

Return to Sport After Lumbar Microdiscectomy in High School and College-Age Athletes

Previous studies have reported the return to play (RTP) rates for athletes after lumbar discectomy but not specifically for younger athletes. The purpose of the present study was to evaluate the RTP rate for young athletes after lumbar microdiscectomy. The medical records from a single spine surgeon were reviewed to identify patients who had undergone lumbar microdiscectomy. The patients were included if they were aged ≤21 years at surgery and were athletes. A total of 38 patients (25 males and 13 females) were identified, with a mean age at surgery of 19 years. The level of the herniated nucleus pulposus, variant anatomy, degenerative changes, gender, preoperative blocks, ring apophyseal fractures, and duration of symptoms from onset until surgery were recorded. The patients were interviewed to determine when and if they had returned to play. Most patients had had degenerative changes at surgery, with a mean Pfirrmann score of 2.2. The average time from symptom onset to surgery was 11 months. All patients were reached for follow-up at an average of 51 months postoperatively. Of the 38 patients, 71% had returned to play at an average of 4.5 months postoperatively. No statistically significant differences were found in the Pfirrmann grade and RTP rates between the high school and collegiate athletes, between the genders, nor between patients with 2-level and 1-level discectomy. The Pfirrmann grade was not significantly different between the patients who had and had not returned to play. The prognosis for returning to competitive sports after lumbar microdiscectomy in young athletes is good. The RTP rate and Pfirrmann grade were not related to gender, sport level, or discectomy level.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy presenting as severe herniated nucleus pulposus: A case report

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy is the most common inherited cerebral microangiopathy. Its clinical features include recurrent central nervous system symptoms—including lacunar stroke, migraine, psychiatric disturbance, acute reversible encephalopathy, and cognitive impairment. We report a case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy in a patient presenting with severe low back pain and a herniated nucleus pulposus. A 45-year-old female patient with a prior history of right-sided sciatic pain, hypoesthesia, and paresthesia in the right S1 sensory dermatome was referred after back surgery because of persistent low back pain and a spastic gait abnormality. Imaging revealed a right protruding disc herniation of L5/S1 with right S1 nerve root compression and right posterior disc bulging at L4/5 with foraminal stenosis and disc degeneration, for which she underwent surgery. After surgery, she experienced mild sciatica, an antalgic limping gait with foot-dragging, and progressive motor weakness. Her family history was significant for a parent and sibling affected by stroke. The diagnosis of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy was established by polymerase chain reaction sequencing, which showed a mutated exon 11 of NOTCH3 on chromosome 19. Clinicians should assess patients with non-specific extra-central nervous system symptoms or atypical courses for potential underlying diseases.

Acute motor weakness of lower extremity after a novel balloon-inflatable catheter for percutaneous epidural adhesiolysis and decompression: A case report

Background: As our population ages and the rate of spine surgery continues to rise, the use of epidural lysis of adhesions has emerged as a popular treatment for spinal stenosis and disc herniation. Percutaneous Epidural Adhesiolysis (PEA) causes pain by preventing the release of increased spinal nerve movement and nerve sensitivity due to nerve compression. PEA and decompression with a newly developed inflatable balloon catheter have been widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. Case presentation: A 64-year-old female patient who had lower back pain and right buttock pain radiating to the leg caused by an L4- L5 severe spinal stenosis underwent PEA and decompression using a Zigzag-motion Inflatable Neuroplasty (ZiNeu®, JUVENUI, Seoul, Korea) catheter. After the procedure, the patient complained of acute motor weakness in the right leg. After conservative treatment, motor weakness and paresthesia gradually improved over time. At the follow-up visit after 3 weeks, there were no signs of motor or sensory abnormalities. Conclusions: Practitioners should be aware that these complications can occur at any time, and a skilled practitioner should undertake the procedure. Keywords: cute motor weakness; percutaneous epidural adhesiolysis and decompression; spinal stenosis. Abbreviations: HIVD: Herniated Intervertebral Disc; MRI: Magnetic Resonance Imaging; NRS: Numeric Rating Scale; ODI: Oswestry Disability Index; PEA: Percutaneous Epidural Adhesiolysis.

Venous congestion as a central mechanism of radiculopathies.

Compression of roots/nerves can disrupt some of their functions, but does not necessarily cause pain. This is illustrated by the frequency of nearly asymptomatic spinal stenosis or disc herniations. In fact, pain of radiculopathies (and nerve entrapments) may mostly be the consequence of intraneural oedema induced by microscopical venous stasis around roots/spinal ganglia (or nerves) not or poorly shown by imaging. This narrative review first lists arguments for a role of congestion of vasa-nervorum in the pathophysiology of radiculopathies, including those induced by disc herniation and spinal stenosis, but also other sources of overpressures in spinal venous plexuses (pregnancy, vena cava atresia and thrombosis, portal hypertension, epidural varices, arterio-venous fistula, vertebral hemangioma or hemangioblastoma). It also details sources of venous congestion around nerves outside the spine, from pelvis (May-Thurner syndrome, Nut-cracker syndrome) to buttocks (superior and inferior gluteal veins), and even thighs and legs. A better recognition of a preeminent role of venous congestion in radiculopathies, plexopathies, and nerve entrapments, should have major consequences: (i) discard the dogma that compression is mandatory to induce root/nerve suffering, since root/nerve adherences in two locations can impair blood flow in vasa-nervorum through root/nerve stretching; (ii) implementation of sensitive techniques to visualise impingement of blood flow around or within roots and nerves; (iii) better prevention of roots/nerves adherence, or arachnoiditis induced by extravascular fibrin deposition secondary to venous stasis.; (iv) optimizing treatments dampening clot formation and/or extravascular fibrin leakage in the intradural/peridural spaces, or around roots/nerves, like guided injection of tissue plasminogen activator.

Dual Role of Neck Disability Index in the Assessment of Quality of Life in Cervical Spine Patients.

The Neck Disability Index (NDI) is a well-established measure for patients with cervical myelopathy, radiculopathy, or myeloradiculopathy. Few studies have examined the relationship between NDI and mental health outcomes after anterior cervical diskectomy and fusion (ACDF). Our study sets out to determine the possible correlations between NDI and mental health outcome measures after ACDF. A prospectively maintained surgical registry was retrospectively reviewed for elective ACDF procedures from December 2013 to December 2019. Demographic and perioperative characteristics were collected. Primary outcomes of interest were NDI, 12-Item Short Form Mental Component Summary (SF-12 MCS), and Patient Health Questionnaire-9 (PHQ-9). Outcomes were collected preoperatively and postoperatively (6 weeks, 12 weeks, 6 months, 1 year, and 2 years). Postoperative improvement for all outcomes was evaluated using a paired Student t-test. Correlations between NDI and mental health outcomes were evaluated using the Pearson correlation coefficient. Strength of association was determined using the following criteria: weak (0.1 ≤ |r| < 0.3), moderate (0.3 ≤ |r| < 0.5), and strong (|r| ≥ 0.5). A total of 225 patients were included in this study. Most of the patients underwent a single-level procedure and had a spinal pathology of herniated nucleus pulposus. NDI demonstrated significant improvements through 2 years compared with preoperative values (all P < 0.001). Similarly, SF-12 MCS and PHQ-9 significantly improved through 1-year postoperatively (all P ≤ 0.010) but was not maintained at 2 years (P = 0.835; P = 0.128). NDI demonstrated a significant but moderate correlation with SF-12 MCS at the preoperative time point, but a strong correlation was observed at all postoperative time points (all P ≤ 0.001). A significant and strong correlation between NDI and PHQ-9 was demonstrated at all time points (all P ≤ 0.002). NDI demonstrated notable and strong correlations with mental health outcome measures at all postoperative time points. NDI is an effective measure to assess neck disability but may also help capture changes to mental health symptoms after ACDF.