L4-L5 Disc Herniation Research Articles

Biomechanical Study of Symmetric Bending and Lifting Behavior in Weightlifter with Lumbar L4-L5 Disc Herniation and Physiological Straightening Using Finite Element Simulation.

Physiological curvature changes of the lumbar spine and disc herniation can cause abnormal biomechanical responses of the lumbar spine. Finite element (FE) studies on special weightlifter models are limited, yet understanding stress in damaged lumbar spines is crucial for preventing and rehabilitating lumbar diseases. This study analyzes the biomechanical responses of a weightlifter with lumbar straightening and L4-L5 disc herniation during symmetric bending and lifting to optimize training and rehabilitation. Based on the weightlifter's computed tomography (CT) data, an FE lumbar spine model (L1-L5) was established. The model included normal intervertebral discs (IVDs), vertebral endplates, ligaments, and a degenerated L4-L5 disc. The bending angle was set to 45°, and weights of 15 kg, 20 kg, and 25 kg were used. The flexion moment for lifting these weights was theoretically calculated. The model was tilted at 45° in Abaqus 2021 (Dassault Systèmes Simulia Corp., Johnston, RI, USA), with L5 constrained in all six degrees of freedom. A vertical load equivalent to the weightlifter's body mass and the calculated flexion moments were applied to L1 to simulate the weightlifter's bending and lifting behavior. Biomechanical responses within the lumbar spine were then analyzed. The displacement and range of motion (ROM) of the lumbar spine were similar under all three loading conditions. The flexion degree increased with the load, while extension remained unchanged. Right-side movement and bending showed minimal change, with slightly more right rotation. Stress distribution trends were similar across loads, primarily concentrated in the vertebral body, increasing with load. Maximum stress occurred at the anterior inferior margin of L5, with significant stress at the posterior joints, ligaments, and spinous processes. The posterior L5 and margins of L1 and L5 experienced high stress. The degenerated L4-L5 IVD showed stress concentration on its edges, with significant stress also on L3-L4 IVD. Stress distribution in the lumbar spine was uneven. Our findings highlight the impact on spinal biomechanics and suggest reducing anisotropic loading and being cautious of loaded flexion positions affecting posterior joints, IVDs, and vertebrae. This study offers valuable insights for the rehabilitation and treatment of similar patients.

Lumbar sacralization and L4-L5 microdiscectomy, a prospective cohort study on radiologic and clinical outcomes

AimTo evaluate the role of lumbar sacralization (LS) on the surgical outcomes of L4-L5 microdiscectomy. MethodsThis prospective cohort study was conducted in a university referral hospital. The patients with L4-L5 disc herniation and eligible for microdiscectomy were enrolled and allocated in G1 (with LS) and G2 (no LS). After the L4-L5 microdiscectomy patients were followed, clinical and radiological parameters were collected to investigate the influence on the outcomes. Recurrence, low back outcome score (LBOS), and the Oswestry disability index (ODI) were defined as main outcomes. ResultsTwo hundred and forty patients (n = 120, each), were reviewed in the final analysis. There was no difference between groups regarding baseline characteristics. Postoperative radicular and back pain was more severe in LS(P < 0.05). Univariate analysis showed recurrence was significantly higher in LS with a direct correlation with postoperative back pain persistence and low LBOS (p = 0.001). Age had a negative impact on G2 recurrence(p = 0.008). LS had a negative impact on LBOS and ODI scores. Postoperative radicular pain and higher lumbar lordosis were associated with a higher disability (ODI) index. ConclusionL4-L5 microdiscectomy in patients with lumbar sacralization was associated with higher recurrence rates, worse ODI and LBOS scores, persistent postoperative axial back pain, and radicular pain. Postoperative axial back pain and poor LBOS results could effectively predict a higher recurrence rate following L4-L5 microdiscectomy in lumbar sacralization.

Paravertebral Muscle Morphology in L4-L5 Disc Herniation: Insights from the Michigan State University Classification.

BACKGROUND Lumbar disc herniation (LDH) at L4-L5 impacts paravertebral muscle morphology. Intervertebral disc degeneration is linked to paravertebral muscle changes, affecting LDH treatment outcomes. This study explored L4-L5 LDH paravertebral muscle alterations, specifically in the erector spinae, multifidus, and psoas major, using Michigan State University's classification to guide LDH treatment. MATERIAL AND METHODS The study enrolled 160 patients, including 39 normal patients and 121 L4-L5 LDH patients. Patients with LDH were grouped according to MSU classification and compared to the normal group according to demographics and imaging changes. RESULTS In patients with L4-L5 herniation in Zone B, the FI of the ES muscle at L3-L4 level, L4-L5 level, and L5-S1 level was higher than that of normal people (P=0.018, P=0.043, P=0.010, respectively), and there was no difference between FI of MF and normal people. The Zone B patients also had a smaller CSA of the ES muscle at L4-L5 level than that in the normal group (P=0.049). Patients in the Zone C group were older than those in the normal group (P=0.014). The CSA of the PM of patients with Grade 3 herniation differed from that of the normal group at the L4-L5 and L5-S1 level. They were higher than in normal people at L4-L5 level (P=0.011) and lower at L5-S1 level (P=0.028). CONCLUSIONS In patients with L4-L5 herniation in Zone B, the FI of ES at L3-S1 level was higher than in normal people, and the CSA at L4-L5 level was smaller than in normal people. In patients with Grade3 herniation, PM CSA was larger at L4-L5 level and smaller at L5-S1 level than in normal people.

Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey.

Durotomy during endoscopic spine surgery can cause a patient's neurological or cardiovascular status to deteriorate unexpectedly intra- or postoperatively. There is currently limited literature regarding appropriate fluid management strategies, irrigation-related risk factors, and clinical consequences of incidental durotomy during spinal endoscopy, and no validated irrigation protocol exists for endoscopic spine surgery. Thus, the present article sought to (1) describe 3 cases of durotomy, (2) investigate standard epidural pressure measurements, and (3) survey endoscopic spine surgeons on the incidence of adverse effects believed to result from durotomy. The authors first reviewed clinical outcomes and analyzed complications in 3 patients with intraoperatively recognized incidental durotomy. Second, the authors conducted a small case series with intraoperative epidural pressure measurements during gravity-assisted irrigated video endoscopy of the lumbar spine. Measurements were conducted on 12 patients with a transducer assembly that was introduced through the endoscopic working channel of the RIWOSpine Panoview Plus and Vertebris endoscope to the decompression site in the spine. Third, the authors conducted a retrospective, multiple-choice survey of endoscopic spine surgeons to better understand the frequency and seriousness of problems they attributed to irrigation fluid escaping from the surgical decompression site into the spinal canal and neural axis. Descriptive and correlative statistical analyses were performed on the surgeons' responses. In the first part of this study, durotomy-related complications during irrigated spinal endoscopy were observed in 3 patients. Postoperative head computed tomographic (CT) images revealed massive blood in the intracranial subarachnoid space, the basal cisterns, the III and IV ventricle, and the lateral ventricles characteristic of an arterial fisher grade IV subarachnoid hemorrhage, and hydrocephalus without evidence of aneurysms or angiomas. Two additional patients developed intraoperative seizures, cardiac arrhythmia, and hypotension. The head CT image in 1 of these 2 patients had intracranial air entrapment.In the second part, epidural pressure measurements in 12 patients who underwent uneventful routine lumbar interlaminar decompression for L4-L5 and L5-S1 disc herniation showed an average epidural pressure of 24.5 mm Hg.In the third part, the online survey was accessed by 766 spine surgeons worldwide and had a response rate of 43.6%. Irrigation-related problems were reported by 38% of responding surgeons. Only 11.8% used irrigation pumps, with 90% running the pump above 40 mm Hg. Headaches (4.5%) and neck pain (4.9%) were observed by nearly a 10th (9.4%) of surgeons. Seizures in combination with headaches, neck and abdominal pain, soft tissue edema, and nerve root injury were reported by another 5 surgeons. One surgeon reported a delirious patient. Another 14 surgeons thought that they had patients with neurological deficits ranging from nerve root injury to cauda equina syndrome related to irrigation fluid. Autonomic dysreflexia associated with hypertension was attributed by 19 of the 244 responding surgeons to the noxious stimulus of escaped irrigation fluid that migrated from the decompression site in the spinal canal. Two of these 19 surgeons reported 1 case associated with a recognized incidental durotomy and another with postoperative paralysis. Patients should be educated preoperatively about the risk of irrigated spinal endoscopy. Although rare, intracranial blood, hydrocephalus, headaches, neck pain, seizures, and more severe complications, including life-threatening autonomic dysreflexia with hypertension, may arise if irrigation fluid enters the spinal canal or the dural sac and migrates from the endoscopic site along the neural axis rostrally. Experienced endoscopic spine surgeons suspect a correlation between durotomy and irrigation-related extra- and intradural pressure equalization that could be problematic if associated with high volumes of irrigation fluid LEVEL OF EVIDENCE: 3.

The Management of Lumbosciatic Disc Related Disease at Renaissance University Teaching Hospital of N’Djamena-Chad: About 156 Cases

Introduction: Low back disc disease (LSD) is a neurosurgical condition with significant socioeconomic repercussions. The objective of this study was to determine the frequency and report the modalities of management. Methodology: This study on lumbosciatic disc disease was carried out in the neurosurgery department of the University Hospital Center (CHU), la Renaissance in N’Djamena. It covered a period of 12 months (from September 2019 to August 2020). A descriptive and an analytical approach were used. The variables studied were epidemiology, clinic, radiology and therapy. Results: the results showed that LSD represented 14.7% of the reasons for consultation in neurosurgery. The average age was 45.8, and to some extent, it ranges between 18 and 76. Lifting was the main reason behind lumbosciatic disc disease with 35.9% of cases, followed by a sedentary life style which represents 30.8%. Lumbosciatica L5 was noted in 49.4%. Obesity and overweight were significant risk factors (P = 0.02) reported in 59% of cases. Motor and sensory deficits were observed in 14.8% and 17.3% of cases, respectively. CT of the lumbar spine was performed in 91% and MRI in 28.9%. The L4-L5 disc herniation represented 74.3% of cases, with a lateral location in 44.2% and L5 radicular impingement in 30.8%. Conservative treatment was instituted in 87.2% and surgical treatment in 12.8% of cases. Conclusion: LSD is caused by a sedentary lifestyle, physical work and overweight. Surgery deals with complicated cases and cases not responding to conservative treatment.

Free-run electromyography assisted interlaminar endoscopic lumbar disckectomy at L4L5 and L5S1 under general anesthesia

IntroductionInterlaminar Endoscopic Lumbar Disckectomy has been found to offer symptomatic alleviation comparable to open disckectomy while reducing blood loss, postoperative discomfort, complications, hospital stay, and narcotic use. General anesthesia decreases intraoperative stress, but surgeons may not be sure whether they injure nerve roots. Free-run electromyography may protect nerve roots that are thought to be in danger from surgery. MethodsPatients with L4L5 or L5S1 lumbar disc herniation were treated with IELD. EMG was monitored via needle electrodes in lateral vastus lateralis, anterior tibialis, abductor hallucis muscles. Surgeons were asked to halt the surgery and adjust their manipulation right when abnormal EMG appeared on the screen. The severity of signs and symptoms were noted pre- and post-operatively. ResultsIn all 26 cases, the median of visual analogue scale (VAS) of low back pain was 4.5. That of radicular pain was 7. Two patients had motor weakness at L4 or S1 muscles. One patient has sensory loss at L5 dermatome. The level of disc herniation was 46% at L4L5 and 56% at L5S1. The complications included only superficial infection in two patients that were effectively managed with antibiotics. During postoperative follow-up, all patients recovered completely without any neurological deficit. f-EMG signal included uneventful (9 patients), burst/spike (10 patients), A-train (3 patients, and C-train (4 patients) ConclusionFree-run EMG is a protective mean in IELD. All surgeons will profit from this technique in the early stages of their learning curve. To examine the outcomes, further comparative research and prospective, randomized, controlled trials should be undertaken.

Regression of lumbar disc herniation with a self-managed comprehensive exercise program: A case report

Background: Conservative therapeutic interventions may improve the regression of lumbar disc herniations, reducing the demand for surgical intervention. However, the vast number of conservative methods, variability in treatment combinations, including patient treatment preferences, delay the time-to-recovery and impact the recovery rates of patients. Current study presents the methods and outcomes of 15-week self-managed functional rehabilitation training. Case presentation: Patient is a 40-year-old recreational female runner with L4-L5 disc herniation, which occurred after lifting a heavy object three weeks prior. After initial three weeks of rehabilitation program, patient’s pain reduced from 8/10 to 5/10 to VAS scale, and after 12 weeks of stabilization and functional program, patient has regained full functionality with pain score of 0/10 on VAS scale. Conclusion: The presented case demonstrates that a self-managed functional rehabilitation exercise program may lead to regression of lumbar disc herniation and full reduction of symptoms after 15 weeks.

Progressive muscle weakness due to lumbar disc herniation in pregnancy: A case report

Purpose: Low back pain with radiculopathy caused by lumbar disc herniation is a rare presentation in pregnancy. Appropriate management is based on helping the gravida, while protecting her unborn offspring.&#x0D; Case report: A case of a 35–year–old pregnant woman in the 15th week of pregnancy with disabling pain and progressive motor weakness due to L4–L5 disc herniation is presented. Surgical decompression was performed with an aim to alleviate disabling pain and improve muscle strength.&#x0D; Conclusions: Treatment of disc herniation in pregnancy is conservative in the majority of cases. In the rare likelihood of permanent neurologic sequelae, surgical decompression is indicated, taking into account the specific physiologic condition of pregnancy.

Discectomy Compared with Standardized Nonoperative Care for Chronic Sciatica Due to a Lumbar Disc Herniation: A Secondary Analysis of a Randomized Controlled Trial with 2-Year Follow-up.

Randomized controlled trials evaluating acute sciatica have not demonstrated prolonged improvements in terms of patient-reported pain and function. For chronic sciatica, however, microdiscectomy has been found to be superior at 1 year. Whether this effect persists during the second year is not known. The purpose of the present study was to report the 2-year outcomes following lumbar microdiscectomy as compared with standardized nonoperative care for the treatment of chronic sciatica resulting from a lumbar disc herniation. The present study is a secondary analysis of a previously reported randomized controlled trial with extension to 2 years of follow-up. Patients with radiculopathy for 4 to 12 months resulting from an L4-L5 or L5-S1 disc herniation were randomized to microdiscectomy or 6 months of nonoperative care followed by surgery if needed. Intention-to-treat analysis was performed at 2 years for the primary outcome (the intensity of leg pain) (range of possible scores, 0 [no pain] to 10 [worst pain]) as well as for secondary outcomes (including the Oswestry Disability Index score, the intensity of back pain, and quality of life). One hundred and twenty-eight patients were randomized in the present study. Twenty-four (38%) of the 64 patients who had been randomized to nonoperative care crossed over to surgical treatment by 2 years following enrollment. At the 2-year time point, the follow-up rate was approximately 70%. At 2 years, the operative group had less leg pain than the nonoperative group (mean, 2.8 ± 0.4 compared with 4.2 ± 0.4; treatment effect, 1.3 [95% confidence interval, 0.3 to 2.4]). The treatment effect favored surgery for all secondary outcome measures at 6 months and 1 year and for back pain intensity and physical function at 2 years. At 2 years, the present study showed that microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation. However, the difference between the groups did not surpass the minimal clinically important difference at 2 years as was reached at earlier follow-up points, likely as the result of patients crossing over from nonoperative to operative treatment. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Radiological risk factors for recurrent lumbar disc herniation after percutaneous transforaminal endoscopic discectomy: a retrospective matched case-control study

To investigate radiological risk factors for recurrent lumbar disc herniation (rLDH) after percutaneous transforaminal endoscopic discectomy (PTED). Patients who underwent PTED due to a single-level L4-L5 or L5-S1 disc herniation from January 2013 to May 2019 were enrolled in this study. A matched case-control design was carried out in a single institution. Cases were defined as those who developed rLDH, and controls were matched from those patients without rLDH according to corresponding clinical characteristics. The radiological parameters were compared between two groups. The radiological risk factors for rLDH after PTED were identified by univariate and multivariate logistic regression analysis. A total of 2186 patients who underwent PTED at L4-L5 or L5-S1 level were enrolled in this study. Sixty-eight patients were diagnosed with rLDH, and 136 patients were selected from the remaining 2118 nonrecurrent patients as matched controls. Univariate analysis demonstrated that herniation type (P = 0.009), surgical-level disc degeneration (P < 0.001), adjacent-level disc degeneration (P = 0.017), disc height index (DHI) (P = 0.003), and sagittal range of motion (sROM) (P < 0.001) were significantly related to rLDH. Multiple logistic regression analysis showed that low grade of surgical-level disc degeneration (P < 0.001), senior grade of adjacent-level disc degeneration (P < 0.001), a high DHI (P = 0.012), and a large sROM (P < 0.001) were the radiological independent risk factors. This study showed that low grade of surgical-level disc degeneration, senior grade of adjacent-level disc degeneration, a high DHI, and a large sROM were the radiological independent risk factors for rLDH after PTED.

Open fenestration discectomy versus microscopic fenestration discectomy for lumbar disc herniation: a randomized controlled trial

BackgroundFenestration discectomy, for symptomatic lumbar disc herniation, is the most common surgical procedure in spine surgery. It can be done by open or microscopic procedures. This study compared the results of fenestration microdiscectomy with open fenestration discectomy in the treatment of symptomatic lumbar disc herniation as a relation to the functional outcome, leg pain, back pain, hospital stay, returns to daily activity, cost, recurrence, reoperation and type of surgery for recurrent disc herniation.Methods60 patients age (29 - 50 years), with L4-L5 disc herniation, are divided randomly into group A- 30 patients underwent an open fenestration discectomy- and group B- 30 patients underwent fenestration microdiscectomy. All patients are assessed at 1 week, 3 months, 6 months, 12 months after surgery for Oswestry disability index and Visual analogue scale for back pain and leg pain and followed up for 4 years.ResultsIn both groups, all patients have minimal disability by Oswestry Disability Index after surgery.There were significant differences between means of post-operative Visual Analogue Scale for back pain between these two groups after 1 week (3.7 in group A versus 2.2 in group B) (t = 13.28, P = < 0.001*) and after 3 months (1.73 in group A versus 0.43 in group B) (t = 10.54, P = < 0.001*).There were no significant differences between two groups regarding post-operative VAS for leg pain, recurrence (5 patients in group A versus 4 patients in group B) and reoperation rate (2 patients in each group).There were significant differences between means of length of hospital stay (2.10 in group A versus 1.06 in group B) (P < 0.001), time of returning to daily activities (7.33 in group A versus 4.03 in group B) (P < 0.001) and cost of surgery (1996.66 in group A versus 3003.3 in group B) (P < 0.001).ConclusionUse of microscope in fenestration discectomy for treatment of symptomatic lumbar disc herniation can achieve the same goals of open fenestration regarding nerve root decompression and relief of leg pain with advantage of less back pain, less hospital staying and early return to daily activities with disadvantage of more cost with the use of microscope. With 4 years follow up, there was no significant deference in rate of recurrence and reoperation with the use of microscope but we found that type of surgery for recurrent cases may be less invasive if microscope was used in primary surgery.Trial registrationNCT, NCT04112485. Registered 30 September 2019 - Retrospectively registered, https://clinicaltrials.gov/NCT04112485

Using isokinetic dynamometry for treatment patients with compression radiculopathy after surgical treatment L4-L5 herniated disc

Purpose was to evaluate the dynamics of the L5 root restoration. 17 patients (46,3 years old) with L4-L5 disc herniation and with L5 compression radiculopathy. A diagnostic test was the isokinetic dynamometry system by Humac of the hip and shin muscles in comparison with the healthy limb. The patient was tested before an operation, 1 month after microdiscectomy and 1 month after rehabilitation. Isokinetics and isometry in eccentricity and concentricity at the maximum torque (MT), joint angle with MT (JAMT) in the thigh and shin muscles were estimated. Isokinetic. M.Tibialis ant: Concentric: MT (before surgery vs 30 days after surgery vs 1 month after rehabilitation) 49.2Nm vs 60.1Nm vs 46.9Nm, JAMT -10.10 vs -16.30 vs -6.20. Eccentric: MT 53.3Nm vs 84.1Nm vs 43.4Nm, JAMT -22.10 vs -17.10 vs -220; Second part was isometry. M.Gastrocnemius: MT 5.2Nm vs 12Nm vs 15.4Nm, TRMT 1.75s. vs 0.9s vs 1.32s; M.Tibialis ant: MT 14Nm vs 28Nm vs 33.3Nm, TRMT 1.59s. vs 3.01s vs 1.7s; The comparison dynamics in intact legs was noted: M.Tibialis ant: Concentric: MT 53.2Nm vs 58.1Nm vs 41.6Nm, JAMT -11.10 vs -21.20 vs -30. Eccentric: MT 52.3Nm vs 65.1Nm vs 41.4Nm, JAMT -22.10 vs -20.10 vs -70; Second part was isometry. M.Gastrocnemius: MT 9.2Nm vs 12Nm vs 16.4Nm, TRMT 4.39s. vs 1.05s vs 1.64s; M.Tibialis ant: MT 19.1Nm vs 33.2Nm vs 28.3Nm. The isokinetic dynamometer system is an effective method and makes possible to evaluate muscular force and a joint range of motion in rehabilitation period.

Full-Endoscopic Visualized Foraminoplasty and Discectomy Under General Anesthesia in the Treatment of L4-L5 and L5-S1 Disc Herniation.

Retrospective analysis of clinical records. The aim of this study is to evaluate the clinical outcomes and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia for the treatment of L4-L5 and L5-S1 disc herniation. Full-endoscopic visualized foraminoplasty and discectomy, which is our newly developed technique, has been used in the treatment of lumbar disc herniation and lumbar spinal stenosis. While the clinical effect, safety, and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia are still uncertain. Between May 2015 and April 2017, 84 patients with lumbar disc herniation were included, and categorized into L4-L5 group and L5-S1 group according to the discectomy segment. Full-endoscopic visualized foraminoplasty and discectomy was performed under general anesthesia. Operative time, fluoroscopy time, hospitalization time, and complications were recorded. Each patient included was followed for at least 12 months. Visual analog scale score for leg and back pain and Oswestry Disability Index score were evaluated preoperatively and at 3, 6, and 12 months postoperatively. The modified MacNab criteria were also used to evaluate surgical effectiveness. The mean operative time, fluoroscopy time, and hospitalization time at L4-L5 and L5-S1 were of no significant difference. The mean visual analog scale and Oswestry Disability Index postoperative scores were significantly improved over the preoperative scores. Intraoperative nerve injury occurred in one case at L4-L5, with a neurological complication rate of 2.1% in L4-L5 group. One case at L4-L5 suffered recurrence 2 weeks after the surgery, resulting in a recurrence rate of 2.1% in L4-L5 group. This recurrence case was treated by a second full-endoscopic visualized foraminoplasty and discectomy under general anesthesia. Full-endoscopic visualized foraminoplasty and discectomy under general anesthesia is efficient and safe for the treatment of L4-L5 and L5-S1 disc herniation. 4.

Revisiting Ligament-Sparing Lumbar Microdiscectomy: When to Preserve Ligamentum Flavum and How to Evaluate Radiological Results for Epidural Fibrosis.

Preserving the ligamentum flavum (LF) during lumbar spine surgery can help to limit the extent of postoperative epidural fibrosis (EF), which is a potential cause of persistent leg pain. We present a retrospective analysis of microdiscectomy with preservation of the LF to evaluate the effects of the two LF mobilizing techniques (reflecting inferiorly or medially vs. removing completely) on EF and clinical outcomes. Microdiscectomy was performed through a unilateral laminotomy in 93 patients (52 male, 41 female; mean age, 46 years; range, 25-65 years) with L3-L4 (n= 3), L4-L5 (n= 40), and L5-S1 (n= 50) lumbar disc herniation. Patients whose LF was removed were assigned to group 1 (n=42), and patients whose LF was preserved by mobilizing it medially (n= 31) or inferiorly (n= 20) were assigned to groups 2 and 3, respectively. Follow-up visual analog scale (VAS) scores and magnetic resonance images were evaluated. EF scores, particularly for the anterior quadrants, were significantly higher in group 1 than in groups 2 (P= 0.012) and 3 (P= 0.001). Likewise, postoperative VAS scores in group 1 were also significantly higher than in groups 2 (P= 0.009) and 3 (P= 0.044). Our results demonstrate that 1) preserving the LF during lumbar microdiscectomy reduces the formation of postoperative EF and improves clinical outcomes; 2) EF in the anterior, rather than the posterior epidural space, is correlated with clinical results; and 3) the ligament mobilizing technique used should be individually tailored on the basis of the features of disc herniation.

Ochronotic Lumbar Disc Herniation with Radiculopathy: Report of Two Cases

Alkaptonuria is a rare genetic disorder caused by deficiency of the enzyme homogentisic acid dioxidase (HGA). This deficiency leads to deposition of HGA and its products as an ochre-colored pigment in the large joints, intervertebral discs, skin, and within major arteries. Affection of the intervertebral discs mostly occurs at the thoracic and lumbar regions which ultimately results in degeneration, calcification, pseudo-blocked vertebra, and ankyloses in a stepwise manner. Rarely, an affected lumbar disc might herniate into the canal and cause radiculopathy before its calcification. Herein we present two women in whom neuroradiological evaluation of an acute left lower limb radiculopathy revealed a sequestrated L4-L5 disc herniation in both cases. Disc prolapse in these patients was associated with calcification of the thoracic and the upper lumbar intervertebral discs, compatible with ochronosis. Following removal of the pigmented disc material, both patients exhibited marked recovery. With careful review of the literature, we found that besides our cases, only 19 cases have been published previously

Symptomatic L4-L5 Disc Herniation in a Professional Hockey Player

In volume 4, Issue 1 of the JSMAHS you will find Professional Research Abstracts, as well as Bachelor Student Research Abstracts and Case Reports.

Factors that influence recurrent lumbar disc herniation.

The most common cause of poor outcome following lumbar disc surgery is recurrent herniation. Recurrence has been noted in 5% to 15% of patients with surgically treated primary lumbar disc herniation. There have been many studies designed to determine the risk factors for recurrent lumbar disc herniation. In this study, we retrospectively analysed the influence of disc degeneration, endplate changes, surgical technique, and patient's clinical characteristics on recurrent lumbar disc herniation. Patients who underwent primary single-level L4-L5 lumbar discectomy and who were reoperated on for recurrent L4-L5 disc herniation were retrospectively reviewed. All these operations were performed between August 2004 and September 2009 at the Neurosurgery Department of Ataturk Education and Research Hospital in Ankara, Turkey. During the study period, 126 patients were reviewed, with 101 patients underwent primary single-level L4-L5 lumbar discectomy and 25 patients were reoperated on for recurrent L4-L5 disc herniation. Preoperative higher intervertebral disc height (P<0.001) and higher body mass index (P=0.042) might be risk factors for recurrence. Modic endplate changes were statistically significantly greater in the recurrent group than in the non-recurrent group (P=0.032). Our study suggests that patients who had recurrent lumbar disc herniation had preoperative higher disc height and higher body mass index. Modic endplate changes had a higher tendency for recurrence of lumbar disc herniation. Well-planned and well-conducted large-scale prospective cohort studies are needed to confirm this and enable convenient treatment modalities to prevent recurrent disc pathology.

Impact of Obesity and Underweight on Surgical Outcome of Lumbar Disc Herniation

Background. The relationship between underweight and lumbar spine surgery is still unknown. Aim. To evaluate the effect of underweight versus obesity based on surgical outcome of lumbar disc herniation. Material and Method. In this retrospective study, we evaluated 206 patients (112 male and 94 female) with a mean age of 37.5±3.1 years old (ranged 20–72) who have been surgically treated due to the refractory simple primary L4-L5 disc herniation. We followed them up for a mean period of 42.4±7.2 months (ranged 24–57). We used Body Mass Index (BMI), Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS) for categorization, disability, and pain assessment, respectively. We used Wilcoxon and Mann-Whitney U tests for statistics. Results. Surgical discectomy in all weight groups was associated with significant improvement in pain and disability, but intergroup comparison showed these improvements in both underweight and obese groups and they were significantly lower than in normal weight group. Excellent and good satisfaction rate was also somewhat lower in both these ends of weight spectrum, but statistically insignificant. Conclusion. Both obesity and underweight may have adverse prognostic influences on the surgical outcome of lumbar disc herniation, although their impact on subjective satisfaction rate seems to be insignificant.

Does Duration of Preoperative Sciatica Impact Surgical Outcomes in Patients with Lumbar Disc Herniation?

Background. In lumbar disc herniation, most authors recommend nonoperative treatment for the first few weeks of presentation, but what about the upper limit of this golden period? The aim of this study is to assess the effect of preoperative sciatica duration on surgical outcome of lumbar disc herniation. Methods. We retrospectively evaluated 240 patients (124 males and 116 females) with a mean age of 36.4 ± 5.9 years (range 16 to 63) surgically treated due to primary stable L4-L5 disc herniation. The patients were placed into two groups: with more and less than 12-month duration of preoperative sciatalgia. Disability and pain were measured by Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS). Wilcoxon test and Mann-Whitney U test were used for statistical analysis. Results. Total mean duration of preoperative sciatalgia and follow-up period were 13.3 months (range 2 to 65) and 33.7 ± 5.1 months (range 24 to 72), respectively. Comparison between the groups showed that duration of preoperative sciatalgia either less or more than 12 months did not affect the surgical outcomes significantly. Conclusions. More or less than 12-month duration of preoperative sciatalgia may not affect the surgical outcomes of simple lumbar disc herniation in the patients undergoing discectomy.

Prevalence and severity of preoperative disabilities in Iranian patients with lumbar disc herniation.

Literature recommends that refractory cases with lumbar disc herniation and appropriate indications are better to be treated surgically, but do all the patients throughout the world consent to the surgery with a same disability and pain threshold? We aim to elucidate the prevalence and severity of disabilities and pain in Iranian patients with lumbar disc herniation who have consented to the surgery. In this case series study, we clinically evaluated 194 (81 female and 113 male) admitted patients with primary, simple, and stable L4-L5 or L5-S1 lumbar disc herniation who were undergoing surgical discectomy. The mean age of the patients was 38.3±11.2 (range: 18-76 years old). Disabilities were evaluated by the items of the Oswestry Disability Index (ODI) questionnaire and severity of pain by the Visual Analogue Scale (VAS). Chi-square test was used to compare the qualitative variables. Severe disability (39.2%) and crippled (29.9%) were the two most common types of disabilities. Mean ODI score was 56.7±21.1 (range: 16-92). Total mean VAS in all patients was 6.1±1.9 (range: 0-10). Sex and level of disc herniation had no statistical effect on preoperative ODI and VAS. The scale of six was the most frequent scale of preoperative VAS in our patients. Iranian patients with lumbar disc herniation who consented to surgery have relatively severe pain or disability. These severities in pain or disabilities have no correlation with sex or level of disc herniation and are not equal with developed countries.