L5-S1 Level Research Articles

Surgical management of sacral neurogenic tumors

To observe the efficacy and complications of one-stage tumor resection to treat primary sacral neurogenic tumors and to discuss some details in the clinically relevant anatomy. A retrospective analysis of 26 patients with neurogenic turors of the sacral spine who were surgically treated from January 2001 to January 2018, including 16 males and 10 females, aged from 21 to 69 years old with an average age of (39.3±10.9) years old. The courses of diseases ranged from 3 to 56 months with an average of (17.9±10.1) months. The diameters of presacral components ranged from 3.3 to 19.6 cm with an average of (8.7±4.1) cm. The proximal margin of presacral lesions was above the L5S1 level in 6 cases, and lower than L5S1 in 20 cases. A posterior incision approach for one-stage complete resection of the tumor was used firstly, and an anterior approach was combined when necessary. Spinal-pelvic reconstruction with the modified Galveston technique was also carried out in relevant cases. Whether to preserve the tumor-involved nerve roots depended on the situation during the operation. The operation time, intraoperative blood loss, pain relief, and complications were recorded. The lumbosacral spine stability and sacral plexus neurological function were evaluated during postoperative follow-up, and local recurrence and distant metastasis were examined as well. Total excision was achieved in all 26 patients, with an operation time of (160.4±35.3) mins and an intraoperative blood loss of (1 092.3±568.8) ml. Tumors have been removed via a posterior-only approach in 21 cases and via combined anterior/posterior approaches in 5 cases. The diameter of presacral masses components ranged from 11.3 to 19.6 cm with an average of (15.1±3.2) cm in patients with combined anterior/posterior approaches, and ranged from 3.3 to 10.9 cm with an average of (7.2±2.4) cm in patients with a posterior-only approach. Five of the six patients whose proximal margin of presacral masses was above the L5S1 level adopted combined anterior/posterior approaches, and 20 patients lower than the L5S1 level adopted the posterior-only approach. All the patients were followed up for 6 to 82 months with an average of(45.4±18.2)months. Postoperative lumbosacral pain and lower extremity radicular pain were significantly relieved, and sensation, muscle strength and bowel and bladder function were also improved to varying degrees. The postoperative early complications included superficial wound infection in 1 case and cerebrospinal fluid leakage in 2 cases. Pathology confirmed 17 cases of schwannoma, 7 cases of neurofibroma and 2 cases of malignant schwannoma. Local recurrence was observed in two cases of benign neurogenic tumors. One patient with a malignant nerve sheath tumor had lung metastasis, who died 20 months after the operation. In 17 cases of upper sacral neurogenic tumors, 4 cases did not undergo spinal-pelvic reconstruction with internal fixation, of which 2 cases suffered from postoperative segmental instability. Tumor-involved nerve roots were resected during surgery in 7 cases. One of these patients who had S2 and S3 nerve roots sacrificed simultaneously had an impaired bladder and bowel function postoperatively, and did not recover completely. In the other 6 cases, the neurological function was not damaged obviously or recovered well. The posterior approach can directly expose the lesions, and it is also convenient to deal with nerve roots and blood vessels. The operation time, intraoperative blood loss, degree of symptom relief, complication rate, and recurrence and metastasis rate can be controlled at an appropriate level. It is a safe and effective surgical approach. When the upper edge of the presacral mass is higher than the L5S1 level or the diameter of the presacral mass exceeds 10 cm, an additional anterior approach should be considered. The stress between the spine and pelvis is high, and internal fixation should be used to restore the mechanical continuity of the spine and pelvis during resection of neurogenic tumors of the high sacral spine. Most of the parent nerve roots have lost their function. Resection of a single parent nerve root is unlikely to cause severe neurological dysfunction, while the adjacent nerve roots have compensatory functions and should be preserved as much as possible during surgery.

Postoperative spinal alignment comparison of lateral versus supine patient position L5-S1 anterior lumbar interbody fusion.

Over the past decade, alternative patient positions for the treatment of the anterior lumbar spine have been explored in an effort to maximize the benefits of direct anterior column access while minimizing the inefficiencies of single or multiple intraoperative patient repositionings. The lateral technique allows for access from L1 to L5 through a retroperitoneal, muscle-splitting, transpsoas approach with placement of a large intervertebral spacer than can reliably improve segmental lordosis, though its inability to be used at L5-S1 limits its overall adoption, as L5-S1 is one of the most common levels treated and where high levels of lordosis are optimal. Recent developments in instrumentation and techniques for lateral-position treatment of the L5-S1 level with a modified anterior lumbar interbody fusion (ALIF) approach have expanded the lateral position to L5-S1, though the positional effect on L5-S1 lordosis is heretofore unreported. The purpose of this study was to compare local and regional alignment differences between ALIFs performed with the patient in the lateral (L-ALIF) versus supine position (S-ALIF). Retrospective, multi-center data and radiographs were collected from 476 consecutive patients who underwent L5-S1 L-ALIF (n = 316) or S-ALIF (n = 160) for degenerative lumbar conditions. Patients treated at L4-5 and above with other single-position interbody fusion and posterior fixation techniques were included in the analysis. Baseline patient characteristics were similar between the groups, though L-ALIF patients were slightly older (58 vs. 54years), with a greater preoperative mean L5-S1 disk height (7.8 vs. 5.8mm), and with less preoperative slip (6.6 vs. 8.5mm), respectively. 262 patients were treated with only L-ALIF or S-ALIF at L5-S1 while the remaining 214 patients were treated with either L-ALIF or S-ALIF at L5-S1 along with fusions at other thoracolumbar levels. Lumbar lordosis (LL), L5-S1 segmental lordosis, L5-S1 disk space height, and slip reduction in L5-S1 spondylolisthesis were measured on preoperative and postoperative lateral X-ray images. LL was only compared between single-level ALIFs, given the variability of other procedures performed at the levels above L5-S1. Mean pre- to postoperative L5-S1 segmental lordosis improved 39% (6.6°) and 31% (4.9°) in the L-ALIF and S-ALIF groups, respectively (p = 0.063). Mean L5-S1 disk height increased by 6.5mm (89%) in the L-ALIF and 6.4mm (110%) in the S-ALIF cohorts, (p = 0.650). Spondylolisthesis, in those patients with a preoperative slip, average reduction in the L-ALIF group was 1.5mm and 2.2mm in the S-ALIF group (p = 0.175). In patients treated only at L5-S1 with ALIF, mean segmental alignment improved significantly more in the L-ALIF compared to the S-ALIF cohort (7.8 vs. 5.4°, p = 0.035), while lumbar lordosis increased 4.1° and 3.6° in the respective groups (p = 0.648). Use of the lateral patient position for L5-S1 ALIF, compared to traditional supine L5-S1 ALIF, resulted in at least equivalent alignment and radiographic outcomes, with significantly greater improvement in segmental lordosis in patients treated only at L5-S1. These data, from the largest lateral ALIF dataset reported to date, suggest that-radiographically-the lateral patient position can be considered as an alternative to traditional ALIF positional techniques.

Spinal exposure for anterior lumbar interbody fusion (ALIF) in the lateral decubitus position: anatomical and technical considerations.

Single position surgery has demonstrated to reduce hospital length of stay, operative times, blood loss, postoperative pain, ileus, and complications. ALIF and LLIF surgeries offer advantages of placing large interbody devices under direct compression and can be performed by a minimally invasive approach in the lateral position. Furthermore, simultaneous access to the anterior and posterior column is possible in the lateral position without the need for patient repositioning. The purpose of this study is to outline the anatomical and technical considerations for performing anterior lumbar interbody fusion (ALIF) in the lateral decubitus position. Surgical technique and technical considerations for reconstruction of the anterior column in the lateral position by ALIF at the L4-5 and L5-S1 levels. Topics outlined in this review include: Operating room layout and patient positioning; surgical anatomy and approach; vessel mobilization and retractor placement for L4-5 and L5-S1 lateral ALIF exposure, in addition to comparative technique of disc space preparation, trialing and implant placement compared to the supine ALIF procedure. Anterior exposure performed in the lateral decubitus position allows safe-, minimally invasive access and implant placement in ALIF. The approach requires less peritoneal and vessel retraction than in a supine position, in addition to allowing simultaneous access to the anterior and posterior columns when performing 360° Anterior-Posterior fusion.

Minimally Invasive versus Conventional Lumbar Interbody Fusion at L5–S1: A Retrospective Comparative Study

Objective: This study aimed to evaluate the radiologic and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and conventional posterior lumbar interbody fusion (PLIF) at the L5–S1.Methods: We retrospectively reviewed patients who underwent posterior lumbar fusion (MIS-TLIF and PLIF) at only the L5–S1 and were followed up for more than 12 months. Age, sex, body mass index (BMI), bone mineral density (BMD), diagnosis, comorbid conditions, fusion rate, perioperative results, and pre- and postoperative radiographic parameters at the L5–S1 level, pelvic parameters and degree of spondylolisthesis, and clinical results were analyzed.Results: A total of 102 patients (46 male, 56 female) with a mean age of 57.1 years were evaluated. Fifty and fifty-two patients underwent MIS-TLIF and PLIF surgeries, respectively. Radiologic parameters increased from their preoperative measures at the last follow-up study; similarly, there were no intergroup differences. The fusion rates in the MIS-TLIF and PLIF groups were 86% and 82.7%, respectively. The subsidence rates in the MIS-TLIF and PLIF groups were 6% and 3.8%, respectively. There was no intergroup difference in terms of fusion rate and subsidence. Clinical outcomes also gradually improved after surgery in both groups without intergroup differences.Conclusion: In L5–S1 posterior spinal surgery, there was no significant difference between MIS-TLIF and conventional PLIF. Considering the operation time and estimated blood loss, MIS-TLIF is more effective than PLIF surgery in terms of postoperative health care and economics.

Analysis of Risk Factors for Adjacent Segment Degeneration after Minimally Invasive Transforaminal Interbody Fusion at Lumbosacral Spine.

Background Adjacent segment degeneration (ASD) has been considered as a serious complication from changes in the biological stress pattern after spinal fusion. The sagittal balance significantly associated with lumbar loading is largely dependent on L5-S1 segment. However, the evidence indicating risk factors for radiological and symptomatic ASD after minimally invasive transforaminal interbody fusion (MIS-TLIF) remains insufficient. Methods This single-central retrospective study recruited patients with lumbosacral degeneration receiving MIS-TLIF at the L5-S1 level from January 2015 to December 2018. The targeted variables included demographic information, radiological indicators, surgery-related parameters, and patient-reported outcomes (PROs) extracted from the electronic medical system by natural language processing. In these patients, a minimum of 3-year follow-up was done. After reviewing the preoperative and postoperative follow-up digital radiographs, patients were assigned to radiological ASD group (disc height narrowing ≥3 mm, progressive slipping ≥3 mm, angular motion >10°, and osteophyte formation >3 mm), symptomatic ASD group, and control group. We identified potential predictors for radiological and symptomatic ASD with the service of stepwise logistic regression analysis. Results Among the 157 consecutive patients treated with MIS-TLIF in our department, 16 cases (10.2%) were diagnosed with radiological ASD at 3-year follow-up. The clinical evaluation did not reveal suspicious risk factors, but several significant differences were confirmed in radiological indicators. Multivariate logistic regression analysis showed postoperative PI, postoperative DA, and ∆PI-LL in radiological ASD group were significantly different from those in control group. Nevertheless, for patients diagnosed with simultaneously radiological and symptomatic ASD, postoperative DA and postoperative PT as risk factors significantly affected the clinical outcome following MIS-TLIF. Conclusion In this study, while approximately 10% of lumbosacral degenerations develop radiographic ASD, prognosis-related symptomatic ASD was shown not to be a frequent postoperative complication. Postoperative PI, postoperative DA, and mismatched PI-LL are risk factors for radiological ASD, and postoperative DA and postoperative PT are responsible for the occurrence of symptomatic ASD following MIS-TLIF. These radiological risk factors demonstrate that restoration of normal sagittal balance is an effective measure to optimize treatment strategies for secondary ASD prevention.

Does Conventional Open TLIF cause more Muscle Injury when Compared to Minimally Invasive TLIF?-A Prospective Single Center Analysis.

Prospective, observational. The aim of our study was to assess the amount of reduction in lean muscle mass (LMM) of multifidus muscle (MFM) between conventional open Transforaminal lumbar interbody fusion (CO-TLIF) as compared to Minimally invasive spine Transforaminal lumbar interbody fusion (MIS-TLIF). This study was conducted between 2017 and 2020. It included 100 patients divided into two groups, 50 patients treated with CO-TLIF, 50 treated with MIS-TLIF. Only patients undergoing single level, primary lumbar fusion at L4-5 or L5-S1 level for degenerative pathologies were included. All patients were assessed by magnetic resonance imaging (MRI) scans 1-year post surgery. Measurements were performed using ImageJ image processing program. Mean percentage reduction in LMM in CO-TLIF group was 45.52 ± 12.36% and MIS-TLIF group was 25.83 ± 9.64% [statistically significant (t = 8.78, P < .001)]. Mean percentage reduction in LMM on side of cage insertion was 39.63 ± 15.96% and opposite side was 31.40 ± 15.01% [statistically significant (t = 9.06, P < .001)]. Mean reduction of LMM among males was 29.38 ± 15.23% and females was 40.42 ± 12.67% [statistically significant (t = -3.95, P < .001)].We observed significant but weak degree of correlation between age and percentage reduction of LMM (r = .22, P = .028). Mean reduction in LMM was greater in CO-TLIF group as compared to MIS-TLIF. There was greater reduction in LMM in females and on side of cage insertion. We also found greater reduction in LMM with increasing age in both groups.

Facet Tropism/Inclination and Its Association with Intervertebral Disc Herniation in the Lumbar Spine - A Radiological Evaluation.

Objective To assess the role of facet tropism (FT) in intervertebral disc prolapse. Methods A total 98 patients with lower back pain were included in the study. Magnetic resonance imaging scans were performed and analyzed. The angles of the right and left facets were measured on the axial section. Patients without disc prolapse at the L3-L4, L4-L5 and L5-S1 levels act as controls for those with disc prolapse at the same levels. A statistical analysis was also performed. Results The incidence of FT at the L3-L4 level was of 85.2% in patients with disc herniation ( n = 27), and of 56.3% in the control group, which was statistically significant ( p = 0.008). Similarly, at the L4-L5 level, incidence of FT among cases and controls was of 71.4% ( n = 35) and 52.4% respectively ( p = 0.066). At the L5-S1 the incidence was of 66% and 51% among cases and controls respectively ( p = 0.13). Conclusion We found a positive association between FT and disc herniation at the L3-L4 level, but no association at the L4-L5 and L5-S1 levels.

Are Morphometric and Biomechanical Characteristics of Lumbar Multifidus Related to Pain Intensity or Disability in People With Chronic Low Back Pain After Considering Psychological Factors or Insomnia?

IntroductionLumbar multifidus muscle (LMM) dysfunction is thought to be related to pain and/or disability in people with chronic low back pain (CLBP). Although psychosocial factors play a major role in pain/disability, they are seldom considered as confounders in analyzing the association between LMM and CLBP.ObjectivesThis study aimed to determine: (1) differences in psychological factors, insomnia, and LMM characteristics between people with and without CLBP; (2) associations between psychological factors, insomnia, or LMM characteristics and low back pain (LBP) intensity or LBP-related disability in people with CLBP; and (3) whether LMM characteristics are related to LBP symptoms in people with CLBP after considering confounders.MethodsSeventy-eight volunteers with CLBP and 73 without CLBP provided sociodemographic information, filled the 11-point numeric pain rating scale and Roland-Morris disability questionnaire (RMDQ). They completed the Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), Fear Avoidance Belief Questionnaire (FAB), and Insomnia Severity Index Scale (ISI). Resting and contracted thickness of LMM at L4-S1 levels were measured from brightness-mode ultrasound images. Percent thickness changes of LMM at L4-S1 levels during contraction were calculated. Resting LMM stiffness at L4-S1 was measured by shear wave elastography. Associations among LMM, psychosocial or insomnia parameters and clinical outcomes were analyzed by univariate and multivariate analyses.ResultsPeople with CLBP demonstrated significantly higher LBP-intensity, RMDQ, HADS, FAB, PCS, and ISI scores than asymptomatic controls (p < 0.05). The former also had significantly smaller percent thickness changes of LMM at L4/L5 during contraction. LBP-intensity was positively related to scores of PCS-total, PCS-helplessness, FAB-total, FAB-work, and ISI in people with CLBP (p < 0.05). RMDQ scores were positively associated with the scores of HADS-total, HADS-depression, PCS-total, FAB-total, FAB-physical activity, PCS-helplessness, and ISI in people with CLBP (p < 0.05). FAB-work and ISI scores together explained 24% of LBP-intensity. FAB-total scores alone explained 34% of variance of LBP-related disability in people with CLBP.ConclusionMore fear-avoidance belief or insomnia is related to greater LBP-intensity and/or LBP-related disability in people with CLBP. Although people with CLBP were thought to have aberrant LMM morphometry/function, no LMM characteristics were related to LBP-intensity or LBP-related disability after considering other confounders.

Schmorl’s nodes could be associated with intervertebral disc degeneration at upper lumbar levels and end-plate disease at lower lumbar level in patients with low back pain

Schmorl’s nodes (SNs) have increasingly been recognized on vertebral end-plates using advanced imaging techniques. Even though vertebral end-plates are the closest structures to discs, their pathologies are underestimated in the etiology of low back pain (LBP). We aimed to detect the prevalence of SNs and other end-plate defects in subjects with/without LBP and to understand whether SNs were associated with LBP and spinal degeneration. Subjects were evaluated in terms of end-plate defects, intervertebral disc degeneration (IVDD), and vertebral end-plate changes (Modic changes) at all lumbar levels on lumbar spine magnetic resonance imagings (MRI). Control subjects were compared to patients with LBP. Higher Pfirrmann scores (OR: 2.696) and higher SN scores (OR: 8.076) were significantly associated with Modic changes at L4-L5 disc level. Patients with higher SN scores at L1-L2 or L2-L3 levels had approximately 7-fold increased risk of severe IVDD at the corresponding levels. The most significant factor associated with presence of SNs was body weight of the patients (OR: 1.417). The most significant factor associated with intensity of LBP was severe IVDD at L5-S1 level (OR: 3.670). Having higher total SN score had an OR of 1.230 (95% CI: 1.003–1.509; p = 0.047) for predicting LBP. Schmorl’s nodes were seen in 33.1% of patients and 11.5% of asymptomatic subjects. Body weight was the most significant factor associated with SNs. The most significant factor associated with LBP was severe IVDD at L5-S1 level.

Sacral Epidural Laser Discectomy Efficacy in Non-Operated Lumbar Disc Herniation-A Single Center Experience

Sacral Epidural Laser Discectomy (SELD) which is an effective and minimally invasive procedure for the direct visualization and therapeutic treatment of pain due to spinal disorders. The aim of this study is to share the effect of SELD on clinical findings and pain. 43 patients who had not undergone back surgery and were found to have lumbar intervertebral disc herniation at L4-5 or L5-S1 level without any indication for back surgery, and who underwent SELD for the treatment patients with low back and/or radicular pain were evaluated. Physical examination findings (the straight leg raising test (SLR) <45 degrees positive(+), SLR >45 degrees negative(-) test were accepted) and visual pain scale (VAS) values were evaluated at admission, on the same day of post-op, 1st and 6th months. Disc herniation was observed at L4-5 level in 27 patients (62.79%) and at L5-S1 level in 16 patients (37.21%). 31 patients (72.09%) benefited from SELD treatment, while surgery was recommended for 10 patients (23.26%). With SELD procedure no permanent complication was observed. The clinical response of SELD according to the lumbar disc level, a more significant improvement was found in both physical examination and VAS scores in patients with disc herniation at the L5-S1 level (p<0.001). There was no statistically significant relationship between the SLR (+) side and the outcome. SELD is a more effective option, especially in patients with good physical examination findings at admission and mild-to-moderate soft disc herniation at the L5-S1 level.

INICIOS DE LA CIRUGÍA ENDOSCÓPICA DE COLUMNA EN EL PERÚ

In recent years, spinal endoscopy has become increasingly common in our setting; however, its use is not recent. The first reported cases date back to the early 2010s by a team from the Cayetano Heredia Hospital in charge of Drs. Wesley Alaba and Jerson Flores. Although other minimally invasive procedures such as nucleoplasty, nucleolysis, or percutaneous rhizotomies had already been used since the 2000s, it was not until 2011 that endoscopy was used for the first time in a standardized manner in spinal surgery with the endoscope as the only element of vision, successfully resecting a vertebral lesion. The first cases of vertebral pathology in which endoscopic surgery was used were the resection of a synovial cyst and a tuberculous abscess, followed by the resection of herniated discs at the L5-S1 level and later at the L3-L4 and L4-L5 levels. The first approach was the tubular interlaminar posterior approach, followed by the transforaminal endoscopic approach and the percutaneous posterior interlaminar approach. In the following years, endoscopy has been used not only in resecting herniated discs but also in treating central and lateral canal stenosis, reaching significant experience in this technique. The development of spinal endoscopy and its increasingly widespread use by neurosurgeons and traumatologists from different hospitals in the country represents an important advance in spinal surgery in Peru, which brings greater benefit to patients. Keywords: Endoscopy, Intervertebral Disc Displacement, Endoscopes, Neurosurgeons (source: MeSH NLM)

SPONDYLOPTOSE DYSPLASIQUE L5-S1 CHEZ UN ENFANT DE 7 ANS: ETUDE DE CAS ET REVUE DE LA LITTERATURE

A 7-year-old girl, a history of cleft palate surgery, presented with primary complaints of severe back pain with radiation to both lower limbs below the knees 2 months following, with inability to stand or walk, of unknown cause history. Her obstetric, developmental, and family history was normal. Inspection of her posture on standing revealed severe sagittal plane deformity including lumbosacral kyphosis and lumbar hyperlordosis with flexion at hips and knees (crouched position). with back pain radiating to the legs, motor and sensory dysfunction of the lower extremities, bladder dysfunction, and saddle anesthesias. Plain radiography and computed tomography (CT scan) showed bilateral L5 pars defect, dysplastic L5- S1 facets, trapezoidal L5 vertebral body, retroverted sacrum with rounding of proximal endplate, and complete anterior descent of the L5 vertebrae to the sacrum (Figures 2(a)–2(d)). Magnetic resonance imaging (MRI) of lumbosacral region revealed severe dural compression at L5-S1 level and L5-S1 intervertebral disc degeneration (Figure 3).

The impact of interbody approach and lumbar level on segmental, adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery

Interbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals. The purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery. Retrospective cohort. This retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology. Measurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1. Due to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened. 474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position. In this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level.

Application of electroneurostimulation of the peroneal and tibial nerve in the treatment of patients with neurological deficiencies after lumbosacral discectomy

In most patients after lumbar discoectomy, despite the elimination of root compression, the manifestations of chronic radiculopathy continue. Pain syndrome persists in 85.8% of patients, numbness in 74.1%, and paresthesia in 44.7%. Objective:to study the efficacy of transcutaneous electroneurostimulation (TENS) of the peroneal and tibial nerves in the treatment of patients with neurological deficit after undergoing discoectomy at the L4–S1 level. Materials and methods. After a course of pharmacotherapy, 15 patients underwent a course of direct stimulation of the peroneal and tibial nerves using transcutaneous electroneurostimulation, and 15 patients underwent a course of sham stimulation. Conclusion. Direct labile stimulation of the peroneal and tibial nerves using a monopolar current with a frequency of 1Hz, a duration of 200 μs and an amplitude that induces a painless motor response is a highly effective method of treating patients with residual clinical neurological manifestations after undergoing discoectomy at the L4–S1 level. Against the background of this method, the symptoms of tension, motor deficit, gait disturbance, impaired аchilles reflex and pain syndrome in the sensory and affective aspects are reliably regressed.

Unilateral approach with two-cage insertion for full endoscopic transforaminal lumbar interbody fusion: technical report.

The advantages of performing a transforaminal lumbar interbody fusion (TLIF) with two cages rather than a single cage include a larger cage-bone contact area and higher interbody stability. A customized cage guide is docked in the disc space created after a total facet resection. The first cage is inserted deeply into the contralateral disc space. The second cage is then inserted using the cage guide device while protecting the exiting and traversing nerve roots. We successfully inserted two cages from unilateral side during full endoscopic TLIF. This technique is recommended for L4-L5 and L5-S1 levels.

The Effect of Conventional Lumbar Spine Surgery on the Lumbar Multifidus Fat Infiltration

Aims: Low back pain is considered as a common problem that affects most adults at least once in their lives. Almost 90% of people experience back pain during their lifetime. The total cost of treating chronic low back pain in the United States is estimated at more than $ 100 billion annually. Hence, the present study aimed to investigate the effect of lumbar spine surgery on the lumbar multifidus fat infiltration in the patients referred to Imam Reza Hospital in 2020.&#x0D; Study Design: Prospective study.&#x0D; Place and Duration of Study: Department of Neurosurgery, AJA University of Medical Sciences (AJAUMS), Imam-Reza Hospital, Tehran between January 2020 and January 2021.&#x0D; Methodology: In the present prospective study, patients with disk herniation or lumbar spine canal stenosis referred to the neurosurgery clinic of Imam Reza Hospital in 2020 that underwent surgery were enrolled. After six months, they underwent lumbosacral MRI again. Multifidus muscles in primary MRI and sixth month MRI were compared at L4-L5 and L5-S1 levels and the changes were recorded.&#x0D; Results: A total number of 288 patients were enrolled in the present study during the study period. Based on the results, moderate fat infiltration (grade II) have had the highest frequency amongst the patients, and 52% of patients were in the moderate state in terms of adipose tissue infiltration in multifidus muscle postoperatively.&#x0D; Conclusion: Increased adipose tissue infiltration in the postoperative period was high and can be considered as a cause of disability and severe pain in patients after surgery. Due to the muscle atrophy six months post-surgery owing to intraoperative muscle injuries and consequently postoperative movement restriction, some exercises and physical therapy can be suggested to correct movement patterns and further reduce pain in the patients.

Effect of Pedicle Screw Fixation on Adjacent Segments in Osteoporotic Spine Following Transforaminal Lumbar Interbody Fusion Under Whole Body Vibration

Adjacent segmental degeneration (ASD) is the long-term complication of transforaminal lumbar interbody fusion (TLIF) combined with pedicle screw fixation. Both osteoporosis and whole-body vibration (WBV) can alter the biomechanics of adjacent segments. However, the effect of pedicle screw fixation on ASD in an osteoporotic spine after TLIF under WBV was unknown. According to a previously validated model of L1-S1, 2 osteoporotic TLIF models with and without pedicle screw fixation were developed. In each model, a 400 N preload was applied and a 5-Hz, 40 N sinusoidal vertical load with a 40-kg mass point was imposed on the superior surface of L1. The parameters of intradiskal pressure, shear stress of annulus fibrosus, disk bulge, superior and inferior end plate stress, and facet joint contact pressure at L3-L4 and L5-S1 levels were evaluated. At L3-L4, the dynamic responses in intradiskal pressure, shear stress, facet joint contact pressure, superior end plate stress, and inferior end plate stress generated an increase after pedicle screw fixation, and their maximum values increased by 15.1%, 9.5%, 18.6%, 10.6%, and 9.3%, respectively. However, the parameter of disk bulge demonstrated an opposite trend. At L5-S1, the differences in maximum values of the parameters were slight and the corresponding dynamic response curves were close, overlapping, or intersecting. In an osteoporotic spine after TLIF, removal of pedicle screw fixation can mitigate ASD in the upper adjacent segment but has no apparent influence on the lower adjacent segment under WBV.

Evaluation of the Association between Lumbar Spinal Stenosis and Lumbar Subcutaneous Fat Tissue Thickness by MRI: A Novel Perspective.

To evaluate whether lumbar subcutaneous fat tissue thickness (LSFTT) on midsagittal magnetic resonance imaging (MRI) is associated with lumbar spinal stenosis (LSS). Observational cross-sectional study. Department of Radiology and Neurosurgery, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey between January 2018 and December 2020. The study group included 79 patients, who had undergone surgery for lumbar spinal stenosis. The control group included MRI scans of 80 individuals without lumbar spinal stenosis. Association between LSFTT and LSS was analysed through a comparison of both the groups. The agreement between the two observers was found to be very good agreement with a two-way mixed intra-class correlation coefficient of 0.986 or higher (p <0.001). There was statistically significant differences between the LSS and non-LSS groups for both L5-S1 and L4-5 level measurements, p=0.001, and p=0.004, respectively. L5-S1 level measurements in the LSS group showed 29% increase in average with respect to the non-LSS group; and in L4-L5 level measurements, the increase was 40% in median. Females exhibited significantly higher values in both levels, (p <0.001 and p <0.001, respectively). Lumbar subcutaneous fat tissue thickness is significantly associated with lumbar spinal stenosis. Measuring LSFTT on mid-sagittal MRI is an easily applicable, reproducible alternative method for predicting LSS. Key Word: Lumbar, Spinal canal, Stenosis, Subcutaneous fat tissue, Magnetic resonance imaging.

Rehabilitation Following Lumbar Total Disc Replacement, With a Focus on Lumbar Multifidus Morphology and Function: A Case Report and Review of the Literature

Background Lumbar total disc replacement (TDR) is an option for patients with severe low back pain from degenerative disc disease who have failed conservative treatment. Paraspinal muscles have played an important role in clinical outcomes after lumbar surgery. The purpose of this study was to investigate lumbar multifidus morphology and function in a patient following lumbar TDR and a postoperative rehabilitation exercise program. Case Presentation A 52-year-old man underwent TDR surgery at the L5-S1 level to treat his chronic low back pain, which had been present for several years and unresponsive to previous conservative management. Six weeks after the operation, the patient initiated an 8-week postoperative rehabilitation program focusing on motor control and strengthening exercises. Outcome and Follow-Up The patient experienced clinically important improvements in pain and disability, as well as improvements in lumbar multifidus size ranging from 3.17% to 13.84% and changes in thickness contraction ranging from 4.04% to 16.48%, following the postoperative rehabilitation program. However, differences in lumbar multifidus muscle morphology and function were observed when comparing the surgical site to the superior motion segment. Discussion This case report displays limited evidence regarding the effects and implementation of a motor control and strengthening exercise program following lumbar TDR. Some improvements in muscle morphology and function were observed, along with improvements in pain and disability, after the completion of the exercise program. The importance of including lumbar multifidus morphology and function in the postoperative rehabilitation of this population may warrant further research. JOSPT Cases 2022;2(1):34–41. doi:10.2519/josptcases.2022.10163

Association between severe lumbar disc degeneration and self-reported occupational physical loading.

ObjectivesOccupational physical loading has been reported to be associated with intervertebral disc degeneration. However, previous literature reports inconsistent results for different vertebral levels. The aim of our study was to investigate the association between lumbar disc degeneration (LDD) at different vertebral levels and the self‐reported physical loading of occupation.MethodsThe study population consisted of 1,022 postmenopausal women and was based on the prospective Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study cohort. The severity of LDD was graded from T2‐weighted MRI images using the five‐grade Pfirrmann classification. Five intervertebral levels (L1–L2 to L5–S1) were studied (total 5110 discs). The self‐rated occupational physical loading contained four groups: sedentary, light, moderate, and heavy.ResultsThe heavy occupational physical loading group had higher odds for severe LDD at the L5–S1 vertebral level (OR 1.86, 95% CI: 1.19–2.92, p = .006) in comparison with the sedentary work group. A clear trend of increasing disc degeneration with heavier occupational loading was also observed at the L5–S1 level. Age, smoking, and higher body mass index (BMI) were associated with more severe LDD. Leisure‐time physical activity at the age of 11–17 years was associated with less severe LDD. Controlling for confounding factors did not alter the results.ConclusionsThere appears to be an association between occupational physical loading and severe disc degeneration at the lower lumbar spine in postmenopausal women. Individuals in occupations with heavy physical loading may have an increased risk for work‐related disability due to more severe disc degeneration.