L5-S1 Disc Research Articles

Adolescent Lumbar Intervertebral Disc Herniation: Conservative versus Surgical Treatment

BACKGROUND: Lumbar disc herniation (LDH) in adolescents is relatively a rare condition among those cases presented with low back pain. Trauma and genetics are the most common predisposing factors. Furthermore, the clinical presentations differ from those of the adults. Back pain is not all marked in adolescent patients. AIM: This study was subjected to discuss the etiology, diagnosis and treatment modalities, and the variable outcomes for both medical and surgical treatment of LDH in adolescents. PATIENTS AND METHODS: This prospective study was conducted on 20 patients (12 males, eight females) age range 10–19 years presenting with LDH, managed and treated conservatively and/or surgically in Neurosurgery Department at Kasr Al Ainy School of medicine, Cairo University in the period from October 2015 to September 2016 with 12-month follow-up period. RESULTS: In our study, 12 patients (60%) gave a positive family history, also nine cases (45%) had a history of back trauma before affection with LDH. All the cases (100%) were presented with sciatic pain while only half of them had low back pain, also two cases with motor deficit. After performing magnetic resonance imaging of lumbosacral spine, L5-S1 disc level was the most common level affected. All the patients were subjected to medical treatment which was effective in 40% of the cases and surgical treatment was the only curative method in 12 cases (60%). In this study, the outcome was excellent in 90% of cases where significant to complete relief of pain and significant improvement in the neurological deficits was achieved. CONCLUSION: Conservative treatment is less effective for adolescent LDH patients as compared with adults, even though it remains the fi rst-line treatment for adolescent LDH.

Correlation of Magnetic Resonance Imaging findings with Clinical Grading in Lumbar Disc Degeneration: A Cross-sectional Study

Introduction: Low Back Pain (LBP) is the most common musculoskeletal symptom encountered on a daily basis in clinical practice and has a significant impact on healthcare resources. Magnetic Resonance Imaging (MRI) is the most sensitive tool for diagnosing spinal degenerative disease and has proven to be a standard imaging modality for its evaluation. Assessment of the correlation between clinical and radiological severity of lumbar disc degeneration will help in better management of the LBP patients. Aim: To determine the correlation between the clinical and radiological severity of lumbar disc degeneration in non surgical LBP patients. Materials and Methods: This observational, cross-sectional study was conducted at the Department of Radiology and Imaging, Sagar Hospitals, Bengaluru, Karnataka, India, from December 2019 to June 2021. A total of 90 patients with LBP who were referred for MRI evaluation were included. Modified Oswestry questionnaire was given to the patients and the clinical severity of the LBP was quantified. Patients with disc degeneration were evaluated on MRI based on six parameters viz., T2-signal intensity, Disc Extension Beyond Interface (DEBIT), annular fissure, modic changes, endplate integrity and osteophytes. Fisher's exact test was used for qualitative data to look into the association between clinical and MRI grades of severity. Correlation was assessed for continuous variables using Pearson correlation analysis. Results: The study included a total of 90 patients with LBP, with a mean age of 57±13.75 years with equal sex preponderance (45 (50%) male and 45 (50%) female). Clinically, 51 (56.7%) of the study population revealed moderate disability. On quantifying the MRI total score of disc degeneration, 65 (72.3%) of the patients were found to show mild degeneration. In terms of involvement of all the evaluated six MRI parameters, the L4-L5 disc was most commonly affected, followed by the L5-S1 disc. Disc desiccation 353 (78.45%) and osteophytes 336 (74.67%) were the most consistently observed variations. Disc bulges 251 (55.78%) were the next most frequently observed parameter in disc degeneration. Conclusion: The correlation between the clinical and radiological severity of disc degenerative disease was found to be weakly positive and statistically insignificant. Disc desiccation, osteophytes and disc bulges were the most commonly observed parameters that contributed to lumbar degenerative disease.

Effectiveness of ultrasonography-guided caudal epidural steroid injection in improving pain and functional status of geriatric patients with spinal pain

Introduction: Treatment of lumbar spinal pain in geriatric patients is challenging. This study retrospectively investigated the effects of an ultrasonography-guided caudal epidural steroid injection on pain and functional recovery in geriatric patients (age ≥65 years). Materials and Methods: Fifty-eight patients who received ultrasonography-guided caudal epidural steroid injection between December 2019 and March 2023 were retrospectively evaluated. Pain levels were evaluated using the Visual Analog Scale, and functional recovery was assessed using Oswestry Disability Index. The time points for evaluation were preoperative, immediately post-procedure, and at three weeks and three months post-procedure. Results: The main underlying conditions in this cohort were lumbar spondylosis, lumbar disc herniation, and lumbar spondylolisthesis. Thirty patients had multiple-level lumbar canal narrowing, 13 had L4-5 and L5-S1 disc herniation, and five had lumbar spondylolisthesis. Ten patients had a history of lumbar spinal surgery. Fourteen patients had at least three comorbid conditions (cardiovascular disease, morbid obesity, renal disease, etc.), and six had four comorbid conditions. Pain Visual Analog Scale scores in the immediate postoperative period and at three weeks and three months were significantly lower than the preoperative score (p < 0.001). Oswestry Disability Index scores at three weeks and three months postoperatively were significantly better than the pre-procedure scores (p < 0.001). Conclusions: Ultrasonography-guided caudal epidural steroid injection is an excellent pain management modality in the treatment of spinal pain, especially in the geriatric age group. Keywords: Pain; Steroid; Ultrasonography; Comorbidity.

The effect of lumbar multifidus cross-sectional areas on transforaminal epidural steroid injection: An observational clinical study.

Multifidus has an important role in spinal stability, and multifidus degeneration causes long-term disability and low back pain. This study aimed to investigate the effect of multifidus cross-sectional area on transforaminal epidural steroid injections (TFESI). Patients with single-level disc herniation were included in the study. Total multifidus cross-sectional area (TM-CSA) and functional cross-sectional area (FM-CSA) were measured from axial T2 MRI of the patients, and FM-CSA/TM-CSA ratio was calculated for determination of muscle degeneration or fat infiltration. Numerical Rating Scale (NRS) scores at the pre-injection, 3rd week, and 3rd month visits were recorded. A decrease of 50% or more in the NRS score in the 3rd month was accepted as a treatment success (TS), and patients were divided into TS and treatment failure groups. A total of 120 patients were included in the study; 57 of the patients were female, and 63 of them were male. Of the patients included in the study, 68 had herniation at the L5-S1 disc level and 52 had herniation at the L4-L5 disc level. FM-CSA and FM-CSA/TM-CSA ratio were found to be significantly lower below the disc herniation level on the affected side (p<0.05). The affected side TM-CSA and FM-CSA were higher in the TS group and TM-CSA/FM-CSA ratios were equal in both groups. Multifidus CSA was found to be lower on the affected side. However, the effect of multifidus CSA on the success of TFESI has not been determined.

Management of Lumbar Disc Herniation with Radiculopathy Through Ayurveda - A Case Study

Lumbar disc herniation is a major health problem, affecting the most productive population globally. It has closest resemblance with Gridhrasi mentioned in Ayurvedic classics. Treatments available in conventional sciences have limitations such as relapse of acute episodes. Here an effort was made to treat a case of L5-S1 disc extrusion with radiculopathy using a comprehensive Ayurveda treatment protocol. The protocol includes a set of treatment procedures along with certain internal medicines. Changes were analysed with the help of VAS scale, SLRT and Oswestry disability index and showed significant improvements. This case is an evidence to demonstrate the effectiveness of Ayurveda treatments in case of LDH with radiculopathy.

Performing 2-Stage Circumferential Fusion in an Adolescent With High-Grade Spondylolisthesis: A Surgical Technique.

The surgical approach to high-grade spondylolisthesis at the lumbosacral junction remains controversial. Appropriate surgical techniques can be challenging with the potential for high complication rates, particularly with reduction. Multiple techniques have been described including posterior only reduction and instrumentation, posterior only instrumentation with in situ arthrodesis, and anterior-posterior reduction and instrumentation. Regardless of technique, the operative goals are to provide sufficient stability and biological support to promote bony fusion, maintain global balance, and decompress the neural elements while avoiding neurological complications. During instrumentation of a high-grade spondylolisthesis at the lumbosacral junction, it can be difficult to obtain access to the L5-S1 disc space for interbody insertion. We present a novel technique for improving access to the L5-S1 disc space through an osteotomy of the anterior-inferior aspect of the L5 vertebral body as part of a 2-stage circumferential fusion in the treatment of high-grade spondylolisthesis in an adolescent.

Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation.

Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation. To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5-S1 disc herniation. A total of 32 patients (average age: 49.4 years, range: 23-78) with L5-S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical "The Medical Research Council of the United Kingdom" method. The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz-Ilbay plantar flexion test yielded the correct classification for all cases. We suggest that the proposed method "Yilmaz-Ilbay plantar flexion test" can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5-S1 herniation.

P122. Comparing long term deformity correction and other outcomes between single level circumferential XLIF and MI-TLIF: a retrospective review with 5-year minimum follow up

<h3>BACKGROUND CONTEXT</h3> XLIF with percutaneous pedicle screw fixation (circumferential XLIF) and MI-TLIF are two commonly used minimally invasive approaches to the lumbar spine. Because of its lateral approach, traditional XLIF is blocked to the L5-S1 disc space by the iliac crest. Studies that have compared these two techniques typically do not account for this limitation and, furthermore, tend to not restrict their analysis by number of levels operated on. Additionally, studies evaluating long term (>5-year) outcomes of these techniques are less numerous. Therefore, this study aims to compare the clinical and radiological outcomes of single level circumferential XLIF and MI-TLIF exclusively at the L4-L5 disc space. <h3>PURPOSE</h3> To compare the clinical and radiological outcomes of single level XLIF and MI-TLIF at L4-L5. <h3>STUDY DESIGN/SETTING</h3> Retrospective comparative study. <h3>PATIENT SAMPLE</h3> A total of 108 total patients (75 MI-TLIF and 33 circumferential XLIF) that underwent single level surgery at L4-L5 at a single institution from 2008 to 2015 with a minimum of 5-year follow up. <h3>OUTCOME MEASURES</h3> 1) Patient demographics: age, sex, BMI, length of follow up; 2) rate of complications requiring a return to the OR (RTO); 3) Radiographic outcomes: graft subsidence, final anterior and posterior disc height (ADH and PDH); 4) Patient outcome scores: Oswestry Disability Index (ODI), Visual Analogue Scale (VAS). <h3>METHODS</h3> A retrospective review was performed to identify all patients between 2008-2015 who underwent circumferential XLIF or MI-TLIF with a minimum followup of 5 years. Demographic data, complication-related data, radiographic outcomes and patient outcome scores were recorded and compared between cohorts. Standard binominal and categorical comparative analyses were performed. <h3>RESULTS</h3> A total of 108 patients were included for analysis (75 MI-TLIF and 33 circumferential XLIF). Mean age (53.5 MI-TLIF and 53.9 XLIF), BMI (32.3 MI-TLIF and 31.4 XLIF), and length of follow up (90 months MI-TLIF and 103 months XLIF) were similar between cohorts. Overall RTO rate was found to be statistically similar between groups at 16.0% (95% CI, 9.24-26.07) in the MI-TLIF group and 6.1% (95% CI, 0.68-20.60) in the XLIF group. Final ADH was 9.03±1.10 mm in the MI-TLIF group and 12.3±2.60 mm in the XLIF group (p < 0.0001). Final PDH was 9.97±1.96 mm for MI-TLIF and 7.12±2.2 mm for XLIF (p < 0.0001). Average DH was 9.50±1.59 mm and 9.71±2.41 mm for the MI-TLIF and XLIF groups, respectively (p=0.593). Change in ODI and VAS scores at final follow up were similar between MI-TLIF and XLIF groups (p=0.629 for ODI and p=0.322 for VAS). <h3>CONCLUSIONS</h3> This long-term comparative study demonstrates similar clinical and radiological outcomes between single level MI-TLIF and circumferential XLIF at the L4-L5 level. As expected, MI-TLIF had significantly greater long-term improvement in posterior disc height and XLIF had significantly greater improvement in anterior disc height. However, average disc height was found to be similar between groups. This suggests that although MI-TLIF and circumferential XLIF lead to equivalent long-term improvement at the L4-L5 level, choosing one's approach based on the anterior versus posterior disc anatomy of the patient may enhance patient outcome. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Incidence and Characteristics of Clinical L5-S1 Adjacent Segment Degeneration after L5 Floating Lumbar Fusion: A Multicenter Study.

Retrospective study. This study aimed to evaluate the incidence, characteristics, and risk factors for clinical L5-S1 adjacent segment degeneration (ASD) after L5 floating lumbar fusion. ASD is known to occur after lumbar spine fusion at a certain frequency. Several studies on radiological L5- S1 ASD have been reported. However, there are only a few studies on L5-S1 ASD with clinical symptoms, including back pain and/or radiculopathy. In total, 306 patients who received L5 floating lumbar fusion were included in this study. Clinical L5-S1 ASD was defined as newly developed radiculopathy in relation to the L5-S1 segment. Patients' medical records and imaging data were retrospectively analyzed. The risk factors for clinical ASD were assessed by an inverse probability of treatment weighting-adjusted logistic regression analysis. Clinical L5-S1 ASD occurred in 17 patients (5.6%). The mean onset time of L5-S1 ASD was 12.9±7.5 months after the primary surgery. Among these patients, 10 (58.8%) presented with clinical L5-S1 ASD within 12 months. Reoperation was performed in three patients (1.0%). The severity of L5-S1 disk degeneration did not affect the occurrence of L5-S1 ASD. Logistic regression analysis showed that the number of fusion levels was a significant risk factor for clinical L5-S1 ASD. The incidence and characteristics of clinical L5-S1 ASD after L5 floating lumbar fusion were retrospectively investigated. This study established that the number of fusion levels was a significant candidate factor for clinical L5-S1 ASD. Careful clinical follow-up is deemed necessary after L5 floating lumbar fusion surgery, especially for patients who received multiple-level fusions.

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 nerve compression after malunion of vertical sacrum fractures.

Introduction and importanceUnstable pelvic ring injuries often occur in high energy traumas. Vertical sacrum fracture is an associated injury. This report describes a late spinal nerve compression that occurred following surgical reduction and fixation of pelvic ring injuries caused by traumatic L5-S1 disc herniation and malposition of the sacral fracture.Case presentationA 61-year-old female presented with radiculopathy in her right leg after surgical reduction and fixation of a sacral and pelvic fracture. Physical examination revealed numbness and weakness of the right leg. Radiographic studies showed spinal compression caused by a fracture spike from the malunion of the sacrum and protruding disc from the L5/S1 level. The fracture spikes were removed by laminectomy and discectomy after which the patient's condition had improved and she had no recurrent symptoms at the one-year follow-up.Clinical discussionMalunion of a posterior pelvic ring fracture and a herniated adjacent intervertebral disc can cause sacral nerve root compression. This complication can be managed and satisfactory results achieved by surgical intervention.ConclusionTraumatic L5-S1 disc herniation and malposition following surgical reduction and fixation of a sacrum fracture can be avoided. Posterior decompression by laminectomy and discectomy is an effective alternative treatment for patients with this condition.

Comparative analysis of the effects of OLIF and TLIF on adjacent segments after treatment of L4 degenerative lumbar spondylolisthesis

BackgroundThe fusion of the lumbar spine may lead to the degeneration of the adjacent segments. In this study, the effects of OLIF and TLIF on adjacent segments after treatment of L4 degenerative lumbar spondylolisthesis (DLS) were compared and analysed.MethodsThis was a retrospective analysis of the medical records of consecutive patients treated with OLIF or TLIF for L4DLS. They were divided into the OLIF group and TLIF group based on different treatment methods. Cage height, segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were compared between the two groups, and the postoperative biomechanical changes were analysed by establishing the disc angle (DA). The clinical outcomes were analysed by comparing the visual analogue scale (VAS), Oswestry Disability Index (ODI) and incidence of adjacent segment disease (ASDis) between the two groups. The intervertebral disc height (IDH), intervertebral foramen height (IDH), intervertebral foramen area (IFA), sliding distance (SD), and angular displacement (AD) in L3-4 and L5-S1 were compared between the two groups. The incidence of aggravated disc degeneration (ADD), the incidence of aggravated zygapophyseal joint degeneration (AJD) and the incidence of adjacent segment degeneration (ASDeg) were compared between the two groups for radiological degeneration.ResultsAt the last follow-up, there was one case of ASDis in the OLIF group (2.78%) and two cases in the TLIF group (5.56%). At the last follow-up, compared with the preoperative values, IDH, IFH, and IFA of the adjacent segments above and below L4-5 decreased in both groups (P < 0.05); the SD and AD increased in both groups (P < 0.05). The cage height and L4-5 IDH in the OLIF group were significantly higher than those in the TLIF group (P < 0.05). SL, LL, PT, SS, and L5- S1DA were significantly improved in the OLIF group compared with the TLIF group (P < 0.05). The incidence of L3-4ASDeg in the two groups was higher than that of L5-S1. The incidence of ASDeg and the incidence of L5-S1ADD in the OLIF group were lower than those in the TLIF group, but the incidence of L5-S1AJD was higher than that in the TLIF group.ConclusionL4DLS after OLIF and TLIF treatment will cause adjacent segment degeneration, and L3-4 degeneration is more obvious than L5-S1 degeneration. OLIF has more advantages in restoring lumbar sagittal balance. Compared with TLIF, OLIF can weaken the degeneration of the L5-S1 disc and increase the degeneration of the L5-S1 zygapophyseal joints.

Does the sagittal spinal profile differ between the elderly Chinese populations with and without lumbar disc herniation?

To explore the characteristics of the sagittal spinopelvic profile in the elderly Chinese population with lumbar disc herniation (LDH) and to evaluate its influence on the severity, location and number of disc degeneration. A retrospective analysis was conducted on 212 elderly Chinese patients with LDH and 213 asymptomatic volunteers with matched age and sex. Sagittal spinopelvic parameters were measured on the full-length X-ray and the sagittal profiles were determined according to the Roussouly classification. The severity, location and number of lumbar disc degeneration were evaluated from the L12 to L5S1 discs on the MRI images. There were no significant differences in BMI between the two groups. Patients with LDH were found to have significantly smaller TK, LL, and SS than those in the asymptomatic population (P<0.05), while contradicting observations were obtained of PT and TPA (P<0.05). In the LDH group, Roussouly type 1 and type 2 (50.4% and 28.7%, respectively) were predominant and the proportion of type 1 in the elderly LDH population was further increased compared to the younger LDH population. LDH population with Roussouly type 1 and 2 showed more caudal herniated locations and fewer herniated numbers than those with type 3 and 4. The sagittal spinopelvic profile was significantly different between the elderly Chinese population with and without LDH. There were significant differences in the Roussouly distribution between the elderly and the younger groups and different Roussouly types have different effects on the lumbar disc degeneration patterns.

Disc Degeneration in Lumbar Spine of Asymptomatic Young Adults: A Descriptive Cross-Sectional Study.

This descriptive cross-sectional observational study aimed to investigate the prevalence of various types of disc degeneration in the lumbar spine of asymptomatic young adults. The disc degeneration of lumbar spine could be due to age-related physiological changes than to pathological changes in asymptomatic people. Due to the ethnic and racial differences in lifestyle, it is proposed that the prevalence of disc degeneration in the normal population in different region of the world would differ. There are scarce data on the Indian population on the same. Fifty individuals between 15 and 30years of age, with no history of low back pain undergoing MR imaging for spinal pathology other than the lumbar spine, were included in the study. Various abnormalities (herniation HN, annular fissure AF, nuclear degeneration ND) were recorded and their prevalence was calculated by disc counts (DC) and person count (PC). DC is the number of discs with degeneration and PC is the number of patients with disc degeneration. 56% asymptomatic individuals were found to have either HN or AF or ND at one or more levels. The DC of disc degeneration was 20.8% and it was most commonly observed in L4-L5 intervertebral disc (38%) followed by L5-S1 disc (30%). Thirteen individuals had disc degeneration at single level, 12 at two levels and 3 individuals at all the five lumbar intervertebral disc levels. The current study showed a high prevalence of disc degeneration (either HN, AF or ND) in young asymptomatic individuals. Even if the MRI shows disc degeneration, patients can be asymptomatic and one needs to correlate the symptoms with the MRI. The limitations of the current study are small numbers of patients from a localized geographical area; hence, we recommend a larger multi-centric study as a follow-up.

Treatment of lumbar osteochondrosis by intercuteneous laser diskectomy

Fifteen patients with lumbar osteochondrosis complicated by L4-L5 and L5-S1 disk protrusion treated by interosseous laser diskectomy are reviewed. Early and long-term results are given. In 14 patients (93%) good results were achieved, 1 patients (7%) had satisfactory outcome. Indications for intercutaneous laser diskectomy are the following: low back pain irradiating to lower extremity, and persistent over 3 months, failed conservative treatment, absence of neurologic complications, such as paresis, disturbance of pelvic organs function as well as disk protrusion (size up to 6 mm) confirmed by CT, MRI. This method does not damage soft tissues and allows to achieve persistent release of pain syndrome.

Minimally Invasive Deformity Correction Technique: Initial Case Series of Anterior Lumbar Interbody Fusion at L5–S1 for Multilevel Lumbar Interbody Fusion in a Lateral Decubitus Position

Many surgical options exist for multilevel lumbar interbody fusion, including anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF). While current technique of repositioning patients between supine ALIF and lateral decubitus LLIF offers many benefits, intraoperative repositioning can be cumbersome. We present a novel approach that accomplishes both multilevel LLIF and L5-S1 ALIF in a lateral decubitus position. This case series retrospectively enrolled 12 consecutive patients who underwent L5-S1 ALIF in the lateral decubitus position and anterior-to-psoas LLIF at more cranial levels as part of a multilevel lumbar interbody fusion surgery between September 2020 and December 2021. All surgeries were performed by a single spine-focused neurosurgeon at an urban academic hospital. Radiographic imaging analysis demonstrated significant changes in coronal Cobb angle (-5.43°±3.81°; P=0.0029), global lumbar lordosis (6.77°±12.04°; P=0.0049), segmental lumbar lordosis (8.91°±10.21°; P=0.0005), spinopelvic mismatch (-7.93°±7.91°; P=0.0010), average disc height (5.30±1.64mm; P=0.0005), and L5-S1 disc height (6.68±2.10mm; P=0.0005). Two patients developed postoperative complications including wound dehiscence and grade I graft subsidence at L4-L5. This case series demonstrated that a combined lateral decubitus L5-S1 ALIF and LLIF at more cranial levels is a safe, efficient approach to multilevel lumbar interbody fusions. This technique significantly restored spinopelvic alignments with a low complication rate and no patient repositioning. Efficacy of this minimally invasive deformity correction technique should be further investigated through a multicenter trial.

Surgically Relevant Morphological Parameters of the L5-S1 Interlaminar Window: A Statistical Analysis Based on 3D Reconstruction of CT Data.

The interlaminar window is the most important anatomical corridor during the posterior approach for lumbar and lumbosacral pathologies. Three-dimensional (3D) reconstruction of the L5-S1 interlaminar window including accurate measurements may be beneficial for the surgeon. The aim of this study was to measure relevant surgical parameters of the L5-S1 interlaminar window based on 3D reconstruction of lumbar computed tomography (CT). Fifty thin-layer CT data were retrospectively collected, segmented, and reconstructed. Relevant surgical parameters included the width, left height, right height, interpedicular distance (IPD), area, and suitable approach area of the L5-S1 interlaminar window. Morphological measurements were performed independently by two experienced experts. Patients with disk herniation at L5-S1 were regarded as group A (n = 28) and those without L5-S1 disk herniation were regarded as group B (n = 22). The average left height, right height, width, and area of the L5-S1 interlaminar window were 9.14 ± 2.45 mm, 9.55 ± 2.46 mm, 23.55 ± 4.91 mm, and 144.57 ± 57.05 mm2, respectively. The average IPD at the superior, middle, and inferior pedicle levels was 29.29 ± 3.39, 27.96 ± 3.38, and 37.46 ± 4.23 mm, respectively, with significant differences among these three parameters (p < 0.05). The average suitable approach areas of the L5-S1 interlaminar window were the following: left axilla-24.52 ± 15.91 mm2; left shoulder-27.14 ± 15.48 mm2; right axilla-29.95 ± 17.17 mm2; and right shoulder-31.12 ± 16.40 mm2 (p > 0.05). There were no significant differences between groups A and B in these parameters (p > 0.05), except the inferior IPD (36.69 ± 3.73 vs. 39.23 ± 3.01 mm, p = 0.017 < 0.05). The morphological measurement of the L5-S1 interlaminar window based on 3D reconstruction provided accurate and reliable reference data for posterior microsurgical and endoscopic approaches as well as percutaneous infiltrations.

Localization of L5–S1 Disc Space by Utilizing Simple on Table Surface Marking in Posterior Lumbar Spine Surgery without Any Radiological Assistance

Background: Localization of the spinal levels is an important task during any spinal surgery. The purpose of the study is to assess the accuracy and reliability in identifying L5–S1 disc space by surface localization using Venus of dimple as a landmark in posterior spinal surgery without undertaking any radiological assistance. Methodology: We prospectively analyzed 39 patients, who had undergone primary posterior spine surgery, especially for Prolapsed intervertebral disc mostly affecting the lumbosacral region. Following surface marking using Venus of dimple as a landmark, patients were subjected to surgery with or without prior X-ray evaluation solely on surface localization of L5–S1 disc space. Intraoperatively, the accuracy and reliability of the surface marking were determined. Results: Sixty-four percent of the patients had accurate L5–S1 spine level localization utilizing the above clinical palpatory methods, while 23% of the cases identified L5 spine intraoperatively. On analyzing this surface topographical method with that of X-ray in standing position, the sensitivity and specificity came to be 93.3% and 49%, respectively, with a positive predictive value of 77.8%. Conclusion: The method of localization of L5–S1 space described although cannot fully replace the role of fluoroscopic assistance during spinal surgery, still it is an important, simple, and reliable alternative method of localization which demands its application by the spine surgeons, especially in the beginning of their carrier and in certain specific situations.

Lumbar Multifidus Muscle Fatty Atrophy and Lumbar Disc Degeneration: Are they Associated in Middle Aged Patients with Low Backache?

Introduction: Low backache being one of the most common problems faced in the society mainly due to sedentary lifestyle and reduced physical activity which inturn leads to overweight, obesity and atrophy of paraspinal muscles. Disc prolapse is one of the most common causes of low backache. Hence, knowing the aetiological factors and treatment of the same at an early stage is beneficial. Aim: To determine the association between the grades of lumbar disc degeneration with degree of fatty infiltration of lumbar multifidus muscle in middle aged patients with low backache using Magnetic Resonance Imaging (MRI). Materials and Methods: A prospective observational study was conducted from April 2020 to February 2021 in Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India, with a study population of 201 middle aged patients who complaints of low back pain for more than three months. All patients who met the inclusion and exclusion criteria underwent plain MRI for Lumbosacral (LS) spine with 16 channel 1.5 tesla strength MR machine. Lumbar intervertebral disc degeneration was graded according to the Pfirrmann classification using T2 sequence in the sagittal plane. For the evaluation of the degree of fatty infiltration of lumbar multifidus muscle, axial T2-weighted slices were used to detect the cross-sectional area of the right and left lumbar multifidus muscle involvement. Chi-square test was used to find the association between varying grades of disc degeneration and severity of fat infiltration at Lumbar (L)4-L5 and L5-Sacral (S) 1 regions. Results: There was significant association between the grade of lumbar disc degeneration and the degree of atrophy of multifidus muscle with p-value &lt;0.001 in middle aged patients with low backache. There was significant relation with fatty muscle infiltration with a p-value of &lt;0.001 in L4-L5 and 0.03 in L5-S1 disc spaces. Most of the patients had grade III intervertebral disc degeneration in both L4/L5 and L5/S1. Conclusion: Lumbar multifidus muscle atrophy is common in grade 3 Pfirrmann classification of lumbar disc degeneration at both L4/L5 and L5/S1 levels.

Should the Surgical Instrument Parts That Are Broken and Remain in the Distance of the Disc Be Removed? Should It Be Quit? A Case Report

Background and Aim: Lumbar posterior open microdiscectomy is a procedure that is widely used to treat lumbar disc diseases. These operations have a low risk of complications. It is unusual for the tool to break and remain in the intervertebral space during surgery. In this situation, we wanted to provide a set of suggestions based on our research of the literature on pituitary forceps blade fractures and the procedure for removing the fractured portion from the disc space during lumbar posterior open microdiscectomy surgery. Case Presentation: 10 days ago, a 37-year-old female patient presented to our clinic complaining of low back pain, left leg pain, and left foot weakness. A diagnosis of lumbar disc herniation necessitating surgery was obtained following neurological and radiographic examinations. The patient was advised to have surgery. The patient had standard lumbar microdiscectomy surgery. However, the tip of the pituitary forceps was broken during disc removal and remained in the L5-S1 disc space. The scope confirmed that the alien object was in space. After the evaluation, it was decided to remove the piece of instrument that was broken and remained in the disc space. The broken surgical handpiece was removed and documented under fluoroscopy. Additionally, it was forwarded to the technical unit for examination. Conclusion: A few case reports in the literature describe a surgical tool piece fracture that remained in the disc distance of the lumbar microdiscectomy. Complication management may be time-consuming and risky. Such a complication should be addressed and resolved appropriately because this situation might have detrimental terms on surgical risks and the legal procedure.