L5-S1 Disc Herniation Research Articles

Retrolisthesis and lumbar disc herniation: a postoperative assessment of outcomes at 8-year follow-up

BACKGROUND CONTEXTLumbar disc herniation and retrolisthesis have been shown to be significant degenerative changes that can be associated with back pain. Current literature has shown evidence that retrolisthesis is associated with similar baseline function in patients with L5–S1 disc herniation, but worse postoperative outcomes 2 years after lumbar discectomy. However, literature comparing long-term postoperative outcomes at 8-year follow-up in patients with L5–S1 disc herniation with retrolisthesis is lacking. PURPOSEThe purpose of the present study is to compare long-term postoperative outcomes at 8-year follow-up in patients with retrolisthesis and L5–S1 disc herniations to patients with L5–S1 disc herniations without retrolisthesis. STUDY DESIGNRetrospective review of prospectively collected data from the Spine Patients Outcomes Research Trial (SPORT) database. PATIENT SAMPLESixty-five patients who underwent lumbar discectomy for L5–S1 disc herniations with 8-year follow-up from the SPORT. OUTCOME MEASURESShort Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index, Sciatica Bothersomeness Index, and reoperation rate. METHODSBaseline surgical parameters, length of stay, complication rates, reoperation rates, and outcome measures were recorded in the SPORT database. Follow-up data were collected at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. Retrolisthesis was defined as posterior subluxation ≥8%. Patients with and without retrolisthesis were compared using a mixed-effects model of longitudinal regression. Outcomes were calculated as time-weighted averages over 8 years. Reoperation rates were compared using the log-rank test based on time to first reoperation. RESULTSOne hundred-twenty five patients met inclusion criteria for the present study, including 29 patients with retrolisthesis (23.3%) and 96 patients who did not have retrolisthesis (76.7%). The greatest difference in clinical outcome measures was found at 2 years postoperatively. This was the only point at which both the Short Form-36 Bodily Pain scale (SF-36 BP) and PF showed significant differences between the retrolisthesis and nonretrolisthesis group. At 3 years, SF-36 BP was significantly lower in patients with retrolisthesis (39.9 vs. 52, p=.046).At 8-year follow-up, the presence of retrolisthesis in patients undergoing L5–S1 discectomy was not associated with worse outcome measure scores based on the area under the curve analysis for any metric investigated (SF-36 BP 41.4 vs. 47.1, p=.18; SF-36 Physical Function scale 38.9 vs. 45.4, p=.12; Oswestry Disability Index −39.4 vs. −34.8, p=.23; −11.6 vs. −10.4, p=.25) or a difference in reoperation rate (retrolisthesis group 10%, nonretrolisthesis group 17%, p=.41). CONCLUSIONSWhile retrolisthesis can contribute to low back pain and dysfunction in patients undergoing lumbar discectomy for L5–S1 herniated nucleus pulposus in early follow-up, no significant difference was found in postoperative outcomes after 3 years. Additionally, retrolisthesis was not found to be associated with different reoperation rates at 8 years postoperatively.

Outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar and transforaminal approaches in the treatment of L5-S1 disc herniation: An observational study.

The purpose of this retrospective study was to assess the clinical outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar approach versus the transforaminal approach under general anesthesia in the treatment of L5-S1 disc herniation.Sixty patients with L5-S1 disc herniation were non-randomly recruited and assigned into two groups. One group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the interlaminar approach under general anesthesia, while the other group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the transforaminal approach under general anesthesia. The operative time, fluoroscopy time, and perioperative complications were recorded. The visual analog scale (VAS) score for leg and back pain and Oswestry disability index (ODI) score were evaluated preoperatively and at 3, 6, and 18 months postoperatively.The mean operative time and fluoroscopy time in the interlaminar group were significantly shorter compared with those in the transforaminal group. The mean VAS and ODI postoperative scores were significantly improved over the preoperative scores in both groups. According to the MacNab classification system, more than 90.0% of the patients achieved an excellence/good rating in both groups. An intraoperative epineurium injury occurred in both groups. The total recurrence rate during 18 months follow-up was 3.3% in the interlaminar group and 0% in the transforaminal group.It is efficient and safe to perform discectomy by using full-endoscopic visualization technique via both interlaminar and transforaminal approaches under general anesthesia in patients with L5-S1 disc herniation. Discectomy performed by using full-endoscopic visualization technique via the interlaminar approach requires a shorter operative time and suffers less radiation exposure than the transforaminal approach.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 212. Surgery versus standardized nonoperative care for the treatment of lumbar disc herniations with 4-12 months of symptoms

BACKGROUND CONTEXT The beneficial treatment effect surgery demonstrates over conservative care for radiculopathy secondary to acute lumbar disc herniation (LDH), occurs in the first three to six months, thereafter outcomes are recognized to be similar. This is not surprising given the favorable natural history; 90% will experience gradual resolution of their symptoms within 4 months. In Canada, due to the inherent wait time to see a surgeon and the referring physician's expectation that most patients will improve without surgery, symptomatic patients presenting to surgeons are often the 10% that have remained symptomatic longer than the expected 4 months. Little is known about the effectiveness of treatments for this population with chronic sciatica. PURPOSE The purpose of this study is to determine if surgery is superior to conservative care in a patient population that has had persistent symptoms for more than four months. STUDY DESIGN/SETTING A single blinded (assessor) prospective randomized control trail performed at a single academic center. PATIENT SAMPLE We enrolled 18-60 year old patients with a unilateral, single radiculopathy from a posterolateral L4-5 or L5-S1 disc herniation. Radiculopathy duration had to be greater than 4 months but less than 12 months. OUTCOME MEASURES The primary outcome was numerical rating scale (NRS) for intensity of leg pain (0–10) and Oswestry Disability Index (ODI) measured at 6 months following treatment. Secondary outcome measures included NRS for back pain and leg pain, ODI, SF-36, work status, and satisfaction and is reported for 6 weeks, 3, 6, and 12 months follow-up. METHODS Patients on a waiting list to see surgeons at one academic hospital center were invited to a study screening session. Participation in the study expedited the patient's care to receive almost immediate care by either a study surgeon or physiatrist. Consented patients were randomized to early microdiscectomy or standardized nonoperative care including medications, education, physiotherapy, and steroid injections. Patients were excluded prior to randomization if they had previously received these conservative modalities or they were not a candidate for/or agree to possible lumbar discectomy. At the time of randomization, all patients randomized to the nonoperative treatment group were placed on the surgical consultation waiting list of one of the participating surgeons and were re-assessed for surgery when they reached the top of the regular waiting list. This waiting list is a minimum of six months. Therefore, the opportunity for cross-over to surgery at our center due to ongoing radiculopathy was possible only after a minimum of six months had passed following randomization, which was the primary outcome time point. RESULTS A total of 168/376 patients screened were determined eligible for enrollment.A total of 40 patients refused study participation. A total of 64 patients were randomized to early surgery and 64 to nonoperative care. There was no difference between groups in demographic characteristics or pretreatment patient-rated outcome measures. PretreatmentNSR leg pain was 8.0 (SD 1.8) for the nonoperative cohort and 7.7 (SD 2.0) for the surgical cohort. Pretreatment ODI was 50.2 (SD 15.9) for the nonoperative cohort and 49.7 (SD 15.8) for the surgical cohort. At the 6 months primary outcome data was available for 51/64 patients in the surgical cohort (11 missed visit, two withdrew) and 54/64 patients in the nonoperative cohort (eight missed visits, two withdrew). At 6 months NSR leg pain improved to 5.1 (SD 3.0) and 2.9 (SD 2.9) for the nonoperative and surgical cohorts respectively (p=.0001), while the ODI improved to 33.2 (SD 19.1) and 23 (SD 19.7) respectively (p=.008) on the intent-to-treat analysis. Treatment effect for all secondary outcome measures favored surgery. 22 patients in the nonoperative cohort crossed into surgical treatment; two received surgical treatment in another city at 8 weeks following enrollment which violated study protocol, 20 received surgery more than 6 months after enrollment by a study surgeon. Eight patients randomized to surgical treatment did not receive surgery; one developed a cardic event precluding surgery, seven patients improved before surgery and surgery was cancelled. A time-weighted overall treatment effect favored early surgery over delayed surgery (the 22 patients which crossed-over) for ODI, NSR back and leg pain, SF-36 physical and mental component summary scores. CONCLUSIONS Microdiscectomy is superior to nonoperative care for patients presenting with sciatica lasting greater than 4 months secondary to lumbar disc herniation.

Interlaminar Percutaneous Endoscopic Lumbar Discectomy: Rotate and Retract Technique

Interlaminar percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique to treat soft disc herniation. However, the currently used single working channel does not allow for safe nerve root retraction. This study aims to describe the rotate and retract technique for safe nerve root retraction during L5-S1 interlaminar PELD. A total of 17 patients who underwent interlaminar PELD with the rotate and retract technique between November 2016 and August 2017 were retrospectively evaluated. Both pre- and postoperative visual analog scale (VAS) scores (back and leg) and Oswestry Disability Index (ODI) scores were used for clinical assessment. The mean preoperative VAS scores for back and leg pain were 3.84 ± 1.15 (range, 2-6) and 8.7 ± 0.2 (range, 8-10), respectively. The mean preoperative ODI score was 64.2 ± 13.2 (range, 48-90). The mean VAS scores for back and leg pain decreased to 1.24 ± 1.34 (range, 0-6) and 1.15 ± 0.65 (range, 0-4), respectively, at the last follow-up (P < 0.001). The mean ODI score also improved to 13.2 ± 5.1 (range, 9-29) at the last follow-up (P < 0.001). The rotate and retract technique for interlaminar PELD is an effective maneuver for the treatment of L5-S1 disc herniations in selected patients if performed by experienced surgeons.

Soleus muscle H-reflex monitoring in endoscopic surgery under general anesthesia percutaneous interlaminar approach.

The clinical value of soleus muscle H-reflex monitoring in general anesthesia percutaneous interlaminar approach was investigated. A total of 80 cases with unilateral L5-S1 disc herniation between January 2015 and October 2016 were randomly divided into control group (without soleus muscle H-reflex monitoring, n=40) and observation group (with soleus muscle H-reflex monitoring, n=40). Results showed that the operation time of the observation group was shorter than that of the control group (P<0.05), and the blood loss during the operation was less than that of the control group (P<0.05). The length of postoperative hospital stay was shorter than that of the control group (P<0.05). At 24 h after operation, the amplitude of H-reflex in diseased side soleus muscle was significantly lower than that in healthy side (P<0.05). The preoperative, postoperative and 24 h postoperatively, the latency of H-reflex in diseased side soleus muscle was shorter than that of healthy side (P<0.05). The latency and amplitude of H-reflex latency in soleus muscle were significantly lower (P<0.05), and the height of intervertebral space in observation group was significantly higher than that in control group (P<0.05). The total percentage of postsurgical sensory dysfunction, dyskinesia, post-root canal stenosis, disc herniation and cerebrospinal fluid leakage was lower than that of the control group (P<0.05). Japanese Orthopaedic Association score of the observation group was significantly higher at 1 month, and 1 year after operation lower than the control group (P<0.05). Taken together, soleus muscle H-reflex monitoring can effectively reduce the damage to the nerve roots under percutaneous endoscopic intervertebral endoscopic surgery under general anesthesia, improve the accuracy of surgery, reduce the complications, shorten the operation time and reduce the surgical bleeding, which is more beneficial to patients smooth recovery.

A novel preoperative trajectory evaluation method for L5-S1 transforaminal percutaneous endoscopic lumbar discectomy

Background ContextL5-S1 transforaminal percutaneous endoscopic lumbar discectomy (PELD) is a demanding procedure because of structures such as iliac crest, L5 transverse process, hypertrophic L5-S1 facet joint, and sacral ala. There has been no definite preoperative evaluation method to evaluate the surgical validity of L5-S1 transforaminal PELD. PurposeThe authors report a new preoperative trajectory evaluation method for L5-S1 transforaminal PELD using magnetic resonance imaging (MRI) or computed tomography (CT) examinations. Study Design/SettingThis is a technical report study. Patient SamplePatients who were diagnosed L5-S1 soft disc herniation were included in the present study. Outcome MeasuresSuccess rate of transforaminal PELD according to height of iliac crest was measured. MethodsTwelve patients who were diagnosed L5-S1 disc herniation were preoperatively evaluated with this new method. A skin marker is attached to patient's back as a tentative skin entry point, which was determined by usual preoperative MRI or CT. A new tilted axial and coronal MRI or CT scan is performed according to axis of L5-S1 transforaminal working channel. The images show good relationship between working channel and iliac crest. ResultsSix patients underwent a transforaminal PELD, and the results were successful. The other six patients were considered to be “unsuitable” for transforaminal PELD because of the probable blockade by iliac crest. ConclusionsThe tilted MRI or CT provides precise evaluation for L5-S1 transforaminal PELD trajectory and may achieve good outcome.

Rapid Return To Sport After Lumbar Epidural Steroid Injection

HISTORY: A 66-year-old healthy active adult male with acute onset lumbosacral pain with referral into left leg while putting weights down after exercising. Initial primary care evaluation was unremarkable and patient was given Naprosyn, Percocet and an XRay was ordered, showing grade 1 spondylolithesis L2-3. Pain continued and he presented one week later with continued severe pain and new left lateral leg numbness. Oral steroids and physical therapy were initiated and pain continued. Gabapentin was tried with no response. He was seen at 9 weeks and complained of pain with all activities, including sitting. MRI was ordered and he was referred to physiatrist. He was seen one week later with 6/10 severe pain in left low back radiating down the left leg into lateral foot and ankle. Activity remains limited with pain even in the seated position and ADLs affected PHYSICAL EXAMINATION: Positive straight leg raise, decreased sensation left lower limb in the entire foot and lateral calf, 4/5 strength left ADF. DIFFERENTIAL DIAGNOSIS: Lumbar disc herniation, lumbar radiculopathy, spondylolithesis, lumbar stenosis. TESTS AND RESULTS: MRI Lumbar Spine without Contrast:L4-L5 broad-based left-sided disc herniation extruding inferiorly left paracentral measuring 16 x 14 x 15 mm effacing the thecal sac and displacing the left L5 nerve root. FINAL WORKING DIAGNOSIS:L5-S1 disc herniation with left L5 radiculopathy. TREATMENTS AND OUTCOMES: Symptoms persisted despite oral steroids, NSAIDs, and physical therapy, and lumbar epidural steroid injection was performed. Patient had 98% pain relief with resolution of numbness. Left ankle dorsiflexion strength that improved (5-/5), pain was only 1/10 in left lumbosacral junction. Physical therapy was restarted for 4 weeks to improve core strengthening. At 6 wks, numbness had resolved, strength had normalized, and he was back to normal activities of biking 21 miles and lifting regularly.

Percutaneous Endoscopic Interlaminar Discectomy for L5-S1 Adolescent Lumbar Disc Herniation.

L5/S1 Adolescent lumbar disc herniation (ALDH) is usually ignored for its low incidence. Recently, percutaneous endoscopic procedures have been widely used. To investigate the surgical techniques and clinical outcomes of percutaneous endoscopic interlaminar discectomy (PEID) in the treatment of adolescent L5-S1 disc herniation (ALDH). A retrospective study was performed between May 2012 and September 2014, which included 23 adolescent patients who underwent PEID for L5/S1 lumbar disc herniation. Ten females and 13 males were included, with a mean age of 15.4 years and a mean BMI of 25.1 kg/m2. The pre- and postoperative visual analogue scale (VAS), Japanese Orthopaedic Association (JOA), and modified MacNab scores, as well as perioperative data, were collected. The mean follow-up period was 19.7 months. The average operation time and hospital stay were 80.9 ± 7.3 minutes and 5.8 ± 1.2 days, respectively. During the follow-up period, the VAS for back and leg pain decreased significantly, and JOA scores greatly increased (p < 0.05). In terms of modified MacNab criteria, 86.9% of patients showed excellent or good results. After surgery, two patients complained of leg numbness, and another patient underwent a subsequent open discectomy due to recurrent disc herniation. Considering specific anatomical peculiarities and expectation for rapid recovery, PEID is a safe and effective minimally invasive technique for ALDH at the L5-S1 level.

Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation Via an Interlaminar Approach Versus a Transforaminal Approach: A Prospective Randomized Controlled Study With 2-Year Follow Up.

A prospective, randomized controlled study of patients with L5-S1 lumbar disc herniations, operated with endoscopic discectomy through an interlaminar or transforaminal approach. To compare the results of percutaneous endoscopic lumbar discectomy in L5-S1 disc herniation through an interlaminar or transforaminal approach. The transforaminal and interlaminar techniques are both acceptable approaches for L5-S1 disc herniation. This is the first study to compare these two approaches in terms of their surgical effects and advantages. From January 2010 to June 2010, 60 patients with L5-S1 disc herniation were randomly recruited into two groups; one group underwent percutaneous endoscopic interlaminar discectomy (PEID) and the other group underwent percutaneous endoscopic transforaminal discectomy (PETD). There were 30 patients in each group. The operation time, intraoperative radiation time, postoperative bed rest time, hospitalization time, and complications were compared between the groups. The surgical effectiveness was assessed according to the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and modified MacNab criteria. All the patients completed follow up with a mean of 27.6 months (range, 24-37 months). In the PEID group, the mean operation time was 65.0 ± 14.9 minutes, and the intraoperative radiation time was 0.60 ± 0.24 seconds. For the PETD group, the mean operation time was 86.0 ± 15.4 minutes, and the intraoperative radiation time was 6.50 ± 1.52 seconds. There were significant differences in operation time and radiation time between the two groups (P < 0.01) but not in the postoperative bed rest time, hospitalization time, or complication rate (P > 0.05). The postoperative ODI and VAS were obviously improved in both groups when compared with preoperation (P < 0.01). According to the MacNab criteria, the satisfactory rates were 93.3% and 90.0% in the two groups, without a significant difference (P > 0.05). PEID can escape the blockade of crista iliaca, and advantages include a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure. PETD requires higher punctuation skill and more intraoperative radiation exposure. 4.

Case Study

INTRODUCTION: Low back pain is a common complaint in pregnancy reported by over 50% of patients, however disc herniation is rare, affecting 1:10,000 pregnancies. Providers must be able to recognize severe and progressive neurological symptoms, like cauda equina syndrome, to prevent long-term sequelae. There are no other cases reported of a vaginal delivery as soon as 6 weeks after spinal surgery. METHODS: Case Study. RESULTS: A 32 yo G4P2 with longstanding back pain developed L5-S1 disc displacement at 32 weeks gestation. Due to progressive neurological dysfunction, she underwent bilateral hemilaminectomy and foraminotomy with L5-S1 discectomy under general anesthesia in the prone position. Her obstetrician scheduled her primary cesarean delivery at 39 weeks due to her spinal surgeon's concern of damaging her recent surgery. She had a precipitous vaginal delivery 1 day prior to her scheduled cesarean and 6 weeks after her surgery. Her back pain symptoms began to return 4 days postpartum and necessitated repeat surgery 4 weeks after delivery due to recurrent L5-S1 disc herniation and lower extremity radiculopathy. CONCLUSION: Data is lacking on the best mode of delivery on patients who have undergone spinal surgery. There are no case reports of vaginal delivery after a spinal surgery as recent as the third trimester. It is unclear whether vaginal delivery was the cause of reherniation in our case report. Cesarean delivery is not necessarily protective as demonstrated by a case report of herniation after scheduled cesarean delivery. We recommend a multidisciplinary team approach to manage patients on a case-by-case basis.

Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation: Consideration of the Relation between the Iliac Crest and L5-S1 Disc

Percutaneous transforaminal techniques for the treatment of lumbar disc herniation have markedly evolved. Percutaneous endoscopic lumbar discectomy (PELD) for L5-S1 disc herniation is regarded as challenging due to the unique anatomy of the iliac crest, large facet joint, and inclinatory disc space. Among these, the iliac crest is considered a major obstacle. There are no studies regarding the height of the iliac crest and their appropriate procedures in PELD. This study discusses PELD for L5-S1 disc herniation and the appropriate approach according to the height of iliac crest. Retrospective evaluation. 100 consecutive patients underwent PELD via the transforaminal route for L5-S1 disc herniation by a single surgeon. The study was divided into 2 groups: the foraminoplasty group requiring foraminal widening to access the herniated disc and the non-foraminoplasty group treated by conventional posterolateral access. Radiological parameters such as iliac height, the relative position of the iliac crest to the landmarks of the L5-S1 level, iliosacral angle and foraminal height, and disc location were considered. Clinical outcomes were assessed by the Visual Analogue Scale (VAS, 0 - 10) for back and leg pain, the Oswestry Disability Index (ODI, 0 - 100%), and the modified MacNab criteria. The overall VAS scores for back and leg pain decreased from 6.0 to 2.3 and from 7.5 to 1.7. The mean ODI (%) improved from 54.0 to 11.6. Using modified MacNab criteria, a good outcome was 92%. Foraminoplasty was required in 19 patients. Iliac crest height was significantly higher in the foraminoplasty group than the non-foraminoplasty group (37.7 mm vs 30.1 mm, P < 0.001). In the foraminoplasty group, the iliac crest is above the mid L5 pedicle on lateral radiography in all cases. There were no significant differences in foraminal height, foraminal width, iliosacral angle, or disc height between the 2 groups. In addition, there were no differences in clinical outcome between the 2 groups. This study is a retrospective analysis and simplifies the complexity of the L5-S1 level and iliac bone using two-dimensional radiography. In high iliac crest cases where the iliac crest is above the mid L5 pedicle in lateral radiography, foraminoplasty may be considered for transforaminal access of L5-S1 disc herniation. Conventional transforaminal access can be utilized with ease in low iliac crest cases where the iliac crest is below the mid-L5 pedicle.

Contralateral interlaminar approach for intraforaminal lumbar degenerative disease with special emphasis on L5-S1 level: A technical note.

Background:Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. Intracanal approaches frequently require partial or total facetectomy, which may lead to instability. Solely extraforaminal approaches may offer limited visualization of the more medial superiorly exiting and inferiorly exiting nerve roots; this approach is also more complicated at L5-S1 due to the often large L5 transverse process and the iliac wing.Methods:Nine patients with intraforaminal L5-S1 disc herniations, foraminal stenosis, or synovial cysts underwent contralateral interlaminar approaches for lesion resection. Preoperative and postoperative visual analog scale scores were evaluated, and complications were reviewed.Results:All 9 patients demonstrated immediate postoperative clinical improvement. None of the patients exhibited complications and none developed instability or neuropathic disorders.Conclusions:Although the number of cases in our sample was very small (9 in total), the contralateral interlaminar approach appeared to effectively address multiple degenerative L5-S1 foraminal pathologies. Large studies are needed to further evaluate the pros and cons of this approach.

Calcific Tendinopathy of the Gluteus Medius Mimicking Lumbar Radicular Pain Successfully Treated With Barbotage: A Case Report.

We report a case of calcific tendinopathy of the gluteus medius initially misdiagnosed as a lumbar herniated intervertebral disc. It was successfully treated with barbotage under ultrasonographic guidance finally. A 56-year-old woman was referred to interventional pain clinic for right hip pain due to an L5-S1 disc herniation. Serial L5 and S1 spinal nerve root blocks and epidural steroid injections were administered. However, pain relief was sustained only for a very short period. Plain radiography of the right hip revealed a solid calcific nodule at adjacent to the insertion site of the gluteus medius tendon. Physical modalities and extracorporeal shock wave therapy failed to improve the pain. Therefore, we attempted ultrasound-guided barbotage of the calcification. Barbotage was performed twice serially and her pain was considerably improved. At 6-month follow-up, the calcification was completely resolved.

L5 nerve root duplication in the setting of MRI-depicted L5-S1 disk herniation

Abstract Lumbosacral nerve root anomalies are rare anatomic variations with a predilection for the lumbosacral spine. Among these, conjoined nerve roots are the most common with other rare variants such as nerve root duplication occurring far less frequently. While these anatomic variations are exceedingly rare, their presence has significant clinical ramifications. Undiagnosed lumbosacral nerve root anomalies are at risk for iatrogenic injury, may contribute to wrong-site surgery and contribute to continued postoperative symptoms. Herein, we present a case of a 74 year-old female with diskogenic back pain and L5 radiculopathy found to have a duplicated L5 nerve root intraoperatively. Interestingly, the L5-S1 disk was found to be normal and unlikely to contribute to her presentation. She underwent L5-S1 laminectomy and L5 foraminotomy with resolution of her L5 radicular symptoms postoperatively.

Spinal subdural abscess following epidural steroid injection

The authors report the case of a 58-year-old man who presented with a cervicothoracolumbosacral spinal subdural abscess about a month after receiving an epidural steroid injection for management of low-back pain due to L5-S1 disc herniation. Although he presented with symptoms concerning for a spinal etiology, the subdural empyema was not evident on the initial MRI study and was observed on imaging 5 days later. This patient was successfully managed with surgical intervention and antibiotic treatment, and he is doing well more than 21 months after the operation. It is possible that a prior history of disc herniation or other spinal abnormality may increase a patient's risk of developing spinal subdural empyema. This case illustrates the risk of infection following spinal epidural steroid injections and the importance of early recognition and intervention to successfully treat an extensive subdural abscess.

Adjacent disc and facet joint degeneration in young adults with low-grade spondylolytic spondylolisthesis: A magnetic resonance imaging study.

Premature adjacent-level degeneration has been attributed to vertebral fusion, but spondylolisthesis has not been reported as a pathological factor responsible for the degeneration of adjacent disc and facet joint. We hypothesized that the degeneration of disc and facet joints in the adjacent levels is correlated with spondylolisthesis. Magnetic resonance images of 35 symptomatic young adults (16-29 years old) with low-grade L5-S1 spondylolytic spondylolisthesis (Meyerding Grade 1 or 2) and 50 symptomatic young referents (20-29 years old) with L5-S1 disc herniation without spondylolisthesis were recruited to compare the differences between disc and facet-joint degenerations at the olisthetic and adjacent levels using the Mantel extension test. There were statistically significant degenerative changes of the discs and facet joints at the olisthetic and adjacent levels of patients with spondylolytic spondylolisthesis compared with the reference group. There is a trend that the disc and facet joints degenerate the most at the olisthetic level and become less affected at adjacent levels away from the lesion of pars defect. Low-grade spondylolytic spondylolisthesis was associated with significant degenerations of the disc and facet joints at olisthetic and adjacent levels in young adults.

Microdiscectomy with and without insertion of interspinous device for herniated disc at the L5–S1 level

The role of interspinous devices (ISD) after lumbar herniated disc surgery for the prevention of postoperative back pain is controversial. The aim of this comparative prospective study was to determine outcomes in a selective cohort with L5–S1 disc herniation and degenerative disc changes after microdiscectomy with or without insertion of an ISD. One hundred and two consecutive patients underwent an L5–S1 microdiscectomy with or without implantation of an ISD. Group 1 consisted of 47 patients, with mild (n=22), moderate (n=14) or severe (n=11) degenerative disc changes who had microdiscectomy alone. Group 2 comprised 45 patients with similar types of disc changes who underwent microdiscectomy with an ISD implant. The Visual Analogue Scale (VAS) was used to grade low-back pain and postoperative clinical status was rated according to the modified MacNab criteria. Mean VAS score for low-back pain improved significantly at 1year follow-up from 7.3 at baseline to 2.75 (p<0.001) in Group 1 and from 6.7 to 1.5 (p=0.001) in Group 2. VAS score at 1year showed significant improvements in 21 Group 1 patients versus 30 Group 2 patients (p=0.001). Forty four percent of Group 1 patients and 80% of Group 2 patients showed improvement using the modified MacNab criteria. Patients in both groups reported significant improvement in sciatic pain and disability after microdiscectomy with or without an ISD implant. Patients with mild degenerative disc changes were more likely to achieve improvement of their low-back pain when treated with both microdiscectomy and ISD insertion.

DIAM Implantation for Degenerative Disc Disease

Introduction Lumbar disc degeneration (LDD) is among the most common causes of low back pain. Typical symptoms include axial low back pain, buttock pain, with or without radiation to posterior thighs or legs, and intolerance to upright positions. Several surgical treatment options are available, including intradiscal injections, intradiscal electrothermal therapy, discectomy, total disc arthroplasty, and fusion. Recently, implantation of interspinous process devices has been shown to decrease low back pain, and provide morphological alterations of the degenerative discs, resulting in satisfactory clinical outcomes. This study was conducted to review our results of using stand-alone DIAM implantation as the treatment for symptomatic LDD. Materials and Methods A total of 24 selected cases of LDD were treated surgically with stand-alone DIAM implantation. In 20 patients, the presenting symptoms were predominantly axial low back/buttock pain with little leg pain, while in 4 patients there was only axial pain. Motor weakness and sensory disturbance involving the corresponding nerve roots were present in eight cases. Three patients had undergone previous lumbar discectomy of the afflicted discs. Typical MRI findings included loss of height, signal changes, and/or annular tear of the discs. On the basis of Pfirrmann grading scale for disc degeneration, three cases were categorized as Grade II, and 21 cases as Grade III. Our exclusion criteria included intermittent claudication due to lumbar spinal stenosis, severe disc space collapse with Modic changes, greater than Grade II spondylolisthesis, facet ankylosis, and L5-S1 pathology. Provocative test with intradiscal injection of normal saline-induced concordant pain in all cases. Results All patients reported significant symptom relief after surgery, as reflected by VAS and ODI improvements. The final outcomes were excellent in 19, good in 2, fair in 2, and poor in 1 cases. Segmental flexion/extension mobility was maintained in 20, and restricted or lost in 2, of 22 cases with preoperative mobility. In the other two cases with no preoperative mobility, DIAM implantation did not change the status. MRI was repeated in the two cases showing fair, and the one case showing poor outcomes. In all of them, enlargement of neuroforamens at the implanted levels were found. In one fair case, disappearance of annular tear was observed. In the other fair case (L4-5 implantation), L5-S1 disc herniation was disclosed, and removed in a second operation. The case with poor outcome was diagnosed with depression, having concomitant multiple joint pain, dysmenorrhea, sleep disorder, despite normal findings on different exams ordered by different specialists. Conclusion In highly selected cases with symptomatic LDD, stand-alone interspinous DIAM implantation is effective for alleviation of symptoms, and stabilization of disc status. Disclosure of Interest None declared References Sandu N, Schaller B, Arasho B, Orabi M. Wallis interspinous implantation to treat degenerative spinal disease: description of the method and case series. Expert Rev Neurother 2011;11(6):799–807 Buric J, Pulidori M, Sinan T, Mehraj S. DIAM device for low back pain in degenerative disc disease : 24 months follow-up. Acta Neurochir Suppl (Wien) 2011;108:177–182 Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 2001;26(17):1873–1878

Microdiscectomy and Translaminar Approach: Mini-Invasiveness and Posterior Elements Conservation Relevance

Introduction Interlaminar approach represents the standard procedure for lumbar disc herniation surgical treatment. In case of cranial or lateral fragment migration into the neuroforamen (hidden zone), it is necessary to perform partial or total arterectomy to remove the herniated material, thus leading to iatrogenic vertebral instability risk. Materials and Methods Since January 2010, 40 patients with lumbar disc herniation and with disc fragment migration into the “hidden zone” underwent microdiscectomy by translaminar approach. Using a micro high-speed cutter, a 8 ± 2 mm fenestration at the level of affected side hemilamina was performed, displaying the involved root and removing the disc fragment. A clinical follow-up at months 1, 3, 6, and 12 was performed by mean of the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). A radiographic control at months 1, 6, and 12 was obtained (dynamic radiographic studies in last two times). Results In over 60% of cases, L4-L5 was the disk involved. Roots visualization was successfully achieved through translaminar approach. There was no need to associate neither partial or complete arterectomy nor flavectomy. An intraoperative bleeding occurred only in 5% of cases, as a consequence of an epidural veins involvement, treated through local hemostasis (Avitene) and without surgery time prolongation (mean duration 60 ± 10 minutes). There were no dural injuries. Patients showed an immediate and lasting radicular symptoms resolution. There was no need to perform revision surgery. Dynamic radiographic studies at months 6 and 12 did not detected instabilities. Conclusion Surgical microdiscectomy allowed us to successfully treat patients affected by lumbar disc herniation. Low back pain treatment and disc-root conflict resolution must be done conservatively avoiding iatrogenic instability risk. In case of cranial or lateral fragment migration into the neuroforamen, because a partial or total arterectomy could be requested for herniated disc fragment removal, this is not always possible. A conservative and minimally invasive approach, which allows to resolve disc-root conflict without affecting spine stability, represents a crucial technique. The translaminar approach is an anatomical, effective, and minimally invasive technique, suitable in cases of lumbar disc herniations with disc fragment migration into the hidden zone. It can be performed in all lumbar segments, not involving posterior elements (both bony and ligamentous ones), which are necessary for spine stability. In case of proper indications, this technique is more effective than the standard one because it allows symptoms relief, faster recovery times, less postoperative pain, and reduction in iatrogenic instability risk. Disclosure of Interest None declared References Papavero L, Kothe R. The translaminar approach for cranially extruded lumbar disc herniations. Oper Orthop Traumatol 2013;25(1):6–15 Seiz M, Pechlivanis I, Bag S, Schmieder K, Thome C, Tuettenberg J. [Translaminar fenestration for caudally herniated lumbar discs—a technical note]. Z Orthop Unfall 2009;147(5):597–599 Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach. Pain Physician 2013;16(6):547–556

(129) Refractory pain as a diagnostic symptom in uterine artery hematoma formation following vaginal labor: a case report

Spontaneous rupture of uterine arteries and their branches with hematoma formation are a rare, but known complication during vaginal labor. A hallmark feature of this complication is intense rectal pain immediately following delivery that is atypical of patients receiving epidural analgesia. In this case report, we discuss the refractory nature of this pain and its potential as a diagnostic symptom. Patient was a 31 year old G1P0 parturient at 37 +3 weeks of being induced for oligohydraminos and had a history of exercise-induced asthma, GERD, and L4-L5/L5-S1 disc herniations treated with steroid injections peripartum.