Symptomatic Disc Research Articles

Tandem Disc Herniation of the Lumbar and Cervical Spine: Case Series and Review of the Epidemiological, Pathophysiological and Genetic Literature.

IntroductionLumbar disc herniation (LDH) and cervical disc herniation (CDH) represent a relevant public health problem. Patients with symptomatic tandem herniations of the cervical and lumbar spine are rare and not described in the literature. In these patients, certain variables may predispose the development of disc herniation which could increase the understanding of the development of disc herniations. Our aim is to present the first case series of tandem disc herniation, and to elucidate whether tandem herniation is attributable to a certain propensity for disc herniation or not.Methods From a prospective registry, patients with symptomatic tandem disc herniations were included, and the literature was reviewed on the comparative pathophysiology, genetics, and epidemiology of disc herniation and disc degeneration.ResultsOut of 3,156 patients with disc herniations in our registry, 16 presented with symptomatic tandem LDH and CDH that required discectomy. Therefore, we estimate the incidence of tandem disc herniation at 0.51% (95% confidence interval (CI): 0.26% - 0.75%) in the surgical population. The mean number of degenerated lumbar discs was 2.1 ± 1.1. Compared to the 1,241 patients with isolated LDH, no investigated factors were significantly associated with tandem herniations.ConclusionFrom a genetic, pathophysiological, and epidemiological position, disc herniation is not commonly a consequence of disc degeneration. Rather, degeneration and herniation seem to exist as two separate and distinctly different processes. Based on the literature, it is tenable that tandem disc herniation does not deviate from the normal pathophysiology, but rather occurs in the rare case that two individual herniated discs coincide.

Validation of Patient-reported Outcomes Measurement Information System Computer Adaptive Tests in Lumbar Disk Herniation Surgery.

Inadequate validation, floor/ceiling effects, and time constraints limit utilization of standardized patient-reported outcome measures. We aimed to validate Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) for patients treated surgically for a lumbar disk herniation. PROMIS, CATs, Oswestry Disability Index, and Short Form-12 measures were administered to 78 patients treated with lumbar microdiskectomy for symptomatic disk herniation with radiculopathy. PROMIS CATs demonstrated convergent validity with legacy measures; PROMIS scores were moderately to highly correlated with the Oswestry Disability Index and Short Form-12 physical component scores (r = 0.41 and 0.78, respectively). PROMIS CATs demonstrated similar responsiveness to change compared with legacy measures. On average, the PROMIS CATs were completed in 2.3 minutes compared with 5.7 minutes for legacy measures. The PROMIS CATs demonstrate convergent and known groups' validity and are comparable in responsiveness to legacy measures. These results suggest similar utility and improved efficiency of PROMIS CATs compared with legacy measures. Level II.

Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach.

Although symptomatic thoracic disk herniation (TDH) is relatively rare, its treatment is quite difficult. Our aim is to present the outcomes and complications in patients with thoracic disk herniation treated with minimally invasive lateral transthoracic approach (LTTA). Fifty-nine consecutive patients with 69 symptomatic disk herniations that underwent minimally invasive LTTA to treat TDH between 2007 and 2016 were enrolled. Medical records were reviewed retrospectively. The numbers of TDH were as follows: 41 central, 10 paracentral, and 18 both central and paracentral. The number of calcified disk herniations was found to be 32. No patient developed neurological deficit. Postoperative neurological improvement occurred in 39 (90.7%) of 43 patients with myelopathy. Preoperative VAS scores, ODI scores, and SF-36 scores improved at the follow-up, respectively. Mean blood loss, hospitalization period, and follow-up period were found to be 391.2mL, 4.7days, and 60months; respectively. The following complications were observed: dural tear (five patients), intercostal neuralgia (three patients), rib fracture (one patient), pleural effusion requiring chest tube (two patients), hydropneumothorax requiring chest tube (one patient), small pneumothorax (one patient), atelectasis (one patient), pulmonary embolism (one patient), and pneumonia (one patient). Minimally invasive LTTA not only minimizes the manipulation of the thecal sac decreasing the risk for neurological injury compared to traditional posterior methods but also significantly decreases the pulmonary complications associated with traditional open procedures. Based on the authors' experience, anterior approach should be preferred especially in calcified central disk herniations regardless of surgeon's experience.

Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease.

Background:Anterior cervical discectomy and fusion (ACDF) is a well-described surgical approach for symptomatic degenerative cervical disc disease which does not respond to conservative management. In the present study, we assessed clinical presentation and outcomes of ACDF.Materials and Methods:The present study was conducted from October 1, 2015, to October 31, 2017, in the Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, among 100 consecutive adult patients who underwent single- or two-level ACDF for degenerative cervical disc disease.Results:The mean age was 47.2 ± 12.8 years (range: 20–74 years). Majority of the patients were male (86/100). Presenting symptoms were neck pain (77%), limb weakness (73%), paresthesias (53%), radicular pain (49%), stiffness in limbs (16%), and bladder involvement (13%). Fusion was done with stand-alone titanium cage/bone graft or titanium cage/bone graft with anterior cervical plate. At the time of discharge, significant improvement in preoperative symptoms (neck pain [47/77-61%], radicular pain [31/49-63%], limb weakness [53/73-72.6%], paresthesias [44/53-83%], stiffness in limbs [13/16-81%], and bladder symptoms [8/13-61%]) was reported by majority of these patients. Majority of these patients also reported improvement in preoperative sensory deficits at the time of discharge. Postoperative complications were hoarseness of voice (22%), dysphagia (16%), deterioration of motor power (8%), and postoperative hematoma (7%).Conclusions:A significant proportion of patients with degenerative cervical disc disease show remarkable recovery after ACDF.

The NECK trial: Effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blinded randomized controlled trial

BACKGROUNDMotion preserving anterior cervical disc arthroplasty (ACDA) in patients with cervical radiculopathy was introduced to prevent symptomatic adjacent disc degeneration as compared with anterior cervical discectomy and fusion (ACDF). Prior reports suggest that ACDF is not more effective than anterior cervical discectomy (ACD) alone for the treatment of cervical radiculopathy. PURPOSETo evaluate whether patients with cervical radiculopathy due to a herniated disc benefit more from undergoing ACDA, ACDF, or ACD in terms of clinical outcome measured by the neck disability index (NDI). STUDY DESIGNDouble-blinded randomized controlled trial. METHODSOne hundred-nine patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without fusion. Clinical and radiological outcome was measured by NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF36, EQ-5D, patients’ self-reported perceived recovery, radiographic cervical curvature, and adjacent segment degeneration parameters at baseline and until two years after surgery. BBraun Medical paid €298.837 to cover the costs for research nurses. RESULTSThe NDI declined from 41 to 47 points at baseline to 19 ± 15 in the ACD group, 19 ± 18 in the ACDF group, and 20 ± 22 in the ACDA group after surgery (p=.929). VAS arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life, measured by the EQ-5D, increased in all three groups. Adjacent segment degeneration parameters were comparable in all three groups as well. No statistical differences were demonstrated between the treatment groups. CONCLUSIONSThe hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a 2-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA.

Treatment outcome of quality of life and clinical symptoms in patients with symptomatic lumbar degenerative disc diseases: which treatment modality is superior?

This was to assess the quality of life and clinical symptoms before and after treatment of patients with symptomatic lumbar degenerative disc disease (LDDD). It was also to determine the superior treatment for well-selected patients: conservative versus surgical treatment. Prospective interventional analytical study. We studied 160 adult symptomatic patients aged 31-60years with diagnosis of LDDD who were enrolled between May 2016 and November 2017. Their pre- and post-treatment clinical symptoms and signs and quality of life were studied using the Oswestry disability index (ODI). The data was analysed using SPSS version 24. One hundred fifty-three adult patients aged 31 to 60years completed the study. The male-to-female ratio was 1:1.5 while the symptom duration ranged between one and 14years. The treatment modalities were medical (46%), epidural steroid injection (26%) and operative treatment (28%). The responses to the treatment were worsened symptoms (10.5%), no improvement (13.1%), moderate/slight improvement (27.5%) and significant improvement (49%). There were statistically significant improvements (p value < 0.05) in clinical symptoms, sign and ODI at six months after treatment. Surgical treatment was superior to all other form of care. This study showed significant improvement in outcome among the participants in different treatment modalities with surgical treatment being the superior. We recommend surgical treatment for well-selected adult patients with symptomatic LDDD and assessment of quality of life and clinical symptoms before and after treatment.

319. Is Chronic Vertebral Disk Infection With Low Virulence Bacteria a Common Cause of Back Pain?

BackgroundIn 1998 Modic described changes in vertebral body marrow with magnetic resonance imaging, and related those changes to pathological findings in the adjacent disc that were similar to those seen in bacterial discitis. As early as 2001 Stirling noted a relationship between sciatica and Propionibacterium acnes cultured from disc space material obtained at discectomy. In 2013 Albert demonstrated that Modic type I changes, strongly associated with low back pain, responded to 100 days of antibiotic treatment in a large randomized controlled trial. The findings were controversial, and we proposed that modern microdiscectomy techniques would minimize the potential for contamination with the common skin bacteria reported most often in previous studies.MethodsWe performed a prospective uncontrolled case series of patients undergoing microdiscectomy for symptomatic disc degeneration or herniation. Subjects were greater than 18 years old, nonpregnant, with chronic low back pain, and meeting standard criteria for microdiscectomy. After giving informed consent, data were extracted from existing medical records and cultures of disc material were obtained at discectomy prior to perioperative prophylactic antibiotics, and were processed by standard methodology for aerobic, anaerobic and acid-fast bacterial growth.ResultsThirty-three patients were included in the study, mean age 52.6 (SE 3.1), 19 females and 14 males. The study was terminated after these 33 cases when only one aerobic culture was positive from one male subject, and this for a minimal growth of Staphylococcus epidermidis.ConclusionIf a significant fraction of chronic low back pain is indeed caused by chronic infection with low-virulence bacteria, this would be a paradigm shift in the evaluation and management of a common and often debilitating condition. In our study of patients with chronic low back pain undergoing microdiscectomy, we did not find evidence of chronic low-virulence bacterial infection.Disclosures All authors: No reported disclosures.

Cervical disc degeneration and neck pain.

Cervical intervertebral disc has long been considered a common source of neck pain. However, the pain caused by the disc itself has not been clearly defined so far, and its diagnosis and treatment has always been controversial. Degenerative cervical disc has a rich supply of nerve fibers, is prone to inflammatory reactions, and is susceptible to pain that can be provoked by disc stimulation or distention, and can be eliminated by block. Overwhelming clinical evidence demonstrates that neck pain in patients with degenerative cervical radiculopathy or myelopathy can be subsided rapidly by anterior cervical surgery, further indicating that this neck pain stems from the pathology of cervical disc itself. Cervical discography is advocated as the only test that connects disease to symptoms, but the procedure remains controversial. If strict criteria and technique are maintained, discography can discriminate painful, symptomatic discs from nonpainful, asymptomatic discs. Discogenic neck pain alone without cervical disc herniation or cervical spondylosis accounts for a large proportion of chronic neck pain. For these patients who continue to have refractory neck pain and fail to respond to conservative treatment, anterior cervical fusion surgery or artificial cervical disc replacement may be a better choice, and preoperative cervical discography can guarantee the excellent surgical results. Existing basic and clinical studies have scientifically shown that cervical intervertebral disc degeneration can lead to neck pain.

Efficacy of an ethyl alcohol gel in symptomatic disc herniation

PurposeTo evaluate the clinical outcome of DiscoGel® chemonucleolysis for symptomatic disc herniation in patients who fail conservative treatment. Material and methodsConsecutive patients with symptomatic disc herniation confirmed on MRI who failed conservative management for at least 6 months were included. Visual analogue scale (VAS), Oswestry Disability Index (ODI) scores, and analgesic use were recorded at baseline, and 12 months after treatment. Multidetector CT (MDCT) was performed at baseline, and 12 months after treatment to assess for DiscoGel® extravasation and alteration in treated disc volume. In a unique long-term subgroup analysis of 31 patients, telephonic follow-up was performed utilizing VAS and ODI parameters 7 years after the procedure. ResultsA total of 87 disc herniations were treated in 71 patients; majority (54%) were treated at L4/5 and L5/S1. VAS score of 8 before treatment was reduced to 3 at 12 months after treatment (p = 0.0001); ODI score of 51 before treatment was reduced to 15 at 12 months after treatment (p = 0.0001). Analgesic use of 70.4% was reduced to 29.6% after treatment. There were no symptomatic procedural complications; MDCT revealed 1 asymptomatic peri-neural DiscoGel® extravasation. In the 31 subjects that underwent telephonic follow-up the VAS and ODI parameters maintained their values without statistically significant differences when compared with the 12-month follow-up. ConclusionPatients with symptomatic disc herniation who failed conservative treatment and were treated with DiscoGel® chemonucleolysis achieved significant gains in pain relief and reduced disability without symptomatic complication. DiscoGel® chemonucleolysis is a feasible, minimally invasive technique for treatment of symptomatic disc herniation.

Lumbar Total Disc Replacement by the Lateral Approach–Up to 10 Years Follow-Up

This study aimed to analyze radiologic and clinical results with a minimum 5 years follow-up (FUP) of lateral lumbar total disc replacement for the treatment of symptomatic lumbar degenerative disc disease. We performed a prospective, single-center, clinical, and radiologic study. Patients were treated with lumbar total disc replacement (extreme lateral total disc replacement) by a lateral transpsoas approach. From 2005 to 2012, 60 patients were enrolled (31 male, 29 female; total, 66 levels; average age, 42.8 years [standard deviation (SD), 9.7 years, range, 22-64 years]; mean body mass index, 26.0 [SD, 3.4]). Clinical end points included visual analog scale and Oswestry Disability Index questionnaires, complications, and reoperation. Radiographic end points included heterotopic ossification (McAfee classification), adjacent level disease, and prosthesis migration or subluxation. The mean surgical duration was 122 minutes (SD, 45 minutes) with mean 58 mL (SD, 21 mL) of estimated blood loss. No intraoperative complication occurred. The exceptions were 1 patient with postanesthesia apnea and 2 patients with quadriceps motor deficit (resolved within 4 months with physiotherapy). Of 60 patients, 9 were missed to FUP and 51 (85%) were enrolled in the study, with mean FUP of 92 months (range, 60-122 months). In total, 5 levels (9%; 5 of 55) required to be fused. Both removal of the prostheses and interbody fusion were performed by the lateral transpsoas approach. One patient experienced CrCo allergy (at 2 months); 4 experienced persistent pain from different causes (at 7, 9, 24, and 88 months). Five patients (10%) presented with progression at adjacent levels and 2 (4%) required surgery. One patient required sacroiliac fusion at 63 months. There were no complications during the retrieval surgeries. One partial disc migration occurred but the patient refused retrieval. There was no bone bridging in 9% of the discs (grade 0 heterotopic ossification): grade I, 22%; grade II, 31%; grade III, 20%; grade IV (fusion), 18%. Most heterotopic ossification cases (93%) occurred in the lateral aspect of the disc space, and mostly at the contralateral side of the surgical approach. Patient-reported outcomes significantly improved (P < 0.01) at the last FUP. Visual analog scale back pain score was preoperatively 8.5, early postoperatively 2.5, and at last FUP 3.1. Oswestry Disability Index was preoperatively 55%, early postoperatively 31%, and at last FUP 21%. This study presents mid-term to long-term results of extreme lateral total disc replacement artificial disc for the treatment of lumbar degenerative disease, with fast mobilization, sustained pain relief, and improved physical function. Despite the low rate of ALDis, some discs evolved to ankyloses and others were retrieved. Lumbar artificial disc replacement by the lateral approach seems to be a safe and effective treatment.

Comparing stand-alone oblique lumbar interbody fusion with posterior lumbar interbody fusion for revision of rostral adjacent segment disease: A STROBE-compliant study.

Spinal fusion has become a standard treatment for symptomatic intervertebral degenerative disc disease. The present study aimed to compare perioperative parameters, clinical outcomes, and radiographic results of stand-alone oblique lumbar interbody fusion (OLIF) with posterior lumbar interbody fusion (PLIF) for the revision of rostral adjacent segment disease (ASD) following prior posterior lumbar fusion.Thirty-six patients who underwent revision surgeries for rostral ASD were retrospectively reviewed. Among them, 17 patients underwent stand-alone OLIF (OLIF group) and 19 patients underwent PLIF (PLIF group). The length of operation, intraoperative hemorrhage, bed rest duration, and length of hospital stay were compared between the 2 groups. Clinical results were evaluated with the Oswestry Disability Index (ODI) and visual analog scale (VAS). Radiological results were evaluated with disc height (DH), foraminal height (FH), retrolisthesis index (RI), and lumbar lordosis (LL), as well as the fusion rate and cage subsidence. Follow-up results at 1 week, 3 months, and 12 months postoperatively were compared between the 2 groups.The OLIF group had less intraoperative blood loss, shorter operative time, bed rest time, and hospital stay than did the PLIF group (P < .05). The OLIF group had lower VAS scores for back pain than the PLIF group at 1 week and 3 months postoperatively (P < .05), and lower VAS scores for leg pain than the PLIF group at 1 week postoperatively (P < .05). The OLIF group had lower ODI than the PLIF group at 1 week and 3 months postoperatively (P < .05). No significant differences were found in DH and FH between the 2 groups preoperatively (P > .05); the OLIF group showed higher DH and FH than the PLIF group at all time points (P < .05). No significant differences were found in RI and LL between the 2 groups at any time point. All patients achieved fusion at 12 months postoperatively, and cage subsidence was not observed in either group.OLIF is effective and safe for the treatment of rostral ASD following prior posterior lumbar fusion, and is superior to PLIF in terms of perioperative parameters, short-term clinical outcomes, and DH restoration, with similar fusion and reduction rates.

Motion analysis of dynamic cervical implant stabilization versus anterior discectomy and fusion: a retrospective analysis of 70 cases.

Retrospective kinematic analysis of treated level, adjacent levels, and overall cervical spine after single-level dynamic cervical implant (DCI) stabilization versus anterior cervical discectomy and fusion (ACDF). Between June 2009 and March 2013, 70 consecutive patients with a symptomatic single-level cervical degenerative disk disease (DDD) were enrolled in this study and divided into DCI (n = 35) group and ACDF (n = 35) group. All cases were followed up for more than 5years. The study compared perioperative parameters; clinical outcomes; and radiological parameters. Kinematic analysis included range of motion (ROM) of treated level and adjacent level, overall ROM (C2-C7), and changes in adjacent disk spaces. There were no significant differences between the DCI group and ACDF group in terms of improvement in the SF-36, VAS, NDI, and JOA scores. DCI stabilization resulted in better ROM of C2-C7 and the treated level than ACDF did. The ROM of treated level decreased significantly at 24months after surgery and last follow-up in the DCI group, and the C2-C7 ROM showed different degrees of reduction after the 24months after surgery. Radiological evidence of adjacent segment degeneration (ASD) at last follow-up was observed in 4/22 patients (18.2%) in the DCI group and 5/23 patients (21.7%) in the ACDF group which was not a significant difference between groups (p > 0.05). DCI stabilization for the treatment of cervical DDD cannot preserve the normal kinematics of the cervical spine for a long time, especially the treated level. DCI stabilization cannot decrease the risk of ASD compared with ACDF. These slides can be retrieved under Electronic Supplementary Material.

Transfacet and Transpedicular Posterior Approaches to Thoracic Disc Herniations: Consecutive Case Series of 24 Patients

Various approaches are advocated for symptomatic thoracic disc herniation (TDH). The aim of this series is to demonstrate the feasibility, safety, and results of posterior transfacet or transpedicular approaches for excision of all types of extradural TDH. We report a consecutive series of patients undergoing posterior approach surgery for TDH. Twenty-four patients (17 women, 7 men) underwent surgery at 25 disc levels. Mean age was 56.3 years (range, 23-79 years). A posterior transfacet or transpedicular approach was used. Patients presented with myelopathy (n= 21, 88%), radiculopathy (n= 8, 33%), sphincter dysfunction (n= 16, 67%), and axial back pain (n= 10, 43%). Preoperative imaging revealed 7 (30%) central, 14 (61%) calcified, and 10 (43%) large disc herniations. The mean follow-up period was 6.0 months (range, 2-36 months). Eighteen patients underwent unilateral approach surgery (5 transfacet and 13 transfacet plus transpedicular), and 7 patients required bilateral approach laminectomy for unilateral (n= 4) or bilateral (n= 3) discectomy. One patient required unplanned reoperation for resection of residual disc. Average operative time was 95 minutes (range, 40-175 minutes). Mean hospital stay was 4.9 days (range, 2-35 days). There were no major complications. Postoperative Frankel scores were maintained or improved in all patients at last review. TDH including large central calcified discs can be safely removed through posterior transfacet or transpedicular approaches with reduced morbidity in comparison with more invasive anterior approaches. Careful microsurgical technique and use of specialized instruments are important for successful excision of TDH from a posterior approach.

Annular closure device for disc herniation: meta-analysis of clinical outcome and complications

BackgroundLumbar intervertebral disc herniation is a common cause of lower back and leg pain, with surgical intervention (e.g. discectomy to remove the herniated disc) recommended after an appropriate period of conservative management, however the existing or increased breach of the annulus fibrosus persists with the potential of reherniation. Several prosthesis and techniques to reduce re-herniation have been proposed including implantation of an annular closure device (ACD) – Barricaid™ and an annular tissue repair system (AR) – Anulex-Xclose™. The aim of this meta-analysis is to assist surgeons determine a potential approach to reduce incidences of recurrent lumbar disc herniation and assess the current devices regarding their outcomes and complications.MethodsFour electronic full-text databases were systematically searched through September 2017. Data including outcomes of annular closure device/annular repair were extracted. All results were pooled utilising meta-analysis with weighted mean difference and odds ratio as summary statistics.ResultsFour studies met inclusion criteria. Three studies reported the use of Barricaid (ACD) while one study reported the use of Anulex (AR). A total of 24 symptomatic reherniation were reported among 811 discectomies with ACD/AR as compared to 51 out of 645 in the control group (OR: 0.34; 95% CI: 0.20,0.56; I2 = 0%; P < 0.0001). Durotomies were lower among the ACD/AR patients with only 3 reported cases compared to 7 in the control group (OR: 0.54; 95% CI: 0.13, 2.23; I2 = 11%; P = 0.39). Similar outcomes for post-operative Oswestry Disability Index and visual analogue scale were obtained when both groups were compared.ConclusionEarly results showed the use of Barricaid and Anulex devices are beneficial for short term outcomes demonstrating reduction in symptomatic disc reherniation with low post-operative complication rates. Long-term studies are required to further investigate the efficacy of such devices.

Posterolateral Endoscopic Thoracic Discectomy: Transforaminal Approach

Objective: Symptomatic soft herniated thoracic disc (HTD) before the use of magnetic resonance imaging (MRI) was a rare disease with less than 1% of all spinal disc herniation. The frequency of diagnosis of thoracic disk herniation has increased with the routine use of MRI. To avoid high morbidity and complications associated with conventional approach, the authors applied posterolateral endoscopic technique.Methods: From January 2001 to December 2016, 87 patients with non-sequestrated and soft lateral or central thoracic disc herniation underwent posterolateral endoscopic thoracic discectomy (PLETD). Under local anaesthesia with intravenous sedation, we removed the herniated disc through thoracic intervertebral foramen after foraminoplasty. The enlargement of the foramen by partially cutting the lateral aspect of superior facet with a Reamer or high-speed diamond drills. Clinical outcome was measured by the Oswestry Disability Index (ODI) and the visual analogue scale.Results: Fifty-one males and thirty-six females, aged 21 to 89 years were enrolled in this study. Mean follow-up period was 10 months (1 to 56 months). The mean ODI scores improved from 53.7 before surgery to 16.9 at the final follow-up (p &lt;0.05). Mean VAS scores improved from 7.3 before surgery to 2.1 at the final follow-up (p &lt;0.05). One patient required conversion to an open procedure for recurred disc protrusion in 17 days. Another one patient required repeated PLETD for recurring disc in l year. Three patients experienced transient low extremity paresthesia but all improved. There were no other serious complications associated with this procedure.Conclusion: Conventional treatment of HTD is known for its high morbidity and complications, posing a challenge to physicians. This PLETD technique for symptomatic non-sequestrated and soft HTD is a safe and effective method that provides a direct route to the lesion under local anaesthesia with less morbidity.

Posterolateral Endoscopic Thoracic Discectomy: Transforaminal Approach

Objective: Symptomatic soft herniated thoracic disc (HTD) before the use of magnetic resonance imaging (MRI) was a rare disease with less than 1% of all spinal disc herniation. The frequency of diagnosis of thoracic disk herniation has increased with the routine use of MRI. To avoid high morbidity and complications associated with conventional approach, the authors applied posterolateral endoscopic technique.Methods: From January 2001 to December 2016, 87 patients with non-sequestrated and soft lateral or central thoracic disc herniation underwent posterolateral endoscopic thoracic discectomy (PLETD). Under local anaesthesia with intravenous sedation, we removed the herniated disc through thoracic intervertebral foramen after foraminoplasty. The enlargement of the foramen by partially cutting the lateral aspect of superior facet with a Reamer or high-speed diamond drills. Clinical outcome was measured by the Oswestry Disability Index (ODI) and the visual analogue scale.Results: Fifty-one males and thirty-six females, aged 21 to 89 years were enrolled in this study. Mean follow-up period was 10 months (1 to 56 months). The mean ODI scores improved from 53.7 before surgery to 16.9 at the final follow-up (p &lt;0.05). Mean VAS scores improved from 7.3 before surgery to 2.1 at the final follow-up (p &lt;0.05). One patient required conversion to an open procedure for recurred disc protrusion in 17 days. Another one patient required repeated PLETD for recurring disc in l year. Three patients experienced transient low extremity paresthesia but all improved. There were no other serious complications associated with this procedure.Conclusion: Conventional treatment of HTD is known for its high morbidity and complications, posing a challenge to physicians. This PLETD technique for symptomatic non-sequestrated and soft HTD is a safe and effective method that provides a direct route to the lesion under local anaesthesia with less morbidity.

Endoscopic Access to the Ventral Thoracic spine: PETD vs. Thoracoscopy

Symptomatic thoracic disc herniation (TDH) is estimated to afflict between 1 in 1,000 and 1 in 1,000,000 people; affecting men more frequently than women, with the highest incidence seen at 40-50 years of age. TDH occurs at all levels of the thoracic spine but 75% of cases occur below T8, with T11-T12 being the most common site due to spinal mobility and weakness of the posterior longitudinal ligament.Manipulation of the thoracic spinal cord through the conventional posterior approach has been associated with poor outcomes. A conventional posterior approach consisting of laminectomy, cord retraction, and disc removal was historically done to treat TDH but this causes spinal cord injury and irreversible paraplegia due to cord manipulation on the relatively rigid spinal cord.The anterior approach to the spine is also intimidating to the spine surgeon due to the unique anatomy of the thoracic spine. Conventional open approaches to the thoracic spine involve a thoracotomy, rib resection, and corpectomy to view the spinal cord anteriorly. This has been associated with perioperative morbidity due to surgical site pain, difficult/painful breathing, shoulder girdle dysfunction, and wound healing problems.In order to spare the patients suffering from these postoperative iatrogenic sequelae, the author presents two different minimally invasive approach techniques; percutaneous endoscopic thoracic discectomy (PETD) vs. thoracoscopy, each applied to a different indication or thoracic pathology, to gain an enough but safe access to the ventral thoracic spinal canal through minimized surgical damages without yielding a postsurgical morbidity.

Elevated inflammatory cytokine expression in CSF from patients with symptomatic thoracic disc herniation correlates with increased pain scores

BACKGROUNDThe pathophysiology of pain in patients with symptomatic thoracic disc herniation (TDH) remains poorly understood. Mere mechanical compression of the spinal cord and/or the exiting nerve root by a prolapsed disc cannot explain the pathogenesis of pain in all cases. Previous studies report a direct correlation between the levels of proinflammatory cytokines in disc biopsies and the severity of leg pain in patients with lumbar disc herniation. A similar correlation in patients with TDH has not been investigated. PURPOSETo correlate the cerebrospinal fluid (CSF) expression of cytokines and pain-related amino acids with preoperative pain scores in patients with symptomatic TDH. STUDY DESIGNA prospective human study of CSF samples and clinical outcome scores. METHODSUsing enzyme-linked immunosorbent assay (ELISA) and high-performance liquid chromatography (HPLC), we determined inflammatory cytokine levels (TNF-α, IL-1β, and IL-10) and amino acid levels (glutamate, aspartate, gamma-aminobutyric acid, glycine, and arginine) in CSF samples from 10 patients with TDH and 10 control subjects who did not suffer an inflammatory disease nor pain related to spinal cord compression and subsequently correlated these levels with preoperative pain scores. Differences between both groups were evaluated by a Mann-Whitney U test. In order to estimate the correlation between cytokine or amino acid expression and pain scores, data were analyzed using a linear regression analysis. RESULTSNo inflammatory cytokines were found in CSF samples from control subjects, whereas TNF-α, IL-1β, and IL-10 were detectable by ELISA in all CSF samples from patients with TDH. TNF-α and IL-10 but not IL-1β levels moderately correlated with preoperative pain scores. Elevated TNF-αlevels positively correlated with high pain scores; elevated IL-10 levels negatively correlated with high pain scores. Amino acids were detectable in all samples from both groups. There were no significant differences between the groups in any of the amino acids measured with HPLC. CONCLUSIONIncreased proinflammatory cytokine expression is associated with elevated pain scores in patients with symptomatic TDH. On the other hand, there is no conclusive correlation between the intensity of pain and the local or systemic presence of amino acids associated with pain transmission.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P62. Application of laparoscopic lumbar discectomy and artificial disc replacement: at least two years of follow-up

BACKGROUND CONTEXT Symptomatic degenerative disc disease is the major cause of low back pain with lumbar segmental instability. Artificial disc replacement (ADR) has increased in popularity as an alternative treatment for lumbar disc herniation. However, the traditional approach to spinal surgery carries the risk of catastrophic bleeding from injury to major vessels, as well as iatrogenic injury to the viscera and associated structures. Therefore, laparoscopic lumbar discectomy and ADR may represent a useful alternative. PURPOSE The current study aimed to assess the safety and efficacy of ADR using a laparoscopic technique for lumbar disc herniation. STUDY DESIGN/SETTING This prospective observational study included 22 patients who were diagnosed with symptomatic degenerative disc disease treated via ADR with a laparoscopic technique. PATIENT SAMPLE Twenty-two patients (8 males and 14 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Seven cases involved the L4/5 level, and 15 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. OUTCOME MEASURES Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up. METHODS Twenty-two patients (8 males and 14 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Seven cases involved the L4/5 level, and 15 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up. RESULTS All surgeries were successfully completed. The average operation time was 120 minutes (range 110–150 minutes), and the average hemorrhage was 145 mL (range 80–360 mL). All cases underwent X-ray imaging at 3days, 3 months, 6 months, 1 year, and the final postoperative follow-up. The outcome indicated that there was no mobilization, displacement, or subsidence in all patients with the exception of one case with prosthesis migration. The follow-up time was 43.8 months (range 24–64 months). The mean visual analog scale (VAS) and Oswestry scores were decreased postoperatively. The mean improvement rate of the VAS score was 73.5%. CONCLUSIONS Lumbar ADR using a laparoscope represents a novel, minimally invasive treatment for symptomatic degenerative disc disease and severe lumbar discogenic pain.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P134. Application of laparoscopic lumbar discectomy and anterior lumbar interbody fusion: at least six years of follow-up

BACKGROUND CONTEXT Symptomatic degenerative disc disease is the major cause of low back pain with lumbar segmental instability. Anterior discectomy and interbody fusion has increased in popularity as an alternative treatment for lumbar disc herniation. However, the traditional approach to spinal surgery carries the risk of catastrophic bleeding from injury to major vessels, as well as iatrogenic injury to the viscera and associated structures. Therefore, laparoscopic lumbar discectomy and interbody fusion may represent a useful alternative. PURPOSE The current study aimed to assess the mid-term safety and efficacy of lumbar discectomy and anterior lumbar interbody fusion (ALIF) using a laparoscopic technique for lumbar disc herniation. STUDY DESIGN/SETTING This prospective observational study included 32 patients who were diagnosed with symptomatic degenerative disc disease treated via lumbar discectomy and ALIF with a laparoscopic technique. PATIENT SAMPLE Thirty-two patients (12 males and 20 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Four cases involved the L4/5 level, and 28 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. OUTCOME MEASURES All patients were followed up for more than 6years, X-ray and CT were reviewed regularly to evaluate the height change of intervertebral space and the fusion of bone graft. The clinical effects of preoperative, postoperative and follow-up were evaluated by VAS score, and the complications of laparoscopic surgery were observed. METHODS Thirty-two patients (12 males and 20 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Four cases involved the L4/5 level, and 28 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up for more than 6years, X-ray and CT were reviewed regularly to evaluate the height change of intervertebral space and the fusion of bone graft. The clinical effects of preoperative, postoperative and follow-up were evaluated by VAS score, and the complications of laparoscopic surgery were observed. RESULTS All surgeries were successfully completed. All cases were followed up for more than 6years, the average follow-up time was 9years (range 6–12 years). All cases got bone fusion, the average time was 4.5 months (range 3–12 months). The mean VAS were decreased postoperatively, The VAS score of low back pain for preoperative, postoperative (1 week) and final follow-up was 5.8±1.1, 1.8±0.7, 0.9±0.7, the change were statistically significant (p .05). The outcome indicated that there was no mobilization, displacement or intestinal adhesion in all patients in the mid-term follow-up. CONCLUSIONS Laparoscopic lumbar discectomy and ALIF is an effective treatment for severe degenerative lumbosacral diseases