Symptomatic Disc Research Articles

SDF1/CXCR4 axis facilitates the angiogenesis via activating the PI3K/AKT pathway in degenerated discs.

Symptomatic degenerative disc disease (DDD) is considered the leading cause of chronic lower back pain (LBP). As one of the main features of intervertebral disc degeneration (IDD), vascular ingrowth plays a crucial role in the progression of LBP. Stromal cell-derived factor 1 (SDF1) and its receptor C-X-C receptor 4 (CXCR4) were reported to be overexpressed in the degenerated intervertebral discs, suggesting that they may be involved in the pathogenesis of IDD. Moreover, SDF1 has been identified to induce neovascularization in rheumatoid arthritis disease. However, the roles of the SDF1/CXCR4 axis in the neovascularization of IDD remain unclear. Therefore, the objective of the present study was to elucidate whether the SDF1/CXCR4 axis takes part in neovascularization in degenerated intervertebral discs and its underlying mechanisms. Adenovirus infection was used to upregulate SDF1 expression in primary nucleus pulposus cells (NPCs). The effects of SDF1 on the proliferation and angiogenesis of vascular endothelial cells (VECs) were assessed by Cell Counting Kit-8 and tube formation assays after VECs were treated with the supernatants derived from SDF1 overexpressed or not treated NPCs. Transwell chambers using the supernatants from NPCs as chemokines were applied to assess VEC migration and invasion. AMD3100, MK-2206 and SF1670 were used to antagonize CXCR4, AKT serine/threonine kinase 1 (AKT) and phosphatase and tensin homolog (PTEN) in VECs. The results revealed that SDF1 overexpression significantly increased the ratio of phosphorylated AKT to AKT and decreased PTEN expression in NPCs, as well as enhanced the proliferation, migration, invasion and angiogenesis abilities of VECs. However, these effects induced by SDF1 overexpression in NPCs were all reversed when VECs were pretreated with AMD3100 or MK-2206, whereas enhanced by SF1670 treatment. Collectively, the present study indicated that enhancement of the SDF1/CXCR4 axis in NPCs can significantly accelerate angiogenesis by regulating the PTEN/phosphatidylinositol-3-kinase/AKT pathway.

81. Seven-year results of a randomized controlled IDE trial for lumbar artificial discs in single-level degenerative disc

BACKGROUND CONTEXT The activL artificial disc received Food and Drug Administration approval in 2015 based on 2-year follow-up data. PURPOSE To compare the 7-year safety and efficacy of the activL® artificial disc with ProDisc-L total disc replacement (TDR) in the treatment of patients with symptomatic single-level lumbar degenerative disc disease (DDD). Study Design/Setting Prospective, randomized, multicenter IDE. Patient Sample A total of 206 patients who underwent single-level lumbar arthroplasty with either Activ L or Prodisc L. OUTCOME MEASURES ODI, SF-36, VAS, complications, re-operations. METHODS Eligible patients presented with symptomatic, single-level, lumbar DDD who failed ≥6 months of nonsurgical management. At entry, 283 patients were randomly allocated to treatment with activL (n=218) or ProDisc-L (n=65) TDR. At 7-years follow-up, a total of 206 patients (activL: 160, ProDisc-L: 46) were available for analysis. RESULTS The activL group was non-inferior compared to the ProDisc-L group in the primary composite end point at 7 years (p=0.0369). Relative to baseline, significant reductions in visual analog scale (VAS) back/leg pain severity as well as improvements in Oswestry Disability Index (ODI) and SF36 Questionnaire were observed in both treatment groups at 7 years. The activL group showed significantly better range of motion for flexion-extension (FE) rotation, disc height/angle and higher proportion of patients without heterotopic ossification, compared with ProDisc-L. Freedom from a serious adverse event through 7 years was 62% in activL patients and 43% in ProDisc-L patients (log-rank p=0.011). Significant reduction in narcotic usage compared to baseline were observed in both treatment groups over time, with 0% of TDR patients using narcotics at 7 years. Freedom from reoperation was high for TDR patients at 95%. Patients who experienced improvements in radiographic (FE rotation, FE translation, lateral rotation), VAS leg pain, ODI, and SF36 measures at 2 years were more likely to experience improvements at 7 years. CONCLUSIONS Long-term evidence supports TDR as safe and efficacious treatment for lumbar DDD. The results demonstrated short-term benefits of TDR are maintained at 7 years, with patients no longer requiring narcotic use. The next generation activL Artificial Disc is more effective at preserving range of motion compared to first generation TDR (ProDisc-L) and offers an improved safety profile. Other primary and secondary outcomes are similar between disc designs. FDA DEVICE/DRUG STATUS Activ L (Approved for this indication), Prods L (Approved for this indication)

267. The impact of preventative multimodal analgesia on postoperative opioid requirement and pain control in patients undergoing lumbar fusions

BACKGROUND CONTEXT Preventive multimodal analgesia (PMA) addresses multiple sources and pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. PURPOSE The main objectives of this study were to determine the impact of PMA on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. STUDY DESIGN/SETTING A prospective observational study with a historical reference group was performed. PATIENT SAMPLE The study compared postoperative opioid requirement and analgesic effect in a total of 103 patients undergoing elective, one- or two-level transforaminal lumbar interbody fusion (TLIF) surgeries for symptomatic lumbar degenerative disc disease. The PMA patient group included 52 consecutive patients who received 1000 mg of acetaminophen, 300 – 900 mg of gabapentin, and 200 – 400 mg of celecoxib 1 hour before the procedure. The reference group included 51 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively. OUTCOME MEASURES Postoperative opioid requirement and pain scores. METHODS Multiple linear regression was used to evaluate the influence of PMA on pain, MED and acetaminophen use over 4 postoperative days (PODs), while controlling for all variables likely to influence these outcomes, including age, gender, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and administration of muscle relaxants and anticonvulsants. RESULTS The differences in opioid requirement and postoperative pain scores were statistically significant on all four postoperative days. The effect size varied from -0.54 to -0.99 for the postoperative opioid requirement and from -0.59 to -1.16 for postoperative pain indicating that these measures were reduced by about ½ to 1 standard deviation in the PMA patient group. CONCLUSIONS PMA is a highly effective method for postoperative pain management in patients undergoing lumbar fusion surgeries, which not only improves pain control, but also reduces opioid requirement. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

85. Incidence and resolution strategies for early onset postoperative leg pain following lumbar total disc replacement

BACKGROUND CONTEXT Lumbar total disc replacement (TDR) was introduced in the 1980s and is becoming more common. Anecdotally, there have been reports of patients reporting the onset of new leg pain following TDR surgery. To date, there has been little formal investigation into this clinical phenomenon. PURPOSE The purpose of this study was to determine the incidence of new-onset leg pain following lumbar TDR and investigate treatment strategies for this occurrence. STUDY DESIGN/SETTING This study was based on a post hoc analysis of data collected prospectively as part of an FDA IDE trial. PATIENT SAMPLE The study population was comprised of 283 patients who received ProDisc-L or activL® as part of the multicenter, randomized FDA IDE trial for the latter device. Patients were treated for symptomatic single-level disc degeneration unresponsive to at least 6 months of nonoperative care. OUTCOME MEASURES The primary outcome measures in the study were the onset of leg pain following TDR surgery and the outcomes of treatments for this condition. METHODS New onset of leg pain following TDR surgery was identified from adverse event reports collected prospectively during the trial. It was defined as leg pain beginning 0- to 4 weeks postoperatively. The treatment of these symptoms was at the operating surgeon's discretion. Treatment strategies were classified as: medication, nonoperative care, injections, and/or subsequent surgery. RESULTS New onset of postoperative leg pain occurred in 9.2% of lumbar TDR patients (26/283). The new onset pain resolved in 76.9% (20/26) of patients. Most patients (24 of 26) were treated with one or more medications, the most common of which was anticonvulsant drugs such as gabapentin or pregabalin, commonly used to treat neurogenic-type pain. Symptoms resolved in 75% of patients receiving this type of medication. Some also received narcotics and 30.8% were treated with steroids, most commonly a Medrol dose-pack. Twelve patients received other nonoperative care (PT, acupuncture, etc.) and 7 received injections. Three patients went on to have subsequent surgery, none of whom had resolution of the new onset leg pain after the additional procedure. Among the 20 patients whose new symptoms resolved, resolution occurred within 3 months in 11 patients. CONCLUSIONS Early-onset postoperative leg pain occurred in approximately 10% of lumbar TDR patients. The source of the symptoms is not clear. In the majority of patients, the new symptoms resolved, often within 3 months of onset. While challenging to definitively evaluate in this relatively small subset of patients, it appears the most effective treatment strategy is gabapentin or pregabalin. The role of other nonoperative interventions could not be discerned. Surgical re-intervention is likely unnecessary and did not lead to resolution of early onset leg pain post-TDR. FDA DEVICE/DRUG STATUS activL and ProDisc-L (Approved for this indication).

215. Outcomes with transforaminal endoscopic versus percutaneous laser decompression for contained lumbar herniated disc: a survival analysis of treatment benefit

BACKGROUND CONTEXT Contained lumbar disc herniations frequently cause back- and leg pain. Clinical outcomes with surgical treatment may be affected by the size and location of the disc herniation. The surgical directly visualized transforaminal endoscopic decompression has gained acceptance and popularity, while the simplified percutaneous laser disc decompression has fallen out of favor in spite of its initial success as a minimally invasive intervention. In an attempt to better understand the durability of both procedures, the authors performed a comparative analysis of clinical outcomes in patients with contained lumbar disc herniations. PURPOSE In an attempt to better understand the durability of both procedures, the authors performed a comparative analysis of clinical outcomes in patients with contained lumbar disc herniations. STUDY DESIGN/SETTING This retrospective study selected from groups of consecutive patients seen in clinics of the participating study sites. PATIENT SAMPLE The study population consisted of 248 patients consisting of 162 patients in the endoscopy group (group 1) and 86 patients in the laser group (group 2). OUTCOME MEASURES Primary outcome measures were Macnab criteria. METHODS Herniations were classified as large or small. Additional parameters of advanced degeneration of the lumbar motion segment including posterior disc- and lateral recess height of RESULTS The mean follow-up was 43.5 months. The serial time recorded for Kaplan-Meier analysis ranged from 1.5 to 84 months. The mean age was 53.4 years (standard deviation=14.65 years). The majority of patients had excellent and good Macnab outcomes (212/248; 85.5%) regardless of treatment. Fair and poor results were achieved in another 36 patients (14.5%). There was a higher percentage of excellent Macnab outcomes in the endoscopy group (94/162; 58.0%) than in the laser group (38/86; 44.2%) at a statistically significant level (P CONCLUSIONS Transforaminal endoscopic decompression for symptomatic herniated disc is an effective and durable surgical treatment to alleviate sciatica-type and back symptoms in the vast majority of patients with good long-term survival of pain relief for up to 6 years. Interventional percutaneous nonvisualized laser decompression for the same condition may provide favorable outcomes in the short-term with soft protrusions. However, the treatment effect deteriorates much faster with a median survival of 17 months. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Clinical Outcomes After Standard Discectomy and Microdiscectomy for Lumbar Disc Herniation: A Single-Center Study

Summary Unsatisfactory results from lumbar disc herniation (LDH) conservative treatment suggest referral of patients for neurosurgical treatment. The time required for such a decision is considered to be about 4-6 weeks. In most cases, surgery quickly relieves pain symptoms, all along with the restoration of patient functions. The optimal surgical technique for LDH is theoretically controversial. We consider two discectomy methods as quite effective in our clinic: standard open discectomy (SD) and microdiscectomy (MD). Many retrospective studies have demonstrated the superiority of one of these techniques. Most studies describe microdiscectomy as a golden standard for surgical treatment of symptomatic disc herniation. We focused on the clinical aspects and correlations in the surgical treatment of LDH, as presented in the literature. The patients we present were divided by type of surgical procedure (SD or MD), and other parameters: sex, age, duration of symptoms, blood loss, duration of the operation, reoperation rate, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI). We used chi-square tests (ANOVA analysis) and directional measures to determine statistically significant data. Five hundred eighty-nine single-level lumbar discectomies were performed for five years (2012-2017), and all the patients presented with classical signs of the condition, i.e., vertebral and radicular syndromes. SD was performed on 498 patients, and MD – on 91 patients. Analyses of the parameters mean VAS values of lumbar and leg pain postoperatively, and within one month after surgery demonstrated statistically significant differences between standard and microdiscectomy (p<0.05). LDH surgical techniques have become more and more sophisticated over the last 40 years, but without substantial improvement in the functional and clinical results. Appropriate patient selection is a crucial factor for the postoperative outcome. Neurosurgeons should fully master the chosen technique for satisfactory postoperative results.

Economics of Cervical Disc Replacement.

Although extensive reports of clinical outcome after cervical disc replacement (CDR) and anterior cervical discectomy and fusion exist, few reviews of the cost-effectiveness research in cervical spine surgery exist. The purpose of this study was to review the concepts of cost-effectiveness research, the various approaches to cost-effectiveness studies in the context of cervical spine surgery, and some of the literature results. Review article describing cost-effectiveness research concepts, methodology, and results. The article reviews the concept of value, cost, utility, incremental cost-effectiveness ratio, and recent research. Mixed data on cost-effectiveness of CDR compared with fusion exist. Notably, several studies performed within the last 5 years that use prospectively collected utility scores, costs, and adverse event calculations demonstrate a significant cost savings associated with CDR compared with fusion. The recent literature confirms that, in properly selected patients, CDR is more effective and less costly over a 7-year time horizon for patients with symptomatic degenerative disc disease. The primary driver of the differential in cost effectiveness is the difference in secondary surgery rates. Level 5 CLINICAL RELEVANCE: In properly selected patients, CDR is more effective and less costly over a 7-year time horizon for patients with symptomatic degenerative disc disease.

Clinical Outcomes of Cervical Hybrid Reconstructions: A Prospective Study.

The study design was a prospective clinical cohort study. The aim of this study was to assess the patient-reported outcome measures (PROMs), patient satisfaction, as well as complication and reoperation rate of cervical hybrid procedures for symptomatic cervical multilevel degenerative disc disease (MLDDD). Cervical total disc replacement (CTDR) has been shown to be safe and effective for the treatment of degenerative pathologies. However, there is minimal PROMs data on the outcomes of combined CTDR and anterior cervical decompression and fusion procedures, commonly referred to as cervical hybrid surgery. Prospectively collected PROMs were analyzed from patients receiving cervical hybrid surgery for symptomatic cervical MLDDD. Between 2004 and 2016, data were collected preoperatively and postoperatively at 3, 6, and 12 months, then yearly thereafter. Patient reported outcome measures included patient satisfaction, visual analog score for neck and arm, and Neck Disability Index. Complication and reoperation rates were also assessed. A total of 151 patients (80 males, 71 females) who had a minimum of 12 months follow up were included. The mean age was 53 years (range = 24-81), and median follow up was 2 years (range = 1-10). The median number of levels treated was 3, with 29.8%, 49.0%, and 21.2% of patients having 2, 3, and 4 levels treated, respectively. The most common indication for surgery was multilevel cervical spondylotic radiculopathy (52.8%), followed by combined cervical spondylotic radiculomyelopathy (16.7%), axial neck pain (16%), and cervical spondylotic myelopathy (13.9%). Improvement in pain and disability scores were both clinically and statistically significant (P < .001), and these improvements were sustained throughout the course of follow up. There was a 16% incidence of minor adverse events, and 3 (1.9%) reoperations. Cervical hybrid surgery for cervical MLDDD demonstrates favorable and sustained clinical outcomes at short-term to midterm follow up. 4. Statistically and substantial clinical benefits can be achieved by cervical hybrid surgery, in the treatment of cervical pathologies including radiculopathy and myelopathy. The key principles is to follow strict indications, and to match technology with the pathology.

Synovial tissue cytokine profile in disc displacement of the temporomandibular joint.

Symptomatic disc displacement (DD) of the temporomandibular joint (TMJ) may cause pain and limited mouth opening. The aetiopathogenesis is obscure and probably complex, which makes the diagnostic classification crude and mainly based on clinical criteria rather than disease mechanisms, and tissue characteristics. The study aim was to characterise and quantify synovial tissue in DD, where specific cytokine patterns might serve as potential biomarkers. An observational cohort study was performed harvesting synovial tissue from 63 patients: 44 with DD without reduction (DDwoR) and 19 with DD with reduction (DDwR). DDwoR was subdivided depending on type of onset (sudden, n=17; delayed, n=27), and DDwR served as the control group. Proteins were extracted from tissue samples and investigated in a multi-analytic profiling system. DDwoR patients had significantly higher concentrations in 12 out of 28 analysed cytokines compared to DDwR. In the same statistical model, significantly lower concentrations of interferon gamma-induced protein (IP) 10, osteoprotegerin (OPG) and RANTES were detected in DDwoR patients. Women showed significantly higher concentrations of epidermal growth factor and interleukin (IL) 1ra compared to men. DDwoR with sudden onset had significant higher concentrations of bone morphogenetic protein 4, eotaxin and IL-8 compared to DDwoR with delayed onset. Characterising the biomarker panel for TMJ conditions may serve as suggestible targets for disease classification and novel treatment options. The significantly lower concentrations of IP-10, OPG and RANTES could be proposed as putative markers for the separation of the studied conditions to other TMJ diseases.

Evaluation of clinical profile, radiological and functional outcome following anterior cervical discectomy and fusion for cervical compressive myelopathy

Background: Symptomatic cervical disc prolapse is best managed with anterior cervical discectomy with or without fusion. We studied the clinical, radiological and surgical profile with postoperative outcome of the patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical compressive myelopathy at one level.Methods: In this retrospective study, data was collected from patients who underwent ACDF for cervical compressive myelopathy in our hospital between 2016 and 2019. Clinical, radiological profile with surgical outcome were studied.Results: A total of 283 patients were recruited. They could be followed up for a period of at least 6 months and so were recruited for the study. Out of these 283 patients (201 males; 82 females; mean age, 48.4 years, range, 22 years to 83 years), magnetic resonance imaging (MRI) cervical spine without contrast and x-ray cervical spine was available for all the patients. Nape of neck pain was the most common presenting symptom followed by tingling sensation in all four limbs and trunk. Average time taken for surgery was 2 hours 10 minutes with an average blood loss of 50 ml. Mean follow up duration was 2.7 years (range 6 months to 4 years).Conclusions: ACDF is the treatment of choice for the patients with clinical and radiological evidence of cervical cord compression. The techniques is associated with minimal blood loss and exceptionally good surgical outcome. Following discectomy, putting an autologous graft or titanium cage improves the spine stability and maintains the cervical lordosis.

Low Back Pain Induced by Posterior Longitudinal Ligament Incision in Percutaneous Transforaminal Endoscopic Lumbar Discectomy.

ObjectiveTo illustrate the posterior longitudinal ligament is one of the tissue candidates who can contribute to low back pain (LBP).MethodsThis is a retrospective study. A series of 72 patients who underwent single‐level percutaneous endoscopic lumbar discectomy performed for lumbar disc herniation with LBP from June 2014 to June 2016 were examined. There are 42 males and 30 females. The ages of patients were 40 to 57 years, and the mean age was 49.8 years. The symptomatic disc level was at L4‐5 in 43 patients and L5S1 in 29 patients. Thirty‐two patients (19 patients in L4‐5 disc level, 13 patients in L5S1 disc level) had LBP (which was limited to the lower back and buttock area) before the operation. All of the operative approaches were performed under local anesthesia. A posterior body diagram (15 cm × 10 cm) was made for this study to record the pain distribution. The centered foci of low back pain were subjectively recorded before, during, and after the operation. The transforaminal endoscopic spine system technology was used in this study. Radiological examinations (X‐ray, computed tomography, and magnetic resonance imaging) were performed prior to and after surgery. The Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) scores were taken before and after the surgery to observe the degree of pain. The VSA and ODI score before and after operation were expressed as mean ± SD, and compared by t‐test for statistical analysis.ResultsWhen inciting the posterior longitudinal ligament during the operation, all 72 patients had provoked low back pain. Forty‐three patients with symptomatic discs at L4‐5 had pain foci in the lower back and upper gluteal region under the L4 spinous process. Twenty‐nine patients with symptomatic discs at L5S1 had pain foci in the gluteal region under the S1 spinous process. The pain localizations of L4‐5 and L5S1 were different. After the surgery, the provoked low back pain disappeared, and had not returned in any of the patients at the 6‐month follow‐up. After the operation, one patient suffered from lower limb pain that he did not have before the operation, and the lower limb pain abated a few days later. Three patients had cerebrospinal fluid leakage and were treated with higher pressure applied on the incision and bed rest for 10 days. During the 6‐months follow‐up period, the mean VAS decreased from 5.97 ± 1.10 to 2.13 ± 0.78. The mean ODI score decreased from 23.14 ± 3.28 to 7.92 ± 1.85.ConclusionsThe intervertebral posterior longitudinal ligament may be one of the tissues from which low back pain originates.

Severity of intervertebral disc herniation regulates cytokine and chemokine levels in patients with chronic radicular back pain

The contributions of intervertebral disc disease and subject-specific covariates to systemic inflammation in low back pain are unknown. We examined the effects of symptomatic disc herniation (DH) and MRI herniation severity on serum cytokine levels in clinical subjects. Cytokine levels from lumbar DH subjects (N=78) were compared to control subjects (N=57) accounting for effects of DH, age, body mass index (BMI) and gender. Effect of DH severity on cytokine levels was analyzed on subsets of subjects with acute or chronic pain. Serum cytokines were also analyzed in a subset of patients between pre- and 3 months post-surgery. Cytokine levels were elevated in the serum of patients with symptomatic DH, and the covariates age, BMI and gender significantly contributed to levels of some cytokines. Severity of herniation was a significant contributor to pain intensity (VAS), serum levels of HMGB1, PDGFbb, and IL-9. The relationship between DH severity and cytokine levels was confirmed in subjects with chronic, but not acute symptoms. Serum levels of macrophage migration inhibitory factor (MIF) decreased, whereas levels of CCL3, CCL11, CXCL1, and CXCL10 were significantly elevated post surgery. This study is the first to show that DH severity is coordinately associated with changes in serum levels of inflammatory cytokines in chronic pain subjects. HMGB1, PDGFbb and IL-9 are novel mediators of increasing DH severity, indicative of cellular damage, neuro-inflammation and angiogenesis. Resolution of inflammation was observed with decrease in MIF post surgery. However, elevated chemokine levels indicate ongoing remodeling and wound healing at 3-month time point.

Lumbar disc lesion: Study of epidemiology and surgical intervention

Background: As per European studies the incidence of a herniated disc is about 5 to 20 cases per 1000 adults annually and is most common in people in their third to the fifth decade of life, with a male to female ratio of 2:1. The estimated prevalence of symptomatic herniated disc of the lumbar spine is about 1-3 percent of patients. Epidemiology of lumbar disc disease among Indian population needing operative intervention is not clear. Aim: To study the Epidemiology of lumbar disc disease among Indian population needing operative intervention. Material and Methods: In this prospective study all the adult (above 18 years) age group presenting with lumbar disc lesion and canal stenosis admitted in orthopaedic department of Tertiary Care Centre satisfying inclusion were taken for study after obtaining their consent. Results: Out of 120 patients 25% patients needed and rest were managed by conservative line of management. The more common age group affected was 40 to 60 years age group (53.33%). Gender distribution has a male predominance (73.33%) compare to females (26.66%). Majority of the cases studied were presented with low backache, radiculopathy and paraesthesia. Majority having L4-L5 disc involvement (70%). Conclusion: Out of 120 patients 30 (25%) patients needed operative intervention and rest were managed by conservative line of management. All patients with lumbar disc lesion needs conservative trial. Only if conservative trial fails or patient with persistent disabilating pain or neurological deficit are subjected to operative intervention. Majorly affect 40 to 60 years age group with mean of 44.9 years & males outnumbering females in incidence with majority involving L4-L5 disc level.

A review on the current state of ball-on-socket type artificial lumbar disc prosthesis

Total lumbar disc replacement is an alternative to interbody fusion for the effective treatment of symptomatic degenerative disc disease. This paper reviewed the history of ball-on-socket type artificial lumbar disc (ALD) prosthesis, which is a typical ALD prosthesis and summarized the ALD prosthesis research progress, according to different materials such as metal-on-metal, metal-on-polymer, and polymer-on-polymer prosthesis. The structural design factors of ball-on-socket type ALD prosthesis were analyzed and its prospect of development was also presented. The purpose of this paper is to provide a theoretical reference for the design of the ball-on-socket ALD prosthesis by reviewing the current state of ball-on-socket type ALD prosthesis.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

Purpose The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches. Methods Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12–79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions. Results Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X2 4.13 P:0.042). Severe post-operative neuralgia (VAS 7–10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X2 7.07 p 0.0078). Conclusions MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion for degenerative cervical disc disease

Background: Anterior cervical discectomy and fusion (ACDF) is the most commonly performed surgical procedure for symptomatic cervical disc disease. In this study, we analysed the upper and lower limb motor functions after ACDF for disc prolapse in patients with degenerative cervical disc disease.&#x0D; Methods: One hundred consecutive adult patients who underwent ACDF for single or two-level cervical disc prolapse during the study period (October 2015 to October 2017) were included in the study.&#x0D; Results: Preoperative motor deficits in limbs were noted in 73% (73/100) of the patients. Enhance recovery of motor deficits was noted in 72.6% (53/73) of these patients and persisting motor deficits in the remaining patients (20/73- 27.4%). Five patients (5/27- 18.5%) without any preoperative motor deficits developed motor deficits after ACDF. Detailed pre and postoperative (at the time of discharge) motor power (graded by MRC grade) in all 4 limbs (Shoulder abduction/adduction/flexion/extension, elbow flexion/extension, wrist flexion/extension, hip abduction/adduction/flexion/extension, knee flexion/extension, ankle flexion/extension) was recorded. Statistically significant improvement in motor power (as recorded at the time of discharge) was noted in all the tested muscle groups after ACDF.&#x0D; Conclusion: Early improvement in preoperative motor deficits can be expected in the majority of the patients with cervical PIVD following ACDF.

Preclinical ex-vivo Testing of Anti-inflammatory Drugs in a Bovine Intervertebral Degenerative Disc Model.

Discogenic low back pain (LBP) is a main cause of disability and inflammation is presumed to be a major driver of symptomatic intervertebral disc degeneration (IDD). Anti-inflammatory agents are currently under investigation as they demonstrated to alleviate symptoms in patients having IDD. However, their underlying anti-inflammatory and regenerative activity is poorly explored. The present study sought to investigate the potential of Etanercept and Tofacitinib for maintaining disc homeostasis in a preclinical intervertebral disc (IVD) organ culture model within IVD bioreactors allowing for dynamic loading and nutrient exchange. Bovine caudal IVDs were cultured in a bioreactor system for 4 days to simulate physiological or degenerative conditions: (1) Phy—physiological loading (0.02–0.2 MPa; 0.2 Hz; 2 h/day) and high glucose DMEM medium (4.5 g/L); (2) Deg+Tumor necrosis factor α (TNF-α)—degenerative loading (0.32–0.5 MPa; 5 Hz; 2 h/day) and low glucose DMEM medium (2 g/L), with TNF-α injection. Etanercept was injected intradiscally while Tofacitinib was supplemented into the culture medium. Gene expression in the IVD tissue was measured by RT-qPCR. Release of nitric oxide (NO), interleukin 8 (IL-8) and glycosaminoglycan (GAG) into the IVD conditioned medium were analyzed. Cell viability in the IVD was assessed using lactate dehydrogenase and ethidium homodimer-1 staining. Immunohistochemistry was performed to assess protein expression of IL-1β, IL-6, IL-8, and collagen type II in the IVD tissue. Etanercept and Tofacitinib downregulated the expression of IL-1β, IL-6, IL-8, Matrix metalloproteinase 1 (MMP1), and MMP3 in the nucleus pulposus (NP) tissue and IL-1β, MMP3, Cyclooxygenase-2 (COX2), and Nerve growth factor (NGF) in the annulus fibrosus (AF) tissue. Furthermore, Etanercept significantly reduced the IL-1β positively stained cells in the outer AF and NP regions. Tofacitinib significantly reduced IL-1β and IL-8 positively stained cells in the inner AF region. Both, Etanercept and Tofacitinib reduced the GAG loss to the level under physiological culture condition. Etanercept and Tofacitinib are able to neutralize the proinflammatory and catabolic environment in the IDD organ culture model. However, combined anti-inflammatory and anabolic treatment may be required to constrain accelerated IDD and relieving inflammation-induced back pain.

Differences in clinical and radiological features of thoracic disc herniation presenting with acute progressive myelopathy.

Symptomatic thoracic disc herniation (TDH) is relatively rare, but patients with progressive myelopathy require surgical treatment without delay in diagnosis. The aim of this study was to review clinical and radiological features in patients with TDH presenting with myelopathy. A total of 28 consecutive patients with thoracic myelopathy (Frankel grade C or worse) due to TDH who underwent surgery were divided into 3 groups based on the time for development of myelopathy (acute (< 72h), subacute (within a few weeks), and chronic [gradually over > 1month)] and their data were analyzed. The patients in the acute group were significantly younger and had a higher body mass index (BMI) compared to those in the subacute and chronic groups. Most cases of acute myelopathy were affected in the upper thoracic level, whereas all patients with subacute and chronic myelopathy had lesions in the lower thoracic level below T8-9. Interestingly, the affected thoracic level in patients with acute myelopathy matched the upper line of the sternum. The rate of acquired walking ability without assistance was only 50.0% in the acute group. This study suggests that TDH presenting with acute myelopathy may have different clinical and radiological features compared to those of TDH with subacute and chronic myelopathy. Upper TDH should be suspected in cases of acute myelopathy that develops with sudden-onset back pain after certain triggers in younger and higher BMI people. These affected thoracic level matched with the upper line of the sternum in each case.

Transforaminal endoscopic thoracic discectomy with foraminoplasty for the treatment of thoracic disc herniation.

Symptomatic thoracic disc herniation (TDH) is a rare clinical entity and surgical intervention for it is even more uncommon. Despite several surgical techniques being described for thoracic discectomy, considering the unique surgical challenges, none of them have been accepted universally. Minimally invasive techniques have brought in a paradigm shift in the management of cervical/lumbar spinal disorders and similar techniques have been extrapolated to the thoracic region too. The purpose of this paper is to describe our technique, surgical experience, and the clinical results of transforaminal endoscopic thoracic discectomy (TETD). Consecutive patients who underwent TETD (2001-2018) were reviewed. Patients who had a minimum of 6 months of follow-up, and without cervical and lumbar spine surgery or trauma during the follow-up period were included in the study. TETD was performed in patients who presented with symptomatic disc herniation of the thoracic spine and did not respond to conservative treatments. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament (OPLL) were excluded. Under local anesthesia and intravenous sedation, a 4.7-mm endoscope (TESSYS, Joimax GmbH, Germany) was introduced via transforaminal approach with foraminoplasty using reamer. Patient outcome was evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Patient satisfaction was measured using Macnab's criteria. Ninety-two consecutive patients (mean age was 48.9 years, 57 males) who underwent TETD from 2001 to 2018 met the inclusion criteria. Patients underwent surgery at different levels: 16 patients for T2-3 to T5-6 level, 41 cases for T6-7 to T8-9, and 35 patients for T9-10 to T12-L1. During follow-up for an average of 38.4 months, all patients showed a significant improvement of pain (7.6 to 1.6 in VAS and 68.2 vs. 13.2 for ODI, P<0.05 for both). There was one patient who had transient motor weakness. TETD for soft, paramedian or lateral symptomatic TDH is a feasible and effective minimally invasive treatment option with favorable clinical results.

Total disc replacement compared with fusion for cervical degenerative disc disease: A systematic review of overlapping meta-analyses.

Study design:The present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.Objective:The present study aimed to conduct a systematic review of overlapping meta-analyses comparing ACDR with fusion for treating CDDD in order to assist decision makers in their selection among conflicting meta-analyses and to provide treatment recommendations based on the best available evidence.Summary of background data:Although several meta-analyses have been performed to compare total disc replacement (TDR) and fusion for treating cervical degenerative disc disease (CDDD), their findings are inconsistent.Methods:Multiple databases were comprehensively searched for meta-analyses comparing TDR with fusion for treating CDDD. The meta-analyses that comprised only randomized controlled trials (RCTs) were included. Two authors independently assessed the meta-analysis study quality and extracted the data. The Jadad decision algorithm was used to ascertain which meta-analysis studies represented the best evidence.Results:A total of 14 meta-analysis studies were included. All these studies only included RCTs and were determined as Level-II evidence.Conclusions:Cervical disc arthroplasty was superior compared to anterior discectomy and fusion for the treatment of symptomatic cervical disc disease.