Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration

Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial

CONTEXT

The biopsychosocial approach to managing low back pain (LBP) has the potential to improve the quality of care for patients. However, LBP trials that have utilized the biopsychosocial approach to treatment have largely neglected sexual activity, which is an important social component of individuals with LBP.

OBJECTIVES

The objectives of the study are to determine the effects of manual therapy plus sexual advice (MT+SA) compared with manual therapy (MT) or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for these individuals.

METHODS

This was a single-blind randomized controlled trial. Fifty-four participants diagnosed as having chronic DHR (>3 months) were randomly allocated into three groups with 18 participants each in the MT+SA, MT and ET groups. The participants in the MT+SA group received manual therapy (including Dowling's progressive inhibition of neuromuscular structures and Mulligan's spinal mobilization with leg movement) plus sexual advice, those in the MT group received manual therapy only and those in the ET group received exercise therapy only. Each group received treatment for 12 weeks and then followed up for additional 40 weeks. The primary outcomes were pain, activity limitation, sexual disability and kinesiophobia at 12 weeks post-randomization.

RESULTS

The MT+SA group improved significantly better than the MT or ET group in all outcomes (except for nerve function), and at all timelines (6, 12, 26, and 52 weeks post-randomization). These improvements were also clinically meaningful for back pain, leg pain, medication intake, and functional mobility at 6 and 12 weeks post-randomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at 6, 12, 26, and 52 weeks post-randomization (p<0.05). On the other hand, many preferred sexual positions for individuals with DHR emerged, with "side-lying" being the most practiced sexual position and "standing" being the least practiced sexual position by females. While "lying supine" was the most practiced sexual position and "sitting on a chair" was the least practiced sexual position by males.

CONCLUSIONS

This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

Role of unilateral partial facet joint preservation in postero-lateral approach lumbar interbody fusion for patients with degenerative lumbar spinal stenosis presenting bilateral lower limb symptoms: a retrospective study

BACKGROUND

Posterolateral decompression and fusion with internal fixation is a commonly used surgical approach for treating degenerative lumbar spinal stenosis (DLSS). This study aims to evaluate the impact of preserving a portion of the unilateral facet joint during decompression on surgical outcomes and long-term recovery in patients.

METHODS

This study analyzed 73 patients with DLSS accompanied by bilateral lower limb neurological symptoms who underwent single-level L4/5 posterolateral decompression and fusion surgery from January 2022 to March 2023. Patients were categorized into two groups based on the type of surgery received: Group A comprised 31 patients who underwent neural decompression without facet joint preservation, while Group B consisted of 42 patients who underwent neural decompression with preservation of partial facet joints on one side. Regular follow-up evaluations were conducted, including clinical and radiological assessments immediately postoperatively, and at 3 and 12 months thereafter. Key patient information was documented through retrospective chart reviews.

RESULTS

Most patients in both groups experienced favorable surgical outcomes. However, four cases encountered complications. Notably, during follow-up, Group B demonstrated superior 1-year postoperative interbody fusion outcomes (P < 0.05), along with a trend towards less interbody cage subsidence and slower postoperative intervertebral disc height loss. Additionally, Group B showed significantly reduced postoperative hospital stay (P < 0.05).

CONCLUSION

Under strict adherence to surgical indications, the posterior lateral lumbar fusion surgery, which preserves partial facet joint unilaterally during neural decompression, can offer greater benefits to patients.

The role of melatonergic system in intervertebral disc degeneration and its association with low back pain: a clinical study

Objective

The mechanisms of intervertebral disc degeneration (IVDD) in low back pain (LBP) patients are multiples. In this study, we attempt to investigate whether melatonergic system plays a potential role in IVDD patients with LBP by analyzing their clinical specimens. The fucus will be given to the correlation between the melatonin receptor expression and intervertebral disc tissue apoptosis.

Methods

In this clinical study, 107 lumbar intervertebral disc nucleus pulposus (NP) specimens from patients with LBP were collected with patients' consents. The disc height (DH) discrepancy ratio, range of motion and sagittal parameters of the pathological plane were measured and Pfirrmann grade was used to classified the grades of IVDD level. Discs at grades 1-3 were served as normal control and grades 4-5 were considered as IVDD. The expression levels of melatonin receptor 1A (MT1) and 1B (MT2) were measured by immunohistochemistry. The apoptosis of NP was assessed using TUNEL staining. Their potential associations among MT1/2, DH, apoptosis, sagittal parameters with IVDD and LBP were evaluated with statistical analysis.

Results

The incidence of IVDD was positively associated with age and negatively related to VAS scores for LBP (p < 0.001). Patients with higher degree of IVDD also have higher DH discrepancy ratio (p < 0.001), higher prevalence of lumbar instability (p = 0.003) and higher cell apoptosis compared to the control. Nevertheless, no statistically significant correlation was identified between Pfirrmann grade and lumbar sagittal parameters. MT1 and MT2 both were highly expressed in the NP tissues. Importantly, MT1 expression but not MT2 was significantly increased in the intervertebral disc tissue of patients with IVDD and its level correlated well with cell apoptosis level and the severity of IVDD as well as lower VAS scores for LBP.

Conclusion

The highly elevated MT1 expression was found in NP tissues of patients with IVDD and LBP compared to the control. This phenomenon probably reflects the compensating response of the body to the pathological alteration of the IVDD and LBP. Therefore, these findings provide the novel information to use selective agonists of MT1 to target IVDD and LBP clinically.

Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature

INTRODUCTION

There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin.

MATERIAL AND METHODS

A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria.

RESULTS

Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive.

CONCLUSIONS

Pain in response to contrast medium injection, assessed with the visual analog pain scale≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.

[Translated article] Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature

INTRODUCTION

There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin.

MATERIAL AND METHODS

A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria.

RESULTS

Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive.

CONCLUSIONS

Pain in response to contrast medium injection, assessed with the visual analogue pain scale ≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.

Outcome of Percutaneous Endoscopic Lumbar Discectomy in Relation to the Surgeon's Experience: Propensity Score Matching

Percutaneous endoscopic lumbar discectomy (PELD) presents a challenging learning curve, and the correlation between surgeon experience and clinical outcomes remains contentious. This retrospective study aimed to compare the outcomes of PELD performed by a single surgeon at beginner and experienced stages. Propensity score matching selected 150 patients (75 per group) with a minimum 3-year follow-up. Clinical and radiological outcomes, perioperative complications, and adverse events were assessed. Baseline characteristics, pain improvement, patient satisfaction, and radiological outcomes did not differ between the groups. However, operation time was longer in the beginner group than in the experienced group (57.5 min [IQR, 50.0-70.0] versus 50.0 min [IQR, 45.0-55.0], p < 0.001). The beginner group had higher perioperative complication rates (eight patients [10.7%] versus one patient [1.3%], with a hazard ratio of 8.836 [95% CI, 1.077-72.514], p = 0.034) and lower 3-year survival without adverse events (19 patients [25.3%] in the beginner group and 10 patients [13.3%] in the experienced group, p = 0.045). Our findings indicate that the clinical outcomes were more favorable in patients operated on at the experienced stage compared to those treated at the beginner stage.

L4/5 Disc Herniation: Not Unusually Accompanied with L5/S1 Low-Grade Spondylolytic Spondylolisthesis

OBJECTIVE

Isthmic spondylolisthesis (IS) is distinguished by a congenital defect or acquired fracture of the pars interarticularis. Numerous studies on L5 low-grade IS have been carried out; however, there is a paucity of data regarding the condition of L5 IS concomitant with L4/5 disc herniation. This study aimed to identify the incidence rate and to illustrate the possible risk factors for L4/5 disc herniation in L5 low-grade IS patients.

METHODS

A total of 268 consecutive patients diagnosed as L5/S1 low-grade IS between May 2017 and May 2022 were retrospectively enrolled in this study. Depending on the presence of L4/5 disc herniation or not, patients were divided into an L4/5 disc herniation group (L4/5 DH) and an L4/5 non-disc herniation group (L4/5 non-DH). Radiographic parameters were measured, and the ratios of L4-S1 segmental lordosis (SL) to lumbar lordosis (LDI), L4 inferior endplate (IEP) to L5 superior endplate (SEP) (L4 IEP/L5 SEP), and L5 IEP to S1 SEP (L5 IEP/S1 SEP) were compared between groups. The Pfirrmann grade of the L4/5 disc and the L5/S1 disc, and Roussouly classifications of each patient were also recorded. Univariate analysis (including independent-samples t-test and χ2 -test) and multiple logistic regression analysis were performed to analyze the data.

RESULTS

There were 40 patients (14.9%) in the L4/5 DH group. The Roussouly classification differed significantly between groups. As demonstrated by the Pfirrmann grade, the L4/5 DH group showed more advanced disc degeneration at L4/5 than the L4/5 non-DH group. In contrast to the L4/5 non-DH group, the L4/5 DH group had a significantly larger L4 IEP, L4 IEP/L5 SEP, S1 SEP, and LDI while smaller L4/5 disc angle, L4/5 disc height, slip percentage, lumbar lordosis, and sacral slope. Multivariate logistic regression analysis revealed that higher L4/5 disc Pfirrmann grade (p = 0.004), decreased L4/5 disc height (p < 0.001), and lower L5 slip percentage (p = 0.022) were significantly associated with the occurrence of L4/5 DH.

CONCLUSIONS

L4/5 disc herniation is not unusually accompanied by L5/S1 low-grade IS. Advanced L4/5 disc degeneration, decreased L4/5 disc height, and lower L5 slip percentage might be significantly associated with L4/5 disc herniation.

Digital therapeutics-based lumbar core exercise for patients with low back pain: A prospective exploratory pilot study

Objective

This study aimed to implement a digital therapeutics-based approach based on motion detection technology and analyze the clinical results for patients with chronic low back pain (LBP).

Methods

A prospective, single-arm clinical trial was conducted with 22 patients who performed mobile app-based sitting core twist exercise for 12 weeks. Clinical outcomes were assessed using the visual analog scale (VAS) for LBP, Oswestry Disability Index-Korean version (K-ODI), and EuroQol-5 dimension 5-level version (EQ-5D-5L) every 4 weeks after the initiation of treatment. Laboratory tests for factors associated with muscle metabolism, plain X-ray for evaluating sagittal balance, and magnetic resonance imaging for calculating cross-sectional area (CSA) of back muscles were performed at pretreatment and 12 weeks post-treatment.

Results

The study population included 20 female patients with an average age of 45.77 ± 15.45 years. The clinical outcomes gradually improved throughout the study period in the VAS for LBP (from 6.05 ± 2.27 to 2.86 ± 1.86), K-ODI (from 16.18 ± 6.19 to 8.64 ± 5.58), and EQ-5D-5L (from 11.09 ± 3.24 to 7.23 ± 3.89) (p < 0.001, respectively). The laboratory test results did not show significant changes. Pelvic incidence (from 53.99 ± 9.70° to 50.80 ± 9.20°, p = 0.002) and the mismatch between pelvic incidence and lumbar lordosis (from 8.97± .67° to 5.28 ± 8.57°, p = 0.027) decreased significantly. Additionally, CSA of erector spinae and total back muscles increased by 5.20% (p < 0.001) and 3.08% (p = 0.013), respectively.

Conclusions

The results of this study suggest that the efficacy of digital therapy-based lumbar core exercise for LBP is favorable. However, further large-scale randomized controlled studies are necessary.

What does degeneration at the cervicothoracic junction tell us? A kinematic MRI study of 93 individuals

PURPOSE

Current decision-making in multilevel cervical fusion weighs the potential to protect adjacent levels and reduce reoperation risk by crossing the cervicothoracic junction (C7/T1) against increased operative time and risk of complication. Careful planning is required, and the planned distal and adjacent levels should be assessed for degenerative disc disease (DDD). This study assessed whether DDD at the cervicothoracic junction was associated with DDD, disc height, translational motion, or angular variation in the adjacent superior (C6/C7) or inferior (T1/T2) levels.

METHODS

This study retrospectively analyzed 93 cases with kinematic MRI. Cases were randomly selected from a database with inclusion criteria being no prior spine surgery and images having sufficient quality for analysis. DDD was assessed using Pfirrmann classification. Vertebral body bone marrow lesions were assessed using Modic changes. Disc height was measured at the mid-disc in neutral and extension. Translational motion and angular variation were calculated by assessing translational or angular motion segment integrity respectively in flexion and extension. Statistical associations were assessed with scatterplots and Kendall's tau.

RESULTS

DDD at C7/T1 was positively associated with DDD at C6/C7 (tau = 0.53, p < 0.01) and T1/T2 (tau = 0.58, p < 0.01), with greater disc height in neutral position at T1/T2 (tau = 0.22, p < 0.01), and with greater disc height in extended position at C7/T1 (tau = 0.17, p = 0.04) and at T1/T2 (tau = 0.21, p < 0.01). DDD at C7/T1 was negatively associated with angular variation at C6/C7 (tau = - 0.23, p < 0.01). No association was appreciated between DDD at C7/T1 and translational motion.

CONCLUSION

The association of DDD at the cervicothoracic junction with DDD at the adjacent levels emphasizes the necessity for careful selection of the distal level in multilevel fusion in the distal cervical spine.

Efficacy of Transforaminal Endoscopic Lumbar Discectomy in Elderly Patients Over 65 Years of Age Compared to Young Adults

OBJECTIVE

Spine surgery rates are increasing in the elderly population due to social aging, and it is known that prognoses related to surgery are worse for the elderly compared to younger individuals. However, minimally invasive surgery, such as full endoscopic surgery, is considered safe with low complication rates due to minimal damage to surrounding tissues. In this study, we compared outcomes of transforaminal endoscopic lumbar discectomy (TELD) in elderly and younger patients with disc herniation in the lumbosacral region.

METHODS

We retrospectively analyzed the data of 249 patients who underwent TELD at a single center between January 2016 to December 2019, with a minimum follow-up of 3 years. Patients were allocated to 2 groups: a young group aged ≤ 65 years (n = 202) or an elderly group aged > 65 years (n = 47). We evaluated baseline characteristics, clinical outcomes, surgery-related outcomes, radiological outcomes, perioperative complications, and adverse events during the 3-year follow-up period.

RESULTS

Baseline characteristics, including age, general condition based on American Society of Anesthesiologist physical status classification grade, age-Charlson Comorbidity Index, and disc degeneration, were worse in elderly group (p < 0.001). However, except for leg pain at 4 weeks after surgery, overall outcomes, including pain improvement, radiological change, operation time, blood loss, and hospital stay, were not different between the 2 groups. Furthermore, the rates of perioperative complications (9 patients [4.46%] in the young group and 3 patients [6.38%] in the elderly group, p = 0.578) and adverse events over the 3-year follow-up period (32 patients [15.84%] in the young group and 9 patients [19.15%] in the elderly group, p = 0.582) were comparable in the 2 groups.

CONCLUSION

Our findings suggest that TELD produces similar outcomes in both elderly and younger patients with a herniated disc in the lumbosacral region. TELD can be considered a safe option for appropriately selected elderly patients.

Comparison of robot-assisted versus fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: 2-year follow-up

This study was performed to prospectively compare the clinical and radiographic outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (FA MIS-TLIF) in patients with degenerative lumbar spinal diseases. One hundred and twenty-three patients with lumbar degenerative diseases (lumbar spinal stenosis with instability and spondylolisthesis [degenerative spondylolisthesis or isthmic spondylolisthesis]) who underwent MIS-TLIF in our hospital were included in this study. Sixty-one patients underwent RA MIS-TLIF (Group A) and 62 patients underwent FA MIS-TLIF (Group B). Group A was further divided into Subgroup AI (46 single-level procedures) and Subgroup AII (15 double-level procedures). Group B was further divided into Subgroup BI (45 single-level procedures) and Subgroup BII (17 double-level procedures). The clinical outcome parameters were the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, operative time, number of intraoperative fluoroscopies, blood loss, postoperative hospital stay, and postoperative complications. The radiographic change measures were the accuracy of screw placement, facet joint violation (FJV), fusion status, and change in disc height at the proximal adjacent segment at the 2-year follow-up. There were no significant differences in the VAS and ODI scores, blood loss, or postoperative hospital stay between Groups A and B (p > 0.05). The operative time was longer in Group A than B (p = 0.018). The operative time was longer in Subgroup AI than BI (p = 0.001). However, there was no significant difference between Subgroups AII and BII (p > 0.05). There was no significant difference in the number of intraoperative fluoroscopies for patients between Groups A and B (p > 0.05). Although the number of intraoperative fluoroscopies for patients was significantly higher in Subgroup AI than BI (p = 0.019), there was no significant difference between Subgroups AII and BII (p > 0.05). The number of intraoperative fluoroscopies for the surgeon was significantly lower in Group A than B (p < 0.001). For surgeons, the difference in the average number of intraoperative fluoroscopies between Subgroups AI and AII was 2.98, but that between Subgroups BI and BII was 10.73. In Group A, three guide pins exhibited drift and one patient developed a lateral wall violation by a pedicle screw. One pedicle screw perforated the anterior wall of the vertebral body and another caused an inner wall violation in Group B. The rate of a perfect screw position (grade A) was higher in Group A than B (p < 0.001). However, there was no significant difference in the proportion of clinically acceptable screws (grades A and B) between the two groups. The mean FJV grade was significantly higher in Group B than A (p < 0.001). During at 2-year postoperative follow-up, there was no significant difference in the fusion status between the two groups (p > 0.05); however, the decrease in disc height at the proximal adjacent segment was significantly less in Group A than B (p < 0.001). Robot-assisted percutaneous pedicle screw placement is a safer and more accurate alternative to conventional freehand fluoroscopy-assisted percutaneous pedicle screw insertion in MIS-TLIF.

Comparison of adjacent segment disease after minimally invasive versus open lumbar fusion: a minimum 10-year follow-up

OBJECTIVE

The object of this study was to compare, after a long-term follow-up, the incidence and features of adjacent segment disease (ASDis) following lumbar fusion surgery performed via an open technique using conventional interbody fusion plus transpedicular screw fixation or a minimally invasive surgery (MIS) using a tubular retractor together with percutaneous pedicle screw fixation.

METHODS

The authors conducted a retrospective chart review of patients with a follow-up period > 10 years who had undergone instrumented lumbar fusion at the L4-5 level between January 2004 and December 2010. The patients were divided into an open surgery group and MIS group based on the surgical method performed. Baseline characteristics and radiological findings, including factors related to ASDis, were compared between the two groups. Additionally, the incidence of ASDis and related details, including diagnosis, time to diagnosis, and treatment, were analyzed.

RESULTS

Among 119 patients who had undergone lumbar fusion at the L4-5 level in the study period, 32 were excluded according to the exclusion criteria. The remaining 87 patients were included as the final study cohort and were divided into an open group (n = 44) and MIS group (n = 43). The mean follow-up period was 10.50 (range 10.0-14.0) years in the open group and 10.16 (range 10.0-13.0) years in the MIS group. The overall facet joint violation rate was significantly higher in the open group than in the MIS group (54.5% vs 30.2%, p = 0.022). However, in terms of adjacent segment degeneration, there were no significant differences in corrected disc height, segmental angle, range of motion, or degree of listhesis of the adjacent segments between the two groups during follow-up. The overall incidence of ASDis was 33.3%, with incidences of 31.8% in the open group and 34.9% in the MIS group, showing no significant difference between the two groups (p = 0.822). Additionally, detailed diagnosis and treatment factors were not different between the two groups.

CONCLUSIONS

After a minimum 10-year follow-up, the incidence of ASDis did not differ significantly between patients who had undergone open fusion and those who had undergone MIS fusion at the L4-5 level.