Role of the Lumbosacral Transition Vertebra and Vertebral Lamina in the Pathogenesis of Lumbar Disc Herniation

The effect of lumbosacral transitional vertebra on lumbar spine degeneration and spondylolisthesis among patients with low back pain

AIM

To examine the impact of lumbosacral transitional vertebra (LSTV) on lumbar spine degeneration, disc protrusion, and spondylolisthesis among patients with low back pain.

METHODS

The records of the patients who had undergone anterioposterior lumbar radiographs and lumbar magnetic resonance imaging (MRI) for low back pain between November 2014 and September 2021 were extracted retrospectively and assessed for eligibility. Of the remaining patients, those with LSTV were assigned as "case group." Age- and sex-matched patients without LSTV were assigned as "control group." On digitalized lumbar MRIs, Modic degeneration (type I-III) and Pfirrman's disc degeneration (grade I-V) immediately cephalad to the transitional level were evaluated; intervertebral disc height (mm), disc protrusion (mm), and percentage of vertebral slippage (%) were measured.

RESULTS

Of the 501 patients with low back pain, 128 ineligible patients were excluded; 113 patients with LSTV and 117 age- and sex-matched controls were included in the study. LSTV group revealed decreased intervertebral disc height, increased vertebral endplate degeneration, and slippage, as well as increased disc degeneration and protrusion when compared with controls (p < 0.001). Patients with type III LSTV had greater disc protrusion and higher percentage of slippage compared to those with type I LSTV (p = 0.008 and p = 0.009, respectively). Vertebral endplate degeneration, disc height, and disc degeneration did not differ across categories of LSTV type.

CONCLUSION

Lumbosacral transitional vertebra malformation is related to decreased intervertebral disc height, increased disc degeneration, vertebral endplate degeneration, disc protrusion, and slippage above the level of transition. Patients with type III LSTV revealed the highest percentage of slippage and disc protrusion.

Magnetic Resonance Imaging Evaluation of Multifidus Muscle in Patients with Low Back Pain after Microlumbar Discectomy Surgery

Cross-sectional area (CSA) and signal intensity ratio (SIR) of the multifidus muscle (MFM) on magnetic resonance imaging (MRI) was used to evaluate the extent of injury and atrophy of the MFM in patients with negative treatment outcomes following microlumbar discectomy (MLD). Negative treatment outcome was determined by pain score improvement of <50% compared to baseline. Patients in groups 1, 2, and 3 were evaluated at <4 weeks, 4-24 weeks, and >24 weeks postoperatively, respectively. The associations between the follow-up, surgery time and the changes in the MFM were evaluated. A total of 79 patients were included, with 22, 27, and 30 subjects in groups 1, 2, and 3, respectively. The MFM SIR of the ipsilateral side had significantly decreased in groups 2 (p = 0.001) and 3 (p < 0.001). The ipsilateral MFM CSA significantly decreased postoperatively in groups 2 (p = 0.04) and 3 (p = 0.006). The postoperative MRI scans found significant MFM changes on the ipsilateral side in patients with negative treatment outcomes regarding pain intensity following MLD. As the interval to the postoperative MRI scan increased, the changes in CSA of the MFM and change in T2 SIR of the MFM showed a tendency to increase.

Adolescent Lumbar Intervertebral Disc Herniation: Conservative versus Surgical Treatment

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

A Comparison Between Retaining and Resecting the Posterior Longitudinal Ligament in Percutaneous Endoscopic Transforaminal Discectomy for Disc Herniation: A Retrospective Cohort Study

Objective

To compare the efficacy and safety of retaining the posterior longitudinal ligament (PLL) with resecting the PLL in inside‐out percutaneous endoscopic transforaminal discectomy (PETD) surgery for lumbar disc herniation (LDH).

Method

A total of 135 patients with symptomatic LDH who were treated by inside‐out PETD surgery from January 2015 to January 2017were included in this retrospective analysis. There were 38 males and 30 females in the PLL resection group (mean age = 52.40 ± 8.73 years) and 35 males and 32 females in the PLL retention group (mean age = 53.50 ± 9.24 years). The visual analogue scale (VAS) score, Oswestry disability index (ODI), and modified MacNab criteria were used to evaluate clinical outcomes. Operation time, blood loss, recurrence of LDH, and complications were recorded. Three months after surgery, magnetic resonance imaging was performed to confirm that nerve root compression was relieved.

Results

The VAS and ODI scores improved significantly immediately after surgery, at 1 month after surgery, at 3 months after surgery, and at last follow‐up compared with those before surgery (P < 0.01). The scores also improved significantly between immediately after surgery and 1 month after surgery in the two groups (P < 0.001). Multivariate analysis indicated that age ≥ 50 years (odds ratio (OR) = 6.33, 95% confidence interval (CI): 1.64–21.98, P = 0.014), pain duration ≥6 months (OR = 4.68, 95% CI: 1.29–6.51, P = 0.025), pre‐ODI score ≥ 40% (OR = 5.97, 95% CI: 2.41–14.86, P = 0.003) were all associated with poor functional outcomes. There was no significant difference in the excellent/good ratio between the two groups and the mean operation time of the retention group was 71.5% of that of the resection group (82.7 ± 18.5 min vs 115.6 ± 24.6 min, P < 0.01). In the patients, no serious complications, such as dural tear, wound infection, or persistent nerve root injury, were observed during the follow‐up period. There was no significant difference in the complication rate between the two groups (6/68 vs 6/67, P = 0.979). Although the recurrence rate was higher in retention group, there was no significant difference between the two groups (1/68 vs 2/67, P = 0.551).

Conclusion

The PLL is recommended to be retained for inside‐out PETD surgery.