The probability of spontaneous regression of lumbar herniated disc: a systematic review

Recovery of ambulation in small, nonbrachycephalic dogs after conservative management of acute thoracolumbar disk extrusion

BACKGROUND

Currently, low-level evidence suggests loss of ambulation associated with acute thoracolumbar disk extrusion is best treated by decompressive spinal surgery. Conservative management can be successful, but the proportion of dogs that recover and the fate of herniated material are uncertain.

OBJECTIVES

Determine the proportion of nonambulatory dogs with conservatively treated acute thoracolumbar disk extrusion that recover ambulation and measure the change in spinal cord compression during the first 12 weeks after presentation.

ANIMALS

Seventy-two client-owned nonambulatory dogs with acute thoracolumbar intervertebral disk extrusion.

METHODS

This is a prospective cohort study. Enrolled dogs underwent magnetic resonance imaging at presentation and owners were provided with conservative management recommendations. Imaging was repeated after 12 weeks. Recovery of ambulation was defined as 10 consecutive steps without falling. Spinal cord compression was determined from the cross-sectional area of the vertebral canal and extradural compressive material at the lesion epicenter. The association between recovery and change in compression over the 12-week observational period was examined.

RESULTS

Forty-nine of fifty-one (96%; 95% confidence interval [CI], 87%-99%) of deep pain-positive and 10/21 (48%; 95% CI, 28%-68%) of deep pain-negative dogs recovered ambulation within the 12-week period. The median time to ambulation was 11 and 25 days for deep pain-positive and -negative dogs, respectively. Reduction in spinal cord compression varied among individuals from minimal to complete and apparently was unrelated to the recovery of ambulation.

CONCLUSIONS AND CLINICAL IMPORTANCE

A high proportion of conservatively treated dogs recovered ambulation after conservative management of acute thoracolumbar disk herniation. Recovery was not dependent on the resolution of compression.

Assessing the impact of health-care access on the severity of low back pain by country: a case study within the GBD framework

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is key for policy making. Low back pain is the leading cause of disability in terms of years lived with disability (YLDs). Due to sparse data, a current limitation of GDB is that a uniform severity distribution is presumed based on 12-Item Short Form Health Survey scores derived from US Medical Expenditure Panel Surveys (MEPS). We present a novel approach to estimate the effect of exposure to health interventions on the severity of low back pain by country and over time.

METHODS

We extracted treatment effects for ten low back pain interventions from the Cochrane Database, combining these with coverage data from the MEPS to estimate the hypothetical severity in the absence of treatment in the USA. Severity across countries was then graded using the Health Access and Quality Index, allowing estimates of averted and avoidable burden under various treatment scenarios.

FINDINGS

We included 210 trials from 36 Cochrane systematic reviews in the network analysis. The pooled effect sizes (measured as a standardised mean difference) for the most effective intervention classes were -0·460 (95% uncertainty interval -0·606 to -0·309) for a combination of psychological and physical interventions and -0·366 (-0·525 to -0·207) for surgery. Globally, access to treatment averted an estimated 17·6% (14·8 to 23·8) of the low back pain burden in 2020. If all countries had provided access to treatment at a level estimated for Iceland with the highest Health Access and Quality Index score, an extra 9·1% (6·4 to 11·2) of the burden of low back pain could be avoided. Even with full coverage of optimal treatment, a large proportion (65·9% [56·9 to 70·4]) of the low back pain burden is unavoidable.

INTERPRETATION

This methodology fills an important shortcoming in the GBD by accounting for low back pain severity variations over time and between countries. Assumptions of unequal treatment access increased YLD estimates in resource-poor settings, with a modest decrease in countries with higher Health Access and Quality Index scores. Nonetheless, the large proportion of unavoidable burden indicates poor intervention efficacy. This method, applicable to other GBD conditions, provides policy makers with insights into health gains from improved treatment and underscores the importance of investing in research for new interventions.

FUNDING

Bill and Melinda Gates Foundation and Queensland Health.

Three Stages on Magnetic Resonance Imaging of Lumbar Degenerative Spine

PURPOSES

To propose a new lumbar degenerative staging system using the current radiological classification system.

METHODS

A cross-sectional analysis of retrospective databases between January 2018 and December 2022 was performed. Total of 410 patients for Modic changes, paravertebral muscle fat infiltration, disc degeneration, articular process degeneration, vertebral endplate degeneration and other structures, and disc displacement, Spondylolisthesis, and stenosis, and grouped patients according to stage were assessed. Visual analog scale, Japanese Orthopaedic Association, and Oswestry Disability Index scores were used to assess low back pain strength, neurological function, and quality of life, respectively.

RESULTS

The lumbar degeneration staging system consists of 8 variables, which can be divided into 3 steps: early, middle and late, and the correlation between each variable is strong (P < 0.05). The later the staging, the worse the Japanese Orthopaedic Association, visual analog scale, and Oswestry Disability Index scores.

CONCLUSIONS

Patients with later stages have worse clinical scores. This staging system recommends a uniform classification to assess lumbar degeneration.

Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-analysis

STUDY DESIGN

A meta-analysis.

OBJECTIVE

This study aimed to analyze the incidence of spontaneous resorption of lumbar disk herniation (LDH) after conservative treatment.

SUMMARY OF BACKGROUND DATA

The resorption of intervertebral disks has been more frequently reported, but there is a lack of reference to the probability of resorption.

METHODS

We strictly refer to the standard established in the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-analysis) statement, comprehensively searched electronic databases using the terms related to the spontaneous resorption of LDH. Two reviewers independently evaluated the potential studies, extracted, and analyzed the enrolled data.

RESULTS

Thirty-one studies with 2233 patients who received conservative treatment were included for this analysis. We found that the pooled overall incidence of disk resorption was 70.39%, 87.77% for disk sequestration, 66.91% for disk extrusion, 37.53% for disk protrusion, and 13.33% for disk bugle, respectively. The resorption incidence in of 25%≤ reduction of disk herniation (RDH) 50%, RDH≥50%, and RDH=100% were 40.19%, 43.62, and 36.89%. The resorption incidence was 66.98% in Japan, 61.66% in the United States, 83.52% in Korea, 60.68% in China, 78.30% in the UK, 56.70% in Italy, and 83.68% in Turkey, respectively. Subgroup analysis showed that there was no significant difference in resorption incidence among prospective, retrospective studies and randomized controlled trials ( P =0.77), and there was no significant difference in evaluation method among qualitative and quantitative studies ( P =0.05).

CONCLUSIONS

The existing evidence shows that the overall resorption incidence of LDH was 70.39%, the resorption incidence of ruptured LDH is higher than that of contained LDH. There are significant differences in the resorption incidence among countries. The resorption process mainly occurred within 6 months of conservative treatment.

Case Report: Integrative naturopathic approach for the management of sequestered lumbar disc herniation with neurological impairments: a case series with two year follow up

Lumbar Disc Herniation (LDH) is a common condition, and contemporary pain research emphasizes the importance of adopting a comprehensive biopsychosocial perspective in pain treatment for positive clinical outcomes. Integrated Naturopathy and Yoga (INY) is a non-invasive medical system that takes a holistic and patient-centric approach to healing diseases. However, there is limited evidence on the effectiveness of INY, particularly in managing Sequestered LDH. We present two cases of patients experiencing radicular low back pain, lower limb weakness, and neuro-claudication who opted for conservative naturopathic management with INY. Following the INY treatments, both patients reported gradual relief from lower back pain, radicular pain, and neurological deficits. These findings are significant and contribute valuable evidence, suggesting that INY could be a viable therapeutic approach for managing sequestered LDH. This represents the first report on a non-invasive method for resolving sequestered LDH by utilizing INY.

Prediction and Mechanisms of Spontaneous Resorption in Lumbar Disc Herniation: Narrative Review

The major symptoms of lumbar disc herniation (LDH) are low back pain, radiative lower extremity pain, and lower limb movement disorder. Patients with LDH suffer from great distress in their daily life accompanied by severe economic hardship and difficulty in self-care, with an increasing tendency in the aging population. PubMed and the Cochrane Central Register of Controlled Trials were searched for relevant studies of spontaneous resorption or regression in LDH after conservative treatment and for other potential studies, which included those from inception to June 30, 2023. The objective of this narrative review is to summarize previous literatures about spontaneous resorption in LDH and to discuss the mechanisms and influencing factors in order to assess the probability of spontaneous resorption by conservative treatment. Spontaneous resorption without surgical treatment is influenced by the types and sizes of the LDH, inflammatory responses, and therapeutic factors. If the lumbar disc herniated tissue comprises a higher percentage of cartilage or modic changes have been shown on magnetic resonance imaging (MRI), resorption in LDH is prevented. The bull's eye sign on enhanced MRI, which is a ring enhancement around a protruding disc, is a vital indicator for easy reabsorption. In addition, the type of extrusion and sequestration in LDH could forecast the higher feasibility of natural reabsorption. Moreover, the higher the proportion of protrusion on the intervertebral disc tissue within the spinal canal, the greater the likelihood of reabsorption. Therefore, which illustrates the feasibility of conservative treatments for LDH. Nonsurgical management of LDH with clinical symptoms is recommended by the authors.

Can self-powered piezoelectric materials be used to treat disc degeneration by means of electrical stimulation?

Intervertebral disc degeneration (IDD) due to multiple causes is one of the major causes of low back pain (LBP). A variety of traditional treatments and biologic therapies are currently used to delay or even reverse IDD; however, these treatments still have some limitations. Finding safer and more effective treatments is urgent for LBP patients. With increasing reports it has been found that the intervertebral disc (IVD) can convert pressure loads from the spine into electrical stimulation in a variety of ways, and that this electrical stimulation is of great importance in modulating cell behavior, the immune microenvironment and promoting tissue repair. However, when intervertebral disc degeneration occurs, the normal structures within the IVD are destroyed. This eventually leads to a weakening or loss of self-powered. Currently various piezoelectric materials with unique crystal structures can mimic the piezoelectric effect of normal tissues. Based on this, tissue-engineered scaffolds prepared using piezoelectric materials have been widely used for regenerative repair of various types of tissues, however, there are no reports of their use for the treatment of IDD. For this reason, we propose to utilize tissue-engineered scaffolds prepared from piezoelectric biomaterials with excellent biocompatibility and self-powered properties to be implanted into degenerated IVD to help restore cell type and number, restore extracellular matrix, and modulate immune responses. It provides a feasible and novel therapeutic approach for the clinical treatment of IDD.

Role of surgery in primary lumbar disk herniation: WFNS spine committee recommendations

Objective

To provide the most up-to-date recommendations on the role of surgery in first-time lumbar disk herniations (LDH) in order to standardize surgical management.

Methods

We performed a literature search in PubMed, Scopus, and Embase from 2012 to 2022 using the following keywords: "lumbar disk herniation AND surgery". Our initial search yielded 2610 results, which were narrowed down to 283 papers after standardized screening critera were applied. The data from these 283 papers were presented and discussed at two international meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee, where the Delphi method was employed and ten spine experts voted on five final consensus statements.

Results

and Conclusions: The WFNS Spine Committee's guidelines cover four main topics: (1) role and timing of surgery in first-time LDH; (2) role of minimally invasive techniques in LDH; (3) extent of disk resection in LDH surgery; (4) role of lumbar fusion in the context of LDH. Surgery for LDH is recommended for failure of conservative treatment, cauda equina syndrome, and progressive neurological impairment, including severe motor deficits. In the latter cases, early surgery is associated with faster recovery and may improve patient outcomes. Minimally invasive techniques have short-term advantages over open procedures, but there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure. Sequestrectomy and standard microdiscectomy demonstrated similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short and medium-term follow-up. Lumbar fusion is not recommended as a routine treatment for first-time LDH, although it may be considered in specific patients affected by chronic axial pain or instability.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

MRI characteristics of disc degeneration after condoliase injection in young patients: A consecutive case series

BACKGROUND

Lumbar disc herniation (LDH) results in low back pain due to nerve root compression caused by nucleus pulposus degeneration. Chemonucleolysis of the nucleus pulposus by injection of condoliase is less invasive than surgery, but may cause disc degeneration. The purpose of the study was to examine outcomes of condoliase injection in patients in their teens and twenties using Pfirrmann criteria on MRI.

METHODS

A single-center retrospective study was performed in 26 consecutive patients (19 men, 7 women) who underwent condoliase injection (1 mL, 1.25 U/mL) for LDH and had MRI scans at 3 and 6 months. Cases with and without an increase in Pfirrmann grade at 3 months post-injection were included in groups D (disc degeneration, n = 16) and N (no degeneration, n = 10). Pain was measured on a visual analogue scale (VAS). MRI findings were evaluated using the % change in disc height index (ΔDHI).

RESULTS

The mean age of the patients was 21.1 ± 4.1 years and 12 were <20 years old. At baseline, 4, 21 and 1 were in Pfirrmann grades II, III and IV. In group D, no case had a further increase in Pfirrmann grade from 3 to 6 months. Pain significantly decreased in both groups. There were no adverse events. MRI showed a significant decrease in ΔDHI from 100% pre-injection to 89.4 ± 9.7% at 3 months in all cases (p < 0.05). There was a significant recovery in ΔDHI in group D from 3 to 6 months (85.4 ± 9.3% vs. 86.7 ± 9.1%, p < 0.05).

CONCLUSIONS

These results suggest that chemonucleolysis with condoliase is effective and safe for LDH in young patients. Progression of Pfirrmann criteria at 3 months post-injection occurred in 61.5% of cases, but disc degeneration showed recovery in these patients. A longer-term study of the clinical symptoms related to these changes is required.

Contextual effects: how to, and how not to, quantify them

The importance of contextual effects and their roles in clinical care controversial. A Cochrane review published in 2010 concluded that placebo interventions lack important clinical effects overall, but that placebo interventions can influence patient-reported outcomes such as pain and nausea. However, systematic reviews published after 2010 estimated greater contextual effects than the Cochrane review, which stems from the inappropriate methods employed to quantify contextual effects. The effects of medical interventions (i.e., the total treatment effect) can be divided into three components: specific, contextual, and non-specific. We propose that the most effective method for quantifying the magnitude of contextual effects is to calculate the difference in outcome measures between a group treated with placebo and a non-treated control group. Here, we show that other methods, such as solely using the placebo control arm or calculation of a 'proportional contextual effect,' are limited and should not be applied. The aim of this study is to provide clear guidance on best practices for estimating contextual effects in clinical research.

Autophagy in an extruded disc compared to the remaining disc after lumbar disc herniation in the same patient

PURPOSE

The purpose of this study was to investigate autophagy in an extruded disc and to compare this activity with the activity in the remaining disc after lumbar disc herniation in the same patient.

METHODS

In total, 12 patients (females 4, males 8) with the extruded type of lumbar disc herniation (LDH) were surgically treated. Their mean age was 54.3 ± 15.8 years (range: 29 ~ 78 years). The mean interval from the occurrence of symptoms to the operation was 9.8 ± 9.4 weeks (range: 2 ~ 24 weeks). The extruded discs were excised, and the remaining disc material removed, to prevent recurrence of herniation. Immediately after specimen collection, all tissues were stored at -70 °C prior to analysis. Autophagy was assessed immunohistochemically and via Western blotting for Atg5, Atg7, Atg12, Atg12L1, and Beclin-1. And the relationship between autophagy and apoptosis was investigated by correlation analysis of caspase-3 with autophagy proteins.

RESULTS

The expression levels of autophagic markers were significantly increased in the extruded discs compared to the remaining discs within the same patients. The mean expression levels of Atg5, Atg7, Atg12, and Beclin-1 in extruded discs were statistically significantly higher than those in the remaining discs (P < 0.01, P < 0.001, P < 0.01, and P < 0.001 respectively).

CONCLUSIONS

The autophagic pathway was more active in extruded disc material than in remaining disc material within the same patient. This may explain spontaneous resorption of the extruded disc after LDH.

The McKenzie Method versus guideline-based advice in the treatment of sciatica: 24-month outcomes of a randomised clinical trial

OBJECTIVE

To compare the effectiveness of a McKenzie Method intervention in patients with sciatica with guideline-based patient education.

DESIGN

Multi-centre, assessor-blinded, parallel-group, randomised trial.

SETTING

Two tertiary hospitals providing operative spinal care.

SUBJECTS

Sciatica patients with magnetic resonance imaging-confirmed lumbar disc herniation compressing a nerve root.

INTERVENTIONS

The McKenzie group received specific back exercises for seven visits combined with an educational book, and the Control group received a single session of self-management guidance according to usual practices.

MAIN MEASURES

The primary outcome was the number of surgical operations. Secondary outcomes were pain measured using the Visual Analogue Scale, disability using the Oswestry Disability Index and health-related quality of life using a RAND-36 questionnaire at baseline and 24-month follow-up.

RESULTS

Altogether 66 patients, mean age of 43 years, of which 50% were females with long-lasting sciatica, mean 16 weeks, were randomised to two groups. Nineteen patients (29%) had surgery. There was no significant difference in surgery rates between the groups. Back and leg pain decreased, and disability improved in both groups. Health-related quality of life improved in six dimensions out of eight in both groups. There were no significant between-group changes in the patient-reported outcomes at the follow-up.

CONCLUSIONS

Multiple sessions of McKenzie-based back exercises with a McKenzie-specific patient's educational book produced effects equal to guideline-based advice at long-term follow-up. However, the power of these results is diminished due to the small patient population and confounding factors.

The Clinical Utility of Repeating Magnetic Resonance Imaging (MRI) Scans Within 12 Months in the Management of Lumbosacral Degenerative Disc Disease

PURPOSE

Magnetic resonance imaging (MRI) is the gold standard investigation for lumbosacral degenerative disc disease. However, there is controversy regarding the clinical value of repeating an MRI scan within 12 months when a patient presents with recurring or changing symptoms. This study measures rates of radiological change in a real-world cohort to guide clinicians when deciding to repeat a scan.

METHODS

All patients over a 10-year window in one general hospital who underwent two lumbosacral MRI scans for degenerative disc disease within 12 months of each other were included in the study. All MRI reports were manually reviewed. The level of main vertebral pathology was recorded, along with the location of a disc prolapse. Time intervals between the two scans were calculated, and these were collated into 30-day intervals for analysis. The repeat scans were categorized into three groups: no change, radiological improvement, and radiological deterioration. Patients who had clinically significant deterioration in the form of cauda equina compression on MRI scans were recorded.

FINDINGS

Four hundred and eighty-one patients were included for analysis. Three hundred and ninety (81%) showed no change in MRI findings, 18 (3.7%) had improvements in their repeat scans, and 73 (15.3%) demonstrated deterioration in their repeat scans. Of the 73 patients with radiological deterioration, three patients (0.62% of the total) required urgent surgical intervention for cauda equina syndrome (CES).

CONCLUSIONS

Though there is no alternative to detailed clinical assessment in determining whether a repeat MRI scan is indicated, the findings demonstrate that repeating MRI within 12 months for patients with lumbosacral degenerative disc disease has a low chance of altering the management plan. Over the 10-year period, only three patients required an urgent change to their clinical management. We believe this data can help guide clinical decision-making when considering a repeat scan.

Predicting the Need for Surgery in Patients with Lumbar Disc Herniation: A New Internally Validated Scoring System

STUDY DESIGN

Prospective study.

PURPOSE

To propose a scoring system for predicting the need for surgery in patients with lumbar disc herniation (LDH).

OVERVIEW OF LITERATURE

The indications for surgery in patients with LDH are well established. However, the exact timing of surgery is not. According to surgeons, patients with failed conservative treatment who underwent delayed surgery, often after 6 months postsymptom initiation, have poor functional recovery and outcome.

METHODS

The current study included patients with symptomatic LDH. Patients with an indication for emergent surgery such as profound or progressive motor deficit, cauda equina syndrome, and diagnoses other than single-level LDH were excluded from the analysis. All patients followed a conservative treatment regimen (a combination of physical therapy, pain medications, and/or spinal epidural steroid injections). Surgery was indicated for patients who continuously experienced pain despite maximal conservative therapy.

RESULTS

In total, 134 patients met the inclusion and exclusion criteria. Among them, 108 (80.6%) responded to conservative management, and 26 (19.4%) underwent unilateral laminotomy and microdiscectomy. The symptom duration, disc degeneration grade on magnetic resonance imaging (Pfirrmann disc grade), herniated disc location and type, fragment size, and thecal sac diameter significantly differed between patients who responded to conservative treatment and those requiring surgery. The area under the receiver operating characteristic curve of the scoring system based on the anteroposterior size of the herniated disc fragment and herniated disc location and type was 0.81.

CONCLUSIONS

A scoring system based on herniated disc/fragment size, location, and type can be applied to predict the need for surgery in patients with LDH. In the future, this tool can be used to prevent unnecessarily prolonged conservative management (>4-8 weeks).

Are there any correlations among the number of discopathy levels and pain intensity or disability in patients with symptomatic low back pain?

INTRODUCTION

Low back pain (LBP) is considered a civilization disease that affects people in an increasing number. Discopathy (degeneration of intervertebral discs) is recognised as one of LBP causes. Still, the relationship between the number of discopathy levels and LBP remains unclear. The aim of this study was to evaluate the correlation between the number of discopathy levels with intensity of LBP, functional level and the degree of disability.

MATERIALS AND METHODS

The prospective, cohort study involved 200 patients aged 27 to 55 years (44.9 ± 9.2 years) with single- or multilevel lumbar discopathy confirmed by imaging examinations. Functional examination included NRSscale, goniometric measurements, Modified Laitinen Pain Questionnaire, Oswestry Disability Index and Back Pain Function Scale.

RESULTS

There were statistically significant positive correlations between the number of discopathy levels and the age of the subjects (r = 0.266; p = 0.000), BMI (r = 0.158; p = 0.029) and ODI (r = 0.157; p = 0.026). Positive correlation (r = 0.142; p = 0.044) was also observed between the results of Fingertip-to-floortest and the number of levels of discopathy.

CONCLUSIONS

The number of levels of discopathy was depended on the age and BMI of the patients. It had no effect on pain intensity, range of rotational motion of the lumbar spine and functional status of patients. As the number of levels of discopathy increased, a higher degree of everyday disability was observed.

Regression of a large prolapsed lumbar disc herniation achieved by conservative treatment: A case report and literature review

A common spinal condition known as lumbar disc herniation (LDH) can result in radicular and low back discomfort. A 27-year-old man was admitted to our hospital with a 6-year history of persistent low back pain, and his low back pain had recurred with radiation to his lower extremities over the last two months. An extensive right-sided paracentral disc herniation in the L5/S1 intervertebral region, which compressed the nerve root, was discovered by magnetic resonance imaging (MRI) of his lumbar spine. After receiving conservative treatment, the patient reported that his lower back discomfort and neurogenic claudication had gradually subsided after 4 months. After one year, a follow-up MRI showed that the massive, prolapsed disc herniation at the L5/S1 level had totally disappeared. The sagittal protrusion length of the L5/S1 intervertebral disc shrank from 12.35 mm to 3.49 mm. However, there remained a chance of vertebral height loss. During the course of treatment, the height of the L5/S1 intervertebral space was still slightly reduced. The intervertebral space height declined from 7.705 mm to 7.201 mm after one year of treatment. The current case and a review of the literature demonstrate that LDH can decrease with conservative therapy over a short period of time. We stress the effectiveness of conservative treatment in very select LDH cases that lack a clear surgical justification.

Spinal Injections: A Narrative Review from a Surgeon's Perspective

Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.

Macrophage-based therapy for intervertebral disc herniation: preclinical proof-of-concept

Intervertebral disc (IVD) degeneration and herniation is a leading cause of disability globally and a large unmet clinical need. No efficient non-surgical therapy is available, and there is an urgency for minimally invasive therapies capable of restoring tissue function. IVD spontaneous hernia regression following conservative treatment is a clinically relevant phenomenon that has been linked to an inflammatory response. This study establishes the central role of macrophages in IVD spontaneous hernia regression and provides the first preclinical demonstration of a macrophage-based therapy for IVD herniation. A rat model of IVD herniation was used to test complementary experimental setups: (1) macrophage systemic depletion via intravenous administration of clodronate liposomes (Group CLP2w: depletion between 0 and 2 weeks post-lesion; Group CLP6w: depletion between 2 and 6 weeks post-lesion), and (2) administration of bone marrow-derived macrophages into the herniated IVD, 2 weeks post-lesion (Group Mac6w). Herniated animals without treatment were used as controls. The herniated area was quantified by histology in consecutive proteoglycan/collagen IVD sections at 2 and 6 weeks post-lesion. Clodronate-mediated macrophage systemic depletion was confirmed by flow cytometry and resulted in increased hernia sizes. Bone marrow-derived macrophages were successfully administered into rat IVD hernias resulting in a 44% decrease in hernia size. No relevant systemic immune reaction was identified by flow cytometry, cytokine, or proteomic analysis. Furthermore, a possible mechanism for macrophage-induced hernia regression and tissue repair was unveiled through IL4, IL17a, IL18, LIX, and RANTES increase. This study represents the first preclinical proof-of-concept of macrophage-based immunotherapy for IVD herniation.

Non-surgical Restoration of L3/L4 Disc Herniation

We report the case of a 52-year-old Asian man presenting with severe lower back pain and bilateral radiculopathy due to acute L3/L4 disc extrusion, causing severe spinal canal stenosis and bilateral L4 nerve root compression. Following a ten-week conservative management plan consisting of high-velocity, low-amplitude spinal manipulation, adjunctive therapies, and home exercise, the patient experienced significant pain relief, functional improvement, and near resolution of deficits. A six-month follow-up MRI revealed the resolution of the L3/L4 disc extrusion, and the patient remained asymptomatic at nine months. This case highlights the potential for spontaneous resorption of a lumbar disc herniation and symptomatic improvement with conservative management, including chiropractic treatment. A favorable natural course of a disc herniation should be considered when deciding between early surgical intervention and conservative management, warranting further prospective studies to evaluate the effectiveness of chiropractic treatment and the role of spontaneous regression in symptomatic lumbar disc herniation.

Clinical Characteristics of Minimal Lumbar Disc Herniation and Efficacy of Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach: A Retrospective Study

Objective: To define the characteristics of Mini LDH, develop new diagnostic references and examine the clinical efficacy of percutaneous endoscopic lumbar discectomy via a transforaminal approach (TF-PELD) for it. Methods: A total of 72 patients who underwent TF-PELD with Mini LDH from September 2019 to October 2022 were enrolled in this retrospective study. The patients’ basic information, symptoms, number of outpatient visits, duration of conservative treatment, physical examination findings and so on were obtained from the medical records. Clinical effects of TF-PELD for Mini LDH were assessed by means of the following: the Visual Analog Scale (VAS) for low back pain (LBP) and leg pain, Oswestry Disability Index (ODI) for functional status assessment and Modified Mac Nab criteria for patient satisfaction. Results: Mini LDH have specific clinical characteristics and imaging features. All included patients achieved obvious pain relief after TF-PELD surgery. Pain scores were repeated at postoperative day 1 and 1, 3, 6, 12 and 24 months later. Results were statistically analyzed. The average VAS-Back, VAS-Leg and ODI scores were all significantly reduced at the first postoperative day and gradually decreased with the follow-up time continuing. In total, 66 out of 72 patients received an excellent or good recovery and no poor result was reported according to the Modified Mac Nab criteria. Conclusions: Mini LDH is a type of LDH with special characteristics and in need of correct diagnosis and active treatment in clinical work. TF-PELD was also found to be an effective procedure for the treatment of Mini LDH.

Incidence of lumbar discectomy during pregnancy and within 12 months post-partum in Finland between 1999 and 2017: a retrospective register-based cohort study

BACKGROUND CONTEXT

Both lumbar disc herniation in the general population and lower back pain in the pregnant population are known to be common conditions. The physiological and anatomical of the mother predispose to increased strain of the lumbar disc, whereas pregnancy may promote caution in physicians contemplating surgical care.

PURPOSE

We aimed to report the incidence of lumbar discectomy during pregnancy and 12 months postpartum in Finland between 1999 and 2017.

STUDY DESIGN

Retrospective register-based cohort study.

PATIENT SAMPLE

Using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register, all women aged 15 to 49 years with a lumbar discectomy or pregnancy ending in delivery from 1st January, 1999 to 31st December, 2017 were included.

OUTCOME MEASURES

Incidence rates and their 95% confidence intervals were calculated for lumbar discectomy. Incidence rate ratios (IRR) were calculated between the study population and the control population. The effect of smoking on surgery risk was reported using odds ratios.

METHODS

A retrospective statistical analysis was performed to identify patients undergoing lumbar discectomy during pregnancy or the first 12 months after delivery. Incidence rates were compared with the age-adjusted values of the age-matched female general population. The effect of smoking on the risk of lumbar discectomy was analyzed using age-adjusted odds ratios.

RESULTS

In total, 91 discectomies were performed during pregnancy and 508 within 12 months postpartum. The total incidence of lumbar discectomy during pregnancy was 11 operations per 100,000 person-years with an IRR of 0.2 (95% CI 0.1-0.2) when compared with the age-adjusted female general population. Women with active smoking before pregnancy were at a higher risk for lumbar discectomy during pregnancy (OR 2.0, 95% CI 1.2-3.2). Caesarean section was more common after lumbar discectomy (22%). No perinatal mortality was observed. During the first-year postpartum the rate of lumbar discectomy increased to 47 per 100 000 person-years with an IRR of 0.7 (95% CI 0.6-0.8). 90-day reoperation rates were higher than in the general population with an IRR of 1.7 (95% CI 1.1- 2.7).

CONCLUSIONS

Lumbar discectomy during pregnancy is rare, but smoking increases the risk. Lumbar discectomy during pregnancy seems to be safe for the neonate. Postpartum incidences increased towards the end of the first year, but remained below the rates in the general population with a higher risk for short-term reoperation.

[The use of a fixed combination of diclofenac and orphenadrine in the treatment of acute pain syndrome in patients with discogenic lumbosacral radiculopathy and lumboischialgia]

Acute pain syndromes caused by discogenic lumbosacral radiculopathy and lumboischialgia are not uncommon in clinical practice and characterized by a high risk of becoming chronic. The pathogenetic aspects, features of the clinical picture, existing approaches to conservative treatment of these conditions are analyzed in this paper. Data on the efficacy and safety of a fixed combination of diclofenac and orphenadrine (Neodolpasse) use in the treatment of vertebrogenic pain syndromes based on the NEODOLEX study results are presented, and the authors' own clinical observations are given. Possible reasons for the high efficacy of Neodolpasse in patients with discogenic radiculopathies and nonspecific back and neck pain are discussed.

Resorption of Lumbar Disk Herniation: Mechanisms, Clinical Predictors, and Future Directions

INTRODUCTION

Resorption after lumbar disk herniation is a common yet unpredictable finding. It is hypothesized that nearly 70% of lumbar herniated nucleus pulposus (HNP) undergo the resorption to a significant degree after acute herniation, which has led to nonoperative management before surgical planning.

METHODS

This narrative review on the literature from 4 databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Cochrane) examines historical and recent advancements related to disk resorption. Studies were appraised for their description of the predictive factor (e.g., imaging or morphologic factors), pathophysiology, and treatment recommendations.

OBSERVATIONS

We reviewed 68 articles considering the possibility of resorption of lumbar HNP. Recent literature has proposed various mechanisms (inflammation and neovascularization, dehydration, and mechanical traction) of lumbar disk resorption; however, consensus has yet to be established. Current factors that increase the likelihood of resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial gadolinium-based magnetic resonance imaging (MRI), composition of inflammatory mediators, and involvement of the posterior longitudinal ligament.

CONCLUSION

Heterogeneity in imaging and morphologic factors has led to uncertainty in the identification of which lumbar herniations will resorb. Current factors that increase the likelihood of disk resorption include the initial size of the herniation, sequestration, percentage of rim enhancement on initial MRI, composition of cellular and inflammatory mediators present, and involvement of the posterior longitudinal ligament. This review article highlights the role of disk resorption after herniation without surgical intervention and questions the role of traditional noninflammatory medications after acute herniation. Further research is warranted to refine the ideal patient profile for disk resorption to ultimately avoid unnecessary treatment, thus individualizing patient care.

Update on the roles of macrophages in the degeneration and repair process of intervertebral discs

Intervertebral disc (IVD) degeneration is the common cause of lumbar degenerative diseases, causing severe social and economic burden. The process of IVD degeneration involves a complex of pathologic changes on both extracellular matrix degradation and resident cell apoptosis. In recent years, there is increasing evidence that macrophages play vital roles during the damage and repair process of IVD degeneration. Nevertheless, the interactions between macrophages and IVD are not well understood, even if the IVD has long been regarded as the immune privileged site. Therefore, this review mainly focuses on the progress and obstacles of studies investigating the blood supply, immune response and especially macrophages during the IVD degeneration process.

[Research progress of resorption of lumbar disc herniation]

OBJECTIVE

To summarize the research progress of resorption of lumbar disc herniation (RLDH).

METHODS

The literature on RLDH at home and abroad in recent years was reviewed to summarize its influencing factors, pathogenesis, imaging findings, and predictive effect, as well as its influence on the treatment selection of lumbar disc herniation (LDH).

RESULTS

The main mechanism of RLDH is the combined effect of inflammatory response and neovascularization. Age, smoking, body mass index, and clinical manifestations are the influencing factors. Studies have shown that the annular enhancement around the nucleus pulposus on enhanced MRI images is the characteristic imaging manifestation of RLDH, which is a predictor of whether RLDH occurs. In the treatment of LDH, cyclooxygenase 2 inhibitors may have a negative impact on RLDH.

CONCLUSION

The occurrence of RLDH suggests that strict conservative treatment is the first choice for LDH treatment, but surgery is still an important treatment method when the patient's symptoms and imaging symptoms don't significantly improved after conservative treatment.

Selective Nerve Root Block in Treatment of Lumbar Radiculopathy: A Narrative Review

Selective Nerve Root Block (SNRB) is a precise local injection technique that can be utilised to target a particular inflamed nerve root causing lumbar radiculopathy for both diagnostic and therapeutic purposes. Usually, for SNRB to be therapeutic, a combination of a local anaesthetic agent and a steroid is injected under imaging guidance, whereas for diagnostic purposes, just the local anaesthetic agent is injected. While the ideal treatment strategy is to relieve the nerve root from its compressing pathology, local injection of steroids targeted at the affected nerve root can also be attempted to reduce inflammation and thus achieve pain relief. Although the general principle for administering an SNRB remains largely the same across the field, there are differences in techniques depending on the region and level of the spine that is targeted. Moreover, drug combinations utilised by clinicians vary based on preference. The proven benefits of SNRBs largely outweigh their risks, and the procedure is deemed safe and well tolerated in a majority of patients. In this narrative, we explore the existing literature and seek to provide a comprehensive understanding of SNRB as a treatment for lumbar radiculopathy, its indications, techniques, outcomes, and complications.

Characteristics and mechanisms of resorption in lumbar disc herniation

Lumbar disc herniation (LDH) can be spontaneously absorbed without surgical treatment. However, the pathogenesis and physiological indications for predicting protrusion reabsorption are still unclear, which prevents clinicians from preferentially choosing conservative treatment options for LDH patients with reabsorption effects. The purpose of this review was to summarize previous reports on LDH reabsorption and to discuss the clinical and imaging features that favor natural absorption. We highlighted the biological mechanisms involved in the phenomenon of LDH reabsorption, including macrophage infiltration, inflammatory responses, matrix remodeling, and neovascularization. In addition, we summarized and discussed potential clinical treatments for promoting reabsorption. Current evidence suggests that macrophage regulation of inflammatory mediators, matrix metalloproteinases, and specific cytokines in intervertebral disc is essential for the spontaneous reabsorption of LDH.

The Effects of Ambient Temperature on Lumbar Disc Herniation: A Retrospective Study

Purpose

This article was designed to provide critical evidence into the relationship between ambient temperature and intensity of back pain in people with lumbar disc herniation (LDH).

Methods

Data concerning patient's age, gender, diagnostic logout, admission time, discharge time, residence area, and work area (residence area and work area were used to ensure research area) from 2017 to 2019 were obtained from the Neck-Shoulder and Lumbocrural Pain Hospital in Jinan, China. A total of 1,450 hospitalization records were collected in total. The distributed lag non-linear model (DLNM) was used to evaluate the relationship between lag–response and exposure to ambient temperature. Stratification was based on age and gender. Days 1, 5, 20, and 28 prior to admission were denoted as lags 0, 5, 20, and 28, respectively.

Results

An average daily temperature of 15–23°C reduced the risk of hospitalization the most in men. Conversely, temperatures <10°C drastically increased hospitalization in men, particularly in lags 0–5 and lags 20–28. Men aged between 40 and 50 years old showed less effect in pain sensation during ambient temperature.

Conclusion

High or low ambient temperature can increase the hospitalization risk of LDH, and sometimes, the temperature effect is delayed.

Neurologic Complication Due to Crystallization After Drug Interaction Between Alkalized Lidocaine and Ropivacaine: A Case Report and in vitro Study

Background

For pregnant women transferred to emergency cesarean section after receiving epidural labor analgesia, there is still a debate over the effective and safe means of rapidly delivering surgical anesthesia. Alkalized lidocaine is often adopted for fast onset time; however, crystallization of the anesthetic may cause severe neurologic symptoms.

Case Presentation

We report a case of a pregnant woman who underwent emergency cesarean section with satisfied analgesia but experienced severe weakness and paranaesthesia in the lower limb. After excluding lumbar disc herniation, obstetric nerve injury, and anesthesia technique causes by symptoms signs and magnetic resonance imaging, drug-related injury became the most likely cause. Our in vitro testing confirmed the obvious precipitation of additional anesthetic-concentrated ropivacaine (0.5–1%) with pretreated alkalized lidocaine. With trophic neurotherapy, the parturient attained prompt relief of weakness by day four, but delayed recovery of numbness, which lasted for 4 weeks.

Conclusion

To date, this is the first case reporting neurologic complication possibly due to drug crystallization in cesarean section. Our study confirmed the rapid onset of alkalized lidocaine and its safety to pretreated routine labor dose of ropivacaine (0.09%). However, additional anesthetic-concentrated ropivacaine (0.5–1%) to maintain the anesthesia and analgesia level is not suggested.

Use of Artificial Intelligence for the Development of Predictive Model to Help in Decision-Making for Patients with Degenerative Lumbar Spine Disease

Context  The aim of the study was to develop a prognostic model using artificial intelligence for patients undergoing lumbar spine surgery for degenerative spine disease for change in pain, functional status, and patient satisfaction based on preoperative variables included in following categories—sociodemographic, clinical, and radiological.

Methods and Materials  A prospective cohort of 180 patients with lumbar degenerative spine disease was included and divided into three classes of management—conservative, decompressive surgery, and decompression with fixation. Preoperative variables, change in outcome measures (visual analog scale—VAS, Modified Oswestry Disability Index—MODI, and Neurogenic Claudication Outcome Score—NCOS), and type of management were assessed using Machine Learning models. These were used for creating a predictive tool for deciding the type of management that a patient should undergo to achieve the best results. Multivariate logistic regression was also used to identify prognostic factors of significance.

Results  The area under the curve (AUC) was calculated from the receiver-operating characteristic (ROC) analysis to evaluate the discrimination capability of various machine learning models. Random Forest Classifier gave the best ROC-AUC score in all three classes (0.863 for VAS, 0.831 for MODI, and 0.869 for NCOS), and the macroaverage AUC score was found to be 0.842 suggesting moderate discriminatory power. A graphical user interface (GUI) tool was built using the machine learning algorithm thus defined to take input details of patients and predict change in outcome measures.

Conclusion  This study demonstrates that machine learning can be used as a tool to help tailor the decision-making process for a patient to achieve the best outcome. The GUI tool helps to incorporate the study results into active decision-making.

Perioperative Hidden Blood Loss in Lumbar Disk Herniation Patients With Percutaneous Endoscopic Transforaminal Discectomy and Influencing Factors

STUDY DESIGN

This was a retrospective study.

OBJECTIVES

This study aimed to evaluate hidden blood loss (HBL) and its influencing factors in lumbar disk herniation (LDH) patients treated with percutaneous endoscopic transforaminal discectomy (PETD).

SUMMARY OF BACKGROUND DATA

PETD is a minimally invasive spine surgery and is widely used to treat LDH. It is generally believed that there is less bleeding during PETD. However, HBL during the perioperative period is always ignored.

MATERIALS AND METHODS

From January 2018 to March 2021, 74 LDH patients treated with PETD was selected. The patient's sex, age, height, weight, previous medical history (hypertension and diabetes) and other basic information were recorded. The preoperative fibrinogen (FIB) level, activated partial thromboplastin time and prothrombin time were recoded. The hemoglobin, hematocrit, and platelet immediately after admission and the next day postoperative were recorded. The surgical time, intraoperative blood loss, intervertebral disk degeneration grade and soft tissue thickness of the PETD approach were recorded. The total blood loss was calculated according to the Gross formula, and then HBL was calculated based on total blood loss and visible blood loss (VBL). The influencing factors were analyzed by single factor correlation analysis and multivariate linear regression analysis.

RESULTS

Among the 74 patients, there were 34 males (20-68 y old) and 40 females (26-75 y old). The mean amount of VBL was (85.04±26.53) mL and HBL was (341.04±191.15) mL. There were statistically significant differences between HBL and VBL (P=0.000). Multiple linear regression analysis showed that sex (P=0.000), disk degeneration grade (P=0.000), preoperative FIB level (P=0.022) and preoperative platelet (P=0.026) were independent risk factors that contributed to HBL, but age (P=0.870), BMI (P=0.480), hypertension (P=0.867), diabetes (P=0.284), soft tissue thickness (P=0.701), preoperative prothrombin time (P=0.248) and preoperative activated partial thromboplastin time (P=0.521) were not.

CONCLUSIONS

There was a large amount of HBL during the perioperative period of PETD in patients with LDH. Sex, disk degeneration grade, preoperative FIB level and preoperative platelet are the independent risk factors of HBL in the perioperative period of PETD. More attention should be paid to the patients with risk factors to ensure perioperative safety.

Posterior epidural intervertebral disc migration and sequestration: A systematic review

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

PAIN INTENSITY AND FUNCTIONAL STATUS 30 DAYS AFTER SURGERY: DIFFERENCE BETWEEN TRANSFORAMINAL AND INTERLAMINAR PERCUTANEOUS ENDOSCOPICLUMBAR DISCECTOMIES

ABSTRACT Objective: To compare the differences between transforaminal and interlaminar endoscopic approaches in terms of pain intensity and functionality 30 days after the surgical procedure. Methods: A retrospective cohort study, with patients treated by percutaneous interlaminar or transforaminal endoscopic discectomy at the Spine Service of the ISCMPA, in southern Brazil. Data were collected from the patients’ electronic medical records by two independent physicians. The clinical outcomes of pain intensity and lumbar functionality were evaluated, respectively, using the visual analogue scale and the Oswestry Disability Index. Results: Thirty-six patients were included in the study, with a mean age of 50.8 ± 15.3 years, 19 (52.8%) of whom were males. As for the clinical outcomes for both transforaminal and interlaminar percutaneous endoscopic approaches, we observed a statistically significant reduction in pain intensity (mean difference of 3.5 points, p < 0.001) and a statistically significant improvement in functionality (mean difference of 33.2 points, p < 0.001) when we compared the pre- and 30-day postoperative periods, with no significant differences in terms of approaches. The type of technical approach also differed in relation to the patients’ age, the location, type, and migration of the herniated disc, and the patient’s time in the operating room. Conclusion: There was a similar effect on pain reduction and restoration of lumbar functions, 30 days after percutaneous endoscopic discectomy, in both technical approaches, with no significant differences between them. Level of Evidence III; Retrospective comparative study.

Effect of Nonsurgical Spinal Decompression on Intensity of Pain and Herniated Disc Volume in Subacute Lumbar Herniated Disc

OBJECTIVE

Nonsurgical spinal decompression therapy (NSDT) is a conservative treatment for the lumbosacral herniated intervertebral disc (L-HIVD). This study aimed to evaluate the clinical effectiveness of the NSDT and change in disc volume through magnetic resonance imaging (MRI) in subacute L-HIVD.

METHODS

Sixty patients with subacute L-HIVD were randomized into either the decompression group (group D, n = 30) or the nondecompression group (group N, n = 30). In group D, NSDT was performed ten times in eight weeks. In group N, pseudodecompression therapy (no force) was performed with the same protocol. Lower back and lower leg pain intensities and functional improvements were measured by the visual analog scale and the Korean Oswestry Disability Index (K-ODI). The change in the lumbosacral disc herniation index (HI) was evaluated through a follow-up MRI three months after the therapy.

RESULTS

The lower leg pain intensity in group D was lower than that in group N at two months (p=0.028). Additionally, there were significantly lower K-ODI scores in group D at two and three months (p=0.023, 0.019) than in group N. The change in HI after the therapy was -27.6 ± 27.5 (%) in group D and -7.1 ± 24.9 (%) in group N, with a significant difference (p=0.017). Approximately 26.9% of patients in group D and no patients in group N showed over 50% reduction in HI (p=0.031).

CONCLUSION

NSDT may be a suitable treatment option for conservative treatment of subacute L-HIVD.

Lifting Techniques: Why Are We Not Using Evidence To Optimize Movement?

Lifting something off the ground is an essential task and lifting is a documented risk factor for low back pain (LBP). The standard lifting techniques are stoop (lifting with your back), squat (lifting with your legs), and semi-squat (midway between stoop and squat). Most clinicians believe the squat technique is optimal; however, training on squat lifting does not prevent LBP and utilizing greater lumbar flexion (i.e. stoop) when lifting is not a risk factor for LBP. The disconnect between what occurs in clinical practice and what the evidence suggests has resulted in ongoing debate. Clinicians must ask the right questions in order to apply the evidence appropriately. A proposed clinical framework of calm tissue down, build tissue up, improve work capacity can be used to determine which lifting technique is optimal for a patient at any given time. When applying this clinical framework, clinicians should consider metabolic, biomechanical, physical stress tolerance, and pain factors in order to address the movement system. For example, stoop lifting is more metabolically efficient and less challenging to the cardiopulmonary system. There may be few biomechanical differences in spinal postures and gross loads on the lumbar spine between stoop, squat, and semi-squat lifting; however, each lift has distinct kinematic patterns that affects muscle activation patterns, and ultimately the movement system. Clinicians must find the optimal dosage of physical stress to address all aspects of the movement system to minimize the risk of injury. There is no universal consensus on the optimal lifting technique which will satisfy every situation; however, there may be a lifting technique that optimizes movement to achieve a specific outcome. The calm tissue down, build tissue up, improve work capacity framework offers an approach to determine the best lifting technique for an individual patient at any give time.

LEVEL OF EVIDENCE

5.

Efficacy of DiscoGel in Treatment of Degenerative Disc Disease: A Prospective 1-Year Observation of 67 Patients

Patients with degenerative disc disease may suffer from chronic lumbar discogenic (DP) or radicular leg (RLP) pain. Minimally invasive DiscoGel therapy involves the percutaneous injection of an ethanol gel into the degenerated disk's nucleus pulposus. This paper compares the 1-year outcome of such treatment in DP and RLP patients. We operated on 67 patients (49 men and 18 women) aged 20-68 years (mean age 46 ± 11 years) with DP (n = 45) and RLP (n = 22), of at least 6-8 weeks duration, with no adverse effects. We evaluated the treatment outcome with Core Outcome Measures Index (COMI) and Visual Analog Scale (VAS). A year after the ethanol gel injection, in the DP cohort, COMI and VAS dropped by 66% (6.40 vs. 2.20) and 53% (6.33 vs. 2.97), respectively. For the RLP patients, the corresponding values dropped 48% (7.05 vs. 3.68) and 54% (6.77 vs. 3.13). There were no differences between the cohorts in COMI and VAS at the follow-up end. Six months into the study, 74% of DP and 81% of RLP patients did not use any analgesics. Ethanol gel therapy can be effective for many patients. Moreover, its potential failure does not exclude surgical treatment options.

Vertebral Endplate Changes Correlate with Presence of Cartilaginous Endplate in the Herniated Disc Tissue: Factor Predicting Failure of Conservative Treatment

Study Design

Cross-sectional comparative.

Purpose

To characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI).

Overview of Literature

Considering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported.

Methods

Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19–65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid–Schiff stain; examined for histological degeneration scores (HDS; 0–15), inflammation (0 [absence]–3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm². Data was analyzed, and p<0.05 was considered to indicate statistical significance.

Results

VEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02).

Conclusions

VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

PAIN INTENSITY AND FUNCTIONALITY AFTER PERCUTANEOUS ENDOSCOPIC DISCECTOMY: A RETROSPECTIVE COHORT STUDY

ABSTRACT Objectives To evaluate pain intensity and functional status before and 30 days following percutaneous lumbar endoscopic discectomy. Methods A retrospective cohort study that included patients who underwent percutaneous endoscopic discectomy from January 2019 to October 2020 at the Irmandade Santa Casa de Misericórdia Hospital, in Porto Alegre. The data were collected from the electronic medical records of the patients by two independent physicians. Clinical outcomes were assessed using visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. Results Forty-six patients with a mean age of 52.6 ± 15.8 years, 27 of whom (58.7%) were male, were evaluated. Regarding clinical outcomes, a statistically significant improvement was observed in the comparison between the pre- and 30-day postoperative VAS and ODI scores, with no significant difference in relation to sex. No peri- or postoperative complications were observed. All patients successfully completed surgery and were discharged after recovery from anesthesia. Conclusion There was a significant improvement in pain and functional status 30 days after percutaneous endoscopic discectomy performed to correct lumbar disc herniation, with no difference in relation to sex. In addition, no peri- or postoperative complications were observed. Future studies, with longer follow-up times, comparing clinical outcomes from the various techniques of percutaneous endoscopic discectomy are necessary. Level of evidence III; Retrospective comparative study.

Intervertebral Disk Degeneration: The Microenvironment and Tissue Engineering Strategies

Intervertebral disk degeneration (IVDD) is a leading cause of disability. The degeneration is inevitable, and the mechanisms are complex. Current therapeutic strategies mainly focus on the relief of symptoms, not the intrinsic regeneration of the intervertebral disk (IVD). Tissue engineering is a promising strategy for IVDD due to its ability to restore a healthy microenvironment and promote IVD regeneration. This review briefly summarizes the IVD anatomy and composition and then sets out elements of the microenvironment and the interactions. We rationalized different scaffolds based on tissue engineering strategies used recently. To fulfill the complete restoration of a healthy IVD microenvironment, we propose that various tissue engineering strategies should be combined and customized to create personalized therapeutic strategies for each individual.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis

BACKGROUND

Recalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management.

METHODS

An evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis. The primary outcome measure was the proportion of patients with significant pain relief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months).

RESULTS

This assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence.

CONCLUSIONS

Based on the present systematic review, with one RCT and 5 nonrandomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

The effectiveness of chemonucleolysis with condoliase for treatment of painful lumbar disc herniation

BACKGROUND

Chemonucleolysis with condoliase, which degrades chondroitin sulfate, could be a new, minimally invasive therapeutic option for patients with lumbar disc herniation (LDH). The purpose of this study was to analyze prognostic factors for clinical outcomes in LDH patients subjected to chemonucleolysis with condoliase.

METHODS

Inclusion criteria for this procedure were 1) 18-70 years of age; 2) unilateral leg pain and positive straight leg raise (SLR) (<70°) or femoral nerve stretching test; 3) subligamentous extrusion verified on magnetic resonance imaging; 4) neurological symptoms consistent with a compressed nerve root on magnetic resonance imaging (MRI) images; and 5) minimum six months of follow-up. In total, 82 patients (55 men, 27 women; mean age, 47.2 ± 15.5 years; mean follow-up, 9.1 ± 3.0 months) who underwent chemonucleolysis with condoliase for painful LDH were included. An improvement of 50% or more in the Visual analogue scale (VAS) of leg pain was classified as effective.

RESULTS

Seventy patients (85.4%) were classified into the effective (E) group and 12 patients (14.6%) into the less-effective (L) group. Surgical treatment was required in four patients. No severe adverse complications were reported; 41.3% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level. Univariate analysis revealed that young age (p = 0.036), without history of epidural or nerve root block (p = 0.024), and injection into the central portion of the intervertebral disc (p = 0.014) were significantly associated with clinical effectiveness. A logistic regression analysis revealed that injection into the central portion of the intervertebral disc (p = 0.049; odds ratio, 4.913; 95% confidence interval, 1.006-26.204) was significantly associated with clinical effectiveness.

CONCLUSIONS

Chemonucleolysis with condoliase is a safe and effective treatment for painful LDH; 85.4% of the patients showed improvement after the treatment without severe adverse events. To obtain the best outcome, condoliase should be injected into the center of the intervertebral disc.

Can Imaging Characteristics on Magnetic Resonance Imaging Predict the Acuity of a Lumbar Disc Herniation?

BACKGROUND

Currently, no authors of existing studies have attempted to classify the signal characteristics of disc herniation on magnetic resonance imaging (MRI) and their temporal relationship to symptoms of lumbar radiculopathy. The purpose of this study was to determine whether the MRI signal characteristics are predictive of acuity of symptoms in patients with lumbar disc herniation (LDH).

METHODS

A retrospective cohort study was conducted on patients treated at an academic center for LDH from 2015 to 2018. Patients were divided into 2 groups based on symptom duration (acute: ≤6 weeks; or chronic: >4 months). Two independent observers measured T1, T2 signal, and other MRI characteristics at the affected disc level. Univariate analysis was used to compare differences between groups. Multiple logistic regression was used to determine predictors of acuity.

RESULTS

Eighty-nine patients were included (33 acute, 56 chronic) with no significant baseline differences between groups. Rater 2 observed a higher proportion of disc bulges in the chronic group (P = .021) and a higher abnormal T1 herniation signal in the acute group (P = .048). Rater 1 found a higher Pfirrmann grade (P = .005) and a higher prevalence of vertebral body spurring (P = .007) in the chronic group. Interobserver agreement for T1 central and herniation signals demonstrated poor to fair agreement, whereas the remainder of the measurements showed moderate to substantial agreement (κ = 0.4-0.8). Multiple logistic regression showed that Pfirrmann Grade 5 (odds ratio = 0.12, 95% confidence interval [0.02, 0.74], P = .022) and anterior/posterior spurring (odds ratio = 0.053 [0.03, 0.85], P = .023) were not associated with acuity.

CONCLUSIONS

Other than Pfirrmann grade or vertebral body spurring, no MRI characteristics could be reliably identified that correlate with acuity of symptoms.

LEVEL OF EVIDENCE

3.

Isolated Lumbar Extension Resistance Exercise in Limited Range of Motion for Patients with Lumbar Radiculopathy and Disk Herniation-Clinical Outcome and Influencing Factors

(1) Background: Reconditioning of the paraspinal lumbar extensor muscles by isolated lumbar extension resistance exercises (ILEX) has shown good clinical results for patients with chronic unspecific low back pain. However, the clinical value and safety for patients with specific spine pathologies is unclear. In this study, clinical outcome and influencing factors were retrospectively analyzed for patients with lumbar disk herniation (LDH) and radiculopathy. (2) Methods: 189 consecutive patients (123 men and 66 women; mean age, 36 years) with clinically diagnosed LDH and relative indications for surgery started a 9-week rehabilitation program (2x/week) including ILEX in limited range of motion (ROM) adjusted to patients’ symptoms. Patients diagnosed with advanced levels of spine degeneration were excluded. Pain/radiculopathy (PR), influence on mental health (IOMH), satisfaction rates were measured via Numeric Rating Scales (NRS, 0–10), and overall clinical outcome was stated in % (100% = full recovery). Isometric extension strength was tested before and after the program. (3) Results: 168 patients (88.9%) completed the program. For 162 out of 168 patients (96.4%) there was a significant reduction of clinical symptoms, whereas 6 patients reported no changes in symptoms. Scores (mean) for symptom intensity decreased from 4.2 (±1.5) to 1.9 (±1.5) (p < 0.001), the impact on mental health decreased from 5.9 (±2.3) to 2.4 (±2.0) (p < 0.001). There was a (weak) correlation between lower scores for PR and IOMH before the study and better clinical outcomes; PR also weakly correlated with satisfaction. Other factors such as age, strength increase, level/location and number of LDH did not have a significant impact on the clinical results. (4) Conclusion: The results indicate that ILEX in limited ROM can be an effective treatment for the majority of patients with LDH. For patients with high pain levels, the results are less consistent, and surgery may be considered.

When Should You Trust Your Doctor? Establishing a Theoretical Model to Evaluate the Value of Second Opinion Visits

In order to produce a mathematical model for better understanding of the benefits and utilization of second opinions and to understand the contradiction between the value of second opinions and their perceived underuse, we developed an expected utility theory model to quantify their value. We use a case-based example to find types of biases that could affect second opinions. Although the baseline expected utility theory model presented assumes providers are rational, we relax this and discuss the implications for how these alternative specifications alter predicted use. We found that second opinions are valuable when diagnostic accuracy is variable across physicians or access to high-quality care is restricted. In a stylized simulation example in which about half (50.1%) of diagnoses were incorrect, receipt of 1 second opinion reduced the error rate to 25.8% and receipt of 2 second opinions reduced the error rate to 16.0%. After incorporating potential biases into the model, the value of second opinions increases only when aversion to changing the initial diagnosis is greater than aversion to correcting a mistake. Additionally, this model reveals that second opinions have value even when diagnostic accuracy is perfect. Further, when financial incentives differ from the incentives of the initial consult, a second opinion offers patients a reasonable bound of their treatment options. To conclude, we identify numerous reasons for underuse of second opinions. Specifically, value depends on the degree of diagnostic uncertainty, presence of behavioral biases, and variation in local compensation regimes. Despite their value, recent trends could actually decrease the value of second opinions.

Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States

BACKGROUND

There is a lack of consensus for optimal management of patients with foot drop due to acute lumbar disc herniation (LDH) with lumbar radiculopathy (LR), which is a clinical scenario that may be encountered by physical therapists. Consequently, it is important to explore physical therapists' referral practice patterns for surgical consult. Currently, physical therapist referral patterns for surgical consult in this patient population are unknown.

OBJECTIVES

To describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to suspected acute LDH with LR.

DESIGN

Cross-sectional descriptive research design using an electronic, internet-based survey that utilized two clinical vignettes.

METHOD

An electronic survey was developed by an expert peer review panel. Survey participants were licensed physical therapists in the United States and members of the Orthopedic Section of the American Physical Therapy Association.

RESULTS

Of the individuals receiving the survey invitation, 2172 completed the survey. Depending on the severity of foot drop, 34-61% were likely to refer for immediate neurosurgical consult. Presence of imaging to confirm suspected clinical diagnosis slightly affected the likelihood of referral (4-12% increase) for immediate neurosurgical consult.

CONCLUSION

In patients with foot drop due to suspected acute LDH with LR, this study found that physical therapist referral patterns for immediate neurosurgical consult varied and are likely influenced by the severity of weakness and availability of MRI findings. Further research regarding the optimal management of this patient population and potential reasons for variation in practice is warranted.

Case of the week: Updating a cervical MR scan avoided unnecessary cervical surgery

Background:

As spinal surgeons, we have all likely seen cases in which lumbar disc herniations regressed/resolved on successive MR studies. Here, we present a patient whose original cervical MR showed a large C4-C5 cervical disc herniation that completely resolved on the follow-up MR obtained 9 months later, thus avoiding cervical surgery.

Case Description:

A young patient (e.g. <30 years old) sustained multiple prior traumatic events over the past 3 years. The last episode 9 months ago resulted in the performance of an MR scan that demonstrated a significant central C4-C5 disc herniation with cord/root compression. Despite pain and mild radiculopathy, the patient had no focal neurological deficit, and did not undergo surgery. When the patient recently consulted multiple spinal orthopedists and neurosurgeons, the uniform recommendation was for a C4-C5 anterior cervical discectomy/ fusion (ACDF). However, a telemedicine consultation with a spinal neurosurgeon resulted in a follow-up cervical MR scan that demonstrated cervical disc resorption, and, therefore, no need for cervical surgical intervention. When the new study showed full resolution of the C4-C5 disc, the telemedicine and local neurosurgeon agreed that cervical surgery was unnecessary.

Conclusion:

The spinal literature shows that predominantly lumbar disc herniations (LDH) spontaneously regress on MR studies 34.7–95% of the time over 6–17 month intervals, with full resolution being seen in 43–75% of cases. As cervical disc herniations likely demonstrate similar resorption/resolution on successive MR studies, old cervical MR examinations should probably be updated/repeated in patients who are being considered for cervical surgical intervention. If/when cervical discs have resorbed, cervical surgery may be avoided.