A New Grading System for Migrated Lumbar Disc Herniation on Sagittal Magnetic Resonance Imaging: An Agreement Study

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis

BACKGROUND

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transforaminal endoscopic lumbar discectomy (TELD) with two-segment foraminoplasty to manage VHM-LDH and evaluated its radiographic and midterm clinical outcomes.

MATERIALS AND METHODS

The present study is a retrospective analysis of 33 consecutive patients with VHM-LDH who underwent TELD with two-segment foraminoplasty. The foraminoplasty was performed on two adjacent vertebrae on the basis of the migration direction of disc fragments to fully expose the disc fragments and completely decompress the impinged nerve root. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. Additionally, imageological observations were evaluated immediately after the procedure via magnetic resonance image and computerized tomography. Clinical outcomes were evaluated by calculating the visual analog scale (VAS) score and Oswestry Disability Index (ODI). The MacNab criterion was reviewed to assess the patients' opinions on treatment satisfaction. The resection rate of bony structures were quantitatively evaluated on postoperative image. The segmental stability was radiologically evaluated at least a year after the surgery. Additionally, surgery-related and postoperative complications were evaluated.

RESULTS

The average age of the patients was 56.87 ± 7.77 years, with a mean follow-up of 20.95 ± 2.09 months. The pain was relieved in all patients immediately after the surgery. The VAS score and ODI decreased significantly at each postoperative follow-up compared with those observed before the surgery (P < 0.05). The mean operation duration, blood loss, and hospital stay were 56.17 ± 16.21 min, 10.57 ± 6.92 mL, and 3.12 ± 1.23 days, respectively. No residual disc fragments, iatrogenic pedicle fractures, and segmental instability were observed in the postoperative images. For both up- and down- migrated herniation in the upper lumbar region, the upper limit value of resection percentage for the cranial SAP, caudal SAP, and pedicle was 33%, 30%, and 34%, respectively; while those in the lower lumbar region was 42%, 36%, and 46%, respectively. At the last follow-up, the satisfaction rate of the patients regarding the surgery was 97%. Surgery-related complications including dural tear, nerve root injury, epidural hematoma, iatrogenic pedicle fractures, and segmental instability were not observed. One patient (3%) suffered from the recurrence of LDH 10 months after the initial surgery and underwent revision surgery.

CONCLUSIONS

The TELD with two-segment foraminoplasty is safe and effective for VHM-LDH management. Proper patient selection and efficient endoscopic skills are required for applying this technique to obtain satisfactory outcomes.

Lumbar disc herniation is an independent predictor of plaque burden in the patients with unstable angina

Objective

Assessing the impact of lumbar disc herniation (LDH) on the plaque burden of coronary atherosclerosis is our objective.

Methods

In this study, a total of 212 patients (age 46-80 years) with unstable angina (UA) who underwent coronary angiography (CAG) in our hospital from January 2018 to July 2022 due to UA were included. Patients were divided into LDH group (n = 106) and no LDH group (n = 106). Gensini scores were calculated to assess the plaque burden of coronary. Logistic analysis was used to examine potential risk variables linked to the Gensini score. The association between lumbar disc lesions grading and coronary plaque burden was analysed by Spearman's correlation test. LDH patients with higher plaque burden (n = 56) were further divided into evolocumab treatment group (n = 28) and conventional treatment group (n = 28). Cox regression analysis were performed.

Results

Patients with LDH had higher Gensini scores (P < 0.01) and triglyceride (TG) levels (P = 0.04), but HDL-C (P = 0.01) levels were lower. LDH was found to be an independent risk factor for higher Gensini scores (OR = 2.38, P < 0.01) by logistic analysis. The Spearman's correlation test suggested that the degree of lumbar disc lesions was related to the Gensini score and the level of blood lipid. Cox regression analysis showed that evolocumab treatment could significantly reduce the composite MACE events (cardiac death, nonfatal myocardial infarction, nonfatal stroke, and readmission due to angina) (HR = 0.26, P = 0.04) in higher coronary plaque burden patients.

Conclusion

LDH is an independent risk factor for the higher coronary plaque burden. Evolocumab treatment significantly reduced the occurrence of cardiovascular events in LDH patients with higher plaque burden. Additionally, our data indicate that LDH is associated with increased blood lipid, which may contribute to the development of plaque burden.

Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to evaluate the reliability of modified classification system of migrated nucleus pulposus and its clinical application value.

METHODS

We retrieved 1000 lumbar MRI of different patients in Hangzhou Hospital of Traditional Chinese Medicine from January 2016 to December 2019 for interpretation, and screened 105 migrated lumbar MRI for inclusion in the study. Three spinal surgeons made classification according to the modified classification method. Two weeks later, the sorting data of the patients were shuffled and the classification was judged by three doctors again. The consistency and repeatability of the improved classification were evaluated by Kappa coefficient. The general data of the included patients were collected. The patients were followed up for 2 years, and the risk factors of surgical treatment of patients with migrated lumbar disc herniation were analyzed. The treatment plan, surgical approach, operation time, VAS score, ODI score and other relevant data of the included patients were collected to evaluate the guiding effect of the classification system on clinical practice.

RESULTS

In this study, the incidence of migrated lumbar disc herniation was about 10.5%, and most of the patients were male. Patients with higher BMI are more likely to develop this disease. Our study confirmed that the modified classification has moderate to high confidence. During the 2-year follow-up period, 66 patients (62.9%) were treated conservatively, and the patients with conservative treatment were mainly A2 and B2 type (59.1%). Thirty-nine patients (37.1%) underwent surgical treatment. The patients recovered well after operation, and the low back pain and ODI index were significantly improved at 1 year after operation (P < 0.05). We suggest that type A1 and B1 migrated nucleus pulposus can be removed by posterior approach. For type A2, B2, C1, C2, the lateral approach is recommended to remove the nucleus pulposus directly. Logistic regression and ROC analysis showed that disease duration (≥ 1 year) and BMI (≥ 24) maybe were risk factors for surgical treatment of patients with migrated lumbar disc herniation.

CONCLUSION

The modified classification has good reliability. In the current study, the experience level of spine surgeons does not affect the reliability of the classification system. Our study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach.

Knowledge Areas and New Trends in Lumbar Disc Herniation Research: Bibliometrics and Knowledge Mapping Analysis

OBJECTIVE

To determine the coalitions and impact of authors, countries, institutions, and journals, evaluate the knowledge base, find the hotspot trends, and identify the emerging topics in lumbar disc herniation (LDH).

METHOD

The articles related to LDH were obtained from the Web of Science Core Collection on August 21, 2021. Two scientometric software (CiteSpace 5.8.R.1 and VOSviewer 1.6.17) were used to perform bibliometric and knowledge-map analysis.

RESULTS

From the set parameters, 4642 articles were included in the literature. Although the total number of publications fluctuated between 2001 and 2020, a general trend toward increase was observed. Respectively, the most productive country and institution in the field were the United States and Wooridul Spine Hospital. The most active and cited authors were Lee and Weinstein. Spine was the most impactful and cited journal. Weinstein (JAMA 296:2441-2450, 2006) had the highest number of co-citations and Weinstein(N Engl J Med 358:794-810, 2008) had the highest number of citations. The keyword "low back pain" was ranked first for frequency and total link strength, whereas "risk factor" was ranked first for centrality. Topics including pathogenesis (disc herniation), examination methods (MRI), treatment methods (non-surgical treatment, surgical treatment), surgical options (laminectomy, discectomy), clinical observations (double-blind, efficacy, outcome, learning curve), and evaluation of efficacy (meta-analysis) of LDH have been the focus of leading-edge research in 2001-2020.

CONCLUSION

Using bibliometric methods, this study mapped the knowledge map of LDH research in the past 20 years. The study identifies existing trends to provide a framework for further research.