Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms

Endoscopic Interlaminar Standalone Decompression for Lumbar Lateral Recess Stenosis With Subligamentous Disc Herniation: A Disc-Preserving Alternative to Discectomy

OBJECTIVE

Lumbar lateral recess stenosis (LRS) with subligamentous disc herniation often causes debilitating radicular pain. While discectomy is commonly performed, it risks disc degeneration and spinal instability. This study aimed to evaluate the clinical and radiographic outcomes of full-endoscopic interlaminar standalone decompression as a minimally invasive, disc-preserving alternative to discectomy for treating single-level LRS with subligamentous disc herniation.

METHODS

We retrospectively reviewed 55 patients with single-level lumbar LRS and subligamentous disc herniation who underwent full-endoscopic interlaminar standalone decompression between 2013 and 2021. Inclusion criteria required radicular pain refractory to conservative treatment and magnetic resonance imaging (MRI) confirmation of subligamentous herniation. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for leg and back pain, Oswestry Disability Index (ODI), and Short Form-12 Physical and Mental Component Scores (SF-12 PCS/MCS). Radiographic evaluations included disc height index (DHI) measurements and Bartynski grading for lateral recess stenosis. Pre- and postoperative data were compared using the Wilcoxon signed-rank test.

RESULTS

At the 2-year follow-up, leg and back pain VAS scores improved significantly from 8.8 and 8.5 preoperatively to 1.0 and 0.9, respectively. ODI scores declined from 66.9 to 10.6, while SF-12 PCS and MCS improved from 30.1 to 42.5 and 26.3 to 42.6, respectively. According to the modified MacNab criteria, 96.3% of patients achieved "good" or "excellent" outcomes. Postoperative DHI remained stable, and no reoperations were required during follow-up.

CONCLUSIONS

Full-endoscopic interlaminar standalone decompression offers substantial symptom relief and functional improvement for single-level lumbar LRS with subligamentous disc herniation. By preserving disc integrity, this minimally invasive technique avoids the risks associated with discectomy, such as disc degeneration and instability. These findings suggest a paradigm shift in treating LRS, supporting the use of this disc-preserving approach as a viable alternative to conventional surgical methods in properly selected patients. Further research with larger cohorts and longer follow-up is warranted to validate these results.

Implementing appropriateness criteria for use of imaging technology (Project ACUITY) in magnetic resonance imaging of the lumbar spine: a Singapore experience

INTRODUCTION

Uncomplicated acute low back pain is usually self-limiting and does not warrant imaging. However, despite current recommendations, many patients continue to receive spinal imaging, increasing healthcare costs. The Ministry of Health, Singapore, convened a multidisciplinary workgroup to develop a consensus guideline on magnetic resonance imaging (MRI) of the lumbar spine (Agency for Care Effectiveness [ACE] guideline) for low back pain that was incorporated into electronic radiology order forms. We analysed the MRI orders following implementation of the guideline.

METHODS

A list of 'appropriate' and 'inappropriate' indications was developed based on existing literature. These indications were inserted into the MRI of the lumbar spine request form within the electronic system. It was mandatory for clinicians to specify on a drop-down list of indications. For 'inappropriate' indications, clinicians are required to fill out a free-text 'pop up' elaborating on their clinical reasoning for the MRI request.

RESULTS

Baseline pre-intervention data were collected over 3 months. A total of 492 MRI scans were performed with 64 (13.0%) inappropriate orders. Post-intervention, we retrospectively analysed two sets of data over 3 months each in 2021 and 2022. In 2021, there were 86 (9.1%) inappropriate orders out of 940 scans performed. In 2022, there were 38 (7.3%) inappropriate studies out of 521 scans performed. There was a statistically significant overall decrease in inappropriate scans from 13.0% pre-intervention to 7.3% post-intervention ( P = 0.01). Among all the 124 inappropriate studies post-intervention, only one patient eventually required surgery.

CONCLUSION

Our study demonstrates the positive impact of implementing a local guideline through electronic medical records in reducing inappropriate MRI of the lumbar spine for low back pain. Further studies on the impact of other behavioural nudges are recommended.

Local Prophylactic Teicoplanin Effect on Spinal Fusion Surgery: A Comparative Retrospective Study

BACKGROUND

 Surgical site infection (SSI) is one of the most severe complications of spinal fusion surgery that lead to increased morbidity and mortality rates. Prophylactic antibiotic usage is one of the methods that reduce the possibility of SSI in this procedure. The aim of this study was to determine the effect of local subfascial teicoplanin usage on radiologic and functional outcomes and compare it to the effect of vancomycin on surgical outcomes in patients who underwent decompression with posterior instrumentation (DPI) for lumbar spinal stenosis (LSS).

METHODS

 Medical charts of patients with LSS who received DPI and met the study criteria were divided into three groups: the teicoplanin group included patients who underwent DPI with local teicoplanin before closure, the vancomycin group included patients who underwent DPI with local vancomycin, and the control group included patients who underwent DPI without any local prophylactic antibiotics.

RESULTS

 A total of 101 patients were included in the study. No significant differences were found among groups regarding demographics, follow-up, and clinical and functional outcomes. No significant differences were observed among groups regarding postoperative improvements in SF-36-MCS, SF-36-PCS, Oswestry Disability Index, and Visual Analog Scale (VAS; p > 0.05). In the teicoplanin and vancomycin groups, the SSI rate was lower than that in the control group (2/35, 1/34, and 5/32, respectively, p = 0.136) without statistical significance; however, the postoperative fusion volume was significantly higher in the teicoplanin group when compared to the other groups (3.35 ± 1.08, 2.68 ± 1.17, and 2.65 ± 1.28 cm3, respectively, p = 0.007).

CONCLUSIONS

 Although its cost is relatively higher, teicoplanin was a good alternative to vancomycin in preventing SSIs with a higher fusion rate, but no superiority was observed regarding other outcomes.

Microsurgical and Descriptive Three-Dimensional Analysis of the Subarticular Trigone: A Guidemap for Standardizing Lateral Recess Decompression

Background Lateral recess decompression has remained a cornerstone spinal procedure for decades. Despite its popularity, a significant lack of evidence in the literature exists concerning microsurgical anatomy and pertinent surgical landmarks, resulting in non-standardized nomenclature, descriptions, and surgical approaches. Objective This study provides an in-depth microsurgical and descriptive analysis of the subarticular trigone (SAT), serving as an anatomical guide and a tool to foster consistency in nomenclature and standardization of surgical approaches. Methods We analyzed 35 high-resolution lumbar spine CT scans, employing three-dimensional (3D) processing techniques. The SAT is introduced to delineate the bony prominence enveloping the superiomedial quadrant of the pedicle. The SAT encompasses two zones: (1) a superior zone above the superior pedicular line, corresponding to the medial part of the body of the ascending facet (AF), and (2) an inferior zone between the superior and middle pedicular lines, corresponding to the root of the AF and the medial pars/superior lamina. The superior subarticular point (SSP) and medial subarticular point (MESP) serve as key reference landmarks. The SAT forms the roof of the lateral recess and the region requiring resection during decompression of the traversing root in this anatomical corridor. Various measurements, including SSP and MESP to lateral pars, tip of the facet and spino-laminar junction distance, mean width of the sublaminar ridge (SLR), and percentage of the facet that requires resection for adequate SAT decompression, were carried out. Results The mean distance of the SSP to the lateral pars ranges from 7 to 9.2 mm, to the tip of the descending from 9.3 to 10.1 mm, and to the spino-laminar junction from 6.7 to 8.1 mm. The MESP is located at a mean distance of 5.4-6.9 mm from the medial pedicular line. The mean width of the SLR varies from 18.6 to 29.4 mm. Finally, the percentage of total facet width that needs to be removed to adequately decompress the SAT extends from 32% at L4 to 36% at L1. Conclusions This study presents comprehensive insights into the surgical, descriptive, and correlative anatomy of the lateral recess, emphasizing the SAT. The extrapolated data offer a framework for achieving uniformity in surgical planning and advocate for standardized nomenclature.

Transforaminal Full-Endoscopic Ventral Facetectomy: Midterm Results and Factors Associated with Poor Surgical Outcomes

BACKGROUND

 Full-endoscopic spine surgery (FESS) is a well-established procedure for herniated nucleus pulposus. It is a minimally invasive surgery that can be performed under local anesthesia through only an 8-mm skin incision. With improvements in surgical equipment such as high-speed drills, the indications for FESS have expanded to include lumbar spinal stenosis (LSS). We perform a transforaminal full-endoscopic ventral facetectomy (TF-FEVF) for unilateral nerve root-type lateral recess stenosis (LRS) using a transforaminal approach under local anesthesia.The aim of this study was to examine the postoperative results of TF-FEVF for LRS and to identify factors associated with poor surgical outcomes. 85 patients who underwent TF-FEVF for LRS under local anesthesia. Clinical outcomes were determined by visual analog scale (VAS) and the modified MacNab criteria. Evaluation was performed using magnetic resonance imaging (MRI), computed tomography (CT), and flexion-extension radiographs.

METHODS

 This study involved 85 patients (47 males and 38 females) who underwent TF-FEVF for LRS. The mean age was 70.5 years and the mean follow-up duration was 14.8 months. Data were collected on sex, age, level of operation, diagnosis, history of spine surgery at the same level, and duration of follow-up. The diagnosis was categorized as LSS with or without disk bulging. Clinical evaluation was performed using the VAS and modified MacNab criteria. MRI was used to evaluate the degree of disk degeneration, vertebral endplate degeneration, disk height, thickening of the ligamentum flavum, and stenosis. Bony stenosis was evaluated using CT. Sagittal translation and sagittal angulation were also measured by flexion-extension radiographs, and the Cobb angle was measured using a standing front view radiograph. All variables were compared between patients with excellent/good outcomes (E/G group) and those with fair/poor outcomes (F/P group) using the modified MacNab criteria.

RESULTS

 Postoperative VAS showed that leg pain decreased from 59.0 ± 28.6 preoperatively to 17.9 ± 27.2 at the final follow-up (p < 0.01) and that lower back pain also decreased from 60.7 ± 26.6 preoperatively to 27.3 ± 28.6 at final follow-up (p < 0.01). According to the modified MacNab criteria, the results during the final follow-up were excellent in 39 cases, good in 21 cases, fair in 13 cases, and poor in 12 cases. There were no significant differences in sex, age, diagnosis, history of spine surgery, and duration of follow-up periods between the 60 cases (70.6%) in the E/G group and the 25 cases (29.4%) in the F/P group. Imaging evaluation revealed statistically significant differences between the E/G group and the F/P group in intervertebral angle flexion (3.2 vs. 0.4 degrees; p < 0.05), sagittal angulation (4.3 vs. 8.1 degrees; p < 0.05), slip in flexion (0.9 vs. 2.8 mm; p < 0.05), sagittal translation (0.7 vs. 1.6 mm; p < 0.05), and Cobb angle (-0.5 vs. -1.9 degrees; p < 0.05).

CONCLUSION

 Midterm results of TF-FEVF were generally favorable; factors contributing to good or poor TF-FEVF outcomes were large sagittal angulation, large sagittal translation, and concave side.

Results from an expedited spinal nerve root block clinic at a UK tertiary neurosurgical centre

STUDY DESIGN

Retrospective Observational Study.

INTRODUCTION

Lumbar radicular pain has a prevalence of 3-5%. Level 1 evidence has demonstrated equivalence between surgical and injection treatment. We assess the outcomes from a transforaminal epidural steroid injection clinic in a tertiary neuroscience referral centre.

METHODS

We performed an analysis of data from consecutive patients entered into a new internal referral database between August 2018 to May 2021. Radicular pain was classified as one of "first presentation" or "recurrence". Outcomes were obtained from follow up clinic letters and recorded in a binary manner of "positive result" or "negative result". Spinal pathology was documented from radiology reports and MRI images.

RESULTS

We analysed 208 patients referred to the clinic. Excluding those who improved to a point of not requiring treatment, and those who underwent surgical intervention, 119 patients undergoing injection were included, of which 14 were lost to follow-up. 68 % of patients had a positive result from injection. Subgroup analysis demonstrated good outcomes for both hyperacute (<6 weeks) and chronic (>12 months). Contained disk pathologies had better outcomes than uncontained. There was no difference in outcomes across grades of compression, but previous same level surgery was associated with poorer response rates.

CONCLUSIONS

There is a high rate of natural resolution of symptoms in patients with LSRP. In those where pain persists, TFESI is a valuable first line treatment modality. This study suggests the efficacy of TFESI is potentially independent of grade of stenosis and chronicity of symptoms. Contained disc pathologies respond better than uncontained.

Transforaminal Endoscopic Lumbar Lateral Recess Decompression for Octogenarian Patients

The incidence of radiculopathy due to lumbar spinal stenosis has been on the increase in the aging population. However, patients aged ≥ 80 years hesitate to undergo conventional open surgery under general anesthesia because of the risk of postoperative morbidity and adverse events. Therefore, less invasive surgical alternatives are required for the elderly or medically handicapped patients. Transforaminal endoscopic lumbar lateral recess decompression (TELLRD) may be helpful for those patients. This study aimed to demonstrate the efficacy of TELLRD for treating radiculopathy in octogenarian patients. A total of 21 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELLRD between January 2017 and January 2021. The inclusion criterion was unilateral radiculopathy, which stemmed from lumbar lateral recess stenosis. The pain source was verified using imaging studies and selective nerve blocks. Full-scale lateral canal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. We found the pain scores and functional status improved significantly during the 24-month follow-up period. The clinical improvement rate was 95.24% (20 of 21 patients) with no systemic complication. In conclusion, endoscopic lateral recess decompression via the transforaminal approach is practical for octogenarian patients.

Hip-spine syndrome: Diagnostic difficulties

Introduction. Hip-spine syndrome (HSS) is a combination of coexisting hip osteoarthritis (OA) and degenerative lumbar spine stenosis (LSS). Main difficulties in treating patients with HSS are in early diagnostics and in choosing right surgery, because mistakes lead to pain maintenance. Existing diagnostic algorithms show right surgery choosing failure in 15–20%. We present results of examination patients with HSS in our survey.

The aim – to present clinical and instrumental results of examination of patients with hip-spine syndrome.

Materials and methods. We have examined 378 patients with typical pain pattern (buttocks, low back spine, groin and lateral hip) and difficulties in pain source definition. We performed hip X-rays and low back spine MRI.

Due to results we divided patients into three groups – patients with HSS (n=100), with hip OA (n=172) and patients with LSS (n=106). We used Harris Hip Score, Oswestry Disability Index and Visual Analogue Score to determine hip and lumbar spine functional status and pain level.

Results. Patients with HSS had higher (p<0.05) pain levels (76.5±9.1 mm) than patients with hip (68.3±7.9 mm) or lumbar spine pathology (67.4±7.9 mm). Harris Hip Score in patients wirh HSS (52.7±8.1 points) was same as in patients with hip OA (55.5±9.1 points), Oswestry Disability Index in these patients (44.2±7.6%) was same as in patients with LSS (43.2±7.8%).

Conclusion. High pain level and low Harris Hip Score and Oswestry index, along with clinical examination, on first visit can help suspect hip-spine syndrome and recommend both hip and lumbar spine imaging.

Lateral Lumbar Spinal Stenosis: Associations With the Oswestry Disability Index, Visual Analogue Scale, and Magnetic Resonance Imaging

Introduction Degenerative lumbar spinal stenosis is a communal problem in the sixth decade of life involving L4/L5 and L5/S1 levels. Lateral spinal stenosis is often underestimated because of no established relationship between the clinical symptoms and MRI findings. We conducted a study to establish an association between the degree of anatomical lateral stenosis, posterior disc height, and disc degeneration from MRI with the daily disability and pain severity for lateral lumbar spinal stenosis. Methods This was a cross-sectional study involving 121 patients with distinct clinical symptoms of lateral lumbar spinal stenosis evaluated from February 2018 to December 2019. The clinical data were evaluated using the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS), while magnetic resonance imaging (MRI) was assessed qualitatively for the anatomical gradation of lateral spinal stenosis, the magnitude of posterior disc height, and the extent of disc degeneration. Statistical analysis for the correlation between posterior disc height and ODI and VAS scores was evaluated using Pearson's correlation test via SPSS version 23.0 (IBM Inc., Armonk, New York), and the association between the extent of lateral stenosis and disc degeneration on MRI with ODI and VAS scores was determined by the Fisher Exact Test via STATA version 14.0 (StataCorp LLC, College Station, Texas). The association was considered statistically significant with a P-value of less than 0.05. Results The analysis of 121 patients showed the mean age of the patients was 58.7 ± 7.1 years old. The number of female patients was higher compared to male patients, 52.9% and 47.1%, respectively. 97.5% of the patients were married or cohabiting, and 76.0% had an abnormal body mass index. The mean score of ODI and VAS was 62.2 ± 10.7% and 79.3 ± 8.6 respectively. 49.6% of the patient presented with a crippling disability with ODI assessment, while 59.5% presented with high pain intensity with VAS assessment. MRI assessment of anatomical grading lateral stenosis of L4/L5 level revealed that 45.5% of the patients had grade 2 lateral recess stenosis, 63.6% had grade 2 foraminal stenosis, and 44.6% had extraforaminal stenosis. L5/S1 level analysis showed that 43.0% had grade 2 lateral recess stenosis, 62.0% had grade 2 foraminal stenosis, and 29.8% had extraforaminal stenosis. 64.5% of patients had grade 4 disc degeneration of L4/L5 with mean posterior disc height of 7.0mm ±1.7mm while 59.5% had grade 4 disc degeneration of L5/S1 with mean posterior disc height of 6.3mm ±1.8mm. However, no statistically significant association between clinical symptoms and MRI findings was found.  Conclusions There was no significant association between the clinical symptoms of pain and disability and the MRI findings for the anatomical gradation of lateral spinal stenosis, the magnitude of posterior disc height, and the extent of disc degeneration. A comprehensive clinical evaluation remains essential for an accurate diagnosis, emphasizing the necessity of appropriately correlating MRI findings with their clinical significance.

An in vivo model of ligamentum flavum hypertrophy from early-stage inflammation to fibrosis

Multi-joint disease pathologies in the lumbar spine, including ligamentum flavum (LF) hypertrophy and intervertebral disc (IVD) bulging or herniation contribute to lumbar spinal stenosis (LSS), a highly prevalent condition characterized by symptomatic narrowing of the spinal canal. Clinical hypertrophic LF is characterized by a loss of elastic fibers and increase in collagen fibers, resulting in fibrotic thickening and scar formation. In this study, we created an injury model to test the hypothesis that LF needle scrape injury in the rat will result in hypertrophy of the LF characterized by altered tissue geometry, matrix organization, composition and inflammation. An initial pilot study was conducted to evaluate effect of needle size. Results indicate that LF needle scrape injury using a 22G needle produced upregulation of the pro-inflammatory cytokine Il6 at 1 week post injury, and increased expression of Ctgf and Tgfb1 at 8 weeks post injury, along with persistent presence of infiltrating macrophages at 1, 3, and 8 weeks post injury. LF integrity was also altered, evidenced by increases in LF tissue thickness and loss of elastic tissue by 8 weeks post injury. Persistent LF injury also produced multi-joint effects in the lumbar IVD, including disc height loss at the injury and adjacent to injury level, with degenerative IVD changes observed in the adjacent level. These results demonstrate that LF scrape injury in the rat produces structural and molecular features of LF hypertrophy and IVD height and histological changes, dependent on level. This model may be useful for testing of therapeutic interventions for treatment of LSS and IVD degeneration associated with LF hypertrophy.

An Injectable Engineered Cartilage Gel Improves Intervertebral Disc Repair in a Rat Nucleotomy Model

Lower back pain is a major problem caused by intervertebral disc degeneration. A common surgical procedure is lumbar partial discectomy (excision of the herniated disc causing nerve root compression), which results in further disc degeneration, severe lower back pain, and disability after discectomy. Thus, the development of disc regenerative therapies for patients who require lumbar partial discectomy is crucial. Here, we investigated the effectiveness of an engineered cartilage gel utilizing human fetal cartilage-derived progenitor cells (hFCPCs) on intervertebral disc repair in a rat tail nucleotomy model. Eight-week-old female Sprague-Dawley rats were randomized into three groups to undergo intradiscal injection of (1) cartilage gel, (2) hFCPCs, or (3) decellularized extracellular matrix (ECM) (n = 10/each group). The treatment materials were injected immediately after nucleotomy of the coccygeal discs. The coccygeal discs were removed six weeks after implantation for radiologic and histological analysis. Implantation of the cartilage gel promoted degenerative disc repair compared to hFCPCs or hFCPC-derived ECM by increasing the cellularity and matrix integrity, promoting reconstruction of nucleus pulposus, restoring disc hydration, and downregulating inflammatory cytokines and pain. Our results demonstrate that cartilage gel has higher therapeutic potential than its cellular or ECM component alone, and support further translation to large animal models and human subjects.

Full Endoscopic Ligamentum Flavum Sparing Unilateral Laminotomy for Bilateral Recess Decompression: Surgical Technique and Clinical Results

OBJECTIVE

Interlaminar endoscopic spine surgery has been introduced and utilized for lumbar lateral recess decompression. We modified this technique and utilized it for bilateral lateral recess stenoses without significant central stenosis. Here we present the surgical details and clinical outcome of ligamentum flavum sparing unilateral laminotomy for bilateral recess decompression (ULBRD).

METHODS

Prospectively collected registry for full-endoscopic surgeries was reviewed retrospectively. One hundred eighty-two consecutive cases from a single center between September 2015 and March 2021 were reviewed and 57 of them whom underwent ULBRD were enrolled for analysis. Basic patient demographic data, perioperative details, surgeryrelated complications, and clinical outcome were reviewed. The detailed surgical technique is presented as well.

RESULTS

Among the 57 patients enrolled, 37 were males while the other 20 were females. The mean age was 58.53 ± 14.51 years, and a bimodal age distribution at the age of mid-fifties and mid-sixties or older was noted. The later age-peak was related to coexistence of degenerative scoliosis. The average operative time per lamina was 70.34 ± 20.51 minutes and mean length of stay was 0.56 ± 0.85 days. Four perioperative complications were reported (7.0%) and the overall reoperation rate at the index level within 1 year was 8.8%. The preoperative back/leg visual analogue scale scores and functional outcome scales including EuroQol-5 dimension questionnaire, Oswestry Disability Index presented significant improvement immediately after surgery and were maintained until final follow-up.

CONCLUSION

ULBRD for bilateral lateral recess stenoses without significant central stenosis resulted in good clinical outcomes with acceptably low perioperative complications rates. Sufficient decompression was achieved with the central ligamentum flavum being preserved.

The effectiveness of percutaneous endoscopic decompression compared with open decompression and fusion for lumbar spinal stenosis: protocol for a multicenter, prospective, cohort study

Background

Lumbar spinal stenosis (LSS) is one of the most frequent indications for spine surgery. Open decompression and fusion surgery was the most common treatment and used to be regarded as the golden standard treatment for LSS. In recent years, percutaneous endoscopic decompression surgery was also used for LSS. However, the effectiveness and safety of percutaneous endoscopic decompression in the treatment of LSS have not been supported by high-level evidence. Our aim is to 1) compare the effectiveness of percutaneous endoscopic decompression surgery and open decompression and fusion for the treatment of LSS. 2) Investigate the prognosis risk factors for LSS. 3) Evaluate the influence of percutaneous endoscopic decompression for the stability of operative level, and degeneration of adjacent level.

Methods

It’s a prospective, multicenter cohort study. The study is performed at 4 centers in Beijing. This study plans to enroll 600 LSS patients (300 patients in the percutaneous endoscopic decompression group, and 300 patients in the open decompression and fusion group). The demographic variables, healthcare variables, symptom related variables, clinical assessment (Visual analogue score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association score (JOA)), and radiological assessment (dynamic X-ray, CT, MRI) will be collected at baseline visit. Patients will follow up at 3, 6, 12 months. The primary outcome is the difference of improvement of ODI between baseline and 12-month follow-up between the two groups. The secondary outcome is the score changes of preoperative and postoperative VAS, the recovery rate of JOA, MacNab criteria, patient satisfaction, degeneration grade of adjacent level, ROM of operative level and adjacent level, complication rate.

Discussion

In this study, we propose to conduct a prospective registry study to address the major controversies of LSS decompression under percutaneous spinal endoscopy, and investigate the clinical efficacy and safety of percutaneous endoscopic decompression and open decompression in the treatment of LSS.

Trial registration

This study has been registered on clinicaltrials.gov in January 15, 2020 (NCT04254757). (SPIRIT 2a).

Mechanism Underlying Painful Radiculopathy in Patients with Lumbar Disc Herniation

BACKGROUND

Painful lumbar radiculopathy is a neuropathic pain condition, commonly attributed to nerve root inflammation/compression by disc herniation. The present exploratory study searched for associations between pain intensity and inflammatory markers, herniated disc size, infection, psychological factors and pain modulation in patients with confirmed painful lumbar radiculopathy scheduled for spine surgery.

METHODS

Prior to surgery, 53 patients underwent the following evaluation: pain intensity measured on a 0-10 numeric rating scale (NRS) and the Short-Form McGill Pain Questionnaire; sensory testing (modified DFNS protocol); pain processing including temporal summation and conditioned pain modulation (CPM); neurological examination; psychological assessment including Spielberger's Anxiety Inventory, Pain Sensitivity Questionnaire and the Pain Catastrophizing Scale. Pro-inflammatory cytokine levels (IL-1b, IL-6, IL-8, IL-17, TNFα, IFNg) and microbial infection (ELISA and rt-PCR) in blood and disc samples obtained during surgery. MRI scans assessments for disc herniation size/volume (MSU classification/ three-dimensional volumetric analysis).

RESULTS

Complete data was available from 40 (75%) patients (15 female) aged 44.8±16.3 years. Pain intensity (NRS) positively correlated with pain catastrophizing and CPM (r=0.437, P=0.006; r=0.421, P=0.007; respectively), but not with disc/blood cytokine levels, bacterial infection or MRI measures. CPM (P=0.001) and gender (P=0.029) were associated with average pain intensity (adjusted R2=0.443).

CONCLUSIONS

This exploratory study suggests that pain catastrophizing, CPM and gender, seem to contribute to pain intensity in patients with painful lumbar radiculopathy. The role of mechanical compression and inflammation in determining the intensity of painful radiculopathy remains obscure.

The association between clinical symptoms of lumbar spinal stenosis and MRI axial imaging findings

Purpose:

In diagnosing lumbar spinal stenosis (LSS), Magnetic Resonance Imaging (MRI) is appropriate to confirm the presence of anatomical stenosis of the spinal canal or compression of the nerve roots. However, it is known that morphological LSS is often present in asymptomatic subjects. There is still controversy about the relationship between anatomical LSS and symptomatic LSS. The aim of this study was to assess the association between qualitative imaging findings on MRI of the lumbar spine and symptomatic LSS.

Patients and methods:

This was a cross-sectional study of 239 volunteers from an epidemiological survey that included 1,862 participants in total. MRI of the lumbar spine was evaluated in four categories: morphological grading of central stenosis and lateral recess stenosis, presence of the sedimentation sign, and severity of facet joint effusion. The relationship between these morphological evaluations and typical LSS symptoms as assessed by the self-administered, self-reported history questionnaire for lumbar spinal stenosis (LSS-SSHQ) was investigated by multiple logistic regression analysis.

Results:

The odds ratio of the most severe central stenosis to no stenosis was 15.5 (95%CI: 1.4-164.9). Only the most severe central stenosis was associated with typical LSS symptoms, but not all cases with typical LSS symptoms were due to severe central stenosis.

Conclusion:

Extreme severe central stenosis was strongly related to typical LSS symptoms. However, although subjects with severe central stenosis showed symptoms suggestive of LSS, these subjects did not always show typical LSS symptoms.

ACR Appropriateness Criteria® Low Back Pain: 2021 Update

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Evaluating the outcome of classic laminectomy surgery alone versus laminectomy with fixation surgery in patients with lumbar canal stenosis regarding improvement of pain and function

Background

Management of lumbar canal stenosis should be started with conservative treatment and preferably with a multimodal approach, but in cases of severe pain with extensive neurogenic claudication symptoms, surgical intervention is indicated. This retrospective study targets to evaluate the outcome of classic laminectomy surgery alone versus laminectomy with fixation surgery in patients with lumbar canal stenosis regarding improvement of pain and function.

Methods

Data of 184 patients of the study groups were divided into group A (data from patients who underwent laminectomy and foraminotomy only) and group B (data from patients who underwent laminectomy and foraminotomy with spinal fixation). Preoperative, operative, postoperative (PO), and follow-up data were extracted and analyzed from files of patients fulfilling the inclusion criteria.

Results

Primary outcome was at least 50% improvement of pain severity regarding numeric rating scale (NRS) and Oswestry disability index (ODI) score at 6-months PO compared to preoperative scores. Operative time was significantly longer in group B than group A. Immediate PO data regarding PO analgesic requirement, amount of wound drainage, and PO hospital stay showed non-significant difference between both groups. There was a statically significant improvement of EHL muscle strength regarding Odom’s scoring in group B in which the success rate for pain improvement was 81.8% and for disability was 66.8%. There were insignificant differences in patient’s satisfaction to surgery with variable ages, a significant outcome in females and in patients with fewer levels of affection of both groups.

Conclusion

The present study reported the efficacy and safety of the laminectomy, foraminotomy, discectomy, and medial facetectomy with spinal fixation using trans-pedicular screws for management of patients with spinal canal stenosis.

Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin's Triangle Approach

Purpose

Dispersion of contrast media into the anterior epidural space is correlated with better outcomes after transforaminal epidural injection (TFEI). Needle tip position is an important factor affecting the pattern of contrast media dispersion. It is difficult to advance the needle medially to the interpedicle line with a conventional approach, especially in a severe spinal stenosis. But, with Kambin’s triangle approach, the needle can be advanced more medially even in the severe stenosis. We aimed to compare contrast media dispersion patterns according to the needle tip position in TFEI with Kambin’s triangle approach.

Patients and Methods

This single-center retrospective study analyzed fluoroscopic data of patients who underwent TFEI from March 2019 to July 2019. Data on the history of lumbar spinal fusion surgery and MRI findings were collected. The needle tip position was evaluated in three positions on fluoroscopic images (final anteroposterior [AP] view): extraforaminal (EF), lateral foramen (LF), and medial foramen (MF). Contrast media dispersion into the epidural space (epidural pattern) in the AP view was evaluated as a dependent variable. The relationship between the contrast media dispersion pattern and needle tip position was analyzed, and other factors affecting the contrast media dispersion pattern were identified.

Results

Ninety-eight TFEI cases were analyzed (51 LF, 35 MF, and 12 EF). An epidural pattern of dispersion was observed more frequently in the LF and MF groups than in the EF group. The LF and MF groups showed no significant difference in epidural pattern frequency. On logistic regression analysis, needle tip position emerged as a major factor influencing epidural pattern, while other factors including spine conditions had no significant effect.

Conclusion

Positioning the needle tip medial to the pedicle helps in the spread of the contrast media into the epidural space during TFEI with Kambin’s approach. Factors other than the needle tip position did not significantly affect the contrast media dispersion pattern.

Ligamentum flavum fibrosis and hypertrophy: Molecular pathways, cellular mechanisms, and future directions

Hypertrophy of ligamentum flavum (LF), along with disk protrusion and facet joints degeneration, is associated with the development of lumbar spinal canal stenosis (LSCS). Of note, LF hypertrophy is deemed as an important cause of LSCS. Histologically, fibrosis is proved to be the main pathology of LF hypertrophy. Despite the numerous studies explored the mechanisms of LF fibrosis at the molecular and cellular levels, the exact mechanism remains unknown. It is suggested that pathophysiologic stimuli such as mechanical stress, aging, obesity, and some diseases are the causative factors. Then, many cytokines and growth factors secreted by LF cells and its surrounding tissues play different roles in activating the fibrotic response. Here, we summarize the current status of detailed knowledge available regarding the causative factors, pathology, molecular and cellular mechanisms implicated in LF fibrosis and hypertrophy, also focusing on the possible avenues for anti-fibrotic strategies.

Measurement of spinal root angle at spinal canal and foraminal levels in cases of facet arthropathy: T2-weighted turbo spin echo magnetic resonance myelography with SPACE technique

BACKGROUND

Magnetic resonance myelography (MRM) with three-dimensional (3D) T2-weighted (T2W) turbo spin echo (TSE) sampling perfection with application-optimized contrasts using different flip angle evolution (SPACE) may be a guide to the etiology of low back pain.

PURPOSE

To research the efficiency of a 3D T2W TSE SPACE MRM sequence for visualization of anatomic details of spinal nerve root at the spinal canal and lateral recess levels in the patients with low back pain.

MATERIAL AND METHODS

Lumbar spinal MRM 3D T2W TSE SPACE was performed in a total of 70 patients (median age 46 years). Patients were imaged while lying in a supine position with straightened legs. According to the degree of facet arthropathy findings, patients were divided into four separate subgroups in our retrospective cross-sectional study. Spinal nerve root angle was measured within the spinal canal and at lateral recess level, and facet joint angle and lumbar lordosis measurements were measured by two radiologists, independently.

RESULTS

Lumbar level was strongly negatively correlated with facet joint angle (r = -0.95) as well as nerve root angle within the spinal canal (NRA_SC) (r = -0.857) and at the lateral recess level (NRA_LR) (r = -0.947). Intracanal decline of the spinal root angle caused by spinal stenosis findings was also observed (P < 0.05). For the measurements of NRA_SC and NRA_LR, inter-observer correlation was 0.85 and 0.82 for the spinal canal and at lateral recess level, respectively.

CONCLUSION

3D T2W SPACE in NRA_SC and NRA_LR provided high resolution images for evaluation. Therefore, this method may be a qualitative guide for the clinician and the surgeon in terms of root anatomy before any intervention.

Optimization of a rat lumbar IVD degeneration model for low back pain

INTRODUCTION

Intervertebral disc (IVD) degeneration is often associated with low back pain and radiating leg pain. The purpose of this study is to develop a reproducible and standardized preclinical model of painful lumbar IVD degeneration by evaluation of structural and behavioral changes in response to IVD injury with increasing needle sizes. This model can be used to develop new therapies for IVD degeneration.

METHODS

Forty-five female Sprague Dawley rats underwent anterior lumbar disc needle puncture at levels L4-5 and L5-6 under fluoroscopic guidance. Animals were randomly assigned to four different experimental groups: needle sizes of 18 Gauge (G), 21G, 23G, and sham control. To monitor the progression of IVD degeneration and pain, the following methods were employed: μMRI, qRT-PCR, histology, and biobehavioral analysis.

RESULTS

T1- and T2-weighted μMRI analysis showed a correlation between the degree of IVD degeneration and needle diameter, with the most severe degeneration in the 18G group. mRNA expression of markers for IVD degeneration markers were dysregulated in the 18G and 21G groups, while pro-nociceptive markers were increased in the 18G group only. Hematoxylin and Eosin (H&E) and Alcian Blue/Picrosirius Red staining confirmed the most pronounced IVD degeneration in the 18G group. Randall-Selitto and von Frey tests showed increased hindpaw sensitivity in the 18G group.

CONCLUSION

Our findings demonstrate that anterior disc injury with an 18G needle creates severe IVD degeneration and mechanical hypersensitivity, while the 21G needle results in moderate degeneration with no increased pain sensitivity. Therefore, needle sizes should be selected depending on the desired phenotype for the pre-clinical model.

Posterolateral fusion combined with posterior decompression shows superiority in the treatment of severe lumbar spinal stenosis without lumbar disc protrusion or prolapse: a retrospective cohort study

Background

Currently, discectomy and posterior decompression combined with lumbar circumferential fusion (CF) have been accepted as a major procedure for severe lumbar spinal stenosis (LSS). However, studies on severe LSS without protruded intervertebral disc to minimize study bias are lacking. We aimed to investigate the effectiveness of sole posterior decompression with lumbar posterolateral fusion (PLF) and the necessity of discectomy and CF in patients with severe LSS without lumbar disc protrusion or prolapse.

Methods

This retrospective cohort study included 153 severe LSS patients without lumbar disc protrusion or prolapse who were admitted in a tertiary spine center with at least a 2-year follow-up between January 2014 and August 2017. Patients were divided into the PLF (n = 77; those who underwent posterior decompression with PLF in 1–3 segments) or CF (n = 76; those who underwent posterior decompression and discectomy with CF in 1–3 segments) groups. Pedicle screw instrumentation was applied to avoid postoperative instability. Clinical outcomes were assessed by visual analog scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association Score (JOA, lumbar pain score). Duration of operation, blood loss, surgical cost, and postoperative complications were analyzed. Height of intervertebral space, lumbar lordosis, and bone union were confirmed by lumbar radiography or computed tomography.

Results

Both groups achieved significant improvement in JOA, ODI, and VAS compared with preoperative values (P < 0.001), but without significant difference between the two groups. Both groups achieved high fusion rate without difference and correction of lumbar lordosis and intervertebral space height (P < 0.001), especially in the CF group (P < 0.05). Duration of operation, blood loss, and operation cost were significantly higher in the CF group than in the PLF group (P < 0.001). Eight complications were found in both groups (1, PLF group; 7, CF group; P < 0.05).

Conclusions

After posterior decompression, PLF successfully achieves bony fusion and symptom relief with lower complication rate, lesser surgical blood loss, shorter operative time, and lesser cost than CF. Thus, sole posterior decompression with PLF is an effective treatment for severe LSS without lumbar disc protrusion or prolapse.

Factors Associated with Successful Response to Balloon Decompressive Adhesiolysis Neuroplasty in Patients with Chronic Lumbar Foraminal Stenosis

Epidural neuroplasty, often called percutaneous epidural adhesiolysis, is often performed in refractory patients with chronic lumbar radiculopathy or neurogenic claudication. Recent studies have showed that decompressive adhesiolysis with an inflatable balloon catheter (balloon neuroplasty) is efficient in patients who experience refractory pain from epidural steroid injection or even epidural neuroplasty with a balloon-less catheter. However, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, to assess associated factors that could affect a favorable outcome, we analyzed a prospectively collected multicenter cohort of patients with chronic refractory lumbar foraminal stenosis after balloon neuroplasty. At the 6-month point in follow-up, 92 (44.4%) patients among 207 subjects were classified as successful responders according to a robust combination of outcome measures. Multivariate logistic regression analysis also showed that mild grade lumbar foraminal stenosis may be an independent factor associated with a successful response 6 months after balloon neuroplasty (odds ratio = 2.829; 95% confidence interval = 1.351–5.923; p = 0.006). However, we found that there were 29.4% and 24.6% successful responders with moderate and severe foraminal stenosis, respectively. Attempting balloon neuroplasty in refractory lumbar foraminal stenosis, especially mild grade, may be worthwhile.

Imaging of the spine: Where do we stand?

The number of patients presenting with spine-related problems has globally increased, with an enormous growing demand for the use of medical imaging to address this problem. The last three decades witnessed great leaps for diagnostic imaging modalities, including those exploited for imaging the spine. These developments improved our diagnostic capabilities in different spinal pathologies, especially with multi-detector computed tomography and magnetic resonance imaging, via both hardware and software improvisations. Nowadays, imaging may depict subtle spinal instability caused by various osseous and ligamentous failures, and could elucidate dynamic instabilities. Consequently, recent diagnostic modalities can discern clinically relevant spinal canal stenosis. Likewise, improvement in diagnostic imaging capabilities revolutionized our understanding of spinal degenerative diseases via quantitative biomarkers rather than mere subjective perspectives. Furthermore, prognostication of spinal cord injury has become feasible, and this is expected to be translated into better effective patient tailoring to management plans with better clinical outcomes. Meanwhile, our confidence in diagnosing spinal infections and assessing the different spinal instrumentation has greatly improved over the past few last decades. Overall, revolutions in diagnostic imaging over the past few decades have upgraded spinal imaging from simple subjective and qualitative indices into a more sophisticated yet precise era of objective metrics via deploying quantitative imaging biomarkers.

Transforaminal Endoscopic Decompression for Lumbar Lateral Recess Stenosis: An Advanced Surgical Technique and Clinical Outcomes

OBJECTIVE

The clinical application of endoscopic techniques for lumbar lateral recess stenosis (LRS) is still challenging. This study aimed to describe a transforaminal endoscopic decompression (TED) technique for LRS and to demonstrate its clinical results.

METHODS

Two-year follow-up data were collected from 45 consecutive patients who underwent TED for LRS. Full-scale endoscopic decompression was performed in the dorsal and ventral aspects of the lateral recess with combined partial pediculectomy using an articulating bone burr and endoscopic instruments. Surgical outcomes were evaluated using the Visual Analog Pain Score (VAS), Oswestry Disability Index (ODI), and modified Macnab criteria.

RESULTS

The mean age of the 27 female and 18 male patients was 64.9 years. The mean VAS for leg pain and mean ODI improved from 7.93 and 75.87 at baseline to 1.71 and 17.87, respectively, at 2 years after surgery (P < 0.001 and P < 0.001, respectively). Based on the modified Macnab criteria, excellent or good results were obtained in 86.7% of the patients, and symptomatic improvements were obtained in 97.8%. One patient underwent revision surgery because of incomplete decompression, and 2 experienced transient dysesthesia.

CONCLUSION

TED with the patient under local anesthesia can be effective for the treatment of LRS, especially for the elderly or patients at a high risk for general anesthesia.

Relationship Between Magnetic Resonance Imaging Findings and Clinical Symptoms in Patients with Suspected Lumbar Spinal Canal Stenosis: a Case-control Study

Introduction:

Despite the availability of many imaging and clinical criteria for diagnosis of lumbar spinal stenosis (LSS), its correct diagnosis is a challenge for clinicians and radiologists.

Aim:

The aim of this study was to examine the relationship between magnetic resonance imaging (MRI) findings and clinical symptoms in symptomatic and asymptomatic patients with suspected LSS in MRI.

Methods:

This study is a case-control study. Two groups of 100 symptomatic and asymptomatic individuals (aged 20 to 84 years) with suspected lumbar spinal canal stenosis who referred to the imaging unit for lumbosacral MRI were included. The clinical symptoms and radiological parameters in MRI for all patients were recorded and relationship between them were evaluated.

Results:

Among the quantitative imaging findings, only the anterior-posterior diameter of the canal at the level of the intervertebral disc, the central spinal canal cross-section area and lateral recesses cross-sectional area were valuable. Coefficient of stenosis was calculated for the case and control groups which had statistically significant difference (p<0.001). The difference between qualitative findings such as disc protrusion, extrusion, sequestration and Cauda Equine serpain or redundant was significant between the two groups.

Conclusion:

According to the results, among the quantitative criteria of MRI imaging findings, central spinal canal cross-section (less than 77.5 mm2 for central stenosis) and lateral recesses cross-section (less than 22.5 mm2 for lateral stenosis) had the highest sensitivity and specificity for LSS diagnosis in symptomatic and asymptomatic patients with suspected LSS. Strongest observed correlation was between neurogenic claudication and LSS diagnostic radiological markers.

Pedicle distraction increases intervertebral and spinal canal area in a cadaver and bone model

INTRODUCTION

Lumbar spinal stenosis is degenerative narrowing of the spinal canal and/or intervertebral foramen causing compression of the spinal cord and nerve roots. Traditional decompression techniques can often cause significant trauma and vertebral instability. This paper evaluates a method of increasing pedicle length to decompress the spinal and intervertebral foramen, which could be done minimally invasive.

METHODS

Three Sawbone (Sawbones Europe, Sweden) and 1 cadaveric lumbar spine underwent bilateral pedicle distraction at L4. A pedicle channel was drilled between the superior articular process and transverse process into the vertebral body. The pedicles underwent osteotomy at the midpoint. Screws were inserted bilaterally and fixated distraction of 0 mm, 2 mm, 4 mm and 6 mm. CT images were taken at each level of distraction. Foramen area was measured in the sagittal plane at L3/4. Spinal canal area was measured at L4 in the axial images. The cadaver was used to evaluate safety of osteotomy and soft tissue interactions preventing distraction. Statistical analysis was by student paired t-test and Pearson rank test.

RESULTS

Increasing distraction led to greater Spinal canal area. From 4.27 cm² to 5.72 cm² (p = 0.002) with 6 mm distraction. A Maximal increase of 34.1%. Vertebral foramen area also increased with increasing pedicle distraction. From 2.43 cm² to 3.22 cm² (p = 0.022) with 6 mm distraction. A maximal increase of 32.3%. The cadaver spinal canal increased in area by 21.7%. The vertebral foramen increased in area by 36.2% (left) and 22.6% (right).

DISCUSSION

For each increase in pedicle distraction the area of the spinal and vertebral foramen increases. Pedicle distraction could potentially be used to alleviate spinal stenosis and root impingement. A potential osteotomy plane could be at the midpoint of the pedicle with minimal risk to nerve roots and soft tissue restrictions to prevent distraction.

Leptin-induced inflammation by activating IL-6 expression contributes to the fibrosis and hypertrophy of ligamentum flavum in lumbar spinal canal stenosis

The ongoing chronic inflammation and subsequent fibrosis play an important role in ligamentum flavum (LF) fibrosis and hypertrophy in patients with lumbar spinal canal stenosis (LSCS). Leptin is a chronic inflammatory mediator and involved in the fibrotic process in multiple organ systems. The present study aimed to investigate the role of leptin in LF fibrosis and its related regulatory mechanisms. The LF specimens were obtained during the surgery from 12 patients with LSCS (LSCS group) and 12 control patients with lumbar disc herniation (LDH) group. The morphologic changes and fibrosis score of LF were assessed by Hematoxylin and eosin (H&E) and Masson’s trichrome staining respectively. The location and expression of leptin in LF tissues were determined. Then, the LF cells were cultured and exposed to recombinant human leptin (rhleptin). Collagen I and III were used as fibrosis markers and IL-6 was used as the inflammatory factor. As a result, the LF thickness and fibrosis score in the LSCS group were significantly higher than those in the LDH group (P<0.05). Leptin was detected in the hypertrophied LF and its expression was substantially increased in the LSCS group and positively correlated with LF thickness and fibrosis score (P<0.05). Moreover, our in vitro experiments revealed that rhleptin treated LF cells elevated the expression of collagen I and III. Finally, leptin administration induced IL-6 expression via nuclear factor-κB (NF-κB) pathway in LF cell (P<0.05). Our study demonstrated novel molecular events for leptin-induced inflammation in LF tissue by promoting IL-6 expression and thus might have potential implications for clarifying the mechanism underlying LF fibrosis and hypertrophy.