Lumbar Disc Herniation with Contralateral Symptoms: A Case-Series of 11 Patients and Literature Review

OBJECTIVE

Lumbar disc herniation (LDH) is a common pathology that typically causes unilateral radiculopathy on the same side as herniation, while patients may occasionally present with contralateral symptoms. Owing to the rare incidence of LDH with contralateral symptoms, the pathological mechanism remains unclear and the optimal surgical strategy is a subject of debate. This study aimed to provide new insights into the pathological mechanism of contralateral symptoms and assess the efficacy of ipsilateral hemilaminectomy and discectomy surgery in this population.

METHODS

This study was a retrospective, single-center, clinical case series, including 11 LDH cases with exclusive contralateral symptoms. We searched for LDH cases that were presented at our institution between January 2011 and December 2020. Adult LDH Patients with contralateral radicular pains were included, while those with ipsilateral radiculopathy, lumbar stenosis, foraminal stenosis on the symptomatic side, multilevel disc herniations, scoliosis, and lumbar operation history were excluded. Visual Analog Scale (VAS), clinical features, radiographic images, and other data were collected from the study cohort of 11 cases for further analysis. We also reviewed LDH cases in English literature from 1978 to 2023 to analyze their clinical characteristics and treatment.

RESULTS

The incidence rate of LDH with contralateral symptoms in single-level LDH cases was 0.32%. The average age of our 11 cases was 49.3 years old, and five of them were female (45.5%). All individuals had single-level lateral LDH, with six cases (54.5%) located at L4-5 and five cases (45.5%) located at L5-S1. Upon admission, patients presented with lower back pain (seven cases, 63.6%), radicular pain (seven cases, 63.6%), hypoesthesia (seven cases, 63.6%), and muscle weakness (one case, 9.1%) on the contralateral side alone. Each case experienced ipsilateral hemilaminectomy and discectomy, and no lateral recess stenosis, hypertrophy of facets or ligaments, and sequestrated discs were found during surgery. All of them have good pain relief with two cases reporting no pain and nine cases reporting only mild pain at the last follow-up.

CONCLUSIONS

Based on the surgical findings of our 11 LDH cases with contralateral symptoms, we hypothesized that the contralateral symptoms might be produced when the nerve root on the contralateral symptomatic side was tightly pulled by the herniated disc via the dural mater. Ipsilateral hemilaminectomy and discectomy surgery effectively and efficiently relieve the symptoms without postoperative complications for these patients.

A Comparison of Corpectomy ACDF Hybrid Procedures with Nano-Hydroxyapatite/Polyamide 66 Cage and Titanium Mesh Cage for Multi-level Degenerative Cervical Myelopathy: A Stepwise Propensity Score Matching Analysis

OBJECTIVE

Previous studies have found satisfactory clinical results with the nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage to reconstruct the stability of anterior cervical column. However, studies evaluating the long-term outcomes of the n-HA/PA66 cage in multi-level degenerative cervical myelopathy (MDCM) have not been reported. This study aims to compare the outcomes of corpectomy anterior cervical discectomy and fusion (ACDF) hybrid procedures between the n-HA/PA66 cage and titanium mesh cage (TMC) to treat MDCM.

METHODS

After the screening for eligibility, this retrospective study involved 90 patients who underwent corpectomy ACDF hybrid (CACDFH) procedure from June 2013 to June 2018. The CACDFH procedure is the combination of ACDF and anterior cervical corpectomy and fusion (ACCF). According to the cage utilized, we categorized patients into a n-HA/PA66 cage group and a TMC group. Then, stepwise propensity score matching (PSM) was performed to maintain comparable clinical data between groups. All the patients were followed up ≥4 years and the longest follow-up time was 65.43 (±11.49) months. Cage subsidence, adjacent segment degeneration (ASD), segmental height (SH), segmental angle (SA), cervical lordosis (CL), and clinical data (visual analogue scale [VAS] and Japanese Orthopaedic Association [JOA] score) was evaluated preoperatively, at 1 week, and at the final surgery follow-up. The independent student's t test and chi-square test were applied to compare the differences between groups.

RESULTS

Through PSM analysis, 25 patients from the n-HA/PA66 group were matched to 25 patients in the TMC group. The occurrence of ASD was 16.0% (4/25) in the n-HA/PA 66 group, which was significantly less than in the TMC group at 44.0% (11/25) (p = 0.031). Moreover, the cage subsidence rate was significantly higher in the TMC group as compared to the n-HA/PA 66 group (40.0% vs. 12.0%, p = 0.024). But there was no significant difference in SH, SA, and CL at any time after surgery as determined through follow-up. The VAS and JOA scores significantly improved in both groups at 3 months postoperative and at final follow-up. However, there were no significant differences in the VAS and JOA score at any time between the two groups in preoperative (p > 0.05).

CONCLUSION

The n-HA/PA66 cage is associated with lower rate of cage subsidence and ASD than the TMC in the treatment of MDCM. The n-HA/PA66 cage could be superior to the TMC in corpectomy ACDF hybrid procedures.

Tranexamic acid can reduce blood loss in adolescent scoliosis surgery: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) has been widely used in orthopedic surgery, but its efficacy in adolescent scoliosis (AS) surgery remains unclear in the literature. The purpose of this systematic review and meta-analysis is to evaluate the safety and efficacy of TXA compared to placebo treatment during or after AS surgery, by gathering data from randomized both controlled trials (RCTs) and non-RCTs.

METHODS

English and Chinese electronic databases including PubMed, Web of Science, Embase, Cochrane, CNKI, and Wan Fang database were searched to identify the relevant literature up until August 2022. The primary outcomes were intraoperative blood loss and total blood loss. The secondary outcomes included the need for transfusion, postoperative hemoglobin (Hb) level, and change in Hb level. Stata 17 was used for data analysis and the risk of bias was assessed. We followed the PRISMA checklist to ensure the quality of this article.

RESULTS

Twelve studies (795 participants) were included in the meta-analysis for intraoperative blood loss during surgery. The results suggest that TXA can reduce the intraoperative blood loss of the patients (MD = -306.40ml, 95%CI = -404.04ml to -208.77ml, p < 0.001). Six studies (2027 patients) were included in the meta-analysis for total blood loss. The pooled result shows that the total blood loss of the TXA group was significantly lower than that of the control group (MD = -779.24ml, 95% CI = -1157.10ml to -410.39ml, p < 0.001). Five studies (419 patients) were included in the meta-analysis for postoperative Hb level and shows a non-significant outcome (MD = 5.09 g/l, 95%CI = 2.92 g/l to 7.25 g/l, p = 0.611). Three studies (268 patients) were included in the meta-analysis for the postoperative Hb level. There is a non-significant decrease in the TXA group (MD = -0.23 g/l, 95%CI = -0.48 g/l to 0.01 g/l, p = 0.319). Eight studies (670 patients) reported data on the need for transfusion after surgery. The overall relative risks (RR) showed a significant difference between the TXA and control group, with a lower risk of transfusion in the TXA group (RR = 0.547, 95%CI = 0.308 to 0.972, p = 0.04).

CONCLUSIONS

The meta-analysis of the data reveals that TXA usage is associated with a significant reduction in intraoperative and total blood loss, a lower risk of transfusion, and a non-significant change in postoperative Hb levels in AS surgery However, it should be noted that the surgical operation situations varied across different studies. Therefore, further research is required to investigate the effects of TXA on specific subgroups of gender, operation time, and blood transfusion indicators. Overall, our study provides valuable evidence for the clinical management of AS surgery and may inform the development of practice guidelines and protocols for the use of TXA in this setting.

Towards ion beam therapy based on laser plasma accelerators

Only few ten radiotherapy facilities worldwide provide ion beams, in spite of their physical advantage of better achievable tumor conformity of the dose compared to conventional photon beams. Since, mainly the large size and high costs hinder their wider spread, great efforts are ongoing to develop more compact ion therapy facilities. One promising approach for smaller facilities is the acceleration of ions on micrometre scale by high intensity lasers. Laser accelerators deliver pulsed beams with a low pulse repetition rate, but a high number of ions per pulse, broad energy spectra and high divergences. A clinical use of a laser based ion beam facility requires not only a laser accelerator providing beams of therapeutic quality, but also new approaches for beam transport, dosimetric control and tumor conformal dose delivery procedure together with the knowledge of the radiobiological effectiveness of laser-driven beams. Over the last decade research was mainly focused on protons and progress was achieved in all important challenges. Although currently the maximum proton energy is not yet high enough for patient irradiation, suggestions and solutions have been reported for compact beam transport and dose delivery procedures, respectively, as well as for precise dosimetric control. Radiobiological in vitro and in vivo studies show no indications of an altered biological effectiveness of laser-driven beams. Laser based facilities will hardly improve the availability of ion beams for patient treatment in the next decade. Nevertheless, there are possibilities for a need of laser based therapy facilities in future.