How Does Resorption Differ Among Single-Level and Multilevel Lumbar Disc Herniations? A Prospective Multi-Imaging and Clinical Phenotype Study.

Cartilaginous endplate avulsion is associated with modic changes and endplate defects, and residual back and leg pain following lumbar discectomy

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 214. Application of gelatin sponge impregnated with a mixture of three drugs to intraoperative nerve root block to promote early postoperative recovery of lumbar disc herniation

The use of minimally invasive surgical techniques, including microscope-assisted tubular lumbar microdiscectomy (tLMD), has gained increasing popularity in treating lumbar disc herniations (LDHs). This particular procedure has been shown to be both cost-efficient and effective, resulting in outcomes comparable to those of open surgical procedures. Lumbar disc herniation recurrence necessitating reoperation, however, remains an issue following spinal surgery, with an overall reported incidence of approximately 3-13%. The authors' aim in the present study was to report their experience using tLMD for single-level LDH, hoping to provide further insight into the rate of surgical recurrence and to identify potential risk factors leading to this complication. The authors retrospectively reviewed the cases of 217 patients who underwent tLMD for single-level LDH performed identically by 2 surgeons (J.B., R.H.) between 2004 and 2008. Evaluation for LDH recurrence included detailed medical chart review and telephone interview. Recurrent LDH was defined as the return of preoperative signs and symptoms after an interval of postoperative resolution, in conjunction with radiographic demonstration of ipsilateral disc herniation at the same level and pathological confirmation of disc material. A cohort of patients without recurrence was used for comparison to identify possible risk factors for recurrent LDH. Of the 147 patients for whom the authors were able to definitively assess symptomatic recurrence status, 14 patients (9.5%) experienced LDH recurrence following single-level tLMD. The most common level involved was L5-S1 (42.9%) and the mean length of time to recurrence was 12 weeks (range 1.5-52 weeks). Sixty-four percent of the patients were male. In a comparison with patients without recurrence, the authors found that relatively lower body mass index was significantly associated with recurrence (p = 0.005), such that LDH in nonobese patients was more likely to recur. Recurrence rates following tLMD for LDH compare favorably with those in patients who have undergone open discectomy, lending further support for its effectiveness in treating single-level LDH. Nonobese patients with a relatively lower body mass index, in particular, appear to be at greater risk for recurrence.

Background:Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation.Materials and Methods:Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification.Results:The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%).Conclusions:TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.

Background For young patients, the surgical method for lumbar disc herniation remains controversial. The aim of this study was to prospectively determine the short-term clinical outcome after surgery for young patients with lumbar disc herniation. Methods In this prospective comparative study between April 2010 and August 2011, a total of 80 patients underwent primary surgery at a single level for lumbar disc herniation. The patients were divided into two groups: decompression alone and decompression with instrumented fusion. An independent examiner clinically evaluated the patients at preoperation and at 1, 3, 6, and 12 months after surgery. The patients filled out the instruments for back and leg pain using a Visual Analog Scale (VAS), Oswestry Low Back Pain Disability Questionnaire (ODI), and Japanese Orthopaedic Association (JOA) scores. The differences between the two groups were analyzed. Results The mean age of all the patients at the time of surgery was 33.7 years. Of the 80 patients, 38 patients underwent decompression alone and 42 patients underwent posterior lumbar interbody fusion. Increasing complexity of surgery was associated with a longer surgery time, greater blood loss, and a longer hospital stay after surgery. Both methods of surgery independently improved outcomes compared with baseline status based on VAS, ODI, and JOA scores (P <0.05), and no significant differences were found between the two groups at most of the measuring points in time, although patients with decompression alone had a higher JOA score (P=0.016) and higher JOA recovery rate (P=0.010) at the 3-month follow-up. Conclusions The short-term results of our study showed that both methods of surgery obtained effective clinical outcomes, but decompression alone had some advantages (shorter surgery time, less blood loss, shorter hospital stay, and lower cost) compared with decompression with instrumented fusion. Young patients with decompression alone could achieve great physical function earlier.

The optimal timing of lumbar diskectomy in patients with lumbar disk herniation and radiculopathy has not been studied in the workers' compensation (WC) population. A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disk herniation between 2005 and 2012. The primary outcome was whether subjects return to work (RTW). To determine the impact time to surgery had on RTW status, the authors performed a multivariate logistic regression analysis. They compared other secondary outcomes using chi-square and t tests. The authors identified 1287 WC patients with single-level disk herniation and radiculopathy. Average time from injury to surgery was 364 days (range, 2-2710 days). The WC patients with shorter duration of radiculopathy before diskectomy had higher RTW rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses (P<.05). A multivariate logistic regression model showed that time to surgery was an independent, negative predictor of RTW (odds ratio [OR], 0.97 per month; P<.01). Legal representation (OR, 0.56; P<.01), psychological comorbidity (OR, 0.32; P=.01), and mean household income (OR, 1.01 per $1000; P<.01) also significantly affected RTW status. These results confirm that the duration of radiculopathy due to single-level lumbar disk herniation has a predictive value for the WC population undergoing diskectomy. Within 12 weeks of injury, post-diskectomy patients do reasonably well, with 70.0% of subjects returning to work. [Orthopedics. 2021;44(1):e43-e49.].

Source Citation Muralikuttan KP, Hamilton A, Kernohan WG, Mollan RA, Adair IV. A prospective randomized trial of chemonucleolysis and conventional disc surgery in single level lumbar disc herniation. Spine. 1992 May;17:381-7.

Background: Lumbar disc herniation is frequently-occurring and the most common spine-related disease in orthopedic surgery. However, nearly more than 50% of affected persons usually respond to conservative treatment. Furthermore, there is another group of patients who are suffering from incapacitating low back pain and sciatica although they have been treated for more than 6 weeks or who are suffering from early or progressive neurological impairment that required another approach far from the conservative treatments. Aim of the Study: The present study is designed to unveil the most reliable procedure which should be most adopted for single level lumbar disc herniation in Iraqi patients. Patients and Methods: A total of 40 patients who were suffering from back pain radiated to the lower limb were included in the present investigation. Out of them, 20 patients underwent open discectomy and the other 20 patients underwent tubular discectomy. Results: 1- At the 10th day of postoperatively assessment, an obvious statistically significant decrease in the mean total Oswestry low back pain disability score was recorded in micro-tubular discectomy compared with the open discectomy ( P&lt;0.001). 2- At the 6th month of postoperatively, the mean total Oswestry low back pain disability score was increased in both groups; nonetheless, there has still been a decrease in the micro-tubular discectomy group in comparison with that of open discectomy group (P&lt;0.001).

Study DesignRetrospective cohort study.BackgroundForaminal and extraforaminal disc herniations account for 7 to 12% of lumbar herniated discs. Various surgical methods, including midline approaches with facetectomy and paramedian techniques, involve significant bone removal, risking spinal instability. The percutaneous transforaminal approach for endoscopic access to lateral disc herniations presents several advantages over traditional techniques and may be more suitable for these cases.ObjectivesThis article evaluates the clinical outcomes and potential complications associated with the treatment of foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels in patients who have undergone transforaminal percutaneous endoscopic lumbar discectomy.Materials and MethodsBetween 2016 and 2020, a total of 32 patients diagnosed with single-level lumbar disc herniation at the L3/4 or L4/5 foraminal or extraforaminal levels, who had not responded to conservative management, underwent transforaminal endoscopic discectomy. Follow-up evaluations were performed on postoperative day 1 and at 2 weeks, 6 weeks, 3 months, and 12 months. Both pre- and postoperative assessments employed the visual analog scale (VAS) and the Oswestry Disability Index (ODI) to quantify pain levels and functional outcomes. Clinical outcomes were assessed according to the MacNab criteria to determine the efficacy of the surgical intervention.ResultsThe average age of patients was 52.6 years, with L4/5 (81.3%) and L3/4 (18.7%) being the most affected levels. The median follow-up was 18.2 months (range, 1–44 months). There was a significant reduction in VAS and ODI scores at follow-ups compared to preoperative levels (p < 0.01). All patients with preoperative neurological deficits improved, though six patients (18.7%) experienced transient dysesthesia that resolved in 6 weeks. Per the MacNab criteria, clinical efficacy was excellent in 56.3% of patients, good in 37.5%, and fair in 6.2%.ConclusionTransforaminal endoscopic lumbar discectomy is a safe and effective minimally invasive procedure for foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels. It preserves spinal stability, minimizes blood loss, reduces postoperative pain, and allows for quicker recovery, presenting a strong alternative for patients needing surgery for these conditions.

Background: Lumbar disc herniation is a common cause of lower back and radicular pain, often necessitating surgical intervention when conservative treatments fail. Traditional lumbar discectomy (TLD) is widely practiced and involves the removal of the herniated disc fragment to relieve nerve root compression. However, concerns remain about postoperative segmental instability, recurrent disc herniation and long-term degenerative changes. The effectiveness of cage-assisted discectomy in improving clinical outcomes, reducing recurrence and maintaining spinal alignment remains an area of ongoing debate. Objectives: 1- To compare postoperative pain relief between traditional lumbar discectomy and lumbar discectomy with cage fixation. Methodology: This prospective, comparative study was conducted over a 24-month period from January 2023 to December 2024 at Sughra Shafi Medical Complex Narowal. A total of 80 patients diagnosed with single-level lumbar disc herniation, refractory to at least six weeks of conservative management were enrolled and equally divided into two groups: Group A (n = 40) Underwent traditional lumbar discectomy (TLD) and Group B (n = 40) Underwent lumbar discectomy with interbody cage fixation (LDCF). Data were analyzed using appropriate statistical tests, with p &lt; 0.05 considered statistically significant. Results: A total of 80 patients were included in the study, with 40 undergoing traditional lumbar discectomy (Group A) and 40 undergoing lumbar discectomy with cage fixation (Group B). The demographic characteristics, including age, sex distribution, and baseline clinical parameters, were comparable between the two groups, with no statistically significant differences (p &gt; 0.05). Postoperative pain relief, as measured by the Visual Analogue Scale (VAS) and Oswestry Disability Index and showed a statistically significant improvement in both groups Conclusion: Lumbar discectomy with cage fixation offers superior outcomes in terms of pain relief, functional recovery, and spinal stability when compared to traditional discectomy alone. Although the procedure involves longer operative time and higher initial cost, the benefits of reduced recurrence and better long-term outcomes make it a valuable surgical option, particularly in patients at risk of instability. However careful patient selection and surgical expertise are essential to maximize benefits and minimize complications.

ObjectiveTo evaluate the early clinical effect of percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery in the treatment of middle-aged and elderly patients with single-level lumbar disc herniation accompanied by lumbar instability.MethodsFrom January 2019 to June 2020, a total of 82 consecutive patients were categorised into PE-TLIF group and MIS-TLIF group based on different surgical methods. The visual analog scale (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, perioperative objective serological index, operation time, intraoperative blood loss, time to back to work or normal life, and Modified MacNab score were used as the evaluation indexes. The differences between the two groups were analyzed and the clinical effects were compared.ResultsThe VAS back pain of PE-TLIF group was decreased compared to that of MIS-TLIF group in the postoperative 1 week and 1 month. The operative time in PE-TLIF group was obviously longer than that in MIS-TLIF group. The hospital stay was significantly shorter in PE-TLIF group than that in MIS-TLIF group. More intraoperative blood loss and postoperative drainage were recorded in MIS-TLIF group. Compared with MIS-TLIF, PE-TLIF surgery was associated with a shorter time to ambulation after surgery and a shorter time to back to work or normal life. Significant statistical differences were observed in IL-6, CRP, and CK on postoperative 3 days between the two groups.ConclusionFor middle-aged and elderly patients, PE-TLIF and MIS-TLIF surgery both have obvious clinical efficacy and safety. However, with less intraoperative blood loss, shorter recovery time and less injury to the patients, people undergoing PE-TLIF surgery can return to work or normal life faster. It is speculated that PE-TLIF has a higher incidence of complications and recurrence rate than that MIS-TLIF. PE-TLIF may be a better choice for middle-aged and elderly patients with single-level lumbar disc herniation.

The impact of endplate changes, such as Modic changes (MCs), on symptoms following discectomy remains uncertain. This study aimed to investigate the postoperative progression of MCs and bony endplate defects after discectomy for lumbar disc herniation (LDH) and to elucidate its association with clinical outcomes. A total of 247 patients who underwent microscopic discectomy were included. The natural progression of MCs and bony endplate defects at the operated level were assessed using magnetic resonance imaging. Clinical outcomes were evaluated using a visual analog scale (VAS) and the Roland-Morris Disability Questionnaire. The study examined the progression of endplate changes and their impact on clinical outcomes, with a focus on the type of postoperative MC. The natural progression of postoperative MCs was varied, with MCs coexisting with bony endplate defects (p < 0.001). Persistent or converted type 1-related MCs were more likely to exacerbate pre-existing signal changes at one year and were associated with higher VAS scores for low back pain (LBP) compared to type 2 MCs (p < 0.001). Patients with type 1-related MCs (β: 0.429, p < 0.001) and preoperative LBP (β: 0.215, p = 0.025) were closely associated with residual LBP at one year or more. In patients with baseline signal changes in subchondral bone marrow, the presence of type 1 MCs was more likely to promote the increase of MCs than type 2. Furthermore, the presence of type 1 MCs may predict residual postoperative LBP, suggesting that bone marrow signal changes are more strongly associated with clinical symptoms than morphological changes in bony endplates in patients with LDH.

Lumbar disc herniation (LDH) remains a leading cause of radicular pain and disability worldwide. 1Despite the familiarity of this condition in clinical practice, persistent challenges continue to affect patient management: variable symptom severity despite similar imaging findings, unpredictable rates of spontaneous resorption, and heterogeneous outcomes following both conservative and surgical treatments. 2 Current clinical approaches still rely primarily on history, physical examination, and magnetic resonance imaging evidence of neural compression.However, these methods alone often fail to fully explain prognosis or guide optimal timing for intervention. 3,4As a result, the field is increasingly moving toward integrated and predictive models of care, combining morphology with biological, biomechanical, psychosocial, and technological insights.This Special Issue addresses these challenges by integrating evidence across several complementary domains: Natural history and spontaneous resorption: Improved understanding of when and how disc herniation resorption occurs provides a biological rationale for conservative management in selected patients and highlights imaging and inflammatory mechanisms underlying disc regression. Biomechanics and mechanobiology: Advances in the biomechanical characterization of disc injury are clarifying how mechanical loading, tissue failure patterns, and cellular responses interact to drive herniation, degeneration, and regenerative potential. Risk stratification and recurrence prediction: Systematic evidence on preoperative clinical and radiographic risk factors offers critical insight into predictors of recurrent LDH, supporting more informed surgical decision-making and follow-up strategies. Emerging molecular biomarkers: Circulating inflammatory and molecular signatures are opening new avenues for patient stratification, outcome prediction, and the future development of biologically informed therapies. Microbiome and the gut-spine axis: Growing evidence suggests that gut microbiota may influence systemic inflammation, pain modulation, and disc degeneration, introducing a novel biological dimension to LDH pathophysiology. Optimization of surgical techniques: Comparative analyses of surgical approaches, including the expanding role of endoscopic discectomy, reflect the ongoing evolution toward Neurospine

Introduction Low back pain is the world's most disabling condition. Modic changes (MC) are associated with low back pain. These changes are spinal phenotypes that represent vertebral endplate and adjacent marrow changes on MRI. MC are classified into three main types (type I, type II, and type III) and mixed types (type I/II and II/III). Due to methodological biases in previous studies, the morphology, involvement of MC, and their association with other spinal phenotypes remain speculative. As such, the aim of this study was to evaluate the relationship of MC with other spinal MRI phenotypes in a large-scale population-based study. Materials and Methods Based on the Hong Kong Disc Degeneration Cohort of Southern Chinese, we assessed the T1- and T2-weighted MRIs of 1,604 subjects (62.4% females; mean age: 49 years) from L1 to S1. The MC assessment included the presence, type, vertical height, and axial area of MC. MC were evaluated as type I, type I/II, type II, type II/III, and type III. Types were regrouped in the analyses as “type I” (types I and I/II) and “type II” (types II and II/III). Very small MC, such as MC in only one sagittal plane, were excluded. Additional imaging phenotype findings were assessed (disc bulges/extrusions, Schmorl nodes, disc degeneration). Disc degeneration was based on the Pfirrmann classification. A degenerative disc disease (DDD) score was tabulated, which represented the global severity of disc degeneration of the lumbar spine. The lumbar spine was further stratified to upper (L1-L4) and lower (L4-S1) regions. Results The prevalence of MC was 24.7% (“type I”: 6.3%, “type II”: 15.5%). Of all MC, 77% were at L4-S1. Subjects with MC were older (mean age: 53 vs. 48 years, p &lt; 0.001) and had higher DDD scores ( p &lt; 0.001). “Type I” MC were more common at lower lumbar levels ( p = 0.021), were less likely to be located only in the anterior region ( p = 0.017), and were more associated with disc bulges/extrusions ( p &lt; 0.001) in comparison to “type II” MC. MC of the lower lumbar levels were not commonly noted only in the anterior region, involved more likely only the left or right endplate and had a higher prevalence of disc bulges/extrusions and disc degeneration in comparison to upper lumbar levels ( p &lt; 0.001). Large MC (≥2/3 of the axial area) were more likely located at lower lumbar levels (83 vs. 73%, p = 0.001) and had a higher prevalence of disc bulge/extrusion (83 vs. 72%, p = 0.001) and Schmorl node at the affected level (52 vs. 39%, p &lt; 0.001) compared with smaller MC. Conclusion Based on one of the largest population-based studies, our findings strengthen the belief that MC are clearly associated with disc pathology, such as disc degeneration, disc bulges/extrusions, and endplate abnormalities (e.g., Schmorl nodes). MC type- and level-related findings in relation to additional MRI phenotypes were also identified. This study further refines the phenotypic classification of MC, which if standardized can have immense utility in studies assessing the role of biomarkers (e.g., genetics) in relation to clinically relevant spinal changes. Acknowledgments The study has been supported by AOSpine Research Network Exchange Award. Disclosure of Interest None declared

Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work (with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry unto itself. Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed surgically and to compare the results of different surgeries performed. Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or impending cauda equina syndrome. Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 % patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic discectomy. L4-L5 level was the most common level to get involved. Mean Pre operative VAS score for male patients was 6.64 and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean Pre operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95 and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed. Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures. We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient satisfaction was high, and a cost savings was realized. Keywords: Degenerative, Lumbar Spine, Disc Surgeries, Microscopic Discectomy, Laminectomy, Decompression