Osteolytic Lumbar Discal Cyst -Case Report-

Study 1. The Roles of IL-19, IL-20 on Intervertebral Disc Herniation and Degenerative Lumbar Spondylolisthesis The inflammatory reaction after intervertebral disc herniation (HIVD) was considered as the major cause of low back pain and sciatica. IL-19 and IL-20, members of IL-10 family, are involved in various inflammatory diseases. However, little is known on how IL-19 and IL-20 affect the inflammation, healing process, and degeneration of spine after intervertebral disc injury. We reported the expression of IL-20 and its receptors in the primarily cultured disc cells as well as in human herniated intervertebral disc (HIVD) tissues. Disc cells express IL-20 receptors and are targeted by IL-20. In vitro, IL-1β induced the expression of IL-20, and IL-20 combined with IL-1β induced the expression of various cytokines, chemokines, angiogenetic factors, and matrix metalloproteinases (MMPs) in human disc cells. Therefore, IL-20 together with IL-1β enhances the inflammatory process after disc injury, and IL-20 may contribute to the pathogenesis of HIVD. Degenerative lumbar spondylolisthesis (DLS) results from disc injury, which usually occurs at the L4/L5 level after the facet-joint locking mechanism fails. The etiology of DLS is multifactorial, and includes spinal instability, neurological compromise and inflammation. In clinical practice, symptoms are not well correlated with the severity of degeneration and neural compression on MRIs of patients with DLS. Inflammation may play an important role in the pathogenesis of DLS; however, expression of IL-19 and IL-20 and their pathophysiological function in DLS has not been explored. Thus, we explored if IL-19 and IL-20 were associated with DLS. We found that IL-19, IL-20, IL-20R1 and IL-20R2, TNF-α, IL-1β and MCP-1 were co-localized in tissue samples of degenerated discs, facet joints, and ligamentum flavum retrieved from patients with DLS. The expression of IL-19 and IL-20 is associated with the expression of the inflammatory cytokines, TNF-α and IL-1β and the chemokines, MCP-1 and IL-8. In vitro, IL-19 and IL-20 induced the expression of proinflammatory cytokines, chemokine, and angiogenesis under CoCl2-mimicked hypoxia condition in the primarily cultured human disc cells, which isolated from degenerated disc tissues of patients with DLS. Therefore, IL-19 and IL-20 may contribute to the inflammatory process in discs, facet joints, and the ligamentum flavum in patients with DLS；IL-19 and IL-20 may be involved in the pathogenesis of DLS. Study 2. The in vivo Biological Effects of Intra-discal RhBMP-2 on the Injured Intervertebral Disc RhBMP-2, a potent osteoinductive and chondroinductive factor, has been approved for use in human anterior spinal fusion and can promote cartilage repair. We found that BMP-2 can be expressed in the human herniated disc specimen. However, the in vivo response of intra-discal rhBMP-2 on the injured IVDs is not clear. We found that various degrees of degenerative change around the injured disc space in our rabbit disc injury model. More severe spondylosis, such as spur formation, was found in the groups treated with rhBMP-2. The pathological findings revealed that rhBMP-2 promotes angiogenesis and inflammation after disc injury; which are known as the first two stages of bone incorporation for fusion. Therefore, rhBMP-2 might contribute to the injury response, healing process and subsequent degeneration after disc injury. Study 3. Factors Affecting Disability and Physical Function in Degenerative Lumbar Spondylolisthesis Axially-loaded magnetic resonance image (MRI) is a useful diagnostic tool, enabling detection of dynamic or occult changes of spinal disorders by simulating the upright position under normal gravity and mimicking the condition of axial compression in the lumbar spine. Except the roles of IL-19 and IL-20 in the inflammation process of degenerative lumbar spondylolisthesis (DLS), we aimed to further analyze the critical biomechanical factors responsible for the disability and physical function of patients with DLS using axially-loaded MRI, and to investigate the effect of axial loading on the morphology of the spine and the spinal canal. All patients underwent unloaded and axially-loaded MRI. We measured the predictors on MRI, including the differences of disc height (DH), sagittal translation (ST), segmental angulation (SA), and dural sac cross-sectional area (DCSA) at L4-5 between the unloaded and axially-loaded condition, as well as pre-load and post-load lumbar lordotic angles (LLA) at L1-5. We discovered that angular instability is correlated with physical disability and physical function for patients with L4-5 DLS in an axially-loaded magnetic resonance image (MRI); the post-load lumbar lordotic curve angle is also well correlated with physical function for patients with L4-5 DLS. Segmental angulation of L4-5 can be a good indicator of disability in patients with L4-5 DLS. In conclusion, we discovered that IL-19, IL-20, and BMP-2 may be the key factors to modulate inflammation, healing process and degeneration of spine after intervertebral disc injury. Besides, we also discovered that angular instability of intervertebral disc is correlated with physical disability and physical function for patients with L4-5 DLS.

Discal cysts are rare intraspinal extradural cysts that communicate with the corresponding intervertebral discs, and the diagnosis is difficult to distinguish from other causes of low back pain and radiculopathy. Optimal management for this type of cyst has not been determined because of its rarity. Here, we report successful treatment of a discal cyst and lumbar disc herniation using full endoscopic surgery in a professional baseball player with a chief complaint of weakness in his left lower leg. He had been treated conservatively but symptoms did not improve. Discography helped us to differentially diagnose discal cyst from other cystic lesions. Conventional surgical treatment would have resulted in considerable loss of baseball playing time for the patient. We opted to perform minimally invasive transforaminal full endoscopic surgery under local anesthesia to treat the discal cyst and lumbar disc herniation simultaneously without resection of bone and ligament handling. We removed the discal cyst and disc herniation, which released tension on the left nerve root at the L5 level, and then performed thermal annuloplasty to avoid recurrence. Postoperative course was good and he returned to play baseball at his original competitive level 3 months later. To our knowledge, there have been no previous reports of successful full endoscopic surgery for discal cyst and lumbar disc herniation performed simultaneously in a professional baseball player. It can be difficult to decide on the proper treatment for discal cysts, but full endoscopic surgery for symptomatic discal cyst might be one good option especially for elite athletes.

Objective To discuss diagnosis and anterior surgical treatment of hyperextensian cervical spine injury combined with intervertebral disk injury. Methods A retrospective study was done on clinical data of 27 patients who suffered from hyperextension cervical spine injury combined with intervertebral disk injury to analyze their age distribution, clinical symptomes, X-ray and MRi manifesta-tions and perioperative intervertebral disk injury. All patients were treated with discectomy, strut bone grafting within vertebral bodies and internal fixation with titanium plate. The clinical outcomes were evalu-ated by using Frankel scale and ASIA motor score (AMS). Results Both MRI and X-ray detected following abnormal pathological changes in all patients: rupture of anterior longitudinal ligament, horizon-tal tear of disk, intervertebral disk hernia, compression and edema of spinal cord. The follow-up lasted for 9-32 months (average 17.5 months), which showed that all patients got improvement for 1-3 scales except that one patient with Frankel A had no improvement in neurological function. Compared with AMS on admission, both AMS at two months after surgery and at final follow-up was increased significantly, with recovery rate of AMS for 44.9% and 68.1%, respectively. There found no hardware related compli-cations such as implant loosening, defluxion or breakage. Bone fusion was found in all fixation segments. Conclusions MRI and X-ray are important examination means for hyperextension cervical spine injury combined with intervertebral disk injury. On a specified diagnosis, anterior surgical treatment should be done early and can get satisfactory recovery of spinal cord function. Key words: Spinal cord injury; Cervical spine; Intervertebral disk; Diagnosis,computer-assisted

Discal cyst is a lumbar intraspinal cyst communicating with intervertebral disc, and previously reported series described the wall of these cysts as consisting of dense fibrous connective tissue. We report a 29-year-old Japanese male with discal cyst showing unusual histological features. Clinical symptoms in the current case as well as imaging features including discography were similar to those previously reported. However, the wall of the cyst consisted of disc material with myxoid degeneration. In addition, apoptosis of chondrocytes was diffusely observed in the herniated disc material. The current case was considered a histological variant of discal cyst. Myxoid degeneration of herniated disc material with diffuse apoptotic change of chondrocytes was probably associated with the formation of discal cyst.Intraspinal cysts with a distinct connection to the corresponding intervertebral disc has been called discal cyst [1]. To clarify the location of this lesion, Coscia and Broshears in 2002 introduced the term “intracanalicular discal cyst” [2]. In the largest series of this condition, Chiba et al. reported that the wall of the discal cyst consisted of dense fibrous connective tissue [1]. We recently encountered a case showing typical clinical and imaging features of discal cyst, but its histological findings differed from those of previous reports. This study describes a case showing unusual histological features of discal cyst, and discusses its pathogenesis. All protocols were accepted by the Institutional Review Board at our institution. Informed consent was obtained from the patient.

To analyze the clinical characteristics of intervertebral disc tissue injury and herniation into the vertebral body in thoracolumbar fracture on fracture healing, vertebral bone defect volume and intervertebral space height. From April 2016 to April 2020, a total of 140 patients with thoracolumbar single vertebral fracture combined with upper intervertebral disc injury treated with pedicle screw rod system reduction and internal fixation in our hospital. There were 83 males and 57 females, aged from 19 to 58 years old, with an average age of (39.33±10.26) years old. All patients were followed up regularly 6 months, 12 months and 18 months after surgery. The patients with injured intervertebral disc tissue not herniated into the fractured vertebral body were the control group, and the patients with injured intervertebral disc and herniated into the fractured vertebral body were the observation group. By detecting the thoracolumbar AP and lateral X-ray films, CT and MRI of the thoracolumbar segment at different follow-up time, calculate the changes of the wedge angle of the fractured vertebral body, the sagittal kyphosis angle and the height of the superior adjacent intervertebral space, the changes of the fracture healing and bone defect volume after the reduction of the vertebral body, and the changes of the intervertebral disc degeneration grade. The prognosis was evaluated by visual analogue scale(VAS) and Oswestry disability index(ODI). Finally, the differences of the above results among different groups were comprehensively analyzed. All the patients had normal wound healing without complications. A total of 87 patients received complete follow-up data, at least 18 months after internal fixation. Thoracolumbar AP and lateral X-ray films showed that 18 months after the reduction and internal fixation operation, the vertebral wedge angle, sagittal kyphosis angle and the height of the upper adjacent intervertebral space in the observation group were greater than those in the control group(P<0.05). CT scanning showed that the deformity of the fracture healed 12 months after the vertebral body reduction in the observation group and formed a "cavity" of bone defect connected with the intervertebral space, and its volume was significantly increased compared with that before (P<0.05). MRI scanning showed that the degeneration rate of injured intervertebral discs in the observation group was more serious than that in the control group 12 months after operation(P<0.05). However, there was no significant difference in VAS and ODI score at each time. Herniation of injured intervertebral disc tissue hernias into the fractured vertebral body leads to increased bone resorption defect volume around the fracture and forms a malunion "cavity" connected with the intervertebral space. This may be the main reason for the change of vertebral wedge angle, the increase of sagittal kyphosis angle and the decrease of intervertebral space height after removal of internal fixation devices.

A rare calcified thrombosis of the dilated epidural venous plexus presenting with lumbar radiculopathy: a case report

The diskal cyst is a relatively new clinical entity and develops clinical symptoms of a unilateral single nerve root lesion. Although many cases of diskal cyst have been reported, the pathogenesis of diskal cyst remains unclear, and several theories regarding the pathogenesis have been proposed. This article presents 2 cases of diskal cyst communicating with an adjacent herniated disk. Magnetic resonance imaging findings showed diskal cysts in the epidural space of the lumbar spine. Surgical resection was performed, and apparent connections between the corresponding disk and cysts were found. Histopathologic examinations of the cyst wall demonstrated cartilaginous tissue including nucleus pulposus and annulus fibrosis. These patient's symptoms improved remarkably postoperatively, and there was no recurrence of diskal cyst.The hypothesis supported by many authors is hemorrhage from the epidural venous plexus. Diskal cysts arise first from an underlying intervertebral disk injury that causes an annulus fibrosis fissure in the posterior intervertebral disk. Hemorrhage from the epidural venous plexus with a rich blood flow then occurs in the space between the peridural membrane and vertebral body. However, in our cases, we confirmed that the diskal cyst could have developed from the resorption process of an intervertebral disk herniation. Only 5 cases of diskal cyst demonstrating the presence of cartilaginous tissue in the cyst have been reported. Our 2 cases are rare and support the hypothesis of resorption of intervertebral disk herniation.

Interleukin‐6 and interleukin‐6 receptor expression, localization, and involvement in pain‐sensing neuron activation in a mouse intervertebral disc injury model

Complex loading affects intervertebral disc mechanics and biology

BackgroundRecently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.ObjectivesIn this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.MethodsIn our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0.9% were injected by a 25-gauge pencil-point Quincke needle at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.ResultsThe mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.ConclusionsSpinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.

Longitudinal case-control animal model. To investigate effects of mesenchymal stem cell (MSC) treatment on multifidus muscle remodeling after intervertebral disc (IVD) lesion. Lesion and degeneration of IVDs cause structural remodeling of the multifidus muscle. Proinflammatory cytokines are thought to contribute. MSC treatment restores IVD health after lesion but its effects on surrounding tissues remains unknown. Using an animal model of IVD degeneration, we assessed the effects of MSC treatment of IVDs on the structural remodeling and cytokine expression within the multifidus muscle. An anterolateral lesion was performed on the L1-2, L3-4, and L5-6 IVDs in sheep. At either 4 (early treatment) or 12 (late treatment) weeks after IVD lesion, MSCs were injected into the lesioned IVD. Multifidus muscle was harvested from L2 (gene expression analysis) and L4 (histological analysis) at 3 or 6 months after IVD lesion and naïve controls for histological analysis of muscle, adipose, and connective tissue cross-sectional areas, and immunohistochemistry to study muscle fiber types. Real-time polymerase chain reactions quantified expression of tumor necrosis factor, interleukin-1β, and transforming growth factor-β1. MSC treatment of IVD lesion prevented the increased adipose and connective tissue cross-sectional area expected after IVD lesion. MSC treatment did not prevent slow-to-fast muscle fiber type transformation. Gene expression of proinflammatory cytokines within the muscle was altered by the MSC treatment of IVD. Increased interleukin-1β expression was prevented in the early treatment group and tumor necrosis factor and transforming growth factor-β1 expression was upregulated at 6 months. Results show that although MSC treatment prevents fatty infiltration and fibrosis of the multifidus muscle after IVD lesion, it cannot prevent a muscle inflammatory response and muscle fiber transformation. These findings highlight the potential role of MSC therapy after IVD injury, but reveals that other interventions may also be necessary to optimize recovery of muscle. 4.

Discal cysts, which lie directly over intervertebral discs, are rare. Two old dogs with tetraparesis were referred to our facility. In both animals, magnetic resonance imaging revealed intraspinal extradural cystic mass lesions that were dorsal to degenerative intervertebral discs at the C3-C4 level. These lesions had low signal intensity on T1-weighted images, and high signal intensity on T2-weighted images. A ventral slot approach was used to perform surgical decompression, after which the symptoms improved remarkably. Discal cysts should be included in the differential diagnosis of dogs with cervical pain and tetraparesis. One effective treatment for discal cysts is surgical intervention.

Intervertebral disc (IVD) is an avascular tissue under hypoxic condition after adulthood. Our previous data showed that inflammatory cytokines (interleukin (IL)-1β), IL-20, and bone morphogenetic protein-2 (BMP-2) play important roles in the healing process after disc injury. In the current study, we investigated whether IL-1β, IL-20, or BMP-2 modulate the expression of pro-inflammatory cytokines, chemotaxis factor, and angiogenesis factor on IVD cells under hypoxia. IVD cells were isolated from patients with intervertebral disc herniation (HIVD) at the levels of L4–5 and L5–S1. We found that the expression of IL-1β, IL-20, BMP-2, hypoxia-inducible factor (HIF)-1α, IL-6, IL-8, angiogenetic factor (vascular endothelial growth factor (VEGF)), chemotactic factor (monocyte chemoattractant protein 1 (MCP-1)), and matrix metalloproteinase-3 (MMP-3) was upregulated in IVD cells under hypoxia conditions. In addition, IL-1β upregulated the expression of pro-inflammatory cytokines (IL-6 and IL-8), VEGF, MCP-1, and disc degradation factor (MMP-3) in IVD cells under hypoxia conditions. IL-20 upregulated MCP-1 and VEGF expression. BMP-2 also upregulated the expression of MCP-1, VEGF, and IL-8 in IVD cells under hypoxia conditions. Treatment with antibody against IL-1β decreased VEGF and MMP-3 expression, while treatment with IL-20 or BMP-2 antibodies decreased MCP-1, VEGF, and MMP-3 expression. Moreover, IL-1β modulated both the expression of IL-20 and BMP-2, but IL-20 only modulated BMP-2 either under a hypoxic or normoxic condition. Therefore, we concluded that the inflammation, chemotaxis, matrix degradation, and angiogenesis after disc herniation are influenced by the hypoxic condition and controlled by IL-1β, IL-20, and BMP-2.

Objective To study the value of T2-mapping in the diagnosis of non-compressive lumbar disc herniation. Methods Seven healthy adult Chinese piglets were scanned with T2-mapping under general anesthesia before injecting 2 ml homogenated nucleus pulposus into one side of intervertebral foramen at the level of L4-5, L5-6 and L6-S1 under CT guidance to induce nerve root inflammation. After 14 days of making model, the pigs were scanned again with T2-mapping used the same method to obtain T2 values of bilateral L5, L6, S1 spinal nerve roots. Finally the T2 values were compared with their contralateral normal nerve roots as well as the ipsilateral nerve root value obtained before induction of inflammation. Results The mean T2 values of bilateral nerve roots were (52.5±1.5) vs (52.1±1.3) respectively. There was no significant difference between the bilateral normal nerve roots (P>0.05) . After induction of inflammation, the mean T2 values of the contralateral nerve roots and the inflamed spinal nerve roots were (51.7±2.0) vs (63.2±2.1) respectively. There was statistical difference (P<0.05) . Pathological finding of the induced nerve root inflammation revealed that there were edema, infiltration of inflammatory cell and damage of the membrane structure. Conclusion The value of T2-mapping can reflect the characteristics of radiculitis caused by nucleus fluid leaked from adjacent disc. Key words: Magnetic resonance imaging; T2-mapping; T2 value; Non-compressive lumbar intervertebral disc herniation

Some reports have been published on clinical features in dogs with early recurrence of type I thoracolumbar intervertebral disk herniation (TL-IVDH), but there is little understanding of the changes involved. This retrospective study describes the clinical features, including radiographic image results at the time of recurrence, of dogs with type I TL-IVDH that had undergone hemilaminectomy but then suffered early recurrence. Our medical records were searched between June 2007 and December 2022. Nine dogs showed deterioration in neurological signs within 4 to 6 weeks after surgery. All nine were Miniature Dachshunds. Radiographic images at initial onset showed calcification at the affected intervertebral disk space in all 9 dogs. Disk herniations at the initial onset were located between T11-12 and L1-2. After the first surgery, neurological function improved in all dogs. Recurrence occurred at the same site as at initial onset in all dogs. No calcification was observed at the affected intervertebral disk space on images at the time of recurrence. The extruded disk materials were surgically removed, and neurological function improved after the second surgery. In conclusion, calcification at the affected disk space at the time of initial onset is indicative of residual nucleus materials not yet fully extruded, and is a risk factor for early recurrence of type I TL-IVDH.