Risk factors and clinical significance of posterior slip of the proximal vertebral body after lower lumbar fusion

BACKGROUND Adjacent segment disease(ASD)after fusion surgery is frequently manifests as a cranial segment instability,disc herniation,spinal canal stenosis,spondylolisthesis or retrolisthesis.The risk factors and mechanisms of ASD have been widely discussed but never clearly defined.AIM To investigate the risk factors and clinical significance of retrograde movement of the proximal vertebral body after lower lumbar fusion.METHODS This was a retrospective analysis of the clinical data of patients who underwent transforaminal lumbar interbody fusion surgery between September 2015 and July 2021 and who were followed up for more than 2 years.Ninety-one patients with degenerative lumbar diseases were included(22 males and 69 females),with an average age of 52.3 years(40-73 years).According to whether there was retrograde movement of the adjacent vertebral body on postoperative X-rays,the patients were divided into retrograde and nonretrograde groups.The sagittal parameters of the spine and pelvis were evaluated before surgery,after surgery,and at the final follow-up.At the same time,the Oswestry Disability Index(ODI)and Visual Analogue Scale(VAS)were used to evaluate the patients’quality of life.RESULTS Nineteen patients(20.9%)who experienced retrograde movement of proximal adjacent segments were included in this study.The pelvic incidence(PI)of the patients in the retrograde group were significantly higher than those of the patients in the nonretrograde group before surgery,after surgery and at the final follow-up(P<0.05).There was no significant difference in lumbar lordosis(LL)between the two groups before the operation,but LL in the retrograde group was significantly greater than that in the nonretrograde group postoperatively and at the final follow-up.No significant differences were detected in terms of the|PI–LL|,and there was no significant difference in the preoperative lordosis distribution index(LDI)between the two groups.The LDIs of the retrograde group were 68.1%±11.5%and 67.2%±11.9%,respectively,which were significantly lower than those of the nonretrograde group(75.7%±10.4%and 74.3%±9.4%,respectively)(P<0.05).Moreover,the patients in the retrograde group had a greater incidence of a LDI<50%than those in the nonretrograde group(P<0.05).There were no significant differences in the ODI or VAS scores between the two groups before the operation,but the ODI and VAS scores in the retrograde group were significantly worse than those in the nonretrograde group after the operation and at the last follow-up,(P<0.05).CONCLUSION The incidence of posterior slippage after lower lumbar fusion was approximately 20.9%.The risk factors are related to a higher PI and distribution of lumbar lordosis.When a patient has a high PI and insufficient reconstruction of the lower lumbar spine,adjacent segment compensation via posterior vertebral body slippage is one of the factors that significantly affects surgical outcomes.

EFFECT OF ACUPUNCTURE ON POST-OPERATIVE FUNCTIONAL RECOV-ERY IN PATIENTS WITH LUMBAR INTERVERTEBRAL DISC PROTRUSION

Objective To observe the influence of acupuncture on the post-operative rehabilitation in patients undergoing vertebral pulp extraction due to lumbar intervertebral disc protrusion （LIDP） so as to evaluate its efficacy in the treatment of lumbago induced by LIDP. Methods A total of 69 patients undergoing vertebral pulp extraction were randomized into acupuncture group （ n = 35） and control group （ n = 34）. Patients of acupuncture group were treated with routine rehabilitation method and electroacupuncture （EA） stimulation on Zhìbiān （秩边 BL54） and Wěizhōng （委中 BL40）, acupuncture on Shènshū （ 肾俞 BL23）, Dàchángshū （大肠俞 BL25）, BL54, BL40, Jiájǐ （夹脊 EX-B 2）, Shàngliáo （上髎 BL31）, etc., and cupping on BL40, with 15 days being a therapeutic course and for average 7. 36 courses. Patients of control group were treated with simple rehabilitation method. Functional recovery state was judged before and after surgery by using the standards of Japanese Orthopedic Association （JOA）. Results The average recovery rates of 3 months, 6 months and one year after surgery were 49.93% ,90.31% and 95.08% separately in acupuncture group, and 26.24% ,63.42% and 71.36% successively in control group. The recovery rates of acupuncture group were significantly higher than those of control group at the same time-points （P〈0. 05）. Conclusion Acupuncture has a definite effect on promoting post-operative functional recovery in LIDP patients undergoing vertebral pulp extraction and spinal fusion.

Methods of predicting vertebral body fractures of the lumbar spine

Lumbar vertebral body(VB) fractures are increasingly common in an ageing population that is at greater risk of osteoporosis and metastasis. This review aims to identify different models, as alternatives to bone mineral density(BMD), which may be applied in order to predict VB failure load and fracture risk. The most representative models are those that take account of normal spinal kinetics and assess the contribution of the cortical shell to vertebral strength. Overall, predictive models for VB fracture risk should encompass a range of important parameters including BMD, geometric measures and patient-specific factors. As interventions like vertebroplasty increase in popularity for VB fracture treatment and prevention, such models are likely to play a significant role in the clinical decision-making process. More biomechanical research is required, however, to reduce the risks of post-operative adjacent VB fractures.

Apparent diffusion coefficient in normal and abnormal pattern of intervertebral lumbar discs: initial experience

The aim of the present study was to compare the relationship of morphologically defined non-bulging/herni-ated, bulging and herniated intervertebral lumbar discs with quantitative apparent diffusion coefficient （ADC）. Thirty-two healthy volunteers and 28 patients with back pain or sciatica were examined by MRI. All intervertebral lumbar discs from L1 to S1 were classified according to morphological abnormality and degenerated grades. The ADC values of nucleus pulposus （NP） were measured and recorded. The significant differences about mean ADC values of NP were found between non-bulging/herniated discs and bulging discs as well as herniated discs （P 0.05）, whereas there were no significant differences in ADC values between bulging and herniated discs （P 0.05）. Moreover, statistically significant relationship was found in the mean ADC values of NP between ＂non-bulging/herniated and non-degenerated discs＂ and ＂non-bulging/herniated degenerated discs＂ as well as herniated discs （P 0.05）. Linear regression analysis between ADC value and disc level revealed an inverse correlation （r = -0.18）. The ADC map of the NP is a potentially useful tool for the quantitative assessment of componential and molecular alterations accompanied with lumbar disc abnormalities.

CLINICAL OBSERVATION ON THE THERAPEUTIC EFFECT OF ACUPUNCTURE PLUS ATOMIZED HERBAL MEDICINE IN THE TREATMENT OF LUMBAR INTERVERTEBRAL DISC PROTRUSION

Objective To observe the therapeutic effect of acupuncture combined with atomized herbal medicine in the treatment of protrusion of lumbar intervertebral disc. Methods A total of 211 patients with lumbar intervertebral disc protrusion were randomized into two groups, with 106 cases being in trealment group and 105 in control group. The treatment was given once everyday, 12 days as one course of treatment. After two courses of treatment, the results were analyzed. Results The curative rate was 97.1% in the treatment group and 81.0% in the control group. Conclusion Acupuncture together with herbal medicine for the protrusion of lumbar intervetebral disc was better in effect than acupuncture only.

Full-endoscopic spine surgery treatment of lumbar foraminal stenosis after osteoporotic vertebral compression fractures:A case report

BACKGROUND Few reports have described lumbar foraminal stenosis-induced radiculopathy after treatment by full-endoscopic spine surgery(FESS)combined with percutaneous vertebroplasty(PVP)in patients with vertebral compression fractures.We herein report such a case,including the patient’s treatment process and doctor’s surgical experience.CASE SUMMARY A 79-year-old man presented with symptoms of radiculopathy after sustaining L4 vertebral compression fractures.Imaging and physical examination revealed L4 vertebral compression fractures combined with L3/4 Lumbar foraminal stenosis(LFS).The patient’s symptoms were low back pain with pain in the lateral left leg.Although many reports have described radiculopathy induced by osteoporotic vertebral compression fractures,the use of FESS combined with PVP has rarely been reported.This case report indicates that the combination of FESS and PVP is a safe and effective approach for the treatment of LFS-induced radiculopathy after vertebral compression fractures.This minimally invasive technique has great potential to replace traditional lumbar fixation and decompression surgery.Thus,we suggest the continued accumulation of similar cases to discuss the wider application of FESS.CONCLUSION For patients with osteoporotic vertebral compression fracture(OVCF)and LFS,PVP and FESS can be used to restore the vertebral height and reduce the pressure around the intervertebral foramen.Additionally,the combination of FESS and PVP can treat the pain or numbness of the low back and lower limbs and allow for recovery in a short time with excellent postoperative effects.In general,FESS is a good treatment for radiculopathy caused by foraminal stenosis after OVCF.

Age- and direction-related adaptations of lumbar vertebral trabecular bone with respect to apparent stiffness and tissue level stress distribution

The objective of this study was to study the age-related adaptation of lumbar vertebral trabecular bone at the apparent level, as well as the tissue level in three orthogonal directions. Ninety trabecular specimens were obtained from six normal L4 vertebral bodies of six male cadavers in two age groups, three aged 62 years and three aged 69 years, and were scanned using a high-resolution micro-computed tomography （micro-CT） system, then converted to micro- finite element models to do micro-finite element analyses. The relationship between apparent stiffness and bone volume fraction, and the tissue level yon Mises stress distribution for each trabecular specimen when compressed separately in the longitudinal direction, medial-lateral and anterior-posterior directions （transverse directions） were derived and compared between two age groups. The results showed that at the apparent level, trabecular bones from 69-year group had stiffer bone structure relative to their volume fractions in all three directions, and in both age groups, changes in bone volume fraction could explain more variations in apparent stiffness in the longitudinal direction than the transverse directions; at the tissue level, aging had little effect on the tissue von Mises stress distributions for the compressions in all the three directions. The novelty of the present study was that it provided quantitative assessments on the age and direction- related adaptation of Chinese male lumbar vertebral trabecular bone from two different levels： stiffness at the apparent level and stress distribution at the tissue level. It may help to understand the failure mechanisms and fracture risks of vertebral body associated with aging and direction for the prevention of fracture risks in elder individuals.

Three dimensional digital measurement of the facet joint in normal and lumbar intervertebral disc herniation aged 13-18 years

To find out the normal lumbar facet joints between 13 and 18 years old,in order to provide anatomical basis for early diagnosis and therapy of lumbar disc herniation.CT imagings of 32 subjects with lumbar disc herniation aged from 13 to 18 years old in Inner Mongolia have been collected as the ALDH group,and 62 healthy subjects in the equal period had been chosen as the normal group.Continuous scanning lumbar tomography pix were imported into Mimics 21.0 for evaluation and size in DICOM format.

Relationship between Facet Joint Asymmetry and Adjacent Intervertebral Disc Degeneration in Lumbar Disc Herniation

Objective: To analyze the relationship between facet joint asymmetry and adjacent intervertebral disc degeneration in lumbar disc herniation. Methods: Fifty patients with L4/5 lumbar disc herniation were enrolled in the study. All patients underwent lumbar MRI examination, to compare the facet asymmetry of lumbar disc herniation and the degeneration of cartilage endplate and intervertebral disc of adjacent segments, and analyze the relationship between them. Results: There was no significant correlation between L4/5 facet asymmetry and L5/S1 intervertebral disc degeneration score and cartilage endplate degeneration score (P > 0.05). L4/5 facet asymmetry was significantly correlated with L3/4 disc degeneration score (P < 0.01), but not with cartilage endplate degeneration score (P > 0.05). Conclusion: There was a positive correlation between the facet joint angle of lumbar disc herniation and the degeneration of upper proximal segment intervertebral disc. Early correction of lumbar facet angle asymmetry can provide beneficial guidance for further prevention and treatment.

CLINICAL OBSERVATION ON THE THERAPEUTIC EFFECT OF ACUPUNCTURE PLUS MANUAL REPOSITION FOR TREATMENT OF ACUTE LUMBAR VERTEBRAL ARTICULAR DYSKINESIA

Objective: To observe the therapeutic effect of acupuncture plus manual reposition for treatment of acute lumbar vertebral articular dyskinesia for choosing a better remedy. Methods: 66 cases of acute lumbar vertebral articular dyskinesia were randomly divided into acupuncture plus manual reposition group (treatment group, n=33) and routine manual reposition group (control group, n=33). Yaotong point was punctured, when, the patient was asked to move his or her waist simultaneously. Results: After one session of treatment, of the two 33 cases in treatment and control groups, 28 (84.85%) and 20 (60.61%) were cured, 4 (12.12%) and 9 (27.27%) were improved, and 1 (3.03%) and 4 (12.12%) failed in the treatment. The therapeutic effect of treatment group was significantly superior to that of control group (P<0.05). Conclusion: Acupuncture combined with manual reposition is apparently superior to simple routine manual reposition in relieving acute lumbar vertebral articular dyskinesia.

Treatment of Protrusion of the Lumbar Intervertebral Disc by TCM Massage

Protrusion of the lumbar intervertebral disc is a common disorder frequently encountered in clinic. With TCM massage and the maneuver of manual reduction, we have treated 82 cases of protrusion of the lumbar intervertebral disc, with satisfactory therapeutic results reported in the following.……

Tuina Therapy of Lumbar Intervertebral Disc Protrusion

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Epidural fat distribution patterns in patients with lumbar intervertebral disc protrusion

Objective： To investigate epidural fat distribution patterns in patients with lumbar intervertebral disc protrusion. Methods： Medical records were selected randomly from 30 patients whose diagnoses were consistent with the inclusion criteria of the study. Thickness of bilateral fat, the longest length of posterior fat, thickness of bilateral yellow ligament and the hernial distance of lumbar discs were measured by MRI at L3/L4, L4/L5 and L5/S 1 levels. According to clinical symptoms of lumbar intervertebral disc protrusion, the patients were divided into two groups at all space levels. All data were analyzed by statistical software. Results： The longest length of posterior epidural fat at the symptomatic levels was shorter than that at the non-symptomatic levels in each disc space. The symptomatic levels had no effect on the whole thickness of the lateral fat and lateral yellow ligaments. Conclusion： Epidural fat distribution in patients with lumbar intcrvertebral disc protrusion is different from that in normal adults. It is affected by the hernial distance of lumbar discs. The diagnostic criteria for spinal epidural lipomatosis in normal adults may therefore prove to be inappropriate for patients with lumbar intervertebral disc protrusion.

Treatment of Protrusion of Lumbar Intervertebral Disc by Pulling and Turning Manipulations

The authors treated 62 cases of protrusion oflumbar intervertebral disc by pulling and turningmanipulations from February 1993 to February 1998.Another 50 cases were treated by traction as controls.Statistical data showed that pulling and turningmanipulations had much better therapeuticeffectiveness than traction(P<0.05).

CLINICAL OBSERVATION ON LUMBAR INTERVERTEBRAL DISC HERNIATION TREATED BY TRACTION COMBINED WITH ACUPUNCTURE

Objective: To observe the therapeutic effect of traction combined with acupuncture on lumbar intervertebral disc herniation (LIDH). Methods:Eighty-three patients diagnosed as LIDH were randomly divided into treatment group (n=42)and control group (n=41). In the treatment group, besides lumbar traction, electroacupuncture at Jiaji (EX-B 2, L 3～5), Shenshu (BL 23), Qihai (CV 6), Mingmen (GV 4), Huantiao (GB 30), Chengshan (BL 57) and Yanglingquan (GB 34) was added. In the control group, only lumbar traction was applied. Results: In treatment group, the cure plus markedly effective rate was 80.95% with a total effective rate of 92.86%, while in control group, it was 39.02% with a total effective rate of 80.48%. The therapeutic effect in the treatment group was obviously better than that in the control group (P<0.001). Conclusion: Lumbar traction plus EA can effectively alleviate or even eliminate clinical symptoms and signs of lumbar intervertebral disc herniation.

Applied anatomy of intrusive operations of lumbar intervertebral foramen

Objective:To provide anatomical datum for intrusive operations of lumbar intervertebral foramen,especially that using acupuncture-knife as intrusive tool.Methods:To dissect 10 antisepsis cadavers and observe the exposed blood vessels,ligaments,nerves and their adjacent relations in L1/2~L5/S1intervertebral foramen.Results:Lumbar intervertebral foramen exit zones were almost sealed by nerves and blood vessels.There were two zones with relatively no blood vessel and nerve(triangular working zones)located in the midpoint of the distance between two adjacent roots of transverse processus,and clung to lamina of vertebral arch,and they were also found upon the margo superior of the root of transverse processus,but the ascending lumbar vein or(and)the rami anastomoticus between the remi inferior of intervertebral vein and lumbar veins were observed in 12%triangular working zones upon the margo superior of root of transverse processus.Conclusions:"Triangular working zone"was relatively avascular zone.Pay attention to the possibilty of presence of blood vessels on the entrance passage of intrusive operations on lumbar side rear.The needlepoint should be pierced at the midpoint of the distance between two adjacent roots of transverse processus and cling to the outer edge of lamina of vertebral arch when doing the foraminal lumbar puncture.As lumbar intervertebral foramina exit zone was almost sealed by nerves and blood vessels,blind incising and debonding with acupuncture-knife in this area was relatively much more dangerous.

CLINICAL OBSERVATION ON ELECTRO-ACUPUNCTURE TREATMENT OF 51 CASES OF PROTRUSION OF LUMBAR INTERVERTEBRAL DISC

Through electroacupuncture(EA) treatment of 51 cases of protrusion of lumbar interver-tebral disc, it was further demonstrated that the specific action and characteristics of Siyao and Wuyao acupoints were significant and elucidated by using some objective indexes and obvious therapeutic ef-fect, which lays a foundation for the development, research, popularization and application of shu-point and provides an effective and practicable way for treatment of lumbar intervertebral disc.

INNERVATION OF SENSORY NERVE TERMINALS IN RAT LUMBAR INTERVERTEBRAL DISC AND POSTERIOR LONGITUDINAL LIGAMENT

Objective To investigate the distribution of sensory nerve terminals in the lumbar intervertebral disc and posterior longitudinal ligament (PLL) in an animal model. Methods Immunohistochemical method was used to visualize nerve terminals with antibodies of substance P(SP) and calcitonin gene-related peptide(CGRP), and to characterize sensory nerve terminals on sections from lumbar intervertebral disc and posterior longitudinal ligament(PLL) of the Sprague Dawley rats.Results The immunostaining revealed an extensive distribution of SP and CGRP immunoreactive nerve fibers in the surface and most superficial portions of all annulus fibrosus and PLL. Most immunoreactions were observed in ventral and lateral regions of the annulus fibrosus. Morphologically, both thin varicose nerve fibers and tiny punctate nerve terminals could be observed. Conclusion This study demonstrates an extensive distribution of SP and CGRP immunoreactive nerve fibers throughout the PLL and the peripheral annulus fibrosus and provides an illustration of this distribution. This finding supports a role for the disc as a source of low back pain and provides the neuroanatomic foundation of the disc-genic pain.

Isolation of <i>Gemella morbillorum</i>in Herniated Intervertebral Disc Tissue in a Lumbar Discectomy Patient: A Case Report

Back pain associated with lumbar disc herniation is a common musculoskeletal disorder that leads to absence at work place worldwide. Studies have proven in addition to the traditional factors, microbes play a role in disc herniation causing chronic back pain. A 34-year-old male who has not involved in any traumatic work but has a family history of disc herniation presented with lower back pain and numbness in his right leg. He had previously undergone lumbar discectomy at L4/L5 ten years back. Magnetic Resonance Imaging (MRI) showed L5/S1 right para central disc herniation impinging on the right S1 and S2 nerve roots. Standard protocols for disinfection of instruments, external skin and all transport media were adhered. Skin scrapings, muscle biopsy and excised disc tissue were obtained for anaerobic and aerobic bacterial cultures. Anaerobic microbial cultures of excised disc tissue following lumbar discectomy showed Gram positive growth. Further anaerobic isolation carried out using RapID ANA ID kit confirmed the growth as Gemella morbillorum. In addition, neither of the control samples (muscle nor skin) had any anaerobic growth indicating the absence of contamination. Aerobic bacterial growth was not present in the skin, muscles and disc cultures. The study findings add to the available literature, on the role of microorganisms in lumbar disc herniation and future treatment regimens with antibiotics.

Comparison of pain media and inflammatory factors after percutaneous transforaminal endoscopic discectomy and traditional fenestration operation treatment of protrusion of lumbar intervertebral disc

Objective:To compare the differences in pain mediators and inflammatory factors after percutaneous transforaminal endoscopic discectomy and traditional fenestration operation treatment of protrusion of lumbar intervertebral disc. Methods:80 patients with protrusion of lumbar intervertebral disc treated in our hospital between March 2013 and December 2015 were collected and divided into observation group and control group (n=40) according to randomized parallel contrast. Control group received traditional fenestration operation and observation group received percutaneous transforaminal endoscopic discectomy. Before operation and 1 week after operation, fluorescence spectrophotometry was used to determine serum pain medium levels;ELISA was used to determine pro-inflammatory factor and anti-inflammatory factor levels. Results:Before operation, differences in serum pain medium and inflammatory factor levels were not statistically significant between two groups (P>0.05). 1 week after operation, serum pain media norepinephrine (NE), dopamine (DA), 5-hydroxytryptamine (5-HT), prostaglandin E2 (PGE2) and substance P (SP) levels as well as pro-inflammatory factors interleukin-1β(IL-1β), interleukin-6 (IL-6), interleukin-18 (IL-18) and tumor necrosis factor alpha (TNF-α) levels of observation group were lower than those of control group (P<0.05) while serum anti-inflammatory factors interleukin-4 (IL-4), interleukin 10 (IL-10), soluble tumor necrosis factor receptor I (sTNF-RI) levels were higher than those of control group (P<0.05). Conclusions:Percutaneous transforaminal endoscopic discectomy can effectively treat protrusion of lumbar intervertebral disc and is more advantageous in alleviating patients’ perception of pain and reducing inflammation.