Percutaneous lumbar discectomy: a systematic review / Discectomia percutânea lombar: uma revisão sistemática

Introduction: Low back pain is a clinical condition with a multifactorial etiopathogenesis, which has a high socioeconomic impact, especially in the economically active population, as it is associated with frequent absenteeism and reduced quality of life. Through intervertebral disc degeneration, a progressive instability of the compromised region is observed, triggering a harmful positive feedback mechanism that further promotes intervertebral disc disease. Built by the interaction between the predisposing biopsychosocial components, a multidisciplinary therapeutic proposition is suggested. In persistent low back pain, treatment involves surgical procedures such as Percutaneous Lumbar Discectomy. Objectives: to evaluate the scientific evidence regarding the clinical outcomes and safety of this surgery. Method: systematic review duly registered in Prospero (CRD42022370811), based on the PICOD question, elaborated from a Boolean search in different databases for scientific articles, evaluated and selected in a paired way based on the eligibility criteria. In addition to extracting data related to the proposed objectives, the articles included were evaluated in relation to their level of evidence and strength of recommendation. Results: among the 12 articles included, it was observed that it is a clinically effective and safe procedure. In the set of evidences gathered, they are of high and moderate level of evidence with respective strength of recommendation strong/good and weak/moderate. Conclusion: Percutaneous Lumbar Discectomy promotes significant reduction of pain and increase in body functionality, in addition to preserving local musculoskeletal structures and preventing post-surgical joint instability. It is, therefore, a safe and clinically effective minimally invasive procedure for patients with herniated discs.

Introdução: a lombalgia é uma condição clínica de etiopatogenia multifatorial, que desencadeia um elevado impacto socioeconômico especialmente na população economicamente ativa, por associar-se ao absenteísmo frequente e à redução da qualidade de vida. Observa-se mediante a degeneração do disco intervertebral, uma instabilidade progressiva da região comprometida desencadeando um mecanismo de feedback positivo prejudicial que promove ainda mais a doença do disco intervertebral. Edificada pela interação entre os componentes biopsicossocial predisponentes, sugere-se uma proposição terapêutica multidisciplinar. Na dor lombar persistente o tratamento envolve procedimentos cirúrgicos como a Discectomia Percutânea Lombar. Objetivo: avaliar as evidencias científicas relativas aos desfechos clínicos e à segurança desta cirurgia. Método: revisão sistemática devidamente registrada no Prospero (CRD42022370811), fundamentada na pergunta PICOD acrônimo para Paciente, Intervenção, Comparação, Desfechos (outcomes) e Design, elaborada a partir de busca booleana em diferentes bases de dados por artigos científicos, avaliados e selecionados de forma pareado com base nos critérios de elegibilidade. Além da extração de dados relativos aos objetivos propostos, os artigos incluídos foram avaliados em relação ao respectivo nível de evidencia e força de recomendação. Resultados: dentre os 12 artigos incluídos, observou-se que se trata de um procedimento clinicamente efetivo e seguro. No conjunto de evidencias reunidas são de alto e moderado nível de evidencia com respectiva força de recomendação forte/boa e, fraca/moderada. Conclusão: a Discectomia Percutânea Lombar promove relevante redução da dor e aumento da funcionalidade corporal, além de preservar as estruturas musculoesqueléticas locais e prevenir a instabilidade articular pós-cirúrgica. Trata-se, portanto, de um procedimento minimamente invasivo seguro e clinicamente efetivo para os pacientes portadores de hérnia discal.

Anterior lumbar interbody fusion (alif): epidemiological and radiological profile / Artrodese lombar anterior: perfil epidemiológico, radiológico / Artrodesis lumbar anterior: perfil epidemiológico, radiológico

ABSTRACT: Objective: Evaluate the epidemiological and radiographic data of patients submitted to the Anterior Lumbar Interbody Fusion (ALIF) technique and the possible complications related to this procedure. Methods: A longitudinal and retrospective study was carried out to analyze electronic medical records and image files of patients who underwent spinal surgery using the ALIF technique between February 2019 and January 2021. Epidemiological data such as age, gender, and level of surgery were analyzed. Radiographic evaluations of lumbar lordosis from L1 to S1 were performed using the COBB technique and the anterior and posterior height of the disc space. The presence of intraoperative and postoperative complications in the patients was analyzed. Results: Initially, 70 patients were analyzed. The most prevalent operated level was L5-S1. The length of stay of the patients varied between 36 and 72 hours. Intraoperative bleeding ranged from 20mL to 400mL. Three patients had significant venous lesions. Differences between anterior and posterior lordosis and height measurements were significant (p < 0.001). Lordosis had a mean increase of 10.3°, anterior height had a mean increase of 7.9mm, and posterior height of 4.0mm. Six cases of intra and postoperative complications were observed. Conclusion: The patients showed improvement in the radiological parameters of the anterior and posterior height of the vertebral discs, with a significant increase in lumbar lordosis. Complication rates were 9.8%, and we had a short hospital stay. Level of Evidence II; Retrospective Longitudinal Study.

RESUMO: Objetivo: Avaliar os dados epidemiológicos e radiográficos de pacientes submetidos à técnica de Artrodese Lombar Anterior (ALIF) e avaliar as possíveis complicações relacionadas a este procedimento. Métodos: Realizou-se um estudo longitudinal e retrospectivo com análise dos prontuários eletrônicos e arquivos de imagem dos pacientes submetidos a cirurgia da coluna pela técnica de ALIF, no período entre fevereiro de 2019 e janeiro de 2021. Dados epidemiológicos como idade, sexo e nível de cirurgia foram analisados. Foram feitas avaliações radiográficas da lordose lombar de L1 a S1 através da técnica de COBB e da altura anterior e posterior do espaço discal. Foram analisados a presença de complicações intra e pós-operatórias dos pacientes. Resultados: Foram analisados inicialmente 70 pacientes. O nível operado mais prevalente foi L5-S1. O tempo de internamento dos pacientes variou entre 36 e 72 horas. O sangramento intraoperatório variou de 20mL a 400mL. Três pacientes apresentaram lesões venosas importantes. As diferenças entre as medidas de lordose e altura anterior e posterior foram significativas (p < 0,001). A lordose teve aumento médio de 10,3°, a altura anterior teve aumento médio de 7,9mm e a altura posterior de 4,0mm. Foram observados 06 casos de complicações intra e pós-operatórias. Conclusão: Os pacientes apresentaram melhora nos parâmetros radiológicos de altura anterior e posterior dos discos vertebrais, com um aumento da lordose lombar significativo. As taxas de complicações foram de 9,8 % e tivemos um curto período de internação hospitalar. Nível de Evidência II; Estudo Longitudinal e Retrospectivo.

RESUMEN: Objetivo: Evaluar los datos epidemiológicos y radiográficos de pacientes sometidos a la técnica de Artrodesis Lumbar Anterior (ALIF) y evaluar las posibles complicaciones relacionadas con este procedimiento. Métodos: Se realizó un estudio longitudinal y retrospectivo con análisis de historias clínicas electrónicas y archivos de imágenes de pacientes intervenidos de columna vertebral mediante la técnica ALIF, en el período comprendido entre febrero de 2019 y enero de 2021. Datos epidemiológicos como edad, sexo y nivel quirúrgico fueron analizados. Las evaluaciones radiográficas de la lordosis lumbar de L1 a S1 se realizaron mediante la técnica COBB y la altura anterior y posterior del espacio discal. Se analizó la presencia de complicaciones. Resultados: Se analizaron 70 pacientes. El nivel operado más prevalente fue L5-S1. El tiempo de estancia de los pacientes varió entre 36 y 72 horas. El sangrado intraoperatorio osciló entre 20 ml y 400 ml. Tres pacientes tenían lesiones venosas importantes. Las diferencias entre la lordosis anterior y posterior y las medidas de altura fueron significativas (p < 0,001). La lordosis tuvo un aumento medio de 10,3°, la altura anterior tuvo un aumento medio de 7,9 mm y la altura posterior de 4,0 mm. Se observaron seis casos de complicaciones intra y postoperatorias. Conclusiones: Los pacientes mostraron mejoría en los parámetros radiológicos de altura anterior y posterior de los discos vertebrales, con aumento significativo de la lordosis lumbar. Las tasas de complicaciones fueron del 9,8% y hubo una corta estancia hospitalaria. Nivel de Evidencia II; Estudio Longitudinal y Retrospectivo.

Biomechanical Study on Contiguous Three-Level Cervical Hybrid Surgery and Anterior Cervical Discectomy and Fusion / 医用生物力学

Objective To compare the biomechanical effects of contiguous three-level cervical Hybrid surgery[anterior cervical discectomy and fusion (ACDF) + cervical disc arthroplasty ( CDA)] and three-level ACDF. Methods The finite element model of C1-T1 cervical-thoracic spine was developed based on CT data. Three models were simulated by the implantation of Prestige LP and Zero-P prostheses, including two Hybrid models (AFA, Prestige LP implanted at C3-4 and C5-6 segments and Zero-P implanted at C4-5 segment; FAF, Zero-P implanted at C3-4 and C5-6 segments and Prestige LP implanted at C4-5 segment) and three-level ACDF model(FFF). The changes in range of motion (ROM) of adjacent levels during flexion, extension, lateral bending and axial rotation, the overall ROM, as well as the intradiscal pressure ( IDP) and facet contact force ( FCF) of adjacent levels were compared. Results The ROM in adjacent levels and the overall ROM of the AFA modelwere closer to the intact model, and the maximum increases in the ROM of the adjacent levels for the FAF and FFF models were 15. 0% and 23. 4% , respectively. For AFA, FAF and FFF models, the maximum increases in the maximum IDP of adjacent levels were 19. 0% , 66. 7% , 147. 6% , and the maximum increases in FCF were 17. 4% , 55. 7% , 80. 1% , respectively. Conclusions This study provides biomechanical basis for three-level cervical Hybrid surgery in treating patients with the contiguous three-level cervical degenerative disc disease.

Percutaneous cement discoplasty in the treatment of degenerative disc disease. case series / Cimento discoplastia percutânea no tratamento da doença degenerativa do disco. série de casos / Cemento discoplastia percutánea en el tratamiento de la enfermedad discal degenerativa. serie de casos

ABSTRACT Introduction: Percutaneous cement discoplasty (PCD) is a minimally invasive surgical technique, which provides segmental stabilization and an indirect decompression effect in cases of severe degenerative disc disease with vacuum phenomenon, useful in patients with comorbidities that contraindicate invasive surgical procedures. Materials and methods: A retrospective analysis of 6 patients undergoing PCD was carried out, reporting the demographic variables, the segments treated and the clinical result evaluated by means of the visual analog pain scale (VAS) both in the presurgical and in the 6-month follow-up. Finally, a literature review was carried out. Results: 6 cases of PCD were included, of which 5 had a diagnosis of dyscarthrosis and 1 dyscarthrosis with spondylolisthesis. 4 female and 2 male patients. In 3 patients, PCD was performed in 1 segment and in 3 patients in multiple segments. Regarding the clinical result, an improvement was presented in 5 of the patients (mean 5.6 VAS points), 1 of the patients did not present improvement and required another surgical intervention. Conclusions: PCD is a minimally invasive technique useful in the treatment of spine pain secondary to degenerative disc disease in those patients with comorbidities that contraindicate a major procedure. Indirect foraminal decompression by PCD in one or more segments appears to contribute to pain relief. Level of Evidence III. Series of cases and controls.

RESUMO Introdução: O cimento discoplastia percutânea (PCD) é uma técnica cirúrgica minimamente invasiva, que proporciona estabilização segmentar e efeito descompressivo indireto nos casos de doença discal degenerativa grave com fenômeno de vácuo, útil em pacientes com comorbidades que contra-indicam procedimentos cirúrgicos agressivos. Materiais e métodos: Foi realizada uma análise retrospectiva de seis pacientes submetidos à PCD, relatando as variáveis demográficas, os segmentos tratados e o resultado clínico avaliado por meio da escala visual analógica de dor (EVA) tanto no pré-cirúrgico quanto no de seis meses acompanhamento. Por fim, foi realizada uma revisão da literatura. Resultados: foram incluídos seis casos de PCD, dos quais cinco apresentavam diagnóstico de disartrose e um de disartrose com espondilolistese. Quatro pacientes do sexo feminino e dois do sexo masculino. Em três pacientes, o PCD foi realizado em um segmento e em três pacientes em vários segmentos. Em relação ao resultado clínico, houve melhora em cinco dos pacientes (média 5.6 pontos EVA), um dos pacientes não apresentou melhora e necessitou de nova intervenção cirúrgica. Conclusões: A PCD é uma técnica minimamente invasiva útil no tratamento da dor da coluna secundário à doença degenerativa do disco em pacientes com comorbidades que contra-indicam um procedimento de grande porte. A descompressão foraminal indireta por PCD em um ou mais segmentos parece contribuir para o alívio da dor. Nível de Evidência III; Série de casos e controles.

RESUMEN Introducción: La cemento discoplastia percutánea (PCD) es una técnica quirúrgica de mínima invasión, la cual brinda estabilización segmentaria y un efecto de descompresión indirecta en caso de enfermedad discal degenerativa severa con fenómeno de vacío, útil en pacientes con comorbilidades que contraindican procedimientos quirúrgicos más agresivos. Materiales y métodos: Se realizó un análisis retrospectivo de 6 pacientes sometidos a PCD, reportando las variables demográficas, los segmentos tratados y el resultado clínico evaluado mediante la escala visual análoga del dolor (EVA) tanto en el prequirúrgico como en el seguimiento a 6 meses. Finalmente se realizó una revisión de la literatura. Resultados: Se incluyeron 6 casos de PCD, de los cuales 5 presentaron diagnóstico de discartrosis y 1 discartrosis con espondilolistesis. 4 pacientes de género femenino y 2 masculino. En 3 pacientes se realizó PCD en 1 segmento y en 3 pacientes en múltiples segmentos. Respecto al resultado clínico se presentó mejoría en 5 de los pacientes (promedio 5.6 puntos EVA), 1 de los pacientes no presento mejoría y requirió de otra intervención quirúrgica. Conclusiones: La PCD es una técnica de mínima invasión útil en el tratamiento del dolor de columna secundario a enfermedad degenerativa discal en aquellos pacientes con comorbilidades que contraindiquen un procedimiento mayor. La descompresión foraminal indirecta mediante PCD en uno o varios segmentos parece contribuir a la mejoría del dolor. Nivel de Evidencia III. Serie de casos y controles.

Plasma rico en plaqueta en el tratamiento de la enfermedad degenerativa discal / Platelet-rich plasma in the treatment of degenerative disc disease

Introducción: La enfermedad degenerativa discal es una entidad frecuente y uno de los principales motivos de consulta. Genera altas tasas de discapacidad, años útiles perdidos, así como altos costos económicos por asistencia médica y grandes pérdidas monetarias. Su tratamiento es generalmente conservador, aunque en la actualidad se incluyen terapias biológicas novedosas. Objetivo: Describir las principales propiedades biológicas que hacen del plasma rico en plaquetas una terapéutica efectiva para la enfermedad degenerativa discal. Métodos: Se realizó una revisión no sistemática de la bibliografía basada en artículos que se publicaron en bases de datos indexadas en Infomed como Hinari, Ebsco, Scielo, Pubmed, Cubmed, Cocrhane, Scopus, LILACS; en idioma español, inglés y portugués, durante los últimos diez años. Desarrollo: Se expusieron características clínico epidemiológicas de la enfermedad degenerativa discal, así como las propiedades biológicas que le permiten al plasma rico en plaqueta tener una función activa en la regeneración del disco intervertebral o el retraso de la cascada de degradación de este. Se resaltan los principales estudios de acuerdo a la vía de administración del plasma rico en plaquetas y sus resultados. Conclusiones: De acuerdo con lo publicado por los autores, el plasma rico en plaquetas es una alternativa efectiva en el tratamiento de la enfermedad degenerativa discal por la producción de factores derivados de las plaquetas, que intervienen en la degeneración del disco intervertebral, siendo la vía intradiscal la que más se emplea(AU)

Introduction: Degenerative disc disease is a frequent condition and one of the main reasons to attend the consultation. It generates high rates of disability, useful years lost, as well as high economic costs for medical assistance and large monetary losses. Its treatment is generally conservative, although novel biological therapies are currently included. Objective: To describe the main biological properties that make platelet-rich plasma an effective therapy against degenerative disc disease. Methods: A nonsystematic review of the bibliography was carried out based on articles published, during the last ten years, in databases indexed in Infomed, such as Hinari, Ebsco, Scielo, Pubmed, Cubmed, Cocrhane, Scopus, and LILACS, in Spanish, English and Portuguese. Development: Clinical-epidemiological characteristics of degenerative disc disease were presented, as well as the biological properties that allow platelet-rich plasma to have an active function in the regeneration of the intervertebral disc or the delay of its degradation cascade. The main studies are highlighted, according to the route of administration of platelet-rich plasma and their results. Conclusions: According to what has been published by authors, platelet-rich plasma is an effective alternative in the treatment of degenerative disc disease, due to the production of factors derived from platelets, which intervene in the degeneration of the intervertebral disc, being the intradiscal pathway the most used(AU)

Involvement and significance of large transmembrane protein piezo1 in orthopedic related diseases / 中国组织工程研究

BACKGROUND: Recent studies found that mesenchymal stem cells, osteoblasts and osteoclasts, cartilage cells, nucleus pulposus cells, and osteosarcoma cells can receive mechanical stimulation from extracellular environment through Piezo1 protein so as to activate cell signal transduction pathways, affecting cell proliferation, differentiation, migration and apoptosis, which determines physiological and pathological processes of physiological structure of bone, joint degeneration, and fracture healing. OBJECTIVE: To review Piezo1 related to osteoporosis and degenerative osteoarthropathy, summarize the latest advances by reviewing the latest discovery of Piezo1 in other orthopedic diseases, and provide ideas for novel treatment strategies for orthopedic related diseases. METHODS: A computer search was conducted on the literatures related to the research progress of Piezo1 in orthopedic diseases in CNKI and PubMed from inception to January 2020. The Chinese keywords were “mechanically sensitive ion channel proteins, osteoporosis, degenerative osteoarthropathy, orthopedic diseases”, and the English keywords were “Piezo1, osteoporosis, degenerative osteoarthropathy, orthopedic diseases”. A full web search was conducted, and finally 60 literatures were included for review and discussion. RESULTS AND CONCLUSION: (1) Piezo1 can release biological signals and regulate osteoclast activity during the development of osteoporosis by directly detecting the mechanical load in osteoblastic lineage cells. (2) In the progression of degenerative osteoarthropathy, Piezo1 on the cartilage cell membrane was able to effectively recognize stimuli of different strengths and types of external mechanical stress and eventually induce chondrocyte apoptosis. (3) In bone metabolic diseases, degenerative arthritis of joints and other orthopedic diseases, Piezo1 is involved in the pathological process of the disease. The emergence of Piezo1 provides a more specific molecular basis for the application of mechanical stimulation in orthopedics, opens a new thinking and perspective, and also lays a “hint” for the future dual drug administration and precision medicine.

Cauda Equina Syndrome by Facet Synovial Pseudocyst Secondary to Epidural Injection / 대한정형외과학회잡지

A 77-year-old woman presented with bilateral leg weakness, accompanied by severe axial back and radicular pain, after a L4–5 epidural injection. She had been receiving misappropriated epidural injections for the last few months. A contrast-enhanced magnetic resonance image showed rim enhancing, spinal canal compromising cystic lesion at the posterior epidural space of L4–5. During surgery, a severely central compromised non-communicating cystic lesion located at posterior epidural space was resected. A histological report of this lesion confirmed a pseudocyst containing a degenerated synovial tissue. Herein, we report our experience of cauda equine syndrome after epidural injection with successful treatment.

Nucleoplasty: Percutaneous Plasma Disc Decompression for the Treatment of Lumbar Disc Herniation

STUDY DESIGN: A review of the literature regarding nucleoplasty. OBJECTIVES: This aim of this article is to provide current information on nucleoplasty as a therapeutic intervention for herniated disc or discogenic back pain in degenerative disc disease. SUMMARY OF LITERATURE REVIEW: Nucleoplasty as a therapeutic intervention for discogenic pain is performed with increasing frequency, and has been reported to involve few complications and to have satisfactory clinical results. MATERIALS AND METHODS: Review of the literature. RESULTS: In nucleoplasty, the intervertebral disc is approached percutaneously. In this paradigm, a bipolar high frequency device in combination with ablation and coagulation is used to create a channel in the intervertebral disc in order to reduce intervertebral disc volume and to decrease intervertebral pressure and inflammatory markers. Standard indications for nucleoplasty have not been established, but it has been reported that the procedure had excellent outcomes regardless of the presence of radiculopathy or the results of discography. Many studies have reported their outcomes using various categories, because the procedure is comparatively new. Concomitantly, long-term follow-up studies remain to be performed, and each study reported a different follow-up period. CONCLUSIONS: Nucleoplasty has been found to show an excellent prognosis for discogenic back pain and a low incidence of complications. Moreover, since it is a minimally invasive procedure, it offers improved possibilities for return to daily life and work. If degenerative changes have not progressed to a great extent or the intervertebral level remains intact, nucleoplasty may be considered prior to surgery. Due to the lack of reports on the subject, prospective analyses in the future are required.

The Clinical Correlations between Diabetes, Cigarette Smoking and Obesity on Intervertebral Degenerative Disc Disease of the Lumbar Spine

STUDY DESIGN: Retrospective analysis of a nationwide private insurance database. Chi-square analysis and linear regression models were utilized for outcome measures. PURPOSE: The purpose of this study was to investigate any relationship between lumbar degenerative disc disease, diabetes, obesity and smoking tobacco. OVERVIEW OF LITERATURE: Diabetes, obesity, and smoking tobacco are comorbid conditions known to individually have effect on degenerative disc disease. Most studies have only been on a small populous scale. No study has yet to investigate the combination of these conditions within a large patient cohort nor have they reviewed the combination of these conditions on degenerative disc disease. METHODS: A retrospective analysis of insurance billing codes within the nationwide Humana insurance database was performed, using PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA), to identify trends among patients diagnosed with lumbar disc degenerative disease with and without the associated comorbidities of obesity, diabetes, and/or smoking tobacco. Patients billed for a comorbidity diagnosis on the same patient record as the lumbar disc degenerative disease diagnosis were compared over time to patients billed for lumbar disc degenerative disease without a comorbidity. There were no sources of funding for this manuscript and no conflicts of interest. RESULTS: The total number and prevalence of patients (per 10,000) within the database diagnosed with lumbar disc degenerative disease increased by 241.4% and 130.3%, respectively. The subsets of patients within this population who were concurrently diagnosed with either obesity, diabetes, tobacco use, or a combination thereof, was significantly higher than patients diagnosed with lumbar disc degenerative disease alone (p <0.05 for all). The number of patients diagnosed with lumbar disc degenerative disease and smoking rose significantly more than patients diagnosed with lumbar disc degenerative disease and either diabetes or obesity (p <0.05). The number of patients diagnosed with lumbar disc degenerative disease, smoking and obesity rose significantly more than the number of patients diagnosed with lumbar disc degenerative disease and any other comorbidity alone or combination of comorbidities (p <0.05). CONCLUSIONS: Diabetes, obesity and cigarette smoking each are significantly associated with an increased diagnosis of lumbar degenerative disc disease. The combination of smoking and obesity had a synergistic effect on increased rates of lumbar degenerative disc disease. Patient education and preventative care is a vital goal in prevention of degenerative disc disease within the general population.

Reliable Magnetic Resonance Imaging Based Grading System for Cervical Intervertebral Disc Degeneration

STUDY DESIGN: Observational. PURPOSE: To develop a simple and comprehensive grading system for cervical discs that precisely, consistently and meaningfully presents radiologic and morphologic data. OVERVIEW OF LITERATURE: The Thompson grading system is commonly used to classify the severity of degenerative lumbar discs on magnetic resonance imaging (MRI). Inherent differences in the morphological and physiological characteristics of cervical discs have hindered development of precise classification systems. Other grading systems have been developed for degenerating cervical discs, but their versatility and feasibility in the clinical setting is suboptimal. METHODS: MRIs of 46 human cervical discs were de-identified and displayed in PowerPoint format. Each slide depicted a single disc with a normal (grade 0) disc displayed in the top right corner for reference. The presentation was given to 25 physicians comprising attending spine surgeons, spine fellows, orthopaedic residents, and two attending musculoskeletal radiologists. The grading system included Grade 0 (normal height compared to C2-3, mid cleft still visible), grade 1 (dark disc, normal height), grade 2 (collapsed disc, few osteophytes), and grade 3 (collapsed disc, many osteophytes). The ease of use of the system was gauged in the participants and the interobserver reliability was calculated. RESULTS: The intraclass correlation coefficient for interobserver reliability was 0.87, and 0.94 for intraobserver reliability, indicating excellent reliability. Ninety-five percent and 85 percent of the clinicians judged the grading system to be clinically feasible and useful in daily practice, respectively. CONCLUSIONS: The grading system is easy to use, has excellent reliability, and can be used for precise and consistent clinician communication.

Role of IL-17 in nucleus pulposus cell proliferation and metabolism culturedin vitro

Objective:To explore the role of cytokine, interleukin-17(IL-17) in human degenerative disc disease.Methods:Through magnetic resonance imaging, human degenerative disc tissues were confirmed from the isolated nucleus pulposus cells, which were then cultured in vitro.The cells were cultured with and without different concentrations ofIL-17.2 ng/mL,5 ng/mL,10 ng/mL,15 ng/mL and20 ng/mLIL-17 concentrations were used for stimulation.After72 hours, the inhibition rate of proliferation was measured byMTS method.For48 and96 hours, the nucleus pulposus cells were cultured with and without the appropriateIL-17 concentrations.The mRNA and protein expression levels of the matrix macromolecules and degrading tissue genes were measured byReal-timePCR andWestern blot analysis.Results:It was noted that nucleus pulposus cell proliferation was inhibited after culturing in vitro withIL-17 stimulation, and it was further observed that the inhibition effect was significantly stronger with15 ng/mLIL-17 concentration.With the dosage of15 ng/mL,IL-17 stimulation induced multiple cellular responses, such as the significant increase in mRNA expression for both aggrecan(ACAN) and type Ⅰ collagen(COL1A1) genes(P<0.05), and the significant decrease in mRNA expression of both degrading tissue genes,MMP3 andTIMP3(P<0.05).Western blot results also showed that the protein level ofCOL1A1 was significantly decreased(t=3.199,P=0.006), while the protein level of one peptidases(ADAMTS5) significantly increased(t=2.667, P=0.021).Conclusions:These findings suggest thatIL-17 can inhibit proliferation and affect the metabolism of the cultured nucleus pulposus cells in vitro, and these findings could possibly contribute to the degenerative changes that occur inDDD through extracellular matrix synthesis inhibition, promoting nucleus pulposus extracellular matrix degradation and disrupting the metabolic balance.

Role of IL-17 in nucleus pulposus cell proliferation and metabolism cultured in vitro

Objective: To explore the role of cytokine, interleukin-17 (IL-17) in human degenerative disc disease. Methods: Through magnetic resonance imaging, human degenerative disc tissues were confirmed from the isolated nucleus pulposus cells, which were then cultured in vitro. The cells were cultured with and without different concentrations of IL-17. 2 ng/mL, 5 ng/mL, 10 ng/mL, 15 ng/mL and 20 ng/mL IL-17 concentrations were used for stimulation. After 72 hours, the inhibition rate of proliferation was measured by MTS method. For 48 and 96 hours, the nucleus pulposus cells were cultured with and without the appropriate IL-17 concentrations. The mRNA and protein expression levels of the matrix macromolecules and degrading tissue genes were measured by Real-time PCR and Western blot analysis. Results: It was noted that nucleus pulposus cell proliferation was inhibited after culturing in vitro with IL-17 stimulation, and it was further observed that the inhibition effect was significantly stronger with 15 ng/mL IL-17 concentration. With the dosage of 15 ng/mL, IL-17 stimulation induced multiple cellular responses, such as the significant increase in mRNA expression for both aggrecan (. ACAN) and type I collagen (. COLLA1) genes (. P<0.05), and the significant decrease in mRNA expression of both degrading tissue genes, MMP3 and TIMP3 (. P<0.05). Western blot results also showed that the protein level of COL1A1 was significantly decreased (. t=3.199, P=0.006), while the protein level of one peptidases (ADAMTS5) significantly increased (. t=2.667, P=0.021). Conclusions: These findings suggest that IL-17 can inhibit proliferation and affect the metabolism of the cultured nucleus pulposus cells in vitro, and these findings could possibly contribute to the degenerative changes that occur in DDD through extracellular matrix synthesis inhibition, promoting nucleus pulposus extracellular matrix degradation and disrupting the metabolic balance.

Role of IL-17 in nucleus pulposus cell proliferation and metabolism cultured in vitro

OBJECTIVE@#To explore the role of cytokine, interleukin-17 (IL-17) in human degenerative disc disease.@*METHODS@#Through magnetic resonance imaging, human degenerative disc tissues were confirmed from the isolated nucleus pulposus cells, which were then cultured in vitro. The cells were cultured with and without different concentrations of IL-17. 2 ng/mL, 5 ng/mL, 10 ng/mL, 15 ng/mL and 20 ng/mL IL-17 concentrations were used for stimulation. After 72 hours, the inhibition rate of proliferation was measured by MTS method. For 48 and 96 hours, the nucleus pulposus cells were cultured with and without the appropriate IL-17 concentrations. The mRNA and protein expression levels of the matrix macromolecules and degrading tissue genes were measured by Real-time PCR and Western blot analysis.@*RESULTS@#It was noted that nucleus pulposus cell proliferation was inhibited after culturing in vitro with IL-17 stimulation, and it was further observed that the inhibition effect was significantly stronger with 15 ng/mL IL-17 concentration. With the dosage of 15 ng/mL, IL-17 stimulation induced multiple cellular responses, such as the significant increase in mRNA expression for both aggrecan (ACAN) and type I collagen (COLLA1) genes (P<0.05), and the significant decrease in mRNA expression of both degrading tissue genes, MMP3 and TIMP3 (P<0.05). Western blot results also showed that the protein level of COL1A1 was significantly decreased (t=3.199, P=0.006), while the protein level of one peptidases (ADAMTS5) significantly increased (t=2.667, P=0.021).@*CONCLUSIONS@#These findings suggest that IL-17 can inhibit proliferation and affect the metabolism of the cultured nucleus pulposus cells in vitro, and these findings could possibly contribute to the degenerative changes that occur in DDD through extracellular matrix synthesis inhibition, promoting nucleus pulposus extracellular matrix degradation and disrupting the metabolic balance.

Total Disc Replacement in Lumbar Degenerative Disc Diseases

More than 10 years have passed since lumbar total disc replacement (LTDR) was introduced for the first time to the world market for the surgical management of lumbar degenerative disc disease (DDD). It seems like the right time to sum up the relevant results in order to understand where LTDR stands on now, and is heading forward to. The pathogenesis of DDD has been currently settled, but diagnosis and managements are still controversial. Fusion is recognized as golden standard of surgical managements but has various kinds of shortcomings. Lately, LTDR has been expected to replace fusion surgery. A great deal of LTDR reports has come out. Among them, more than 5-year follow-up prospective randomized controlled studies including USA IDE trials were expected to elucidate whether for LTDR to have therapeutic benefit compared to fusion. The results of these studies revealed that LTDR was not inferior to fusion. Most of clinical studies dealing with LTDR revealed that there was no strong evidence for preventive effect of LTDR against symptomatic degenerative changes of adjacent segment disease. LTDR does not have shortcomings associated with fusion. However, it has a potentiality of the new complications to occur, which surgeons have never experienced in fusion surgeries. Consequently, longer follow-up should be necessary as yet to confirm the maintenance of improved surgical outcome and to observe any very late complications. LTDR still may get a chance to establish itself as a substitute of fusion both nominally and virtually if it eases the concerns listed above.

Analysis of crucial molecules involved in herniated discs and degenerative disc disease

OBJECTIVES: Herniated discs and degenerative disc disease are major health problems worldwide. However, their pathogenesis remains obscure. This study aimed to explore the molecular mechanisms of these ailments and to identify underlying therapeutic targets. MATERIAL AND METHODS: Using the GSE23130 microarray datasets downloaded from the Gene Expression Omnibus database, differentially co-expressed genes and links were identified using the differentially co-expressed gene and link method with a false discovery rate ,0.25 as a significant threshold. Subsequently, the underlying molecular mechanisms of the differential co-expression of these genes were investigated using Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis. In addition, the transcriptional regulatory relationship was also investigated. RESULTS: Through the analysis of the gene expression profiles of different specimens from patients with these diseases, 539 differentially co-expressed genes were identified for these ailments. The ten most significant signaling pathways involving the differentially co-expressed genes were identified by enrichment analysis. Among these pathways, apoptosis and extracellular matrix-receptor interaction pathways have been reported to be related to these diseases. A total of 62 pairs of regulatory relationships between transcription factors and their target genes were identified as critical for the pathogenesis of these diseases. CONCLUSION: The results of our study will help to identify the mechanisms responsible for herniated discs and degenerative disc disease and provides a theoretical basis for further therapeutic study.

Avaliação da resposta clínica da estabilização pedicular, sem fusão, em pacientes com lombalgia / Evaluación de la respuesta clínica de la estabilización pedicular, sin fusión, en pacientes con lumbalgia / Clinical outcomes with non-fusion stabilization in low back pain

OBJETIVO: Avaliar o resultado clínico do tratamento cirúrgico da doença discal degenerativa (DDD) com o uso de sistemas de estabilização pedicular sem fusão em 22 pacientes na cidade de Aracaju/Sergipe. MÉTODOS: Foram utilizadas escala visual analógica da dor (EVA) e qualidade de vida ( questionários Oswestry e Roland Moris) no pré-operatório e seis meses após o tratamento cirúrgico instituído. De acordo com as queixas clínicas e as alterações morfofisiológicas encontradas nos exames complementares de imagem, grau de acometimento articular (artrose facetária), doença discal em níveis adjacentes, microdiscectomias prévias, optou-se pela utilização de implantes que permitem graus de mobilidade variáveis. RESULTADOS: Dos 22 pacientes incluídos no estudo, 16 eram do sexo masculino e seis do sexo feminino, com média de idade de 41,77 ± 11,6 anos. Foi estabilizado um total de 43 níveis, sendo a instrumentação de L4 a S1 a mais frequente (12) e o sistema mais utilizado foi a placa Dinamika® (GMReis) para dois níveis (08), com fusão do nível inferior (estabilização híbrida). Houve melhora importante da sintomatologia quando observamos a diminuição da EVA no pré-operatório (8,59±1,1) e 6 meses no pós-operatório (2,41±1,8), com melhora na qualidade de vida nas escalas de Oswestry e Roland Moris (ODI pré: 55,18 ± 15,5 e ODI pós: 13,91 ± 13,1 ; RM pré: 27,23 ± 4,9 e RM pós: 41,68 ± 4,8) respectivamente. CONCLUSÃO: Apesar de todos os pacientes incluídos no estudo terem obtido melhora expressiva tanto na qualidade de vida como na diminuição da sintomatologia, novos estudos biomecânicos devem ser realizados a fim de se padronizar uma abordagem eficiente no tratamento dessa patologia.

OBJECTIVE: To evaluate the clinical outcome of surgical treatment of degenerative disc disease (DDD) with the use of pedicular stabilization systems without fusion in 22 patients in the city of Aracaju/Sergipe. METHODS: We used the visual analogic scale (VAS) and quality of life questionnaires (Oswestry and Roland Moris) preoperatively and 6 months after surgical treatment. According to the clinical symptoms and morpholophysiological changes found in the imaging exams, articular changes (facet degeneration), disc disease at adjacent levels, previous microdiscectomy, were determinant parameters for chose the use of implants that allow varying degrees of mobility. RESULTS: Of the 22 patients studied, 16 were male and six female with mean age of 41.77±11.6 years.A total of 43 levels were stabilized and the instrumentation from L4 to S1 was the most frequent segment (12) and the Dinamika® (GMReis - Brazil) plate for 2 levels was the most frequent used system (08), with fusion of the lower level (hybrid stabilization). There was significant improvement in symptoms when we observe a decrease of VAS preoperatively (8,59±1,1)and 6 months postoperatively (2,41±1,8) with improvement in quality of life scores in Oswestry and Roland Moris questionnaires (ODI pre: 55,18±15.5 and ODI post: 13,91±13,1 ; RM pre: 27,23 ± 4,9 e RM post: 41,68 ± 4,8), respectively. CONCLUSION: Although all patients included in the study had achieved a significant improvement both in quality of life and in reducing symptoms, further biomechanical studies should be performed in order to standardize an efficient approach to treat this pathology.

OBJETIVO: Evaluar el resultado clínico del tratamiento quirúrgico de la enfermedad del disco degenerativa (EDD) con la utilización de los sistemas de estabilización pedicular sin fusión en 22 enfermos en la ciudad de Aracajú/Sergipe. MÉTODOS: Fueron utilizadas escalas visual analógica del dolor (EVA) y de calidad de vida (cuestionarios Oswestry e Rolland Morris) antes de la cirugía y seis meses después del tratamiento quirúrgico realizado. De acuerdo con las quejas clínicas y las alteraciones morfofisiológicas encontradas en los exámenes complementarios de imagen, grado de acometimiento articular (artrosis de las facetas), enfermedad discal en niveles adyacentes, microdiscectomías anteriores, se optó por la utilización de implantes que permiten grados de movilidad variables. RESULTADOS: De los 22 enfermos que se incluyeron en el estudio, 16 eran del sexo masculino, y seis del sexo femenino, con el promedio de edad de 41,77 años, más o menos 11,6 años. Se estabilizó un total de 43 niveles, siendo la instrumentación de L4 a S1 la más frecuente (12) y el sistema más utilizado fue la placa Dinamika® (GMReis) para dos niveles (08), con fusión del nivel inferior (estabilización híbrida). Hubo mejoría importante de la sintomatología cuando observamos la disminución del EVA antes del procedimiento cirúrgico (8,59 más o menos 1,1) y seis meses después del procedimiento quirúrgico (2,41 más o menos 1,8), con mejora de la cualidad de vida segúnlas escalas de Oswestry e Rolland Morris (ODI antes: 55,18 más o menos 15,5 y ODI después: 13,91 más o menos 13,1; RM antes: 27,23 más o menos 4,9 y RM después: 41,68 más o menos 4,8), respectivamente. CONCLUSIÓN: Aunque todos los enfermos incluidos en el estudio hayan obtenido una mejoría significativa tanto en la calidad de vida como en la disminución de la sintomatología, nuevos estudios biomecánicos deberán ser realizados para que se llegue a estandarizar un abordaje eficiente en el tratamiento de la patologia.

Comparative Analysis of Cervical Disc Arthroplasty Using Two Types of Artificial Cervical Discs: Bryan(R) versus Mobi-C(R)

OBJECTIVE: Since the 1990s, due to postoperative loss of mobility and adjacent segmental disease after anterior cervical fusion, many different types of cervical artificial discs have been developed as alternative implants. The purposes of this study are investigation and comparison of radiographic and clinical outcomes between two different types of prostheses, Bryan(R) and Mobi-C(R). METHODS: We retrospectively evaluated 33 patients who were treated for cervical degenerative disc disease that resulted in radiculopathy and/or myelopathy between May 2004 and April 2009. Seventeen patients underwent Bryan(R) cervical disc arthroplasty and sixteen patients underwent Mobi-C(R) arthroplasty. The radiographic outcomes were assessed by measuring the cervical lordosis, segmental lordosis, range-of-motion (ROM) of the cervical spine (C2-7), functional segmental unit (FSU), prosthesis' shell and the upper adjacent segment. The clinical results were evaluated according to the Visual Analogue Scale (VAS) for axial pain and radiculopathy, Odom's criteria, and the modified Prolo's economic and functional outcome rating scale. RESULTS: The age of the study population ranged from 24 to 69 years with a mean age of 48 years vs. 46 years in the Bryan(R) and Mobi-C(R) groups, respectively. The mean duration of follow-up was 23.7 months in the Bryan(R) group and 11.3 months in the Mobi-C(R) group. The changes of overall cervical sagittal angle were not significantly different between two groups, but the increase of segmental sagittal angle (0.85degrees in Bryan(R), 8.04degrees in Mobi-C(R)), ROM of the FSU(-0.51degrees in Bryan(R), 2.47degrees in Mobi-C(R)) and ROM of the shell (1.77degrees in Bryan(R), 5.28degrees in Mobi-C(R)) were significantly higher in Mobi-C(R) group than in Bryan(R) group (p<0.05). The clinical results were not significantly different between two groups. CONCLUSION: The Mobi-C(R) prosthesis showed more favorable radiographic results than that of the Bryan(R) prosthesis, however, the clinical outcomes were similar in both groups. Large-scale and long-term follow-up studies are needed to confirm our results.

Degenerative disc disease of the lumbar spine on MRI / La enfermedad degenerativa del disco de la espina lumbar en IRM

A retrospective analysis was done of all patients referred for MRI of the lumbar spine at the University Hospital of the West Indies, Kingston, Jamaica, during the three-year period January 1, 2005 and December 31, 2007. Data were collected to determine patients' age, gender, weight and the presence or absence of degenerative disc disease (DDD). The patients' presenting symptoms were not evaluated. There were 362 patients examined: 154 males, 204 females and four uncharacterized, aged between 8 and 87 (mean age = 50.45) years. Degenerative Disc Disease (DDD), was found in 283 (78.2%) patients: 121 males, 159 females and three unidentified, with a total of 669 degenerate discs. L 4/5 and L 5/S 1 were most frequently affected accounting for 31.2% and 30.6% of degenerate discs respectively. Patients with DDD were significantly heavier and significantly older than patients without disc disease. Gender was not predictive of DDD in general nor of involvement of any particular disc though a marginally significant tendency was found for males to more frequently have DDD at L1/2 and L5/S1. CONCLUSION: Degenerative disc disease of the lumbar spine occurred more frequently in older and heavier patients. Gender did not affect the presence or the extent of the disease; compared to females, males showed a marginally increased tendency to have DDD at L1/2 and L5/S1.

Se realizó un análisis retrospectivo de todos los pacientes remitidos para IRM de la espina lumbar en el Hospital Universitario de West Indies, Kingston, Jamaica, durante el periodo de tres años comprendido de enero 1 de 2005 a diciembre 31 de 2007. Se recogieron datos de los pacientes a fin de determinar su edad, género, peso y la presencia o ausencia de la enfermedad degenerativa del disco (EDD). Los síntomas presentes en los pacientes no fueron evaluados. Se examinaron 362 pacientes: 154 varones, 204 hembras y cuatro no caracterizados, de edades entre 8 y 87 (edad promedio = 50.45) años. La enfermedad degenerativa del disco (EDD) se halló en 283 (78.2%) pacientes: 121 varones, 159 hembras y tres no identificados, para un total de 669 discos degenerados. L 4 /5 y L 5 / S 1 fueron los más frecuentemente afectados, representando el 31.2% y 30.6% de los discos degenerados, respectivamente. Los pacientes con EDD tenían significativamente más peso y mayor edad que aquellos sin la enfermedad del disco. El género no era en general predictivo de EDD ni de involucración de disco alguno en particular, si bien se halló marginalmente una tendencia significativa a una mayor frecuencia en la manifestación de EDD en L1 / 2 y L5 / S1 entre los varones CONCLUSIÓN: La enfermedad degenerativa del disco de la espina lumbar se presentó en pacientes de mayor edad y mayor peso. El género no afectó la presencia o la magnitud de la enfermedad. Sin embargo, en comparación con las hembras, los varones mostraron una tendencia marginalmente mayor a presentar EDD en L1/2 y L5/S1.

Long Term Efficacy of Posterior Lumbar Interbody Fusion with Standard Cages alone in Lumbar Disc Diseases Combined with Modic Changes

OBJECTIVE: Posterior lumbar interbody fusion (PLIF) is considered to have the best theoretical potential in promoting bony fusion of unstable vertebral segments by way of a load sharing effect of the anterior column. This study was undertaken to investigate the efficacy of PLIF with cages in chronic degenerative disc disease with Modic degeneration (changes of vertebral end plate). METHODS: A total of 597 patients underwent a PLIF with threaded fusion cages (TFC) from 1993 to 2000. Three-hundred-fifty-one patients, who could be followed for more than 3 years, were enrolled in this study. Patients were grouped into 4 categories according to Modic classification (no degeneration : 259, type 1 : 26, type 2 : 55, type 3 : 11). Clinical and radiographic data were evaluated retrospectively. RESULTS: The clinical success rate according to the Prolo's functional and economic outcome scale was 86% in patients without degeneration and 83% in patients with Modic degeneration. The clinical outcomes in each group were 88% in type 1, 84% in type 2, and 73% in type 3. The bony fusion rate was 97% in patients without degeneration and 83% in patients with Modic degeneration. The bony fusion rate in each group was 81% in type 1, 84% in type 2, and 55% in type 3. The clinical success and fusion rates were significantly lower in patients with type 3 degeneration. CONCLUSION: The PLIF with TFC has been found to be an effective procedure for lumbar spine fusion. But, the clinical outcome and bony fusion rates were significantly low in the patients with Modic type 3. The authors suggest that PLIF combined with pedicle screw fixation would be the better for them.

Clinical and Radiographic Analysis of Cervical Total Disc Replacement Versus Anterior Cervical fusion using Stand-alone Cage

OBJECTIVE: Total intervertebral disc replacement is designed to preserve motion and avoid limitations of fusion after removing local pathology. The authors report the results of a signle-center study to determine functional and radi- ologic outcomes associated with cervical total disc replacement versus those of cervical fusion. METHODS: We retrospectively reviewed the charts and radiographs of patients who underwent a total intervertebral disc replacement(TDR) or a single-level anterior cervical fusion(ACDF) between January 1, 2004, and September 31, 2007. Clinical symptom was assessed using the Visual Analog Scale(VAS) of the neck and of the arm pain. Range of motion was determined by radiologic assessment of flexion-extension radiographs. Data were collected before surgery and at 6 weeks, 3, 6, 12, and 24 months after surgery. RESULT: A total of 125 patients were identified with 63 having TDR(43 males and 20 females) and 62 having fusion(42 males and 20 females). The average age was 49.1 years(TDR) and 51.7 years(ACDF)(p=0.229). The mean neck pain VAS before surgery was 6.52(TDR) and 6.61(ACDF)(p=0.732). At 2-year follow-up, the average neck pain VAS for the TDR group was 1.59 and ACDF 1.85(p=0.168). The mean arm pain VAS before surgery was 6.37(TDR) and 6.60(ACDF)(p=0.335). At 2 years: 1.41(TDR) and 1.65(ACDF)(P = 0.148). More motion(an average of 9.00 degrees at 24 months) was retained after surgery in the TDR group than the fusion group at the treatment level. There was no significant diffe- rence in motion at adjacent levels. CONCLUSION: Total disc replacement maintained physiological segmental motion at the 2-year follow-up. The finding that there was no statistically significant difference between the groups in motion at adjacent levels must be verified on further studies.