Analyses of imaging presentations, full endoscopic and pathological features of a novel interlaminar ligament.

BACKGROUND: To analyze the characteristics of an unnamed interlaminar ligaments(ILL) through magnetic resonance image (MRI), endoscopy and pathological examination. METHOD: A retrospective study was conducted to analyze the clinical data of patients who underwent posterior endoscopic surgery for lumbar disc herniation or lumbar spinal stenosis from January 2021 to February 2022 at our medical center. The height, width and cross-sectional thickness of the ligament was analyzed using T2 weighted MRI. Meanwhile, the morphological and pathological characteristics were also compared with those of the ligamentum flavum to highlight the differences between above mentioned ligaments. RESULT: Forty-three patients were included in this study, including 27 males and 16 females, with an average age of 46.6 ± 12.1y. There were 20 cases of lumbar disc herniation and 23 cases of lumbar spinal stenosis. The width, length, thickness of the ILL, the thickness of LF and surgical time in the lumbar disc group were 17.7 ± 3.5 mm, 4.3 ± 1.3 mm, 18.3 ± 3.5 mm, 5.3 ± 1.9 mm, 53.2 ± 14.5 min, respectively. In the lumbar spinal stenosis group, the corresponding parameters were 16.0 ± 3.1 mm, 4.1 ± 1.6 mm, 17.6 ± 4.8 mm, 6.3 ± 0.8 mm, 61.8 ± 12.4 min, respectively. The intergroup difference in thickness of the ligamentum flavum was statistically significant (P = 0.02). The difference in surgical time was also established(P = 0.04). Endoscopic differences were identified as to the location of the anchor points and appearances among the two ligaments. Significant differences in the density and direction of fibrous structures were also observed under biopsy. Under endoscopy, significant difference as to the grade of ILL thickness was established when compared regarding disease spectrum (P = 0.09.) CONCLUSION: The interlaminar ligament is a structure that has not yet been officially named, which has significant structural differences from those of the ligamentum flavum. For posterior endoscopic procedure, its clinical significance lies in its ability to serve as the endpoint of soft tissue channel establishment. The thickness of the ligamentum flavum in MRI and the thickness of ILL under endoscopy vary according to the disease spectrum.

Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes.

STUDY DESIGN: A technical note and retrospective case series. OBJECTIVE: Highly upward-migrated lumbar disc herniation (LDH) is challenging due to its problematic access and incomplete removal. The most used interlaminar approach may cause extensive bony destruction. We developed a novel translaminar approach using the unilateral portal endoscopic (UBE) technique, emphasizing effective neural decompression, and preserving the facet joint's integrity. METHODS: This retrospective study included six patients receiving UBE translaminar discectomy for highly upward-migrated LDHs from May 2019 to June 2021. The migrated disc was removed through a small keyhole on the lamina of the cranial vertebra. The treatment results were evaluated by operation time, hospital stays, complications, visual analog scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, and modified MacNab criteria. RESULTS: The mean pre-operative VAS for back pain (5.0 ± 4.9), VAS for leg pain (9.2 ± 1.0), JOA score (10.7 ± 6.6), and ODI (75.7 ± 25.3) were significantly improved to 0.3 ± 0.5, 1.2 ± 1.5, 27.3 ± 1.8, 5.0 ± 11.3 respectively at the final follow-up. Five patients had excellent, and one patient had good outcomes according to the Modified MacNab criteria. The hospital stay was 2.7 ± 0.5 days. No complication was recorded. The MRI follow-up showed complete disc removal, except for one patient with an asymptomatic residual disc. CONCLUSIONS: UBE translaminar discectomy is a safe and effective minimally invasive procedure for highly upward-migrated LDH with satisfactory treatment outcomes and nearly 100% facet joint preservation.

[Surgical treatment of recurrent herniated discs of the lumbar spine depending on risk factors]. / Vybor taktiki khirurgicheskogo lecheniya retsidivov gryzh diskov poyasnichnogo otdela pozvonochnika na osnovanii analiza faktorov riska ikh razvitiya.

According to the literature, recurrent disc herniation of the lumbar spine occurs in 5-10% of cases. Objective. To develop an algorithm for surgical treatment of recurrent lumbar spine disc herniation based on analysis of risk factors of relapse and assessment of intra- and postoperative period. MATERIAL AND METHODS: The study included 61 patients with recurrent intervertebral disc herniation. Thirty patients underwent repeated microdiscectomy without transpedicular fixation, 31 patients - resection of recurrent disc herniation with transpedicular fixation (PLIF technique). The control group included 63 patients without recurrent disc herniation. Mean follow-up period was 3.5 years. RESULTS: Discectomy with transpedicular fixation is characterized by larger extent, prolonged surgery time and rehabilitation period. However, there is lower risk of recurrent disc herniation and CSF leakage. Repeated microdisectomy without transpedicular fixation is characterized by smaller extent and shorter surgery time, as well as faster recovery period. Nevertheless, we have higher risk of recurrent disc herniation and CSF leakage. We developed a method for assessing the probability of recurrent intervertebral disc herniation. This algorithm allows us to predict the probability of recurrent disc herniation in a particular patient with 86.7% accuracy. CONCLUSION: We proposed an algorithm for choosing surgical treatment of recurrent disc herniation. Microdiscectomy without fixation is advisable for the risk of recurrent disc herniation <30%, discectomy with transpedicular fixation - for risk of disc herniation >30%.

Anterior percutaneous full-endoscopic transcorporeal decompression for cervical disc herniation: a finite element analysis and long-term follow-up study.

OBJECTIVE: The purpose of this study was to investigate the long-term consequences on the cervical spine after Anterior transcorporeal percutaneous endoscopy cervical discectomy (ATc-PECD) from the biomechanical standpoint. METHODS: A three-dimensional model of the normal cervical spine C2-T1 was established using finite element method. Subsequently, a disc degeneration model and degeneration with surgery model were constructed on the basis of the normal model. The same loading conditions were applied to simulate flexion, extension, lateral bending and axial rotation of the cervical spine. We calculated the cervical range of motion (ROM), intradiscal pressure, and intravertebral body pressure under different motions for observing changes in cervical spine biomechanics after surgery. At the same time, we combined the results of a long-term follow-up of the ATc-PECD, and used imaging methods to measure vertebral and disc height and cervical mobility, the Japanese Orthopaedic Association (JOA) score and visual analog scale (VAS) score were used to assess pain relief and neurological functional recovery. RESULTS: The long-term follow-up results revealed that preoperative JOA score, neck VAS score, hand VAS score, IDH, VBH, and ROM for patients were 9.49 ± 2.16, 6.34 ± 1.68, 5.14 ± 1.48, 5.95 ± 0.22 mm, 15.41 ± 1.68 mm, and 52.46 ± 9.36° respectively. It changed to 15.71 ± 1.13 (P < 0.05), 1.02 ± 0.82 (P < 0.05), 0.77 ± 0.76 (P < 0.05), 4.73 ± 0.26 mm (P < 0.05), 13.67 ± 1.48 mm (P < 0.05), and 59.26 ± 6.72° (P < 0.05), respectively, at 6 years postoperatively. Finite element analysis showed that after establishing the cervical spondylosis model, the overall motion range for flexion, extension, lateral bending, and rotation decreased by 3.298°, 0.753°, 3.852°, and 1.131° respectively. Conversely, after establishing the bone tunnel model, the motion range for these actions increased by 0.843°, 0.65°, 0.278°, and 0.488° respectively, consistent with the follow-up results. Moreover, analysis of segmental motion changes revealed that the increased cervical spine mobility was primarily contributed by the surgical model segments. Additionally, the finite element model demonstrated that bone tunneling could lead to increased stress within the vertebral bodies and intervertebral discs of the surgical segments. CONCLUSIONS: Long-term follow-up studies have shown that ATc-PECD has good clinical efficacy and that ATc-PECD can be used as a complementary method for CDH treatment. The FEM demonstrated that ATc-PECD can lead to increased internal stresses in the vertebral body and intervertebral discs of the operated segments, which is directly related to cervical spine degeneration after ATc-PECD.

Vertebral body and spinal cord infarction in a pile-driver operator with fibrocartilaginous disc embolism.

We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases.

The Differences on the Fatty Infiltration of Paraspinal Muscles between Single- and Multiple-level Intervertebral Disc Degeneration in Patients with Lumbar Disc Herniation.

OBJECTIVE: Multiple-level Intervertebral disc degeneration (IDD) in patients with lumbar disc herniation (LDH) is related to postoperative re-herniation and low back pain. Although many investigators believed that there is an interdependence between paraspinal muscles degeneration and IDD, few studies focused on the fatty infiltration of paraspinal muscles on single- and multiple-level IDD in patients with LDH. This study aims to investigate the difference on the fatty infiltration of paraspinal muscles between single- and multiple-levels IDD in patients with LDH. and to explore in patients with LDH whether fatty infiltration is a potential risk factor for multiple-level IDD. METHODS: This study was conducted as a retrospective observational analysis of 82 patients with LDH from January 1, 2020 to December 30, 2020 in our hospital were enrolled. Twenty-seven cases had single-level IDD (Group A), and 55 cases had multiple-level IDD (Group B). We measured the mean computed tomography (CT) density value of the paraspinal muscles, including multifidus (MF), erector spinae (ES) and psoas muscle (PM) at each disc from L1 to S1. Subgroups were set to further analyze the odds ratio (OR) of fatty infiltration of paraspinal muscles in different sex and BMI groups. We measured sagittal angles and analyzed the relationships between these angles and IDD. Finally, we use logistic regression, adjusted for other confounding factors, to investigate whether fatty infiltration is an independent risk factor for multi-level IDD. RESULTS: The average age in multi-level IDD (51.40 ± 15.47 years) was significantly higher than single-level IDD (33.37 ± 7.10 years). The mean CT density value of MF, ES and PM in single-level IDD was significantly higher than multi-level IDD (all ps < 0.001). There was no significant difference of the mean value of angles between the two groups. No matter being fat (body mass index [BMI] > 24.0 kg/m2) or normal, patients with low mean muscle CT density value of MF and ES are significantly easier to suffer from multiple-level IDD. In the pure model, the average CT density value of the MF, ES and PM is all significantly associated with the occurrence of multi-IDD. However, after adjusting for various confounding factors, only the OR of the average CT density value for MF and ES remains statistically significant (OR = 0.810, 0.834, respectively). CONCLUSIONS: In patients with LDH, patients with multiple-level IDD have more severe fatty infiltration of MF and ES than those with single-level IDD. Fatty infiltration of MF and ES are independent risk factors for multiple-level IDD in LDH patients.

SymTC: A symbiotic Transformer-CNN net for instance segmentation of lumbar spine MRI.

Intervertebral disc disease, a prevalent ailment, frequently leads to intermittent or persistent low back pain, and diagnosing and assessing of this disease rely on accurate measurement of vertebral bone and intervertebral disc geometries from lumbar MR images. Deep neural network (DNN) models may assist clinicians with more efficient image segmentation of individual instances (discs and vertebrae) of the lumbar spine in an automated way, which is termed as instance image segmentation. In this work, we proposed SymTC, an innovative lumbar spine MR image segmentation model that combines the strengths of Transformer and Convolutional Neural Network (CNN). Specifically, we designed a parallel dual-path architecture to merge CNN layers and Transformer layers, and we integrated a novel position embedding into the self-attention module of Transformer, enhancing the utilization of positional information for more accurate segmentation. To further improve model performance, we introduced a new data synthesis technique to create synthetic yet realistic MR image dataset, named SSMSpine, which is made publicly available. We evaluated our SymTC and the other 16 representative image segmentation models on our private in-house dataset and public SSMSpine dataset, using two metrics, Dice Similarity Coefficient and the 95th percentile Hausdorff Distance. The results indicate that SymTC surpasses the other 16 methods, achieving the highest dice score of 96.169 % for segmenting vertebral bones and intervertebral discs on the SSMSpine dataset. The SymTC code and SSMSpine dataset are publicly available at https://github.com/jiasongchen/SymTC.

Exploring deep learning strategies for intervertebral disc herniation detection on veterinary MRI.

Intervertebral Disc Herniation (IVDH) is a common spinal disease in dogs, significantly impacting their health, mobility, and overall well-being. This study initiates an effort to automate the detection and localization of IVDH lesions in veterinary MRI scans, utilizing advanced artificial intelligence (AI) methods. A comprehensive canine IVDH dataset, comprising T2-weighted sagittal MRI images from 213 pet dogs of various breeds, ages, and sizes, was compiled and utilized to train and test the IVDH detection models. The experimental results showed that traditional two-stage detection models reliably outperformed one-stage models, including the recent You Only Look Once X (YOLOX) detector. In terms of methodology, this study introduced a novel spinal localization module, successfully integrated into different object detection models to enhance IVDH detection, achieving an average precision (AP) of up to 75.32%. Additionally, transfer learning was explored to adapt the IVDH detection model for a smaller feline dataset. Overall, this study provides insights into advancing AI for veterinary care, identifying challenges and exploring potential strategies for future development in veterinary radiology.

Spinal magnetic resonance imaging in cats: differences in clinical significance of intervertebral disk extrusion, intervertebral disk protrusion, and degenerative lumbosacral stenosis.

OBJECTIVE: To determine the occurrence of degenerative changes affecting the vertebral column in cats, assess their clinical significance, and determine the occurrence in cats with intervertebral disk herniation compared to other spinal diseases. ANIMALS: 114 client-owned cats. METHODS: Hospital records were retrospectively reviewed for cats with suspected myelopathy that had undergone spinal MRI. Signalment; history; neurological examination; neurolocalization; primary diagnosis; presence, type, and location of intervertebral disk herniation; and presence and location of other degenerative spinal changes (intervertebral disk degeneration [IVDD], spondylosis deformans [SD], end plate changes, dorsal compressions [DC], and foraminal stenosis [FS]) were recorded. RESULTS: 70% of cats showed at least 1 spinal degenerative change. The most common change was IVDD, followed by SD and intervertebral disk protrusion (IVDP), while intervertebral disk extrusion (IVDE), end plate changes, DC, and FS were uncommon to rare. Primary complaint was attributed to a degenerative condition in 22% of cats, including 100% with IVDE, 9% with IVDP, and 43% with degenerative lumbosacral stenosis (DLSS). The occurrence of degenerative spinal changes and number of intervertebral disks affected by IVDD significantly increased with age and body weight. Age was positively correlated with the occurrence of SD and DLSS. Intervertebral disk degeneration, IVDP, SD, DC, and FS were more prevalent in the lumbosacral junction. Cats with IVDD were significantly more likely to show IVDE and IVDP. CLINICAL RELEVANCE: This study revealed that in a population of cats presenting for signs of myelopathy, IVDE was always responsible for the clinical presentation, DLSS was commonly considered incidental, and IVDP was infrequently related to neurological signs.

An Optimized CT Protocol for Detecting Suspected Cauda Equina Syndrome: A Comparative Analysis with MRI.

BACKGROUND AND PURPOSE: Lumbar disc herniation, potentially leading to nerve root compression and cauda equina syndrome, is typically evaluated using MR imaging. However, the limited availability of MR imaging outside regular hours in certain health care systems poses considerable challenges. This purpose of this study was to prospectively evaluate the diagnostic accuracy of an optimized CT lumbar spine protocol as a potential alternative to MR imaging in assessing suspected neural compression. MATERIALS AND METHODS: Patients presenting to the emergency department with suspected cauda equina syndrome or acute radicular symptoms secondary to lumbar disc herniation referred for MR imaging were prospectively enrolled for an additional CT optimized to assess spinal stenosis. An expert radiologist, blinded to clinical data, graded canal stenosis at each lumbar level on CT. The same grading process was applied to MR imaging after a 4-week interval to maintain blinding. RESULTS: Fifty-nine individuals were included in the final analysis. In 22 (39%) cases, no significant stenosis was identified. In a further 22 (37%) cases, disc pathology was identified that was managed conservatively. Thirteen (22%) individuals proceeded to urgent surgical decompression. In 1 (2%) instance, an alternative diagnosis was identified. Compared with MR imaging, the sensitivity, specificity, and positive and negative predictive values for CT in detecting disc pathology in patients presenting with symptoms suggestive of acute neural compression were 97% (95% CI, 82%-99%), 97% (95% CI, 83%-99%), 97% (95% CI, 92%-99%), and 97% (95% CI, 83%-99%), respectively. CT accurately identified all cases requiring urgent decompression. CONCLUSIONS: CT accurately predicted MR imaging findings in patients with suspected cauda equina and nerve root compression, demonstrating its utility as an adjunct tool for patient triage in emergency settings with limited MR imaging access. This protocol could enhance the allocation of emergency resources by appropriately selecting patients for emergent MR imaging.

Cervical syringomyelia associated with cervical disc disease.

Background and purpose:

Syringomyelia is a neurological condition in which a longitudinal fluid-filled cavity is formed within the spinal cord. It usually occurs in the cervical region and is associated with Chiari malformation, infections, trauma, and tumors of the spinal cord. However, syringomyelia associated with cervical disc disease (SCD) is very rare and only a few cases have been reported so far. This case report presents the clinical and radiological findings of 13 cases of SCD to describe the properties of SCD and explore the nature of the relationship between syringomyelia and cervical disc disease.

SCD was diagnosed in 13 using MRI findings, including coexistence of syringomyelia and cervical disc disease, presence of narrowed cervical subarachnoid space secondary to the cervical disc herniation or cervical local kyphosis associated with cervical disc degeneration or herniation, and the cervical disc herniation or segmental kyphosis and syrinx should be located within the same levels. The MRI findings were used to grade the syrinx and determine whether the cervical disc herniation or local kyphosis was located at the proximal or distal end of the syrinx.

All patients had single-level disc herniation or kyphosis, the most common level being C5–6 (n = 6), followed by C6–7 (n = 4) and C4–5 (n = 3). Eight patients had a distal type (disc disease located in the proximal end of the syrinx) SCD while five had the proximal variety (cervical disc disease located in the distal end of the syrinx). The average length of the syrinx was two vertebral segments. Surgery was performed in five cases and some degree of syrinx resolution was observed in all of them.
Discussion – The main cause of syringomyelia is obstruction of cerebrospinal fluid (CSF) pathways; total obstruction could cause distal syrinx, whereas partial obstruction could cause proximal or distal syrinxes. Restoration of CSF pathways may result in some degree of resolution of syringomyelia. A causal association may exist between cervical disc disease and cervical syringomyelia but needs further exploration.

SCD is a mild form of syringomyelia with symptoms primarily arising due to disc herniation or local kyphosis. The surgical treatment of the cervical disc disease is sufficient and results in a syringomyelia resolution of some degree.

Exploration of the correlation between facet joints cross-sectional area asymmetry and cervical disc herniation.

PURPOSE: To evaluate the association between facet joints cross-sectional area asymmetry (FCAA) and cervical intervertebral disc herniation (CDH). METHODS: Overall, we retrospectively recruited 390 consecutive patients with CDH who underwent surgical treatment at our institution and 50 normal participants. Clinical variables and radiological findings related to CDH were collected. RESULTS: Patients with CDH were more likely to have a higher absolute value of the facet asymmetry factor (FAF) (p < .001), in which the FAF value of the left group was significantly higher than the other groups (p < .001) and the right group was lower than the central group (p < .001). 9.62% (C3/4), 12.19% (C4/5), 8.70% (C5/6), and 8.14% (C6/7) were determined as cutoff values for each variable that maximized sensitivity and specificity. Furthermore, multivariate analysis showed that cross-sectional area asymmetry of the facet joint (FCAA) was an independent risk factor for the occurrence of CDH. Also, the Chi-square test showed a significant difference in the distribution of the degeneration classification of the disc between the facet-degenerated group and the nondegenerated group at C5/6 (p = 0.026) and C6/7 (p = 0.005) in the facet asymmetry (FA) group. CONCLUSIONS: FCAA is evaluated as an independent risk factor for CDH and associated with the orientation of disc herniation. And facet joint orientation may also play a role in cervical spine degeneration rather than facet joint tropism.

Semantic contrast with uncertainty-aware pseudo label for lumbar semi-supervised classification.

BACKGROUND: Lumbar disc herniation (LDH) is a prevalent spinal disease that can result in severe pain, with Magnetic resonance imaging (MRI) serving as a commonly diagnostic tool. However, annotating numerous MRI images, necessary for deep learning based LDH diagnosis, can be challenging and labor-intensive. Semi-supervised learning, mainly utilizing pseudo labeling and consistency regularization, can leverage limited labeled images and abundant unlabeled images. However, consistency regularization solely focuses on maintaining the semantic consistency of transformed unlabeled data but fails to utilize the semantic information from labeled data to guide the unlabeled data, and additionally, pseudo labeling is prone to confirmation bias. METHOD: We propose SeCoFixMatch, an innovative approach that seamlessly integrates semantic contrast and uncertainty-aware pseudo labeling into semi-supervised learning. Semantic contrast constraints the semantic consistency between labeled and unlabeled images. Pseudo labels are generated by combining predictive confidence and uncertainty, with uncertainty computing by optimizing the Kullback-Leibler (KL) loss between predictive and target Dirichlet distribution. RESULTS: Comparison with other semi-supervised models and ablation experiment with varying labeled data demonstrate the effectiveness and generalization of proposed model. Notably, SeCoFixMatch, trained with just 40 labels, outperforms the baseline model trained with 200 labels, reducing the annotation effort by a remarkable 80%. CONCLUSIONS: Proposed pseudo labeling algorithm generates more precise pseudo labels for semantic contrastive learning and semantic contrastive learning facilitates better feature representation, thereby further improving the prediction accuracy of pseudo label. The mutual reinforcement of pseudo labeling and semantic contrast constraints boosts the performance of semi-supervised algorithm.

Thoracolumbar hydrated nucleus pulposus extrusion and intervertebral disc extrusion in dogs: Comparison of clinical presentation and magnetic resonance imaging findings.

Thoracolumbar hydrated nucleus pulposus extrusion (TL-HNPE) is an increasingly recognised pathology with a substantial lack of literature describing its features. The aim of this retrospective case-control study was to analyse the clinical and magnetic resonance imaging (MRI) features of dogs with TL-HNPE compared to dogs affected with thoracolumbar intervertebral disc extrusion (TL-IVDE). Data from dogs diagnosed with TL-HNPE and TL-IVDE via MRI at two referral hospitals, were retrospectively collected and compared in terms of clinical signs and MRI features. Cases diagnosed with TL-IVDE were deemed controls. The MRI features of the affected IVD space, herniated IVD material, affected overlying spinal cord and local epaxial musculature were evaluated for each group. Fifty-one cases with TL-HNPE and 105 randomly selected cases of TL-IVDE were included. Several signalment and neurological signs were identified as statistically distinct between groups in univariate analysis. Multivariate analysis identified that dogs affected with TL-HNPE were typically older, less likely to be chondrodystrophic (62.2 % vs. 91 %), more frequently experiencing a peracute onset (90.2 % vs. 61.9 %) often attributed to a suspected trauma linked with exercise (37.3 % vs. 10.5 %), being less frequently progressive (41.2 % vs. 86.5 %) and with herniated disc material less frequently lateralised (72.6 % vs. 89.5 %) than cases with TL-IVDE. MRI-identifiable intervertebral disc degeneration was found in every TL-IVDE case but only in 60 % of TL-HNPE cases. TL-HNPEs were associated to significantly less spinal cord compression and less hyperalgesia than TL-IVDE.

The Value of 3D SPACE MRI in Differentiating between Sequestrated Lumbar Disc Herniation and Tumors: Two Cases and Literature.

Background: Intervertebral disc herniation, defined as the protrusion or extrusion of the disc mass outside the disc space, is common and easy to diagnose on conventional Magnetic Resonance imaging (MRI) or Computed Tomography (CT) scans. However, the sequestrated disc fragments are challenging to detect, and intervertebral disc mass displacement into the dural sac, which can lead to serious neurological problems such as Cauda equina syndrome (CES). The sequestrated disc fragments do not have specific clinical or radiological characteristics that can differentiate an atypical disc mass from a tumor, making the diagnosis difficult preoperatively. Herein, we describe the use of Sampling Perfection with Application Optimized Contrast using different flip angle Evolution in Magnetic Resonance Imaging (3D SPACE MRI) in the diagnosis of the intervertebral disc fragment that mimicked a tumor. Case presentation: In this study, we report two cases of sequestered lumbar disc herniation. The first case was a 37-year-old patient with a 2-year history of intermittent left lower limb pain that aggravates with exercise and is relieved at rest, while the second case was a 42-year-old patient with a history of 40 days of numbness and pain in the left lower limb. Conclusion: 3D SPACE MRI is a beneficial diagnostic imaging tool for discriminating between disc mass that mimics a tumor and a tumor before surgery. If the disc fragment mimicking a tumor can be identified before the operation, open surgical treatment won't be necessary for all patients.

Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better?

OBJECTIVE: To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes. BACKGROUND: Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH. METHODS: A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal. RESULTS: This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01). CONCLUSIONS: No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.

Brain effect mechanism of lever positioning manipulation on LDH analgesia based on multimodal MRI: a study protocol.

INTRODUCTION: The clinical symptoms of Lumbar Disc Herniation (LDH) can be effectively ameliorated through Lever Positioning Manipulation (LPM), which is closely linked to the brain's pain-regulating mechanisms. Magnetic Resonance Imaging (MRI) offers an objective and visual means to study how the brain orchestrates the characteristics of analgesic effects. From the perspective of multimodal MRI, we applied functional MRI (fMRI) and Magnetic Resonance Spectrum (MRS) techniques to comprehensively evaluate the characteristics of the effects of LPM on the brain region of LDH from the aspects of brain structure, brain function and brain metabolism. This multimodal MRI technique provides a biological basis for the clinical application of LPM in LDH. METHODS AND ANALYSIS: A total of 60 LDH patients and 30 healthy controls, matched by gender, age, and years of education, will be enrolled in this study. The LDH patients will be divided into two groups (Group 1, n = 30; Group 2, n = 30) using a random number table method. Group 1 will receive LPM treatment once every two days, for a total of 12 times over 4 weeks. Group 2 will receive sham LPM treatment during the same period as Group 1. All 30 healthy controls will be divided into Group 3. Multimodal MRI will be performed on Group 1 and Group 2 at three time points (TPs): before LPM (TP1), after one LPM session (TP2), and after a full course of LPM treatment. The healthy controls (Group 3) will not undergo LPM and will be subject to only a single multimodal MRI scan. Participants in both Group 1 and Group 2 will be required to complete clinical questionnaires. These assessments will focus on pain intensity and functional disorders, using the Visual Analog Scale (VAS) and the Japanese Orthopaedic Association (JOA) scoring systems, respectively. DISCUSSION: The purpose of this study is to investigate the multimodal brain response characteristics of LDH patients after treatment with LPM, with the goal of providing a biological basis for clinical applications. TRIAL REGISTRATION NUMBER: https://clinicaltrials.gov/ct2/show/NCT05613179 , identifier: NCT05613179.

The radio anatomical arrangement of nerve roots at L3 level in cauda equina sac is it affected by diseases?

An observational study to discover the common conditions affecting the lumbosacral region that may affect lumbosacral position and tension. All the patients, underwent MRI exaamination (magnetic resonance imaging) in the supine position, were examined by the same consultant radiologist. The article was revised by the institutional ethical approval committee. The position of the nerve roots was observed, and the number of nerve roots was calculated anterior to a line passing between the mid-transvers process of L3(third lumbar vertebra). The number of nerve roots ahead of this line was calculated by the radiologist at the level of the right intervertebral foramen and at the left one. This procedure was applied to the normal group, and 5 common pathological diseases were repeated including single-level lumbar disc prolapse, multiple-disc prolapse, multiple bulge, spinal stenosis and spondylolisthesis (at the level of L45 (fourth to fifth lumbar vertebrae) or L5S1 (fifth lumbar to first sacral vertebrae) being outside the study area, i.e., L3). We noticed significant difference in the number of the nerve roots between the cases with herniated discs, spinal stenosis, and spondylolisthesis with the normal group and the significance was in ascending increment in significance being the highest in cases with spondylolisthesis, and even in the groups of other pathologies which are statistically not significant, we noticed that the significance is proportional to the severity of the disease being the least in single level cases (p 0.427), to be more significant on cases with multiple prolapses(p 0.319) to be more in cases with multiple bulges to start to be statistically significant in herniated, higher significance in cases with spinal stenosis to be the highest in cases with spondylolisthesis.