Lumbar Disc Replacement Surgery

By Jaimig Aljorna

Lumbar disc replacement is a surgical option for some people with degenerative disc disease.   When do doctors recommend it? The 24 bones of the spine (called vertebrae) distribute in the form of a column. The vertebrae support and protect the spinal cord and its numerous nerves. The soft discs between each vertebral bone allow…

A morphological study of lumbar vertebral endplates: radiographic, visual and digital measurements.

By London Spine
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A morphological study of lumbar vertebral endplates: radiographic, visual and digital measurements.

Eur Spine J. 2012 Nov;21(11):2316-23

Authors: Wang Y, Battié MC, Videman T

Abstract
PURPOSE: Clinical observations suggest that endplate shape and size are related to complications of disc arthroplasty surgery. Yet, the morphology of the vertebral endplate has not been well defined. This study was conducted to characterize the morphology of lumbar vertebral endplates and to quantify their morphometrics using radiographic, visual and digital measures.
METHODS: A total of 591 vertebral endplates from 76 lumbosacral spines of men were studied (mean age 51.3 years). The shape of the vertebral endplates was classified as concave, flat and irregular, and was evaluated from both radiographs and cadaveric samples. Each endplate was further digitized using a laser scanner to quantify diameters, surface area and concavity for the whole endplate and its components (central endplate and epiphyseal rim). The morphological characteristics and morphometrics of the vertebral endplates were depicted.
RESULTS: In both radiographic and visual assessments, more cranial endplates (relative to the disc) were concave and more caudal endplates were flat at all disc levels (p < 0.001). On average, the mean concavity depth was 1.5 mm for the cranial endplate and 0.7 mm for the caudal endplate. From L1/2 down to L5/S1 discs, the vertebral endplate gradually changed into a more oval shape. The central endplate was approximately 70% of the diameter of the whole endplate and the width of the epiphyseal rim varied from 3 to 7 mm.
CONCLUSIONS: There is marked morphological asymmetry between the two adjacent endplates of a lumbar intervertebral disc: the cranial endplate is more concave than the caudal endplate. The size and shape of the vertebral endplate also vary considerably between the upper and lower lumbar regions.

PMID: 22743647 [PubMed – in process]

Association of abdominal obesity with lumbar disc degeneration – a magnetic resonance imaging study.

By London Spine
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Association of abdominal obesity with lumbar disc degeneration – a magnetic resonance imaging study.

PLoS One. 2013;8(2):e56244

Authors: Takatalo J, Karppinen J, Taimela S, Niinimäki J, Laitinen J, Sequeiros RB, Samartzis D, Korpelainen R, Näyhä S, Remes J, Tervonen O

Abstract
PURPOSE: To evaluate whether midsagittal (abdominal) obesity in magnetic resonance imaging (MRI), waist circumference (WC) and body fat percentage are associated with lumbar disc degeneration in early adulthood.
METHODS: We obtained the lumbar MRI (1.5-T scanner) of 325 females and 233 males at a mean age of 21 years. Lumbar disc degeneration was evaluated using Pfirrmann classification. We analysed the associations of MRI measures of obesity (abdominal diameter (AD), sagittal diameter (SAD), ventral subcutaneous thickness (VST), and dorsal subcutaneous thickness (DST)), WC and body fat percentage with disc degeneration sum scores using ordinal logistic regression.
RESULTS: A total of 155 (48%) females and 147 (63%) males had disc degeneration. AD and SAD were associated with a disc degeneration sum score of ≥3 compared to disc degeneration sum score of 0-2 (OR 1.67; 95% confidence interval (CI) 1.20-2.33 and OR 1.40; 95% CI 1.12-1.75, respectively) among males, but we found no association among females. WC was also associated with disc degeneration among males (OR 1.03 per one cm; 95% CI 1.00-1.05), but not among females.
CONCLUSION: Measures of abdominal obesity in MRI and waist circumference were associated with disc degeneration among 21-year-old males.

PMID: 23418543 [PubMed – in process]

Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients.

By London Spine
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Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients.

Arch Orthop Trauma Surg. 2010 Jan;130(1):111-8

Authors: Uchida K, Nakajima H, Yayama T, Sato R, Kobayashi S, Chen KB, Mwaka ES, Baba H

Abstract
INTRODUCTION: The aim of this study was to review the patients with lumbar epidural abscess in terms of neurological morbidity, therapeutic outcome, and prognosis, while assessing the usefulness of a new MRI staging classification and specific imaging findings as indicators for surgical management.
MATERIALS AND METHODS: We reviewed 37 patients who sustained epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine. Ten patients were treated conservatively, while 27 required urgent or elective surgical drainage. We studied patients with respect to symptomatology, Frankel-American Spinal Injury Association (ASIA) scale evaluation and a new proposed system of MRI staging of pyogenic spondylodiscitis (stages I–V).
RESULTS: Of the 37 patients with stage IV and V MRI lesions, 13 (35%) had septicemia and 8 (22%) presented with Frankel-ASIA scale C-D neurological status. All cases with ringlike enhancement on gadolinium-enhanced MRI in the epidural abscess lesions were treated surgically. Progression of local kyphosis and loss of intervertebral disk height were significantly prevented in the surgical group (P < 0.05). Improvements of neurological status and laboratory data were better in the surgical group than the conservative group (P < 0.05), with significantly short hospital stay (P < 0.05).
DISCUSSION: Epidural abscess associated with pyogenic spondylodiscitis presents with various neurological symptoms. In addition to assessment of progression by clinical symptomatology, modified neurological Frankel-ASIA scaling and the currently proposed MRI staging regimen may help to consider the timing of surgical intervention. In the acute, subacute or acute-on-chronic phase and the ringlike enhancement pattern of epidural abscess on gadolinium-enhanced MRI may be an indicator for surgery.

PMID: 19565251 [PubMed – indexed for MEDLINE]

Abnormal uterine bleeding following lumbar epidural corticosteroid injections and facet medial branch blocks in both pre- and postmenopausal women: a case series.

By London Spine
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Abnormal uterine bleeding following lumbar epidural corticosteroid injections and facet medial branch blocks in both pre- and postmenopausal women: a case series.

Pain Med. 2012 Sep;13(9):1137-40

Authors: Hirsch JG, Hsu ES

Abstract
BACKGROUND: Epidural steroid injections (ESIs) are now increasing in popularity with regard to the management of chronic lumbar radiculopathy. While ESIs have been shown to be effective in relieving low back and radicular pain, adverse reactions have also been reported, notably abnormal vaginal bleeding.
OBJECTIVE: We present a case series of four women, both pre- and postmenopausal, with chronic lumbar radiculopathy and corresponding pathology who developed abnormal vaginal bleeding after receiving either ESIs or facet medial branch blocks (MBBs) for pain management. Setting.  University of California, Los Angeles.
PATIENTS: Four women, both pre- and postmenopausal.
CONCLUSIONS: We discuss the potential effects of corticosteroids on the hypothalamic-pituitary-ovarian axis and highlight our patients’ risk factors for abnormal vaginal bleeding, both exogenous and endogenous, as well as focus on the technical approaches to corticosteroid administration utilized in our patients’ procedures. We acknowledge that because this is a small case series, further prospective investigation is warranted regarding the above topics. Until then, it may be beneficial to consider whether patients, both pre- and postmenopausal, have risk factors for abnormal uterine bleeding prior to undergoing interventional pain management strategies, specifically ESI and MBB, and to inform all women upon consent that abnormal vaginal bleeding is a potential risk following procedures with corticosteroids.

PMID: 22845001 [PubMed – in process]

Long-term results of percutaneous lumbar decompression mild(®) for spinal stenosis.

By London Spine
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Long-term results of percutaneous lumbar decompression mild(®) for spinal stenosis.

Pain Pract. 2012 Mar;12(3):184-93

Authors: Mekhail N, Vallejo R, Coleman MH, Benyamin RM

Abstract
BACKGROUND: Lumbar spinal stenosis (LSS) generally occurs from a combination of degenerative changes occurring in the lumbar spine. These include hypertrophy of ligamentum flavum, facet joint arthritic changes and bulging of the intervertebral disk. Spinal stenosis leads to compression of the lumbar neural elements (cauda equina), which manifests as low back and leg pain especially on standing and walking known as “neurogenic claudication.” Current treatment options for LSS are varied. Conservative management, including physical therapy with/without epidural steroid injections, may be adequate for mild stenosis. Surgical decompression is reserved for severe cases and results in variable degrees of success. Patients with moderate-to-severe LSS having ligamentum flavum hypertrophy as a key contributor are generally inappropriately treated or undertreated. This is due to ineffectiveness of conservative therapy and possibility that major surgical compression might be too aggressive. Percutaneous decompression offers a possible solution for this patient population.
METHODS: One-year follow-up study was conducted at 11 U.S. sites. Study cohort included 58 mild(®) percutaneous decompression patients who underwent 170 procedures, the majority treated bilaterally at one or two lumbar levels. Outcome measures included the visual analog scale (VAS), Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and SF-12v2(®) Health Survey.
RESULTS: No major mild(®) device or procedure-related complications were reported. One-year data showed significant reduction of pain as measured by VAS. Improvement in physical functionality, mobility, and disability was significant as measured by ZCQ, SF-12v2, and ODI.
CONCLUSIONS: At 1 year this 58-patient cohort demonstrated continued excellent safety profile of the mild(®) procedure and equally important, showed long-term pain relief and improved functionality.

PMID: 21676166 [PubMed – indexed for MEDLINE]