Alleviating Paravertebral Muscle Spasm after Radiofrequency Ablation Treatment of Hypersensitive Basivertebral and Sinuvertebral Nerves for Chronic Discogenic Back Pain

BACKGROUND: Paraspinal muscle spasm caused by pain from a lumbar degenerative disc is frequently investigated in patients with low back pain. Radiofrequency ablation (RFA) surgery could alleviate paraspinal muscle spasms. OBJECTIVES: We performed RFA surgery on the high-intensity zone (HIZ) and hypersensitive sinuvertebral and basivertebral nerves to evaluate its outcome. The paravertebral muscle cross-sectional area (CSA) was measured on magnetic resonance imaging (MRI) before and after surgery to evaluate the effect of RFA surgery on the paravertebral muscle. STUDY DESIGN: Prospective cohort study. SETTING: A single spine surgery center. METHODS: A comparative study was performed on 2 different uniportal spinal endoscopic surgery groups; 23 patients who underwent RFA surgery for chronic discogenic back pain and 45 patients who underwent posterior decompression surgery for lumbar spinal stenosis with 12 months of follow-up. Paravertebral muscle cross-sectional area, Schiza grade, Modic type, and HIZ size were measured on pre- and post-operative MRI. An endoscopic video review was performed to evaluate the presence of intraoperative twitching and grade the degree of epidural neovascularization and adhesion. Visual analog scale VAS, modified Oswestry Disability Index, ODI and MacNab’s criteria were evaluated for outcome measures. RESULTS: Intraoperative endoscopic video evaluation showed neovascularization and adhesion adjacent to the disc and pedicle. In the RFA surgery group, there were 7 patients (30.43%) with grade 2 and 16 (69.57%) with grade 3 neovascularization; intraoperative twitching was observed in 19 out of 23 patients (82.61%). After performing an RFA on the sinuvertebral and basivertebral nerves for the treatment of discogenic back pain, the results showed significant improvement in pain and disability scores. The mean CSA of the paraspinal muscle in the RFA surgery group was significantly increased after surgery at the L4–L5 and L5–S1 levels (L4–L5: 3901 ± 1096.7 mm² to 4167 ± 1052.1 mm², P = 0.000; L5-S1: 3059 ± 968.5 mm² to 3323 ± 1046.2 mm², P = 0.000) compared to preoperative CSA. LIMITATIONS: This study was limited by its small sample size. CONCLUSION: Hypersensitive sinuvertebral and basivertebral nerves are strongly associated with epidural neovascularization with adhesion and the pathological pain pathway in degenerative disc disease. Epidural neovascularization with adhesion reflects aberrant neurological connections, which are associated with reflex inhibitory mechanisms of the multifidus muscle, which induces spasm. RFA treatment of the region of epidural neovascularization with adhesion effectively treated chronic discogenic back pain and could induce paraspinal muscle spasm release. KEY WORDS: Discogenic back pain, high-intensity zone, sinuvertebral nerve, basivertebral nerve, radiofrequency ablation, multifidus muscle

Analysis of Factors Affecting the Clinical Course in C5 Palsy: A Korean Cervical Spine Study Group (KCSSG) Multicenter Cohort Study

The development of C5 palsy is a serious, well-documented complication after cervical spine surgery. Therefore, a more precise and extensive analysis of C5 palsy is required. The present study aimed to evaluate the characteristics and clinical course of C5 palsy using a Korean Cervical Spine Study Group (KCSSG) database. A retrospective review of clinical and radiological data was performed for 85 patients who had C5 palsy. We investigated multiple clinical factors [main pathology, pre-operative symptoms, surgical method, symptom duration, operation method, side of C5 palsy, C5 palsy grade and onset time, course of recovery from C5 palsy, and Japanese Orthopedic Association score] and radiological factors [C4–5 foramen diameter, occupying ratio, T2HIZ (high intensity zone in T2 weighted magnetic resonance image)] .On multivariate analysis, old age (OR 12.73 [95% CI 1.1-147.37]), posterior approach (OR 39.16 [95% CI 2.24-682.31], radiculopathy (OR 13.5 [95% CI 1.06-171.2]), OPLL(OR 13.7 [95% CI 1.33-140.77]), C2-7 angle (pre-OP; OR 0.83 [95% CI 0.71-0.98, post-OP; OR 1.26 [95% CI 1.03-1.53]) were the predictor for early onset of C5 palsy. Small dimension of C4-5 foramen (OR 0.58 [95% CI 0.37-0.92]) and less degree of cord rotation (pre-OP, OR 0.83 [95% CI 0.72-0.96]), were the predictor for severe status of C5 palsy. The clinical course of C5 palsy (onset and severity) was influenced by age, pre-operative symptom, surgical approach, main pathology, C2-7 angle, T2HIZ grade, pre-operative cord rotation and C4-5 foramen diameter.

Prevalence of High Intensity Zone in Lumbar Spine and its Correlation with Lumbar Disc Degeneration in Patients Attending Tertiary Hospital of Eastern Nepal

Introduction: A high intensity zone (HIZ) in intervertebral disc (IVD) of lumbar spine is a high intensity signal located in the annulus fibrosus of T2-weighted magnetic resonance (MR) imaging. There is limited information on the prevalence of HIZ in lumbar spine in Nepalese population. The aim of this cross-sectional study was to identify the prevalence of HIZ according to the age and its correlation with degenerated disc, disc herniation & bulge and modic changes. Methods: This was a prospective MR based study in 268 patients (1380 IVD) with LBP, Leg pain or numbness. The prevalence and correlation of HIZ , degenerated disc, disc herniation and bulge and modic change was evaluated in 5 age groups (<20, 20-39, 40-59, 60-79, >80). Results: The prevalence of HIZ in patients with LBP was 30.5%. Total 1340 IVD were examined out of which122 had HIZ, 742 had degenerated disc, 688 had disc herniation and bulge and 182 had modic changes. Degenerated disc was observed in 95% (116/122) and 51.3% (626/1218) of disc with and without HIZ respectively. Disc herniation and bulge were observed in 98.3% (120/122) and 46.6% (568/1218) of the disc with and without HIZ, respectively. Modic changes were observed in 11.4% (14/122) and 13.7% (168/1218) of disc with and without HIZ respectively. Conclusions: There was statistically significant correlation between existence of HIZ and degenerated discand disc herniation and bulge, but there was no correlation with the existence of modic changes.

Expression and Distribution of M1 and M2 Macrophages in the Degeneration Process of Human Lumbar Intervertebral Disc Herniation: A Histological and Clinical Efficacy Analysis

Background: Macrophages were previously proved to participate in the progression of lumbar disc herniation (LDH), but the phenotypic subtypes of macrophages and the association between M1/M2 positivity and clinical efficacy in LDH are not understood. This study aimed to determine the expression and distribution of M1 and M2 macrophages in LDH and investigate the association between M1/M2 positivity and outcome of LDH therapy. Methods: Immunohistochemical analyses of M1 and M2 markers were used to identify M1/M2 macrophages and their prevalence and distribution in LDH patients. The association among prevalence, clinical characteristics, and clinical efficacy was evaluated. Differences in the presence of M1 and M2 macrophages with or without modic changes (MCs) and those in the high-intensity zone (HIZ) were also analyzed. Results: The induced nitric oxide synthase (iNOS) and CD206 were expressed in all 79 LDH patients tested. The morphology and distribution of iNOS+ and CD206+ cells varied at different degenerative LDH stages. iNOS+ cells significantly decreased with increasing Pfirrmann grade and age, whereas CD206 cells increased. iNOS+ cells showed a positive correction with visual analog scale scores, while CD206+ exhibited positive correction with the Oswestry disability index on pre-operative day 3. A significant increase in iNOS+ cells was observed in the HIZ, whereas more CD206+ cells were found in MC tissues. Conclusions: Differences in morphology and distribution of M1/M2 cells in LDH suggested that these cells originated from both recruited and resident macrophages. Significantly different expression in MCs and the HIZ and significant correlation with clinical efficacy indicated the important role of the M1/M2 transition in the immune and inflammatory response in LDH. Management of the M1/M2 transition may be a feasible approach for preventing LDH.

Anterior High-Intensity Zone in Lumbar Discs: Prevalence and Association with Low Back Pain

Objectives To explore the features of high-intensity zone (HIZ) in anterior annulus fibrosus and assess the association of anterior HIZ with low back pain (LBP). Design, Setting, and Subjects A retrospective study of 5,940 discs in 1,188 individuals was conducted. Methods Subjects’ information and LBP symptoms confirmed by an orthopedic surgeon were acquired from the medical record. Magnetic resonance (MR) image reading and analysis were performed by two experienced blinded radiologists. Results Two hundred eighty individuals exhibited 355 anterior HIZs in 355 discs. The prevalence was 23.57%; 88.45% were located in the inferior part of the annulus fibrosus. It frequently occurred in the middle and upper segments of lumbar spine, especially at L3/4 (45.63%). Of the 355 anterior HIZs, only 79 (22.25%) were consecutive-slides HIZ. Round type (63.38%) was the most common shape of anterior HIZs. The highest prevalence was found in individuals aged 60–69 years. LBP was confirmed in 141 anterior-HIZ individuals. The incidence of LBP in anterior-HIZ individuals was significantly higher than in non-HIZ subjects (50.36% vs 35.24%, χ2 = 18.314, P &lt; 0.001). Conclusions Anterior HIZ is a lower-prevalence, age-related sign on lumbar MR images. The spatial distribution of anterior HIZ can be distinguished from posterior HIZ. The number of consecutive anterior HIZ slides might suggest fewer Dallas grade 4 anterior annular disruptions in this sample. Anterior HIZ was correlated with LBP.

EFFECT OF SMALL-SIDED GAMES RULE CHANGES ON TIME SPENT IN DIFFERENT INTENSITY ZONES, FREQUENCY OF TECHNICAL ACTIONS AND DISTANCE COVERED DURING SOCCER TRAINING

Purpose: The efficacy of SSGs has been difficult to assess as researchers have used a wide-ranging number of players, pitch dimensions and game rules, making comparisons complicated. Therefore this study compared four SSG rules [one (SSG1T), two (SSG2T), three (SSG3T), and unlimited touches (SSGFT)] on time spent in different heart-rate (HR) intensity zones, frequency of technical actions and distance covered involving the starting 11 players and the reserve goalkeeper of a national soccer league team. Methods: The participants (age: 24.3±4.0 yr; height: 171.2±5.9 cm: weight: 61.9±7.4 kg) were measured for previously mentioned dependent variables during each SSG format. Results: Analysis found no significant difference among the four SSGs formats [F(3, 27) = 2.897, p = .053] for time spent in the low-intensity zone, but significant differences were observed for time spent in moderate [F(3, 27) = 13.642, p = .001] and high [F(3, 27) = 13.431, p = .001] intensity zones. Significantly more time was spent in the high intensity zone [F(3, 27) = 13.431, p = .001] when players performed SSG2T and SSGFT when compared SSG1T (p = .002 and p = .009) respectively. SSG1T induced most unsuccessful passing [F(3,27) = 500.498, p = .001] but no differences was observed among SSG2T, SSG3T and SSGFT. SSG2T, SSG3T and SSG3T obtained significantly more shots on goal shots on goal [F(3,27) = 25.398, p = .001], with SSGFT achieving higher numbers than the other three formats. There were no significant differences in goals scored (p = .537) and distance covered (p = 0.574) for all SSG formats. Conclusion: The main findings of this study revealed that all four SSG formats stimulated moderate to high heart rate intensities that could induce positive aerobic and anaerobic adaptations depending on frequency of technical actions and players’ skill level. Therefore coaches could select specific SSG formats to help players achieved intended intensity and technical objectives programmed for different phases of periodized training.

Cardiovascular Responses During Indoor Soccer Competition

In this study, the aim was to investigate the cardiovascular responses that happen in players during indoor soccer (IS) competitions. Nine participants, indoor soccer players in the Universities League, took part in the study (20.66 ± 1.87 age; 177 ± 4.5 height; 73.33 ± 8.07 weight). Cardiovascular changes happening during the competition were measured through a heart rate (HR) monitor that records once per second (Polar V800, Lake Success, NY, USA), and running distances by the Polar GPS (Polar V800, Lake Success, NY, USA) system. Maximum oxygen usage capacity of the participants (VO2max) was determined by using Yo-yo intermittent recovery test level 1, one of the indirect measurement methods. Cardiovascular loads coming out during the competition were separated into three zones for the sake of better understanding: HRmax 70%, low-intensity zone; HRmax between 70-85%, moderate intensity zone; and HRmax 85% and over, high intensity zone. Descriptive statistics were used in the assessment of the data obtained. The average distance that the participants covered, according to the GPS measurements, was found to be 1617 ± 873 m, on average VO2max 47.33 ± 4,47ml.kg per min-1. The participants spent 72,2% of the time that they were active in the game in the high intensity zone. The fact that participants spent a high percentage of time in this zone that consisted of high intensity activities clearly showed that indoor soccer is an intermittent high intensity branch of sports. Participants spent 15,8% in the low intensity zone indicating that repetitive loads without the opportunity for recovery could be found. Having a high percentage of high intensity activity may negatively affect performance because of fatigue; thus, it is important to organize the optimum in-play time for the indoor soccer players to get better performance.