This thesis describes the development of artificial disc technology for the replacement of intervertebral discs in the human lumbar spine. The clinical problem is back pain. There may be a relationship between certain forms of back pain and disc degeneration. The mechanical properties of human intervertebral discs are examined in detail. The genetic basis of disc degeneration is presented. The hypothesis is that such degeneration leads to a loss of normal stiffness in the segments affected leading to abnormal mechanical behaviour which in turn leads to pain. The evidence for this is presented. The development of surgical solutions to relieve back pain, from fusion through first generation mechanical artificial discs to elastomeric designs, is traced. The author‘s personal contributions to this area of knowledge are set out. The appreciation of the requirement for a restoration of physiological stiffness is argued throughout, showing where fusion and first generation discs have not met the clinical aim of pain relief, because they have not restored physiological stiffness. The path to an elastomeric, viscoelastic, polyhydrocarbon, rubber solution in the form of the “Freedom“ disc has filled 17 years of the author‘s academic pursuits. It will be shown that this technology may represent a possible solution to the clinical problem. Failure is part of all new advancement and this too is presented, to show how that has influenced thinking, producing original ideas to overcome these failures. Providing lessons are learned from these failures then our patients in the future will benefit.

A dor lombar acomete a humanidade desde tempos remotos, tendo seus primeiros relatos descritos no \"Papiro de Edwin Smith\" (1500 a.C.). Acredita-se que durante a vida até 90% da população terá pelo menos um episódio de dor lombar, sendo tal patologia uma das principais causas de afastamento do trabalho, acarretando em vultosos prejuízos financeiros anuais. Cinco a 10% dos pacientes que possuem lombalgia também apresentam dor irradiada para o membro inferior (ciatalgia) e esta última, 85% das vezes é secundária à hérnia de disco lombar (HDL), cuja prevalência anual na população geral é estimada em 2.2%. O objetivo deste estudo foi avaliar a eficácia da aplicação do laser diodo de 980 nm intradiscal no tratamento da ciatalgia em pacientes portadores de hérnias lombares contidas em comparação com o grupo controle. Vinte e cinco pacientes (30 discos intervertebrais) com HDL e dor neuropática de distribuição metamérica foram randomizados, 12 no grupo controle e treze no grupo laser. No grupo controle foi feita injeção de dexametasona, clonidina e lidocaína intradiscais e no grupo laser aplicada média de 900 J de energia intradiscal, além das mesmas medicações. Os grupos foram avaliados nos tempos antes, imediatamente após, um mês, dois, três, seis e 12 meses decorridos do procedimento quanto aos parâmetros: dor, pela Escala Numérico Visual (ENV), uso de medicações para o controle desse sintoma e efeitos colaterais. Os resultados demonstraram queda nas médias das ENVs e necessidade de medicações para controle da dor em ambos os grupos logo após o tratamento (p<0,05), que perdurou no grupo laser onde houve média de redução de 80,73% nas ENVs, e de 75,51% na necessidade de medicação em um ano de seguimento (p<0,05). Já no grupo controle, as ENVs e as necessidades de analgésicos voltaram a ser semelhantes aos valores anteriores ao tratamento a partir do segundo mês de avaliação (p>0,05). Foi verificada predominância da doença no sexo masculino (68%), com faixa etária média de 44 anos, e baixa incidência de efeitos colaterais semelhantemente a dados anteriormente relatados. O laser diodo de 980 nm é eficaz na redução da ciatalgia secundária à herniação discal contida e superior à injeção intradiscal de clonidina, dexametasona e lidocaína, no que se refere à duração da redução das ENVs e da necessidade de medicações analgésicas. / Lumbar pain affects mankind from earliest times having its first descriptions in the \"Edwin Smith Papyrus\" (1500 BC). It is believed that during life up to 90% of the population will have at least one episode of low back pain, being such pathology one of the main causes of work withdrawal with huge annual financial losses. Five to 10% of patients with low back pain also have lower-limb pain (sciatica), and the latter, 85% of the time, is secondary to lumbar disc herniation (LDH), whose annual prevalence in the general population is estimated at 2.2%. The objective of this study was to evaluate the efficacy of intradiscal diode laser 980 nm wavelength in comparison with a control group on sciatica treatment in patients with contained lumbar disc herniations. A total of 25 patients (30 intervertebral discs) with LDH and neuropathic pain of metameric distribution were randomized, 12 patients in the control group and 13 patients in the laser group. In the control group, intradiscal injection of dexamethasone, clonidine and lidocaine was performed and in the laser group an average of 900 J of intradiscal energy was delivered, in addition to the same medications. The groups were evaluated at the time before, immediately after, 1, 2, 3, 6, and 12 months after the procedure for the parameters: pain measured by Visual Numerical Scale (VNS), medication use to control this symptom and side effects. The results showed a decrease in VNS and the need for pain control medications in both groups after treatment (p<0.05) that lasted in the laser group which demonstrated an average in VNSs reduction of 80,73% and in pain analgesic needs of 75,51% after 1 year (p<0,05). In the control group, VNSs and analgesic needs were again similar to pre-treatment values from the second month of evaluation (p>0.05). The predominance of the disease was found in males (68%), with a mean age of 44 years and a low incidence of side effects similar to the data reported before. The 980 nm diode laser is effective in reducing sciatica due to contained LDH and superior to intradiscal injection of clonidine, dexamethasone and lidocaine for the duration of the reduction of VNS and need for analgesic medications.

Psychosocial factors have been advanced as an explanation for the development of chronic disability in 20 to 30% of patients treated by lumbar disc surgery. Aims: The overall aim of this thesis was to study the role of psychosocial factors in patients undergoing first-time lumbar disc surgery in relation to the outcome of both surgery and subsequent physiotherapy. Methods: Sixty-nine patients with lumbar disc herniation undergoing first-time disc surgery participated in the studies; in addition, Study I included 162 knee patients for comparison. Psychosocial factors were assessed preoperatively, as was the activation of the physiological stress response system. Pain, disabil-ity and quality of life were assessed before, and 3 and 12 months after surgery. Coping and kinesiophobia were analysed before and one year after surgery. The results of two different postoperative training programmes were compared. Results: There were no differences between disc and knee patients regarding the presence of psychosocial stress factors preoperatively (Study I). Disc patients with low diurnal cortisol variability had lower physical function, perceived fewer possibilities to influence their pain and were more prone to catastrophise than patients with high diurnal cortisol variability (Study II). The results of clinic-based physiotherapy and home training did not differ regarding postoperative disability and pain 3 months after surgery. The home-based group had less pain and higher quality of life in comparison to the clinic-based group 12 months after surgery (Study III). Patients’ expectations of returning to work could best predict pain, disability, quality of life and sick leave one year after surgery (Study IV). Psychosocial factors were only weakly asso-ciated to pain, disability, quality of life and sick leave preoperatively. However, these associations were stronger in patients with residual pain one year after surgery. Conclusion: Psychosocial factors and, in particular, patients’ expectations regarding outcome are associated with the results of lumbar disc surgery. Assessing psychosocial factors preoperatively and developing an active home training programme after surgery could create options leading to better results for these patients.

Title: Physical activity of patients after surgical treatment of the lumbar spine. Aim: Main aim of my diploma thesis is to present an up to date review on the topic of postoperative physiotherapy in short-term and long-term phase after lumbar surgery and to find out how recommendations about postoperative physiotherapy are created. Methods: A systematic review on the topic. Results: The review answers the questions about physiotherapy after lumbar surgery in short-term and long-term phase and shows current trends and unique approaches in this study area. Keywords: Lumbar spine, intervertebral disc, discectomy, physiotherapy, physical activity.

The main purpose of this study was to determine whether playing soccer at high intensity training for a long period causes degeneration of the lumbar spine or not. This degeneration may occur without any symptoms or low back pain. Results of the present study were discussed in the framework of lumbar disc degeneration, trunk strength, lumbar and hip bone mineral density, trunk flexibility, activity MET scores for active and veteran soccer groups. There have been four subject groups in this study (15 active soccer players, 15 sedentary participants, 14 veteran soccer players, 13 sedentary participants). The BMD was measured in anterior-posterior view with a second-generation dual energy X-ray absorptiometry (DEXA) device. Isokinetic trunk strength data were recorded with the Biodex System Dynamometer (Biobex Medical Inc, Shirly, NY) at the 60&ordm / /sec and 120&ordm / /sec. Plain lateral radiographs were taken. The presence of degenerative changes of each lumbar vertebra was determined by using the Kellgren and Lowrence Score. A modified Schober test was used to measure lumbar flexion. Findings of the study demonstrated that veteran soccer players displayed greater lumbar disc degeneration than other groups. Moreover, v active soccer group had more BMD than other groups, but the veteran group&amp / #8217 / s BMD results were not different while comparing the control participants. Isokinetic test findings of the current study, trunk extension strength at 60/sec was significantly higher in active 1st group players than 2nd group participants, but there were no significant differences between the 1st group and 2nd group in terms of trunk flexion strength and agonist/antagonist ratio at 60/sec. In conclusion, Findings of the study support the main hypothesis that playing soccer at high intensity training at a long period of time may cause lumbar spine degeneration. Degeneration may occur without low back symptoms. Moreover, results supported the idea that Soccer can be accepted an impact loading sport that are to keep or accelerate bone mineral density. At last, having abnormal trunk extension strength while playing actively may cause lumbar disc degeneration on the spine at later years. A similar study should be carried out with a larger number of subjects, and longitudinal studies should be designed to examine the factors that effect the degeneration on the lumbar spine.

<p>In a prospective randomised double-blind study eighty patients with MRI verified lumbar disc herniation and corresponding clinical findings underwent microscopic disc removal. The patients were peroperatively given systemic and local corticosteroids or placebo, and followed for 2 years. The hospital stay and time to return to full-time work was significantly shorter in the treatment group. Pain measured as worst pain during the last week was also lower in the corticosteroid group. The results indicate that peroperative treatment with corticosteroids reduces pain and improves the functional outcome in patients operated for lumbar disc herniations.</p><p>To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbar disc herniations 66 patients with disc herniations underwent thermal QST. We found that thermal QST reflects sensory dysfunction in patients with lumbar disc herniations. However, thermal QST seems to have a poor predictive value for identifying the anatomic location of a herniated lumbar disc.</p><p>Quantitative sensory testing (QST) was used to detect damage to the myelinated A-delta fibres (cold sense) and the unmyelinated C-fibres (warmth sense). Corticosteroids combined with surgery in lumbar disc surgery improved the normalisation for the warmth disturbance compared to the control group. </p><p>A prospective analysis was performed on the predictive value of preoperatively determined lumbar lordosis and flexion for pain and disability in patients treated by microscopic lumbar disc surgery. Preoperative hyperlordosis correlated to more pain postoperatively (p=0.004). In patients with hypoflexion there was an association between hyperlordosis and moderate or severe pain postoperatively (p<0.001). The same outcomes were found for DRI. The stiff and straight back indicates a good outcome of lumbar disc surgery concerning pain and disability. </p>

In a prospective randomised double-blind study eighty patients with MRI verified lumbar disc herniation and corresponding clinical findings underwent microscopic disc removal. The patients were peroperatively given systemic and local corticosteroids or placebo, and followed for 2 years. The hospital stay and time to return to full-time work was significantly shorter in the treatment group. Pain measured as worst pain during the last week was also lower in the corticosteroid group. The results indicate that peroperative treatment with corticosteroids reduces pain and improves the functional outcome in patients operated for lumbar disc herniations. To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbar disc herniations 66 patients with disc herniations underwent thermal QST. We found that thermal QST reflects sensory dysfunction in patients with lumbar disc herniations. However, thermal QST seems to have a poor predictive value for identifying the anatomic location of a herniated lumbar disc. Quantitative sensory testing (QST) was used to detect damage to the myelinated A-delta fibres (cold sense) and the unmyelinated C-fibres (warmth sense). Corticosteroids combined with surgery in lumbar disc surgery improved the normalisation for the warmth disturbance compared to the control group. A prospective analysis was performed on the predictive value of preoperatively determined lumbar lordosis and flexion for pain and disability in patients treated by microscopic lumbar disc surgery. Preoperative hyperlordosis correlated to more pain postoperatively (p=0.004). In patients with hypoflexion there was an association between hyperlordosis and moderate or severe pain postoperatively (p&lt;0.001). The same outcomes were found for DRI. The stiff and straight back indicates a good outcome of lumbar disc surgery concerning pain and disability.

Tyrimo tikslas – įvertinti liemens raumenų izometrinės jėgos, simetriškumo ir gyvenimo pilnatvės kaitą po taikytos stuburo stabilizavimo ir laikysenos korekcijos programos asmenims, kuriems diagnozuota juosmeninės stuburo dalies išvarža bei vargina lėtinis apatinės nugaros dalies skausmas. Uždaviniai: 1. Įvertinti vyrų ir moterų, kuriuos vargina lėtinis apatinės nugaros dalies skausmas, nugaros, pilvo bei liemens šoninių raumenų izometrinės jėgos kaitą po taikytos kineziterapijos; 2. Įvertinti vyrų ir moterų nugaros-pilvo bei liemens šoninių raumenų izometrinės jėgos santykio kaitą po taikytos kineziterapijos; 3. Įvertinti vyrų ir moterų liemens raumenų statinės ištvermės, juosmens judesių amplitudės kaitą po taikytos kineziterapijos; 4. Nustatyti nugaros bei pilvo raumenų izometrinės jėgos ir apatinės nugaros dalies skausmo sąsajas prieš ir po taikytos kineziterapijos; 5. Įvertinti vyrų ir moterų apatinės nugaros dalies ir kojos skausmo, funkcinės negalios, gyvenimo pilnatvės bei bendros sveikatos būklės kaitą po taikytos kineziterapijos. Tyrime dalyvavo 17 darbingo amžiaus asmenų, 8 moterys ir 9 vyrai. Jiems radiologiškai diagnozuota juosmeninės stuburo dalies išvarža. Taikyta stuburo stabilizavimo ir laikysenos korekcijos pratimų programa 9 k., 3 k. per sav., po 45 min., individualiai. Vertinta: liemens raumenų maksimali izometrinė jėga (dr. Wolff „Back-check“ dinamometras), statinė ištvermė (sekundėmis), apatinės nugaros dalies ir kojos skausmas (SAS), funkcinė negalia... [toliau žr. visą tekstą] / The aim of the investigation – to evaluate changes in trunk muscles isometric strength, symmetry and quality of life under the impact of spine stabilization and posture correction exercises in patients with diagnosed intervertebral disk herniation and low back pain. The tasks of investigation: 1. To evaluate changes in back, abdominal and waist side muscles isometric strength after physical therapy applied in women and men with low back pain; 2. To evaluate changes in symmetry of the back-abdominal and waist side muscles isometric strength after physical therapy applied; 3. To evaluate changes in the muscles static endurance, lumbar movement amplitude after physical therapy applied; 4. To determine the correlation between back, abdominal muscles isometric strength and low back pain before and after physical therapy. 5. To evaluate changes of low back and leg pain, functional impairment, quality of life and common health condition of the patients after physical therapy applied in women and men. Methods and materials. There took part 17 working-age persons (8 women and 9 men) diagnosed with lumbar intervertebral disk herniation and low back pain in the investigation. They were applied spine stabilization and posture correction exercises program to - 9 times altogether, 3 times a week individually, 45 min. each. There were evaluated: trunk muscles isometric strength (Dr. Wolff “Back-check”), low back and leg pain (SAS), static endurance (in sec.), functional impairment... [to full text]

<p dir="ltr">People suffering from COPD are also known to suffer from other musculoskeletal issues like fracture risk, back pain, etc. Intervertebral disc degeneration (IVD) is a prominent cause of back pain and inflammation, influenced by factors such as aging, sudden loading, and genetics. <i>SERPINA1</i>, a common genetic variant in individuals with chronic obstructive pulmonary disease (COPD), encodes the alpha-antitrypsin protein (AAT). AAT deficiency is also associated with IVD degeneration, bone loss, and gait impairment. Currently, AAT-deficient individuals receive costly and short-lived weekly AAT injections, with no established guidelines for managing IVD degeneration and osteoporosis. Our primary research objective was to examine the effects of <i>serpinA1a/c</i> using a mouse model with global knockout (KO) of <i>serpinA1a/c</i>, generated through CRISPR technology, on intervertebral discs (IVD) and bone. We found that global deletion of <i>serpinA1a/c</i> was found to cause IVD elastin degradation, leading to a loss of mechanical properties. Moreover, <i>serpinA1</i> was associated with increased bone-resorbing cells (osteoclasts) and a reduction in bone-forming cells (osteoblasts). Notably, sexual dimorphism was observed, with female IVDs exhibiting less degeneration than male counterparts, and <i>serpinA1a/c</i> KO mice were protected from mechanically-induced tail compression. Even in human IVDs, males expressed more AAT-1 compared to female IVDs. There are no FDA-approved drugs currently existing for IVD degeneration. Since IVD degeneration frequently occurs in individuals with osteoporosis, it shows a probable cross-talk happening between IVD and bone. In our study, we found the association of <i>serpinA1 </i>with estrogen receptor alpha and osteoclasts. Hence, we investigated the potential of raloxifene, an FDA-approved selective estrogen receptor modulator (SERM) typically prescribed to post-menopausal women for osteoporosis treatment, in averting IVD degeneration and improving mechanical characteristics in IVD. Our findings suggest that raloxifene injection may retard IVD degeneration induced by AAT deficiency, particularly in male mice. Furthermore, the latter study touched upon a conditional <i>serpinA1a</i> mouse model crossed with aggrecan-cre, specifically targeting <i>serpinA1a</i>-expressing cells in the IVD while sparing bone. Conditional <i>serpinA1a</i> deletion induced mild IVD degeneration without affecting bone loss. In summary, this study serves as a foundation for testing potential treatments for AAT patients with IVD degeneration and osteoporosis. It also provides compelling evidence for considering raloxifene as a treatment option for IVD degeneration in AAT-deficient patients experiencing IVD-related pain.</p>