INTERVERTEBRAL DISC Normal Structure And Function The intervertebral disc is the largest avascular structure in the body

. It arises from notochordal cells between the cartilaginous endplates, which regress from about 50% of the disc space at birth to about 5% in the adult, with chondrocytes replacing the notochordal cells. Intervertebral discs are located in the spinal column between successive vertebral bodies and are oval in cross section. The height of the discs increases from the peripheral edges to the center, appearing as a biconvex shape that becomes successively larger by about 11% per segment from cephalad to caudal (ie, from the cervical spine to the lumbosacral articulation). A longitudinal ligament attaches to the vertebral bodies and to the intervertebral discs anteriorly and posteriorly; the cartilaginous endplate of each disc attaches to the bony endplate of the vertebral body. Images of herniated nucleus pulposus are provided below:

Hyaluronan long chains form a backbone for attracting electronegative or hydrophilic branches, which hydrate the nucleus pulposus and cause a swelling pressure within the annulus to allow it to stabilize the vertebrae and act as a shock absorber. Deterioration within the intervertebral disk results in loss of these water-retaining

branches and eventually in the shortening of the chains. Nuclear material is normally contained within the annulus, but it may cause bulging of the annulus or may herniate through the annulus into the spinal canal. This commonly occurs in a posterolateral

A fibril network. In this picture. This fibrous ring has alternating layers oriented at 60° from the horizontal to allow isovolumic rotation. proteoglycan. A herniated nucleus pulposus within the canal would embarrass the traversing root (L5). which then projects toward the nerve root situated just under the pedicle. including a number of collagen types along with fibronectin. That is. which is connected by link protein to the long hyaluronan. forming the posterior arch. contains the nucleus pulposus. and it provides protection for the neural elements within the acceptable constraints of clinical stability. The spinal nerves exit the spinal canal through the foramina at each level. and each side of the posterior elements has a facet joint or articulation to allow motion. The major proteoglycan constituent is aggrecan. thereby encroaching on the room available for the exiting nerve root (L4). hydrated nucleus within the annulus acts as a shock absorber to cushion the spinal column from forces that are applied to the musculoskeletal system. just as a shark swimming and turning in the water does not buckle its skin. decorin. The functional segmental unit is the combination of an anterior disc and the 2 posterior facet joints. Decreased disk height causes decreased foramen height to the same degree. which is yellow because of the high elastin content and allows significant extensibility and flexibility of the spinal column. These negatively charged regions have a strong avidity for water molecules and hydrate the nucleus or center of the disc by an osmotic swelling pressure effect. L4-5 has loss of disk height and some facet hypertrophy. the nucleus pulposus. The centra are stacked in a weightbearing column and are supported by the intervertebral discs. does not affect the hydrostatic pressure of the inner portion of the disc. The nucleus pulposus consists predominantly of type II collagen. branching side chains. Each vertebra of the spinal column has an anterior centrum or body. The facet joints connect the vertebral bodies on each side of the lamina. The disc's annular structure is composed of an outer annulus fibrosus. and the superior articular facet of the caudal vertebral body may become hypertrophic and develop a spur. . A corresponding posterior bony arch encloses and protects the neural elements. The hydraulic effect of the contained. thus. which is a constraining ring that is composed primarily of type 1 collagen. the intervertebral disc has the ability to rotate or bend without a significant change in volume and. These joints are connected at each level by the ligamentum flavum. and lumican. as depicted. which have regions with highly hydrophilic.location of the intervertebral disk. and hyaluronan long chains.

The authors noted that although the findings at 2 years postoperatively suggest that arthroplasty is equivalent to arthrodesis in these cases. they did not evaluate the treatment of retrovertebral compression as occurs with ossification of the posterior longitudinal ligament. Improvement in all outcome measures was observed 6 weeks after surgery. Progression of disc degeneration was 35% in the discography group. The study also found significantly greater loss of disc height and signal intensity in the discography discs. 83% of the patients had favorable outcomes based on the Odom criteria.[3] Carragee et al compared progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects who were not exposed to discography. which progressed to 26% by 2 years. ligaments. They noted. and the authors concluded that the use of bioabsorbable plates is a reasonable alternative to metal. surgery may be necessary to reestablish stability. then annually. In 11 (10. at 19. The authors found that absorbable instrumentation provides better stability than the absence of a plate but that graft subsidence and deformity rates may be higher than those associated with metal implants. avoiding the need for lifelong metallic implants. The authors found that patients in both the arthroplasty and arthrodesis groups had improvement following surgery. randomized multicenter trials to evaluate the efficacy of cervical disc arthroplasty for myelopathy with a single-level abnormality localized to the disc space. According to the authors.[1] Any disruption of the components holding the spine together (ie.Clinical stability has been defined as the ability of the spine under physiologic load to limit patterns of displacement so as to avoid damage or irritation to the spinal cord or nerve roots and to prevent incapacitating deformity or pain caused by structural changes. with 55 new disc herniations occurring in the discography group and 22 in the control group. When the spine loses enough of these components to prevent it from adequately providing the mechanical function of protection. with improvement being similar and with no worsening of myelopathy occurring in the arthroplasty group. intervertebral discs. that careful consideration of risk and benefit are necessary in regard to disc injection. therefore. the fusion rate and outcome were found to be comparable to the results achieved with metallic plates. Recent studies     Tomasino et al presented radiologic and clinical outcome data on patients who underwent single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylosis and/or disc herniation using bioabsorbable plates for instrumentation.5 months after surgery. patients who had larger anular defects and removal of smaller disc volumes had increased risk of .2%) patients. In this study. facets) decreases the clinical stability of the spine. At 3 months after surgery.[4] McGirt et al performed a prospective cohort study with standardized postoperative lumbar imaging with CT and MRI every 3 months for a year.[2] Buchowski et al performed a cross-sectional analysis of 2 large prospective. 18% loss of disc height was observed. The authors found that in all graded or measured parameters. to assess same-level recurrent disc herniation. Overall.5 months postoperatively. compared to 14% in the control group. revision discectomy was required at a mean of 10. discs exposed to puncture and injection had greater progression of degenerative findings than the control (noninjected) discs.

However. indicating that APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse. effective anular repair may behelpful. and those who had greater disc volumes removed had more progressive disc height loss by 6 months after surgery.   recurrent disc herniation. the indicated evidence for APLD is level II-2 for short. Patients were categorized by the presence or absence of 4 types of cervical MRI findings: disc herniation. controlled trials in the literature covering this subject. According to the authors. based on United States Preventive Services Task Force (USPSTF) criteria. They therefore concluded that the MRI finding of central canal stenosis is a potential indication that CESI may be merited. of central canal stenosis was associated with significantly superior therapeutic response to CESI. in such cases. Reoperation was more common with limited (tubular) exposure but not statistically significant and total complications did not differ. The authors suggested.[6] Hirsch et al did a systematic review of the literature to determine the effectiveness of automated percutaneous lumbar discectomy (APLD).[5] Fish et al performed a retrospective single-center study to analyze whether MRI findings can be used to predict therapeutic responses to cervical epidural steroid injections (CESI) in patients with cervical radiculopathy.and long-term relief. neuroforaminal stenosis. the authors noted that there is a paucity of randomized. and central canal stenosis. that in cases of larger anular defects or less aggressive disc removal. concern for recurrent herniation should be increased and that. The authors found that only the presence. nerve root compromise. versus the absence.[8] . based on the findings.[7] Dasenbrock et al performed a meta-analysis of 6 trials of 837 patients comparing open discectomy with minimally invasive discectomy and found similar visual analog scale (VAS) scores at short and long-term follow-up. Results showed no significant difference in relief of leg pain between the 2 approaches.