Lumbar disc herniation (LDH) is highly associated with inflammation in the context of low back pain. Currently, inflammation is associated with adverse symptoms related to the stimulation of nerve fibers that may lead to pain. However, inflammation has also been indicated as the main factor responsible for LDH regression. This apparent controversy places inflammation as a good prognostic indicator of spontaneous regression of LDH. This review addresses the molecular and cellular mechanisms involved in LDH regression, including matrix remodeling and neovascularization, in the scope of the clinical decision on conservative versus surgical intervention. Based on the evidence, a special focus on the inflammatory response in the LDH context is given, particularly in the monocyte/macrophage role. The phenomenon of spontaneous regression of LDH, extensively reported in the literature, is therefore analyzed here under the perspective of the modulatory role of inflammation.

Object: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has the potential advantage of minimizing soft-tissue damage and reducing recovery time compared to open procedures. A steep learning curve has been described for the technique. The aim of the present study was to define the learning curve that describes the progress of a single surgeon performing the MI-TLIF. Methods: One hundred fifty consecutive patients with degenerative lumbar disease who underwent 1- or 2-level MI-TLIF were included in the study. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a negative exponential curve-fit regression analysis. Results: One hundred ten patients underwent 1-level and 18 patients underwent 2-level MI-TLIF; the remaining 22 underwent a single-level procedure plus an ancillary procedure (decompression at adjacent level, vertebral augmentation through fenestrated pedicle screws, interspinous device at adjacent level). Negative exponential curves appropriately described the relationship between operative time and experience for 1-level surgery and after correction of operative time per level (R ² = 0.65 and 0.57). The median operative time was 140 minutes (interquartile range 120–173 minutes), and a 50% learning milestone was achieved at Case 12; a 90% learning milestone was achieved at Case 39. No patient required transfusion in the perioperative period. The overall complication rate was 12.67% and the most frequent complication was a dural tear (5.32%). Before the 50% and 90% learning milestones, the complication rates were 33% and 20.51%, respectively. Conclusions: The MI-TLIF is a reliable and effective option for lumbar arthrodesis. According to the present study, 90% of the learning curve can be achieved at around the 40th case.

OBJECTIVE AND IMPORTANCE: This case report illustrates the possible occurrence of intracranial aneurysms after surgery and radiation-induced vasculopathy.CLINICAL PRESENTATION: An internal carotid bifurcation aneurysm was diagnosed in a 19-year-old woman in a routine follow-up examination by magnetic resonance imaging 5 years after subtotal removal of a giant cystic craniopharyngioma treated by postoperative external radiotherapy. The presence of the aneurysm was confirmed by angiography.INTERVENTION: It was decided to treat the aneurysm by embolization with Guglielmi detachable coiling. However, at the beginning of the procedure, a few weeks after the diagnosis, a dramatic reduction in the carotid artery blood flow was observed, along with signs of thrombosis inside the aneurysm. In light of these findings, the procedure was aborted. Four months later, another angiographic examination confirmed the exclusion of the aneurysm and compensatory flow through the external carotid artery.CONCLUSION: During the assessment of patients who have undergone postoperative radiotherapy, the potential for the development of aneurysms and radiation-induced vasculopathy exists and should be kept in mind. Considering the potential for spontaneous thrombosis of these aneurysms, cautious judgment is recommended before making a decision to treat them.

Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.