Lumbar intervertebral disc herniation in children less than 16 years of age. Long-term follow-up study of surgically managed cases

STUDY DESIGN: In this retrospective study, the long-term clinical results of lumbar intervertebral disc herniation in children less than 16 years of age were reviewed. OBJECTIVES: To evaluate the effectiveness of surgical treatment including posterior discectomy, extraperitoneal anterolateral discectomy, and anterior interbody fusion for lumbar intervertebral disc herniation in children less than 16 years of age. SUMMARY OF BACKGROUND DATA: Although previous follow-up studies on surgically managed lumbar intervertebral disc herniation in children and adolescents generally reveal good outcomes, few reports have focused on the time course of clinical findings and the long-term results. METHODS: The outcome of subjective symptoms, clinical signs, and time-related change of the intervertebral disc space in 11 patients were evaluated with an average follow-up period of 9 years (range, 5-12 years). RESULTS: The posterior discectomy procedure relieved clinical symptoms quickly. In the case of central herniation with or without intervertebral instability, extraperitoneal anterolateral discectomy or anterior interbody fusion led to favorable long-term results. Clinical symptoms (lower back pain, leg pain) and neurologic disturbance disappeared within 3 months after surgery. Recovery of normal straight leg raising test results (tight hamstrings), however, required much more time than recovery of other symptoms. Narrowing of the intervertebral disc space progressed up to 3-6 months after discectomy, but then disc space widening occurred. CONCLUSIONS: Satisfactory long-term clinical results and early return to school life were obtained with each surgical procedure. It is important to aim toward an early return to school via surgical treatment.     

Facet joint asymmetry as a radiologic feature of lumbar intervertebral disc herniation in children and adolescents

STUDY DESIGN: This study compared the incidence of facet joint asymmetry between adult and juvenile patients with lumbar intervertebral disc herniation. OBJECTIVES: To determine the different distribution of the facet joint asymmetry between the adult and juvenile patients. SUMMARY OF BACKGROUND DATA: As early as 1967, it was suggested that asymmetry of the facet joints is correlated with the development of disc herniation. There have been numerous arguments for and against Farfan's hypothesis, however, most studies were carried out on adult patients, and this hypothesis has not been verified in juvenile patients. METHODS: The study group consisted of 29 levels of 25 patients aged 12-20 years (juvenile group) and 50 levels of 33 patients aged 30-49 years (adult group) who underwent posterior discectomy. The shape of facet joints, the facet joint angle, and the moment arm angle and length were measured for each facet joint using computed tomography. Facet joint asymmetry was defined as the difference in facet joint shape or a difference of more than 10 degrees in facet joint angles between the right and left sides. The incidence of facet joint asymmetry and the relationships among the facet joint asymmetry and the location, type of disc herniation, and disc degeneration were examined in juvenile and adult groups. RESULTS: The overall incidence of facet joint asymmetry was significantly higher in the juvenile group (12 levels, 41%) than in the adult group (four levels, 8%; P < 0.01). There were no significant relationships among the facet joint asymmetry, the location, type of disc herniation, and disc degeneration. CONCLUSIONS: This study revealed that the frequency of facet joint asymmetry in the juvenile group was five times higher than that in the adult group. This result indicates that facet joint asymmetry is a radiologic feature of lumbar intervertebral disc herniation in children and adolescents.     

Labor-induced bladder injuries: historical observations]

Eleven cervical intervertebral space calcifications were studied in ten children (5 boys, 5 girls), with mean age of 9.4 years. The aetiology, symptoms, roentgenographic clinic features were analyzied. All ten patients showed evidence of calcification of the cervical intervertebral disc. One had calcification in two disc spaces of the cervical spine and associated with subluxation of C1,2. Two patients had calcification protruded into the spinal canal without symptoms of spinal cord compression. One had symptom of nerve root irritation. Eight of ten patients had symptoms which disappeared in two weeks after treatment. Eight patients had been followed over one year. The calcification disappeared from 2 to 8 months. The diagnostic criteria for the syndrome of this study are: (1) pediatric age group only; (2) local or referred pain; (3) limited cervical spine motiion; (4) evidence of inflammation; (5) visible calcification of the cervercal intervertebral disc on roentgenogram; (6) self-limited course; (7) good result after conservative treatment and good prognosis.     

Progressive scoliosis with vertebral rotation after lumbar intervertebral disc herniation in a 10-year-old girl

A case report of a 10-year old girl with a herniated disc is presented. The most significant symptoms were progressive scoliosis with a flat back and paravertebral muscle spasm. An absent H reflex on the left and an increased latency of the somatosensory-evoked potentials of the left posterior tibial nerve were found. The computed tomographic scan of the lumbar spine showed a large central left-sided disc protrusion at the L5-S1 level. Our case presents the youngest patient with documented intervertebral disc herniation and the only one with severe scoliosis and vertebral rotation. The curve was not structural because it improved with surgery and an orthosis was not necessary.     

Herniated intervertebral disc without pain

The diagnosis of herniated intervertebral disc is often made in cases of radicular pain in the low back, the neck, or sciatica or brachialgia. Practitioners often call upon radiologic imaging to confirm this diagnosis. But on radiologic examination, such a herniation may consist of a bulge, protrusion, prolapse, extension, extrusion or sequestration of this disc. We define and illustrate these terms from the literature. We then review the radiologic studies of normal controls, who have never had sciatica, brachialgia or pain in the low back or neck. In over one-quarter of these controls, studies using the plain x-ray, CT scan, myelogram, and MRI show various radiologic signs of a herniated intervertebral disc. We therefore recommend that practitioners should not exclusively rely on radiologic imaging to confirm the clinical diagnosis of a herniated intervertebral disc.     

Body mass index and height in patients requiring surgery for lumbar intervertebral disc herniation

The immediate preoperative body mass index and standing body height of 1128 patients who underwent surgery for lumbar intervertebral disc herniation were compared in a cross-sectional study with the corresponding values obtained from a general population sample. The material was divided into sex- and age-specific subgroups. To delineate possible differences, the 99% confidence intervals for the anthropometric mean values were constructed instead of hypothesis testing. With the exception of the oldest age group, from 50 to 59 years, the patients who underwent surgery for a disc herniation were more obese and taller than the population on average in all other sex- and age-specific subgroups. The major contrast emerged in women aged 20-29 years, in whom the 99% confidence interval for the mean body mass index of the patients undergoing surgery on was 25.1-27.3 kg/m2 versus 22.3-23.1 kg/m2 in the general population. In patients aged 20-39 years the mean body mass index was increased also when the body height of the patients was less than the mean value of the general population samples. Both an increased body mass index and a tall stature seem to have a clear association with those severe lumbar intervertebral disc herniations that require operative treatment.     

Percutaneous reinsertion of the nucleus pulposus. An experimental study

STUDY DESIGN: An analysis of the histologic changes in intervertebral discs after percutaneous reinsertion of the nucleus pulposus in rats. OBJECTIVE: To devise a way to delay further disc degeneration resulting from spinal deformity and the adverse effects of various treatments. SUMMARY OF BACKGROUND DATA: The role of the nucleus pulposus of the intervertebral disc described by many investigators has not been fully clarified. METHODS: Disc herniation was induced in the tails of 112 Wistar rats, using a fixation device between the 5th and 8th coccygeal vertebrae. After percutaneous nucleotomy at coccygeal vertebrae 5-6 and 6-7, fresh nucleus pulposus, cryopreserved nucleus pulposus, or an artificial substitute was inserted into the intervertebral disc at coccygeal vertebrae 5-6. Two, 4, or 8 weeks after reinsertion, disc sections from each coccygeal level were studied histopathologically. RESULTS: In the groups with reinsertion of fresh or cryopreserved nucleus pulposus, degenerative changes of the disc with the reinserted nucleus at coccygeal vertebrae 5-6 were milder than those of the disc without reinsertion at coccygeal vertebrae 6-7. However, no apparent benefit from reinsertion was observed in the group with artificial substitutes. CONCLUSIONS: Early reinsertion of the nucleus pulposus (fresh or cryopreserved) delays degeneration of such disc materials as the anulus fibrosus, endplate, and remaining nucleus pulposus.     

Regression of cervical disc herniation observed on magnetic resonance images

STUDY DESIGN: A retrospective study of cervical disc herniation using results of repeated magnetic resonance imaging examinations. OBJECTIVES: To clarify the cervical disc herniation morphological changes over time in order to establish a strategy for treatment. SUMMARY OF BACKGROUND DATA: In the authors' previous magnetic resonance imaging follow-up study of patients with lumbar disc herniation, spontaneous regression was observed in the sequestration-type lesions, and it was found that the tendency toward regression differed based on the anatomic position of extruded disc material. METHODS: Thirty-eight patients with cervical disc herniation who underwent repeated magnetic resonance imaging examinations were studied. The changes over time in herniated disc size were evaluated using this imaging technique. Evaluation showed the characteristics of those in whom spontaneous regression was found, such as extrusion pattern, and the clinical outcome was evaluated by symptoms. RESULTS: In 15 patients (40%), the volume of herniated material was decreased. The interval from onset of symptoms to the initial examination was significantly shorter in the regression group than in the group that showed no change in disc herniation. By extrusion pattern, cervical disc herniation, which was divided into migration type on sagittal view and lateral type on axial view, most frequently exhibited spontaneous regression. All of the patients with radicular pain and upper limb amyotrophy were treated successfully with conservative therapy. CONCLUSION: Although the possibility of the combination of hemorrhage and disc material could not be denied, active resorption of herniated material probably occurred during the acute phase. Extruded material exposed to the epidural space may be resorbed more quickly than that beneath the ligament. Vascular supply probably plays a role in the mechanism of resorption. The phase and position of extrusion were the significant factors affecting cervical disc herniation resorption. It was demonstrated that examination performed during the acute phase using magnetic resonance imaging is necessary for elucidation of the pathogenesis of cervical disc herniation, and that migrating, lateral-type herniations regress so frequently that conservative treatment should be chosen not only for patients with radicular pain, but also for those with upper limb amyotrophy.     

Conditions of the thoracolumbar spine

Neurological deficits suggesting trauma to the spinal cord in the thoracolumbar area are the most common clinical presentation of neurosurgical conditions. By far, the most common cause of thoracolumbar spinal cord dysfunction is intervertebral disc disease. Disc herniation and subsequent spinal cord compression usually requires prompt medical treatment, then referral for high detail radiographs, myelogram, and surgical decompression. Other causes of thoracolumbar spinal cord dysfunction include neoplasia, discospondylitis, fibrocartilaginous embolism, and degenerative myelopathy.     

Severe prolonged hypocalcaemia following pamidronate for malignant hypercalcaemia

A review of 105 consecutive cases of chymopapain chemonucleolysis for single level lumbar disc herniation was undertaken. Mean follow-up was 12.2 years (range 10-15.3). Patients were assessed using the Oswestry Disability Questionnaire. Eighty-seven patients were available for follow-up. An excellent or good response occurred in 58 patients (67%); four patients (4.5%) had a moderate response but were only minimally disabled. The treatment failed in 25 patients (28.5%) and 21 of these went on to surgery within a mean of 5.2 months (range 3 weeks-12 months). In 15 patients (71%) disc sequestration or lateral recess stenosis was found. Five of the remaining six cases had a large disc herniation at surgery. Surgery resulted in a significant improvement in nine cases. Discitis following chemonucleolysis occurred in six patients (5.7%). Chymopapain chemonucleolysis has a useful role in the management of lumbar intervertebral disc prolapse. However, its efficacy is dependent on careful clinical and radiological patient selection.     

Revisional lumbar microdiscectomy: an analysis of operative findings and clinical outcome

Forty-one consecutive patients who underwent a revision microlumbar exploration for recurrent or persistent sciatica were reviewed retrospectively to analyse the operative findings and assess the clinical outcome following surgery. Thirty-three (80%) patients were found to have a recurrent intervertebral disc protrusion at the previous site, two patients had a disc herniation at a new site, one had severe perineural scarring, two had lateral recess stenosis, one patient had undergone previous exploration at an incorrect site and in two patients no cause for ongoing symptoms was found. Nineteen of the 33 patients with a re-prolapse presented with persistent or recurrent sciatica within 1 year of their first operation. The other 14 patients presented with a late re-prolapse (after 1 year) and their clinical outcome was better than for those patients with an early re-prolapse (12/14 vs 11/19 satisfactory result, respectively). The result of operating on patients with a late re-prolapse was comparable to the 80-95% satisfactory outcomes following primary lumbar microdiscectomy reported by other authors.     

Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations

OBJECTIVE: To prospectively investigate the effect of chiropractic management on clinical and anatomical outcome of disc pathomorphology in previously magnetic resonance imaging (MRI)-documented disc herniation of the cervical and lumbar spine. SETTING: Private practice. SUBJECTS: Twenty-seven patients with MRI-documented and symptomatic disc herniations of the cervical or lumbar spine. A prospective clinical case series. DESIGN: All patients were evaluated before commencement of chiropractic care by MRI scans for presence of disc herniations. Precare evaluations also included clinical examination and visual analog scores. Patients were then treated with a course of care that included traction, flexion distraction, spinal manipulative therapy, physiotherapy and rehabilitative exercises. All patients were re-evaluated by postcare follow-up MRI scans, clinical examination and visual analog scores. Percentage of disc shrinkage on repeat MRI, resolution of clinical examination findings, reduced visual analog pain scores and whether the patient returned to work were all recorded. RESULTS: Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations. CONCLUSION: This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.     

Distraction of lumbar vertebrae in gravitational traction

STUDY DESIGN: Experimental study of 30 patients diagnosed with low back pain resulting from lumbar disc herniation, disc degeneration, and segmental instability. Patients underwent gravitational traction, and widening of the intervertebral space and posterior facets was measured on radiographs. This same procedure was performed with a group of 30 healthy individuals. OBJECTIVES: To determine the effect of gravitational traction on the widening of the intervertebral space and the other vertebral structures in patients with low back pain and in healthy individuals. SUMMARY OF BACKGROUND DATA: Gravitational traction is performed by suspending the patient in a hanging, upright position for an extended period of time. In spite of disagreement among authors about the effect of lumbar traction, recent innovations have enabled the distraction of vertebrae. METHODS: A specially designed apparatus was used to apply gravitational traction. Pre- and post-traction radiographs were obtained to study the changes in the L2-L3, L3-L4, L4-L5, and L5-S1 intervertebral spaces; Ferguson's angle; L1-S1 total distance; and blood pressure. RESULTS: Distraction was more than approximately 3 mm in each intervertebral space in both groups. CONCLUSION: Gravitational traction had a very apparent effect on intervertebral space and was found to be an effective method to distract lumbar vertebrae. Discomfort experienced by the patient during suspension may be overcome by making biomedical changes to the suspension corset.     

Monocyte chemoattractant protein-1 in the intervertebral disc. A histologic experimental model

STUDY DESIGN: Monocyte chemoattractant protein-1 was investigated in an experimental rat model using immunohistochemistry. OBJECTIVE: To ascertain the precise mechanism of macrophage recruitment in the early phase of disc resorption. SUMMARY OF BACKGROUND DATA: In previous studies, many investigators reported that disc herniation was resorbed by monocytic phagocytosis. However, how the recruitment of monocytes was triggered is still unknown. METHODS: The autologous intervertebral discs from tails of Wistar rats were subcutaneously implanted into the abdomen. These discs were obtained on days 2, 3, 7, and 14 after implantation and were used for immunohistochemical study and for quantitative analysis of monocyte chemoattractant protein-1 by sandwich enzyme-linked immunosorbent assay. RESULTS: Monocyte chemoattractant protein-1-positive granulocytes and macrophages were observed surrounding the intervertebral disc, and monocyte chemoattractant protein-1-positive disc chondrocytes were observed in the nucleus pulposus and the inner anulus fibrosus on day 3. By day 7, monocyte chemoattractant protein-1-positive and TRPM-3-positive macrophages appeared in the granulation tissue, and some of these cells invaded the nucleus pulposus and inner anulus fibrosus. The concentration of monocyte chemoattractant protein-1 was highest on day 3. CONCLUSION: Intervertebral disc chondrocytes have chemotactic properties and play an active role in the recruitment of monocytes involved in disc resorption.     

Prevention of gastric ulcer recurrence with tetraprenylacetone

We have carried out an experimental investigation of lesions of the intervertebral disc produced by flexion, lateral bending and rotational forces in an attempt to produce disc herniations. Adult Wistar rats were divided into 4 groups: control and posterior, lateral and rotational herniation. There were 10 rats in each group. The tail between the 5th and 8th vertebral segments was used. A Kirschner wire was inserted into each of 2 adjacent vertebrae and the movement produced had an apex which was anterior or lateral depending on the group involved. Variables such as rupture of the annulus, the cellularity of the nucleus pulposus and the site of the lesion in the disc were studied histologically. The height of the disc, the protrusion, the thickness, and the surfaces of the annulus fibrosus and the nucleus pulposus were measured. In every case we found a nuclear displacement which did not become a protrusion. The surface parameters and the cellularity of the nucleus pulposus are most useful indicators and should be included in any study examining the disc after the injection of substances for treatment.     

Chronic low back pain

Most episodes of low back pain are mechanical in origin and resolve within a 12-week period. These acute episodes of back pain are associated with muscle strain and intervertebral disc herniation with radiculopathy. A smaller proportion of individuals have back pain with a duration greater than 12 weeks. These patients have back pain secondary to a wide variety of mechanical and nonmechanical disorders. The mechanical disorders associated with chronic low back pain include osteoarthritis and lumbar spinal stenosis; the nonmechanical disorders include infectious, neoplastic, rheumatologic, endocrinologic, vascular, and gynecologic. The clinical symptoms associated with each variety of disorder helps guide the appropriate diagnostic evaluation. Plain roentgenograms are useful in documenting the presence of spinal stenosis, benign or malignant tumors, osteoporosis, sacroiliitis, and spondylitis. CT scan is helpful in defining the bony alterations associated with malignant tumors and the vascular abnormalities associated with aneurysms. MR imaging is the technique of choice to document the extent of malignant processes and the presence of endometriosis in the pelvis. The therapy of these entities are specific for the disease entity causing the chronic low back pain. Although most of the disorders that cause chronic low back pain cannot be cured, therapy can decrease pain and improve function of the symptomatic patient.     

Arthroscopic microdiscectomy and selective fragmentectomy

A prospective outcome study to determine the efficacy and complications associated with posterolateral arthroscopic discectomy was initiated in April 1988. One hundred seventy-five patients with symptoms consistent with a lumbar disc herniation and correlative imaging studies were treated operatively, and 169 were available for followup evaluation. Fifty-nine patients with a central herniation or a nonmigrated sequestered fragment were treated using bilateral biportal posterolateral access, whereas 116 patients with radiographic evidence of a paramedial, foraminal, or extra-foraminal herniation were treated using the unilateral uniportal approach. The minimum duration of nonoperative management ranged from 3.5 to 28 months (average, 16 months), and all patients had a minimum of 24 months of postoperative followup. Outcome analysis indicated that 149 procedures were successful, whereas 20 (11.8%) procedures were failures because of persistent radicular symptoms that, in some cases, required open laminotomy. Complications associated with the procedures included one disc space infection, one transient peroneal neuropraxia, and four index extremity skin hypersensitivity. All of these complications resolved without sequelae, and there were no neurovascular complications directly related to the surgical approach.     

Manual ultrasound of the knee joint. A general practice method for diagnosis of fresh rupture of the anterior cruciate ligament

To determine the long-term outcome of 12 youthful patients with lumbar disc herniation, who, at the time of surgery, were 15 years old and younger (mean age at operation 14.3 years), we assessed their current clinical condition (mean follow-up time 6 years) with a questionnaire inquiring about symptoms and disability, and radiologically with an MRI of the lumbar spine. Clinically, only five patients (40%) were totally asymptomatic and seven patients (60%) had recurring symptoms, both and disability. On MRI, seven patients (60%) had persistent stenosing changes at the operated disc levels and eight patients (65%) also had disc degeneration at other lumbar levels. Despite the symptoms and quite severe radiological findings, the long-term outcome was assessed as good or moderate in eleven patients (90%). As far as comparisons are reasonable, our results appear somewhat less favourable than those in two previous paediatric series, but they agree with those in two recent large series of adults.     

Changes in cross-sectional area of psoas major muscle in unilateral sciatica caused by disc herniation

STUDY DESIGN: A clinical prospective cohort study of 15 healthy volunteers and 25 patients with unilateral sciatica from single-level disc herniation. OBJECTIVES: To detect any changes in the cross-sectional area of the psoas major muscle in patients with single-level (lateral to mediolateral) disc herniation causing unilateral sciatica. SUMMARY OF BACKGROUND DATA: The exact role of the psoas major muscle in the origin of low back pain and sciatica has not been clarified. METHODS: Fifteen healthy volunteers and 25 patients with unilateral sciatica from single-level disc herniation were subjected to magnetic resonance imaging of the lumbar spine. The cross-section area of the psoas major muscle on either side was recorded, and differences were noted. In patients, the cross-section area of either side was compared with and duration of sciatica was related to changes in the cross-section area. RESULTS: Insignificant variation in the cross-section area of the psoas major was observed in volunteers. In the patient group, significant reduction in the cross-section area of the psoas major was observed at the level and the site of the disc herniation. A significant correlation between cross-section area of the psoas major and ipsilateral continuous sciatica was found. There was no relation between the reduction of the cross-section area and the amount of disc herniation. CONCLUSION: The cross-section area of the psoas major is ipsilaterally decreased in unilateral lumbar disc herniation. The reduction in cross-section area is positively correlated with the duration of continuous sciatica.