Idiopathic coccygodynia. Lateral roentgenograms in the sitting position and coccygeal discography

STUDY DESIGN: The authors hypothesized that the source of coccygodynia was a lesion of the coccygeal disc. OBJECTIVES: This study analyzed the motion of the painful coccyx in the sitting position as compared with the lateral decubitus in a patient and a control group and reported the first results of coccygeal discography (dynamic study). SUMMARY OF BACKGROUND DATA: Coccygodynia are usually attributed to soft tissue injuries or psychologic disturbances. No previous study has assessed the coccygeal discs as a source of pain. METHODS: Fifty-one patients with coccygodynia and 51 controls sustained a dynamic study. Coccygeal mobility was documented by superimposing graph paper with a double reading. The accuracy of the measurement was +/- 2.6 degrees intra- and interobserver variations 15.3 and 12.5%. This dynamic study was followed by coccygeal discography in the patient group. RESULTS: An abnormal motion (luxation or hypermobility) of the coccyx that occurred in the sitting position and spontaneously was reducible when placed in the lateral decubitus position was found in 25 patients. Such lesions could be responsible for the pain because no similar findings were seen in the controls and coccygeal discography was positive in these cases. Of the 26 patients with a normal dynamic study, coccygeal discography, using a combination of provocation and anesthetization, was positive in 15 of 21. CONCLUSIONS: Common coccygeal pain could come from the coccygeal disc in approximately 70% of cases.     

Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation

STUDY DESIGN: The correlation between discogenic lumbar pain and disc morphology was investigated by using magnetic resonance imaging and discography. OBJECTIVES: To assess the various pathologic parameters seen on magnetic resonance imaging in patients with discogenic lumbar pain and to correlate them with observations on discography. SUMMARY OF BACKGROUND DATA: Although numerous previous studies on the subject have been performed, the correlations between various pathologic findings on magnetic resonance imaging and pain reproduction by provoked discography have not been explained fully. METHODS: One hundred and one lumbar discs in 39 patients were studied with magnetic resonance imaging and pain provocation discography. When pain reproduction under discography was concordant, various pathologic parameters on magnetic resonance imaging were analyzed by three statistical parameters to determine the associated magnetic resonance imaging findings. RESULTS: Radial tears commonly are demonstrated on magnetic resonance imaging in discs with concordant pain on discography. The presence of these tears is not a reliable predictor of a painful disc on discography. Although a high-intensity zone on T2-weighted images is a relatively reliable predictor of pain, the statistical values were lower than those in previous studies. Massive degeneration and severe disc height loss were rare in this population. These findings were good predictors of pain on disc injection. CONCLUSIONS: Although the lumbar intervertebral discs with posterior combined anular tears are likely to produce pain, the validity of these signs for predicting discogenic lumbar pain is limited.     

Thoracic discography. A safe and reliable technique

OBJECTIVES: To evaluate the safety and reliability of discography used to investigate thoracic disc degeneration observed on magnetic resonance (MR) imaging studies in patients with clinical pain, we analyzed retrospectively the results of thoracic discograms performed on 100 outpatients. METHODS: After MR imaging, clinically suspect, morphologically abnormal thoracic discs and at least one, nearby, control level were injected with either nonionic contrast or saline, filmed, and individually described by the patient as concordant versus nonconcordant relative to clinical pain and rated in intensity on a scale of 0-10. RESULTS: There were no serious complications in the series, and the authors resolved whether the injected discs related to pain in each case. They found discs with anular tears, intrinsic degeneration, and/or associated vertebral body endplate infractions to be painful approximately 75% of the time. Clinical concordance was approximately 50%. Control levels were usually painless. CONCLUSIONS: They conclude that thoracic discography can be performed safely by experienced individuals as a reliable tertiary diagnostic procedure to determine if degenerated discs on MR studies are related to clinical complaints.     

Histocompatibility (HL-A) antigens and primary open-angle glaucoma

For the diagnosis of lumbar P.I.D. discography is much superior to myelography. The risks of both techniques are the same, but the side-effects of discography are clearly less. Higher lesions remain a problem if they do not show up neurologically (s. the prolapsed disc at L 2/3). Here segmental blocking, posterior gaping of the intervertebral space and displacement of the dural sac show clearly the posterior prolapse. In the standard discogram of the lower 3 discs it would have been missed. In spite of this our present experience with lumbar discography is so positive, that we are about to test a long term series, whether and to which extend discography could replace myelography in cases where there is no hint at a space-occupying lesion, other than a disc or whether the order of these investigations should be reversed.     

Objective measurement of the height of lumbar intervertebral disks from lateral roentgen views of the spine

OBJECTIVE: Published methods to quantify height of lumbar discs from lateral radiographic views of the lumbar spine yield inaccurate results due to distortion in central projection. Normal values of disc height have not been compiled. METHODS: Starting from an analysis of the imaging properties of vertebral bodies in a lateral view and following a logical evolution of Farfan's proposal, a new protocol for the measurement of disc height is given which is independent of distortion. A database of normal values of the height of lumbar discs from T12/L1 to L5/S1 was compiled from 892 lateral views of healthy male and female subjects in the age range between 16 and 57 years. RESULTS: Employing the new protocol, height of all discs on a lateral view can be measured. Variations in position (standing, side-lying) do not influence the result. Retrospective investigations are feasible. The precision of the disc height measurement amounts to 4.15%. Normal, age-appropriate values for the height of lumbar discs are given for the first time. In the individual case, disc height can be quantitatively evaluated by comparison with the normative database. CLINICAL RELEVANCE: The new protocol can be employed to quantitatively identify processes which effect a decrease of disc height. In the individual case, the new protocol and the comparison with the normal database can be employed to quantitatively assess overload injury to lumbar discs in compensation cases.     

Knee-chest vs horizontal side position during induction of spinal anaesthesia in patients undergoing lumbar disc surgery

In the prone knee-chest position the spread of plain 0.5% bupivacaine in the cerebrospinal fluid and associated haemodynamic changes may be different compared with the horizontal position. A randomized comparison was performed in 40 ASA I-II patients, aged 24-61 yr, undergoing lumbar disc surgery. Subarachnoid injection (27-gauge needle) at the L2-3 interspace with 3 ml of 0.5% bupivacaine was performed with the patient in the operative knee-chest position (prone knee-chest group, n = 20) or in the horizontal side position (supine side horizontal group, n = 20). Patients in the supine side horizontal group were turned into the horizontal supine position for 20 min, and subsequently they were placed in the operative knee-chest position. In three patients in the prone knee-chest group, the spinal needle was replaced by a larger needle (25-gauge). The final cephalad extension of sensory analgesia on skin tested by pinprick was T5 (median) in the prone knee-chest group and T6 in the supine side horizontal group. Recovery was also similar, on average 210 min from injection in both groups. The mean decrease in systolic arterial pressure was somewhat greater in the prone knee-chest group (30 mm Hg) than in the supine side horizontal group (13 mm Hg). The need for ephedrine occurred earlier in the supine side horizontal group (three patients, all within 10 min from local anaesthetic injection) than in the prone knee-chest group (six patients, all after 15 min). Four of the latter patients also required administration of an anticholinergic for bradycardia compared with two patients in the supine side horizontal group. Light sedation was given to five patients in the prone knee-chest group and to four in the supine side horizontal group because of numbness and aching in the shoulders. We conclude that spinal block was similar in the two groups but there was a tendency to more frequent episodes of haemodynamic deterioration in the knee-chest position.     

Laryngeal mucociliary clearance: influence of beta-2 agonists, beta antagonists, and alpha-agonists. An experimental study in rabbits

The high sensitivity but poor specificity of contrast enhanced magnetic resonance (MR) imaging for delineating malignant breast lesions is increasing the demand for MR guide breast biopsy. However, the poor patient access offered by conventional MR systems makes such procedures extremely difficult. We describe a method of performing breast biopsy outside the bore of the magnet using the 3-D MR imaging data. This involves a frameless stereotactic technique using an ultrasonic localizer. The position in space of the tip of a pointer with a handle which incorporates two ultrasound emitters can be tracked using an array of ultrasound detectors. MR visible marker beads (fiducials) placed on the breast and imaged at the same time are identified to the computer in relation to images of the breast. The ultrasonic localizer is used to register the position in space of the fiducials by touching them with the tip of the pointer. The image of the lesion within the breast can then be displayed in relation to the position of the tip of the pointer and the needle approach planned. Nine women with foci of enhancement on their dynamic contrast enhanced MR images underwent frameless stereotactic breast cytology. Needle placement within 2 mm of the lesion was achieved at first pass in eight out of nine (89%) cases: in one case the needle had to be re-positioned prior to sampling. This technique provides a means of targetting MR visible lesions using the MR imaging data whilst performing the procedure outside the magnet bore.     

Age-dependent correlation of low-back pain and lumbar disc regeneration

The prevalence of lumbar disc degeneration in subjects suffering from low-back pain (n = 207; age range 10-49 years) and in age-matched asymptomatic controls (n = 216) was investigated by magnetic resonance imaging. The percentage of subjects with degenerated discs increased with age; starting from the age of 15 years, this increase was more rapid in subjects with low-back pain. Concurrently, the number of degenerated discs was higher in the pain group than in controls. Lumbar disc degeneration manifests earlier and in a greater percentage of subjects with low-back pain than in asymptomatic controls.     

Holding the baby: head downwards positioning for physiotherapy does not cause gastro-oesophageal reflux

The head-downwards tipped position for physiotherapy has been claimed to exacerbate gastro-oesophageal reflux (GOR) in infants with cystic fibrosis (CF). This was investigated using lower oesophageal pH monitoring during physiotherapy. Twenty-one infants (age range 1-27 months) with respiratory disorders (CF=11), undergoing lower oesophageal pH monitoring were recruited. Subjects received two physiotherapy episodes in random order, A/B or B/A, 12 h apart. A began the gravity-assisted positioning head downward tip for: right lower lobe, middle lobe, left lower lobe and lingula; then supine with no tip for anterior segments of the upper lobes followed by apical segments of upper lobes in a sitting position. B was in the reverse order. Intermittent chest clapping was carried out for 4 min in each position by a physiotherapist blinded to the pH data. During episode A, the median change in pH from baseline was -0.32 (range -2.07 to +1.0) in non-CF subjects (NS) and -0.52 (range -2.7 to +0.52) in CF subjects (p<0.02). During episode B, the median change in non-CF subjects was -0.1 (NS; range - 1.7 to -0.15) and in CF subjects was -0.05 (NS; range -0.67 to +0.5). There was no order effect for positioning. In the CF subjects the sitting position was twice as likely to have the lowest pH measurement during physiotherapy than the other positions (p<0.04). In conclusion, the head-downward tipped positioning for physiotherapy treatment neither induces nor aggravates gastro-oesophageal reflux. There is no justification for routinely changing the way in which infant physiotherapy is carried out.     

Relation between the level of E. coli gene expression and the structure of translation initiation region (TIR). III. Sites of complementary interaction of TIR with 16S rRNA

The addition of vertebral disc degeneration to the job-related disease register raises the question of vertebral disc degeneration patterns according to loading strain. The readings of the lumbar vertebra of construction workers and nurses were compared with those of a group without workload. In the groups examined, aged 35 to 50, monosegmental damage was found in only 17% of the patients with high workload, as opposed to 29% of those with no workload, mostly with monosegmental damage at level L5/S1. Damage to the upper segments of the lumbar spine with intact discs in between was found exclusively in patients with high workload. Multiple segment damage in the age range examined was found in subjects with activities that add to the load of the spinal column. The value of MRI in assessing and evaluating illness originating from the vertebral discs is currently being discussed.     

Late results of cervical disc surgery

Late results of cervical disc surgery have been reported and statistically studied in 383 cases: 83% were lateral discs, 13% were central spondylosis discs, and 4% central soft discs. Central spondylosis occured at a higher spinal level, and caused cord compression with or without weakness of the hands, but no pain. A posterior approach was used in all lateral discs, and either an anterior or a posterior approach, with or without fusion, for central discs. Preoperative myelography was always done and is recommended postoperatively in central disc surgery to evaluate the results. Our results were good to excellent in 95% of lateral discs, in 64% of central spondylosis discs, and in an unexpected 91% of 11 cases of central soft discs. There were no recurrences and no serious complications, although 20% developed other cervical or lumbar disc herniations.     

Exacerbated pain in cervical radiculopathy at axial rotation, flexion, extension, and coupled motions of the cervical spine: evaluation by kinematic magnetic resonance imaging

RATIONALE AND OBJECTIVES: The authors evaluate the functional changes in patients with cervical radiculopathy and increasing symptoms after provocative maneuvers at flexion, extension, axial rotation, and coupled motions of the cervical spine. METHODS: Twenty-one patients with cervical disc herniation (n = 17) or cervical spondylosis (n = 4) in whom symptoms were elicited at flexion, extension, axial rotation, and coupled motions of the cervical spine were studied. The patients were examined inside a positioning device by using a circular surface coil for signal reception. At neutral position (0 degrees) and at provocative positions sagittal T2-weighted turbo spin-echo, axial T2-weighted two-dimensional flash sequence, sagittal three-dimensional (3D) fast imaging with steady state precision sequence and coronal 3D double-echo-in-the-steady-state sequences were obtained. The 3D sequences were reformatted in the axial and oblique coronal planes perpendicular to the exiting nerve roots. The images were evaluated for the size of disc herniations, the foraminal size and cervical cord rotation or displacement at provocative position compared with neutral position (0 degrees). RESULTS: Compared with neutral position (0 degrees), change in size of disc herniation was not found in any (0%) of the provocative positions. In five (24%) patients cervical cord rotation or displacement was noted at axial rotation. The foraminal size increased at flexion, axial rotation to the opposite side of pain and flexion combined with axial rotation to the opposite side of the pain. The foraminal size decreased at extension combined with axial rotation to the side of the pain. A decrease or no change in foraminal size was observed at either extension or axial rotation to the side of the pain. CONCLUSIONS: In patients with cervical disc herniation or cervical spondylosis, exacerbated pain at defined provocative maneuvers is related more to changes in the foraminal size and to nerve root motion with, in some cases, cervical cord rotation or displacement than to changes in the size of herniated discs.     

Portable fluoroscopy in the management of zygomatic arch fractures

There is no "gold standard" for diagnosing thoracic outlet compression syndrome (TOS), however, anesthetic blocks of the anterior scalene muscle (ASM) have been used as a means of predicting which patients may benefit from surgical decompression. The standard technique of using surface landmarks often results in inadvertent somatic block and sympathetic block because there is no reliable verification of needle tip localization. The present study was undertaken to determine if needle tip localization can be improved by using electrophysiological guidance. ASM blocks were performed for patients with a diagnosis of possible TOS. An insulated hypodermic needle was inserted into the ASM which was identified during electromyogram (EMG) activation maneuvers. Stimulation was performed to make sure that the needle tip was not in the brachial plexus. Local anesthetic was instilled and the intensity of pain induced by TOS stress maneuvers was compared to pain ratings obtained after control injections. The ASM could be identified electromyographically in all 122 cases. There were no instances of inadvertent somatic block nor sympathetic block. Of 38 patients who underwent surgical decompression of the thoracic outlet, 30 of 32 (94%) with a positive block had a good outcome compared with 3 of 6 (50%) who underwent surgery in spite of a negative block. Electrophysiological guidance facilitates accurate needle tip placement in the performance of ASM blocks; the results of these blocks appear to correlate with surgical outcomes.     

zALK-8, a novel type I serine/threonine kinase receptor, is expressed throughout early zebrafish development

AIMS: Progressive loss of neuroretinal rim tissue is known to occur early in glaucoma and measurement of the neuroretinal rim area is possible by magnification corrected analysis of optic disc photographs (planimetry). This study was performed to determine whether the facility to distinguish between glaucomatous and normal optic discs could be improved upon by: (a) taking into account the known relation between optic disc size and neuroretinal rim area, and (b) measuring rim area in a number of segments, in order to detect focal changes. METHODS: Planimetric examination of the optic disc photographs of 88 control subjects and 51 patients with early visual field defects was performed. In the control group, multiple linear regression analysis was performed between neuroretinal rim area and optic disc area, age, sex, eye side, refraction, and keratometry. This was repeated for the whole disc and for each of twelve 30 degree segments. Normal ranges were defined by the 98% prediction intervals of the regression analysis and the sensitivity and specificity for correct identification of optic discs in the two groups determined. RESULTS: Multiple linear regression demonstrated significant associations between the neuroretinal rim area and optic disc area and age in normal subjects. Sensitivity and specificity for glaucoma diagnosis, using the cut off derived from the 98% prediction intervals, was 37.7% and 98.9% respectively when total neuroretinal rim area alone was considered, and 88.7% and 94.3% respectively when the 30 degree segments were included. The most frequent pattern of neuroretinal rim loss was diffuse, followed by thinning in more than one sector and then by thinning in the inferotemporal sector alone. CONCLUSIONS: This method of optic disc analysis enables the examiner to identify glaucomatous optic discs at the stage of early perimetric loss with a high degree of precision. Optic disc photography is simple, and fundus cameras are widely available. This method for glaucoma case identification may therefore be suitable for the primary care setting as well as hospital practice.     

Atraucan: a new needle for spinal anesthesia

BACKGROUND AND OBJECTIVES: Atraucan 26-gauge spinal needles have a tip designed to make a small linear cut (as opposed to a V-shaped cut) in the dura mater. The cut is shorter than the outside diameter of the needle and is dilated as the needle passes through the dura. The needle is used with a 20-gauge introducer. In vitro, it causes less leakage of cerebrospinal fluid than Quincke 26-gauge or Sprotte 24-gauge needles. This study was designed to test the ease of use and any damage caused to the needle tip during lumbar dural puncture. METHODS: This was a multicenter trial (six centers in five countries) involving 362 patients undergoing spinal anesthesia. A detailed questionnaire was filled in for every patient by the anesthesiologist. All the needles were returned to the factory and examined microscopically for damage. RESULTS: Lumbar dural puncture was successful in all but one patient. Spinal anesthesia was satisfactory for the planned surgery in 97%. Microscopy of the needle tips showed only a minor degree (0.01-0.19 mm) of bending in 14%, and none of the tips had a "hook." Postdural puncture headache (PDPH) occurred in nine patients (2.5%), all but one of whom (a 15-year-old male) were females under 55 years of age. CONCLUSIONS: The Atraucan needle is easy to use and has a high success rate in identifying the subarachnoid space. Lumbar dural puncture causes minimal damage to the tip. The incidence of PDPH is low, but a larger comparative study needs to be performed.     

Endoscope-assisted transscleral suture fixation of intraocular lenses

We describe a new method for placing transscleral sutures when fixating posterior chamber intraocular lenses to the sulcus. An intraocular microendoscope with an 18 gauge probe is used for direct sulcus observation and needle position assessment. The straight needle of a 10-0 polypropylene suture and the tip of the probe are placed in a 16 gauge silicone rubber tube to hold them together. Fixing the needle to the endoscope allows a direct view of its tip and requires only one hand. The other hand is used to grasp the tip of the needle when it comes out under the scleral flap after passing through the sulcus. Assessment of needle position with an endoscope avoids surgically induced iris root or ciliary body damage. Fixing the needle to the endoscope simplifies the surgical technique.     

A robotic system for percutaneous renal access

PURPOSE: Percutaneous renal access can be challenging, particularly when the collecting system is not distended. Precise entry into a selected calyx facilitates subsequent percutaneous manipulations, but this skill requires extensive experience. In an attempt to improve accuracy while decreasing technical challenges, we developed a robotic system that automates the task of fluoroscopic image-guided percutaneous needle placement. MATERIALS AND METHODS: The prototype system consisted of a three degree-of-freedom robot with a needle injector end-effector. Imaging was provided by a biplanar fluoroscope. After correction of image distortion and fluoroscope calibration, robot to image-space registration was completed. To validate the system's ability to insert a needle into a calyx, ex vivo porcine kidneys suspended in agarose gel and distended with iodinated contrast solution were used as a model. In situ renal access tests with three 20 kg. pigs were performed. Access was confirmed by passing a flexible wire or aspirating iodinated contrast from the collecting system. RESULTS: The diameter of target calyces ranged from 3 to 7 mm. The in vitro accuracy of final needle tip positioning was 0.43 mm. In the ex vivo model, successful "one stick" access occurred on 10 of 12 attempts (83%). In situ access on the first attempt was successful for 6 of 12 target calyces (50%). Needle or tissue deflection accounted for each failure. CONCLUSION: The feasibility of a robotic system to assist in the percutaneous access of small and delicate renal calyces has been demonstrated. Additional work in reducing procedural steps and correcting for tissue deflection during needle passage is necessary to improve accuracy and to allow for clinical application.     

Frozen storage affects the compressive creep behavior of the porcine intervertebral disc

STUDY DESIGN: A biomechanical study of the compressive creep behavior of the porcine intervertebral disc before and after frozen storage. OBJECTIVE: To determine whether frozen storage alters the creep response, hydration, and nuclear swelling pressure of the intact intervertebral disc. SUMMARY OF BACKGROUND DATA: The mechanical response of the disc is dominated by swelling and fluid flow, whose effects are time-dependent. Because fluid content, which may change during storage, plays a significant role in the disc's time-dependent behavior, changes in mechanical response due to freezing may have been missed in previous studies that focused on time-independent behavior only. METHODS: Porcine intervertebral discs were tested in repeated cycles of compressive creep either immediately postmortem or after 3 weeks of frozen storage. Swelling pressure and nuclear hydration were also measured in fresh and frozen discs. A fluid transport model was used to analyze the creep data. RESULTS: The creep behavior of the intact porcine intervertebral disc is dramatically affected by frozen storage. The apparent permeability of the frozen discs was 82% higher than that of the fresh discs, and the swelling pressure of frozen discs was 25% lower in frozen discs (P < 0.01). The behavior of fresh and frozen discs became more dissimilar with repeated cycles of creep. CONCLUSIONS: In vitro tests of frozen porcine intervertebral discs do not represent fresh behavior. Frozen storage appears to permanently alter disc behavior. The precise nature of any freezing-induced damage, and whether frozen storage similarly affects human discs, remains to be seen.     

Methods of transfemoral lumbar epidural venography in the diagnosis of lumbar disc herniation

This article outlines several ways of achieving adequate visualization of the epidural venous plexus in the diagnosis of lumbar disc herniation. Preference is expressed for simultaneous injection of contrast medium via two catheters selecttively introduced into the lateral sacral segmental veins or into the left and right internal iliac veins. For visualization of the epidural veins, the investigator has a choice of over 20 different procedures. The position of choice of the catheter tip(s) can vary during the examination, dependent on diagnostic problems or technical catheterization problems. Epidural venography should be regarded as a very accurate, relatively simple method of demonstrating disc herniations in the lumbar region. This method is especially recommendable in cases that are clinically suspect but have a negative or dubious caudogram. The risk of complications is very small. It is also a good method for azygography. It is possible to perform the examination on outpatients.     

An appraisal of the accuracy of Littmann's method of determining the real dimension of a retinal object

Estimation of the neuroretinal rim area in absolute units is becoming increasingly desirable in the evaluation of optic discs of glaucoma suspects. There are various methods of optic disc biometry, photogrammetric techniques being the most commonly reported. Any method of estimation of the real dimension of a retinal object must consider magnification due to the patient's eye. Photogrammetric techniques use Littmann's method extensively in this respect, assuming that it is an accurate way of performing the necessary correction. The accuracy of Littmann's method has not yet been assessed in a physiological setting. This study has found that, when the normal distributions of the optical elements eye are considered, in estimating the neuroretinal rim area, the method is at least 86% accurate (95% confidence interval) within an ametropia range -4 to +4 dioptres. This level of accuracy should be considered when drawing conclusions from any study in which Littmann's method is used.