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.     

A case report on surgery for chylothorax after anterior spinal fusion: usefulness and effectiveness of intraoperative milk administration and postoperative OK-432 administration]

After having reported preliminary results of soft system stabilization according to Graf in a series of 27 patients with degenerative disc disease of the lumbar spine in early 1995 the authors report long term clinical and radiological results of this patient series (n = 25). At a mean period of postoperative observation of 50 months excellent, good, satisfactory, moderate and poor results were obtained in 62, 9%, 11, 1% and 11, 1%, 7, 4% and 7, 4% of the patients, respectively. The well-known phenomenon of loss of disc height at the level of posterolateral fusion and instrumentation as well as overcharge of adjacent segments were not observed after soft system stabilization. Regional as well as global lumbar lordosis were maintained and, although statistically not significant, an increase of intervertebral distance was observed in adjacent segments in flexion of the lumbar spine. These phenomena might represent pressurization of instrumented as well as adjacent discs after the insertion of ligament prostheses. It is the impression of the authors, that the Graf technique leads to good surgical results in degenerative disc disease with destabilization of lumbar motion segment(s) if the following criteria are strictly respected: 1. No or only mild arthrotic changes of the facet joints 2. Preferably minor disc degeneration/only mild loss of intervertebral distance. 3. Well trained low back muscles and 4. A clear-cut, repeatedly demonstrated pain-relief on trial anaesthesia of the corresponding articular nerves and while wearing a probatory jacket.     

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.     

Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham

STUDY DESIGN: A 25-year follow-up study of 606 members of the population-based Framingham cohort, who had received lateral lumbar radiographs in 1967-1968 and 1992-1993, and completed an interview on back symptoms at the second examination. OBJECTIVES: To evaluate whether calcific lesions in the posterior wall of the abdominal aorta, the source of the feeding arteries of the lumbar spine, are associated with disc degeneration or back pain, which would suggest that ischemia of the lumbar spine leads to disc degeneration. METHODS: The presence of radiographic aortic calcification was ascertained in front of each lumbar segment from L1 through L4, and disc degeneration at intervertebral spaces from L1-L2 through L4-L5. The associations between aortic calcification, disc degeneration, and back pain were tested using logistic regression with adjustment for age and sex. RESULTS: At the baseline examination, aortic calcification was significantly associated with general disc degeneration, that is, disc space narrowing or endplate sclerosis at any lumbar level (odds ratio 1.6; 95% confidence interval 1.0-2.5; P = 0.034). In longitudinal, level-specific analyses, comparing local aortic calcifications with disc degeneration at the matching level, aortic calcifications predicted disc deterioration, that is, a decrease in disc space or appearance of endplate sclerosis, between the examinations (odds ratio 1.5; 95% confidence interval 1.3-1.8; P < 0.001). Furthermore, subjects in whom aortic calcifications developed between the examinations had disc deterioration twice as frequently as those in whom aortic calcifications did not develop (odds ratio 2.0; 96% confidence interval 1.2-3.5; P = 0.013). Also, individuals with severe (Grade 3) posterior aortic calcification in front of any lumbar segment were more likely than others to report back pain during adult life (odds ratio 1.6; 95% confidence interval 1.1-2.2; P = 0.014). CONCLUSIONS: Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for development of disc degeneration and is associated with the occurrence of back pain.     

Long-term socioeconomic outcome of lumbar disc microsurgery]

Lumbar disc surgery is frequently performed but only few long-term outcome studies have been published. To assess the socioeconomic long-term outcome after lumbar disc surgery this study was performed using the Functional Economic Rating scale developed by Prolo et al. in 1986. The study group, mailed a questionnaire, consisted of 663 patients (18 to 60 years) operated on in 1983 or 1984. 23 patients (3.5%) died in the follow-up period. 406 (66% male and 34% female) patients answered the questionnaires (61%), therefore being eligible for further investigation. Mean age at the time of operation was 43 +/- 9.5 years. Preoperatively 29% of patients did sedentary work, 46% were employed in less strenuous and 25% in strenuous occupations. A motor deficit was present in 59% of patients preoperatively. In 51% the L4/5 level and in 38% the L5/S1 level was operated; 5% were operated in more than one level. In 45% an intraspinal sequester was found intraoperatively. Intra- and postoperative complications occurred in 14 patients (complication rate 3.4%). Six weeks after surgery all patients were examined in our outpatient department. 93% were more or less relieved of their complaints. 10 years after lumbar disc surgery a good outcome defined as Prolo scale 8-10 was achieved in 38%, a moderate outcome (Prolo scale 6-7) in 40% and a poor outcome (Prolo scale < 5) in 22%, respectively. Patients with strenuous occupations had a significantly (p < 0.001) less favorable outcome than patients with less strenuous or sedentary occupations. 32% were able to work in the previous profession with no restrictions. 42% were able to work part time at the previous occupation or with limited status and 9% had to change their profession. 17% were not able to gain any occupation postoperatively and retired. Vocational consequences depended on the preoperative type of occupation. 54% of patients with strenuous occupations had to change the profession or to retire compared to 15% of patients with sedentary occupations. During the 10-year follow-up period, 125 patients (31%) underwent at least another lumbar disc operation 4.8 +/- 3.8 years after their first surgery. Recurrence at the same level and the same side occurred in 14%. Reoperated patients had a significantly (p < 0.001) less favorable outcome than patients not operated on again. The results of this study indicate the recommendation of a prolonged postoperative course of treatment, especially in patients with strenuous occupations.     

Intravenous long term infusions of the rat without anesthesia

The lumbar-spine radiographs of 67 patients with idiopathic chondrocalcinosis articularis were reviewed for disc calcification and other changes. Calcification was present in 21 (31%) of the patients, seen most frequently at the L 2-3 disc space. The 21 patients as a group were significantly older than the 46 patients without disc calcification, and also had a much higher incidence of chondrocalcinosis in peripheral joints. There was no association with back pain or spinal stiffness. The 21 patients with disc calcification included six patients with a destructive peripheral arthropathy, and three of them had destructive changes affecting the lumbar spine. Three patients with a destructive peripheral arthropathy were also included in the group without disc calcification, and one of these had a destructive arthritis of the lumbar spine. For comparison, there was a 55% incidence of spinal chondrocalcinosis in nine patients with primary hyperparathyroidism and peripheral joint chondrocalcinosis, and a 6% incidence in 100 anteroposterior lumbar spine radiograph 'controls', taken before intravenous urography, although in this latter group the changes were minimal and confined to the margin of a single disc in each case.     

A long-term outcome analysis of 984 surgically treated herniated lumbar discs

This paper presents a long-term follow-up study of 984 patients operated on for a herniated lumbar disc between 1959 and 1991. It was possible to follow 98% of patients from the time of operation to the time of writing. The mean follow-up period was 10.8 years. The most common presenting complaint was back pain with sciatica in one leg; the most frequent neurological finding was impaired straight-leg raising. Myelography confirmed the diagnosis in 80% of patients, but more recently enhanced computerized tomography and magnetic resonance imaging have been the preferred studies. The operative procedure was either hemilaminectomy or laminectomy with x 3.5 magnification and fiberoptic lighting. Herniated lumbar discs involved L4-5 and L5-S1 with equal frequency (47%). The recurrence rate was 6%, one-third of which developed during the 1st year after operation. The complication rate was 4%; there were no intraoperative vascular or intestinal injuries. The Prolo Functional Economic Outcome Rating Scale was used to measure long-term outcome and the results were compared to those of Pappas, et al. Patients who did sedentary work and housewives had statistically higher total and economic Prolo scores (p < 0.01) than those who did strenuous work. The majority of patients with the "failed-back syndrome" had pending legal or Workers' Compensation claims, or were at psychological risk for surgery. In 89% of patients the outcome was good--defined as a Prolo score of 8 in 10%, 9 in 19%, and 10 in 60%.     

Minimally invasive disc surgery. Nucleotomy versus fragmentectomy

There is continued debate as to the optimum surgical management of a herniated disc with sciatica. There are proponents of conventional microdiscectomy as well as those who advocate minimally invasive approaches, including central disc decompression or nucleotomy as well as arthroscopic lumbar microdiscectomy and fragmentectomy. In this controversy (I), Dr. Gary Onik takes the position that central disc decompression is both safe and efficacious and may be the procedure of choice for recurrent disc herniations (II). Dr. Parvis Kambin takes the opposing position and advocates arthroscopically assisted fragmentectomy as the procedure of choice.     

Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation

STUDY DESIGN: The results of a randomized controlled trial comparing automated percutaneous lumbar discectomy (APLD) with lumbar microdiscectomy for the treatment of small contained lumbar discal herniations are reported. All patients gave full informed consent and were assessed by an independent observer. Seventy-one patients with radiologically confirmed small contained lumbar disc herniations were randomly assigned to undergo either APLD or lumbar microdiscectomy. All patients were formally assessed by the independent assessor using the Macnab outcome classification at 3 weeks, 2 months, and 6 months after the procedure with follow-up being continued for the duration of the study. OBJECTIVE: The objective was to complete the first randomized and blinded study with sufficient numbers to provide a valid statistical evaluation of these procedures. SUMMARY OF BACKGROUND DATA: No previous randomized controlled study comparing these methods has been previously reported. METHODS: Each procedure was performed by the same surgeon using standard techniques. Statistical analysis was by the chi-square method. RESULTS: In the APLD group only 9 of 31 (29%) had satisfactory outcomes as compared to 32 of 40 (80%) for the microdiscectomy group. Of those patients in the APLD group who had an unsatisfactory outcome and who then opted to undergo surgery (20 of 22 patients), the final success rate was only 65%. Thus, the cumulative success rate of the group initially randomized to APLD including those undergoing either APLD alone or APLD and microdiscectomy after unsuccessful APLD was 22 of 31 (71%). CONCLUSION: In this group of patients, APLD is seen to be ineffective in the treatment of contained lumbar disc herniation.     

Noxious fumes in a medical center: chemical and psychological aspects

Due to spine-loading activities nursing professionals have a relatively high incidence/prevalence of low back pain. As lumbar disc disorders can be regarded as occupational diseases (since January 1993, occupational disease BK 2108, normally more than 10 years of exposition, lumbar disc disorders with pain and reduced motility) international literature is reviewed. Own results of different prevalence-, case-control- and incidence studies (relative risk for lumbago sciatica/odds ratio for disc prolaps appr. 3-6 depending on age and occupational age) are presented. Finally the question of compensation and prevention of disc disorders is discussed.     

Low back injury

Low back injuries occur commonly in tennis, but the pathophysiologic, biomechanical, and clinical characteristics are not well defined. Tennis players may be at an increased risk of lumbar disc pathology from rotational and hyperextension shearing effects. Treatment of low back injury at present is empiric, but sport-specific lumbar stabilization and unloading of the lumbar disc should be developed. Prospective longitudinal research protocols are needed to study the lumbar spine in tennis players.     

Intragenic polymorphisms of the vitamin D receptor gene associated with intervertebral disc degeneration

STUDY DESIGN: A study in genetic epidemiology of disc degeneration, based on lifetime exposure data, findings on magnetic resonance imaging, and genotyping of intragenic markers. OBJECTIVES: To pursue the potential correlation between common allelic variations in the vitamin D receptor locus and degeneration of the intervertebral disc. SUMMARY OF BACKGROUND DATA: Familial aggregation has been observed in intervertebral disc degeneration, but the relative significance of the genetic component and shared environmental influences is unknown. The identification of relevant candidate genes associated with disc degeneration would specify a genetic component and increase our understanding of the etiopathogenesis of disc degeneration. METHODS: From the population-based Finnish Twin cohort, 85 pairs of male monozygotic twins were selected based on exposure to suspected risk factors for disc degeneration. Interview data were gathered on relevant lifetime exposures, and thoracic and lumbar disc degeneration was determined through quantitative and qualitative assessments of signal intensity on magnetic resonance imaging, and qualitative assessments of disc bulging and disc height narrowing. Possible associations were examined between disc degeneration measures and two polymorphisms of the coding region of the vitamin D receptor locus. RESULTS: Two intragenic polymorphisms of the vitamin D receptor gene revealed an association with disc degeneration. Quantitatively assessed signal intensities of thoracic and lumbar (T6-S1) discs were 12.9% worse in men with the Taql tt genotype and 4.5% worse in men with the Tt genotype, compared with signal intensity in men with the TT genotype (age adjusted P = 0.003). A similar pattern was found between disc signal intensity and Fokl genotypes; men with the ff and Ff genotypes had mean signal intensities that were 9.3% and 4.3% lower, respectively, than those in men with FF genotypes (age-adjusted P = 0.006). The summary scores of qualitatively assessed signal intensity, bulging, and disc height were 4.0% and 6.9% worse in men with Ff and ff genotypes, respectively, when compared with those in men with the FF genotype (age-adjusted P = 0.029). CONCLUSION: Specific vitamin D receptor alleles were associated with intervertebral disc degeneration as measured by T2-weighted signal intensity, demonstrating for the first time, the existence of genetic susceptibility to this progressive, age-related degenerative process.     

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.     

Production of monozygotic multiple offspring in agricultural domestic animals

The production of monozygotic twins/multiplets in livestock animal can be achieved either by microsurgical bisection of embryos at the morular- or blastocyst stage, isolation and proliferation of blastomeres from early cleavage stages or nuclear transfer. While the success rates of micro-surgical bisection are high in ruminants (pregnancy rates approximately 50%, twinning rates 20-40%) in polyovulatory species such as swine, the efficiency is low with an average of 20% embryonic survival and 2% monozygotic twins that can positively identified via DNA-fingerprinting. Isolated blastomeres from multicellular embryos still possess great developmental capacity in vitro to progress to the blastocyst stage. However, their development in vivo is markedly reduced. This article summarizes the results obtained by the authors during several years of investigation. The results show for the first time that identical twins can be obtained in pigs which have been demonstrated to be a useful tool in biomedical research.     

The sacroiliac joint. Nothing is sacred

One hundred years ago, the sacroiliac joint was considered to be the most common cause of sciatica; over time, however, it became increasingly apparent that the major back enterprise lay in disc extractions. Still, despite the lack of specific clinical tests, the same clinical symptoms suggesting lumbar disc and lumbar facet joint pathology may also justify consideration of the sacroiliac joint as the pain generator. Treatment approaches, including manual therapies, bracing, and exercises, may benefit both the facet and sacroiliac joints as well as intradiscal pathologies. The possibility of utilizing specific local intra-articular steroid injections into the sacroiliac joint may add another useful tool to the armamentarium of back pain relief strategies.     

Folliculotropic mycosis fungoides with large-cell transformation presenting as dissecting cellulitis of the scalp

MRI is routinely used in the evaluation and management of patients with failed back surgery syndrome (FBSS). However, its value is unclear in the early detection of signs that can negatively affect that later course of surgical cases. The purpose of the present study is to describe the MR images of early postoperative MRI at 3 days in 30 unselected patients who underwent lumbar microdiscectomy, and to correlate the findings with follow up MRI at 8 weeks and with final outcome. The findings are correlated with literature data. Early postoperative MRI findings were consisting of pseudohernia in 24 patients (80%), annular rent in 23 patients (80%), and other non-specific postoperative findings. On the late MRI the pseudohernia persisted in 12 patients (50%), the annular rent in 4 patients (15%) and asymptomatic pseudo-spondylodiscitis was apparent in 3 patients (10%) as was a case of true spondylodiscitis. Therefore, early postoperative findings have limited value in the management of patients after surgery for lumbar disc herniation, since the images were not correlated with the immediate clinical course after surgery nor with the late radiological and clinical outcome. The evident imaging changes in the early postoperative period after lumbar disc surgery limit the accuracy of the interpretation of MRI examinations.     

Macrophage tissue infiltration, clinical symptoms, and signs in patients with lumbar disc herniation. A clinicopathological study on 179 patients

It is postulated that in addition to nerve-root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. The clinical relevance of the histologically described inflammatory infiltrates is, however, not clearly defined [8, 22]. It was the aim of this study to assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histological results were compared to prospectively obtained clinical data. Disc specimens of 179 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Preoperatively each patient received a visual analogue scale for classification of the pain level and general clinical data were recorded prospectively. Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical workup no statistically significant correlation between the histological evidence of macrophage infiltrates and the pain grading scale or the clinical data could be found. In our study there is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimen and the obtained clinical data.     

High- and low-bar squatting techniques during weight-training

STUDY DESIGN: Tissues in the area of herniated lumbar discs were examined for inflammatory cytokines to elucidate the causes of sciatic pain in lumbar disc herniation. OBJECTIVES: To determine the role of inflammatory cytokines in the stimulation of sciatic pain in lumbar disc herniation. SUMMARY OF BACKGROUND DATA: It is postulated that in addition to mechanical compression of lumbar nerve roots and sensory root ganglia by herniated discs, there is a chemical stimulus to the production of sciatic leg pain. The exact mechanisms of chemical stimulation are not clearly defined. METHODS: During surgery, cases of lumbar disc herniation in 77 patients were classified macroscopically into protrusion, extrusion, and sequestration types. Tissues adjacent to nerve roots at the herniation were excised and analyzed biochemically and immunohistochemically for the presence of inflammatory cytokines and for the production of these cytokines and prostaglandin E2 in vitro. RESULTS: The homogenates of samples were analyzed for interleukin-1 alpha, interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, and granulocyte-macrophage colony stimulating factor, which were detectable. Most of the cytokine-producing cells were histiocytes, fibroblasts, or endothelial cells in extrusion and sequestration types, and chondrocytes in protrusion type. The secretion of these cytokines and prostaglandin E2 was decreased by the addition of betamethasone. The prostaglandin E2 production was dramatically enhanced by additional interleukin-1 alpha, but decreased by the addition of tumor necrosis factor-alpha. CONCLUSION: The results demonstrate that at the site of lumbar disc herniation, inflammatory cytokines such as interleukin-1 alpha are produced, which increases prostaglandin E2 production. Further studies are required to elucidate the role of inflammatory cytokines in causing sciatic pain.     

Lumbar intervertebral disk herniation in children

A consecutive series of 16 children from 9 to 18 years old, with lumbar intervertebral disc herniation who were treated surgically in Department of Neurosurgery Medical Academy in Poznań, between 1978-1992, was analysed. The clinical symptoms, X-ray assessment, type of operation and outcome are reviewed. In our analysis characteristic features of disc herniation in children are: the onset of pain due to violent injury in relation to lifting, bilateral neurological symptoms and radiculography imaging central intervertebral disc herniation.     

Lumbar disk prolapse. Alcohol, tobacco and prognosis

The aim of the study was to examine whether smoking or the intake of different alcoholic beverages are associated with the outcome after first time lumbar disc surgery. One hundred and forty-eight patients consecutively operated upon for lumbar disk herniation over a one-year period were classified according to various social and demographic variables. Two and a half years later they were asked about their drinking and smoking habits and the outcome of the operation was assessed using a rating scale. Results showed that intake of wine, but not other alcoholic drinks, was associated with a good prognosis. Logistic regression analysis calculated that intake of wine was associated with a fourfold increase in success rate. This odds ratio was not significantly reduced by the following variables: Age, sex, smoking habits, employment status, social class, household income or marital status. In conclusion, intake of wine was associated with a good prognosis after lumbar discectomy.