Intraoperative ultrasound in lumbar intervertebral disk displacement

Intraoperative ultrasound of the spine has been used in neurosurgery (tumours) and traumatology (reposition of fractured vertebral bodies fragments). AIM: To describe initial experiences with this method and to document the opportunities and problems. METHOD: 24 nucleotomies were documented and evaluated. Sonography was performed using a 7.5 MHz sector probe and a typical surgical approach. RESULTS: In 21 of 24 cases, imaging of intraspinal structures was possible. The complete extraction of the herniated disk could be documented. In 3 cases the examination failed because the probe was too large to be pushed down between the spinous processes and the wound retractor to the operative site. CONCLUSIONS: Intraoperative sonography can be used easily as a routine method for exploration of the spinal canal. Technical innovations in the probes would make the method even more feasible.     

Relationship between spine bone mineral density and vertebral body heights

The aim of this study was to investigate the correlation between lumbar spine bone mineral density (LS-BMD) and the vertebral body heights with advancing age and years since menopause. One hundred and sixty-three women ages 39-74 years (77 normal premenopausal, ages 39-54, and 86 normal postmenopausal, ages 46-74 years) were studied. LS-BMD was measured by dual energy X-ray absorptiometry. Vertebral heights were evaluated, using morphometry, as the sum of anterior (AHs), middle (MHs), and posterior (PHs) vertebral body heights from T4 to L5. The AHs/PHs ratio at the same level was also calculated. AHs, MHs, PHs, and AHs/PHs ratio directly correlated with LS-BMD; the correlations are AHs r = 0.80, P < 0.0001, MHs r = 0.75, P < 0.0001, PHs r = 0.76, P < 0.0001, and AHs/PHs r = 0.66, P < 0.001. Both LS-BMD and AHs are inversely correlated with age, and the regressions fit with both linear and cubic curves. The statistical significance of the correlations persists while maintaining age constant. The linear regression curve of AHs with age indicates that the spine height decrement rate is 2.12 mm/year, corresponding to 7.4 cm in 35 years. AHs decreases immediately after menopause fitting with a cubic curve model, with a decrement rate of about 3 cm in the first 5 years after menopause. We conclude that the measurement of the sum of vertebral body heights could usefully integrate LS-BMD evaluation in the clinical and epidemiological investigation of osteoporosis.     

The vertebral body depths of the cervical spine and its relation to anterior plate-screw fixation

STUDY DESIGN: A study was performed to measure the vertebral body depths in different locations from C2 to C7. OBJECTIVES: To measure the vertebral body depths in 10 linear dimension from C2 to C7. SUMMARY OF BACKGROUND DATA: Anterior plate-screw fixation of the cervical spine has been the common surgical procedure for management of multilevel degenerative disc disease and fracture dislocation. However, injury to the spinal cord during drill or screw placement is the most feared complication of this procedure. It is beneficial for one to have a knowledge of the vertebral body depths in different locations of the vertebral body before anterior cervical plating. METHODS: Twenty-seven cervical spines from C2 to C7 were evaluated directly for this study. Anatomic evaluation of the vertebral body included the anteroposterior midline sagittal depth and the anteroposterior parasagittal depth 5 mm lateral to midline on the superior and inferior endplates, as well as on the middle body. Measurements also were made of anteroposterior parasagittal vertebral depth with both medial and lateral inclination of 10 degrees, with respect to the parasagittal plane of the vertebral body. RESULTS: In general, the measurements of male specimens were larger than those of female specimens. Significant differences were noted at 21 measurements over C3 through C7. The mean depths of the superior endplate for all male and female specimens increased consistently from C3 to C7. The mean depths of the inferior endplate varied but generally increased from C2 to C6, then decreased to C7. The mean sagittal and parasagittal middle vertebral body depths were both 14 mm. CONCLUSIONS: This information, in conjunction with preoperative computed tomographic evaluation, may be helpful in determining proper screw length during anterior plating of the cervical spine.     

The relationship between surface contour and vertebral body measures of upper spine curvature

STUDY DESIGN: In this study, parameters of sagittal cervical posture obtained from surface markers and from vertebral body locations were compared. OBJECTIVES: Several postural parameters were examined to establish the degree to which surface measures of cervical alignment reflect the underlying vertebral body alignment. SUMMARY OF BACKGROUND DATA: Previous studies of the relation between surface and vertebral alignment in the thoracic and lumbar regions have shown conflicting results. Some data suggest a connection between surface cervical posture and head and neck pain, but the relation between surface and vertebral posture in the cervical region has not been reported. METHODS: Lateral view radiographs of 24 healthy volunteers were used to give the surface alignment of skin markers and the locations of the geometric centers of vertebral bodies. Three angles describing sagittal alignment were investigated: 1) forward inclination of C2 relative to C7 (cervical inclination); 2) cervicothoracic kyphosis; and 3) cervical lordosis. RESULTS: A strong relationship between surface and vertebral data was not established. Two factors were identified as contributing to the observed differences: length of spinous processes and depth of soft tissue overlying the spinous processes at each spinal level. CONCLUSIONS: The assumption that the surface curve is the same as the vertebral curve is not supported by these results, suggesting caution is needed in inferring vertebral alignment from observed surface contours.     

Transpedicular stabilization in spinal and vertebral column injuries in thoracic and lumbar spine segments

The authors present their own experience in application of transpedicular internal stabilization of the thoracic and lumbar spine. Clinical analysis was carried out in a group of 12 patients after vertebral column and spinal trauma managed surgically in the Department of Neurosurgery in Poznań between 1.06.95 and 31.12.96. Age of patients ranged from 19 to 56 years (mean age 35.08 +/- 13.04 yrs.). The level of vertebral fracture was as follows: thoracic (2 cases), thoraco-lumbar (6 cases) and lumbar (4 cases). Three patients were completely paraplegic. All patients underwent posterior or posterolateral surgical approach. The fractured parts of bones, translocated into vertebral canal were removed and nervous structures were decompressed. Transpendicular stabilization was performed after the decompression. Improvement of neurological condition was observed in 8 patients.     

Effect of osteoarthritis in the lumbar spine and hip on bone mineral density and diagnosis of osteoporosis in elderly men and women

To select for bacterial strains with enhanced phenotypes, random fragments of a whole genome, or a defined region of the genome, are cloned in a nonreplicating vector. The resulting plasmids are integrated by recombination into the homologous DNA region of the original strain. Integration gives rise to a nontandem direct duplication of the corresponding DNA region separated by the vector moiety of the plasmid. Recombination between the direct repeats leads to tandem duplication and further amplification of the entire integrated DNA, including the vector. Bacteria harboring the amplified DNA are selected by increasing the dosage of an antibiotic corresponding to a resistance marker of the integrated vector. Pooled strains carrying amplifications are then challenged with a selective pressure for the desired phenotype. After repeated selection cycles, the most fit strains are isolated. We used this process, which we called random DNA amplification, to select Rhizobium strains with increased competitiveness for nodule formation. Derivatives containing randomly amplified DNA regions of the symbiotic plasmid of Rhizobium tropici CFN299 strain were generated. Pools of amplified strains were inoculated onto various tropical legumes. After several cycles of selection through plants, amplified derivatives showing an increased competitiveness for nodule formation with the leguminous plant Macroptilium atropurpureum were obtained.     

Surgical treatment of herniation of a lumbar intervertebral disk in young people (author's transl)

Among 2755 patients operated on for nerve-root compression there were 38 children and juveniles (aged 11-22 years). Average interval between onset of symptoms and operation was 14 1/2 months and often involved considerable diagnostic effort. 36 of the 38 patients were re-examined an average of 11 years after operation: 15 were free of symptoms, 18 had occasional mild symptoms, two had continuous mild pain and one had occasional severe pain. Re-operation was necessary in six. All patients are able to work. A connection between an accident and the herniation was demonstrated in only two instances.     

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.     

The location of the intervertebral lumbar disc on the posterior aspect of the spine

Lack of in vitro cultivation methods has inhibited the development of rapid, reliable diagnostic procedures for adenovirus-associated necrotizing bronchopneumonia in guinea pigs. Because polymerase chain reaction (PCR) techniques are well established for human adenoviruses, primers for the amplification of guinea pig adenovirus DNA were evaluated. The DNA for PCR was purified from the lung tissue of spontaneously infected and healthy guinea pigs. Adenovirus DNA could only be detected in the lungs of the infected animals. Subsequent sequence analysis of PCR products revealed that the guinea pig adenovirus is a distinct adenovirus.     

Transpedicular decancellation closed wedge vertebral osteotomy for treatment of fixed flexion deformity of spine in ankylosing spondylitis

Limitation of movement of the back, pelvis, chest wall, and other joints are the consequences of ankylosing spondylitis. The most serious problem is severe kyphosis leading to disturbance of the activities of daily living and failure of the respiratory system. Transpedicular decancellation closing wedge vertebral osteotomy, using the posterior approach followed by segmental spinal instrumentation, is a safe and easy technique for correction of the deformity. The authors report the results of this technique in six patients, five men and one woman, who had undergone the operation. The average age of the patients was 29.8 years (range 21-38). Three patients had thoracolumbar kyphosis averaging 104 degrees (range, 80-120), while the others had lumbar kyphosis averaging 46.7 degrees (range, 35-60). The angles of correction in all cases average 33 degrees. Only one case in this report had dura tear due to adhesion between the dura and the ossified ligamentum flavum, which required exploration and repairing with myofascial graft. No case had any neurologic complication. At an average of 24 months' follow-up, all cases had improvement of their general appearance, posture, respiratory and gastrointestinal functions, and had good bony union.     

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.     

Transforaminal and posterior decompressions of the lumbar spine. A comparative study of stability and intervertebral foramen area

STUDY DESIGN: Ten fresh, cadaveric, two-vertebrae, functional spinal units were used to study the pathoanatomy, intervertebral foraminal area, and flexibility changes after posterior and transforaminal decompression. OBJECTIVES: To determine the feasibility of an endoscopic transforaminal approach as an alternative to conventional approaches, to establish the adequacy of transforaminal decompression without destabilizing the spine, and to study the structural changes in the spine after decompressions. SUMMARY OF THE BACKGROUND DATA: Posterior decompression entails major dissection and excision of bone and ligaments to access the spinal canal. Posterior decompression may be complicated by acute or chronic spinal instability, and the adequacy of lateral decompression is highly subjective. METHODS: The functional spinal units were mounted in quick-setting epoxy blocks. Pre- and postoperative computed tomography scans were taken to study changes in the foraminal area. Pre- and postoperative flexibility and anatomic studies were performed to compare the results. RESULTS: A 45.5% increase in the intervertebral foraminal area was possible, there was no flexibility change, and minimal anatomic damage to the spine was noted after transforaminal decompression. A 34.2% increase in the intervertebral foraminal area and a significant increase in extension and axial rotation flexibility were noted after the posterior decompression. CONCLUSION: Transforaminal decompression produced a significantly larger increase in the intervertebral foraminal area than posterior decompression, without increasing the range of motion or neutral zone in any direction. Because there was no violation of the anatomic integrity of the spine in the transforaminal approach, the risk of surgically induced instability was minimized. Endoscopic transforaminal decompression is a feasible alternative to current approaches.     

Prospective study on the relation between living arrangement and change in functional health status of elderly women

BACKGROUND: Our aim was to infect rats with Helicobacter pylori and to study the effects of the infection on the gastric mucosa in normal and in ulcer-operated rats. METHODS: A mouse-adapted H. pylori (cagA-, VacA-) strain was inoculated into 23 rats. Another 20 uninfected rats served as controls. Two months later a gastric ulcer was induced in some rats. The animals were killed 3, 6, or 15 days after the ulcer operation. Tissues were taken for histology and for culture of H. pylori. Serum antibodies were determined. RESULTS: All inoculated rats were infected by H. pylori after 2 months, mainly in the antrum. In these rats a mild to moderate chronic inflammation and a significantly increased frequency of apoptotic cells were observed in the antrum and in the ulcer margin, the ulcer healing was delayed, and the serum level of H. pylori-specific Ig was increased. CONCLUSIONS: H. pylori infection in rats was successful and was accompanied by a mild to moderate mucosal inflammation. Gastric ulcer healing was delayed in infected rats, probably due to the inflammation and the increased apoptosis in epithelium.     

Correlation study on infrared thermography and nerve root signs in lumbar intervertebral disk herniation patient: a short report

OBJECTIVE: To determine whether infrared skin thermography is an objective measurement reflecting the seriousness of nerve root irritation in lumbar disk herniation patients. DESIGN: Quantified nerve root signs by physical examination were collected from the patients along with the infrared skin temperature measurement on the lumbosacral region and posterior part of thighs. A correlation study was applied to observe the relation between the nerve root signs and the skin temperature before a successful conservative treatment (mainly spine manipulation), and between the alteration of nerve root signs and that of skin temperature after the treatment. SETTING: Hospitalized care. PATIENTS: Twenty-seven hospitalized samples with computed tomography or magnetic resonance approval were consecutively selected during the latter half of 1990. MAIN OUTCOME MEASURE: Changes in nerve root signs. RESULTS: The temperature difference between a troubled thigh and healthy one is significantly correlated to the score of the nerve root signs before the treatment; and the reduction of temperature difference between two thighs is also significantly correlated with decreasing score of nerve root signs after the treatment. The correlation between the temperature difference on the left and right sides of the lumbosacral region and the nerve root signs before the treatment is insignificant; and the variation of the temperature difference of the same region after the treatment is not correlated with the decreasing score of the nerve root signs. CONCLUSION: Infrared skin thermography of lower extremities might be an objective sign in signaling the soothing process of the nerve root irritation in lumbar disk herniation patients, which may help a doctor in checking the responses of the patient to treatment.     

Determination of bone mineral density in the third lumbar vertebral body using photon absorptiometry techniques

Dual-photon absorptiometry and triple-energy X-ray absorptiometry were used to investigate the total bone mineral content and density as well as the trabecular bone mineral density in the third lumbar vertebral body. Both anteroposterior (AP) and lateral (LAT) measurements were performed. By combining the two projections it was found that the mean trabecular bone mineral density for all 202 subjects included in the study was 52% (SD +/- 20%) of the total bone mineral density in the third lumbar vertebral body. The mean trabecular bone mineral density as a fraction of the total vertebral body bone mineral density decreased as a function of age. The relative annual change in this fraction differed between males and females. It was also found that neither trabecular nor total bone mineral density differed significantly between male and female subjects aged 25-35 years, and bone mineral density (BMD), expressed in g/cm3, showed no correlation to subject height, body weight or body mass index (BMI). Male and female individuals showed different rates of change of trabecular bone mineral density with age.     

Aging and degeneration in the lumbar intervertebral disc

1. The maintenance of the nucleus pulposus matrix in the adult human disc is dependent on the functional integrity of the cartilage end plate cells. 2. Cartilage end plate senescence is followed by compensatory cartilaginous metaplasia of annulus fibrosus cells. 3. It is proposed that disc narrowing and collapse are related to metabolic failure of matrix production by end plate and annulus fibrosus cells. 4. Calcium pyrophosphate dihydrate crystal deposits, a visible manifestation of a metabolic abnormality, are found frequently in the annulus fibrosus and cartilage end plates of elderly patients with degenerative disc disease.     

A possible correlation between vertebral artery insufficiency and degenerative changes in the cervical spine

We studied 130 patients, aged 20 to 81 years, with symptoms of tinnitus, vertigo or dizziness. Radiological examinations revealed degenerative changes in the cervical spines of all patients such as discopathy or osteophytes. Head and neck and neurological examinations ruled out other symptoms apart from vertebrobasilar artery flow insufficiency. The vertebrobasilar arteries were examined by means of a color Doppler ultrasonograph using duplex scanning. The correlation coefficient (CC) defining the relationship between the number of patients with abnormal blood flow and the total number of patients with radiologically confirmed changes in the cervical spine was 41.5%. When patients were separated by age, the value of the CC coefficient increased proportionally according to age, changing from 0 to 79.1%. Use of the Doppler ultrasonograph was found to be a safe and non-invasive diagnostic method that enabled us to assess the influence of degenerative changes in the cervical spine on hemodynamic disturbances in the inner ear and brain stem. Our findings demonstrated a pathological decrease of vertebral artery flow velocity in relationship to degenerative changes in the cervical spine.     

Static and fatigue failure properties of thoracic and lumbar vertebral bodies and their relation to regional density

This study investigated (1) whether a characterization of the macroscopic architecture within the vertebral centrum would improve predictions of vertebral strength, (2) if regions in the centrum where least bone loss with age occurs are more predictive of vertebral strength, and (3) whether different patterns of the macroscopic architecture are predictive of static as compared to fatigue strength. To characterize the vertebral macroscopic architecture, a regional bone mineral density (rBMD) technique was used that estimated the cancellous density distribution (in 18 specific regions of the vertebral centrum) for vertebrae T7-L4, from spines of 20 female cadavers. Static and fatigue failure properties of whole vertebrae were obtained, and predictive models of static and fatigue failure properties of whole vertebrae were examined. We found that (1) vertebral failure properties were better predicted by combinations of vertebral regional cancellous density (multiple linear regressions) rather than by any individual region of cancellous density alone (simple linear regressions); (2) models using regions of density that demonstrated minimum decline with age [from the data of Flynn and Cody (Calcif. Tissue Int. 53, S170-S175 (1993))] resulted in better correlations with ex vivo vertebral static failure properties than models using density regions that showed maximum decline with age, and (3) static and fatigue characteristics required different density regions to reach significance. (A comparison of models predictive of static and fatigue failure properties revealed that anterior density regions were most often included in predictive models of the static properties while posterior regions were more predictive of the fatigue properties).(ABSTRACT TRUNCATED AT 250 WORDS)     

Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine

STUDY DESIGN: A retrospective clinical study of patients with vertebral osteomyelitis of the lumbar spine necessitating surgical treatment. All patients underwent sequential (same-day) or simultaneous anterior decompression and posterior stabilization of the involved vertebrae. OBJECTIVE: To evaluate the efficacy and clinical out-come of sequential or simultaneous anterior and posterior surgical approaches in the management of vertebral osteomyelitis of the lumbar spine. SUMMARY OF BACKGROUND DATA: Anterior approach alone and staged anterior decompression and posterior stabilization have been advocated as the surgical treatment methods of choice for patients with vertebral osteomyelitis of the lumbar spine. The drawbacks of the latter management plan are the necessity to use external support or the delayed patient mobilization and the need for additional anesthesia and surgical trauma. Sequential (same-day) anterior and posterior approaches are used regularly in the surgical management of scoliosis and other spinal deformities. It would appear advantageous to also use the same strategy (i.e., combined same-day double approaches) in the management of vertebral osteomyelitis of the lumbar spine. METHODS: Ten consecutive patients who had a diagnosis of vertebral osteomyelitis of the lumbar spine underwent combined (same-day) anterior and posterior approaches either in a sequential or simultaneous manner. Indications for surgery included neurologic deficit, abscess formation, instability with localized kyphosis formation, and failure of nonoperative treatment. Patients were evaluated clinically and radiographically after surgery. RESULTS: All 10 patients had uneventful surgery. Only one patient required a second surgical procedure because of expulsion of the anterior bone graft and pull-out of instrumentation. All patients were mobilized within the 2 days immediately after surgery. At the mean follow-up examination 30 months after surgery, all patients had regained their motor function and prior ambulatory status. CONCLUSIONS: Patients with lumbar osteomyelitis necessitating surgery can undergo combined, same-day surgery either in a sequential or simultaneous manner. This is a safe and efficient way to control the infection and stabilize the affected segments, allowing for early mobilization of these sick elderly patients.