Meningovertebral ligaments and their putative significance in low back pain

OBJECTIVE: To determine the presence and morphology of the meningovertebral ligaments (ligaments of Hofmann) as well as postulate their possible contribution to low back pain. DESIGN: Sagittal dissections were performed on 12 embalmed cadaver specimens including the L5/S1 intervertebral level cephalad to T1. Meningovertebral ligaments were labeled and documented in both the lumbar and thoracic regions. RESULTS: Meningovertebral ligaments were found in both the lumbar and thoracic regions of all cadaveric specimens. These ligaments were much more prevalent in the lumbar vertebral column but were also present throughout the thoracic vertebral column. The meningovertebral ligaments in the lumbar region were more robust as well as more frequently encountered than those found in the thoracic region. CONCLUSION: Dural sac attachments to the posterior aspect of the vertebral bodies and the posterior longitudinal ligament could act to traction the dural sac in the event of nuclear bulge or herniation. The prevalence of these ligaments in the lumbar spine, coupled with the high incidence of herniated nucleus pulposus and disc bulges in this region, may compound the effects of disc pathology and result in increased low back pain.     

Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders

Three newborn calves were affected by caudal spinal dysgenesis or agenesis (coccygeal vertebra) and persistent cloaca. The cloacas were lined by a mixture of transitional and colonic epithelium. The vertebral column of one calf was internalized into the cloaca. The association of persistent cloaca and caudal spinal anomalies is thought to be related to cell loss in the caudal cell mass, which affects caudal spinal column formation and cleavage of the cloaca by the urorectal septum. This association is well documented in humans and has been reported in Manx cats. By extrapolation, it appears likely to exist also in neonatal calves. Identification of cloacal lesions in neonatal animals should be cause for careful examination of the vertebral column because many of the associated spinal lesions are occult.     

Morphogenesis of the spinal canal, normal and stenotic

The closest formative developmental dependence of the axial skeleton upon the morphogenesis of the intraspinal nervous structures is reflected in the roentgen features of the individual vertebrae as well as of the vertebral column in its entirety. The vertebroneural developmental events are characterized by a steady relative decrease in size of the nervous structures (the first to be laid down and huge in the embryonic period) under a corresponding increase in size of the skeletogenic tissues. There exists experimental evidence that the maintenance of the necessary developmental balance between the two tissues, the bony and the skeletogenic, is a function of the nervous substance. The tight spinal canal appears to result from a failure of the latter neural function leading to overgrowth of the bony structures, viz., to massive vertebrae and laminae encroaching upon the neural contents. Morphogenesis of the normal and tight lumbar spinal canal is discussed with special reference to the developmental interrelations between the cauda equina complex and the lumbar vertebrae.     

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.     

Computed tomography of the spine as an important diagnostic tool in the management of war missile spinal trauma

Twenty-two patients with spinal injury were evaluated by plain radiography immediately after hospital admission. In 14 patients whose condition was stable, we performed computed tomography (CT) scanning through the involved segments. To provide better planning before neurosurgical management, we divided the vertebral column in thirds. According to this division, we concluded that these injuries are mostly extensive, severely damaging all three thirds of the vertebral column and accompanying neural structures in the majority of cases. The information acquired by Ct concerning bony fragments, bone destruction, dural tear, spinal cord and nerve root compression, and neural damage directly influenced the surgical management. All patients except one underwent surgery while associated injuries of other organs were given priority in management. Injuries of the thoracic and the lumbar spine were the most common ones, frequently found in association with lesions of nearby organs. Penetrating injuries with a dural lesion were present in the majority of cases, while spinal cord injury was obvious in some. They were all well visualized using spinal CT scanning. Our view is that the role of CT is essential in guiding surgical management of war missile injuries to the spine.     

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.     

Heterochronic processes in human evolution: an ontogenetic analysis of the hominid pelvis

Changes in pelvic shape in human ontogeny and hominid phylogeny suggest that the heterochronic processes involved differ greatly from the neotenic process traditionally described in the evolution of the skull. The morphology of 150 juvenile and adult pelves of African apes, 60 juvenile and adult pelves of modern humans, two adult pelves and a juvenile hip bone of australopithecines (Sts 14, AL 288, MLD 7) was studied. Multivariate results, ontogenetic allometries, and growth curves confirm that the pelvic growth pattern in humans differs markedly from those of the African apes. The results permit the following conclusions. First, the appearance of a new feature (acetabulo-cristal buttress and cristal tubercle) at the time of human birth allows the addition of traits, such as the attainment of a proportionally narrower pelvis, with more sagittally positioned iliac blades. Pelvic proportions and orientation change progressively in early childhood as bipedalism is practiced. Other changes in pelvic proportions occur later with the adolescent growth spurt. Second, comparison of juvenile and adult australopithecines to modern humans indicates that 1) some pelvic traits of adult Australopithecus resemble those of neonate Homo; 2) the pelvic growth of Australopithecus was probably closer to that of apes, than to that of humans; and 3) prolonged growth in length of hindlimb and pelvis after sexual maturity seems to be a unique feature of Homo. The position of the acetabulo-cristal buttress and of the cristal tubercle on the ilium are similar in adult Australopithecus and neonate Homo suggesting that this feature may have been displaced later during hominid evolution. Progressive displacement of the acetabulo-cristal buttress on the ilium occurs both during hominid evolution (from Australopithecus to Homo sapiens) and human growth (from neonate to adult). This suggests peramorphic evolution of the pelvic morphology of hominids combining three processes of recapitulation (pre-displacement, acceleration and time hypermorphosis). The results lend credence to the hypothesis that no single heterochronic process accounts for all human evolutionary change; rather this reflects a combination of relative changes in growth rhythm and duration, including other perturbations, such as the appearance of new morphological features.     

Summary of complications of ureteroileal conduit with radical cystectomy: review of 336 cases (by Jerry W. Sullivan, MD, Harry Grabstald, MD, and Willet F. Whitmore, Jr). 1980

Pyogenic infectious spondylitis (PIS) is an uncommon but serious inflammatory disorder of the discovertebral junction with frequent involvement of neural structures including the spinal cord. We report a series of 41 patients (age range 21-75 years, mean age 59 years) with primary PIS confirmed by signal abnormality of the intervertebral disk and adjacent vertebral bodies on magnetic resonance imaging. The prevailing clinical symptom was focal back pain aggravated by percussion in 90% of patients. Radicular signs or symptoms were present in 59% and spinal cord symptoms in 29% of patients, respectively. Evidence of inflammation consisted of an elevated sedimentation rate in 76%, leukocytosis in 61% and fever in 61% of individuals. Predisposing factors such as diabetes mellitus, previous nonspinal surgery and other sites of infection or inflammation were identified in 17 (41%) patients and 30 (73%) were older than 50 years. The lumbar spine was most often affected and PIS was associated with an epidural abscess in 15 (37%) patients. Increased alertness for PIS in the context of focal back pain with clinical or laboratory signs of inflammation is needed to speed up its detection.     

Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT

The aim of this study was to investigate the correlation of vertebral dimensions with somatometric parameters in patients without clinical symptoms and radiological signs of central lumbar spinal stenosis. One hundred patients presenting with low back pain or sciatica were studied with CT. In each of the L3, L4 and L5 vertebra three slices were taken with the following measurements: 1. Slice through the intervertebral disc: (a) spinal canal area; (b) interarticular diameter; (c) interligamentous diameter. 2. Slice below the vertebral arcus: (a) dural sac area; (b) vertebral body area. 3. Pediculolaminar level: (a) anteroposterior diameter and interpedicular diameter of the spinal canal; (b) spinal canal area; (c) width of the lateral recesses. The Jones-Thomson index was also estimated. The results of the present study showed that there is a statistically significant correlation of height, weight and age with various vertebral indices. The conventional, widely accepted, anteroposterior diameter of 11.5 mm of the lumbar spinal canal is independent of somatometric parameters, and it is the only constant measurement for the estimation of lumbar spinal stenosis with a single value. The present study suggests that there are variations of the dimensions of the lumbar spinal canal and correlations with height, weight and age of the patient.     

The function of hairy-related bHLH repressor proteins in cell fate decisions

To obtain a fundamental knowledge of the morphological relationship between nerve root symptoms and circulatory disorders, the distribution pattern of the veins in the lumbar spinal ganglia from the first to fifth vertebrae was investigated in 5 adult human cadavers (mean age 69.6 years) and 5 human fetuses (mean age 6.6 months). The following results were obtained: 1) In the adults the veins perforating from the outer surface of the fifth lumbar spinal ganglion were smaller in number than those perforating from the first to fourth ganglia. In contrast, in the fetuses the number of such veins was increased in the lower lumbar spinal ganglia. In each of the ganglia, the number of veins emerging through the dorsal side was much higher than the number perforating from the outer surface of the ventral sides. The veins perforating through the outer surface of the ganglion formed weak venous networks (periganglionic venous plexus) surrounding the dorsal ramus of the spinal nerve. 2) The veins communicating with the tributaries from the periganglionic venous plexus were classified into three types. Type 1 veins flowed into the intervertebral veins (the frequency ranged from 9.2 to 18.2 in the adults and from 22.4 to 37.0 in the fetuses). Type 2 veins coursed in the spinal cord along the dorsal root fibers and penetrated the dura mater on the way (the frequency ranged from 0.4 to 4.8 in the adults and from 1.2 to 2.2 in the fetuses). Type 3 veins opened directly into the internal vertebral plexus (the frequency ranged from 0.4 to 1.8 in the adults and from 0 to 0.4 in the fetuses). Type 1 veins were the most frequent among the three types of veins in both adults and fetuses. Few type 3 veins were observed in either group. 3) In the first and second lumbar vertebrae in the adults, three-quarters of each spinal ganglion was situated in the vertebral canal. In the lower lumbar region (L3-L5), three quarters of each spinal ganglion lay on the outside of the vertebral canal. In the fetuses, approximately one half to three-quarters of each lumbar spinal ganglion was located in the vertebral canal.     

Measurements of vertebral shape by radiographic morphometry: sex differences and relationships with vertebral level and lumbar lordosis

OBJECTIVE: To examine sex-related and vertebral-level-specific differences in vertebral shape and to investigate the relationships between the lumbar lordosis angle and vertebral morphology. DESIGN AND PATIENTS: Lateral thoracic and lumbar spine radiographs were obtained with a standardized protocol in 142 healthy men and 198 healthy women over 50 years old. Anterior (Ha), central (Hc) and posterior (Hp) heights of each vertebra from T4 to L4 were measured using a digitizing technique, and the Ha/Hp and Hc/Hp ratios were calculated. The lumbar lordosis angle was measured on the lateral lumbar spine radiographs. RESULTS: Ha/Hp and Hc/Hp ratios were smaller in men than women by 1.8% and 0.7%, respectively, and these ratios varied with vertebral level. Significant correlations were found between vertebral shape and the lumbar lordosis angle. CONCLUSIONS: These results demonstrate that vertebral shape varies significantly with sex, vertebral level and lumbar lordosis angle. Awareness of these relationships may help prevent misdiagnosis in clinical vertebral morphometry.     

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)     

Doctors'' attitudes towards empirical data--a comparative study

PROBLEM: The interdependencies between movements of the thighs and the lumbar vertebral shape are of high practical interest. Which are the normals of this phenomenon? METHOD: In an experiment on 107 volunteers without before known spinal disorders and complaints of back pain (47 f, 60 m, 17 a-30 a), the interdependencies between movements of the thighs in the sagittal and the lumbar back profile were analysed. Hip joint movements were provoked by a lift jack, elevating the feet to the volunteers, which sat on a bicycle chair. The hip joint flexion was measured by a Zebris CMS 50. The sagittal profile of the lower back was sensed by a comb of steel needles with low friction support. RESULTS: At 30 degrees of hip flexion, 68% of the volunteers demonstrated a kyphotic, 17% a straight and 15% a lordotic lumbar shape. Starting at 90 degrees of hip flexion, "definitively kyphosating movements" of the lumbar motion segments occur. At the end of the motion, 89% of the volunteers had a kyphotic, 3% a straight and 8% a lordotic lumbar configuration. Each 2 degrees of additional hip joint flexion caudo-cranially one more lumbar motion segment is recruited for the definitive kyphosation of the lumbar spine. CONCLUSIONS: Instead of a "physiological shape of the lumbar spine" its "physiological function" or its "physiological interaction between shape und function" should be in the focus of future discussions. In the sitting, hip joint flexion leads to a coupled motion of the thighs, the pelvic girdle and the lumbar vertebral column with the consequence of a kyphosation of the lumbar back shape.     

Treatment of spinal fractures with paraplegia

Of 206 patients with vertebral fractures in the thoraco-lumbar spine with spinal cord injuries, an antero-lateral decompression with stabilization of the injured segment of the vertebral column was undertaken in 56 cases. In all these cases there was a compression of the spinal cord from the front. 8 patients made a complete recovery, 31 a good recovery, and 6 were improved. In 8 patients no improvement was noted. 2 patients developed pressure sores later and 1 patient died one year after the operation of uraemia. 22 patients out of 55 got a normal function of the bladder and 25 patients out of 54 a normal function of the anal sphincter. 16 patients out of 17 made a complete or good recovery after removal of a displaced rotated vertebral bony fragment from the spinal canal, and 7 patients out of 9 with wedge shaped fractures. In our clinic today, in cases of vertebral fractures with neural involvement, reduction and internal fixation with Harrington rods and fusion of the injured segment is undertaken as soon as possible, also during the night. If narrowing of the neural canal and compression of the spinal cord are verified, a decompression operation with interbody fusion is undertaken during the next days.     

Traumatic instability of the lumbar spine. A dynamic in vitro study of flexion-distraction injury

STUDY DESIGN: This in vitro study determined the effect on the lumbar spine of a dynamic flexion-distraction loading simulating a lap seatbelt injury. The proportion by which the forces and the moments contributed to the injury of the lumbar spinal segment in such a situation was analyzed. The remaining stability of the injured lumbar motion segment was determined together with the threshold for lumbar spine instability in such an injury. OBJECTIVES: Based on the experimental results in this study, radiographic guidelines for instability criteria in lumbar and thoracolumbar dislocations in the sagittal plane without concomitant compression fracture of the middle column were proposed. SUMMARY OF BACKGROUND DATA: A number of check-lists and guidelines were suggested for the diagnosis of spinal instability after trauma, but no conclusive system was established. Those systems were mostly based on experiments performed on spinal segments after sequential ablation of ligaments and facet joints followed by static, unidirectional physiologic loading. We believed that there was a need for more profound knowledge of spinal injury and for instability criteria of lumbar spinal injuries based on more realistic experimental data simulating the clinical situation. In our injury model, we decided to study the biomechanic outcome of a flexion-distraction injury similar to seatbelt type injury seen in frontal motor vehicle collisions. METHODS: Twenty lumbar functional spinal units were first loaded statically with a physiologic flexion-shear load to determine angulations and displacements under noninjurous conditions. Dynamic flexion-shear loading to injury with two different load pulses was then applied. Static physiologic load was then again applied to determine any permanent residual deformation. RESULTS: The viscoelastic effect of loading rate on translatory and angular displacements and the values for translatory and angulation displacements at first sign of injury (yield) and at failure were determined. CONCLUSIONS: Radiographic guidelines for instability criteria in lumbar and thoracolumbar fracture-dislocations without concomitant posterior vertebral body compression are proposed: 1. Instability exists if there is a kyphosis of the lumbar motion segment > or = 12 degrees (impending instability) or > or = 19 degrees (total instability) on lateral radiographs. 2. Relative increase in interspinous process distance > or = 20 mm (impending instability), > or = 33 mm (total instability) on anteroposterior radiographs.     

Postprandial blood glucose and its relation to diabetic gastroparesis--a comparison of two methods

A group of 44 individuals were re-evaluated at a median follow up time of 19 years after radiotherapy for childhood cancer involving some part of the vertebral column. The median age at diagnosis was 2.6 years. The diagnosis included Wilms' tumour (n = 24), neuroblastoma (n = 9) and other solid tumours (n = 11). Scoliosis with or without kyphosis was the most common spinal deformity and was found in 40/44 patients. The apex of the major curvature was on the lumbar vertebral body 1-3 in 23 cases. The kyphosis and lordosis were greater in the subjects with tumour other than Wilms' (P = 0.04 both). Of the subjects restudied, 35 had detectable local soft tissue atrophy in the region of irradiation. Scoliotic deformity often enhanced cosmetic handicap/defect. Five subjects reported some symptoms related to the back; they had more severe scoliotic and kyphotic deformity (P = 0.02). Spinal abnormalities were common in these survivors, but subjective complaints were unusual.     

Lumbar dislocation fracture with paraplegia after pelvic seat belt injury. Case report

This report details a traumatic spinal column lesion due to a lap seat belt. A healthy 22-year-old woman was involved in a car accident and suffered a lumbar luxation fracture at the level L1-L2. She developed acute transsectional symptoms with paraplegia and severe hyperpathia in her legs. Plain radiographs (antero-posterior and lateral projection) and lumbar CT scans demonstrated an instable flexion-distraction fracture with ventral compression of the vertebral body of L2 and ventrolisthesis of L1 over L2. Surgical reposition of the luxation fracture and removal of a spinal epidural hematoma was performed 4 h after the trauma. Stabilization was achieved by monosegmental dorsal transpedicular spondylodesis with a fixateur interne. In follow-up the neurological deficits markedly improved. Six months after the trauma, the patient is able to walk, has no paresis and no genitourinary disturbances: only mild dysesthesia remains. This posttraumatic course confirms that spinal traumas below L1 which spare the conus have a favorable prognosis, because the peripheral nerves of the cauda equina are able to recover. This injured patient was the only one using a lap seat belt; the other four passengers in the same compact car-wearing lap and diagonal seat belts-suffered no harm. We conclude that lap seat belts are not acceptable as an adequate security standard in modern automobile technology.     

Principles of vertebral fracture management

Traumatic disruption of the spine and supporting soft tissue structures may result in vertebral fracture or luxation and subsequent spinal cord compromise. An understanding of the regional anatomy is important to the discussion of pathophysiology and treatment of traumatic disorders. Various traumatic forces result in disruption of specific anatomic structures and reflect inherent stability or instability of the vertebral column. The neurological examination, and sequential neurological examinations, reflect the degree of spinal cord damage and vertebral instability. Patients in whom radiographs show instability, have severe neurological signs or worsening neurological signs, should be treated surgically. Several spinal stabilization techniques are available and their choice is contingent on the location in the spinal column, size of the patient, and the surgeon's experience. The prognosis is determined primarily by the severity of neurological signs, and the stability of the fixation technique.     

Mobility health assessment

Somatosensory evoked potentials at the cortical and spinal levels were dynamically studied in patients with vertebral column and spinal cord injuries before and after radical reparative surgery. The study showed that quantitative determination of the time course of changes occurring was highly effective in neurological disorders. Most significant were changes in the latent periods and amplitude of the peaks N11, N13, N20, P23 in the activation of n. medianus and N21, N28, P37, N45 in the bilateral stimulation of n. tibialis posterior. There was a correlation of neurophysiological and clinical manifestations in 50-60% of cases. Thus, the neurophysiological studies quantitatively verify the efficiency of surgical treatment for vertebral column and spinal cord injuries.     

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.