Growth of the cervical spine with special reference to its lordosis and mobility

STUDY DESIGN: The cervical spine of the healthy Japanese children aged between 1 year and 18 years was radiographically examined. OBJECTIVES: To examine the correlation between growth of the cervical vertebral body and the facet joint and the development of the cervical lordosis and intervertebral motion. SUMMARY OF BACKGROUND DATA: Although the growth of body height and facet angle have been well documented, their correlation with curvature or mobility has not been elucidated. METHODS: We evaluated plain lateral radiographs of 180 boys and 180 girls regarding diameters and central heights of the cervical vertebra, the anterior and posterior vertebral height ratio, body height index, the facet joint angles, and tilting and sliding motions. Cervical length as the summation of the central height from C3 to C7 and the cervical lordosis angle (C3-C7 angle) were also measured. RESULTS: The mean C3-C7 angle and body height index gradually decreased until 9 years of age and then increased. The C3-C7 angle showed a significant correlation with cervical length, body height index, and facet joint angles before 9 years of age, and with cervical length and body height index after 9 years of age but not with facet joint angles. Facet joint angle decreased until 10 years of age and remained almost unchanged thereafter. Total sliding showed a significant age-related decrease and showed a significant correlation with facet joint angle. CONCLUSION: Although the lordosis angle showed a significant correlation with the other values, cervical length, body height index, and facet joint angle, the determinants of the lordosis could not be elucidate in the present study. As for the mobility of the cervical spine, changes of tilting motion were small, whereas changes of sliding motion were restricted by the change of orientation of the facet joints.     

Kinematic analysis of posterolateral fusion in the lumbosacral spine

Three cases operated upon with posterolateral fusion in the lumbosacral spine have been subjected to a kinematic postoperative analysis with the aid of a roentgen stereophotogrammetric method. The primarily diseased intervals became comparatively rigid in spite of significant residual mobility, in two of the patients, not until 174 days postoperatively. Three levels of operation displayed unrestricted residual mobility.     

Sensory and autonomic innervation of the facet joint in the rat lumbar spine

The presence of sensory and autonomic nerves in the synovial membrane of the lumbar facet joint in rats was investigated by immunohistochemistry. Substance P and calcitonin gene-related peptide immunoreactivities, representing sensory nerves, were observed as varicose fibers in the synoviocyte layer. The fibers were predominantly nonvascular. The autonomic innervation was identified by the presence of neuropeptide Y- and tyrosine hydroxylase-positive fibers. Most of these fibers were found adjacent to or within blood vessel walls. Immunoreactivity to vasoactive intestinal polypeptide was seen in varicose nerve terminals in the synoviocyte layer, mostly unrelated to blood vessels. There is accumulating evidence of an involvement of both the sensory and sympathetic nervous systems in inflammatory joint disease. The neuropeptides now identified in lumbar facet joints may prove to play a significant role in the pathogenesis of low-back pain.     

The effects of immobilization of long segments of the spine on the adjacent and distal facet force and lumbosacral motion

Long levels of spinal instrumentation and fusion are common in surgery for spinal deformity. The effect on the remaining mobile segments is not well understood. The changes in lumbar facet loading and lumbosacral motion were evaluated as the number of immobilized levels increased. Four fresh canine cadaveric spines from T6 to sacrum were used. Lumbosacral motion was measured with an instrumented spatial linkage device, and facet loads were measured at L1, L4, and L7 using a strain gauge technique. Lumbosacral motion and facet loading were significantly increased (P < 0.05) after immobilization of proximal segments, and the amount of the increase was dependent on the number of immobilized segments (P < 0.05). This indicates that immobilization of long segments of the spine influences the remaining mobile segments by increasing the load and motion not only at the immediately adjacent segment but also at the distal segments.     

Lumbar facet joint arthrography with the posterior approach

Lumbar facet joint (LFJ) arthrography with intraarticular injections of long-acting steroids and local anesthetics is routinely used for therapeutic purposes in selected patients for relief of low back pain. The procedure may also be used for diagnostic reasons to establish the source of such pain. However, because direct access to the LFJ space is not always possible owing to degenerative changes such as osteophytes, another posterior approach has been proposed for LFJ arthrography. With the patient in the prone position, a spinal needle is inserted vertically into the inferior recess of an LFJ with fluoroscopic guidance and the patient under local anesthesia. To facilitate puncture, cushions are placed under the patient's abdomen to flatten normal lumbar lordosis, which enlarges the inferior recess of the LFJ. Use of cushions also results in a decrease in tissue thickness in the patient, thereby improving image quality and decreasing radiation exposure. LFJ arthrography can demonstrate the causative role of facet disease in abnormalities responsible for low back pain or sciatica and can be performed easily and rapidly with this direct posterior approach.     

Observer variation in plain radiography of the lumbosacral spine

In this study, interobserver and intraobserver variations in the interpretation of plain radiographs of the lumbosacral spine were evaluated. Three radiologists independently interpreted the radiographs from 200 consecutive outpatients, aged 13-93 years, mostly referred from general practitioners. Interobserver agreement was best for vertebral fractures, osteopenia, spondylolisthesis at L5-S1, lumbosacral junctional vertebra, reduced disc height at L4-S1 and osteophytes at L2-S1 (kappa 0.61-0.95), and poorest for spina bifida of S1, degenerative spondylolisthesis and facet joint arthrosis at T12-L4, sacroiliac joint arthrosis, narrow central spinal canal, film quality, and for decisions concerning evaluation of facet joints and spinal canal (kappa < 0.34). For several diagnoses, the number of abnormal findings differed significantly between observers (p < 0.05, McNemar's test), indicating different diagnostic thresholds. Intraobserver agreement in 36 reevaluated patients was fair to excellent for almost all variables (kappa > 0.46). Although some diagnoses related to low back pain were quite consistently evaluated, the substantial disagreement on many findings should alert clinicians and radiologists against overestimating the validity and usefulness of the examinations. To improve diagnostic consistency, it is important to reduce variation caused by different thresholds for abnormality.     

Cerebral abscess with special reference to the angiographic changes

From 1961 to 1973 forty patients with surgically confirmed intracranial abscesses had preoperative cerebral angiography. The findings were abnormal in all cases but one. In 20 patients (50%) the primary diagnosis was a space-occupying lesion. In 19 patients (47.5%) an abscess was suggested by the presence of a capsule, the only finding definitely diagnostic of an abscess. Subtraction technique provided essential information in detecting the capsule. Angiography proved indispensable in suggesting the nature of the lesion.     

Role of facet asymmetry in lumbar spine disorders

The results and the related conditions of 250 undisplaced femoral neck fractures managed by percutaneous Knowles pinning were evaluated. All of the patients were over 59 years old, and the protocol of management and follow-up was determined prospectively. The duration from injury to management was 3.0 (range 1-12) days, the operation time was 20 (range 10-44) min, and most of the patients were discharged without hospitalization. The follow-up period was 74 (range 24-138) months. The final results showed 226 (90.4%) fractures with smooth course of union (mean union time: 24 weeks), 15 (6.0%) fractures with nonunion, and 9 (3.6%) fractures with implant problems. Eighteen (7.2%) hips developed avascular necrosis of femoral head after union. The analysis showed that the rate of complications was higher in elderly persons with undisplaced femoral neck fractures.     

Atherosclerosis, with special reference to vitamin E

The relationship between atherosclerosis and fat soluble vitamin, especially vitamin E is reviewed on the basis of oxidised modification of low density lipoprotein (LDL). Data now support the notion that the oxidised LDL is present in the blood and arterial wall and antioxidant drugs such as probucol and vitamin E, beta-carotene, may prevent the progression of atherosclerosis. LDL alpha-tocopherol levels are generally correlated to the plasma concentrations and supplementation with alpha-tocopherol increases its content in LDL. There is a significant correlation between the LDL alpha-tocopherol level and the resistance to oxidative modification. Epidemiological data also shows the relation between low levels of plasma vitamin E and the increased incidence of coronary heart disease. Clinical application of vitamin E should be clarified in detail to inhibit the progression of atherosclerosis.     

CT-guided interventional procedures for pain management in the lumbosacral spine

The lumbosacral spine is the source of pain, suffering, and disability more frequently than any other part of the body. Pain in the lower back can be managed with computed tomography-guided analgesic interventional procedures, such as periradicular infiltration, percutaneous laser disk decompression, facet joint block, and percutaneous vertebroplasty. Periradicular injection of steroids provides short-term and sometimes even long-term relief of low back pain. Percutaneous laser disk decompression is used to treat radiculalgia caused by disk herniation. Facet joint block is useful in diagnosis and treatment of facet syndrome. Percutaneous vertebroplasty provides short- and long-term pain relief in patients with vertebral body disease. However, precise patient selection is essential to the success of each of these techniques. The interventional radiologist has an active role to play in minimally invasive management of lower back pain and should be part of an interdisciplinary team that determines the appropriate therapy.     

Detection of intracranial tumours with special reference to immunodiagnosis

Approximately 60% of cerebral infarcts between 1 and 4 weeks old may be enhanced by contrast material. A recent infarct can be missed if contrast material is not used; however, recent infarcts can also be partially obscured by the contrast medium, so that a precontrast scan is necessary. Infarcts, arteriovenous malformations, and gliomas may appear similar on the CT scan. Recent infarcts can have a significant mass effect (seen in 22% of cases), and their anatomical location and morphology may or may not be helpful in the differential diagnosis. Ipsilateral ventricular dilatation, homogeneous low-density areas, and sharp margins are usually found in older infarcts.     

Changes in the lumbosacral segment of the spine due to overweight in adults. Preliminary remarks

The Authors studied postural changes in the lumbosacral segment of the spine due to severe obesity in 28 young adults of both sexes. In particular, the preliminary degree of pelvic rotation caused by overweight was evaluated by studying the lumbosacral angle (LSA) amplitude, changes in normal static equilibrium of the spine and lumbar hyperlordosis in relation to the lordotic angle (LA) amplitude. Body Build Index (BBI), the lumbosacral angle and the lordotic angle were compared to determine if any correlations existed among the three. Even though the patient number was limited, pathologic values for both the LSA and the LA were found in all 28 subjects. The Authors found no correlation between LSA and LA increase regarding BBI; on the contrary, a correlation was evident between LSA increase and LA. A decrease in the LSA and LA values took place after reduction in body weight, after therapeutic intervention. The Authors believe that a one year follow-up is necessary to evaluate any long term decrease in the values of the above mentioned angles.     

Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints

STUDY DESIGN: Prospective randomized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain, with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain. OBJECTIVES: To assess the efficacy of single facet joint anesthesia versus placebo (saline injections) and to determine clinical criteria that are predictive of significant relief of LBP after injection. SUMMARY OF BACKGROUND DATA: There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures. Single or double facet joint anesthesia, and single photon emission computed tomography are expensive and time-consuming procedures for selecting patients in controlled clinical trials with large populations. METHODS: Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not. In the current study, a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria. Patients randomly received injection of either lidocaine or saline into the lower facet joints. The result was considered positive if more than 75% pain relief was determined by visual analog scale. The patient, the radiologist, and the investigator were blinded. An analysis of variance was used to seek an interaction between clinical group effect and injection effect, and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75% after the injection. RESULTS: There was a significant interaction between clinical group and injection effect (P = 0.003). In patients with back pain, lidocaine provided greater lower-back pain relief than saline (P = 0.01). Lidocaine also-provided greater pain relief in the back pain group than in the nonpain group (P = 0.02). The presence of five among seven variables (age greater than 65 years and pain that was not exacerbated by coughing, not worsened by hyperextension, not worsened by forward flexion, not worsened when rising from flexion, not worsened by extension-rotation, and well-relieved by recumbency), always including the last item, distinguished 92% of patients responding to lidocaine injection and 80% of those not responding in the lidocaine group. CONCLUSIONS: A set of five clinical characteristics can be used in randomized studies to select lower back pain that will be well relieved by facet joint anesthesia. These characteristics should not, however, be considered as definite diagnostic criteria of lower back pain originating from facet joints.     

Study of portal hypertension in children with special reference to sclerotherapy

Spinal cord injuries are rare in children, in face of their higher mobility comparing to adults. The high cervical and the thoracic segments of the spine are more frequently affected. In the last 10 years we had 90 cases of spinal injuries in our service being 12 with neurologic deficient (8 male and 4 female) and four of them without radiographic abnormality, even in the dynamics studies. The authors emphasise the possibility of occurrence of neurologic deficit in children after trauma, even without any radiographic abnormality.