Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disk that lead to disk space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation, which narrows the space available for the thecal sac and exiting nerve roots. The clinical consequence of this compression is neurogenic claudication and varying degrees of leg and back pain. Degenerative lumbar spinal stenosis is a major cause of pain and impaired quality of life in the elderly. The natural history of this condition varies; however, it has not been shown to worsen progressively. Nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis. PMID:22855855
Issack, Paul S; Cunningham, Matthew E; Pumberger, Matthias; Hughes, Alexander P; Cammisa, Frank P
The clinical and radiologic results of trumpet laminectomy, an improved method of extensive laminectomy preserving the facet joints (n = 35), and extensive laminectomy (n = 15) were compared in patients with degenerative lumbar spinal stenosis. The results were evaluated using a rating system and serial radiographs and a follow-up of 2 to 10 1/2 years (mean, 5.2 years). The overall results corroborate the advantage of the trumpet laminectomy, demonstrating a lower incidence and lower grade of postoperative lumbar scoliosis as well as less symptom recurrence in the trumpet laminectomy group than in the extensive laminectomy group. Risk factors for postoperative spinal instability and scoliosis appear to be facet joint destruction and elderly females with a high level of physical activity. PMID:8347973
Kanamori, M; Matsui, H; Hirano, N; Kawaguchi, Y; Kitamoto, R; Tsuji, H
STRUCTURED ABSTRACT: Study Design. Retrospective cohort study.Objective. To investigate the clinical outcomes of microscopic partial pediculectomy for degenerative lumbar craniocaudal foraminal stenosis, risk factors for postsurgical scoliosis progression, and feasibility of postsurgical pedicle screw insertion.Summary of Background Data. Previous studies have evaluated surgical strategies for degenerative lumbar foraminal stenosis. Although less-invasive decompression surgery is an option for surgical treatment, postsurgical instability and salvaging fusion surgery remain as problems. No analysis has focused on the radiological progression and feasibility of pedicle screw setting after pediculectomy.Methods. Microscopic partial pediculectomy by our original method was performed as a first-choice surgical treatment for lumbar radiculopathy due to degenerative craniocaudal foraminal stenosis. This study included 50 consecutive patients followed up for a minimum of 2 years. Clinical outcomes were evaluated with Japanese Orthopedic Association (JOA) scores and a numerical rating scale (NRS). Radiological changes were obtained from standing X-rays. Foraminal height (FH) and the minimum pedicle diameter (MPD) were measured by reconstructed images on multidetector-row computed tomography.Results. The preoperative JOA score of 14.2 ± 4.2 significantly improved to 21.5 ± 6.2, and 60% of patients were satisfied. The NRS for lumbar back pain, leg pain, and leg numbness significantly improved. Nine patients (18%) showed lumbar Cobb angle progression of ?5° within 2 years, and the risk factor for scoliosis progression was surgery at L3-4 or L4-5 by multivariate logistic regression analysis. FH was enlarged from 5.4 mm preoperatively to 8.9 mm postoperatively. The postoperative MPD was 8.7 ± 1.6 (5.9-11.7) mm.Conclusion. Microscopic lumbar partial pediculectomy provided satisfactory clinical outcomes, but early postsurgical scoliosis progression was likely to occur in patients who underwent the surgery at L3-4 or L4-5. Even if a second surgical procedure is needed, pedicle screws can be set on the resected pedicle. PMID:23462578
Yamada, Kentaro; Matsuda, Hideki; Cho, Hisanori; Habunaga, Hiroshi; Kono, Hiroshi; Nakamura, Hiroaki
Significant degenerative scoliosis together with lumbar spinal stenosis increases the complexity of planning a surgical intervention for iatrogenic instability may be introduced by decompression in the midst of the curve, especially at or near the curve apex, that may lead to more rapid progression of a deformity, especially if surgery is at, or is near, the apex of the curve and a listhesis is present. Surgical options include simple laminectomy, a laminectomy with limited fusion, or an extensive fusion that addresses the overall curve, but there is no consensus as to the best approach. There is scant information in the literature about specific instances of failure of a limited surgical approach from which any instructive lessons may be learned. We report a surgical failure in a 59-year-old woman with degenerative lumbar stenosis and scoliosis from L3-5 and L3-4 disc herniation treated with a simple hemilaminectomy and discectomy, a subsequent fusion for symptomatic progression of deformity, and a third surgery to fuse the entire scoliotic curve after development of severe deformity, pain, and neurological deficits. We conclude that surgical decision-making should take into consideration any risk factors for deformity progression as well as overall sagittal and coronal balance and advise that similar patients be followed for a lengthy period following surgery to monitor for stability. PMID:23274034
Houten, John K; Nasser, Rani
BackgroundAlthough some investigators believe that the rate of postoperative instability is low after lumbar spinal stenosis surgery, the majority believe that postoperative instability usually develops. Decompression alone and decompression with fusion have been widely used for years in the surgical treatment of lumbar spinal stenosis. Nevertheless, in recent years several biomechanical studies have shown that posterior dynamic transpedicular stabilization provides
Tuncay Kaner; Mehdi Sasani; Tunc Oktenoglu; Ahmet Levent Aydin; Ali Fahir Ozer
Study Design Retrospective review of a prospectively collected database. Objective To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers. Summary of Background Data Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated. Methods Spine patient outcomes research trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed. Results A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (SF-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with SF-36 scores trending toward significance. Conclusion There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important. In this retrospective study, outcome variation after surgery for spinal stenosis and degenerative spondylolisthesis among centers participating in the spine patient outcomes research trial (SPORT) were analyzed. Significant variation, including the presence of outlier centers, was found. This suggests that the choice of center influences the outcome after these procedures, although further studies are required to ascertain which center characteristics may be most important.
Desai, Atman; Bekelis, Kimon; Ball, Perry A.; Lurie, Jon; Mirza, Sohail K.; Tosteson, Tor D.; Zhao, Wenyan; Weinstein, James N.
Degenerative lumbar spinal stenosis (DLSS) can be treated by several surgical procedures. However, the choice of procedure and use of instrumentation remain controversial. In this retrospective study of 81 patients with DLSS, 43 patients received decompression and posterolateral fusion without instrumentation, and the surgery for 38 patients was supplemented with posterior transpedicular screw fixation. Both surgeon-based (Fischgrund criteria) and patient-based (Medical Outcome Trust Short-Form 36 [SF-36] questionnaire) standards were used to assess the clinical outcomes. An excellent to good result was achieved in 71.6% of patients and there was no significant difference 6.2 years later between groups with or without instrumentation (Z=0.0358, p>0.05). SF-36 data revealed significant postoperative improvement (p<0.01), and there was no significant difference between the two groups (t=1.67, p>0.05). Successful fusion occurred in 87% of patients with instrumentation versus 67% of the patients without instrumentation (chi(2)=4.23, p<0.05). Thus, surgical treatment of DLSS generally results in satisfactory outcomes. Transpedicular screw fixation may not improve clinical outcomes and the use of posterior instrumentation should be adopted cautiously. PMID:19577930
Gu, Yong; Chen, Liang; Yang, Hui-Lin; Chen, Xiao-Qing; Dong, Ren-Bin; Han, Guo-Sheng; Tang, Tian-Si; Zhang, Zhi-Ming
Background Interlaminar epidural steroid injections (ILESIs) are commonly employed in the management of patients with symptomatic degenerative lumbar spinal canal stenosis despite little experimental evidence to guide technique optimization. One untested performance parameter is the intervertebral level at which the ILESI should be performed for maximum patient relief. Methods This study randomized patients with symptomatic degenerative lumbar spinal canal stenosis to receive an ILESI at the level of maximal spinal canal stenosis or at a normal/less stenotic intervertebral site 2 intervertebral levels cephalad to the level of maximal stenosis. Pain with ambulation and Roland Morris Disability Questionnaire scores were collected prior to the procedure and at 1-, 4-, and 12-week follow-ups. Results Fifty-seven patients were enrolled. Thirty patients (Group 1) received an ILESI at the level of maximal stenosis; 27 patients (Group 2) received an ILESI at a less stenotic level. The mean baseline preprocedural maximal pain with ambulation and disability scores for the 2 groups were not significantly different (P=0.94 and P=0.13, respectively). Patients' pain with ambulation scores were significantly lower in Group 1 compared to Group 2 at 1 and 4 weeks postinjection, but they were not significantly lower at 12 weeks (1 week, P=0.045; 4 weeks, P=0.049; 12 weeks, P=0.08). The mean Roland Morris Disability Questionnaire scores at 1, 4, and 12 weeks postinjection were significantly lower in Group 1 as compared to Group 2 (P=0.001, P=0.009, P=0.003, respectively). Conclusion Results suggest that patient symptom improvement is optimized when the ILESI is performed at the intervertebral level of maximal stenosis.
Milburn, James; Freeman, Jeffrey; Steven, Andrew; Altmeyer, Wilson; Kay, Dennis
Lumbar stenosis is one of the more common radiographic manifestations of the aging process, leading to narrowing of the spinal canal and foramen. When stenosis is clinically relevant, patients often describe activity-related low-back or lower-extremity pain, known as neurogenic claudication. For those patients who do not improve with conservative care, surgery is considered an appropriate treatment alternative. The primary objective of surgery is to reconstitute the spinal canal. The role of fusion, in the absence of a degenerative deformity, is uncertain. The previous guideline recommended against the inclusion of lumbar fusion in the absence of spinal instability or a likelihood of iatrogenic instability. Since the publication of the original guidelines, numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The majority of studies contain a heterogeneous cohort of subjects, often combining patients with and without spondylolisthesis who received various surgical interventions, limiting fusions to those patients with instability. It is difficult if not impossible, therefore, to formulate valid conclusions regarding the utility of fusion for patients with uncomplicated stenosis. Lower-level evidence exists, however, that does not demonstrate an added benefit of fusion for these patients; therefore, in the absence of deformity or instability, the inclusion of a fusion is not recommended. PMID:24980587
Resnick, Daniel K; Watters, William C; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Eck, Jason C; Sharan, Alok; Groff, Michael W; Wang, Jeffrey C; Ghogawala, Zoher; Dhall, Sanjay S; Kaiser, Michael G
Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an aging population. This review focuses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focuses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high quality studies about the relative benefits and harms of commonly used treatments. Interpreting and comparing results of available research is limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favor a shared decision making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
Establishing an appropriate treatment strategy for patients presenting with low-back pain, in the absence of stenosis or spondylolisthesis, remains a controversial subject. Inherent to this situation is often an inability to adequately identify the source of low-back pain to justify various treatment recommendations, such as lumbar fusion. The current evidence does not identify a single best treatment alternative for these patients. Based on a number of prospective, randomized trials, comparable outcomes, for patients presenting with 1- or 2-level degenerative disc disease, have been demonstrated following either lumbar fusion or a comprehensive rehabilitation program with a cognitive element. Limited access to such comprehensive rehabilitative programs may prove problematic when pursuing this alternative. For patients whose pain is refractory to conservative care, lumbar fusion is recommended. Limitations of these studies preclude the ability to present the most robust recommendation in support of lumbar fusion. A number of lesser-quality studies, primarily case series, also support the use of lumbar fusion in this patient population. PMID:24980584
Eck, Jason C; Sharan, Alok; Ghogawala, Zoher; Resnick, Daniel K; Watters, William C; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Groff, Michael W; Wang, Jeffrey C; Dhall, Sanjay S; Kaiser, Michael G
Lumbar spinal stenosis may be congenital or acquired. A classic clinical presentation is described as neurogenic claudication. Physical signs of sensory loss, weakness, and attenuation of reflexes often are mild and limited in distribution. Neuroimaging of the lumbosacral spine with MRI and electrodiagnostic (electromyographic [EMG]) tests are the most informative diagnostic modalities. Conservative management often is successful, but surgical decompression may be indicated in refractory cases. PMID:17445736
Chad, David A
Twenty-eight patients presenting with low back pain, associated with sciatic or femoral neuropathy, were found to have lateral recess stenosis occurring as a result of hypertrophy of the facet joints, with preservation within normal limits of the sagittal AP diameter of the lumbar canal. Pathology was believed to be traumatic in origin, and the variable nature of the adhesions suggested recurrent inflammation; the hypertrophy of the facet joints may have been the result of traumatic inflammatory hyperaemia. Radiological investigations were unhelpful. The diagnosis of the condition was made at the time of surgical exploration by the findings of alteration of the facet joints, adhesions and fixity of the nerve roots, normal sagittal AP diameter of the canal, and absence of other significant lesions. Gratifying results were obtained with decompression by wide laminectomy with excision of overhanging facet joints and release of adhesions.
Choudhury, A R; Taylor, J C
SUMMARY Lumbar spinal stenosis is one of the most common degenerative diseases of the elderly population, and a major cause of debilitating pain and decreased function. Lumbar spinal stenosis is almost always associated with neurogenic claudication characterized as pain worsened by standing or walking and relieved by lumbar flexion or sitting. While initial treatment of lumbar spinal stenosis may involve conservative therapies, as patients become more symptomatic the traditional treatment path has generally led to open laminectomy and other invasive, potentially destabilizing, procedures. More recently, less invasive alternatives to wide laminectomy have been developed. This article describes a new method of percutaneous lumbar decompression for treatment of neurogenic claudication secondary to lumbar spinal stenosis, the minimally invasive lumbar decompression procedure. We review the steps of successfully decompressing the hypertrophic ligamentum flavum and lamina, thereby alleviating pressure on neural structures. This is a major innovation in patient care and a step to reduce risks while minimizing costs. PMID:24645862
Spinal stenosis and degenerative spondylolisthesis share many symptoms and the same treatment, but their causes remain unclear. Bone mineral density has been suggested to play a role. The aim of this study was to investigate differences in spinal bone density between spinal stenosis and degenerative spondylolisthesis patients. 81 patients older than 60 years, who underwent DXA-scanning of their lumbar spine one year after a lumbar spinal fusion procedure, were included. Radiographs were assessed for disc height, vertebral wedging, and osteophytosis. Pain was assessed using the Low Back Pain Rating Scale pain index. T-score of the lumbar spine was significantly lower among degenerative spondylolisthesis patients compared with spinal stenosis patients (-1.52 versus -0.52, P = 0.04). Thirty-nine percent of degenerative spondylolisthesis patients were classified as osteoporotic and further 30% osteopenic compared to only 9% of spinal stenosis patients being osteoporotic and 30% osteopenic (P = 0.01). Pain levels tended to increase with poorer bone status (P = 0.06). Patients treated surgically for symptomatic degenerative spondylolisthesis have much lower bone mass than patients of similar age treated surgically for spinal stenosis. Low BMD might play a role in the development of the degenerative spondylolisthesis, further studies are needed to clarify this. PMID:24024179
Andersen, Thomas; Christensen, Finn B; Langdahl, Bente L; Ernst, Carsten; Fruensgaard, Søren; Østergaard, Jørgen; Andersen, Jens Langer; Rasmussen, Sten; Niedermann, Bent; Høy, Kristian; Helmig, Peter; Holm, Randi; Egund, Niels; Bünger, Cody
Lumbar Degenerative Disc Disease; Spinal Stenosis; Spondylolisthesis; Spondylosis; Intervertebral Disk Displacement; Intervertebral Disk Degeneration; Spinal Diseases; Bone Diseases; Musculoskeletal Diseases; Spondylolysis
Aortic stenosis is the most common valvular heart disease among adult subjects in western countries The current treatment for aortic stenosis is aortic valve replacement. The possibility of a medical treatment that can slow the progression of aortic stenosis is very fascinating and statins have been tested to reduce the progression of degenerative aortic stenosis (DAS). The rationale for statin treatment in DAS has a deep pathophysiological substrate, in fact inflammation and lipid infiltration constitute the same histopathological pattern of both aortic stenosis and atherosclerosis and these two conditions have the same risk factors. Whether retrospective studies have shown some efficacy of statins in halting the progression of DAS, prospective trials have shown controversial results. A recently published large and randomized controlled trial SEAS found that statins have no significant effect on the progression of aortic stenosis, the ASTRONOMER, recently confirmed this data. The most plausible hypothesis is that coronary artery disease and DAS, have a common pathogenetic background and a distinct evolution due to different factors (mechanical stress, genetic factors, interaction between inflammatory cells and calcification mediators). Thus, treatment with statins is not recommended in patients with valvular aortic stenosis and without conventional indications to lipid-lowering treatment. PMID:20863278
Novo, Giuseppina; Fazio, Giovanni; Visconti, Claudia; Carità, Patrizia; Maira, Ermanno; Fattouch, Khalil; Novo, Salvatore
The spinal canal is a type of articulated pipe, with rigid rings articulated by joints. It can be divided into a central part, which contains the dural sac, and lateral parts, which contain the nerve roots. The role of imaging is to detect the presence and characterize the nature, level, and severity of stenotic lesions and their impact on neural elements. Stenoses can be constitutional or acquired and involve the central and/or lateral canal. Constitutional stenoses affect both rigid and soft segments whereas acquired stenoses affect mainly the mobile segments. Signs of constitutional stenoses at conventional radiography, CT and MRI will be described. Acquired stenoses are multi-factorial in etiology and more difficult to evaluate. Intra-spinal soft tissues and dynamic factors, poorly assessed at CT and MRI (static imaging), play a major role in this type of stenoses. Currently, only myelography with dynamic evaluation is able to demonstrate the importance of these factors or degree of dynamic stenosis. The lateral canal is divided in three parts: two mobile segments (disco-articular interval, and intervertebral foramen) on each side of a fixed bony segment (lateral recess). The different types of stenoses involving these segments and best imaging technique to demonstrate their presence are described. PMID:12223974
[Purpose] This study investigated the effect of neurological symptoms and/or signs after the occurrence of neurogenic intermittent claudication (NC) on postural sway during quiet standing of patients with lumbar spinal canal stenosis (LSS). [Subjects and Methods] Thirty-two female patients with LSS at the L4/5 level were studied. We measured the path of center of foot pressure (COP) during quiet standing with eyes open for 30?s using a stabilometer before and after the occurrence of NC. [Results] The total path length of COP (LC) and area surrounded by the outline of the path of COP (AC) significantly increased after NC. Body mass index (BMI) correlated with both the NC rate (after NC/before NC) of LC and that of AC. The average lateral COP displacement from the center of the base of support (COPRL) before NC was located on the asymptomatic side from the center of the base of support in 29 of 32 patients. After NC, COPRL moved to the symptomatic side in 31 patients. [Conclusion] These results suggest that patients with LSS are at risk of falling after NC, especially those with high BMI.
Sasaki, Kentaro; Senda, Masuo; Katayama, Yoshimi; Ota, Haruyuki; Matsuyama, Yoshiyuki
[Purpose] This study investigated the effect of neurological symptoms and/or signs after the occurrence of neurogenic intermittent claudication (NC) on postural sway during quiet standing of patients with lumbar spinal canal stenosis (LSS). [Subjects and Methods] Thirty-two female patients with LSS at the L4/5 level were studied. We measured the path of center of foot pressure (COP) during quiet standing with eyes open for 30?s using a stabilometer before and after the occurrence of NC. [Results] The total path length of COP (LC) and area surrounded by the outline of the path of COP (AC) significantly increased after NC. Body mass index (BMI) correlated with both the NC rate (after NC/before NC) of LC and that of AC. The average lateral COP displacement from the center of the base of support (COPRL) before NC was located on the asymptomatic side from the center of the base of support in 29 of 32 patients. After NC, COPRL moved to the symptomatic side in 31 patients. [Conclusion] These results suggest that patients with LSS are at risk of falling after NC, especially those with high BMI. PMID:24259826
Sasaki, Kentaro; Senda, Masuo; Katayama, Yoshimi; Ota, Haruyuki; Matsuyama, Yoshiyuki
Foot drop is a condition that can substantially add to the disability of patients with degenerative lumbar spinal disorders. The most common degenerative conditions associated with foot drop are lumbar disc herniation and lumbar spinal stenosis. The level most commonly affected is the L4/5 spinal level. Most patients are treated with surgery, although there is insufficient evidence to support that surgery is superior to conservative therapy. In most surgical patients, foot dorsiflexion will improve to some degree. The preoperative power of foot dorsiflexion is the key factor associated with prognosis. PMID:24438801
Wang, Yue; Nataraj, Andrew
Neurogenic claudication is most frequently observed in patients with degenerative lumbar spinal stenosis. We describe a patient with lumbar epidural varices secondary to obstruction of the inferior vena cava by pathological lymph nodes presenting with this syndrome. Following a diagnosis of follicular lymphoma, successful chemotherapy led to the resolution of the varices and the symptoms of neurogenic claudication. The lumbar epidural venous plexus may have an important role in the pathogenesis of spinal stenosis. Although rare, epidural venous engorgement can induce neurogenic claudication without spinal stenosis. Further investigations should be directed at identifying an underlying cause. PMID:22933506
Dabasia, H; Rahim, N; Marshall, R
Purpose To evaluate the clinical outcomes of cantilever transforaminal lumbar interbody fusion (c-TLIF) for upper lumbar diseases. Materials and Methods Seventeen patients (11 males, 6 females; mean ± SD age: 62 ± 14 years) who underwent c-TLIF using kidney type spacers between 2002 and 2008 were retrospectively evaluated, at a mean follow-up of 44.1 ± 12.3 months (2 year minimum). The primary diseases studied were disc herniation, ossification of posterior longitudinal ligament (OPLL), degenerative scoliosis, lumbar spinal canal stenosis, spondylolisthesis, and degeneration of adjacent disc after operation. Fusion areas were L1-L2 (5 patients), L2-L3 (9 patients), L1-L3 (1 patient), and L2-L4 (2 patients). Operation time, blood loss, complications, Japanese Orthopaedic Association (JOA) score for back pain, bone union, sagittal alignment change of fusion level, and degeneration of adjacent disc were evaluated. Results JOA score improved significantly after surgery, from 12 ± 2 to 23 ± 3 points (p < 0.01). We also observed significant improvement in sagittal alignment of the fusion levels, from - 1.0 ± 7.4 to 5.2 ± 6.1 degrees (p < 0.01). Bony fusion was obtained in all cases. One patient experienced a subcutaneous infection, which was cured by irrigation. At the final follow-up, three patients showed degenerative changes in adjacent discs, and one showed corrective loss of fusion level. Conclusion c-TLIF is a safe procedure, providing satisfactory results for patients with upper lumbar degenerative diseases.
Hioki, Akira; Hosoe, Hideo; Sugiyama, Seiichi; Suzuki, Naoki; Shimizu, Katsuji
One of the most common indications for performing magnetic resonance (MR) imaging of the lumbar spine is the symptom complex\\u000a thought to originate as a result of degenerative disk disease. MR imaging, which has emerged as perhaps the modality of choice\\u000a for imaging degenerative disk disease, can readily demonstrate disk pathology, degenerative endplate changes, facet and ligamentous\\u000a hypertrophic changes, and
Todd M. Emch; Michael T. Modic
Background: Iatrogenic instability following laminectomy occurs in patients with degenerative lumbar canal stenosis. Long segment fusions to obviate postoperative instability result in loss of motion of lumbar spine and predisposes to adjacent level degeneration. The best alternative would be an adequate decompressive laminectomy with a nonfusion technique of preserving the posterior ligament complex integrity. We report a retrospective analysis of multilevel lumbar canal stenosis that were operated for posterior decompression and underwent spinaplasty to preserve posterior ligament complex integrity for outcome of decompression and iatrogenic instability. Materials and Methods: 610 patients of degenerative lumbar canal stenosis (n=520) and development spinal canal stenosis (n=90), with a mean age 58 years (33–85 years), underwent multilevel laminectomies and spinaplasty procedure. At followup, changes in the posture while walking, increase in the walking distance, improvement in the dysesthesia in lower limb, the motor power, capability to negotiate stairs and sphincter function were assessed. Forward excursion of vertebrae more than 4 mm in flexion–extension lateral X-ray of the spine as compared to the preoperative movements was considered as the iatrogenic instability. Clinical assessment was done in standing posture regarding active flexion–extension movement, lateral bending and rotations Results: All patients were followed up from 3 to 10 years. None of the patients had neurological deterioration or pain or catch while movement. Walking distance improved by 5–10 times, with marked relief (70–90%) in neurogenic claudication and preoperative stooping posture, with improvement in sensation and motor power. There was no significant difference in the sagittal alignment as well as anterior translation. Two patients with concomitant scoliosis and one with cauda equine syndrome had incomplete recovery. Two patients who developed disc protrusion, underwent a second operation for a symptomatic disc prolapse. Conclusion: Spinaplasty following posterior decompression for multilevel lumbar canal stenosis is a simple operation, without any serious complications, retaining median structures, maintaining the tension band and the strength with least disturbance of kinematics, mobility, stability and lordosis of the lumbar spine.
Tuli, Surendra Mohan; Kapoor, Varun; Jain, Anil K; Jain, Saurabh
Study Design A prospective cohort. Purpose To report the short and long term outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injection (TFESI) in degenerative lumbar spondylolisthesis (DLS) patients. Overview of Literature TFESI has been widely used for the treatment of lumbosacral radicular pains. However, to our knowledge, there has been no study which has evaluated the outcomes of TFESI in patients with DLS. Methods The DLS patients received fluoroscopically guided lumbar TFESI with 80 mg of methylprednisolone and 2 mL of 1% lidocaine hydrochloride. Patients were evaluated by an independent observer before the initial injection, at 2 weeks, at 6 weeks, at 3 months, and at 12 months after the injections. Visual analog scale (VAS), Roland 5-point pain scale, standing tolerance, walking tolerance, and patient satisfaction scale were evaluated for outcomes. Results Thirty three DLS patients treated with TFESI, who were completely followed up, were included in this study. The average number of injections per patient was 1.9 (range from 1 to 3 injections per patient). Significant improvements in VAS and Roland 5-point pain scale were observed over the follow up period from 2 weeks to 12 months. However, the standing and walking tolerance were not significantly improved after 2 weeks. At 2 weeks, the patient satisfaction scale was highest, although, these outcomes declined with time. The DLS patients with one level of spinal stenosis showed significantly better outcome than the DLS patients with two levels of spinal stenosis. Five patients (13%) underwent surgical treatment during the 3 to 12 months follow up. Conclusions TFESI provides short term improvements in VAS and Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale in DLS patients. In the long term, it improves VAS but limits the improvements in Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale.
Wechmongkolgorn, Supaporn; Chatriyanuyok, Bangon; Woratanarat, Patarawan; Udomsubpayakul, Umaporn; Chanplakorn, Pongsathorn; Keorochana, Gun; Wajanavisit, Wiwat
The most common spinal disorder in elderly patients is lumbar spinal canal stenosis, causing low back and leg pain and paresis. The aetiology of degenerative changes occurring in lumbar stenosis remain unclear: some authors hypothesize hyperplasia and others hypertrophy of the LF. The change in LF is known to be related to degenerative changes secondary to the aging process or mechanical instability. This study aimed to analyse the ligamentum flavum (LF) of patients with lumbar canal stenosis and lumbar disc herniation to evaluate the morphology and concentration of the Transforming Growth Factor-beta 1 (TGF-beta 1). The study was undertaken in three phases: A) Measurement of the thickness of the ligamentum flavum in patients with lumbar stenosis and/or herniated lumbar disc through axial T1 weighted lumbo-sacral MR images; B) Removal of ligamentum flavum in patients undergoing intervention for lumbar stenosis and lumbar disc herniation (control group); C) Optical microscopy study of the morphology of degenerated ligamentum and immunohistochemical analysis to assess the concentration of TGF-beta 1 in the LF. Morphological analysis of the LF (i.e. the increase in the number of fibres or distension and relaxation of the same as a result of degenerative processes) and the presence or absence of a high concentration of TGF-beta1 (then more fibroblasts involved in the degenerative process) can be important to establish whether there is hypertrophy or hyperplasia of the LF in lumbar canal stenosis. The current study showed that decreased elasticity of the LF in the elderly is due to a loss of elastic fibres that are degenerated and a concomitant increase in collagenous fibres (hypertrophy). TGF-beta1 concentrations of the LF were higher in lumbar spinal stenosis than in disc herniations. This suggest that LF of lumbar canal stenosis is hypertrophic: LF hypertrophy could be due to thickening of the normal elastic layer and the abnormal collagenous layer and to higher expression of TGF-beta 1 by fibroblasts. PMID:24148597
Rispoli, R; Mastrostefano, R; Brunelli, F
In 250 subjects with normal lumbar spine and 39 patients with lumbar spinal canal stenosis (LSCS), radiographic measurement such as canal-to-body ratio (CBR), intervertebral space, inclination and thickness of the facet were performed to statistically evaluate normal degenerative changes in lumbar spine and the difference between normal degenerative changes and those of LSCS. Results were as follows: in normal subjects, 1) intervertebral space became narrower with aging (below L3-4), 2) the inclination of the facet increased in all lumbar spines, 3) the thickness of facet showed no relationship with aging but correlated with inclination (below L3-4). In LSCS, on the other hand, 1) almost no abnormal CBR values were found, 2) canal stenosis was most common at the level of L4-5 and and L3-4, 3) no factor was independently related to the degree of narrowing. Finally, normal subjects patients with LSCS had significant differences in almost all measurement parameters. PMID:3693997
A large number of interspinous process devices (IPD) have been recently introduced to the lumbar spine market as an alternative to conventional decompressive surgery in managing symptomatic lumbar spinal pathology, especially in the older population. Despite the fact that they are composed of a wide range of different materials including titanium, polyetheretherketone, and elastomeric compounds, the aim of these devices is to unload spine, restoring foraminal height, and stabilize the spine by distracting the spinous processes. Although the initial reports represented the IPD as a safe, effective, and minimally invasive surgical alternative for relief of neurological symptoms in patients with low back degenerative diseases, recent studies have demonstrated less impressive clinical results and higher rate of failure than initially reported. The purpose of this paper is to provide a comprehensive overview on interspinous implants, their mechanisms of action, safety, cost, and effectiveness in the treatment of lumbar stenosis and degenerative disc diseases.
The athletic activity of the adult U.S. population has increased markedly in the last 20 years. To evaluate the possible long-term effects of such activity on the cervical and lumbar spine, we studied a group of asymptomatic currently very active lifelong male athletes over age 40 (41-69 years old, av. age 53). Nineteen active, lifelong male athletes were studied with MRI and the results compared with previous imaging studies of other populations. An athletic history and a spine history were also taken. Evidence of asymptomatic degenerative spine disease was similar to that seen in published series of other populations. Degenerative changes including disk protrusion and herniation, spondylosis, and spinal stenosis were present and increased in incidence with increasing patient age. In this group, all MRI findings proved to be asymptomatic and did not limit athletic activity. The incidence of lumbar degenerative changes in our study population of older male athletes was similar to those seen in other populations. 14 refs., 8 figs., 1 tab.
Healy, J.F.; Healy, B.B.; Wong, W.H.M.; Olson, E.M. [Univ. of California, San Diego, CA (United States)] [Univ. of California, San Diego, CA (United States)
Copeptin is a new biomarker of cardiovascular diseases. Its diagnostic value in degenerative aortic valve stenosis (AS) with preserved left ventricle systolic function is unknown. We aimed to assess the association of serum copeptin levels with AS severity and coexistence of coronary artery disease (CAD). Sixty-four patients with AS and preserved left ventricle systolic function including 40 with severe degenerative AS (group sAS, effective orifice area EOA = 0.67 cm(2)) and 24 with moderate degenerative AS (group mAS, EOA = 1.40 cm(2)) were enrolled into the study. Twenty-three patients without AS and heart failure, matched for age, sex, and CAD occurrence served as the control group (group C). Serum levels of copeptin and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured using enzyme-linked immunosorbent assay. The mean serum copeptin concentrations were significantly higher in patients with AS: sAS (405 pg/ml) and mAS (351 pg/ml; sAS vs mAS P < 0.05), compared with group C (302 pg/ml, P < 0.05). Serum copeptin levels correlated inversely with EOA (r = -0.55; P < 0.001) in AS patients. There was no correlation between copeptin and NT-proBNP or association with the coexisting CAD. Receiver-operating characteristics analysis showed that copeptin was a good marker of severe/moderate AS (sensitivity 71 %; specificity 87 %), with the optimized cut-off value of 354 pg/ml. Serum copeptin concentration constitutes a novel biomarker of degenerative AS. Coexisting CAD does not interfere with copeptin level. PMID:23142954
Mizia-Stec, Katarzyna; Lasota, Bartosz; Mizia, Magdalena; Chmiel, Artur; Adamczyk, Tomasz; Chudek, Jerzy; Gasior, Zbigniew
Degenerative disease may lead to spinal canal stenosis and long-lasting pain. It is among the leading cause of disability that may affect the ability to work. It has become more common in an increasingly aging population. MRI is the most comprehensive imaging modality and provides detailed morphologic information. A standardized terminology facilitates communication with referring physicians. Yet imaging findings need careful interpretation in conjunction with the results of clinical tests and symptoms to truly help guide therapeutic decision making. This review summarizes aspects of normal anatomy of the intervertebral disk, pathologic mechanisms, terminology, and examples of the imaging spectrum of disk degeneration and herniation. PMID:24896740
Heuck, Andreas; Glaser, Christian
The aim of our study is to evaluate the results and effectiveness of bilateral decompression via a unilateral approach in the treatment of degenerative lumbar spinal stenosis. We have conducted a prospective study to compare the midterm outcome of unilateral laminotomy with unilateral laminectomy. One hundred patients with 269 levels of lumbar stenosis without instability were randomized to two treatment groups: unilateral laminectomy (Group 1), and laminotomy (Group 2). Clinical outcomes were assessed with the Oswestry Disability Index (ODI) and Short Form–36 Health Survey (SF-36). Spinal canal size was measured pre- and postoperatively. The spinal canal was increased to 4–6.1-fold (mean 5.1 ± SD 0.8-fold) the preoperative size in Group 1, and 3.3–5.9-fold (mean 4.7 ± SD 1.1-fold) the preoperative size in Group 2. The mean follow-up time was 5.4 years (range 4–7 years). The ODI scores decreased significantly in both early and late follow-up evaluations and the SF-36 scores demonstrated significant improvement in late follow-up results in our series. Analysis of clinical outcome showed no statistical differences between two groups. For degenerative lumbar spinal stenosis unilateral approaches allowed sufficient and safe decompression of the neural structures and adequate preservation of vertebral stability, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life.
Kaya, Ramazan Alper; Turkmenoglu, Osman Nuri; Tuncer, Cengiz; Colak, Ibrahim; Ayd?n, Yunus
Study design: ?Retrospective cohort study. Objective: ?To analyze the surgical results of a group of patients older than 65 years treated for mild degenerative lumbar scoliosis (<30°) with stenosis, treated with decompression alone or decompression and limited fusion. Methods: ?We evaluated 55 patients, all older than 65 years from our prospectively collected database with mild degenerative scoliosis (<30°) and stenosis who underwent surgery. Laminectomy alone was performed in 16 patients, and laminectomy and limited fusion in 39 patients. Mean follow-up was 4.6 years in the decompression group and 5.0 years in the fusion group. Clinical results were graded by patients' self-reported satisfaction and length of symptom-free period to recurrence. Results: ?In the decompression alone group, 6 (37%) of 16 patients developed recurrent stenosis at the previously decompressed level and five developed recurrence within 6 months postoperatively versus the decompression and fusion group where 3 (8%) of 39 (P?=?.0476) developed symptomatic stenosis supra adjacent to the fusion. Of 16 patients in the decompression alone group, 12 (75%) had recurrence of symptoms by the 5-year follow-up period versus only 14 (36%) patients in the decompression and fusion group (P?=?.016). Adjacent segment degenerative changes were common in the fusion group, but only 7% developed symptomatic stenosis. Conclusions: ?Decompression with limited fusion prevents early return of stenotic symptoms compared with decompression alone in the setting of mild degenerative scoliosis (<30°) and symptomatic stenosis in patients 65 years and older. [Table: see text] The definiton of the different classes of evidence is available on page 67. PMID:23531707
Daubs, Michael D; Lenke, Lawrence G; Bridwell, Keith H; Cheh, Gene; Kim, Yongjung J; Stobbs, Georgia
Lumbar spinal stenosis is a common cause of lower back and leg pain in older adults. Stenosis is not considered a contraindication for total knee arthroplasty (TKA); however, it is unclear whether it is associated with less than optimal postoperative outcomes. In a multicenter review of TKAs, 115 patients with lumbar disease were matched by age, gender, body mass index, type of procedure, and length of follow-up to patients who did not have stenosis. Spinal stenosis was found to be associated with significantly lower Knee Society objective and function scores compared with patients without stenosis. There was no observed difference in the revision rates (1%) or radiographic outcomes. Surgeons should consider cautioning patients that they can expect relief of arthritic symptoms following TKA, but they may continue to experience limitations in postoperative function relative to their expectations. PMID:23288774
Pivec, Robert; Johnson, Aaron J; Naziri, Qais; Issa, Kimona; Mont, Michael A; Bonutti, Peter M
Lumbar spinal stenosis is a common condition that affects the aging population because of the natural degenerative changes the spine undergoes during the aging process. The symptoms cause decreased functionality and quality of life. Traditional surgical treatment has been a decompressive laminectomy with or without a fusion. However, a newer less-invasive surgical technique called X-STOP interspinous process device is available for the treatment of neurogenic intermittent claudication because of lumbar spinal stenosis. The main goal of this procedure is to allow the patient to restore functional ability and improve quality of life, which bears significant importance in the aging population. Knowledge of the X-STOP interspinous process device can assist neurosurgical advanced practice nurses in providing optimum care for patients with lumbar spinal stenosis when nonsurgical therapies have failed. PMID:23291871
This study was undertaken to determine whether or not nitric oxide metabolites (NO(2)(-) plus NO(3)(-): NOx levels) in cerebrospinal fluid (CSF) would be predictors of treatment outcome in patients with degenerative lumbar diseases (DLD) including lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LCS). The NOx levels in CSF were measured using an NO analyzer based on the Griess method. Six healthy volunteers and 18 patients with painless diseases were included in the control group. The pre- and postoperative NOx levels in 25 DLD patients, who underwent herniotomy for LDH (17 patients) or selective decompression for LCS (eight patients), were analyzed. The postoperative follow-up periods were approximately 8 months. Nineteen of 25 DLD patients, whose preoperative NOx levels were two standard deviations higher than the mean NOx levels of an age-matched control group, were included in an NO elevated (NOE) group. Among the 25 DLD patients, the preoperative NOx levels in six patients (young LDH group) were within the normal range. The pain-related Japanese Orthopaedic Association score and the Hirabayashi recovery rate were respectively used to evaluate the pain severity and the degree of pain relief. The preoperative and changes of postoperative NOx levels in the NOE group were negatively correlated with the Hirabayashi recovery rate. Normal postoperative NOx levels and excellent pain relief were achieved in young DLD patients. In conclusion, the preoperative and changes in postoperative NOx levels are quantitative predictors of postoperative pain relief in DLD patients. PMID:11376909
Kimura, S; Watanabe, K; Yajiri, Y; Uchiyama, S; Hasegawa, K; Shibuki, K; Endo, N
Context Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture. Findings We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful. Conclusion In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended. PMID:24090267
Syrimpeis, Vasileios; Vitsas, Vasileios; Korovessis, Panagiotis
Background: The management of degenerative spondylolisthesis associated with spinal stenosis remains controversial. Surgery is widely used and has recently been shown to be more effective than nonoperative treatment when the results were followed over two years. Questions remain regarding the long-term effects of surgical treatment compared with those of nonoperative treatment. Methods: Surgical candidates from thirteen centers with symptoms of at least twelve weeks' duration as well as confirmatory imaging showing degenerative spondylolisthesis with spinal stenosis were offered enrollment in a randomized cohort or observational cohort. Treatment consisted of standard decompressive laminectomy (with or without fusion) or usual nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at six weeks, three months, six months, and yearly up to four years. Results: In the randomized cohort (304 patients enrolled), 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. In the observational cohort (303 patients enrolled), 97% of those who chose surgery received it whereas 33% of those who chose nonoperative care eventually received surgery. The intent-to-treat analysis of the randomized cohort, which was limited by nonadherence to the assigned treatment, showed no significant differences in treatment outcomes between the operative and nonoperative groups at three or four years. An as-treated analysis combining the randomized and observational cohorts that adjusted for potential confounders demonstrated that the clinically relevant advantages of surgery that had been previously reported through two years were maintained at four years, with treatment effects of 15.3 (95% confidence interval, 11 to 19.7) for bodily pain, 18.9 (95% confidence interval, 14.8 to 23) for physical function, and ?14.3 (95% confidence interval, ?17.5 to ?11.1) for the Oswestry Disability Index. Early advantages (at two years) of surgical treatment in terms of the secondary measures of bothersomeness of back and leg symptoms, overall satisfaction with current symptoms, and self-rated progress were also maintained at four years. Conclusions: Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
Weinstein, James N.; Lurie, Jon D.; Tosteson, Tor D.; Zhao, Wenyan; Blood, Emily A.; Tosteson, Anna N.A.; Birkmeyer, Nancy; Herkowitz, Harry; Longley, Michael; Lenke, Lawrence; Emery, Sanford; Hu, Serena S.
Executive Summary Objective To assess the safety and efficacy of artificial disc replacement (ADR) technology for degenerative disc disease (DDD). Clinical Need Degenerative disc disease is the term used to describe the deterioration of 1 or more intervertebral discs of the spine. The prevalence of DDD is roughly described in proportion to age such that 40% of people aged 40 years have DDD, increasing to 80% among those aged 80 years or older. Low back pain is a common symptom of lumbar DDD; neck and arm pain are common symptoms of cervical DDD. Nonsurgical treatments can be used to relieve pain and minimize disability associated with DDD. However, it is estimated that about 10% to 20% of people with lumbar DDD and up to 30% with cervical DDD will be unresponsive to nonsurgical treatments. In these cases, surgical treatment is considered. Spinal fusion (arthrodesis) is the process of fusing or joining 2 bones and is considered the surgical gold standard for DDD. Artificial disc replacement is the replacement of the degenerated intervertebral disc with an artificial disc in people with DDD of the lumbar or cervical spine that has been unresponsive to nonsurgical treatments for at least 6 months. Unlike spinal fusion, ADR preserves movement of the spine, which is thought to reduce or prevent the development of adjacent segment degeneration. Additionally, a bone graft is not required for ADR, and this alleviates complications, including bone graft donor site pain and pseudoarthrosis. It is estimated that about 5% of patients who require surgery for DDD will be candidates for ADR. Review Strategy The Medical Advisory Secretariat conducted a computerized search of the literature published between 2003 and September 2005 to answer the following questions: What is the effectiveness of ADR in people with DDD of the lumbar or cervical regions of the spine compared with spinal fusion surgery? Does an artificial disc reduce the incidence of adjacent segment degeneration (ASD) compared with spinal fusion? What is the rate of major complications (device failure, reoperation) with artificial discs compared with surgical spinal fusion? One reviewer evaluated the internal validity of the primary studies using the criteria outlined in the Cochrane Musculoskeletal Injuries Group Quality Assessment Tool. The quality of concealment allocation was rated as: A, clearly yes; B, unclear; or C, clearly no. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the overall quality of the body of evidence (defined as 1 or more studies) supporting the research questions explored in this systematic review. A random effects model meta-analysis was conducted when data were available from 2 or more randomized controlled trials (RCTs) and when there was no statistical and or clinical heterogeneity among studies. Bayesian analyses were undertaken to do the following: Examine the influence of missing data on clinical success rates; Compute the probability that artificial discs were superior to spinal fusion (on the basis of clinical success rates); Examine whether the results were sensitive to the choice of noninferiority margin. Summary of Findings The literature search yielded 140 citations. Of these, 1 Cochrane systematic review, 1 RCT, and 10 case series were included in this review. Unpublished data from an RCT reported in the grey literature were obtained from the manufacturer of the device. The search also yielded 8 health technology assessments evaluating ADR that are also included in this review. Six of the 8 health technology assessments concluded that there is insufficient evidence to support the use of either lumbar or cervical ADR. The results of the remaining 2 assessments (one each for lumbar and cervical ADR) led to a National Institute for Clinical Excellence guidance document supporting the safety and effectiveness of lumbar and cervical ADR with the proviso that an ongoing audit of all clinical outcomes be undertaken owing to a lack of long-term outcome data from clinical trials. Regard
BACKGROUND Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials. METHODS Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years. RESULTS We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and ?16.7 for the Oswestry Disability Index (95% CI, ?19.5 to ?13.9). There was little evidence of harm from either treatment. CONCLUSIONS In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409.)
Weinstein, James N.; Lurie, Jon D.; Tosteson, Tor D.; Hanscom, Brett; Tosteson, Anna N.A.; Blood, Emily A.; Birkmeyer, Nancy J.O.; Hilibrand, Alan S.; Herkowitz, Harry; Cammisa, Frank P.; Albert, Todd J.; Emery, Sanford E.; Lenke, Lawrence G.; Abdu, William A.; Longley, Michael; Errico, Thomas J.; Hu, Serena S.
We describe a rare case of lumbar spinal stenosis due to a large calcified mass in the ligamentum flavum. This patient presented with a 12-month history of severe right leg pain and intermittent claudication. A computed tomography scan was performed, revealing a large calcified mass on the ligamentum flavum at the right-hand side of the lumbar spinal canal. We performed a laminotomy at the L4/5 level with resection of the calcified mass from the ligamentum flavum. The findings of various analyses suggested that the calcified mass consisted mostly of Ca3(PO4)2 and calcium phosphate intermixed with protein and water. The calcified mass in the ligamentum flavum was causing lumbar spinal stenosis. Surgical decompression by resection of the mass was effective in this patient. The calcified material was composed mainly of elements derived from calcium phosphate. Degenerative changes in the ligamentum flavum of the lumbar spine may have been involved in the production of this calcified mass. PMID:24066222
Seki, Shoji; Kawaguchi, Yoshiharu; Ishihara, Hirokazu; Oya, Takeshi; Kimura, Tomoatsu
We describe a rare case of lumbar spinal stenosis due to a large calcified mass in the ligamentum flavum. This patient presented with a 12-month history of severe right leg pain and intermittent claudication. A computed tomography scan was performed, revealing a large calcified mass on the ligamentum flavum at the right-hand side of the lumbar spinal canal. We performed a laminotomy at the L4/5 level with resection of the calcified mass from the ligamentum flavum. The findings of various analyses suggested that the calcified mass consisted mostly of Ca3(PO4)2 and calcium phosphate intermixed with protein and water. The calcified mass in the ligamentum flavum was causing lumbar spinal stenosis. Surgical decompression by resection of the mass was effective in this patient. The calcified material was composed mainly of elements derived from calcium phosphate. Degenerative changes in the ligamentum flavum of the lumbar spine may have been involved in the production of this calcified mass.
Kawaguchi, Yoshiharu; Ishihara, Hirokazu; Oya, Takeshi; Kimura, Tomoatsu
Objective: The goal of this study is to present surgical methods of nerve elements decompression in the vertebral canal and the techniques of internal spine stabilization in patients with degenerative lumbar spondylolisthesis. Methods: Clinical analysis included 36 patients (17 females and 19 males) managed surgically due to degenerative spondylolisthesis at our Departments, between 1997 and 2003. Intervertebral dislocation exceeding 20%
Roman Jankowski; Stanislaw Nowak; Ryszard Zukiel; Andrzej Pucher; Tomasz Blok
Study Design A retrospective study. Purpose To comparatively investigated the rate of the adjacent segment degeneration and the clinical outcomes in patients with spondylolytic spondylolisthesis, spinal stenosis or degenerative spondylolisthesis. Overview of Literature There have been few studies reported on the adjacent segment degeneration following posterior lumbar interbody fusion(PLIF). Many risk factors for the adjacent segment degeneration following PLIF have been proposed. The range of decompression has been presented as one of the risk factors, yet controversial. Methods This study enrolled sixty-three patients who had been treated with single-level PLIF and who were followed up for more than two years. The patients were divided into 3 groups based on the preoperative diagnosis. We analyzed the difference between the preoperative and postoperative intervertebral disc heights of the superior adjacent segments. The incidence rates of instability and the clinical outcomes were comparatively analyzed between each group. Results The average age of the patients was 55.8 years in the spondylolytic spondylolisthesis group, 65.9 years in the degenerative spondylolisthesis group and 60.4 years in the spinal stenosis group. The average follow-up period was 44 months, 43 months and 42 months, respectively. At the last follow-up, compared to the preoperative period, the intervertebral disc height decreased in all three groups. A statistically significant decrease (p < 0.01) was observed only in the spondylolytic spondylolisthesis group and no significant difference was observed between each group (p = 0.41). The incidence rate of instability and the clinical outcome were not significantly different between each group. Conclusions Spondylolytic spondylolisthesis with total laminectomy and single-level PLIF showed no significant difference in the superior adjacent segment degeneration and instability, and the clinical outcome as compared to that of partial laminectomy with single-level PLIF for treating degenerative spondylolisthesis or spinal stenosis.
Yu, Chang Hun; Lee, Jung Eun; Yang, Jae Jun; Lee, Choon-Ki
Background The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain. Objective To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis. Design Prospective cohort study. Data Sources Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants. Target Population Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis. Time Horizon 2 years. Perspective Societal. Intervention Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis). Outcome Measures Cost per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77 600 (CI, $49 600 to $120 000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus non-operative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115 600 (CI, $90 800 to $144 900) per QALY gained. Result of Sensitivity Analysis Surgery cost markedly affected the value of surgery. Limitation The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment non-adherence among randomly assigned participants. Conclusion The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.
Tosteson, Anna N.A.; Lurie, Jon D.; Tosteson, Tor D.; Skinner, Jonathan S.; Herkowitz, Harry; Albert, Todd; Boden, Scott D.; Bridwell, Keith; Longley, Michael; Andersson, Gunnar B.; Blood, Emily A.; Grove, Margaret R.; Weinstein, James N.
Background: With the rise of health care costs, there is increased emphasis on evaluating the cost of a particular surgical procedure for quality adjusted life year (QALY) gained. Recent data have shown that surgical intervention for the treatment of degenerative spondylolisthesis (DS) is as cost-effective as total joint arthroplasty. Despite these excellent outcomes, some argue that the addition of interbody fusion supplemented with bone morphogenetic protein (BMP) enhances the value of this procedure. Methods: This review examines the current research regarding the cost-effectiveness of the surgical management of lumbar DS utilizing interbody fusion along with BMP. Results: Posterolateral spinal fusion with instrumentation for focal lumbar spinal stenosis with DS can provide and maintain improvement in self-reported quality of life. Based on the available literature, including nonrandomized comparative studies and case series, the addition of interbody fusion along with BMP does not lead to significantly better clinical outcomes and increases costs when compared with more routine posterolateral fusion techniques. Conclusions: To enhance the value of the surgical management for DS, costs must decrease or there should be substantial improvement in effectiveness as measured by clinical outcomes. To date, there is insufficient evidence to support the use of interbody fusion devices along with BMP to treat routine cases of focal stenosis accompanied by DS, which are routinely adequately treated utilizing posterolateral fusion techniques.
Moatz, Bradley; Tortolani, P. Justin
The symptoms associated with lumbar spinal stenosis can decrease quality of life and may cause patients to seek treatment. Except in rare cases of rapid neurologic progression or cauda equina syndrome, nonsurgical modalities should be the initial treatment choice. Activity modification, a variety of medications, epidural steroid injections, and other methods are recommended for pain reduction. A formal physical therapy program, which focuses on flexion-based exercises, may lead to improved patientfunction. Surgery is indicated in patients who remain symptomatic despite a course of nonsurgical therapy and who have advanced imaging studies that correspond to existing .symptoms. Adequate decompression of the neural elements and maintenance of bony stability are necessary for a good surgical outcome for patients with spinal stenosis. Laminectomy has long been the method of choice for thorough lumbar decompression. Preserving at least the lateral half of the facet joints bilaterally and bone in the area of the pars interarticularis minimizes the potential for iatrogenic instability. Numerous other decompression techniques have been described, including multilevel laminotomies, fenestration, distraction laminoplasty, and microscopic decompression. Arthrodesis, either with or without instrumentation, is also indicated in some patients. Several studies report that surgical treatment produces better outcomes than nonsurgical treatment in the short term; however, the results tend to deteriorate with time. Lumbar decompressive surgery can be complicated by epidural hematoma, deep venous thrombosis, dural tear, infection, nerve root injury, and recurrence of symptoms. PMID:15948458
Yuan, Philip S; Booth, Robert E; Albert, Todd J
Object Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery. Methods In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups. Results Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28). Conclusions The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies. PMID:24785489
Dangelmajer, Sean; Zadnik, Patricia L; Rodriguez, Samuel T; Gokaslan, Ziya L; Sciubba, Daniel M
Computer-aided diagnosis (CAD) systems are indispensable tools for patients' healthcare in modern medicine. Nevertheless, the only fully automatic CAD system available for lumbar stenosis today is for X-ray images. Its performance is limited due to the limitations intrinsic to X-ray images. In this paper, we present a system for magnetic resonance images. It employs a machine learning classification technique to automatically recognize lumbar spine components. Features can then be extracted from these spinal components. Finally, diagnosis is done by applying a Multilayer Perceptron. This classification framework can learn the features of different spinal conditions from the training images. The trained Perceptron can then be applied to diagnose new cases for various spinal conditions. Our experimental studies based on 62 subjects indicate that the proposed system is reliable and significantly better than our older system for X-ray images.
Koompairojn, Soontharee; Hua, Kathleen; Hua, Kien A.; Srisomboon, Jintavaree
Lumbar spinal stenosis (LSS) is becoming more frequent as the population ages and is now the most common spinal diagnosis for individuals older than 65. Because LSS is a common source of pain and disability among older adults, understanding the pathophysiology, clinical presentation, and clinical management of this condition is important. An individual example is used to highlight classic signs and symptoms. Nursing strategies for LSS-associated pain and symptom management to improve physical function and quality of life are discussed. PMID:21634312
Cadogan, Mary P
Back pain is a common chronic disorder that represents a large burden for the health care system. There is a broad spectrum of available treatment options for patients suffering from chronic lower back pain in the setting of degenerative disorders of the lumbar spine, including both conservative and operative approaches. Lumbar arthrodesis techniques can be divided into sub-categories based on the part of the vertebral column that is addressed (anterior vs posterior). Furthermore, one has to differentiate between approaches aiming at a solid fusion in contrast to motion-sparing techniques with the proposed advantage of a reduced risk of developing adjacent disc disease. However, the field of application and long-term outcomes of these novel motion-preserving surgical techniques, including facet arthroplasty, nucleus replacement, and lumbar disc arthroplasty, need to be more precisely evaluated in long-term prospective studies. Innovative surgical treatment strategies involving minimally invasive techniques, such as lateral lumbar interbody fusion or transforaminal lumbar interbody fusion, as well as percutaneous implantation of transpedicular or transfacet screws, have been established with the reported advantages of reduced tissue invasiveness, decreased collateral damage, reduced blood loss, and decreased risk of infection. The aim of this study was to review well-established procedures for lumbar spinal fusion with the main focus on current concepts on spinal arthrodesis and motion-sparing techniques in degenerative disorders of the lumbar spine.
Lykissas, Marios G; Aichmair, Alexander
A first-generation implant for non-rigid stabilization of lumbar segments was developed in 1986. It included a titanium interspinous blocker and an artificial ligament made of dacron. Following an initial observational study in 1988 and a prospective controlled study from 1988 to 1993, more than 300 patients have been treated for degenerative lesions with this type of implant with clinical and
The objective of this study is to observe the effect of percutaneous laser disc decompression (PLDD) on lumbar spinal stenosis (LSS). Thirty-two LSS patients were treated using pulsed Nd: YAG laser, of which 21 cases (11 males and 10 females with an average age of 64 years old) were followed up for 2 years. All of the 21 patients had intermittent claudication with negative straight leg raising test results. Fifteen patients suffered from anterior central disc herniation which often compressed the cauda equina but seldom compressed the posterior part; six patients suffered from posterior ligamentum flavum hypertrophy which often compressed the cauda equina but seldom compressed the anterior part. The efficacy was evaluated 1, 3, 6, 12 and 24 months after surgery on 21 patients using the performance evaluation criteria of the lumbago treatment by the Japanese Orthopaedic Association (JOA 29 scores). The fineness (i.e. excellent and good treatment outcome) rate 1, 3, 6, 12 and 24 months after the operation were 46.7 %, 66.7 %, 66.7 %, 66.7 % and 66.7 %, respectively, in patients with severe anterior compression and 16.7 %, 33.3 %, 33.3 %, 33.3 % and 33.3 %, respectively, in patients with severe posterior compression. PLDD had certain positive efficacy on the treatment of lumbar spinal stenosis, which was more significant on LSS dominated by the anterior compression than that by the posterior compression. PMID:23996073
Ren, Longxi; Han, Zhengfeng; Zhang, Jianhua; Zhang, Tongtong; Yin, Jian; Liang, Xibin; Guo, Han; Zeng, Yanjun
(320 of 394 (81%)). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 (95% CI, 0.12 to 0.22)) at a cost of $77 600 (CI, $49 600 to $120 000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 (93%)) and most with instrumentation (269
Anna N. A. Tosteson; Jon D. Lurie; Tor D. Tosteson; Jonathan S. Skinner; Harry Herkowitz; Todd Albert; Scott D. Boden; Keith Bridwell; Michael Longley; Gunnar B. Andersson; Emily A. Blood; Margaret R. Grove; James N. Weinstein
Study Design. A population-based study. Objective. To study the prevalence and features of symptomatic degenerative lumbar osteoarthritis in adults. Summary of Background Data. Lumbar osteoarthritis adversely affects individuals and is a heavy burden. There are limited data on the prevalence of lumbar osteoarthritis. Methods. A representative, multistage sample of adults was collected. Symptomatic degenerative lumbar osteoarthritis was diagnosed by clinical symptoms, physical examinations, and imaging examinations. Personal information was obtained by face-to-face interview. Information included the place of residence, age, sex, income, type of medical insurance, education level, body mass index, habits of smoking and drinking, type of work, working posture, duration of the same working posture during the day, mode of transportation, exposure to vibration, and daily amount of sleep. Crude and adjusted prevalence was calculated. The features of populations were analyzed by multivariable logistic regression in total and subgroup populations. Results. The study included 3859 adults. The crude and adjusted prevalence of lumbar osteoarthritis was 9.02% and 8.90%, respectively. There was no significant difference in the prevalence of lumbar osteoarthritis between urban, suburban, and rural populations (7.66%, 9.97%, and 9.44%) (P = 0.100). The prevalence of lumbar osteoarthritis was higher in females (10.05%) than in males (9.1%, P = 0.021). The prevalence of lumbar osteoarthritis increased with increasing age. Obese people (body mass index >28 kg/m2), those engaged in physical work, those who maintained the same work posture for 1 to 1.9 hours per day, those who were exposed to vibration during daily work, and those who got less than 7 hours of sleep per day had a higher prevalence. These features differed by subgroup. Conclusion. This study established epidemiological baseline data for degenerative lumbar osteoarthritis in adults, especially for people younger than 45 years. Lumbar osteoarthritis is epidemic in Beijing and will become a more severe problem in aging society. Different populations have different features that require targeted interventions. Level of Evidence: 2
Liu, Yajun; Xiao, Bin; Han, Xiao
Lumbar fusion has been developed for several decades and became the standard surgical treatment for symptomatic lumbar degenerative disc disease (DDD). Artificial total disc replacement (TDR), as an alternative for spinal arthrodesis, is becoming more commonly employed treating lumbar DDD. It is still uncertain whether TDR is more effective and safer than lumbar fusion. To systematically compare the effectiveness and safety of TDR to that of the fusion for the treatment of lumbar DDD, we performed a meta-analysis. Cochrane review methods were used to analyze all relevant randomized controlled trials published up to July 2009. Five relevant randomized controlled trials involving 837 patients were identified. Patients in TDR group have sightly better functioning and less back or leg pain without clinical significance, and significantly higher satisfaction status in TDR group compared with lumbar fusion group at the 2-year follow-up. But these outcomes are highly influenced by the study with BAK cage interbody fusion, the function/pain and patient satisfaction status are no longer significantly different between two groups after excluding this study. At 5 years, these outcomes are not significantly different between comparing groups. The complication and reoperation rate of two groups are similar both at 2 and at 5 years. In conclusion, TDR does not show significant superiority for the treatment of lumbar DDD compared with fusion. The benefits of motion preservation and the long-term complications are still unable to be concluded. More high-quality RCTs with long-term follow-up are needed.
Yajun, Wu; Xiuxin, Han; Cui, Cui
Lumbar canal stenosis (LCS) is a common condition affecting elderly patients for which a significant number undergo surgery. The validity and safety of simple laminectomy in this condition is not fully understood. Furthermore, the presence of pre-existing spondylolisthesis is controversial with respect to the need for additional spinal stabilization. We prospectively studied a consecutive cohort of 100 patients with clinical and radiological LCS under the care of a single spinal surgeon. Outcome measures (SF-36, visual analogue scores for back and leg symptoms, and the Roland/Morris back pain scores) were assessed preoperatively, 3 months postsurgery and at long-term (median 2 years) follow-up. We have shown a significant improvement in outcome sustained in the long-term with minimal morbidity. Patients with pre-existing spondylolisthesis accounted for 23% of the cohort and, having received identical treatment, showed no significant difference in outcome compared with patients with normal alignment. PMID:17439091
Wilby, M J; Seeley, H; Laing, R J
Priapism, a persistent long-lasting involuntary erection of the penis, is uncommon in dogs. In this report, the case of a 13-year-old male Pointer, referred to our services due to persistent exposition of the penis, is described. This condition was consecutive to an intermittent priapism situation lasting for several days, which has been initially attributed to the inflammation and haematoma associated with a perianal bite. The owners became unable to retract the penis into the prepuce. At presentation, the dog was anorectic for 48 h, intolerant to manipulation, and showed poor body condition and unsteady locomotion. During physical evaluation, a marked engorgement of the local vessels in the prepuce and penis was found. An abdominal X-ray was asked under the suspicion of a neurogenic origin for the clinical situation, which showed evidences of spondylosis. After discussion of the clinical condition, the owners asked for euthanasia. The necropsy confirmed the engorgement of the regional vessels deriving from the pudendal arteries and blood accumulation within all the cavernous spaces, accompanied by congestion and thrombosis within the erectile structures of the penis. No significant changes were observed in the pelvic organs that could be at the origin of priapism. The lumbar-sacral spinal regions were carefully inspected and evidenced signs of L7-S1 stenosis due to spondylosis. The case presented herein is a rare situation of priapism of neurogenic origin in a dog. Necropsy findings suggest that it was consecutive to cauda equina compression due to lumbar spinal stenosis. PMID:23551292
Payan-Carreira, R; Colaço, B; Rocha, C; Albuquerque, C; Luis, M; Abreu, H; Pires, M A
Objective: This study was designed to evaluate the feasibility of the implantation of a new interspinous device (Falena) in patients with lumbar spinal stenosis. The clinical outcomes and imaging results were assessed by orthostatic MR during an up to 6-month follow-up period. Methods: Between October 2008 and February 2010, the Falena was implanted at a single level in 26 patients (17 men; mean age, 69 (range, 54-82) years) who were affected by degenerative lumbar spinal stenosis. All of the patients were clinically evaluated before the procedure and at 1 and 3 months. Furthermore, 20 patients have completed a 6-month follow-up. Pain was assessed before and after the intervention using the Visual Analogue Scale score and the Oswestry Disability Index questionnaire. Orthostatic MR imaging was performed before the implantation and at 3 months to assess the correlation with the clinical outcome. Results: The mean ODI score decreased from 48.9 before the device implantation to 31.2 at 1 month (p < 0.0001). The mean VAS score decreased from 7.6 before to 3.9 (p < 0.0001) at 1 month and 3.6 at 3 months after the procedure (p = 0.0115). These values were stable at 6 months evaluation. No postimplantation major complications were recorded. MRI evaluation documented in most cases an increased size of the spinal canal area. Similarly a bilateral foraminal area improvement was found. The variation of the intervertebral space height measured on the posterior wall was not significant. Conclusions: In our preliminary experience with the Falena in a small cohort of patients, we obtained clinical and imaging results aligned to those reported with similar interspinous devices.
Masala, Salvatore; Fiori, Roberto; Bartolucci, Dario Alberto, E-mail: firstname.lastname@example.org; Volpi, Tommaso; Calabria, Eros [University of Rome 'Tor Vergata', Department of Diagnostic and Molecular Imaging, Interventional Radiology, Nuclear Medicine and Radiation Therapy (Italy); Novegno, Federica [University of Rome 'Tor Vergata', Department of Neurosurgery (Italy); Simonetti, Giovanni [University of Rome 'Tor Vergata', Department of Diagnostic and Molecular Imaging, Interventional Radiology, Nuclear Medicine and Radiation Therapy (Italy)
Low back pain as a result of degenerative disc disease imparts a large socioeconomic impact on the health care system. Traditional concepts for treatment of lumbar disc degeneration have aimed at symptomatic relief by limiting motion in the lumbar spine, but novel treatment strategies involving stem cells, growth factors, and gene therapy have the theoretical potential to prevent, slow, or even reverse disc degeneration. Understanding the pathophysiological basis of disc degeneration is essential for the development of treatment strategies that target the underlying mechanisms of disc degeneration rather than the downstream symptom of pain. Such strategies ideally aim to induce disc regeneration or to replace the degenerated disc. However, at present, treatment options for degenerative disc disease remain suboptimal, and development and outcomes of novel treatment options currently have to be considered unpredictable.
Taher, Fadi; Essig, David; Lebl, Darren R.; Hughes, Alexander P.; Sama, Andrew A.; Cammisa, Frank P.; Girardi, Federico P.
Study Design This study is a prospective, clinical study for lumbar degenerative kyphosis. Purpose To determine the factors affecting postoperative clinical outcomes in patients who undergo corrective osteotomy for lumbar degenerative kyphosis. Overview of Literature Only a small number of studies have reported clinical results for surgery for lumbar degenerative kyphosis. There are almost no studies about prognostic factors that predict postoperative clinical results. Methods This study involved 25 patients who were diagnosed with lumbar degenerative kyphosis and who underwent corrective osteotomy following gait analysis. A pedicle subtraction osteotomy was done at the third lumbar vertebra (L 3). Regarding the fusion level, surgery was done within a range from T10 proximally to S1 distally. Of these, for rigid fixation of a distal part, an iliac screw was used. Pain was evaluated using a 10-point pain scale and a questionnaire about activities. We also evaluated cosmesis and subjective satisfaction using a modified version of the Scoliosis Research Society Outcome-22 (SRS-22) instrument. This assessment was done using a 5-point scale which was designed by us. We assigned patients to group A (good clinical outcomes) if their postoperative pain score was lower than 4 (of 10 points) and if scores indicating activity, cosmesis and subjective satisfaction were higher than 11 (of 15 points). All other patients were assigned to group B (poor clinical outcomes). Results Clinical outcomes were good in 64% of patients (16/25) and poor in 36% (9/25). Regarding cosmesis and subjective satisfaction, there were significant differences between the two groups. There were also significant differences in physical factors of individual patients such as body mass index (BMI): 23.78 ± 2.79 in group A and 26.44 ± 2.75 in group B. On gait analysis, there was a significant difference in the dynamic pelvic tilt: 7.5 ± 3.3° in group A and 11.72 ± 1.89° in group B. Conclusions There is no correlation between preoperative degree of kyphotic deformity and clinical outcomes. The degree of anterior rotation of pelvic tilt does not change significantly; rather, compensatory mechanisms of the pelvis and BMI were found to have more influence. Because neither the degree of satisfaction with clinical outcomes nor the increased activity was relatively higher, a more sincere decision should be made before recommending corrective osteotomy for degenerative lumbar kyphosis.
Kim, Whoan Jeang; Kang, Sung Il; Sung, Hwan Il; Park, Kun Young; Park, Jae Guk; Kwon, Won Cho; Choy, Won Sik
The objective of this study is to evaluate the effectiveness and safety of total disc replacement surgery compared with spinal\\u000a fusion in patients with symptomatic lumbar disc degeneration. Low back pain (LBP), a major health problem in Western countries,\\u000a can be caused by a variety of pathologies, one of which is degenerative disc disease (DDD). When conservative treatment fails,\\u000a surgery
Karin D. van den Eerenbeemt; Raymond W. Ostelo; Barend J. van Royen; Wilco C. Peul; Maurits W. van Tulder
Postero-lateral fusion by means of rod-and-screws\\/hooks constructs is still the gold standard in the treatment of lumbar degenerative\\u000a spinal diseases. However, fusion remains fraught with a high risk of adjacent levels degeneration, sometimes leading to suboptimal\\u000a clinical outcomes. Dynamic stabilization is supposed to compensate for disadvantages associated with rigid fusion. Preliminary\\u000a results of spinal stabilization by means of dynamic devices
Jacques Benezech; Anca Mitulescu
Sagittal- or coronal-plane deformity considerably complicates the diagnosis and treatment of lumbar spinal stenosis. Although decompressive laminectomy remains the standard operative treatment for uncomplicated lumbar spinal stenosis, the management of stenosis with concurrent deformity may require osteotomy, laminectomy, and spinal fusion with or without instrumentation. Broadly stated, the surgery-related goals in complex stenosis are neural decompression and a well-balanced sagittal and coronal fusion. Deformities that may present with concurrent stenosis are scoliosis, spondylolisthesis, and flatback deformity. The presentation and management of lumbar spinal stenosis associated with concurrent coronal or sagittal deformities depends on the type and extent of deformity as well as its impact on neural compression. Generally, clinical outcomes in complex stenosis are optimized by decompression combined with spinal fusion. The need for instrumentation is clear in cases of significant scoliosis or flatback deformity but is controversial in spondylolisthesis. With appropriate selection of technique for deformity correction, a surgeon may profoundly improve pain, quality of life, and functional capacity. The decision to undertake surgery entails weighing risk factors such as age, comorbidities, and preoperative functional status against potential benefits of improved neurological function, decreased pain, and reduced risk of disease progression. The purpose of this paper is to review the pathogenesis, presentation, and treatment of lumbar spinal stenosis complicated by scoliosis, spondylolisthesis, or flatback deformity. Specific attention is paid to surgery-related goals, decision making, techniques, and outcomes. PMID:15766223
Fraser, Justin F; Huang, Russel C; Girardi, Federico P; Cammisa, Frank P
APTA is a sponsor of the Decade, an international, multidisciplinary initiative to improve health-related quality of life for people with musculoskeletal disorders. Background and Purpose. Spinal stenosis is a common, often disabling, condition resulting from compression of the cauda equina and nerve roots. This study was designed to: (1) characterize the impairments of patients with lumbar spinal stenosis (LSS) and
Maura D Iversen
Three Chinese patients suffered from severe lumbar spinal stenosis with debilitating symptoms due to a rare condition of ligamentum flavum cysts in the midline of the lumbar spine. This disease is distinct from synovial cyst of the facet joints or ganglion cysts, both intraoperatively and histopathologically. Magnetic Resonance imaging features of the ligamentum flavum cyst are also demonstrated. We share our surgical experiences of identification of the ligamentum flavum cysts, decompression and excision for two of the patients with demonstrably good recovery. This disease should be considered in the differential diagnosis of an extradural instraspinal mass in patients with lumbar spinal stenosis.
Lumbar canal stenosis most commonly affects the elderly population by entrapment of the cauda equine roots surrounding the spinal canal often associated with pain in the back and lower extremities, difficulty ambulating. The locomotive syndrome refers to high-risk conditions under requiring care services, and lumbar canal stenosis is an important underlying disease. As one of the key capacities of frailty identified muscluloskeletal function, the locomotive syndrome is considered to musculoskeletal frail syndrome. Surgical treatment should be recommended to take the pressure off the nerves in the lumbar spine when the conservative treatments failed, and several studies revealed that the surgery generally resulted in a preferable outcome in the lumbar canal stenosis patients. Among lumbar canal stenosis patients treated with surgery, locomotive syndrome was contained 44% and many of which were seen in thin females. The patients with locomotive syndrome had lower muscle volume both in the extremities and the trunk than those without locomotive syndrome, and surgical results were poorer in the activity of daily life whereas the pain relief was adequately obtained. Treatment of the lumbar canal stenosis should be attended to locomotive frailty, and muscle strengthening training should be incorporated into pre and postoperative therapy. PMID:22460512
Fusion and rigid instrumentation have been currently the mainstay for the surgical treatment of degenerative diseases of the spine over the last 4 decades. In all over the world the common experience was formed about fusion surgery. Satisfactory results of lumbar spinal fusion appeared completely incompatible and unfavorable within years. Rigid spinal implants along with fusion cause increased stresses of the adjacent segments and have some important disadvantages such as donor site morbidity including pain, wound problems, infections because of longer operating time, pseudarthrosis, and fatigue failure of implants. Alternative spinal implants were developed with time on unsatisfactory outcomes of rigid internal fixation along with fusion. Motion preservation devices which include both anterior and posterior dynamic stabilization are designed and used especially in the last two decades. This paper evaluates the dynamic stabilization of the lumbar spine and talks about chronologically some novel dynamic stabilization devices and thier efficacies.
Kaner, Tuncay; Ozer, Ali Fahir
The complexity of the clinical, biochemical, hystochemical and immunologic aspects of the intervertebral disk, along with its molecular biology, justifies the object of our study on the extracellular matrix modifications in lumbar disk hernias and their impact on patient quality of life. Material and method: the research lot was composed of 50 patients, aged between 18 and 73, who have undergone lumbar disk hernia surgery. MMP–9 (metalloproteinase–9) and TIMP–1 (tissue inhibitor of matrix metalloprotease 1) have been dosed in order to study the modifications on extracellular disk matrix, and quality of life assessment was carried out both in pre–operatory and post–operatory periods. Conclusions: patients may prevent the appearance of degenerative processes of the intervertebral disk with care and responsibility by controlling their weight, avoiding intense physical activities and ceasing to smoke.
Ciurea, AV; Mitrica, M; Mohan, A
Placing instrumentation into the ilium has been shown to increase the biomechanical stability and the fusion rates, but it has some disadvantages. The diagonal S2 screw technique is an attractive surgical procedure for degenerative lumbar deformity. Between 2008 and 2010, we carried out long fusion across the lumbosacral junction in 13 patients with a degenerative lumbar deformity using the diagonal S2 screws. In 12 of these 13 patients, the lumbosacral fusion was graded as solid fusion with obvious bridging bone (92%). One patient had a rod dislodge at one S2 screw and breakage of one S1 screw and underwent revision nine months postoperatively. So, we present alternative method of lumbopelvic fixation for long fusion in degenerative lumbar deformity using diagonal S2 screw instead of iliac screw.
Kim, Hong-Sik; Baek, Seung-Wook; Lee, Sang-Hyun
Filum terminale arteriovenous fistula (FTAVF) presenting as a cause of failed back surgery syndrome is a rare entity. We report a 48-year-old male patient who presented with clinical features of a conus medullaris/cauda equina lesion. He had upper and lower motor neuron signs in both the lower limbs with autonomic dysfunction. The patient was misdiagnosed and was operated twice earlier for lumbar canal stenosis and disc prolapse. After reviewing his clinical and radiological findings a diagnosis of FTAVF was made. He underwent surgery and there was a significant improvement in his neurological functions. We discuss the case and review the literature on FTAVF's.
Ranjan, Alok; Lath, Rahul
Surgical treatment for degenerative spinal disorders is controversial, although lumbar fusion is considered an acceptable option for disabling lower back pain. Patients underwent instrumented minimally invasive anterior lumbar interbody fusion (mini-ALIF) using a retroperitoneal approach except for requiring multilevel fusions, severe spinal canal stenosis, high-grade spondylolisthesis, and a adjacent segments disorders. We retrospectively reviewed the clinical records and radiographs of 142 patients who received mini-ALIF for L4-5 degenerative lumbar disorders between 1998 and 2010. We compared preoperative and postoperative clinical data and radiographic measurements, including the modified Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back and leg pain, disc height (DH), whole lumbar lordosis (WL), and vertebral wedge angle (WA). The mean follow-up period was 76 months. The solid fusion rate was 90.1% (128/142 patients). The average length of hospital stay was 6.9 days (range, 3-21 days). The mean blood loss was 63.7 ml (range, 10-456 ml). The mean operation time was 155.5 min (range, 96-280 min). The postoperative JOA and VAS scores for back and leg pain were improved compared with the preoperative scores. Radiological analysis showed significant postoperative improvements in DH, WL, and WA, and the functional and radiographical outcomes improved significantly after 2 years. The 2.8% complication rate included cases of wound infection, liquorrhea, vertebral body fractures, and a misplaced cage that required revision. Mini-ALIF was found to be associated with improved clinical results and radiographic findings for L4-5 disorders. A retroperitoneal approach might therefore be a valuable treatment option. PMID:24140782
Hironaka, Yasuo; Morimoto, Tetsuya; Motoyama, Yasushi; Park, Young-Su; Nakase, Hiroyuki
Background We retrospectively evaluated the clinical and radiological outcomes of posterior lumbar interbody fusion (PLIF) with using a unilateral single cage and a local morselized bone graft. Methods Fifty three patients who underwent PLIF with a unilateral single cage filled with local morselized bone graft were enrolled in this study. The average follow-up duration was 31.1 months. The clinical outcomes were evaluated with using the visual analogue scale (VAS) at the pre-operative period, at 1 year post-operation and at the last follow-up, the Oswestry Disability Index, the Prolo scale and the Kim & Kim criteria at the last follow-up; the radiological outcomes were evaluated according to the change of bone bridging, the radiolucency, the instablity and the disc height. Results For the clinical evaluation, the VAS pain index, the Oswestry Disability Index, the Prolo scale and the Kim & Kim criteria showed excellent outcomes. For the the radiological evaluation, 52 cases showed complete bone union at the last follow-up. Regarding the complications, only 1 patient had cage breakage during follow-up. Conclusions PLIF using a unilateral single cage filled with a local morselized bone graft has the advantages of a shorter operation time, less blood loss and a shorter hospital stay, as compared with the PLIF using bilateral cages, for treating degenerative lumbar spine disease. This technique also provides excellent outcomes according to the clinical and radiological evaluation.
Kim, Dong-Hee; Lee, Sang-Soo
Mechanical overloading of the spine is associated with low back pain and intervertebral disc (IVD) degeneration. How excessive loading elicits degenerative changes in the IVD is poorly understood. Comprehensive knowledge of the interaction between mechanical loading, cell responses and changes in the extracellular matrix of the disc is needed in order to successfully intervene in this process. The purpose of the current study was to investigate whether dynamic and static overloading affect caprine lumbar discs differently and what mechanisms lead to mechanically induced IVD degeneration. Lumbar caprine IVDs (n?=?175) were cultured 7, 14 and 21 days under simulated-physiological loading (control), high dynamic or high static loading. Axial deformation and stiffness were continuously measured. Cell viability, cell density, and gene expression were assessed in the nucleus, inner- and outer annulus. The extracellular matrix (ECM) was analyzed for water, glycosaminoglycan and collagen content. IVD height loss and changes in axial deformation were gradual with dynamic and acute with static overloading. Dynamic overloading caused cell death in all IVD regions, whereas static overloading mostly affected the outer annulus. IVDs expression of catabolic and inflammation-related genes was up-regulated directly, whereas loss of water and glycosaminoglycan were significant only after 21 days. Static and dynamic overloading both induced pathological changes to caprine lumbar IVDs within 21 days. The mechanism by which they inflict biomechanical, cellular, and extracellular changes to the nucleus and annulus differed. The described cascades provide leads for the development of new pharmacological and rehabilitative therapies to halt the progression of DDD.
Paul, Cornelis P. L.; Schoorl, Tom; Zuiderbaan, Hendrik A.; Zandieh Doulabi, Behrouz; van der Veen, Albert J.; van de Ven, Peter M.; Smit, Theo H.; van Royen, Barend J.; Helder, Marco N.; Mullender, Margriet G.
This study examines different morphologic measurements in the evaluation of patients with lumbar spinal stenosis. Preoperative CT scans from 24 patients who underwent surgery for central lumbar stenosis were analyzed. No correlation was observed between the size of the bony spinal canal and the size of the dural sac. A new measurement, the transverse area of the dural sac, is introduced. Normal values are provided. Correlation between the cross-sectional area of the dural sac and the anteroposterior diameter of the dural sac was excellent. PMID:4089655
Schonstrom, N S; Bolender, N F; Spengler, D M
Background Lumbar spinal stenosis is a common cause of radicular and generalized back pain among older adults. Endoscopic minimally invasive surgery, in contrast to open decompression, may provide the opportunity for a less invasive surgical intervention. Thus, the purpose of this study is to evaluate the safety (operative complications, estimated blood loss, operative room time) and effectiveness (pre- versus postoperative level of disability and pain severity) of minimally invasive surgery using endoscopic laminotomy and foraminotomy among a large sample of patients with lumbar spinal stenosis. Methods This study is composed of 320 consecutive patients with lumbar spinal stenosis who underwent posterior lumbar laminotomy and foraminotomy between 2008 and 2011. Outcome measures consisted of perioperative complications, estimated blood loss, operative room time, level of disability, and pain severity. Pain severity and level of disability were prospectively analyzed to an average of 18 months (12–36 months) post-surgery. Results There was an average estimated blood loss of 39.3 cc and a mean operative room time of 74 min. Seven patients experienced minor operative complications. All patients were discharged the same day as surgery and reported a significantly lower level of disability (p = 0.00) and pain severity (p = 0.00) postoperative compared to preoperative. Conclusions Minimally invasive surgery using endoscopy for the treatment of lumbar spinal stenosis has a short operative time, a low operative complication rate, and minimal estimated blood loss. This study also indicates that MIS for the treatment of LSS can significantly reduce pain and disability level. Thus, minimally invasive surgery using endoscopic laminotomy and foraminotomy appears to be a safe and effective alternative surgical treatment for open decompression surgery in adult patients with lumbar spinal stenosis.
Polikandriotis, John A.; Hudak, Elizabeth M.; Perry, Michael W.
Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1–48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4–5; 31, L5–6) and 4 two-level (L4–5 and L5–6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5–6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan–Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2–29 months). Kaplan–Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5–6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4–5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5–6 [hazard ratio (HR), 10.3; 95% CI, 1.7–63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2–90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5–6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4–5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5–6 and two-level in patients with LSTV are significant risk factors for reoperation.
Sur, Yoo-Joon; Kong, Chae-Gwan
Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation. PMID:20953966
Sur, Yoo-Joon; Kong, Chae-Gwan; Park, Jong-Beom
Examines patients (N=257) with lumbar spinal stenosis preoperatively and at six months to relate patient expectation to baseline function and pain and to determine how patient expectations and preoperative function interact to predict postoperative outcomes. Results show that patients with many preoperative expectations, particularly those with…
Iversen, Maura D.; Daltroy, Lawren H.; Fossel, Anne H.; Katz, Jeffrey N.
Interbody fusion techniques have been promoted as an adjunct to lumbar fusion procedures in an effort to enhance fusion rates and potentially improve clinical outcome. The medical evidence continues to suggest that interbody techniques are associated with higher fusion rates compared with posterolateral lumbar fusion (PLF) in patients with degenerative spondylolisthesis who demonstrate preoperative instability. There is no conclusive evidence demonstrating improved clinical or radiographic outcomes based on the different interbody fusion techniques. The addition of a PLF when posterior or anterior interbody lumbar fusion is performed remains an option, although due to increased cost and complications, it is not recommended. No substantial clinical benefit has been demonstrated when a PLF is included with an interbody fusion. For lumbar degenerative disc disease without instability, there is moderate evidence that the standalone anterior lumbar interbody fusion (ALIF) has better clinical outcomes than the ALIF plus instrumented, open PLF. With regard to type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome. PMID:24980588
Mummaneni, Praveen V; Dhall, Sanjay S; Eck, Jason C; Groff, Michael W; Ghogawala, Zoher; Watters, William C; Dailey, Andrew T; Resnick, Daniel K; Choudhri, Tanvir F; Sharan, Alok; Wang, Jeffrey C; Kaiser, Michael G
ABSTRACT Study design: Systematic review using a modified network analysis. Objectives: To compare the effectiveness and morbidity of interspinous-device placement versus surgical decompression for the treatment of lumbar spinal stenosis. Summary: Traditionally, the most effective treatment for degenerative lumbar spinal stenosis is through surgical decompression. Recently, interspinous devices have been used in lieu of standard laminectomy. Methods: A review of the English-language literature was undertaken for articles published between 1970 and March 2010. Electronic databases and reference lists of key articles were searched to identify studies comparing surgical decompression with interspinous-device placement for the treatment of lumbar spinal stenosis. First, studies making the direct comparison (cohort or randomized trials) were searched. Second, randomized controlled trials (RCTs) comparing each treatment to conservative management were searched to allow for an indirect comparison through a modified network analysis approach. Comparison studies involving simultaneous decompression with placement of an interspinous device were not included. Studies that did not have a comparison group were not included since a treatment effect could not be calculated. Two independent reviewers assessed the strength of evidence using the GRADE criteria assessing quality, quantity, and consistency of results. The strengths of evidence for indirect comparisons were downgraded. Disagreements were resolved by consensus. Results: We identified five studies meeting our inclusion criteria. No RCTs or cohort studies were identified that made the direct comparison of interspinous-device placement with surgical decompression. For the indirect comparison, three RCTs compared surgical decompression to conservative management and two RCTs compared interspinous-device placement to conservative management. There was low evidence supporting greater treatment effects for interspinous-device placement compared to decompression for disability and pain outcomes at 12 months. There was low evidence demonstrating little to no difference in treatment effects between the groups for walking distance and complication rates. Conclusion: The indirect treatment effect for disability and pain favors the interspinous device compared to decompression. The low evidence suggests that any further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate. No significant treatment effect differences were observed for postoperative walking distance improvement or complication rates; however, findings should be considered with caution because of indirect comparisons and short follow-up periods.
Chou, Dean; Lau, Darryl; Hermsmeyer, Jeffrey; Norvell, Daniel
Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis. The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered. At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups. In this large cohort the addition of fusion to decompression was not associated with an improved outcome. PMID:23814250
Försth, P; Michaëlsson, K; Sandén, B
Background: Spinal fusion is the most rapidly increasing type of lumbar spine surgery for various lumbar degenerative pathologies. The surgical treatment of lumbar spine degenerative disc disease may involve decompression, stabilization, or arthroplasty procedures. Lumbar disc athroplasty is a recent technological advance in the field of lumbar surgery. This study seeks to determine the clinical impact of anterior lumbar disc replacement on the surgical treatment of lumbar spine degenerative pathology. This is a retrospective assessment of the Nationwide Inpatient Sample (NIS). Methods: The NIS was searched for ICD-9 codes for lumbar and lumbosacral fusion (81.06), anterior lumbar interbody fusion (81.07), and posterolateral lumbar fusion (81.08), as well as for procedure codes for revision fusion surgery in the lumbar and lumbosacral spine (81.36, 81.37, and 81.38). To assess lumbar arthroplasty, procedure codes for the insertion or replacement of lumbar artificial discs (84.60, 84.65, and 84.68) were queried. Results were assayed from 2000 through 2008, the last year with available data. Analysis was done using the lme4 package in the R programming language for statistical computing. Results: A total of nearly 300,000 lumbar spine fusion procedures were reported in the NIS database from 2000 to 2008; assuming a representative cross-section of the US health care market, this models approximately 1.5 million procedures performed over this time period. In 2005, the first year of its widespread use, there were 911 lumbar arthroplasty procedures performed, representing 3% of posterolateral fusions performed in this year. Since introduction, the number of lumbar spine arthroplasty procedures has consistently declined, to 653 total procedures recorded in the NIS in 2008. From 2005 to 2008, lumbar arthroplasties comprised approximately 2% of lumbar posterolateral fusions. Arthroplasty patients were younger than posterior lumbar fusion patients (42.8 ± 11.5 vs. 55.9 ± 15.1 years, P < 0.0000001). The distribution of arthroplasty procedures was even between academic and private urban facilities (48.5% and 48.9%, respectively). While rates of posterolateral lumbar spine fusion steadily grew during the period (OR 1.06, 95% CI: 1.05-1.06, P < 0.0000001), rates of revision surgery and anterior spinal fusion remained static. Conclusions: The impact of lumbar arthroplasty procedures has been minimal. Measured as a percentage of more common lumbar posterior arthrodesis procedures, lumbar arthroplasty comprises only approximately 2% of lumbar spine surgeries performed in the United States. Over the first 4 years following the Food and Drug Administration (FDA) approval, the frequency of lumbar disc arthroplasty has decreased while the number of all lumbar spinal fusions has increased.
Awe, Olatilewa O.; Maltenfort, Mitchel G.; Prasad, Srinivas; Harrop, James S.; Ratliff, John K
The objective of this study is to evaluate the effectiveness and safety of total disc replacement surgery compared with spinal fusion in patients with symptomatic lumbar disc degeneration. Low back pain (LBP), a major health problem in Western countries, can be caused by a variety of pathologies, one of which is degenerative disc disease (DDD). When conservative treatment fails, surgery might be considered. For a long time, lumbar fusion has been the “gold standard” of surgical treatment for DDD. Total disc replacement (TDR) has increased in popularity as an alternative for lumbar fusion. A comprehensive systematic literature search was performed up to October 2008. Two reviewers independently checked all retrieved titles and abstracts, and relevant full text articles for inclusion. Two reviewers independently assessed the risk of bias of included studies and extracted relevant data and outcomes. Three randomized controlled trials and 16 prospective cohort studies were identified. In all three trials, the total disc replacement was compared with lumbar fusion techniques. The Charité trial (designed as a non-inferiority trail) was considered to have a low risk of bias for the 2-year follow up, but a high risk of bias for the 5-year follow up. The Charité artificial disc was non-inferior to the BAK® Interbody Fusion System on a composite outcome of “clinical success” (57.1 vs. 46.5%, for the 2-year follow up; 57.8 vs. 51.2% for the 5-year follow up). There were no statistically significant differences in mean pain and physical function scores. The Prodisc artificial disc (also designed as a non-inferiority trail) was found to be statistically significant more effective when compared with the lumbar circumferential fusion on the composite outcome of “clinical success” (53.4 vs. 40.8%), but the risk of bias of this study was high. Moreover, there were no statistically significant differences in mean pain and physical function scores. The Flexicore trial, with a high risk of bias, found no clinical relevant differences on pain and physical function when compared with circumferential spinal fusion at 2-year follow up. Because these are preliminary results, in addition to the high risk of bias, no conclusions can be drawn based on this study. In general, these results suggest that no clinical relevant differences between the total disc replacement and fusion techniques. The overall success rates in both treatment groups were small. Complications related to the surgical approach ranged from 2.1 to 18.7%, prosthesis related complications from 2.0 to 39.3%, treatment related complications from 1.9 to 62.0% and general complications from 1.0 to 14.0%. Reoperation at the index level was reported in 1.0 to 28.6% of the patients. In the three trials published, overall complication rates ranged from 7.3 to 29.1% in the TDR group and from 6.3 to 50.2% in the fusion group. The overall reoperation rate at index-level ranged from 3.7 to 11.4% in the TDR group and from 5.4 to 26.1% in the fusion group. In conclusion, there is low quality evidence that the Charité is non-inferior to the BAK cage at the 2-year follow up on the primary outcome measures. For the 5-year follow up, the same conclusion is supported only by very low quality evidence. For the ProDisc, there is very low quality evidence for contradictory results on the primary outcome measures when compared with anterior lumbar circumferential fusion. High quality randomized controlled trials with relevant control group and long-term follow-up is needed to evaluate the effectiveness and safety of TDR.
van den Eerenbeemt, Karin D.; van Royen, Barend J.; Peul, Wilco C.; van Tulder, Maurits W.
Assessment of functional patient-reported outcome following lumbar spinal fusion continues to be essential for comparing the effectiveness of different treatments for patients presenting with degenerative disease of the lumbar spine. When assessing functional outcome in patients being treated with lumbar spinal fusion, a reliable, valid, and responsive outcomes instrument such as the Oswestry Disability Index should be used. The SF-36 and the SF-12 have emerged as dominant measures of general health-related quality of life. Research has established the minimum clinically important difference for major functional outcomes measures, and this should be considered when assessing clinical outcome. The results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. PMID:24980579
Ghogawala, Zoher; Resnick, Daniel K; Watters, William C; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Eck, Jason C; Sharan, Alok; Groff, Michael W; Wang, Jeffrey C; Dhall, Sanjay S; Kaiser, Michael G
Few reports have described the combined use of unilateral pedicle screw fixation and interbody fusion for lumbar stenosis. We retrospectively reviewed 79 patients with lumbar stenosis. The rationale and effectiveness of unilateral pedicle screw fixation were studied from biomechanical and clinical perspectives, aiming to reduce stiffness of the implant. All patients were operated with posterior interbody fusion using a diagonal cage in combination with unilateral transpedicular screw fixation and had reached the 3-year follow-up interval after operation. The mean operating time was 115 minutes (range=95-150 min) and the mean estimated blood loss was 150 mL (range=100-200 mL). The mean duration of hospital stay was 10 days (range=7-15 days). Clinical outcomes were assessed prior to surgery and reassessed at intervals using Denis' pain and work scales. Fusion status was determined from X-rays and CT scans. At the final follow-up, the clinical results were satisfactory and patients showed significantly improved scores (p<0.01) either on the pain or the work scale. Successful fusion was achieved in all patients. There were no new postoperative radiculopathies, or instances of malpositioned or fractured hardware. Posterior interbody fusion using a diagonal cage with unilateral transpedicular fixation is an effective treatment for decompressive surgery for lumbar stenosis. PMID:21237659
Zhao, Jian; Zhang, Feng; Chen, Xiaoqing; Yao, Yu
Vertebral compression fractures (VCFs) can cause symptomatic spinal canal stenosis secondary to posterior wall retropulsion. This report describes four patients with VCF and lumbar stenosis secondary to posterior wall retropulsion who were treated with combined kyphoplasty and percutaneous interspinous spacer (IS) placement. Clinical and imaging follow-up ranged from 12-36 months. Outcomes were favorable. Combined kyphoplasty and percutaneous IS implant represents a minimally invasive, safe, and efficient option to treat VCF with symptomatic spinal stenosis. PMID:23101915
Bonaldi, Giuseppe; Cianfoni, Alessandro
Few studies have investigated the factors related to the disability and physical function in degenerative lumbar spondylolisthesis using axially loaded magnetic resonance imaging (MRI). Therefore, we aimed to investigate the effect of axial loading on the morphology of the spine and the spinal canal in patients with degenerative spondylolisthesis of L4-5 and to correlate morphologic changes to their disability and physical functions. From March 2003 to January 2004, 32 consecutive cases (26 females, 6 males) with degenerative L4-5 spondylolisthesis, grade 1-2, intermittent claudication, and low back pain without sciatica were included in this study. All patients underwent unloaded and axially loaded MRI of the lumbo-sacral spine in supine position to elucidate the morphological findings and to measure the parameters of MRI, including disc height (DH), sagittal translation (ST), segmental angulation (SA), dural sac cross-sectional area (DCSA) at L4-5, and lumbar lordotic angles (LLA) at L1-5 between the unloaded and axially loaded condition. Each patient's disability was evaluated by the Oswestry Disability Index (ODI) questionnaire, and physical functioning (PF) was evaluated by the Physical Function scale proposed by Stucki et al. (Spine 21:796-803, 1996). Three patients were excluded due to the presence of neurologic symptoms found with the axially loaded MRI. Finally, a total of 29 (5 males, 24 females) consecutive patients were included in this study. Comparisons and correlations were done to determine which parameters were critical to the patient's disability and PF. The morphologies of the lumbar spine changed after axially loaded MRI. In six of our patients, we observed adjacent segment degeneration (4 L3-L4 and 2 L5-S1) coexisting with degenerative spondylolisthesis of L4-L5 under axially loaded MRI. The mean values of the SA under pre-load and post-load were 7.14 degrees and 5.90 degrees at L4-L5 (listhetic level), respectively. The mean values of the LLA under pre-load and post-load were 37.03 degrees and 39.28 degrees , respectively. There were significant correlations only between the ODI, PF, and the difference of SA, and between PF and the post-loaded LLA. The changes in SA (L4-L5) during axial loading were well correlated to the ODI and PF scores. In addition, the LLA (L1-L5) under axial loading was well correlated to the PF of patients with degenerative L4-L5 spondylolisthesis. We suggest that the angular instability of the intervertebral disc may play a more important role than neurological compression in the pathogenesis of disability in degenerative lumbar spondylolisthesis. PMID:19526378
Huang, Kuo-Yuan; Lin, Ruey-Mo; Lee, Yung-Ling; Li, Jenq-Daw
INTRODUCTION Symtomatic lumbar ligamantum flavum calcification is quite rare in the young age group. PRESENTATION OF CASE The authors report a case of young adult with diagnosis of lumbar spinal stenosis, presenting with leg pain and neurological deficits. Computerized tomography (CT) scan and magnetic resonance (MR) imaging studies revealed ossification of the ligamantum flavum as the causative factor of the disease and the patient recovered completely after the decompressive operation. DISCUSSION It is emphasized that attention should be given to this rare etiological factor of lumbar spinal stenosis. CONCLUSION Complete relief can be achieved with early and adequate surgery.
Yilmaz, Murat; Kalemci, Orhan; Yilmaz, Hakan; Palaz, Necdet M.
Background To assess the radiographic results in patients who underwent transforaminal lumbar interbody fusion (TLIF), particularly the changes in segmental lordosis in the fusion segment, whole lumbar lordosis and disc height. Methods Twenty six cases of single-level TLIF in degenerative lumbar diseases were analyzed. The changes in segmental lordosis, whole lumbar lordosis, and disc height were evaluated before surgery, after surgery and at the final follow-up. Results The segmental lordosis increased significantly after surgery but decreased at the final follow-up. Compared to the preoperative values, the segmental lordosis did not change significantly at the final follow-up. Whole lumbar lordosis at the final follow-up was significantly higher than the preoperative values. The disc height was significantly higher in after surgery than before surgery (p = 0.000) and the disc height alter surgery and at the final follow-up was similar. Conclusions When performing TLIF, careful surgical techniques and attention are needed to restore and maintain the segmental lordosis at the fusion level.
Kim, Sang-Bum; Heo, Youn-Moo; Lee, Woo-Suk; Yi, Jin-Woong; Kim, Tae-Kyun; Hwang, Cheol-Mog
BACKGROUND Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials. METHODS Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years. RESULTS A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. The as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes; these changes remained significant at 2 years. CONCLUSIONS In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically. (ClinicalTrials.gov number, NCT00000411.)
Weinstein, James N.; Tosteson, Tor D.; Lurie, Jon D.; Tosteson, Anna N.A.; Blood, Emily; Hanscom, Brett; Herkowitz, Harry; Cammisa, Frank; Albert, Todd; Boden, Scott D.; Hilibrand, Alan; Goldberg, Harley; Berven, Sigurd; An, Howard
Background Degenerative changes of lumbar spine anatomy resulting in the encroachment of neural structures are often regarded progressive, ultimately necessitating decompressive surgery. However the natural course is not necessarily progressive and the efficacy of a variety of nonsurgical interventions has also been described. At present there is insufficient data to compare surgical and nonsurgical interventions in terms of their relative benefit and safety. Previous attempts failed to provide clear clinical recommendations or to distinguish subgroups that substantially benefit from a certain treatment strategy. We present the design of a randomized controlled trial on (cost-) effectiveness of surgical decompression versus prolonged conservative treatment in patients with neurogenic intermittent claudication caused by lumbar stenosis. Methods/Design The aim of the Verbiest trial is to evaluate the effectiveness of prolonged conservative treatment compared to decompressive surgery. The study is a multi-center randomized controlled trial with two parallel groups design. Patients (age over 50) presenting to the neurologist or neurosurgeon with at least 3 months complaints of neurogenic intermittent claudication and considering surgical treatment are eligible for inclusion. Participants are randomly allocated to either prolonged conservative treatment, receiving further treatment from their general practitioner and physical therapist, or allocated to surgery and operated within 4 weeks. Primary outcome measure is the functional assessment of the patient as measured by the Zurich Claudication Questionnaire at 24 months of follow-up. Data is analyzed according to the intention to treat principle. Discussion With a cost-effectiveness analysis the trade off between the costs of prolonged conservative treatment and delayed surgery in a smaller number of patients are compared with the current policy of surgical management. As surgery is expected to be inevitable in certain subgroups of patients, the distinction of and classification by predictive patient characteristics is most relevant to clinical practice. Trial registration Netherlands Trial Register (NTR): NTR2216
Background Relatively few studies have focused on the major medical complications that are more common in older adults. Furthermore, these studies have generally not reported how accurately a risk factor, or combination of risk factors, can distinguish between those who will have a complication and those who will not. Methods A total of 236 consecutive patients who had undergone surgical treatment for degenerative lumbar scoliosis between June 2008 and June 2012 were included retrospectively in this study. The demographic distribution, medical history, and clinical data were collected to investigate the predictive factors of postoperative complications by logistic regression. Results Among 236 eligible patients, major medical complications occurred in 7.2% of cases and wound complications occurred in 1.7% of cases. Ninety-day mortality rate was 0.4%. Postoperative complications were strongly associated with history of severe chronic obstructive pulmonary disease (COPD) (P = 0.031), dyspnea with minimal exertion (P = 0.041), being at least partially dependent (P = 0.041), smoking within the past year (P = 0.044), American Society of Anesthesiologists (ASA) class of more than 2 (P = 0.000), diabetes treated with insulin (P = 0.003), and steroid use for chronic condition (P = 0.003). In logistic regressions, operation time (odds ratio 2.45, 95% confidence interval 1.11–4.78), ASA class (class 3 or 4 vs. class 1 or 2: odds ratio 2.21, 95% confidence interval 1.22–3.45), insulin-dependent diabetes (odds ratio 1.72, 95% confidence interval 1.18–2.43), and steroid use for chronic condition (odds ratio 1.55, 95% confidence interval 1.06–2.32) may be reasonable predictors for an individual's likelihood of surgical complications. Conclusions The occurrence of postoperative complications is most likely multifactorial and is related to operation time, ASA class, insulin-dependent diabetes and steroid use for chronic condition.
The authors report a homogeneously investigated and surgically treated series of 40 patients with degenerative scoliosis of the lumbar spine. The series included 22 females and 18 males with a mean age of 62.8 years. The clinical presentation, the diagnostic work-up, the indication for surgery, the surgical techniques and results are reported. Final evaluation was possible in 30 patients at a mean period of observation of 59.5 months. Following a very precise diagnostic and therapeutic protocol excellent, good and satisfactory surgical results were obtained in 13 (43.3%), 16 (53.3%) and 1 (3.3%) patients, respectively. While scoliosis was converted from a mean preoperative Cobb angle of 18.7 degrees to 7.6 degrees mean pre-operative lumbar lordosis was slightly augmented from 37 degrees to 41.5 degrees. The results suggest that maintainance or correction of lumbar lordosis is more important than the conversion of the scoliotic deformity which is probably treated sufficiently by partial correction and stabilization. Observation over time indicates that the degenerative cascade evolves despite internal fixation and fusion in the majority of the patients until a stable state is reached. This stable state is probably rather the result of ankylosis of the facet joints than the effect of posterolateral fusion. PMID:10071682
Zurbriggen, C; Markwalder, T M; Wyss, S
Objective The purpose of this study was to analyze the clinical features and prognostic factors of surgical outcome of foot drop caused by lumbar degenerative disease and put forward the clinical stage. Methods We retrospectively reviewed 135 patients with foot drop due to lumbar degenerative disease. The clinical features and mechanism were analyzed. Age, sex, duration of palsy, preoperative muscle strength of tibialis anterior (TA), sensation defect of affected lower limb, affected foot, diagnosis and compressed nerve roots were recorded and compared with surgical outcome. Results Foot drop was observed in 8.1% of all inpatients of lumbar degenerative disease. L5 nerve root compression was observed in 126 of all 135 patients (93.3%). Single, double and triple roots compression was observed respectively in 43, 83, and 9 patients (31.9%, 61.5%, and 6.6%). But there was no significant relationship between preoperative muscle strength of TA and the number of compressed roots. The muscle strength of TA was improved in 113 (83.7%) patients after surgery, but it reached to >=4 in only 21 (15.6%) patients. Improvement of the muscle strength of TA was almost stable at the 6-month follow-up. At the last follow-up, the muscle strength of TA was 1, 2, 3, 4, 5 respectively in 28, 24, 62, 13, 8 patients. Multivariate logistic regression showed duration of palsy (p=0.0360, OR=2.543), preoperative muscle strength of TA (p=0.0064, OR=5.528) and age (p=0.0309, OR=3.208) were factors that influenced recovery following an operation. Conclusions L5 nerve root was most frequently affected. The muscle strength of TA improved in most patients after surgery, but few patients can get a good recovery from foot drop. Patients of shorter duration of palsy, better preoperative muscle strength of TA and younger age showed a better surgical outcome.
Shi, Jiangang; Jia, Lianshun; Shi, Guodong; Wang, Yuan; Liu, Ning
Background: The osteoporosis and lumbar canal stenosis, in elderly patients are under diagnosed and under reported. We report a cross sectional study to demonstrate the osteoporotic profile in patients with lumbar spinal stenosis (LSS) and to determine the proportion of patients with LSS who need to be treated for osteoporosis. Materials and Methods: One hundred and six postmenopausal patients with symptomatic LSS were evaluated for osteoporotic profile, which included lumbar and hip bone mineral density (BMD), serum vitamin D concentration, bone resorption and formation markers. Demographic and disease related variables were analyzed to identify the association with the risk of osteoporosis or osteopenia. Statistical analysis used were multivariate logistic regression with a forward stepwise procedure. Results: Twenty-four patients (22.6%) had osteoporosis and 60 (56.6%) had osteopenia. Overall, 84 patients (79.2%) with symptomatic LSS had osteoporosis or osteopenia. Fifty-nine patients (55.6%) had hypovitaminosis D. All bone turnover makers [alkaline phosphatase, osteocalcin, urinary-N-terminal telopeptide (u-NTx)] were demonstrated to be within normal range. Only age was associated with the risk of osteoporosis or osteopenia in the hip region. In the lumbar spine, all variables were not associated with osteoporosis or osteopenia. 44 patients (41.5%) required treatment for osteoporosis as per risk factors for osteoporosis. According to the guidelines from the Health Insurance Review Agency, however, only 20 patients (18.8% required) qualified for reimbursement for osteoporosis medications. Conclusions: LSS is associated with osteopenia, osteoporosis, and hypovitaminosis D, which should prompt careful screening and treatment in cases of osteoporosis and osteoarthritis.
Lee, Byung Ho; Moon, Seong Hwan; Kim, Ho-Joong; Lee, Hwan Mo; Kim, Tae Hwan
Twenty consecutive patients (10 men and 10 women; median age, 68 years) with lumbar spinal stenosis were studied before and after microsurgical decompression without laminectomy. Fourteen of the patients had pure stenosis symptoms, whereas six had intercurrent diseases that could exacerbate the symptoms of stenosis. The mean duration of symptoms was 4.5 years (range, 1 to 15 years). All patients were interviewed before operation, and an assessment form based on and modified from the Oswestry Low Back Pain Disability Questionnaire was completed. The ability to perform physical activities including house work, gardening, going to the post office, and so forth was markedly reduced before operation for nearly all patients, and social life such as traveling, meeting friends, and participating in hobbies was similarly restricted. Sleeping was also greatly affected before operation, as were psychological parameters including irritability, depression, infirmity, energy, patience, and concentration. At follow-up 2.8 years after surgery, 13 of the 14 patients with pure stenosis evaluated their quality of life as much improved and principally normal. Among the patients with intercurrent diseases, only two of six judged the quality of their lives as much improved. PMID:10872762
Schillberg, B; Nyström, B
Objective This multi-center clinical study was designed to determine the long-term results of patients who received a one-level posterior lumbar interbody fusion with expandable cage (Tyche® cage) for degenerative spinal diseases during the same period in each hospital. Methods Fifty-seven patients with low back pain who had a one-level posterior lumbar interbody fusion using a newly designed expandable cage were enrolled in this study at five centers from June 2003 to December 2004 and followed up for 24 months. Pain improvement was checked with a Visual Analogue Scale (VAS) and their disability was evaluated with the Oswestry Disability Index. Radiographs were obtained before and after surgery. At the final follow-up, dynamic stability, quality of bone fusion, interveretebral disc height, and lumbar lordosis were assessed. In some cases, a lumbar computed tomography scan was also obtained. Results The mean VAS score of back pain was improved from 6.44 points preoperatively to 0.44 at the final visit and the score of sciatica was reduced from 4.84 to 0.26. Also, the Oswestry Disability Index was improved from 32.62 points preoperatively to 18.25 at the final visit. The fusion rate was 92.5%. Intervertebral disc height, recorded as 9.94±2.69 mm before surgery was increased to 12.23±3.31 mm at postoperative 1 month and was stabilized at 11.43±2.23 mm on final visit. The segmental angle of lordosis was changed significantly from 3.54±3.70° before surgery to 6.37±3.97° by 24 months postoperative, and total lumbar lordosis was 20.37±11.30° preoperatively and 24.71±11.70° at 24 months postoperative. Conclusion There have been no special complications regarding the expandable cage during the follow-up period and the results of this study demonstrates a high fusion rate and clinical success.
Kim, Jin Wook; Yoon, Seung Hwan; Oh, Seong Hoon; Roh, Sung Woo; Rim, Dae Cheol; Kim, Tae Sung
Dynamic systems in the lumbar spine are believed to reduce main fusion drawbacks such as pseudarthrosis, bone rarefaction, and mechanical failure. Compared to fusion achieved with rigid constructs, biomechanical studies underlined some advantages of dynamic instrumentation including increased load sharing between the instrumentation and interbody bone graft and stresses reduction at bone-to-screw interface. These advantages may result in increased fusion rates, limitation of bone rarefaction, and reduction of mechanical complications with the ultimate objective to reduce reoperations rates. However published clinical evidence for dynamic systems remains limited. In addition to providing biomechanical evaluation of a pedicle-screw-based dynamic system, the present study offers a long-term (average 10.2 years) insight view of the clinical outcomes of 18 patients treated by fusion with dynamic systems for degenerative lumbar spine diseases. The findings outline significant and stable symptoms relief, absence of implant-related complications, no revision surgery, and few adjacent segment degenerative changes. In spite of sample limitations, this is the first long-term report of outcomes of dynamic fusion that opens an interesting perspective for clinical outcomes of dynamic systems that need to be explored at larger scale.
Barrey, Cedric; Perrin, Gilles; Champain, Sabina
Study Design. A case report by Kara Krajewski and Jan Regelsberger.Objective. To demonstrate a case of intradural lumbar disc herniation including imaging studies, intraoperative imaging and an intraoperative video.Summary of Background Data. The first case of lumbar intradural disc herniation was reported as early as 1942; since then over 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced MRI is considered the gold standard for diagnosing this entity, though it is rarely peformed routinely in lumbar disc disease and diagnosis is often made intraoperatively.Methods. A 70-year-old man presented to the emergency department as a referral complaining of lower back pain, loss of sensation in the right thigh and difficulty walking. On examination, he showed uneven gait, right-sided foot drop (1/5), hypesthesias in the right inguinal area and ventral thigh and a positive straight leg raise test on the right. Anal sphincter tone was within normal limits. An MRI of the lumbar spine showed a large mediolateral herniated disc at L3/4, with caudal displacement and unclear signal changes intradurally.Results. Intraoperatively, the herniated disc was found upon opening the dural sac.Conclusion. Intradural disc herniations are a rare entity. The opening and inspection of the dural sack should be considered when the correct spinal level can be confirmed and insufficient herniated disc material can be visualized extradurally. PMID:23462573
Krajewski, K; Regelsberger, J
Paradigm change has recently taken place in spine surgery with the application of minimally invasive techniques. Minimally invasive techniques have several advantages over the open traditional techniques: less blood loss, preservation of spine muscle integrity, shorter hospitalization, early mobilization, reduced pain levels, lower risk of infection. The presented cases cover following lumbar pathologies: segmental spinal instability, LV-SI grade II. spondylolisthesis, degenerative spondylolisthesis, spine trauma. Unilateral or bilateral mini-open technique was employed in the degenerative cases, depending on symptoms and signes. If unilateral symptoms--pathology was identified, screws and rod were implanted percutaneously on the side contralateral to the pathology. The segmental fusion between vertebral bodies was always assured by a cage and autologous bone. The presented trauma case involved combined AO type A2 and B fractures. The anterior column was strengthened with vertebral body stents filled with bone cement, the posterior column was fixed with a percutaneously implanted screw rod system. Insertion of stents in the collapsed vertebra significantly increased the vertebral body height and also improved the stability of the spine. Minimally invasive spine surgery techniques appear more advantageous over the traditional open spine surgery that necessitates for large midline approaches. PMID:23750428
Schwarcz, Attila; Kasó, Gábor; Büki, András; Dóczi, Tamás
Background This study investigated early clinical effects of Dynesys system plus transfacet decompression through the Wiltse approach in treating lumbar degenerative diseases. Material/Methods 37 patients with lumbar degenerative disease were treated with the Dynesys system plus transfacet decompression through the Wiltse approach. Results Results showed that all patients healed from surgery without severe complications. The average follow-up time was 20 months (9–36 months). Visual Analogue Scale and Oswestry Disability Index scores decreased significantly after surgery and at the final follow-up. There was a significant difference in the height of the intervertebral space and intervertebral range of motion (ROM) at the stabilized segment, but no significant changes were seen at the adjacent segments. X-ray scans showed no instability, internal fixation loosening, breakage, or distortion in the follow-up. Conclusions The Dynesys system plus transfacet decompression through the Wiltse approach is a therapeutic option for mild lumbar degenerative disease. This method can retain the structure of the lumbar posterior complex and the motion of the fixed segment, reduce the incidence of low back pain, and decompress the nerve root.
Liu, Chao; Wang, Lei; Tian, Ji-wei
Background The two most common types of surgically treated lumbar spondylolisthesis in adults include the degenerative and isthmic types. The aim of this study was to compare the functional outcomes of surgical decompression and posterolateral instrumented fusion in patients with lumbar degenerative and isthmic spondylolisthesis. Methods In this retrospective study, we reviewed the clinical outcomes in surgically treated patients with single level, low grade lumbar degenerative, and isthmic spondylolisthesis (groups A and B, respectively) from August 2007 to April 2011. We tried to compare paired settings with similar initial conditions. Group A included 52 patients with a mean age of 49.2 ± 6.1 years, and group B included 52 patients with a mean age of 47.3 ± 7.4 years. Minimum follow-up was 24 months. The surgical procedure comprised neural decompression and posterolateral instrumented fusion. Pain and disability were assessed by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. The Wilcoxon and Mann-Whitney U-tests were used to compare indices. Results The most common sites for degenerative and isthmic spondylolisthesis were at the L4-L5 (88.5%) and L5-S1 (84.6%) levels, respectively. Surgery in both groups significantly improved VAS and ODI scores. The efficacy of surgery based on subjective satisfaction rate and pain and disability improvement was similar in the degenerative and isthmic groups. Notable complications were also comparable in both groups. Conclusions Neural decompression and posterolateral instrumented fusion significantly improved pain and disability in patients with degenerative and isthmic spondylolisthesis. The efficacy of surgery for overall subjective satisfaction rate and pain and disability improvement was similar in both groups.
Hasankhani, Ebrahim Ghayem; Rahimi, Mohammad Dawood; Khanzadeh, Reza
Estudo comparativo entre a artroplastia discal tipo metal-metal e a artrodese lombar na discopatia lombar degenerativa Comparative study of lumbar disc arthroplasty and lumbar arthrodesis in lumbar degenerative disc disease Estudio comparativo entre la artroplastia discal tipo metal-metal y la artrodesis lumbar en la discopatía lumbar degenerativa
Objective: to realize a retrospective, long-term study, with clinical com- parative analysis between the pre and post-operative conditions of the patients submitted to lumbar disc replacement using metal-metal type disc, and the group operated for the traditional arthrodesis technique, in a single level for degenerative disc disease. Methods: eighteen patients had been submitted to the disc replacement with metal-metal type
Fernando Dario; Lyra de Freitas Coutinho; Luiz Cláudio Schettino
Background Lumbar spinal stenosis is the most common reason for spinal surgery in older adults. Previous studies have shown that surgery is effective for severe cases of stenosis, but many patients with mild to moderate symptoms are not surgical candidates. These patients and their providers are seeking effective non-surgical treatment methods to manage their symptoms; yet there is a paucity of comparative effectiveness research in this area. This knowledge gap has hindered the development of clinical practice guidelines for non-surgical treatment approaches for lumbar spinal stenosis. Methods/design This study is a prospective randomized controlled clinical trial that will be conducted from November 2013 through October 2016. The sample will consist of 180 older adults (>60 years) who have both an anatomic diagnosis of stenosis confirmed by diagnostic imaging, and signs/symptoms consistent with a clinical diagnosis of lumbar spinal stenosis confirmed by clinical examination. Eligible subjects will be randomized into one of three pragmatic treatment groups: 1) usual medical care; 2) individualized manual therapy and rehabilitative exercise; or 3) community-based group exercise. All subjects will be treated for a 6-week course of care. The primary subjective outcome is the Swiss Spinal Stenosis Questionnaire, a self-reported measure of pain/function. The primary objective outcome is the Self-Paced Walking Test, a measure of walking capacity. The secondary objective outcome will be a measurement of physical activity during activities of daily living, using the SenseWear Armband, a portable device to be worn on the upper arm for one week. The primary analysis will use linear mixed models to compare the main effects of each treatment group on the changes in each outcome measure. Secondary analyses will include a responder analysis by group and an exploratory analysis of potential baseline predictors of treatment outcome. Discussion Our study should provide evidence that helps to inform patients and providers about the clinical benefits of three non-surgical approaches to the management of lumbar spinal stenosis symptoms. Trial registration ClinicalTrials.gov identifier: NCT01943435
Neurogenic claudication due to lumbar spinal stenosis is the commonest cause of back and leg pain in the elderly. It consumes large amounts of healthcare resource and is a common reason for GP consultations. Surgical management by decompressive laminectomy is the traditional method used for those patients in whom conservative management has failed. However, the advent of minimally invasive interspinous distraction devices, which are designed to alleviate symptoms of neurogenic intermittent claudication without subjecting the patient to a major operation, has potentially revolutionised the management of lumbar spinal stenosis. This review describes the principles of interspinous distraction devices, the rationale for their use in the management of lumbar spinal stenosis, indications and predictors of outcome. Published data on the safety and efficacy of the various devices available is encouraging but long term results are awaited. The superiority of interspinous distraction devices over conservative treatment has already been established, however, the precise indication for this new technology and whether the implants can replace conventional decompressive surgery in some situations has not been clearly defined. PMID:22582741
Borg, Anouk; Nurboja, Besnik; Timothy, Jake; Choi, David
Background context Ambulation limitation is the hallmark of impairment in lumbar spinal stenosis (LSS). Capacity and performance have been defined as two distinct aspects of disability. Previous literature suggests that a person’s walking capacity may not be reflected in their daily walking performance. Purpose To examine the relationship between survey instruments, tested walking capacity, and daily ambulatory performance in people diagnosed with LSS. Design/Settings Prospective laboratory and clinical observational study at a tertiary care spine clinic. Patient Sample 12 subjects with LSS significant enough to be scheduled for epidural injection. Outcome measures Questionnaire (including the Swiss Spinal Stenosis Questionnaire, Pain Disability Index, Oswestry Disability Index, Quebec Back Pain Disability Scale, and SF-36), laboratory walk testing (walking capacity) and activity monitors (community ambulation). Methods Subjects filled out functional questionnaires; performed a Self-Paced Walking Test (SPWT) of up to 30 minutes; and wore an Actigraph activity monitor during waking hours for 7 days. Results There was no statistically significant relationship between walking capacity (SPWT) and community ambulation per day (activity monitors), however the maximum time of continuous activity during community ambulation had a strong relationship (r=0.63) with the SPWT. Fifteen self-report measures of ambulation were significantly correlated with the SPWT, activity monitor, or both. Of these, 13 (87%) were more highly correlated to the SPWT than the activity monitor. The SPWT test had a strong relationship (r>.60, p<.05) with global function scales, but community ambulation did not. Conclusions Walking capacity and walking performance in LSS appear to be different constructs. Survey instruments appear to reflect capacity rather than performance. This dissociation between walking capacity and performance has implications for the clinical management and outcomes assessment of people with LSS.
Conway, Justin; Tomkins, Christy; Haig, Andrew J.
Lumber spinal canal stenosis is an important cause of low back pain and it frequently presents with low backache with neurogenic claudication. Operative management of lumbar spinal canal stenosis by decompression surgery is an effective method. This prospective interventional (quasi experimental) study was performed in patient having history of characteristic clinical features like low backache with radicular pain, neurogenic claudication, signs of root compression, positive MRI findings attending in the department of Orthopaedic Surgery and Neurosurgery, Dhaka Medical College Hospital and NITOR. Dhaka, from July 2008 to June 2010. Thirty patients were evaluated among those 18(60%) were 50 years and above. Male to female ratio was roughly 9:1. About 87% of the patients had sensory deficit and 50% had neurogenic claudication. Majority (83.3%) of the patients at presentation had a suffering of 12 or >12 months. Diagnosis shows that 3.5% of patients had L4 lesion, 60% L5, 6.5% patients had L4 & L5 and 30% S1. Laminectomy was done in 43.3% of patients, laminectomy and disectomy in 30% and laminectomy, discectomy & foraminal decompression in 26.7% of patients. Relief of symptoms occurred in 25(83.5%) of patients. Over three-quarter (76.7%) of patients exhibited minimal disability and 23.3% moderate disability based on Oswestry Disability Index, while by MacNab criteria, most (80%) of patients was excellent, 10% good and another 10% fair. Repeated measure ANOVA statistics showed that mean Oswestry score decreased significantly from 54.5% at baseline to 22% at the end of 1 year (p<0.001). PMID:24292296
Islam, M S; Ara, R; Salam, M A; Rahman, M W; Alam, M J; Karim, M R; Rahman, M; Alam, M N; Hussain, M F
The utilization of orthotic devices for lumbar degenerative disease has been justified from both a prognostic and therapeutic perspective. As a prognostic tool, bracing is applied prior to surgery to determine if immobilization of the spine leads to symptomatic relief and thus justify the performance of a fusion. Since bracing does not eliminate motion, the validity of this assumption is questionable. Only one low-level study has investigated the predictive value of bracing prior to surgery. No correlation between response to bracing and fusion outcome was observed; therefore a trial of preoperative bracing is not recommended. Based on low-level evidence, the use of bracing is not recommended for the prevention of low-back pain in a general working population, since the incidence of low-back pain and impact on productivity were not reduced. However, in laborers with a history of back pain, a positive impact on lost workdays was observed when bracing was applied. Bracing is recommended as an option for treatment of subacute low-back pain, as several higher-level studies have demonstrated an improvement in pain scores and function. The use of bracing following instrumented posterolateral fusion, however, is not recommended, since equivalent outcomes have been demonstrated with or without the application of a brace. PMID:24980591
Dailey, Andrew T; Ghogawala, Zoher; Choudhri, Tanvir F; Watters, William C; Resnick, Daniel K; Sharan, Alok; Eck, Jason C; Mummaneni, Praveen V; Wang, Jeffrey C; Groff, Michael W; Dhall, Sanjay S; Kaiser, Michael G
Magnetic resonance (MR) images of the lumbar spine from 150 patients were retrospectively reviewed. In 14 of these patients, at 18 disk levels, a vacuum phenomenon (VP) had been identified on plain radiographs and/or computed tomographic scans. The MR imaging appearance of these gas collections in 17 disks was an area without signal, best seen on spin-echo sequences with short repetition time and echo time in the sagittal view. MR imaging precisely located the VP in the anulus fibrosus, the nucleus pulposus, and Schmorl nodes. In all but one case, degeneration of the disk was complete and associated with adjacent changes in vertebral bone. Pitfalls of MR imaging detection of VP included chemical shift artifact, calcifications, and tears without gas in the disk. PMID:3615888
Grenier, N; Grossman, R I; Schiebler, M L; Yeager, B A; Goldberg, H I; Kressel, H Y
Spinal nerve roots have a peculiar structure, different from the arrangements in the peripheral nerve. The nerve roots are devoid of lymphatic vessels but are immersed in the cerebrospinal fluid (CSF) within the subarachnoid space. The blood supply of nerve roots depends on the blood flow from both peripheral direction (ascending) and the spinal cord direction (descending). There is no hypovascular region in the nerve root, although there exists a so-called water-shed of the bloodstream in the radicular artery itself. Increased mechanical compression promotes the disturbance of CSF flow, circulatory disturbance starting from the venous congestion and intraradicular edema formation resulting from the breakdown of the blood-nerve barrier. Although this edema may diffuse into CSF when the subarachnoid space is preserved, the endoneurial fluid pressure may increase when the area is closed by increased compression. On the other hand, the nerve root tissue has already degenerated under the compression and the numerous macrophages releasing various chemical mediators, aggravating radicular symptoms that appear in the area of Wallerian degeneration. Prostaglandin E1 (PGE1) is a potent vasodilator as well as an inhibitor of platelet aggregation and has therefore attracted interest as a therapeutic drug for lumbar canal stenosis. However, investigations in the clinical setting have shown that PGE1 is effective in some patients but not in others, although the reason for this is unclear. PMID:24829876
Diagnosis of lumbar spinal stenosis (LSS) is based on clinical examination and imaging. The aim of this study was to evaluate the influence of 3D gait analysis as a tool in the differential diagnosis of LSS. Fourteen patients participated in the study that consisted of three phases: (1) capture six gait cycles after rest, (2) walk on a treadmill for a maximum of 20 min, (3) capture six gait cycles after effort. From these data, the kinematic variables were compared with the perception of pain and the cross sectional area of the spinal canal as measured by magnetic resonance. Most of correlations were weak and showed that the most significant results are reported by the Gait Deviation Index (GDI). The Gait Deviation Index demonstrated moderate negative correlation with the perception of pain after effort was made by both limbs. This means that there is a significant decrease in the overall function of the lower limbs according to the increase in pain symptoms. This situation may be reflected in decreased cadence and speed beyond the times of single support for the left limb, and the balance of the right limb, as part of a strategy to protect against pain and imbalance. We found no correlation between gait and pain in the cross-sectional area of the spinal canal. Therefore, we believe that there is no advantage for the patient to make a 3-D gait analysis because the analysis does not add relevant information to clinical diagnosis. PMID:24755459
Garbelotti, Silvio Antonio; Lucareli, Paulo Roberto Garcia; Ramalho, Amâncio; de Godoy, Wagner; Bernal, Milena; D'Andréa Greve, Julia Maria
The objective of this study was to assess the correlation between neurogenic intermittent claudication (NIC) in LSS and different positions as well as loading status, using the treadmill device. The study was a prospective clinical trial on lumbar spinal stenosis (LSS) using a treadmill equipment. The study population comprised of 80 LSS patients with a mean age of 61. The equipment included a treadmill, unloading station and loading vests. The patients were instructed to walk in five different positions. The initiation time of symptoms and total walking time were recorded. The examination was stopped after 20 min or at the onset of severe symptoms. In order to obtain pretest demographic data on subjects, visual analog scale, Roland-Morris questionnaire, pain disability index, and Beck depression index were used. The initiation time of symptoms (ITS) and total walking time (TWT) were measured during the test. Unloading provided a longer and loading a shorter ITS and TWT. Decline or incline positions did not affect ITS or TWT. The changes in posture had no correlation with the appearance of symptoms in LSS patients with NIC on a treadmill in this study, rather ITS and TWT were determined by axial loading and unloading. PMID:17273837
O?uz, Hasan; Levendo?lu, Funda; O?ün, Tunç Cevat; Tantu?, Aysenur
The purpose of this review article is to introduce the concept of activity monitoring, and to discuss the application of accelerometry in rehabilitation research and clinical practice using lumbar spinal stenosis as a model. Function is a complex concept, and changes in function have historically been challenging to measure. The International Classification of Functioning (ICF) defines two distinct components of function: capacity and performance. Capacity, the ability to perform a given task in a controlled environment can be measured through any number of existing functional measures. Performance, defined as activities performed on a day to day basis in the context of real life is challenging to measure, yet important in identifying the impact of pathology on real life. Recent advances in technology have allowed us to begin to measure performance, using activity monitors (accelerometers). Activity monitoring has the potential to change our concepts of outcomes, and as a result, expand our ideas about appropriateness of interventions in rehabilitation. Researchers and clinicians might benefit from using the new technology of activity monitors to measure the impact of intervention and to assess function. Therefore, this review will discuss the concept of activity monitoring and highlight potential uses for activity monitors in spine research and clinical care. PMID:22935856
Tomkins-Lane, Christy C; Haig, Andrew J
Spinal nerve roots have a peculiar structure, different from the arrangements in the peripheral nerve. The nerve roots are devoid of lymphatic vessels but are immersed in the cerebrospinal fluid (CSF) within the subarachnoid space. The blood supply of nerve roots depends on the blood flow from both peripheral direction (ascending) and the spinal cord direction (descending). There is no hypovascular region in the nerve root, although there exists a so-called water-shed of the bloodstream in the radicular artery itself. Increased mechanical compression promotes the disturbance of CSF flow, circulatory disturbance starting from the venous congestion and intraradicular edema formation resulting from the breakdown of the blood-nerve barrier. Although this edema may diffuse into CSF when the subarachnoid space is preserved, the endoneurial fluid pressure may increase when the area is closed by increased compression. On the other hand, the nerve root tissue has already degenerated under the compression and the numerous macrophages releasing various chemical mediators, aggravating radicular symptoms that appear in the area of Wallerian degeneration. Prostaglandin E1 (PGE1) is a potent vasodilator as well as an inhibitor of platelet aggregation and has therefore attracted interest as a therapeutic drug for lumbar canal stenosis. However, investigations in the clinical setting have shown that PGE1 is effective in some patients but not in others, although the reason for this is unclear.
Introduction Symptomatic chronic low back and leg pain resulting from lumbar spinal stenosis is expensive to treat and manage. A randomized, controlled, multicenter US Food and Drug Administration Investigational Device Exemption clinical trial assessed treatment-related patient outcomes comparing the Coflex® Interlaminar Stabilization Device, an interlaminar stabilization implant inserted following decompressive surgical laminotomy in the lumbar spine, to instrumented posterolateral fusion among patients with moderate to severe spinal stenosis. This study uses patient-reported outcomes and clinical events from the trial along with costs and expected resource utilization to determine cost effectiveness. Methods A decision-analytic model compared outcomes over 5 years. Clinical input parameters were derived from the trial. Oswestry Disability Index scores were converted to utilities. Treatment patterns over 5 years were estimated based on claims analyses and expert opinion. A third-party payer perspective was used; costs (in $US 2013) and outcomes were discounted at 3% annually. Sensitivity analyses examined the influence of key parameters. Analyses were conducted using Medicare payment rates and typical commercial reimbursements. Results Five-year costs were lower for patients implanted with Coflex compared to those undergoing fusion. Average Medicare payments over 5 years were estimated at $15,182 for Coflex compared to $26,863 for the fusion control, a difference of $11,681. Mean quality-adjusted life years were higher for Coflex patients compared to controls (3.02 vs 2.97). Results indicate that patients implanted with the Coflex device derive more utility, on average, than those treated with fusion, but at substantially lower costs. The cost advantage was greater when evaluating commercial insurance payments. Subgroup analyses found that the cost advantage for Coflex relative to fusion was even larger for two-level procedures compared to one-level procedures. Conclusion The Coflex Interlaminar Stabilization Device was found to be cost effective compared to instrumented posterolateral fusion for treatment of lumbar spinal stenosis. It provided higher utility at substantially lower cost.
Schmier, Jordana Kate; Halevi, Marci; Maislin, Greg; Ong, Kevin
Purpose. New interspinous process decompression devices (IPDs) provide an alternative to conservative treatment and decompressive surgery for patients with neurogenic intermittent claudication (NIC) due to degenerative lumbar spinal stenosis (DLSS). HeliFix is a minimally invasive IPD that can be implanted percutaneously. This is a preliminary evaluation of safety and effectiveness of this IPD up to 12 months after implantation. Methods. After percutaneous implantation in 100 patients with NIC due to DLSS, data on symptoms, quality of life, pain, and use of pain medication were obtained for up to 12 months. Results. Early symptoms and physical function improvements were maintained for up to 12 months. Leg, buttock/groin, and back pain were eased throughout, and the use and strength of related pain medication were reduced. Devices were removed from 2% of patients due to lack of effectiveness. Conclusions. Overall, in a period of up to 12-month follow-up, the safety and effectiveness of the HeliFix offered a minimally invasive option for the relief of NIC complaints in a high proportion of patients. Further studies are undertaken in order to provide insight on outcomes and effectiveness compared to other decompression methods and to develop guidance on optimal patient selection.
Alexandre, Alberto; Alexandre, Andrea Maria; De Pretto, Mario; Coro, Luca; Saggini, Raul
Purpose The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. Materials and Methods One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. Results Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). Conclusion This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.
Yamashita, Masaomi; Murata, Yasuaki; Eguchi, Yawara; Aoki, Yasuchika; Ataka, Hiromi; Hirayama, Jiro; Ozawa, Tomoyuki; Morinaga, Tatsuo; Arai, Hajime; Mimura, Masaya; Kamoda, Hiroto; Orita, Sumihisa; Miyagi, Masayuki; Miyashita, Tomohiro; Okamoto, Yuzuru; Ishikawa, Tetsuhiro; Sameda, Hiroaki; Kinoshita, Tomoaki; Hanaoka, Eiji; Suzuki, Miyako; Suzuki, Munetaka; Aihara, Takato; Ito, Toshinori; Inoue, Gen; Yamagata, Masatsune; Toyone, Tomoaki; Kubota, Gou; Sakuma, Yoshihiro; Oikawa, Yasuhiro; Inage, Kazuhide; Sainoh, Takeshi; Yamauchi, Kazuyo; Takahashi, Kazuhisa
Lumbar spinal stenosis (LSS) is the leading cause of morbidity and mortality worldwide. LSS pathology is associated with secondary injury caused by inflammation, oxidative damage and cell death. Apart from laminectomy, pharmacological therapy targeting secondary injury is limited. Statins are FDA-approved cholesterol-lowering drug. They also show pleiotropic anti-inflammatory, antioxidant and neuroprotective effects. To investigate the therapeutic efficacy of simvastatin in restoring normal locomotor function after cauda equina compression (CEC) in a rat model of LSS, CEC injury was induced in rats by implanting silicone gels into the epidural spaces of L4 and L6. Experimental group was treated with simvastatin (5 mg/kg body weight), while the injured (vehicle) and sham operated (sham) groups received vehicle solution. Locomotor function in terms of latency on rotarod was measured for 49 days and the threshold of pain was determined for 14 days. Rats were sacrificed on day 3 and 14 and the spinal cord and cauda equina fibers were extracted and studied by histology, immunofluorescence, electron microscopy (EM) and TUNEL assay. Simvastatin aided locomotor functional recovery and enhanced the threshold of pain after the CEC. Cellular Infiltration and demyelination decreased in the spinal cord from the simvastatin group. EM revealed enhanced myelination of cauda equina in the simvastatin group. TUNEL assay showed significantly decreased number of apoptotic neurons in spinal cord from the simvastatin group compared to the vehicle group. Simvastatin hastens the locomotor functional recovery and reduces pain after CEC. These outcomes are mediated through the neuroprotective and anti-inflammatory properties of simvastatin. The data indicate that simvastatin may be a promising drug candidate for LSS treatment in humans.
Shunmugavel, Anandakumar; Martin, Marcus M.; Khan, Mushfiquddin; Copay, Anne G.; Subach, Brian R.; Schuler, Thomas C.
Lumbar spinal stenosis (LSS) is the leading cause of morbidity and mortality worldwide. LSS pathology is associated with secondary injury caused by inflammation, oxidative damage and cell death. Apart from laminectomy, pharmacological therapy targeting secondary injury is limited. Statins are FDA-approved cholesterol-lowering drug. They also show pleiotropic anti-inflammatory, antioxidant and neuroprotective effects. To investigate the therapeutic efficacy of simvastatin in restoring normal locomotor function after cauda equina compression (CEC) in a rat model of LSS, CEC injury was induced in rats by implanting silicone gels into the epidural spaces of L4 and L6. Experimental group was treated with simvastatin (5 mg/kg body weight), while the injured (vehicle) and sham operated (sham) groups received vehicle solution. Locomotor function in terms of latency on rotarod was measured for 49 days and the threshold of pain was determined for 14 days. Rats were sacrificed on day 3 and 14 and the spinal cord and cauda equina fibers were extracted and studied by histology, immunofluorescence, electron microscopy (EM) and TUNEL assay. Simvastatin aided locomotor functional recovery and enhanced the threshold of pain after the CEC. Cellular Infiltration and demyelination decreased in the spinal cord from the simvastatin group. EM revealed enhanced myelination of cauda equina in the simvastatin group. TUNEL assay showed significantly decreased number of apoptotic neurons in spinal cord from the simvastatin group compared to the vehicle group. Simvastatin hastens the locomotor functional recovery and reduces pain after CEC. These outcomes are mediated through the neuroprotective and anti-inflammatory properties of simvastatin. The data indicate that simvastatin may be a promising drug candidate for LSS treatment in humans. PMID:23188522
Shunmugavel, Anandakumar; Martin, Marcus M; Khan, Mushfiquddin; Copay, Anne G; Subach, Brian R; Schuler, Thomas C; Singh, Inderjit
Although epiduroscopy is one of the popular interventions for the management of lumbar spinal stenosis (LSS), only a part of these patients show improvement in pain and functional level. Consequently, the authors thought that holmium:YAG (Ho:YAG) laser can be a reasonable alternative as an adjunct of epiduroscopic procedure, but has not been thoroughly determined yet which influence is resulted by it. This study was conducted to evaluate and compare the efficacy of epiduroscopic neural decompression (END) and END with Ho:YAG laser (ELND) in patients with LSS. Forty-seven patients with LSS were enrolled, all of whom underwent END or ELND and were followed up for 2 years or more. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain and the Roland Morris Disability Questionnaire (RMDQ). Procedure-related complications, especially including laser-related complications, were also evaluated. The only laser-related complication that occurred was transient mild motor paralysis in one case (3.1 %). In the END group, clinical score is exhibiting V-shaped upward trend that ended after procedure with the almost similar score obtained with preoperative status. However, in the ELND group, it is exhibiting relatively consistent improvement after procedure. There was a statistically significant improvement in the VAS and RMDQ score after 6 months after ELND procedure compared with END procedure (p = 0.01, 0.03, respectively). ELND could produce significant improvement of low back pain (LBP) at the last follow-up time (p = 0.01), but radiating pain of leg could not be improved significantly (p = 0.09). In conclusion, the current study suggests that performing Ho:YAG laser ablation concurrently with END could produce more decreased intensity of pain and prolonged effect of pain relief compared with END in LSS patients. LSS patients with LBP would be an ideal candidate for ELND, but radiating pain of LSS might not be managed effectively with ELND. PMID:24398702
Lee, Gun Woo; Jang, Soo-Jin; Kim, Jae-Do
Purpose To assess the safety and effectiveness of a novel, minimally invasive interspinous spacer in patients with moderate lumbar spinal stenosis (LSS). Methods A total of 53 patients (mean age, 70 ± 11 years; 45% female) with intermittent neurogenic claudication secondary to moderate LSS, confirmed on imaging studies, were treated with the Superion® Interspinous Spacer (VertiFlex, Inc, San Clemente, CA) and returned for follow-up visits at 6 weeks, 1 year, and 2 years. Study endpoints included axial and extremity pain severity with an 11-point numeric scale, Zurich Claudication Questionnaire (ZCQ), back function with the Oswestry Disability Index (ODI), health-related quality of life with the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-12, and adverse events. Results Axial and extremity pain each decreased 54% (both P < 0.001) over the 2-year follow-up period. ZCQ symptom severity scores improved 43% (P < 0.001) and ZCQ physical function improved 44% (P < 0.001) from pre-treatment to 2 years post-treatment. A statistically significant 50% improvement (P < 0.001) also was noted in back function. PCS and MCS each improved 40% (both P < 0.001) from pre-treatment to 2 years. Clinical success rates at 2 years were 83%–89% for ZCQ subscores, 75% for ODI, 78% for PCS, and 80% for MCS. No device infection, implant breakage, migration, or pull-out was observed, although two (3.8%) patients underwent explant with subsequent laminectomy. Conclusion Moderate LSS can be effectively treated with a minimally invasive interspinous spacer. This device is appropriate for select patients who have failed nonoperative treatment measures for LSS and meet strict anatomical criteria.
Shabat, Shay; Miller, Larry E; Block, Jon E; Gepstein, Reuven
Study Design Prospective cohort study. Purpose To assess whether additional implantation of Coflex following spinal decompression provided better clinical outcomes compared to decompression alone for symptomatic lumbar spinal stenosis (LSS) and to determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied. Overview of Literature Literature on benefits of additional Coflex implantation compared to decompression alone for symptomatic LSS is limited. Methods Patients with symptomatic LSS who met the study criteria were offered spinal decompression with Coflex implantation. Those patients who accepted Coflex implantation were placed in the Coflex group (n=22); while those opting for decompression alone, were placed in the comparison group (n=24). Clinical outcomes were assessed preoperatively, six-months, one-year and two-years postoperatively, using the Oswestry disability index, 100 mm visual analogue scale (VAS)-back pain and VAS-leg pain, and short form-36 (SF-36). Radiological indices (disc height, foraminal height and sagittal angle) were assessed preoperatively, six months, one year, and two years postoperatively. Results Both groups showed statistically significant (p<0.001) improvement in all the clinical outcome indicators at all points in time as compared to the preoperative status. However, improvement in the Coflex group was significantly greater (p<0.001) than the comparison group. Changes in the radiological indices did not correlate significantly with the improvement in clinical outcome indicators. Conclusions Additional Coflex implantation after spinal decompression in symptomatic LSS offers better clinical outcomes than decompression alone in the short-term. Changes in radiological indices do not correlate with the improvements in clinical outcomes after surgery for symptomatic LSS.
Shah, Siddarth M; Ng, Yau Hong; Pannierselvam, Vinodh Kumar; DasDe, Sudeep; Shen, Liang
Background To evaluate the clinical significance of lateral lumbar spinal canal stenosis (LLSCS), found by magnetic resonance imaging (MRI), through correlating the imaging findings with patient symptoms, walking capacity and electromyography (EMG) measurements. Method 102 patients with symptoms of LSS referred for operative treatment were studied in this uncontrolled study. Of these patients, subjects with distinct only lateral LSS were included. Accordingly, 140 roots in 14 patients (mean age 58, range 48-76 years, male 43%) were evaluated. In MR images the entrance and mid zones of the lateral lumbar nerve root canal were graded as normal, narrowed but not compressed, or compressed. In quantitative analysis, the minimal widths of the lateral recess and mid zone area were measured. Clinical symptoms were recorded with the Oswestry Disability Index (ODI), overall Visual Analogue Scale (VAS), specific low back pain (LBP; NRS-11), specific leg pain (LP NRS-11), Beck Depression Inventory (BDI) and walking distance in the treadmill test. Lumbar paraspinal (L2- L5) and lower limb (L3 – S1) needle EMG studies were performed. The findings were classified root by root as 1 = normal, 2 = abnormal. The associations between radiological, EMG and clinical findings were tested with each other. Results EMG findings were normal in 92 roots and abnormal in 48 roots. All of the patients had at least one abnormal nerve root finding. Severity of the mid zone stenosis in MRI correlated with abnormal EMG findings (p = 0.015). Patients with abnormal EMG had also higher scores in the VAS (41.9 ± 25.7 vs 31.5 ± 18.1; p = 0.018), NRS leg pain (7.5 ± 1.5 vs 6.3 ± 2.1; p = 0.000) and BDI (9.8 ± 3.8 vs 8.0 ± 3.9; p = 0.014). However, no statistically significant correlations between MRI findings and clinical symptoms or walking capacity were found. Conclusions Among persons previously selected for surgery, lateral stenosis seen on MRI correlates with EMG, and thus may be a clinically significant finding. Our EMG findings were also associated with patient symptoms. However, no relationships between the MRI findings and symptoms or walking capacity were found, suggesting their multifactorial etiology.
The SNAP trial: a double blind multi-center randomized controlled trial of a silicon nitride versus a PEEK cage in transforaminal lumbar interbody fusion in patients with symptomatic degenerative lumbar disc disorders: study protocol
Background Polyetheretherketone (PEEK) cages have been widely used in the treatment of lumbar degenerative disc disorders, and show good clinical results. Still, complications such as subsidence and migration of the cage are frequently seen. A lack of osteointegration and fibrous tissues surrounding PEEK cages are held responsible. Ceramic implants made of silicon nitride show better biocompatible and osteoconductive qualities, and therefore are expected to lower complication rates and allow for better fusion. Purpose of this study is to show that fusion with the silicon nitride cage produces non-inferior results in outcome of the Roland Morris Disability Questionnaire at all follow-up time points as compared to the same procedure with PEEK cages. Methods/Design This study is designed as a double blind multi-center randomized controlled trial with repeated measures analysis. 100 patients (18–75 years) presenting with symptomatic lumbar degenerative disorders unresponsive to at least 6 months of conservative treatment are included. Patients will be randomly assigned to a PEEK cage or a silicon nitride cage, and will undergo a transforaminal lumbar interbody fusion with pedicle screw fixation. Primary outcome measure is the functional improvement measured by the Roland Morris Disability Questionnaire. Secondary outcome parameters are the VAS leg, VAS back, SF-36, Likert scale, neurological outcome and radiographic assessment of fusion. After 1 year the fusion rate will be measured by radiograms and CT. Follow-up will be continued for 2 years. Patients and clinical observers who will perform the follow-up visits will be blinded for type of cage used during follow-up. Analyses of radiograms and CT will be performed independently by two experienced radiologists. Discussion In this study a PEEK cage will be compared with a silicon nitride cage in the treatment of symptomatic degenerative lumbar disc disorders. To our knowledge, this is the first randomized controlled trial in which the silicon nitride cage is compared with the PEEK cage in patients with symptomatic degenerative lumbar disc disorders. Trial registration NCT01557829
Interspinous spacers have recently been used in the treatment of lumbar spinal stenosis. In vitro studies have demonstrated a reduction in facet joint forces by 68% and annulus pressures by 63%. MRI studies have demonstrated increased canal and neural foraminal area after implantation of these devices. Previous studies by Zucherman et al. (Spine 30:1351-1358, 2005) demonstrated patient satisfaction rates of 71-73%.We carried out a multicentric retrospective study to assess the clinical outcomes following percutaneous posterior decompression using an interspinous spacer device (Aperius™-PercLID™ System; Kyphon-Medtronic). A total of 70 patients were included in the study. All of them had evidence of radiologically and clinically proven lumbar stenosis. The average age was 63.5 years. Patients completed the Zurich Claudication Questionnaire (ZCQ) and recorded pain levels on a Visual Analogue Scale (VAS). Average stay in hospital was 2 days. The average improvement in ZCQ included both symptomatic pain disappearance and functional ambulatory recovery. The average VAS pain score improved from 8.2 to 3.6 (scale of 1 to 10). The overall patient satisfaction rate was 76%. No complications were detected at 6 months' follow-up. PMID:21107956
Menchetti, P P M; Postacchini, F; Bini, W; Canero, G
The aim of this study was to investigate the effect of individual pain sensitivity on the results of transforaminal epidural steroid injection (TFESI) for the patients with lumbar spinal stenosis (LSS). Seventy-seven patients with LSS were included in this study. Prospectively planned evaluations were performed twice consecutively before and 2 months after TFESI. These included a detailed medical history, a physical examination, and completion of a series of questionnaires, including pain sensitivity questionnaire (PSQ), Oswestry disability index (ODI), and visual analog scale (VAS) for back and leg pain. The correlations were analyzed among variables between total PSQ/PSQ-moderate/PSQ-minor and pain and disability level measured by VAS for back/leg pain and ODI both before and 2 months after TFESI. Two months after TFESI, there were significant decreases in VAS for back/leg pain and ODI compared with those before injection. Before injection, VAS for back pain and leg pain was highly associated with the PSQ scores including total PSQ and PSQ subscores after adjustment for age, BMI, and grade of canal stenosis. However, any subscores of PSQ and total PSQ scores were not correlated with either VAS for back pain/leg pain or ODI 2 months after TFESI with adjustment made to age, BMI, gender, and grade of canal stenosis. This study highlights that individual pain sensitivity does not influence the outcomes of TFESI treatment in patients with LSS, even though pain sensitivity has a significant negative correlation with symptom severity of LSS. PMID:23734752
Kim, Ho-Joong; Yeom, Jin S; Lee, Joon Woo; Chang, Bong-Soon; Lee, Choon-Ki; Lee, Gun-Woo; Im, Seung-Bin; Kim, Han Jo
Summary This paper is dealing with a comparative study of clinico-surgical findings and cortical somatosensory evoked potentials (CSEP's) recordings after stimulation of the right and left common peroneal nerve behind the fibula head, in twenty five patients suffering from lumbar spinal stenosis and disc prolapse.
Ph. Tsitsopoulos; F. Fotiou; D. Papakostopoulos; C. Sitzoglou; G. Tavridis
The medical literature continues to fail to support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. There is limited support for the use of lumbar epidural injections for shortterm relief in selected patients with chronic back pain. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3-6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. There is insufficient evidence to support or refute the use of trigger point injections for chronic lowerback pain without radiculopathy. PMID:24980590
Watters, William C; Resnick, Daniel K; Eck, Jason C; Ghogawala, Zoher; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Sharan, Alok; Groff, Michael W; Wang, Jeffrey C; Dhall, Sanjay S; Kaiser, Michael G
Study Design As-treated analysis of the Spine Patient Outcomes Research Trial (SPORT). Objective To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e. leg vs. back). Summary of Background Data Evidence suggests that degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP). Methods The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant or having equal pain according to baseline pain scores. Baseline characteristics were compared between the three predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared through two years. Longitudinal regression models including baseline covariates were used to control for confounders. Results Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at one and two years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent. Conclusions Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.
Pearson, Adam; Blood, Emily; Lurie, Jon; Abdu, William; Sengupta, Dilip; Frymoyer, John W.; Weinstein, James
Although partial or complete cauda equina compromise due to lumbar stenosis is a recognized entity, cauda equina compromise due to sacral stenosis is extremely uncommon. We present a patient with a three-week history of right thigh and buttock pain who developed right scrotal and buttock numbness, urinary retention, and difficulty with bowel evacuation. The patient had diminished sensation to right buttock and anus pinprick with decreased anal sphincter tone and absent bulbocavernosus reflex. Lumbosacral spine films revealed only minimal degenerative changes, while lumbar myelogram showed L4-L5 and L5-S1 ventral extradural defects. Only a drop of pantopaque descended caudally below the level of the L5-S1 interspace. Operatively, significant stenosis and thickening of the posterior sacrum with compromise of the lower sacral nerve roots was noted. Bilateral sacral laminectomy was performed and the symptoms resolved postoperatively. This case illustrates an unusual clinical entity: partial cauda equina compromise due to sacral stenosis. PMID:4074117
Buszek, M C; Ellenberg, M; Friedman, P
The aim of this study was to evaluate the usefulness of three-dimensional (3D) fast imaging employing steady-state acquisition (3D FIESTA) in the diagnosis of lumbar foraminal stenosis (LFS). Fifteen patients with LFS and 10 healthy volunteers were studied. All patients met the following criteria: (1) single L5 radiculopathy without compressive lesion in the spinal canal, (2) pain reproduction during provocative radiculography, and (3) improvement of symptoms after surgery. We retrospectively compared the symptomatic nerve roots to the asymptomatic nerve roots on fast spin-echo (FSE) T1 sagittal, FSE T2 axial and reconstituted 3D FIESTA images. The ? values for interobserver agreement in determining the presence of LFS were 0.525 for FSE T1 sagittal images, 0.735 for FSE T2 axial images, 0.750 for 3D FIESTA sagittal, 0.733 for axial images, and 0.953 for coronal images. The sensitivities and specificities were 60 and 86 % for FSE T1 sagittal images, 27 and 91 % for FSE T2 axial images, 60 and 97 % for 3D FIESTA sagittal images, 60 and 94 % for 3D FIESTA axial images, and 100 and 97 % for 3D FIESTA coronal images, respectively. 3D FIESTA can provide more reliable and additional information for the running course of lumbar nerve root, compared with conventional magnetic resonance imaging. Particularly, use of 3D FIESTA coronal images enables accurate diagnosis for LFS. PMID:24292491
Nemoto, Osamu; Fujikawa, Akira; Tachibana, Atsuko
Hypertrophy of ligamentum flavum (LF) contributes to lumbar spinal stenosis (LSS) and is caused mainly by fibrosis. Recent data indicate that miR-155 plays a crucial role in the pathogenesis of different fibrotic diseases. This study aimed to test the hypothesis that miR-155 exerts effects on LF thickness by regulating collagen expression. We found that LF thickness and the expression of collagen I and, collagen III were higher in LF from LSS patients than in LF from lumbar disc herniation (LDH) patients (P < 0.01). The expression of miR-155 was significantly higher in LF from LSS group than in LF from LDH group (P < 0.01). miR-155 level was positively correlated with LF thickness (r = 0.958, P < 0.01), type I collagen level (r = 0.825, P < 0.01), and type III collagen level (r = 0.827, P < 0.01). miR-155 mimic increased mRNA and protein expression of collagen I and collagen III in fibroblasts isolated from LF, while miR-155 sponge decreased mRNA and protein expression of collagen I and III in fibroblasts. In conclusions, miR-155 is a fibrosis-associated miRNA and may play important role in the pathogenesis of LF hypertrophy.
Chen, Jianwei; Liu, Zude; Zhong, Guibin; Qian, Lie; Li, Zhanchun; Qiao, Zhiguang; Chen, Bin; Wang, Hantao
Objective We compared the results of two surgical techniques by retrospective study of 60 elderly patients (65 years or older) who underwent either decompression alone or fusion for the treatment of two-level or more lumbar spinal stenosis. Methods During the period of 2003 and 2008, two-level or more decompression alone or fusion was performed for lumbar spinal stenosis by three surgeons at our institution. Patients were allocated to two groups by surgical modality, namely, to a decompression group (31 patients) or a fusion group (29 patients). Overall mean age was 71.1 years (range, 65-84) and mean follow-up was 5.5 years (range, 3-9). A retrospective review of clinical, radiological, and surgical data was conducted. Results No significant difference between the two groups was found with respect to age, follow-up period, surgical levels, or preoperative condition. At the last follow-up, correction of lumbar lordotic angle (determined radiologically) was better in the fusion group. However, clinical outcomes including visual analogue scale, Oswestry Disability Index, and the Odom's criteria were not significantly different in the two groups. On the other hand, surgical outcomes, such as, operation time, estimated blood loss, and surgical complications were significantly better in the decompression alone group. Conclusion Our findings suggest that decompressive laminectomy alone achieves good outcomes in patients with two-level or more lumbar spinal stenosis, associated with an advanced age, poor general condition, or osteoporosis.
Son, Seong; Lee, Sang Gu; Park, Chan Woo; Lee, Keun
Descriptive Epidemiology and Prior Healthcare Utilization of Patients in the Spine Patient Outcomes Research Trial's (SPORT) Three Observational Cohorts: Disc Herniation, Spinal Stenosis and Degenerative Spondylolisthesis
Study Design Prospective Observational Cohorts Objective To describe sociodemographic and clinical features, and non-operative (medical) resource utilization prior to enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria. Summary of Background Data Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses. Methods The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and non-surgical treatments for patients with IDH, SPS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represents all 1,417 patients (745 IDH, 368 SpS, 304 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms. Results The average age was 41 years for the IDH group, 64 years for the SPS group, and 66 years for the DS group. At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.2 vs 33 SPS and 33.7 DS) and were the most impaired (ODI 51 vs 42.3 SPS and 41.5 DS). IDH patients utilized more chiropractic treatment (42% vs 33% SPS and 26% DS); had more Emergency Department (ED) visits (21% vs 7 % SPS and 4% DS); and used more opiate analgesics (50% vs 29% SPS and 28% DS). After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared to other insurance types. (31% Medicaid vs 22% no insurance, 16% employer, 3% Medicare, and 11% private). Conclusion IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared to the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.
Cummins, Justin; Lurie, Jon D.; Tosteson, Tor; Hanscom, Brett; Abdu, William A.; Birkmeyer, Nancy J. O.; Herkowitz, Harry; Weinstein, James
Study Design Retrospective study. Purpose The aims of the current study are to evaluate the minimum 10-year follow-up clinical results of anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. Overview of Literature ALIF has been widely used as a treatment regimen in the management of lumbar spondylolisthesis. Still much controversy exists regarding the factors that affect the postoperative clinical outcomes. Methods The author performed a retrospective review of 20 patients with degenerative spondylolisthesis treated with ALIF (follow-up, 16.4 years). The clinical results were assessed by the Japanese Orthopaedic Association (JOA) score for low back pain, vertebral slip and disc height index on the radiographs. Results The mean preoperative JOA score was 7.1 ± 1.8 points (15-point-method). At 1 year, 5 years, and 10 years or more after surgery, the JOA scores were assessed as 12.4 ± 2.2 points, 12.7 ± 2.6 points, 12.0 ± 2.5 points, respectively (excluding the data of reoperated cases). The adjacent disc degeneration developed in all cases during the long-term follow-up. The progressive pattern of disc degeneration was divided into three types. Initially, disc degeneration occurred due to disc space narrowing. After that, the intervertebral discs showed segmental instability with translation at the upper level. But the lower discs showed osteophyte formation, and occasionally lead to the collapse or spontaneous union. Conclusions The clinical results of the long-term follow-up data after ALIF became worse due to the adjacent disc degeneration. The progressive pattern of disc degeneration was different according to the adjacent levels.
Yasuda, Taketoshi; Hori, Takeshi; Suzuki, Kayo; Kawaguchi, Yoshiharu
Background Transforaminal lumbar interbody fusion (TLIF) is the standard surgical treatment for patients with lumbar degenerative spondylolisthesis who do not respond to a 6-week course of conservative therapy. A number of morbidities are associated with the conventional open-TLIF method, so minimally invasive surgery (MIS) techniques for TLIF (MIS-TLIF) have been introduced to reduce the trauma to paraspinal muscles and hasten postoperative recovery. Because providing cost-effective medical treatment is a core initiative of healthcare reforms, a comparison of open-TLIF and MIS-TLIF must include a cost-utility analysis in addition to an analysis of clinical effectiveness. Methods We compared patient-reported clinical functional outcomes and hospital direct costs in age-matched patients treated surgically with either open-TLIF or MIS-TLIF. Patients were followed for at least 1 year, and patient scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) were analyzed at 6 weeks, 6 months, and ?1 year postoperatively in the 2 treatment groups. Results Compared to their preoperative scores, patients in both the open-TLIF and MIS-TLIF groups had significant improvements in the ODI and VAS scores at each follow-up point, but no significant difference in functional outcome occurred between the open-TLIF and MIS-TLIF groups (P=0.46). However, open-TLIF is significantly more costly compared to MIS-TLIF (P=0.0002). Conclusion MIS-TLIF is a more cost-effective treatment than open-TLIF for patients with degenerative spondylolisthesis and is equally effective as the conventional open-TLIF procedure, although further financial analysis—including an analysis of indirect costs—is needed to better understand the full benefit of MIS-TLIF.
Sulaiman, Wale A. R.; Singh, Manish
Identifying the etiology of pain for patients suffering from chronic low-back pain remains problematic. Noninvasive imaging modalities, used in isolation, have not consistently provided sufficient evidence to support performance of a lumbar fusion. Provocative testing has been used as an adjunct in this assessment, either alone or in combination with other modalities, to enhance the diagnostic capabilities when evaluating patients with low-back pain. There have been a limited number of studies investigating this topic since the publication of the original guidelines. Based primarily on retrospective studies, discography, as a stand-alone test, is not recommended to formulate treatment strategies for patients with low-back pain. A single randomized cohort study demonstrated an improved potential of discoblock over discography as a predictor of success following lumbar fusion. It is therefore recommended that discoblock be considered as a diagnostic option. There is a possibility, based on a matched cohort study, that an association exists between progression of degenerative disc disease and the performance of a provocative discogram. It is therefore recommended that patients be counseled regarding this potential development prior to undergoing discography. PMID:24980583
Eck, Jason C; Sharan, Alok; Resnick, Daniel K; Watters, William C; Ghogawala, Zoher; Dailey, Andrew T; Mummaneni, Praveen V; Groff, Michael W; Wang, Jeffrey C; Choudhri, Tanvir F; Dhall, Sanjay S; Kaiser, Michael G
Intraoperative monitoring (IOM) is commonly used during lumbar fusion surgery for the prevention of nerve root injury. Justification for its use stems from the belief that IOM can prevent nerve root injury during the placement of pedicle screws. A thorough literature review was conducted to determine if the use of IOM could prevent nerve root injury during the placement of instrumentation in lumbar or lumbosacral fusion. There is no evidence to date that IOM can prevent injury to the nerve roots. There is limited evidence that a threshold below 5 mA from direct stimulation of the screw can indicate a medial pedicle breach by the screw. Unfortunately, once a nerve root injury has taken place, changing the direction of the screw does not alter the outcome. The recommendations formulated in the original guideline effort are neither supported nor refuted with the evidence obtained with the current studies. PMID:24980592
Sharan, Alok; Groff, Michael W; Dailey, Andrew T; Ghogawala, Zoher; Resnick, Daniel K; Watters, William C; Mummaneni, Praveen V; Choudhri, Tanvir F; Eck, Jason C; Wang, Jeffrey C; Dhall, Sanjay S; Kaiser, Michael G
Background. We conducted a pilot study to investigate the value of an Iso-C3D imaging system in determining the extent of decompression of lumbar spinal stenosis during surgery. We now address the question whether this imaging has become a routine tool. Material and Methods. Ten patients who underwent unilateral decompression for lumbar spinal stenosis were intraoperatively examined using the Iso-C3D imaging system. Four years after this study, we investigated whether this intraoperative imaging modality is still being used. Results. Evaluable images were intraoperatively obtained for all patients. In two cases, the surgical procedure was changed on the basis of the images. Myelography did not provide any additional information. In the four years following the study, this intraoperative imaging technique has not been used again. Conclusion. Intraoperative imaging using the Iso-C3D system provides additional safety. It, however, has not become established as a routine procedure.
Mauer, Uwe Max; Kunz, Ulrich; Schulz, Chris
Object The purpose of this study was to quantify the perioperative outcomes, complications, and costs associated with posterolateral spinal fusion (PSF) among Medicare enrollees with lumbar spinal stenosis (LSS) and/or spondylolisthesis by using a national Medicare claims database. Methods A 5% systematic sample of Medicare claims data (2005-2009) was used to identify outcomes in patients who had undergone PSF for a diagnosis of LSS and/or spondylolisthesis. Patients eligible for study inclusion also required a minimum of 2 years of follow-up and a claim history of at least 12 months prior to surgery. Results A final cohort of 1672 patients was eligible for analysis. Approximately half (50.7%) had LSS only, 10.2% had spondylolisthesis only, and 39.1% had both LSS and spondylolisthesis. The average age was 71.4 years, and the average length of stay was 4.6 days. At 3 months and 1 and 2 years postoperatively, the incidence of spine reoperation was 10.9%, 13.3%, and 16.9%, respectively, whereas readmissions for complications occurred in 11.1%, 17.5%, and 24.9% of cases, respectively. At 2 years postoperatively, 36.2% of patients had either undergone spine reoperation and/or received an epidural injection. The average Medicare payment was $36,230 ± $17,020, $46,840 ± $31,350, and $61,610 ± $46,580 at 3 months, 1 year, and 2 years after surgery, respectively. Conclusions The data showed that 1 in 6 elderly patients treated with PSF for LSS or spondylolisthesis underwent reoperation on the spine within 2 years of surgery, and nearly 1 in 4 patients was readmitted for a surgery-related complication. These data highlight several potential areas in which improvements may be made in the effective delivery and cost of surgical care for patients with spinal stenosis and spondylolisthesis. PMID:24881637
Ong, Kevin L; Auerbach, Joshua D; Lau, Edmund; Schmier, Jordana; Ochoa, Jorge A
In summary, there is no meaningful evidence in the medical literature that the use of epidural injections is of any long-term value in the treatment of patients with chronic low-back pain. The literature does indicate that the use of lumbar epidural injections can provide short-term relief in selected patients with chronic low-back pain. There is evidence that suggests that facet joint injections can be used to predict outcome after RF ablation of a facet joint. The predictive ability of facet joint injections does not appear to apply to lumbar fusion surgery. No evidence exists to support the effectiveness of facet injections in the treatment of patients with chronic low-back pain. There is conflicting evidence suggesting that the use of local TPIs can be effective for the short-term relief of low-back pain. There are no data to suggest that TPIs with either steroids or anesthetics alone provide lasting benefit for patients suffering from chronic low-back pain. PMID:16028741
Resnick, Daniel K; Choudhri, Tanvir F; Dailey, Andrew T; Groff, Michael W; Khoo, Larry; Matz, Paul G; Mummaneni, Praveen; Watters, William C; Wang, Jeffrey; Walters, Beverly C; Hadley, Mark N
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs. PMID:24980593
Kaiser, Michael G; Groff, Michael W; Watters, William C; Ghogawala, Zoher; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Eck, Jason C; Sharan, Alok; Wang, Jeffrey C; Dhall, Sanjay S; Resnick, Daniel K
The objective of the study was to examine self-reported life satisfaction and associated factors in patients (n=100) with lumbar spinal stenosis (LSS) in secondary care level, selected for surgical treatment. Life satisfaction was assessed with the four-item Life Satisfaction scale. Depression was assessed with a 21-item Beck Depression Inventory (BDI). Psychological well-being was assessed with Toronto Alexithymia Scale and Sense of Coherence Scale. LSS related physical functioning and pain were assessed with Oswestry disability index, Stucki questionnaire, Visual Analogue Scale and pain drawings. All questionnaires were administered before surgical treatment of LSS. Results showed that 25% of the patients with LSS were found to be dissatisfied with life. In a univariate analysis, smoking, elevated subjective disability scores and extensive markings in the pain drawings were more common in the dissatisfied patients. The dissatisfied patients also showed lower coping resources, elevated alexithymia and depression scores, and were more often depressed. In multiple logistic regression analyses, only younger age and somatic comorbidity were associated with life dissatisfaction. This association remained significant even when the BDI score was added into the model. No other significant associations emerged. In conclusion, life dissatisfaction was rather common among preoperative LSS patients. Pain and constraints on everyday functioning were important correlates of life dissatisfaction. However, only younger age and somatic comorbidity were independently associated with life dissatisfaction. These results emphasize the importance of recognizing and assessing the effect of coexisting medical conditions and they need to be addressed in any treatment program.
Aalto, Timo; Airaksinen, Olavi; Herno, Arto; Kroger, Heikki; Savolainen, Sakari; Turunen, Veli; Viinamaki, Heimo
Auto-stabilization consequent to spinal segment instability involves osteophyte formation. The most common lumbar spinal stenoses are due to uncinate process spurs at L 5. These spurs inaccessibly lie ventral to the facet joints. Most surgical methods for lateral stenotic lesions do not address the incipient instability. Facet destructive approaches further destabilize the segment. The new decompressive technique here preserves and stabilizes posterior supporting structures: ligaments are left intact; laminas (and facets) are distracted; 11 mm transfacet holes are bored, exactly dorsal to both the spurs and entrapped ganglia; the entrapment (even a lateral herniated disc) is decompressed through the drilled hole. 12 mm bone dowels are then driven into the holes, immediately stabilizing the segment. The dura is not exposed. Reviewed are fifty transfacet cases. In four, a posterior interbody fusion was performed via the transfacet holes. The procedure presents a new window to spinal lesions. PMID:3063077
Ray, C D
Purpose To examine the effects of conservative and surgical treatments for nocturnal leg cramps in patients with lumbar spinal stenosis (LSS). Nocturnal leg cramps is frequently observed in patients with peripheral neuropathy. However, there have been few reports on the relationship between nocturnal leg cramps and LSS, and it remains unknown whether conservative or surgical intervention has an impact on leg cramps in patients with LSS. Materials and Methods The subjects were 130 LSS patients with low back and leg pain. Conservative treatment such as exercise, medication, and epidural block was used in 66 patients and surgical treatment such as decompression or decompression and fusion was performed in 64 patients. Pain scores and frequency of nocturnal leg cramps were evaluated based on self-reported questionnaires completed before and 3 months after treatment. Results The severity of low back and leg pain was higher and the incidence of nocturnal leg cramps was significantly higher before treatment in the surgically treated group compared with the conservatively treated group. Pain scores improved in both groups after the intervention. The incidence of nocturnal leg cramps was significantly improved by surgical treatment (p=0.027), but not by conservative treatment (p=0.122). Conclusion The findings of this prospective study indicate that the prevalence of nocturnal leg cramps is associated with LSS and severity of symptoms. Pain symptoms were improved by conservative or surgical treatment, but only surgery improved nocturnal leg cramps in patients with LSS. Thus, these results indicate that the prevalence of nocturnal leg cramps is associated with spinal nerve compression by LSS.
Yamashita, Masaomi; Murata, Yasuaki; Eguchi, Yawara; Aoki, Yasuchika; Ataka, Hiromi; Hirayama, Jiro; Ozawa, Tomoyuki; Morinaga, Tatsuo; Arai, Hajime; Mimura, Masaya; Kamoda, Hiroto; Orita, Sumihisa; Miyagi, Masayuki; Miyashita, Tomohiro; Okamoto, Yuzuru; Ishikawa, Tetsuhiro; Sameda, Hiroaki; Kinoshita, Tomoaki; Hanaoka, Eiji; Suzuki, Miyako; Suzuki, Munetaka; Aihara, Takato; Ito, Toshinori; Inoue, Gen; Yamagata, Masatsune; Toyone, Tomoaki; Kubota, Gou; Sakuma, Yoshihiro; Oikawa, Yasuhiro; Inage, Kazuhide; Sainoh, Takeshi; Sato, Jun; Yamauchi, Kazuyo; Takahashi, Kazuhisa
A prospective, randomized, controlled trial was conducted to compare clinical outcomes in patients treated with an investigational interspinous spacer (Superion) versus those treated with an FDA-approved spacer (X-STOP). One hundred sixty-six patients with moderate lumbar spinal stenosis (LSS) unresponsive to conservative care were treated randomly with the Superion (n = 80) or X-STOP (n = 86) interspinous spacer. Study subjects were followed through 6 months posttreatment. Zurich Claudication Questionnaire (ZCQ) symptom severity scores improved 30% with Superion and 25% with X-STOP (both P < 0.001). Similar changes were noted in ZCQ physical function with improvements of 32% with Superion and 27% with X-STOP (both P < 0.001). Mean ZCQ patient satisfaction score ranged from 1.7 to 2.0 in both groups at all follow-up visits. The proportion of subjects that achieved at least two of three ZCQ clinical success criteria at 6 months was 75% with Superion and 67% with X-STOP. Axial pain decreased from 55 ± 27?mm at pretreatment to 22 ± 26?mm at 6 months in the Superion group (P < 0.001) and from 54 ± 29?mm to 32 ± 31?mm with X-STOP (P < 0.001). Extremity pain decreased from 61 ± 26?mm at pretreatment to 18 ± 27?mm at 6 months in the Superion group (P < 0.001) and from 64 ± 26?mm to 22 ± 30?mm with X-STOP (P < 0.001). Back function improved from 38 ± 13% to 21 ± 19% with Superion (P < 0.001) and from 40 ± 13% to 25 ± 16% with X-STOP (P < 0.001). Preliminary results suggest that the Superion interspinous spacer and the X-STOP each effectively alleviate pain and improve back function in patients with moderate LSS who are unresponsive to conservative care.
Miller, Larry E.; Block, Jon E.
A prospective, randomized, controlled trial was conducted to compare clinical outcomes in patients treated with an investigational interspinous spacer (Superion) versus those treated with an FDA-approved spacer (X-STOP). One hundred sixty-six patients with moderate lumbar spinal stenosis (LSS) unresponsive to conservative care were treated randomly with the Superion (n = 80) or X-STOP (n = 86) interspinous spacer. Study subjects were followed through 6 months posttreatment. Zurich Claudication Questionnaire (ZCQ) symptom severity scores improved 30% with Superion and 25% with X-STOP (both P < 0.001). Similar changes were noted in ZCQ physical function with improvements of 32% with Superion and 27% with X-STOP (both P < 0.001). Mean ZCQ patient satisfaction score ranged from 1.7 to 2.0 in both groups at all follow-up visits. The proportion of subjects that achieved at least two of three ZCQ clinical success criteria at 6 months was 75% with Superion and 67% with X-STOP. Axial pain decreased from 55 ± 27?mm at pretreatment to 22 ± 26?mm at 6 months in the Superion group (P < 0.001) and from 54 ± 29?mm to 32 ± 31?mm with X-STOP (P < 0.001). Extremity pain decreased from 61 ± 26?mm at pretreatment to 18 ± 27?mm at 6 months in the Superion group (P < 0.001) and from 64 ± 26?mm to 22 ± 30?mm with X-STOP (P < 0.001). Back function improved from 38 ± 13% to 21 ± 19% with Superion (P < 0.001) and from 40 ± 13% to 25 ± 16% with X-STOP (P < 0.001). Preliminary results suggest that the Superion interspinous spacer and the X-STOP each effectively alleviate pain and improve back function in patients with moderate LSS who are unresponsive to conservative care. PMID:22448323
Miller, Larry E; Block, Jon E
Object Recent years have been marked by efforts to improve the quality and safety of pedicle screw placement in spinal instrumentation. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement. Methods Ninety-five patients suffering from degenerative disease and requiring elective lumbar instrumentation were included in the study. The robot cohort (Group I; 55 patients, 244 screws) consisted of an initial open robot-assisted subgroup (Subgroup IA; 17 patients, 83 screws) and a percutaneous cohort (Subgroup IB, 38 patients, 161 screws). In these groups, pedicle screws were placed under robotic guidance and lateral fluoroscopic control. In the fluoroscopy-guided cohort (Group II; 40 patients, 163 screws) screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The primary outcome measure was accuracy of screw placement on the Gertzbein-Robbins scale (Grade A to E and R [revised]). Secondary parameters were duration of surgery, blood loss, cumulative morphine, and length of stay. Results In the robot group (Group I), a perfect trajectory (A) was observed in 204 screws (83.6%). The remaining screws were graded B (n = 19 [7.8%]), C (n = 9 [3.7%]), D (n = 4 [1.6%]), E (n = 2 [0.8%]), and R (n = 6 [2.5%]). In the fluoroscopy-guided group (Group II), a completely intrapedicular course graded A was found in 79.8% (n = 130). The remaining screws were graded B (n = 12 [7.4%]), C (n = 10 [6.1%]), D (n = 6 [3.7%]), and E (n = 5 [3.1%]). The comparison of "clinically acceptable" (that is, A and B screws) was neither different between groups (I vs II [p = 0.19]) nor subgroups (Subgroup IA vs IB [p = 0.81]; Subgroup IA vs Group II [p = 0.53]; Subgroup IB vs Group II [p = 0.20]). Blood loss was lower in the robot-assisted group than in the fluoroscopy-guided group, while duration of surgery, length of stay, and cumulative morphine dose were not statistically different. Conclusions Robot-guided pedicle screw placement is a safe and useful tool for assisting spine surgeons in degenerative spine cases. Nonetheless, technical difficulties remain and fluoroscopy backup is advocated. PMID:24725180
Schatlo, Bawarjan; Molliqaj, Granit; Cuvinciuc, Victor; Kotowski, Marc; Schaller, Karl; Tessitore, Enrico
Introduction. Degenerative lumbar spinal disorder is common in Japan, and the L5 nerve root is commonly involved in this disorder. The symptoms of L5 radiculopathy are irradiating lateral leg pain, and numbness and weakness of tibialis anterior and the hip abductor muscle. There has been only one report on the results of surgery for hip abductor muscle weakness caused by degenerative lumbar spinal disorder. Patients and methods. In this study, we analyzed the strength of the hip abductor muscle before and after decompressive surgery in 26 cases and the relationship between the lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LSCS) groups. Results. Of the total 26 cases, muscle strength improved in 23 cases (88%), with complete recovery in 17 cases (65%). In the LDH group, the improvement rate was 92%. In the LSCS group, the improvement rate was 68%. Although the improvement rate for the LDH group was higher than that for the LSCS group, the difference was not significant (P = 0.054). Discussion. Decompressive surgery may be an effective method to improve hip abductor muscle weakness in degenerative lumbar spinal disorder.
Horaguchi, Kiyoshi; Yamada, Noboru; Iwai, Kazuo
Background Dynamic interspinous spacers, such as X-stop, Coflex, DIAM, and Aperius, are widely used for the treatment of lumbar spinal stenosis. However, controversy remains as to whether dynamic interspinous spacer use is superior to traditional decompressive surgery. Methods Medline, Embase, Cochrane Library, and the Cochrane Controlled Trials Register were searched during August 2013. A track search was performed on February 27, 2014. Study was included in this review if it was: (1) a randomized controlled trial (RCT) or non-randomized prospective comparison study, (2) comparing the clinical outcomes for interspinous spacer use versus traditional decompressive surgery, (3) in a minimum of 30 patients, (4) with a follow-up duration of at least 12 months. Results Two RCTs and three non-randomized prospective studies were included, with 204 patients in the interspinous spacer (IS) group and 217 patients in the traditional decompressive surgery (TDS) group. Pooled analysis showed no significant difference between the IS and TDS groups for low back pain (WMD: 1.2; 95% CI: ?10.12, 12.53; P?=?0.03; I2?=?66%), leg pain (WMD: 7.12; 95% CI: ?3.88, 18.12; P?=?0.02; I2?=?70%), ODI (WMD: 6.88; 95% CI: ?14.92, 28.68; P?=?0.03; I2?=?79%), RDQ (WMD: ?1.30, 95% CI: ?3.07, 0.47; P?=?0.00; I2?=?0%), or complications (RR: 1.39; 95% CI: 0.61, 3.14; P?=?0.23; I2?=?28%). The TDS group had a significantly lower incidence of reoperation (RR: 3.34; 95% CI: 1.77, 6.31; P?=?0.60; I2?=?0%). Conclusion Although patients may obtain some benefits from interspinous spacers implanted through a minimally invasive technique, interspinous spacer use is associated with a higher incidence of reoperation and higher cost. The indications, risks, and benefits of using an interspinous process device should be carefully considered before surgery.
Wu, Ai-Min; Zhou, Yong; Li, Qing-Long; Wu, Xin-Lei; Jin, Yong-Long; Luo, Peng; Chi, Yong-Long; Wang, Xiang-Yang
Patients suffering from neurogenic intermittent claudication secondary to lumbar spinal stenosis have historically been limited to a choice between a decompressive laminectomy with or without fusion or a regimen of non-operative therapies. The X STOP Interspinous Process Distraction System (St. Francis Medical Technologies, Concord, Calif.), a new interspinous implant for patients whose symptoms are exacerbated in extension and relieved in flexion, has been available in Europe since June 2002. This study reports the results from a prospective, randomized trial of the X STOP conducted at nine centers in the U.S. Two hundred patients were enrolled in the study and 191 were treated; 100 received the X STOP and 91 received non-operative therapy (NON OP) as a control. The Zurich Claudication Questionnaire (ZCQ) was the primary outcomes measurement. Validated for lumbar spinal stenosis patients, the ZCQ measures physical function, symptom severity, and patient satisfaction. Patients completed the ZCQ upon enrollment and at follow-up periods of 6 weeks, 6 months, and 1 year. Using the ZCQ criteria, at 6 weeks the success rate was 52% for X STOP patients and 10% for NON OP patients. At 6 months, the success rates were 52 and 9%, respectively, and at 1 year, 59 and 12%. The results of this prospective study indicate that the X STOP offers a significant improvement over non-operative therapies at 1 year with a success rate comparable to published reports for decompressive laminectomy, but with considerably lower morbidity. PMID:14685830
Zucherman, J F; Hsu, K Y; Hartjen, C A; Mehalic, T F; Implicito, D A; Martin, M J; Johnson, D R; Skidmore, G A; Vessa, P P; Dwyer, J W; Puccio, S; Cauthen, J C; Ozuna, R M
Evaluación post-quirúrgica de la cirugía de estenosis lumbar degenerativa por método descompresivo selectivo Avaliação dos resultados do tratamento da estenose do canal lombar pela técnica da descompressão seletiva
Objective: The Senegas Recalibration Technique consists in a lumbar channel selective decompression conserving the estabilizated elements.The aim of this study was to present our experience in the treatment of the degenerative lumbar stenosis whith the Senegas technique. Methods: Thirth eight patients operated whit this technique whit a follow up of 53.92%(84-24) months were evaluated. Results: In percentual, 52.63 % of
Degenerative lumbar scoliosis is a coronal deviation of the spine that is prevalent in the elderly population. Although the\\u000a etiology is unclear, it is associated with progressive and asymmetric degeneration of the disc, facet joints, and other structural\\u000a spinal elements typically leading to neural element compression. Clinical presentation varies and is frequently associated\\u000a with axial back pain and neurogenic claudication.
Suhel Kotwal; Matthias Pumberger; Alex Hughes; Federico Girardi
BackgroundProsthetic replacement of spinal discs is emerging as a treatment option for degenerative disc disease. Posterior dynamic transpedicular stabilization (PDTS) and prosthetic disc nucleus (PDN) devices have been used sporadically in spinal surgery.
Mehdi Sasani; Ahmet Levent Aydin; Tunc Oktenoglu; Murat Cosar; Yaprak Ataker; Tuncay Kaner; Ali Fahir Ozer
Japan became a superaging society. We have been putting a new focus on locomotive syndrome and frailty. The prevention and treatment of locomotive syndromes, such as osteoarthritis, degenerative spondylosis, lumbar canal stenosis, osteoporosis, upper extremity diseases, rheumatoid arthritis, and many other disorders of the locomotive organs are important. Because, the locomotive syndrome results in deterioration of the exercise function and loss of mental and physical health. The aim of locomotive syndrome exercises are: to reduce pain, to restore and improve joint function. We need to take a comprehensive approach to locomotive syndrome, including lifestyle modification, muscle exercise, stretching and therapeutic exercise. PMID:22460511
X-STOP is the first interspinous process decompres- sion device that was shown to be superior to nonoperative therapy in patients with neurogenic intermittent claudication secondary to spinal stenosis in the multicenter randomized study at 1 and 2 years. We present 4-year follow-up data on the X-STOP patients. Patient records were screened to identify potentially eligible subjects who underwent X-STOP implanta-
Dimitriy G. Kondrashov; Matthew Hannibal; Ken Y. Hsu; James F. Zucherman
In order to satisfy the need of a tool for assessing the treatment of patients with degenerative lumbar spinal stenosis, an evaluation was made of the reliability, construct validity, and responsiveness of the Norwegian version of Spinal Stenosis Measure (SSM, original by Stucki)). This study was a part of a prospective, cohort study. About 75 patients referred for surgery for spinal stenosis participated in the study. A subsample of 30 patients answered the questionnaire twice, test and retest, with at least one week in between. The SSM was translated according to the Guillemin criteria. Reliability was assessed by Bland and Altman’s repeatability, intraclass correlation coefficient (ICC) and the coefficient of variance (CV). Internal consistency was assessed by Cronbach’s alpha. Construct validity was analysed by correlation analyses. Responsiveness was calculated by the effect size. The reliability between test and retest scores was good for all three subscales of SSM as the ICC-values were above 0.9 and the CVs were below 15%. Cronbach’s alpha was above 0.8. The correlation analyses showed high correlation between scales that assessed the same construct, and low to moderate correlation between scales that assessed different constructs. Large effect sizes were found in all the SSM subscales with effect sizes ?1.2.The Norwegian SSM version has added a highly useful tool for assessing the disease specific status and outcome after treatment in patients who suffer from degenerative lumbar spinal stenosis.
Objective To determine the relationship between whole body vibration (WBV) induced helicopter flights and degenerative changes of the cervical and lumbar spine. Methods We examined 186 helicopter pilots who were exposed to WBV and 94 military clerical workers at a military hospital. Questionnaires and interviews were completed for 164 of the 186 pilots (response rate, 88.2%) and 88 of the 94 clerical workers (response rate, 93.6%). Radiographic examinations of the cervical and the lumbar spines were performed after obtaining informed consent in both groups. Degenerative changes of the cervical and lumbar spines were determined using four radiographs per subject, and diagnosed by two independent, blinded radiologists. Results There was no significant difference in general and work-related characteristics except for flight hours and frequency between helicopter pilots and clerical workers. Degenerative changes in the cervical spine were significantly more prevalent in the helicopter pilots compared with control group. In the cervical spine multivariate model, accumulated flight hours (per 100 hours) was associated with degenerative changes. And in the lumbar spine multivariate model, accumulated flight hours (per 100 hours) and age were associated with degenerative changes. Conclusion Accumulated flight hours were associated with degenerative changes of the cervical and lumbar spines in helicopter pilots.
Byeon, Joo Hyeon; Kim, Jung Won; Jeong, Ho Joong; Sim, Young Joo; Kim, Dong Kyu; Choi, Jong Kyoung; Im, Hyoung June
Dissatisfaction with life has been found to be associated with somatic health and the short-term surgery outcome in lumbar spinal stenosis (LSS) patients. This study investigated the effects of the long-term life dissatisfaction burden on the surgery outcome in LSS patients with a 5-year follow-up. This was a prospective clinical study. Altogether, 102 patients who underwent decompressive surgery completed a set of questionnaires preoperatively, 3 and 6 months, and 1, 2 and 5 years after the surgery. The final study population at the 5-year follow-up included 67 patients. The mean age of the patients was 67 years and 35% of the patients were men. Life satisfaction was evaluated using a four-item Life Satisfaction Scale. The life dissatisfaction burden was the sum of all six life satisfaction scores recorded during the follow-up. The outcome of surgery was evaluated using the Oswestry Disability Index (ODI), pain evaluation (Visual Analogue Scale; VAS), overall satisfaction with the surgery and self-reported walking capacity. In linear regression, the long-term life dissatisfaction burden was associated with the 5-year ODI, even after adjusting for age, sex, marital status, preoperative ODI and the 5-year VAS. It was not associated with the 5-year VAS score. Monitoring the life satisfaction of surgically treated LSS patients may enable detection of those at risk of a poorer surgery outcome. PMID:24135635
Pakarinen, Maarit; Koivumaa-Honkanen, Heli; Sinikallio, Sanna; Lehto, Soili M; Aalto, Timo; Airaksinen, Olavi; Viinamäki, Heimo
Degeneration of the intervertebral disc is related to progressive changes in the disc tissue composition and morphology, such as water loss, disc height loss, endplate calcification, osteophytosis. These changes may be present separately or, more frequently, in various combinations. This work is aimed to the biomechanical investigation of a wide range of clinical scenarios of disc degeneration, in which the most common degenerative changes are present in various combinations. A poroelastic non-linear finite element model of the healthy L4-L5 human spine segment was employed and randomly scaled to represent ten spine segments from different individuals. Six different degenerative characteristics (water loss in the nucleus pulposus and annulus fibrosus; calcification and thickness reduction of endplate cartilage; disc height loss; osteophyte formation; diffuse sclerosis) were modeled in 30 randomly generated models, 10 for each overall degree of degeneration (mild, moderate, severe). For each model, a daily loading cycle including 8 h of rest, 16 h in the standing position with superimposed two flexion-extension motion cycles was simulated. A tendency to an increase of stiffness with progressing overall degeneration was observed, in compression, flexion and extension. Hence, instability for mild degeneration was not predicted. Facet forces and fluid loss decreased with disc degeneration. Nucleus, annulus and endplate degeneration, disc height loss, osteophytosis and diffuse sclerosis all induced a statistically significant decrease in the total daily disc height variation, facet force and flexibility in flexion-extension. Therefore, grading systems for disc degeneration should include all the degenerative changes considered in this work, since all of them had a significant influence on the spinal biomechanics. PMID:20936308
Galbusera, Fabio; Schmidt, Hendrik; Neidlinger-Wilke, Cornelia; Gottschalk, Andreas; Wilke, Hans-Joachim
Study Design A randomized prospective study. Purpose To assess postoperative analgesic requirements after Phyback therapy preemptively in patients undergoing lumbar stabilization. Overview of Literature Frequency Rhythmic Electrical Modulation System is the latest method of preemptive analgesia. Methods Forty patients were divided into two groups. Patients who were to receive tramadol were allocated to "group A" and those who were to receive Phyback therapy were allocated to "group B." In patients with a visual analog scale score of >4 or a verbal rating scale score of >2, 75 mg of diclofenac IM was administered. The amount of analgesic consumption, the bolus demand dosage, and the number of bolus doses administered were recorded. Patient satisfaction was evaluated using the visual analog patient satisfaction scale. Results There were statistically significant differences in the visual analog scale and verbal rating scale scores in the fourth, sixth, 12th, and 24th hours. The number of bolus infusions was significantly lower in group B. The amount of analgesic consumption was higher in group A. There was a significant difference between the two groups in the number of bolus infusions and the total amount of analgesic consumption, and this comparison showed better results for group B. Conclusions Application of Phyback therapy reduced postoperative opioid consumption and analgesic demand, and it contributed to reducing patients' level of pain and increased patient satisfaction. Moreover, the application of preemptive Phyback therapy contributed to reducing preoperative pain which may have reduced patient anxiety.
Aydogan, Serhat; Ozlu, Onur
The ability to identify a successful arthrodesis is an essential element in the management of patients undergoing lumbar fusion procedures. The hypothetical gold standard of intraoperative exploration to identify, under direct observation, a solid arthrodesis is an impractical alternative. Therefore, radiographic assessment remains the most viable instrument to evaluate for a successful arthrodesis. Static radiographs, particularly in the presence of instrumentation, are not recommended. In the absence of spinal instrumentation, lack of motion on flexion-extension radiographs is highly suggestive of a successful fusion; however, motion observed at the treated levels does not necessarily predict pseudarthrosis. The degree of motion on dynamic views that would distinguish between a successful arthrodesis and pseudarthrosis has not been clearly defined. Computed tomography with fine-cut axial images and multiplanar views is recommended and appears to be the most sensitive for assessing fusion following instrumented posterolateral and anterior lumbar interbody fusions. For suspected symptomatic pseudarthrosis, a combination of techniques including static and dynamic radiographs as well as CT images is recommended as an option. Lack of facet fusion is considered to be more suggestive of a pseudarthrosis compared with absence of bridging posterolateral bone. Studies exploring additional noninvasive modalities of fusion assessment have demonstrated either poor potential, such as with (99m)Tc bone scans, or provide insufficient information to formulate a definitive recommendation. PMID:24980581
Choudhri, Tanvir F; Mummaneni, Praveen V; Dhall, Sanjay S; Eck, Jason C; Groff, Michael W; Ghogawala, Zoher; Watters, William C; Dailey, Andrew T; Resnick, Daniel K; Sharan, Alok; Wang, Jeffrey C; Kaiser, Michael G
A comprehensive economic analysis generally involves the calculation of indirect and direct health costs from a societal perspective as opposed to simply reporting costs from a hospital or payer perspective. Hospital charges for a surgical procedure must be converted to cost data when performing a cost-effectiveness analysis. Once cost data has been calculated, quality-adjusted life year data from a surgical treatment are calculated by using a preference-based health-related quality-of-life instrument such as the EQ-5D. A recent cost-utility analysis from a single study has demonstrated the long-term (over an 8-year time period) benefits of circumferential fusions over stand-alone posterolateral fusions. In addition, economic analysis from a single study has found that lumbar fusion for selected patients with low-back pain can be recommended from an economic perspective. Recent economic analysis, from a single study, finds that femoral ring allograft might be more cost-effective compared with a specific titanium cage when performing an anterior lumbar interbody fusion plus posterolateral fusion. PMID:24980580
Ghogawala, Zoher; Whitmore, Robert G; Watters, William C; Sharan, Alok; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Eck, Jason C; Groff, Michael W; Wang, Jeffrey C; Resnick, Daniel K; Dhall, Sanjay S; Kaiser, Michael G
Background Interspinous spacers are a minimally invasive surgical alternative for patients with lumbar spinal stenosis (LSS) unresponsive to conservative care. The purpose of this prospective, multicenter, randomized, controlled trial was to compare 2-year clinical outcomes in patients with moderate LSS treated with the Superion® (Experimental) or the X-Stop®, a FDA-approved interspinous spacer (Control). Methods A total of 250 patients with moderate LSS unresponsive to conservative care were randomly allocated to treatment with the Experimental (n?=?123) or Control (n?=?127) interspinous spacer and followed through 2 years post-treatment. Complication data were available for all patients and patient-reported outcomes were available for 192 patients (101 Experimental, 91 Control) at 2 years. Results Zurich Claudication Questionnaire (ZCQ) Symptom Severity and Physical Function scores improved 34% to 36% in both groups through 2 years (all p?0.001). Patient Satisfaction scores at 2 years were 1.8?±?0.9 with Experimental and 1.6?±?0.8 with Control. Axial pain decreased from 59?±?26 mm at baseline to 21?±?26 mm at 2 years with Experimental and from 55?±?26 mm to 21?±?25 mm with Control (both p?0.001). Extremity pain decreased from 67?±?24 mm to 14?±?22 mm at 2 years with Experimental and from 63?±?24 mm to 18?±?23 mm with Control (both p?0.001). Back function assessed with the Oswestry Disability Index similarly improved with Experimental (37?±?12% to 18?±?16%) and Control (39?±?12% to 20?±?16%) (both p?0.001). Freedom from reoperation at the index level was 84% for Experimental and 83% for Control (log-rank: p?=?0.38) at 2 years. Conclusions Both interspinous spacers effectively alleviated pain and improved back function to a similar degree through 2 years in patients with moderate LSS who were unresponsive to conservative care. Trial registration NCT00692276.
Study Design Retrospective study. Purpose The main purpose of this study was to investigate the union-rate of the spinous process after performing a spinous process osteotomy and whether union affects the clinical results after surgery. Overview of Literature In the present study, spinous process osteotomy was used to facilitate access to the spinal canal when performing a decompressive procedure for lumbar spinal stenosis. The aim of this study was to evaluate the union rate of the spinous process and its effect on the clinical results of the procedure. Methods All patients were included in the study that underwent a decompressive procedure through spinous process osteotomy be between January 1, 2007 and December 31, 2007. Operation protocols were reviewed. A computed tomography (CT) scan was performed to evaluate the union of the osteotomies of the spinous process. According to the CT-scans, patients were divided into three groups: "complete-union," "partial-union," and "non-union." Patients reported their clinical results through a self-administered questionnaire. Results The mean period of follow up was 21.6 months (range, 16-28 months). A total of 44% of the performed osteotomies were considered as united. Ten patients (18%) were classified as "complete-union," 30 patients (55%) as "partial-union," and 15 patients (27%) as "non-union." The "complete-union" group showed better clinical results and scored significantly better in the Oswestry Disability Index and EQ-5D. However, no statistical difference was found in the pain-scores. There were no differences between the "partial-union" group and the "no-union" group. Conclusions We found a radiologic union for 60 out of 135 (44%) spinous process osteotomies.
Moen, Gunnar; Fenstad, Anne Marie; Birketvedt, Rune; Indrekvam, Kari
A cross-sectional epidemiological study via personal interviews was performed regarding low back pain and its related clinical aspects in a Hungarian sample of 10,000 people. Joining the international campaign of the "Bone and Joint Decade", our aim was to give data on low back pain prevalence and to explore the underlying possible clinical conditions in a Central European adult and adolescent population. Ten thousand people aged 14-65, selected randomly by the Hungarian central office of statistics from three counties of the south-western Hungarian region, were surveyed using a special questionnaire focusing on low back pain and other degenerative spinal symptoms. People with low back pain complaints and written consent were asked to participate in a further clinical investigation, where radiological and clinical assessment was performed. A total of 4,389 persons (44.1%) reported low back pain in the last month at the time of the survey. Work absenteeism due to low back pain affected 2,140 persons (21.5%). A total of 292 people (2.9%) had already undergone spinal surgery. Upon request 682 people came for a clinical follow-up, where thorough physical examination and radiological analysis was performed and results were statistically interpreted. The Oswestry disability index (ODI) in the examined group of patients averaged 35.1%; radiological degenerative signs were observed in 392/682 (57.5%). Individuals with signs of radiological degeneration had a statistically significant higher ODI value, age, and a higher, yet not significantly increased BMI value than radiographically negative patients (p?0.05). Co-existence of hip and knee osteoarthritis was also investigated. Higher osteoarthritis prevalence was found in individuals with radiographic signs of spinal degeneration. Details of the survey and clinical investigations are discussed. PMID:19997731
Horváth, Gábor; Koroknai, Gabriella; Acs, Barnabás; Than, Péter; Illés, Tamás
Background Lateral lumbar interbody fusion (LLIF) is not associated with many of the complications seen in other interbody fusion techniques. This study used computed tomography (CT) scans, the radiographic gold standard, to assess interbody fusion rates achieved utilizing the LLIF technique in high-risk patients. Methods We performed a retrospective review of patients who underwent LLIF between January 2008 and July 2013. Forty-nine patients underwent nonstaged or staged LLIF on 119 levels with posterior correction and augmentation. Per protocol, patients received CT scans at their 1-year follow-up. Of the 49 patients, 21 patients with LLIF intervention on 54 levels met inclusion criteria. Two board-certified musculoskeletal radiologists and the senior surgeon (JZ) assessed fusion. Results Of the 21 patients, 6 patients had had previous lumbar surgery, and the cohort's comorbidities included osteoporosis, diabetes, obesity, and smoking, among others. Postoperative complications occurred in 12 (57.1%) patients and included anterior thigh pain and weakness in 6 patients, all of which resolved by 6 months. Two cases of proximal junctional kyphosis occurred, along with 1 case of hardware pullout. Two cases of abdominal atonia occurred. By CT scan assessment, each radiologist found fusion was achieved in 53 of 54 levels (98%). The radiologists' findings were in agreement with the senior surgeon. Conclusion Several studies have evaluated LLIF fusion and reported fusion rates between 88%-96%. Our results demonstrate high fusion rates using this technique, despite multiple comorbidities in the patient population. Spanning the ring apophysis with large LLIF cages along with supplemental posterior pedicle screw augmentation can enhance stability of the fusion segment and increase fusion rates.
Waddell, Brad; Briski, David; Qadir, Rabah; Godoy, Gustavo; Houston, Allison Howard; Rudman, Ernest; Zavatsky, Joseph
The intervertebral disc is characterized by a tension-resisting annulus fibrosus and a compression-resisting nucleus pulposus composed largely of proteoglycan. The most important function of the annulus and nucleus is to provide mechanical stability to the disc. Degenerative disc disease in the lumbar spine is a serious health problem. Although the three joint complex model of the degenerative process is widely accepted, the etiological basis of this degeneration is poorly understood. With the recent progress in molecular biology and modern biological techniques, there has been dramatic improvement in the understanding of aging and degenerative changes of the disc. Knowledge of the pathophysiology of the disc degeneration can help in the appropriate choice of treatment and to develop tissue engineering for biological restoration of degenerated discs.
Quantitative fluoroscopy (QF) is an emerging technology for measuring intervertebral motion patterns to investigate problem back pain and degenerative disc disease. This International Forum was a networking event of three research groups (UK, US, Hong Kong), over three days in San Francisco in August 2009. Its aim was to reach a consensus on how best to record, analyse, and communicate QF information for research and clinical purposes. The Forum recommended that images should be acquired during regular trunk motion that is controlled for velocity and range, in order to minimise externally imposed variability as well as to correlate intervertebral motion with trunk motion. This should be done in both the recumbent passive and weight bearing active patient configurations. The main recommended outputs from QF were the true ranges of intervertebral rotation and translation, neutral zone laxity and the consistency of shape of the motion patterns. The main clinical research priority should initially be to investigate the possibility of mechanical subgroups of patients with chronic, nonspecific low back pain by comparing their intervertebral motion patterns with those of matched healthy controls.
Breen, Alan C.; Teyhen, Deydre S.; Mellor, Fiona E.; Breen, Alexander C.; Wong, Kris W. N.; Deitz, Adam
Clinical and radiological outcomes following microscopic decompression utilizing tubular retractor or conventional microscopic decompression in lumbar spinal stenosis with a minimum of 10-year follow-up.
Satisfactory short- and mid-term results have been observed following microscopic decompression with tubular retractor (MDT) and conventional microscopic decompression (CMD) in lumbar spinal stenosis (LSS). It is not yet clear which surgical procedure is the optimal treatment for LSS, especially in long-term follow-up period. To the best of our knowledge, there is no comparative study analyzing the clinical-radiological outcomes of MDT and CMD over a 10-year follow-up periods. The purpose of this study was to evaluate and compare clinical and radiological outcomes of MDT and CMD over a 10-year follow-up period in patients with LSS. Of total 121 patients, 102 patients (53 MDT and 49 CMD) were followed for at least 10 years following MDT and CMD for LSS. We retrospectively reviewed surgical results and clinical outcomes based on the visual analogue scale, McNab's criteria, and the Oswestry Disability Index, and radiological analysis results with the parameters, including the change of disk height and intervertebral distance, obtained preoperatively and 3- and 6-month, and 1-, 6-, and 10-year postoperatively. There was no significant difference in patient demographics between the two groups. Five patients (two in MDT, three in CMD) required re-operation for re-stenotic change of the affected segment. The number of patients requiring re-operation was not significantly different between the two groups (p > 0.05). No statistically significant differences were observed between the groups in a long-term follow-up period after a 3-month follow-up (p > 0.05). However, in the acute postoperative phase of <3-month postoperatively, MDT appears to result in less postoperative pain and better clinical outcomes compared with the CMD. In conclusion, despite relatively small sample size with retrospective design, our study suggested that MDT appears to result in less postoperative pain and better clinical outcomes in the acute postoperative period of <3 months, but both MDT and CMD were no significant differences in clinical and radiological outcomes after that time. PMID:23934439
Lee, Gun Woo; Jang, Soo-Jin; Shin, Seung Mok; Jang, Jae-Ho; Kim, Jae-Do
Many studies attest to the excellent results achieved using anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. The purpose of this report is to document a rare instance of L-4 vertebral body fracture following use of a stand-alone interbody fusion device for L3-4 ALIF. The patient, a 55-year-old man, had suffered intractable pain of the back, right buttock, and left leg for several weeks. Initial radiographs showed Grade I degenerative spondylolisthesis, with instability in the sagittal plane (upon 15° rotation) and stenosis of central and both lateral recesses at the L3-4 level. Anterior lumbar interbody fusion of the affected vertebrae was subsequently conducted using a stand-alone cage/plate system. Postoperatively, the severity of spondylolisthesis diminished, with resolution of symptoms. However, the patient returned 2 months later with both leg weakness and back pain. Plain radiographs and CT indicated device failure due to anterior fracture of the L-4 vertebral body, and the spondylolisthesis had recurred. At this point, bilateral facetectomies were performed, with reduction/fixation of L3-4 by pedicle screws. Again, degenerative spondylolisthesis improved postsurgically and symptoms eased, with eventual healing of the vertebral body fracture. This report documents a rare instance of L-4 vertebral body fracture following use of a stand-alone device for ALIF at L3-4, likely as a consequence of angular instability in degenerative spondylolisthesis. Under such conditions, additional pedicle screw fixation is advised. PMID:24725181
Kwon, Yoon-Kwang; Jang, Ju-Hee; Lee, Choon-Dae; Lee, Sang-Ho
BACKGROUND: The association of lumbar spine instability between laminectomy and laminotomy has been clinically studied, but the corresponding in vitro biomechanical studies have not been reported. We investigated the hypothesis that the integrity of the posterior complex (spinous process-interspinous ligament-spinous process) plays an important role on the postoperative spinal stability in decompressive surgery. METHODS: Eight porcine lumbar spine specimens were
Ching-Lung Tai; Pang-Hsing Hsieh; Weng-Pin Chen; Lih-Huei Chen; Wen-Jer Chen; Po-Liang Lai
Degenerative valvular heart disease, the most common form of valve disease in the Western world, can lead to aortic stenosis (AS) or mitral regurgitation (MR). In current guidelines for the management of patients with degenerative valvular disease, surgical intervention is recommended at the onset of symptoms or in the presence of left ventricular systolic impairment. Whether surgery is appropriate for
Valentin Fuster; Martin Goldman; Robert O. Bonow; Prashant Vaishnava
Lumbar synovial cysts frequently present with back pain, chronic radiculopathy and/or progressive symptoms of spinal canal compromise. These cysts generally appear in the context of degenerative lumbar spinal disease. Few cases of spontaneous hemorrhage into synovial cysts have been reported in the literature.
Alen, Jose F.; Ramos, Ana; Lobato, Ramiro D.; Lagares, Alfonso
In response to the rapid development and demand of outpatient endoscopic minimally invasive lumbar surgical technique, the SMART endoscopic spine system was developed for neurodecompression. This lumbar spine surgery is performed with a small skin incision, dilatation surgical technology, and an endoscopic-assisted spinal surgical system with progressive serial tubular retractors providing superior lighting and better visualization of the operative field for performing minimally invasive spinal surgery (MISS). The SMART system incorporates the advantages of posterior paramedian endoscopic assisted microdecompressive surgical spinal system and posterolateral endoscopic lumbar system. This versatile SMART endoscopic spine system with various sized working channels provides a generous and optimal access for endoscopic MISS of microdecompression of herniated lumbar disc, degenerative spinal disease, spinal stenosis, and removal of intraspinal lesions as well as creating an access for spinal arthroplasty and spinal fixation. With the unique features of the SMART system, the surgeon can take advantage of microscopic, endoscopic, or direct vision for microdecompressive spinal surgery, bridging endoscopic and conventional spinal surgery. It appears easy, safe, and efficacious. This less traumatic and easier outpatient MISS treatment leads to excellent result speedier recovery, and significant economic savings. The SMART endoscopic spine system, surgical indications, operative techniques, and the potential complications and their avoidance are described and discussed herein. PMID:17029182
Chiu, John C
Intraspinous and pedicle screw-based (PSB) dynamic instrumentation systems have been in use for a decade now. By direct or indirect decompression, these devices theoretically establish less painful segmental motion by diminishing pathologic motion and unloading painful disks. Ideally, dynamics should address instability in the early stages of degenerative spondylolisthesis before excessive translation occurs. Evidence to date indicates that Grade II or larger slips requiring decompression should be fused. In addition, multiple segment listhesis, severe coronal plane deformities, increasing age, and osteoporosis have all been listed as potential contraindications to dynamic stabilization. We reviewed the exclusion and inclusion criteria found in various dynamic stabilization studies and investigational drug exemption (IDE) protocols. We summarize the reported limitations for both pedicle- and intraspinous-based systems. We then conducted a retrospective chart and imaging review of 100 consecutive cases undergoing fusion for degenerative spondylolisthesis. All patients in our cohort had been indicated for and eventually underwent decompression of lumbar stenosis secondary to spondylolisthesis. We estimated how many patients in our population would have been candidates for dynamic stabilization with either interspinous or pedicle-based systems. Using the criteria for instability outlined in the literature, 32 patients demonstrated translation requiring fusion surgery and 24 patients had instability unsuitable for dynamic stabilization. Six patients had two-level slips and were excluded. Two patients had coronal imbalance too great for dynamic systems. Twelve patients were over the age of 80 and 16 demonstrated osteoporosis as diagnosed by bone scan. Finally, we found two of our patients to have vertebral compression fractures adjacent to the site of instrumentation, which is a strict exclusion criteria in all dynamic trials. Thirty-four patients had zero exclusion criteria for intraspinous devices and 23 patients had none for PSB dynamic stabilization. Therefore, we estimate that 34 and 23% of degenerative spondylolisthesis patients indicated for surgery could have been treated with either intraspinous or pedicle-based dynamic devices, respectively.
Lawhorne, Thomas W.; Girardi, Federico P.; Pappou, Iaonnis; Cammisa, Frank P.
The aim of the current study was to evaluate changes in lumbar kinematics after lumbar monosegmental instrumented surgery with rigid fusion and dynamic non-fusion stabilization. A total of 77 lumbar spinal stenosis patients with L4 degenerative spondylolisthesis underwent L4-5 monosegmental posterior instrumented surgery. Of these, 36 patients were treated with rigid fusion (transforaminal lumbar interbody fusion) and 41 with dynamic stabilization [segmental spinal correction system (SSCS)]. Lumbar kinematics was evaluated with functional radiographs preoperatively and at final follow-up postoperatively. We defined the contribution of each segmental mobility to the total lumbar mobility as the percent segmental mobility [(sagittal angular motion of each segment in degrees)/(total sagittal angular motion in degrees) × 100]. Magnetic resonance imaging was performed on all patients preoperatively and at final follow-up postoperatively. The discs were classified into five grades based on the previously reported system. We defined the progress of disc degeneration as (grade at final follow-up) - (grade at preoperatively). No significant kinematical differences were shown at any of the lumbar segments preoperatively; however, significant differences were observed at the L2-3, L4-5, and L5-S1 segments postoperatively between the groups. At final follow-up, all of the lumbar segments with rigid fusion demonstrated significantly greater disc degeneration than those with dynamic stabilization. Our results suggest that the SSCS preserved 14% of the kinematical operations at the instrumented segment. The SSCS may prevent excessive effects on adjacent segmental kinematics and may prevent the incidence of adjacent segment disorder. PMID:21301893
Morishita, Yuichiro; Ohta, Hideki; Naito, Masatoshi; Matsumoto, Yoshiyuki; Huang, George; Tatsumi, Masato; Takemitsu, Yoshiharu; Kida, Hirotaka
Non-instrumented lumbar fusion is an accepted technique for the treatment of various spinal degenerative pathologies. The purpose of this study is to report long-term outcomes of patients undergoing in situ fusion. A retrospective review was performed at a single institution over a 20year period. The main outcome variables were symptom resolution at last follow-up, development of adjacent segment disease (ASD) and overall need for re-operation. A total of 376 patients were identified, with a mean age of 61.1±standard deviation of 13.54years. The most common presenting symptom was back pain in 344 (91.5%) patients, followed by radiculopathy in 304 (80.9%) patients. The most common pre-operative diagnosis was multi-level spinal stenosis with claudication in 211 (56.1%) patients. At last follow-up, the prevalence of back pain (60.64%; p<0.001) and radiculopathy (57.71%; p<0.001) were significantly lower. The cumulative rate of ASD was 18.35% (69 patients). In total, the rate of re-operation due to non-improvement or worsening of symptoms was 30.59% (115 patients). In this manuscript, we present one of the largest cohorts of patients undergoing in situ fusion for degenerative lumbar spine disease with a median follow-up time of 92 (range 24-154)months. Although the prevalence of both back pain and radiculopathy was significantly reduced at last follow-up, a significant portion of patients still experienced continued symptoms. Notably, while 18.35% of patients developed ASD, 30.6% of patients required re-operation due to recurrent or worsening symptoms during the follow-up period, highlighting the need for additional stabilization techniques. PMID:24831342
Santiago-Dieppa, David; Bydon, Mohamad; Xu, Risheng; De la Garza-Ramos, Rafael; Henry, Roger; Sciubba, Daniel M; Wolinsky, Jean-Paul; Bydon, Ali; Gokaslan, Ziya L; Witham, Timothy F
Interspinous devices have been introduced to provide a minimally invasive surgical alternative for patients with lumbar spinal stenosis or foraminal stenosis. Little is known however, of the effect of interspinous devices on intersegmental range of motion (ROM). The aim of this in vivo study was to investigate the effect of a novel minimally invasive interspinous implant, InSwing®, on sagittal plane ROM of the lumbar spine using an ovine model. Ten adolescent Merino lambs underwent a destabilization procedure at the L1–L2 level simulating a stenotic degenerative spondylolisthesis (as described in our earlier work; Spine 15:571–576, 1990). All animals were placed in a side-lying posture and lateral radiographs were taken in full flexion and extension of the trunk in a standardized manner. Radiographs were repeated following the insertion of an 8-mm InSwing® interspinous device at L1–L2, and again with the implant secured by means of a tension band tightened to 1 N/m around the L1 and L2 spinous processes. ROM was assessed in each of the three conditions and compared using Cobb’s method. A paired t-test compared ROM for each of the experimental conditions (P < 0.05). After instrumentation with the InSwing® interspinous implant, the mean total sagittal ROM (from full extension to full flexion) was reduced by 16% from 6.3° to 5.3 ± 2.7°. The addition of the tension band resulted in a 43% reduction in total sagittal ROM to 3.6 ± 1.9° which approached significance. When looking at flexion only, the addition of the interspinous implant without the tension band did not significantly reduce lumbar flexion, however, a statistically significant 15% reduction in lumbar flexion was observed with the addition of the tension band (P = 0.01). To our knowledge, this is the first in vivo study radiographically showing the advantage of using an interspinous device to stabilize the spine in flexion. These results are important findings particularly for patients with clinical symptoms related to instable degenerative spondylolisthesis.
Szpalski, Marek; Callary, Stuart A.; Colloca, Christopher J.; Kosmopoulos, Victor; Harrison, Deed; Moore, Robert J.
Anal stenosis occurs most commonly following a surgical procedure, such as hemorrhoidectomy, excision and fulguration of anorectal warts, endorectal flaps, or following proctectomy, particularly in the setting of mucosectomy. Patients who experience anal stenosis describe constipation, bleeding, pain, and incomplete evacuation. Although often described as a debilitating and difficult problem, several good treatment options are available. In addition to simple dietary and medication changes, surgical procedures, such as lateral internal sphincterotomy or transfers of healthy tissue are other potentially good options. Flap procedures are excellent choices, depending on the location of the stenosis and the amount of viable tissue needed. This article presents the definition, pathophysiology, diagnosis, and treatment of anal stenosis, and methods to prevent it. PMID:20109638
Katdare, Mukta V; Ricciardi, Rocco
A case of a midline lumbar extradural ganglion/synovial cyst causing lumbar canal stenosis and mimicking an epidural tumor is presented. The lesion was demonstrated by a magnetic resonance imaging study, and relief of symptoms was achieved with decompressive laminectomy and total removal of the mass. The pathogenesis of lumbar ganglion/synovial cyst is reviewed. PMID:2972941
Azzam, C J
\\u000a When considered separately from mitral valve anomalies associated with atrioventricular septal defects and with hypoplastic\\u000a left heart syndrome, congenital mitral valve malformations resulting in mitral stenosis are rare. Reported prevalence is 0.4–0.5%\\u000a of congenital heart defects [1–3]. Acquired mitral stenosis is primarily related to rheumatic heart disease and, though uncommon\\u000a in the United States, remains a considerable problem for children
Kristin P. Barton; Jacqueline Kreutzer; Victor O. Morell; Ricardo Muñoz
The rapid increase of elderly population has resulted in increased prevalence of adult scoliosis. Adult scoliosis is divided into adult idiopathic scoliosis and adult degenerative scoliosis. These two types of scoliosis vary in patient age, curve pattern and clinical symptoms, which necessitate different surgical indications and options. Back pain and deformity are major indications for surgery in adult idiopathic scoliosis, whereas radiating pain to the legs due to foraminal stenosis is what often requires surgery in adult degenerative scoliosis. When selecting a surgical method, major symptoms and underlying medical diseases should be carefully evaluated, not only to relieve symptoms but also to minimize postoperative complications. Surgical options for adult degenerative scoliosis include: decompression alone; decompression and limited short fusion; and decompression coupled with long fusion and correction of deformity. Decompression and limited short fusion can be applied to patients with a small Cobb's angle and normal sagittal imbalance. For those with a large Cobb's angle and positive sagittal imbalance, long fusion with correction of deformity is required. When long fusion is applied, a careful decision regarding the extent of fusion level should be made when selecting L5 or S1 as the distal fusion level and T10 or the thoracolumbar junction as the proximal fusion level. For the fusion extending to the sacrum, restoration of sagittal balance and rigid fixation with additional iliac screws should be considered. Any surgical procedures for adult degenerative scoliosis are known to have relatively high occurrences of complications; therefore, risks and benefits should be meticulously considered before selecting a surgical procedure.
Kim, Young-Tae; Shin, Sang-hyun; Suk, Se-Il
OBJECT Pseudarthrosis and adjacent-segment degeneration remain problems after fusion surgery. To overcome these complications, many dynamic stabilization methods have been developed. This study was conducted to elucidate the midterm results on the effectiveness of interspinous ligamentoplasty (ILP) to treat degenerative spondylolisthesis. METHODS Thirty-two consecutive surgeries involving decompression and ILP were performed by 2 surgeons at the authors' institution during 2001 and 2002. Nine patients were excluded from the study because of inadequate follow-up or radiological data, leaving a study population of 23 patients with a mean duration of follow-up of 64.6 months (range 60-77). All the patients had symptomatic spinal stenosis and Grade 1 spondylolisthesis at L4-5 level without foraminal stenosis and deformity. Clinical outcomes were evaluated by visual analog scale (VAS) for back and leg pain and the Oswestry Disability Index (ODI). Radiological measurements included segmental lordosis, total lumbar lordosis, posterior disc height, anterior slippage, angular motion, translational motion, and facet degeneration grade. Eighteen patients who had undergone bilateral laminotomy alone were included as a Control Group. RESULTS Twenty-two of the 23 patients who underwent ILP returned to their active daily lives. Symptomatic instability was less common in the ILP Group than in the Control Group (4.3% vs 27.8%). The mean postoperative VAS leg scores, VAS back scores, and ODI scores at final follow-up were significantly improved in both groups, in comparison to preoperative scores; however, the mean difference in ODI scores was significantly greater in the ILP group (29.3% vs 16.6%, p = 0.049). In radiological analysis, segmental and total lordoses were significantly increased in the ILP Group. In both groups slippage increased, disc height decreased, and angular motion was maintained, but translational motion decreased with statistical significance in the ILP Group, whereas it increased in the Control Group. Radiological instability was observed in 3 patients in the ILP Group, and 9 in the Control Group (significant between-groups difference, p = 0.016). CONCLUSIONS Interspinous ligamentoplasty is a good option treating patients with Grade 1 degenerative spondylolisthesis requiring surgery. It is less invasive and effectively stabilizes the unstable spine with a relatively small incidence of postoperative instability. Interspinous ligamentoplasty provides satisfactory clinical and radiological results at midterm follow-up. PMID:20594014
Hong, Soon-Woo; Lee, Ho-Yeon; Kim, Kyeong Hwan; Lee, Sang-Ho
Intradural disc herniation is a rare complication of degenerative disc disease. A correct diagnosis of this process is frequently difficult. If this entity is not preoperatively diagnosed and is omitted at surgery, severe neurologic sequels may be provoked. We report a case of a pathologically proven intradural disc herniation preoperatively diagnosed by MR imaging. Clinically, it was manifested by sudden onset of right leg ciatalgia and progressive right lower extremity weakness. The patient also referred a one-month history of sexual dysfunction. MR imaging revealed interruption of the low signal of the anulus fibrosus and of the posterior longitudinal ligament at L2-L3 level and a voluminous disc fragment migrated in the dural sac that showed rim enhancement with gadolinium.The clinical, neuroradiological, and surgical management of lumbar intradural disc herniation are reviewed. PMID:11412713
Alonso-Bartolomé, P; Canga, A; Vázquez-Barquero, A; García-Valtuille, R; Abascal, F; Cerezal, L
Background Currently, herniated nucleus pulposus (HNP) with radiculopathy and other preconditions are regarded as relative or absolute contraindications for lumbar total disc replacement (TDR). In Switzerland it is left to the surgeon's discretion when to operate. The present study is based on the dataset of SWISSspine, a governmentally mandated health technology assessment registry. We hypothesized that preoperative nucleus pulposus status and presence or absence of radiculopathy has an influence on clinical outcomes in patients treated with mono-segmental lumbar TDR. Methods Between March 2005 and April 2009, 416 patients underwent mono-segmental lumbar TDR, which was documented in a prospective observational multicenter mode. The data collection consisted of perioperative and follow-up data (physician based) and clinical outcomes (NASS, EQ-5D). Patients were divided into four groups according to their preoperative status: 1) group degenerative disc disease ("DDD"): 160 patients without HNP and no radiculopathy, classic precondition for TDR; 2) group "HNP-No radiculopathy": 68 patients with HNP but without radiculopathy; 3) group "Stenosis": 73 patients without HNP but with radiculopathy, and 4) group "HNP-Radiculopathy": 132 patients with HNP and radiculopathy. The groups were compared regarding preoperative patient characteristics and pre- and postoperative VAS and EQ-5D scores using general linear modeling. Results Demographics in all four groups were comparable. Regarding the improvement of quality of life (EQ-5D) there were no differences across the four groups. For the two main groups DDD and HNP-Radiculopathy no differences were found in the adjusted postoperative back- and leg pain alleviation levels, in the stenosis group back- and leg pain relief were lower. Conclusions Despite higher preoperative leg pain levels, outcomes in lumbar TDR patients with HNP and radiculopathy were similar to outcomes in patients with the classic indication; this because patients with higher preoperative leg pain levels benefit from a relatively greater leg pain alleviation. The group with absence of HNP but presence of radiculopathy showed considerably less benefits from the operation, which is probably related to ongoing degenerative processes of the posterior segmental structures. This observational multicenter study suggests that the diagnoses HNP and radiculopathy, combined or alone, may not have to be considered as absolute or relative contraindications for mono-segmental lumbar TDR anymore, whereas patients without HNP but with radiculopathy seem to be suboptimal candidates for the procedure.
The purpose of this prospective study was to determine the overall incidence and distribution of lumbo-sacral degenerative changes (i.e. disc protrusion or extrusion, facet degeneration, disc degeneration, nerve root canal stenosis and spinal stenosis) in patients with and without a lumbo-sacral transitional vertebra (LSTV). The study population consisted of 350 sequential patients with low back pain and\\/or sciatica, referred for
S. Vergauwen; P. M. Parizel; L. van Breusegem; J. W. Van Goethem; Y. Nackaerts; L. Van den Hauwe; A. M. De Schepper
Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or\\u000a synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic\\u000a signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in\\u000a the
H. Taha; Y. Bareksei; W. Albanna; M. Schirmer
Degenerative spinal disorders, including intervertebral disc disease and spondylosis, seldom occur in domestic cats. In contrast, a retrospective study of 13 lions (Panthera leo), 16 tigers (Panthera tigris), 4 leopards (Panthera pardis), 1 snow leopard (Panthera uncia), and 3 jaguars (Panthera onca) from the Knoxville Zoo that died or were euthanatized from 1976 to 1996 indicated that degenerative spinal disease is an important problem in large nondomestic felids. The medical record, radiographic data, and the necropsy report of each animal were examined for evidence of intervertebral disc disease or spondylosis. Eight (three lions, four tigers, and one leopard) animals were diagnosed with degenerative spinal disease. Clinical signs included progressively decreased activity, moderate to severe rear limb muscle atrophy, chronic intermittent rear limb paresis, and ataxia. The age at onset of clinical signs was 10-19 yr (median = 18 yr). Radiographic evaluation of the spinal column was useful in assessing the severity of spinal lesions, and results were correlated with necropsy findings. Lesions were frequently multifocal, included intervertebral disc mineralization or herniation with collapsed intervertebral disc spaces, and were most common in the lumbar area but also involved cervical and thoracic vertebrae. Marked spondylosis was present in the cats with intervertebral disc disease, presumably subsequent to vertebral instability. Six of the animals' spinal cords were examined histologically, and five had acute or chronic damage to the spinal cord secondary to disc protrusion. Spinal disease should be suspected in geriatric large felids with decreased appetite or activity. Radiographic evaluation of the spinal column is the most useful method to assess the type and severity of spinal lesions. PMID:10884118
Kolmstetter, C; Munson, L; Ramsay, E C
The lateral transpsoas approach for interbody fusion is a minimally invasive technique that has been gaining increasing popularity in the management of a variety of spinal degenerative disorders. Recently, there has been increasing utilization of this technique in the management of adult deformity. The authors present a review of the current evidence of using the lateral lumbar transpsoas approach in the correction of adult degenerative scoliosis. PMID:24703453
Dahdaleh, Nader S; Smith, Zachary A; Snyder, Laura A; Graham, Randall B; Fessler, Richard G; Koski, Tyler R
Most reports regarding synovial cysts of the spinal canal have been presentations identifying an unusual pathological entity that is to be included in the differential diagnosis of cauda equina compression syndromes. Most of the 26 cases reported represent isolated examples of this pathological process. We present five cases of lumbar synovial cysts encountered in our practice in the past 8 years. Patients with lumbar synovial cysts do not demonstrate any predictable clinical picture. They may present with a unilateral sciatica or neurogenic claudication. Lumbar extension is usually restricted, whereas flexion is full. Mechanical signs of nerve root entrapment or lumbosacral plexus irritation are unimpressive. Neurological deficits are usually mild, if present. Radiological findings include degenerative spondylosis, spondylolisthesis, and a rounded posterolateral extradural mass of low attenuation value adjacent to a facet shown on computed tomographic scan. The etiology of lumbar synovial cysts is not known. Histological findings of myxoid degeneration, microcystic change, calcification, and hemosiderin deposits suggest that chronic microtrauma with occasional focal hemorrhage may play a major role in the etiology of the cysts. With resection of the cyst, the postoperative course is usually uneventful. Recurrences have not yet been encountered in our patients. PMID:3489903
Kjerulf, T D; Terry, D W; Boubelik, R J
Degenerative-inflammatory lumbar spinal pathology is one of the most common reasons why individuals seek medical care, and\\u000a low back pain is the main symptom among those most commonly associated with this pathologic condition. Pain is commonly attributed\\u000a to degenerative disc disease, particularly herniated discs, but many different spinal and perispinal structures may undergo\\u000a degenerative-inflammatory phenomena and produce pain: discs, bone,
P. D’Aprile; A. Tarantino; J. R. Jinkins; D. Brindicci
Aortic stenosis is a complex disease. About 2-7% of the population over 65 years of age is affected by its degenerative form. In patients with severe aortic stenosis presenting with symptoms or left ventricle ejection fraction (LVEF)<.50, aortic valve replacement is indicated. Management and timing of surgery in asymptomatic patients with preserved LVEF is still a matter of debate. Recent published data show that about one third of these patients present with low left ventricle stroke volume, which may affect survival. For this reason, and considering that aortic valve replacement is in most cases a low risk procedure, early surgery in this subgroup is a strategy that deserves to be taken into account. In this review we report on these recent findings, which allow understanding why patients with asymptomatic severe aortic stenosis should not be considered and treated as a homogenous population. PMID:23849483
Urso, Stefano; Sadaba, Rafael; de la Cruz, Elena
Canine degenerative myelopathy (DM) is an adult-onset fatal neurodegenerative disease that occurs in many breeds. The initial upper motor neuron spastic paraparesis and general proprioceptive ataxia in the pelvic limbs progress to a flaccid lower motor neuron tetraparesis. Recently, a missense mutation in the superoxide dismutase 1 (SOD1) gene was found to be a risk factor for DM, suggesting that DM is similar to some forms of human amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). This article reviews the current knowledge of canine DM with regard to its signalment, clinical spectrum, diagnostic approach, and treatment. The implications of the SOD1 mutation on both diseases are discussed, comparing pathogenic mechanisms while conveying perspectives to translational medicine. PMID:20732599
Coates, Joan R; Wininger, Fred A
As the average life expectancy of the population increases, surgical decompression of the lumbar spine is being performed\\u000a with increasing frequency. It now constitutes the most common type of lumbar spinal surgery in older patients. The present\\u000a prospective study examined the 5-year outcome of lumbar decompression surgery without fusion. The group comprised 159 patients\\u000a undergoing decompression for degenerative spinal disorders
Anne F. MannionR; R. Denzler; J. Dvorak; D. Grob
We enrolled 304 patients in the randomized cohort and 303 in the observational co- hort. The baseline characteristics of the two cohorts were similar. The one-year cross- over rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for
James N. Weinstein; Jon D. Lurie; Tor D. Tosteson; Brett Hanscom; Anna N. A. Tosteson; Emily A. Blood; Nancy J. O. Birkmeyer; Alan S. Hilibrand; Harry Herkowitz; Frank P. Cammisa; Todd J. Albert; Sanford E. Emery; Lawrence G. Lenke; William A. Abdu; Michael Longley; Thomas J. Errico; Serena S. Hu
The dynamic fixation system Dynesys is utilized in the last 10 years for treatment of degenerative segmental disease of the\\u000a lumbar spine. Dynesys is a semi-rigid fixation system that allows minimal lengthening and shortening between two segmental\\u000a pedicle screws as opposed to a rigid metal bar. Thus, the system is regarded to maintain stability and near physiological\\u000a motion patterns of the
Matthias Bothmann; Erich Kast; Gerald Jens Boldt; Joachim Oberle
Lumbar epidural anesthesia is useful in a variety of chronic benign pain syndromes, including lumbar radiculopathy, low back pain syndrome, spinal stenosis, and vertebral compression fractures. Given the increased number of epidural nerve blocks being performed, some have reported unexplained complications of a transient or permanent nature and with varying degrees of severity. However, no case has been reported of a broken epidural needle tip retained in the lumbar facet joint area. This represents the first reported case presentation of foraminal stenosis developing in a patient after a retained epidural needle tip.
You, Ji Wong
The effect of extradural corticosteroid injection in patients with nerve root compression syndromes associated with degenerative disease of the lumbar intervertebral discs was assessed in a double-blind controlled trial on 100 consecutive inpatients assigned by random allocation to treatment and control groups. Assessment during admission and at three months revealed statistically highly significant differences in respect of relief of pain
T. F. W. Dilke; H. C. Burry; R. Grahame
Posterior lumbar interbody fusion (PLIF) is a popular procedure for treating lumbar canal stenosis with spinal instability,\\u000a and several reports concerning fusion assessment methods exist. However, there are currently no definitive criteria for diagnosing\\u000a a successful interbody fusion in the lumbar spine. We suggested evaluating fusion status using computed tomography (CT) in\\u000a extension position to detect pseudoarthrosis more precisely. The
Hiroaki NakashimaYasutsugu; Yasutsugu Yukawa; Keigo Ito; Yumiko Horie; Masaaki Machino; Shunsuke Kanbara; Daigo Morita; Shiro Imagama; Naoki Ishiguro; Fumihiko Kato
Spondylolysis is an osseous defect of the pars interarticularis, thought to be a developmental or acquired stress fracture secondary to chronic low-grade trauma. It is encountered most frequently in adolescents, most commonly involving the lower lumbar spine, with particularly high prevalence among athletes involved in certain sports or activities. Spondylolysis can be asymptomatic or can be a cause of spine instability, back pain, and radiculopathy. The biomechanics and pathophysiology of spondylolysis are complex and debated. Imaging is utilized to detect spondylolysis, distinguish acute and active lesions from chronic inactive non-union, help establish prognosis, guide treatment, and to assess bony healing. Radiography with satisfactory technical quality can often demonstrate a pars defect. Multislice CT with multiplanar reformats is the most accurate modality for detecting the bony defect and may also be used for assessment of osseous healing; however, as with radiographs, it is not sensitive for detection of the early edematous stress response without a fracture line and exposes the patient to ionizing radiation. Magnetic resonance (MR) imaging should be used as the primary investigation for adolescents with back pain and suspected stress reactions of the lumbar pars interarticularis. Several imaging pitfalls render MR imaging less sensitive than CT for directly visualizing the pars defects (regional degenerative changes and sclerosis). Nevertheless, the presence of bone marrow edema on fluid-sensitive images is an important early finding that may suggest stress response without a visible fracture line. Moreover, MR is the imaging modality of choice for identifying associated nerve root compression. Single-photon emission computed tomography (SPECT) use is limited by a high rate of false-positive and false-negative results and by considerable ionizing radiation exposure. In this article, we provide a review of the current concepts regarding spondylolysis, its epidemiology, pathogenesis, and general treatment guidelines, as well as a detailed review and discussion of the imaging principles for the diagnosis and follow-up of this condition. PMID:20440613
Leone, Antonio; Cianfoni, Alessandro; Cerase, Alfonso; Magarelli, Nicola; Bonomo, Lorenzo
Purpose We investigated types and prevalence of coexisting lesions found on whole spine sagittal T2-weighted images (WSST2I) acquired from magnetic resonance imaging (MRI) and evaluated their clinical significance in surgical degenerative spinal diseases. Materials and Methods Coexisting spinal lesions were investigated using WSST2I from 306 consecutive patients with surgical degenerative spinal diseases. Severity of coexisting lesions was classified into four grades (0-3). Lesions of grade 2 and 3 were defined as "meaningful coexisting spine lesions" (MCSL). Degenerative spinal diseases were classified into three pathologies: simple disc herniation, degenerative spinal stenosis, and ligament ossification disease. The relationships between MCSL, gender, age, and primary spine lesions were analyzed. Results MCSL were found in 95 patients: a prevalence of 31.1%. Five out of 95 MCSL were surgically managed. The most common types of MCSL were disc herniation with 13.1% prevalence, followed by degenerative stenosis (9.5%) and ligament ossification diseases (6.8%). Older patients (age ? 40) showed a significantly higher prevalence of MCSL than younger patients. There was no significant difference between male and female patients. The prevalence of MCSL was significantly higher (52.4%) in ligament ossification diseases than in disc herniation or spinal stenosis. Conclusion Degenerative spinal diseases showed a high prevalence of MCSL, especially in old ages and ligament ossification diseases. WSST2I is useful for diagnosing coexisting spinal diseases and to avoid missing a significant cord-compressing lesion.
Han, In-Ho; Suh, Sang-Hyun; Kuh, Sung-Uk; Chin, Dong-Kyu
Summary Lumbar spinal stenosis is a disease that is not always symptomatic, with increasing incidence on the population as it ages. Initial treatment must be conservative, based on medicine, physiokinesiotherapy, while compensating general illnesses. A second stage would include the use of steroid injec- tions, as in the epidural or foraminal space, or in the facet joints. If these treatments
Several methods are used to measure lumbar lordosis. In adult scoliosis patients, the measurement is difficult due to degenerative\\u000a changes in the vertebral endplate as well as the coronal and sagittal deformity. We did the observational study with three\\u000a examiners to determine the reliability of six methods for measuring the global lumbar lordosis in adult scoliosis patients.\\u000a Ninety lateral lumbar
Jae Young Hong; Seung Woo Suh; Hitesh N. Modi; Chang Yong Hur; Hae Ryong Song; Jong Hoon Park
The purpose of this study was to evaluate the feasibility and efficacy of arthroscopic decompression of lateral recess stenosis, determine potential associated complications, and present an alternative method to access the lateral recess of the lumbar spine. Forty patients were selected in whom the authors found clinical and computerized tomography evidence of lateral recess stenosis and sequestered foraminal herniations. All 40 were treated with a posterolateral arthroscopic technique, and 38 were available for this follow-up evaluation. A satisfactory result was obtained in 31 patients (82%). No neurovascular complications were encountered; however, other complications included an infection of the disc space in one patient and a causalgic-type pain in the involved extremity in four patients. The associated postoperative morbidity in this group of patients was minimal and resulted in rapid rehabilitation and return of patients to preoperative functioning level. PMID:8609559
Kambin, P; Casey, K; O'Brien, E; Zhou, L
Previous magnetic resonance imaging (MRI) studies have shown that repeated exposure to +Gz forces can cause premature degenerative changes of the cervical spine (i.e. a work-related disease). This paper reports on two clinical cases of +Gz-associated degenerative cervical spinal stenosis caused by dorsal osteophytes in fighter pilots. Conventional x-rays and MRI were used to demonstrate narrowing of the cervical spinal canal. The first case was complicated by a C6-7 intervertebral disk prolapse and a congenitally narrow spinal canal. The second case involved progressive degenerative spinal stenosis in the C5-6 disk space which required surgery. The findings in this case were confirmed by surgery which showed posterior osteophytes and thickened ligaments compressing the cervical medulla. These two cases suggest that +Gz forces can cause degenerative spinal stenosis of the cervical spine. Flight safety may be jeopardized if symptoms and signs of medullar compression occur during high +Gz stress. It is recommended that student fighter pilots undergo conventional x-rays and MRI studies in order to screen out and reject candidates with a congenitally narrow spinal canal. These examination methods might be useful in fighter pilots' periodic medical check-ups in order to reveal acquired degenerative spinal stenosis. PMID:10223268
Hämäläinen, O; Toivakka-Hämäläinen, S K; Kuronen, P
Background Laminectomy/laminotomy and foraminotomy are well established surgical techniques for treatment of symptomatic lumbar spinal stenosis. However, these procedures have significant limitations, including limited access to lateral and foraminal compression and postoperative instability. The purpose of this cadaver study was to compare bone, ligament, and soft tissue morphology following lumbar decompression using a minimally invasive MicroBlade Shaver® instrument versus hemilaminotomy with foraminotomy (HL). Methods The iO-Flex® system utilizes a flexible over-the-wire MicroBlade Shaver instrument designed for facet-sparing, minimally invasive “inside-out” decompression of the lumbar spine. Unilateral decompression was performed at 36 levels in nine human cadaver specimens, six with age-appropriate degenerative changes and three with radiographically confirmed multilevel stenosis. The iO-Flex system was utilized on alternating sides from L2/3 to L5/S1, and HL was performed on the opposite side at each level by the same investigator. Spinal canal, facet joint, lateral recess, and foraminal morphology were assessed using computed tomography. Results Similar increases in soft tissue canal area and decreases in ligamentum flavum area were noted in nondiseased specimens, although HL required removal of 83% more laminar area (P < 0.01) and 95% more bone resection, including the pars interarticularis and facet joints (P < 0.001), compared with the iO-Flex system. Similar increases in lateral recess diameter were noted in nondiseased specimens using each procedure. In stenotic specimens, the increase in lateral recess diameter was significantly (P = 0.02) greater following use of the iO-Flex system (43%) versus HL (7%). The iO-Flex system resulted in greater facet joint preservation in nondiseased and stenotic specimens. In stenotic specimens, the iO-Flex system resulted in a significantly greater increase in foraminal width compared with HL (24% versus 4%, P = 0.01), with facet joint preservation. Conclusion The iO-Flex system resulted in significantly better decompression of the lateral recess and foraminal areas compared with HL, while preserving posterior spinal elements, including the facet joint.
Lauryssen, Carl; Berven, Sigurd; Mimran, Ronnie; Summa, Christopher; Sheinberg, Michael; Miller, Larry E; Block, Jon E
Study Design: A prospective, non-comparative study of 27 patients to evaluate the safety and performance of the Memory Metal Spinal System used in a PLIF procedure in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease (DDD). Objective: To evaluate the clinical performance, radiological outcome and safety of the Memory Metal Spinal System, used in a PLIF procedure, in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease in human subjects. Summary of Background Data: Spinal systems that are currently available for correction of spinal deformities or degeneration such as lumbar spondylosis or degenerative disc disease, use components manufactured from stainless steel or titanium and typically comprise two spinal rods with associated connection devices. The Memory Metal Spinal System consists of a single square spinal rod made from a nickel titanium alloy (Nitinol) used in conjunction with connection devices. Nitinol is characterized by its shape memory effect and is a more flexible material than either stainless steel or titanium. With current systems there is loss of achieved reposition due to the elastic properties of the spine. By using a memory metal in this new system the expectation was that this loss of reposition would be overcome due to the metal’s inherent shape memory properties. Furthermore, we expect a higher fusion rate because of the elastic properties of the memory metal. Methods: Twenty-seven subjects with primary diagnosis of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease (DDD) were treated with the Memory Metal Spinal System in conjunction with the Brantigan IF® Cage in two consecutive years. Clinical performance of the device was evaluated over 2 years using the Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36) and pain visual analogue scale (VAS) scores. Safety was studied by collection of adverse events intra-operative and during the followup. Interbody fusion status was assessed using radiographs and a CT scan. Results: The mean pre-operative ODI score of 40.9 (±14.52) significantly improved to 17.7 (±16.76) at 24 months postoperative. Significant improvement in the physical component from the SF36 questionnaire was observed with increases from the baseline result of 42.4 to 72.7 at 24 months (p<.0001); The emotional component in the SF36 questionnaires mean scores highlighted a borderline significant increase from 56.5 to 81.7 at 24 months (p=0.0441). The average level of leg pain was reduced by more than 50% postoperation (VAS values reduced from 5.7 (±2.45) to 2.2 (±2.76) at 24 month post-operation with similar results observed for back pain. CT indicated interbody fusion rate was not significantly faster compared to other devices in literature. No device related adverse events were recorded in this study. Conclusions: The Memory Metal Spinal System, different from other devices on the market with regard to material and the one rod configuration, is safe and performed very well by improving clinically important outcomes in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease. In addition the data compares favorably to that previously reported for other devices in the literature.
Kok, D; Grevitt, M; Wapstra, FH; Veldhuizen, AG
Anterior cervical discectomy and fusion (ACDF) and anterior lumbar interbody fusion (ALIF) are common surgical procedures for degenerative disc disease of the cervical and lumbar spine. Over the years, many bone graft options have been developed and investigated aimed at complimenting or substituting autograft bone, the traditional fusion substrate. Here, we summarise the historical context, biological basis and current best evidence for these bone graft options in ACDF and ALIF. PMID:23743981
Chau, Anthony Minh Tien; Xu, Lileane Liang; Wong, Johnny Ho-Yin; Mobbs, Ralph Jasper
Background Most lumbar artificial discs are still composed of stainless steel alloys, which prevents adequate postoperative diagnostic imaging of the operated region when using magnetic resonance imaging (MRI). Thus patients with postoperative radicular symptoms or claudication after stainless steel implants often require alternative diagnostic procedures. Methods Possible complications of lumbar total disc replacement (TDR) are reviewed from the available literature and imaging recommendations given with regard to implant type. Two illustrative cases are presented in figures. Results Access-related complications, infections, implant wear, loosening or fracture, polyethylene inlay dislodgement, facet joint hypertrophy, central stenosis, and ankylosis of the operated segment can be visualised both in titanium and stainless steel implants, but require different imaging modalities due to magnetic artifacts in MRI. Conclusion Alternative radiographic procedures should be considered when evaluating patients following TDR. Postoperative complications following lumbar TDR including spinal stenosis causing radiculopathy and implant loosening can be visualised by myelography and radionucleotide techniques as an adjunct to plain film radiographs. Even in the presence of massive stainless steel TDR implants lumbar radicular stenosis and implant loosening can be visualised if myelography and radionuclide techniques are applied.
Robinson, Yohan; Sanden, Bengt
Study Design Retrospective study. Purpose To evaluate the relationship between a new osteoporotic vertebral fracture and instrumented lumbar arthrodesis. Overview of Literature In contrast to the growing recognition of the importance of adjacent segment disease after lumbar arthrodesis, relatively little attention has been paid to the relationship between osteoporotic vertebral fractures and instrumented lumbar arthrodesis. Methods Twenty five patients with a thoracolumbar vertebral fracture following instrumented arthrodesis for degenerative lumbar disorders (study group) were investigated. The influence of instrumented lumbar arthrodesis was examined by comparing the bone mineral density (BMD) of the femoral neck in the study group with that of 28 patients (control group) who had sustained a simple osteoporotic vertebral fracture. The fracture after instrumented arthrodesis was diagnosed at a mean 47 months (range, 7 to 100 months) after the surgery. Results There was a relatively better BMD in the study group, 0.67 ± 0.12 g/cm2 compared to the control group, 0.60 ± 0.13 g/cm2 (p = 0.013). The level of back pain improved from a mean of 7.5 ± 1.0 at the time of the fracture to a mean of 4.9 ± 2.0 at 1 year after the fracture (p = 0.001). However, 12 (48%) patients complained of severe back pain 1 year after the fracture. There was negative correlation between the BMD of the femoral neck and back pain at the last follow up (r = - 0.455, p = 0.022). Conclusions Osteoporotic vertebral fractures after instrumented arthrodesis contribute to the aggravation of back pain and the final outcome of degenerative lumbar disorders. Therefore, it is important to examine the possibility of new osteoporotic vertebral fractures for new-onset back pain after lumbar instrumented arthrodesis.
Kim, Bung-Hak; Choi, Dong-Hyuk; Jeon, Seong-Hun
Background Context Few studies have directly evaluated the association of lumbar lordosis and segmental wedging of the vertebral bodies and intervertebral disks with prevalence of spinal degenerative features. Purpose To evaluate the association of CT-evaluated lumbar lordosis, segmental wedging of the vertebral bodies and that of the intervertebral disks with various spinal degeneration features. Study design This cross-sectional study was a nested project to the Framingham Heart Study. Sample A random consecutive subset of 191 participants chosen from the 3590 participants enrolled in the Framingham Heart Study who underwent multi-detector CT to assess aortic calcification. Outcome Measures Physiologic Measures Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis, spondylolysis, spondylolisthesis and spinal stenosis and density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on supine CT, as well as the lordosis angle (LA) and the wedging of the vertebral bodies and intervertebral disks. Sum of vertebral bodies wedging (?B) and sum of intervertebral discs wedging (?D) were used in analyses. Methods Mean values (±SD) of LA, ?B and ?D were calculated in males and females and compared using the t-test. Mean values (±SD) of LA, ?B and ?D in 4 age groups: <40, 40–49, 50–59 and 60+ years were calculated. We tested the linear relationship between LA, ?B and ?D and age groups. We evaluated the association between each spinal degeneration feature and LA, ?B and ?D using multiple logistic regression analysis where studied degeneration features were the dependent variable and all LA, ?B and ?D (separately) as well as age, sex, and BMI were independent predictors. Results LA was slightly lower than the normal range for standing individuals, and no difference was found between males and females (p=0.4107). However, the sex differences in sum of vertebral bodies wedging (?B) and sum of intervertebral discs wedging (?D) were statistically significant (0.0001 and 0.001, respectively). Females exhibit more dorsal wedging of the vertebral bodies and less dorsal wedging of the intervertebral discs than do males. All these parameters showed no association (p>0.05) with increasing age. LA showed statistically significant association with presence of spondylolysis (OR(95%CI): 1.08(1.02–1.14)) and with density of multifidus (1.06 (1.01–1.11). as well as a marginally significant association with isthmic spondylolisthesis (1.07(1.00–1.14). ?B showed a positive association with degenerative spondylolisthesis and disc narrowing ((1.14(1.06–1.23) and 1.04 (1.00–1.08), correspondingly), whereas ?D showed negative one (0.93(0.87–0.98) and (0.93(0.89–0.97), correspondingly). Conclusions Significant associations were found between lumbar lordosis evaluated in supine position and segmental wedging of the vertebral bodies and intervertebral disks and prevalence of spondylolysis and spondylolisthesis. Additional studies are needed, to evaluate the association between spondylolysis, isthmic and degenerative spondylolisthesis and vertebral and disc wedging at segmental level.
Kalichman, Leonid; Li, Ling; Hunter, David; Been, Ella
A 69-year-old lady presented with back pain for 5 days associated with spiking temperatures, lower limb weakness and urinary retention. Urgent MRI showed discitis at the disc between cervical vertebra seven (C7), thoracic vertebra one (T1) and lumbar vertebra three and four (L3-4), associated dural inflammation, stenosis of the cervical spinal canal and cervical cord oedema at the level of C3. No definite epidural abscess was seen. She was transferred to the spinal unit for observation. Following transfer she rapidly developed respiratory compromise and required emergency spinal decompression later that day.
Idris, Salah; Collum, Niall
We present a case of lower back pain with lumbar nerve compromise due to a ligamentum flavum haematoma which was successfully treated surgically. A 62-year-old man was evaluated for lower back pain with associated leg pain and early signs of cauda equina syndrome. MRI of the lumbar spine demonstrated a contrast-enhancing mass adjacent to the lamina of L3 which was causing severe canal stenosis. Surgical excision of the lesion was recommended. The patient underwent an L3 laminectomy with excision of the epidural lesion. Histopathology showed it to be a haematoma of the ligamentum flavum with no untoward features. The patient recovered without complication. PMID:24642178
Ghent, Finn; Ye, Xuan; Yan, Max; Mobbs, Ralph J
Objective. Posterior dynamic stabilization is an effective alternative to fusion in the treatment of chronic instability and degenerative disc disease (DDD) of the lumbar spine. This study was undertaken to investigate the efficacy of dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2. Modic types 1 and 2 degeneration can be painful. Classic approach in such cases is spine fusion. We operated 88 DDD patients with Modic types 1 and 2 via posterior dynamic stabilization. Good results were obtained after 2 years of followup. Methods. A total of 88 DDD patients with Modic types 1 and 2 were selected for this study. The patients were included in the study between 2004 and 2010. All of them were examined with lumbar anteroposterior (AP) and lateral X-rays. Lordosis of the lumbar spine, segmental lordosis, and ratio of the height of the intervertebral disc spaces (IVSs) were measured preoperatively and at 3, 12, and 24 months after surgery. Magnetic resonance imaging (MRI) analysis was carried out, and according to the data obtained, the grade of disc degeneration was classified. The quality of life and pain scores were evaluated by visual analog scale (VAS) score and Oswestry Disability Index (ODI) preoperatively and at 3, 12, and 24 months after surgery. Appropriate statistical method was chosen. Results. The mean 3- and 12-month postoperative IVS ratio was significantly greater than that of the preoperative group (P < 0.001). However, the mean 1 and 2 postoperative IVS ratio was not significantly different (P > 0.05). Furthermore, the mean preoperative and 1 and 2 postoperative angles of lumbar lordosis and segmental lordosis were not significantly different (P > 0.05). The mean VAS score and ODI, 3, 12, and 24 months after surgery, decreased significantly, when compared with the preoperative scores in the groups (P = 0.000). Conclusion. Dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2 was effective.
Eser, Olcay; Gomleksiz, Cengiz; Sasani, Mehdi; Oktenoglu, Tunc; Aydin, Ahmet Levent; Ataker, Yaprak; Suzer, Tuncer; Ozer, Ali Fahir
Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature: results of a multicenter, prospective, randomized investigational device exemption study of Charité intervertebral disc: Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004
Object. Arthrodesis is the gold standard for surgical treatment of lumbar degenerative disc disease (DDD). Solid fusion, however, can cause stress and increased motion in the segments adjacent to the fused level. This may initiate and\\/or accelerate the adjacent-segment disease process. Artificial discs are designed to restore and maintain normal motion of the lumbar intervertebral segment. Restoring and maintaining normal
Fred H. Geisler; Scott L. Blumenthal; Richard D. Guyer; Paul C. McAfee; John J. Regan; J. Patrick Johnson; Bradford Mullin
Background Comparatively little is known about the relation between the sagittal vertical axis and clinical outcome in cases of degenerative lumbar spondylolisthesis. The objective of this study was to determine whether lumbar sagittal balance affects clinical outcomes after posterior interbody fusion. This series suggests that consideration of sagittal balance during posterior interbody fusion for degenerative spondylolisthesis can yield high levels of patient satisfaction and restore spinal balance Methods A retrospective study of clinical outcomes and a radiological review was performed on 18 patients with one or two level degenerative spondylolisthesis. Patients were divided into two groups: the patients without improvement in pelvic tilt, postoperatively (Group A; n = 10) and the patients with improvement in pelvic tilt postoperatively (Group B; n = 8). Pre- and postoperative clinical outcome surveys were administered to determine Visual Analogue Pain Scores (VAS) and Oswestry disability index (ODI). In addition, we evaluated full spine radiographic films for pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), thoracic kyphosis (TK), lumbar lordosis (LL), sacrofemoral distance (SFD), and sacro C7 plumb line distance (SC7D) Results All 18 patients underwent surgery principally for the relief of radicular leg pain and back pain. In groups A and B, mean preoperative VAS were 6.85 and 6.81, respectively, and these improved to 3.20 and 1.63 at last follow-up. Mean preoperative ODI were 43.2 and 50.4, respectively, and these improved to 23.6 and 18.9 at last follow-up. In spinopelvic parameters, no significant difference was found between preoperative and follow up variables except PT in Group A. However, significant difference was found between the preoperative and follows up values of PT, SS, TK, LL, and SFD/SC7D in Group B. Between parameters of group A and B, there is borderline significance on preoperative PT, preoperative LL and last follow up SS. Correlation analysis revealed the VAS improvements in Group A were significantly related to postoperative lumbar lordosis (Pearson's coefficient = -0.829; p = 0.003). Similarly, ODI improvements were also associated with postoperative lumbar lordosis (Pearson's coefficient = -0.700; p = 0.024). However, in Group B, VAS and ODI improvements were not found to be related to postoperative lumbar lordosis and to spinopelvic parameters. Conclusion In the current series, patients improving PT after fusion were found to achieve good clinical outcomes in degenerative spondylolisthesis. Overall, our findings show that it is important to quantify sagittal spinopelvic parameters and promote sagittal balance when performing lumbar fusion for degenerative spondylolisthesis.
The procedure of anterior lumbar interbody fusion (ALIF) is commonly performed on patients suffering from pain and/or neurological symptoms associated with disorders of the lumbar spine caused by disc degeneration and trauma. Surgery is indicated when prolonged conservative management proves ineffective. Because an important objective of the ALIF procedure is solid arthrodesis of the degenerative spinal segment, bone graft selection is critical. Iliac crest bone grafts (ICBG) remain the "gold standard" for achieving lumbar fusion. However, patient dissatisfaction stemming from donor site morbidity, lengthier operating times and finite supply of ICBG has prompted a search for better alternatives. Here presented is a literature review evaluating available bone graft options assessed within the clinical setting. These options include autografts, allograft-based, synthetic and cell-based technologies. The emphasis is on the contentious use of recombinant human bone morphogenetic proteins, which is in widespread use and has demonstrated both significant osteogenic potential and risk of complications. PMID:23658041
Mobbs, Ralph J; Chung, Mina; Rao, Prashanth J
Objective. Schmorl's nodes (SN) are common, but little is known of their relationship with degenerative change and back pain or genetic and environmental factors influencing their expression. We studied healthy female twin volunteers to determine the prevalence and clinical features associated with SN. Methods. Serial sagittal T1- and T2-weighted magnetic resonance images of the lower thoracic and lumbar spine were
F. M. K. Williams; N. J. Manek; P. N. Sambrook; T. D. Spector; A. J. Macgregor
PURPOSE OF THE STUDY The aim of this prospective study was to evaluate clinical and radiographic results in the patients who underwent L5-S1 fixation using the technique of percutaneous lumbar interbody fusion (AxiaLIF). MATERIAL The study comprised 23 patients, 11 women and 12 men, who ranged from age of 21 to 63 years, with an average of 48.2 years. In all patients surgical posterior stabilisation involving the L5-S1 segment had previously been done. The initial indications for surgery were L5-S1 spondylolisthesis in 20 and L5-S1 spondylosis and stenosis in three patients. METHODS The AxiaLIF technique for L5-S1 fixation was indicated in overweight patients and in those after repeated abdominal or retroperitoneal surgery. A suitable position and shape of the sacrum or lumbosacral junction was another criterion. The patients were evaluated between 26 and 56 months (average, 40.4 months) after primary surgery and, on the basis of CT and radiographic findings, bone union and lumbosacral junction stability were assessed. The clinical outcome was investigated using the ODI and VAS systems and the results were statistically analysed by the Wilcoxon test for paired samples with statistical significance set at a level of 0.05. RESULTS The average VAS value was 6.6 before surgery and, after surgery, 5.2 at three months, 4.2 at six months, 3.1 at one year, 2.9 at two years and 2.1 at three years (n=18). At two post-operative years, improvement in the VAS value by 56.1% was recorded. The average pre-operative ODI value was 25.1; the post-operative values were 17.0 at six months, 12.3 at one year, 10.6 at two years and 8.2 at three years (n=18). At two years after surgery the ODI value improved by 57.8%. To the question concerning their willingness to undergo, with acquired experience, surgery for the same diagnosis, 21 patients (91.3%) gave an affirmative answer. Neither screw breakage nor neurovascular damage or rectal injury was found. CT scans showed complete interbody bone fusion in 22 of the 23 patients (95.6%), In one patient the finding was not clear. Also, posterolateral fusion was achieved in all but one patients (95.6%). A stable L5-S1 segment was found in all patients at all follow-up intervals. The improvement in both VAS and ODI values was statistically significant. DISCUSSION In addition to indications usual in degenerative disc disease, overweight patients, those who had repeated trans- or retroperitoneal surgery in the L5-S1 region or who underwent long posterior fixation to stabilise the caudal margin of instrumentation are indicated for the AxiaLIF procedure. The clinical results of our study are in agreement with the conclusions of other studies and are similar to the outcomes of surgery using other types of fusion or dynamic stabilisation for this diagnosis. The high rate of fusion in our group is affected by use of a rigid transpedicular fixator together with posterolateral arthrodesis. On the other hand, no negative effects of only synthetic bone applied to interbody space were recorded. CONCLUSIONS The percutaneous axial pre-sacral approach to the L5-S1 interbody space with application of a double-treaded screw is another option for the management of this much strained segment. The technique is useful particularly when contraindications for conventional surgical procedures are present in patients with anatomical anomalies, in overweight patients or in those who have had repeated surgery in the region. Clinical outcomes and the success rate for L5-S1 bone fusion are comparable with conventional techniques. Complications are rare but their treatment is difficult. Key words:AxiaLIF, lumbar spine, spinal fusion, axial lumbar fixation. PMID:24945389
Stulík, J; Adámek, S; Barna, M; Kasp?íková, N; Polanecký, O; Kryl, J
Tasks involving flexed torso postures have a high incidence of low back injuries. Changes in the ability to sense and adequately control low back motion may play a role in these injuries. Previous studies examining position sense errors of the lumbar spine with torso flexion found significant increases in error with flexion. However, there has been little research on the effect of lumbar angle. In this study, the aim of the study was to examine how position sense errors would change with torso flexion as a function of the target lumbar angle. Fifteen healthy volunteers were asked to assume three different lumbar angles (maximum, minimum and mid-range) at three different torso flexion angles. A reposition sense protocol was used to determine a subject's ability to reproduce the target lumbar angles. Reposition sense error was found to increase 69% with increased torso flexion for mid-range target curvatures. With increasing torso flexion, the increase in reposition sense errors suggests a reduction in sensation and control in the lumbar spine that may increase risk of injury. However, the reposition error was smaller at high torso flexion angles in the extreme target curvatures. Higher sensory feedback at extreme lumbar angles would be important in preventing over-extension or over-flexion. These results suggest that proprioceptive elements in structures engaged at limits (such as the ligaments and facet joints), may provide a role in sensing position at extreme lumbar angles. Sensory elements in the muscles crossing the joint may also provide increased feedback at the edges of the range of motion.
Maduri, A.; Wilson, S. E.
Background Although a substantial percentage of patients with rheumatoid arthritis (RA) experience low back pain, the characteristics of lumbar spine pathology in RA patients has been poorly investigated. In our institutions, lumbar spine radiographs indicated scoliosis in 26 patients. The present study aimed to clarify the characteristics of lumbar scoliosis in RA patients. Methods This is a retrospective study of 26 RA patients with lumbar scoliosis. Patient characteristics such as disease duration, disease stage and class according to Steinbrocker's classification, and medication for RA and osteoporosis were reviewed. Radiologic evaluation of scoliosis was performed at two different time points by measuring Cobb angles. The progression of scoliosis per year was calculated by dividing the change in Cobb angles by the number of years. Apical vertebral rotation, lateral listhesis, and the level of the intercrestal line at the first observation were also measured. The correlation between different factors and changes in the Cobb angles per year was analyzed. Results Majority of the patients had a long disease duration and were classified as stage 3 or 4 according to Steinbrocker's classification. During the observation period, most patients were treated with glucocorticoids. Unlike the previous studies on degenerative scoliosis, apical vertebral rotation, lateral listhesis, and the level of the intercrestal line at initial observation were not significantly related to the progression of scoliosis. Initial Cobb angles were inversely related to the progression of scoliosis. Patients who were treated with bisphosphonates showed slower progression of scoliosis. Conclusions Our results indicate that the characteristics of lumbar scoliosis in RA patients differ from those of degenerative lumbar scoliosis. Bone fragility due to the long disease duration, poor control of disease activity, and osteoporosis is possibly related to its progression.
Degenerative spinal disorders, including intervertebral disc disease and spondylosis, seldom occur in domestic cats. In contrast, a retrospective study of 13 lions ( Panthera leo), 16 tigers (Panthera tigris), 4 leopards (Panthera pardis), 1 snow leopard (Panthera uncia), and 3 jaguars (Panthera onca) from the Knoxville Zoo that died or were euthanatized from 1976 to 1996 indicated that degenerative spinal
Christine Kolmstetter; Linda Munson; Edward C. Ramsay
Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in the lower lumbar region, while cervical localization is rare. Complete removal of the cyst leads to excellent results and seems to preclude recurrence. We report the case of a right-sided ligamentum flavum cyst occurring at L3-L4 level in a 70-year-old woman, which was surgically removed with excellent postoperative results and complete resolution of symptoms. In addition, we discuss and review reports in the literature. PMID:20582448
Taha, H; Bareksei, Y; Albanna, W; Schirmer, M
Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in the lower lumbar region, while cervical localization is rare. Complete removal of the cyst leads to excellent results and seems to preclude recurrence. We report the case of a right-sided ligamentum flavum cyst occurring at L3–L4 level in a 70-year-old woman, which was surgically removed with excellent postoperative results and complete resolution of symptoms. In addition, we discuss and review reports in the literature.
Bareksei, Y.; Albanna, W.; Schirmer, M.
Robotic assistance has gained increasing popularity in spinal surgery recently. Robotic assistance provides higher effectiveness and safety especially in conditions of complicated anatomy. It also enables the novel, previously unavailable surgical techniques, such as GO-Lif for lumbar spine fusion. The aim of the study is to assess the applicability and effectiveness of the robotic assistance in surgical treatment of degenerative lesion of lumbar spine. 16 patients were operated with robotic assistance device (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) between August 2009 and February 2010 in Spinal Department of Burdenko Neurosurgical Institute (Moscow, Russia) with degenerative disc disease. Preoperative assessment included MRI, X-rays and high-resolution CT (slice < 1 mm). The CT is essential for preoperative planning using computed work station SpineAssist. The robot was utilized for automated intraoperative positioning of the instruments according to preoperatively planned trajectories. Basic parameters of surgeries were thoroughly recorded: overall surgery time, radiation dose (all manipulations were performed under fluoroscopic control), accuracy of screw placement relative to preoperative planning, which was assessed using postoperative high-resolution CT with 3D reconstruction. Particular interest of the study was focused on the novel fusion technique for lumbar spine: Go-Lif (Guided Oblique Lumbar Interbody Fusion). This fusion modality enables segment fixation with two screws only, it is comparable with pedicular screws in terms of stability, being far less invasive. It may be used standalone or together with TLIF techniques. Robotic assistance enabled optimal screw placement even in complex anatomical cases (thin pedicles and rotational deformity). No implant-related complications were recorded. Surgery time was much longer in first 2 cases, though in further it decreased nearly to conventional (without robot) surgery time. For radiation dose same tendency was observed--in first 2 cases all surgical steps were fluoroscopically controlled, in further cases--only for primary anatomy registration. Based on control CT, accuracy of implant placement with robotic assistance is 1 mm. PMID:21260933
Konovalov, N A; Shevelev, I N; Kornienko, V N; Nazarenko, A G; Zelenkov, P V; Isaev, K A; Asiutin, D S
Cardiologists long assumed that aortic valve sclerosis/stenosis is a wear-and-tear, degenerative process; recent studies suggested that lipoproteins can play a key role in the development of both sclerosis/stenosis in the aortic valve. Thus, sclerosis/stenosis cannot be considered as a simple degenerative process, but on the contrary it is complex and involves multiple pathogenetic mechanisms. Experimental, clinical and epidemiological data support the link between aortic valvulopathy and atherosclerosis: both are caused by inflammation, lipid deposition, and accumulation of extracellular bone matrix protein. In non-randomized clinical studies, hydroxy-methylglutaryl-coenzyme A reductase inhibitors minimized the progression of aortic valvulopathy. The major pharmacological effect, supposed to underlie the inferred (but still unproven) impact of statins on aortic sclerosis/stenosis is plasma cholesterol reduction. Lately, retrospective clinical studies supported this hypothesis and suggested a key role for statins in delaying the progression of aortic valvulopathy. However, the potential favorable effects of statins require confirmation. Prospective trials in Canada and Europe are now ongoing (ASTRONOMER--Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin; SEAS--Simvastatin and the Ezetimibe in Aortic Stenosis) and will address the use of cholesterol-lowering drugs in reducing the progression of aortic valve stenosis and in improving clinical outcomes. PMID:16082823
Scardi, Sabino; Cherubini, Antonella
Lumbar spondylolysis, a well known cause of low back pain, usually affects the pars interarticularis of a lower lumbar vertebra and rarely involves the articular processes. We report a rare case of bilateral spondylolysis of inferior articular processes of L4 vertebra that caused spinal canal stenosis with a significant segmental instability at L4/5 and scoliosis. A 31-year-old male who had suffered from low back pain since he was a teenager presented with numbness of the right lower leg and scoliosis. Plain X-rays revealed bilateral spondylolysis of inferior articular processes of L4, anterolisthesis of the L4 vertebral body, and right lateral wedging of the L4/5 disc with compensatory scoliosis in the cephalad portion of the spine. MR images revealed spinal canal stenosis at the L4/5 disc level. Posterior lumbar interbody fusion of the L4/5 was performed, and his symptoms were relieved. PMID:22111522
Koakutsu, Tomoaki; Morozumi, Naoki; Hoshikawa, Takeshi; Ogawa, Shinji; Ishii, Yushin; Itoi, Eiji
Valvular aortic stenosis is common in the elderly with mild valve thickening affecting 25% of adults over age 65 years and stenosis affecting between 1-3% of elderly adults. Ac- curate diagnosis and quantitation of disease severity are important as valve replacement is needed when severe symptomatic obstruction is present. However, the symp- toms of aortic stenosis are non-specific. Most patients
Karen K. Stout; Catherine M. Otto
Diagnostic Lumbar Puncture is one of the most commonly performed invasive tests in clinical medicine. Evaluation of an acute headache and investigation of inflammatory or infectious disease of the nervous system are the most common indications. Serious complications are rare, and correct technique will minimise diagnostic error and maximise patient comfort. We review the technique of diagnostic Lumbar Puncture including anatomy, needle selection, needle insertion, measurement of opening pressure, Cerebrospinal Fluid (CSF) specimen handling and after care. We also make some quality improvement suggestions for those designing services incorporating diagnostic Lumbar Puncture.
Doherty, Carolynne M; Forbes, Raeburn B
Two cases of anastomotic stenosis after the use of the GIA Auto Suture Stapler are presented as examples of the potential problem that does exist in using this instrument. Possible causes and a suggestion for eliminating this complication have been outlined. PMID:869124
Elliott, T E; Albertazzi, V J; Danto, L A
Study design:?Systematic literature review. Rationale:?Many authors have postulated on various risk factors associated with the pathogenesis of degenerative spondylolisthesis (DS), yet controversies regarding those risk factors still exist. Objective:?To critically appraise and summarize evidence on risk factors for DS. Methods:?Articles published before October 15, 2011, were systematically reviewed using PubMed and bibliographies of key articles. Each article was subject to quality rating and was analyzed by two independent reviewers. Results:?From 382 citations, 30 underwent full-text review. Fourteen studies met inclusion criteria. All but two were considered poor quality. Female gender and higher facet joint angle were consistently associated with an increased risk of DS across multiple studies. Multiple studies also consistently reported no association between back pain and prolonged occupational sitting. Associations between age, parity, lumbosacral angle, lumbar lordosis, facet joint tropism, and pelvic inclination angles were inconsistent. Conclusions:?There appears to be consistent evidence to suggest that the risk of DS increases with increasing age and is greater for females and people with a greater facet joint angle.
DeVine, John G.; Schenk-Kisser, Jeannette M.; Skelly, Andrea C.
STUDY DESIGN:: retrospective analysis of prospectively collected clinical data. OBJECTIVE:: To assess the long-term outcome of patients with monosegmental L4/5 degenerative spondylolisthesis treated with the dynamic Dynesys device. SUMMARY OF BACKGROUND DATA:: The Dynesys® system has been used as a semirigid, lumbar dorsal pedicular stabilization device since 1994. Good short-term results have been reported, but little is known about the long-term outcome following treatment for degenerative spondylolisthesis at the L4/5 level. METHODS:: 39 consecutive patients with symptomatic degenerative lumbar spondylolisthesis at the L4/5 level were treated with bilateral decompression and Dynesys instrumentation. At a mean follow-up of 7.2 years (range 5.0-11.2?y) they underwent clinical and radiographic evaluation and quality of life assessment. RESULTS:: At final follow-up back pain improved in 89% and leg pain improved in 86% of patients compared to preoperative status. 83% of patients reported global subjective improvement. 92% would undergo the surgery again. 8 patients (21%) required further surgery due to symptomatic adjacent segment disease (6 cases), late onset infection (1 case), and screw breakage (1 case). In 9 cases radiological progression of spondylolisthesis at the operated segment was found. 74% of operated segments showed limited flexion-extension range of less than 4°. Adjacent segment pathology, though without clinical correlation, was diagnosed at the L5/S1 (17.9%) and L3/4 (28.2%) segments. In 4 cases asymptomatic screw loosening was observed. CONCLUSION:: Monosegmental Dynesys instrumentation of degenerative spondylolisthesis at L4/5 shows good long-term results. The rate of secondary surgeries is comparable to other dorsal instrumentation devices. Residual range of motion in the stabilized segment is reduced, and the rate of radiological and symptomatic adjacent segment degeneration is low. Patient satisfaction is high. Dynesys stabilization of symptomatic L4/5 degenerative spondylolisthesis is a possible alternative to other stabilization devices. PMID:23075857
Hoppe, Sven; Schwarzenbach, Othmar; Aghayev, Emin; Bonel, Harald; Berlemann, Ulrich
To date, several studies were conducted to find which procedure is superior to the others for the treatment of cervical myelopathy. The goal of surgical treatment should be to decompress the nerves, restore the alignment of the vertebrae, and stabilize the spine. Consequently, the treatment of cervical degenerative disease can be divided into decompression of the nerves alone, fixation of the cervical spine alone, or a combination of both. Posterior approaches have historically been considered safe and direct methods for cervical multisegment stenosis and lordotic cervical alignment. On the other hand, anterior approaches are indicated to the patients with cervical compression with anterior factors, relatively short-segment stenosis, and kyphotic cervical alignment. Recently, posterior approach is widely applied to several cervical degenerative diseases due to the development of various instruments. Even if it were posterior approach or anterior approach, each would have its complication. There is no Class I or II evidence to suggest that laminoplasty is superior to other techniques for decompression. However, Class III evidence has shown equivalency in functional improvement between laminoplasty, anterior cervical fusion, and laminectomy with arthrodesis. Nowadays, each surgeon tends to choose each method by evaluating patients' clinical conditions.
Nishizawa, Kazuya; Mori, Kanji; Saruhashi, Yasuo; Matsusue, Yoshitaka
In this paper, we explore the importance of axial lumbar MRI slices for automatic detection of abnormalities. In the past, only the sagittal views were taken into account for lumbar CAD systems, ignoring the fact that a radiologist scans through the axial slices as well, to confirm the diagnosis and quantify various abnormalities like herniation and stenosis. Hence, we present an automatic diagnosis system from axial slices using CNN(Convolutional Neural Network) for dynamic feature extraction and classification of normal and abnormal lumbar discs. We show 80:81% accuracy (with a specificity of 85:29% and sensitivity of 75:56%) on 86 cases (391 discs) using only an axial slice for each disc, which implies the usefulness of axial views for automatic lumbar abnormality diagnosis in conjunction with sagittal views.
Ghosh, Subarna; Chaudhary, Vipin; Dhillon, Gurmeet
Lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids, however, these therapies may relieve leg pain for weeks to months but do not influence functional status. Furthermore, the majority of patients report no substantial symptom change over the repeated treatment. Utilizing balloon catheters, we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections. Our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology.
Kim, Sung Hoon; Koh, Won Uk; Park, Soo Jin; Choi, Woo Jong; Suh, Jeong Hun; Leem, Jeong Gil; Park, Pyung Hwan
Lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids, however, these therapies may relieve leg pain for weeks to months but do not influence functional status. Furthermore, the majority of patients report no substantial symptom change over the repeated treatment. Utilizing balloon catheters, we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections. Our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology. PMID:22259719
Kim, Sung Hoon; Koh, Won Uk; Park, Soo Jin; Choi, Woo Jong; Suh, Jeong Hun; Leem, Jeong Gil; Park, Pyung Hwan; Shin, Jin Woo
Hypertrophic pyloric stenosis, a relatively common condition, is caused by hyperplasia of the musculature of the pylorus. The diagnosis is made by a history of projectile vomiting and failure to gain weight, the observation of gastric peristaltic waves, and the palpation of a pyloric “tumor.” A method of palpating this tumor is described in detail. Roentgenological studies are rarely indicated. Pylorotomy for treatment of hypertrophic pyloric stenosis was not successful until the development of necessary supporting measures. Preparation for operation consists of intravenous administration of fluids and electrolytes and sometimes serum or whole blood. The position of the tumor governs the choice between two different incisions. The operative procedure herein described is essentially that devised by Ramstedt many years ago, with modifications to facilitate the procedure.
Gans, Stephen L.
The authors studied the nuclear magnetic resonance films and the expression of MMP-1 and TIMP-1 in disk specimens' of patients who had undergone operations for lumbar disk herniation. Forty-one lumbar disk patients were evaluated imaging for degenerative changes and their disk specimens immunohistochemical expression of MMP-1 and TIMP-1. The degree of degenerative changes was based on magnetic resonance imaging films. Sections of disk immunostained for MMP-1 and TIMP-1 were evaluated semiquantitatively. Patients were categorized in three age groups: <30 years, from 30 to 60 years, and >60 years of age. The expressions of MMP-1 and TIMP-1 were related to patients' age and degree of degenerative changes. There were statistical differences in the expression of MMP-1 and TIMP-1 between the age and degree of degenerative changes groups. With the degree of degenerative changes, the expression of MMP-1 and TIMP-1 increased obviously. But in old age group, the expression of MMP-1/TIMP-1 was higher than the young groups. The expressions of MMP-1 and TIMP-1 were strongly correlated to the age and the degree of the degenerative changes. An important finding in this study is the unbalance of the expression of MMP-1 and TIMP-1 along with the growth of the age. PMID:24442990
Xu, Haidong; Mei, Qiang; He, Jin; Liu, Gang; Zhao, Jianning; Xu, Bin
Lumbar disc infection, either after surgical discectomy or caused by haematogenous spread from other infection sources, is a severe complication. Specific antibiotic treatment has to be started as soon as possible to obtain satisfactory results in conservative treatment or operative fusion. The aim of this study was to analyse 16 cases of lumbar disc infection, treated with percutaneous lumbar discectomy
R. G. Haaker; M. Senkal; T. Kielich; J. Krämer
Introduction. The use of extreme lateral interbody fusion (XLIF) and other lateral access surgery is rapidly increasing in popularity. However, limited data is available regarding its use in scoliosis surgery. The objective of this study was to evaluate the clinical outcomes of adults with degenerative lumbar scoliosis treated with XLIF. Methods. Thirty consecutive patients with adult degenerative scoliosis treated by a single surgeon at a major academic institution were followed for an average of 14.3 months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Validated clinical outcome scores were obtained on patients preoperatively and at most recent follow-up. Complications were recorded. Results. The study group demonstrated improvement in multiple clinical outcome scores. Oswestry Disability Index scores improved from 24.8 to 19.0 (P?0.001). Short Form-12 scores improved, although the change was not significant. Visual analog scores for back pain decreased from 6.8 to 4.6 (P?0.001) while scores for leg pain decreased from 5.4 to 2.8 (P?0.001). A total of six minor complications (20%) were recorded, and two patients (6.7%) required additional surgery. Conclusions. Based on the significant improvement in validated clinical outcome scores, XLIF is effective in the treatment of adult degenerative scoliosis.
Caputo, Adam M.; Michael, Keith W.; Chapman, Todd M.; Massey, Gene M.; Howes, Cameron R.; Isaacs, Robert E.; Brown, Christopher R.
BACKGROUND CONTEXT Retrolisthesis is relatively rare but when present has been associated with increased back pain and impaired back function. Neither the prevalence of this condition in individuals with lumbar disc herniations nor its possible relation to pre-operative back pain and dysfunction has been well studied. PURPOSE The purposes of this study were as follows: 1) to determine the prevalence of retrolisthesis (alone or in combination with other degenerative conditions) in individuals with confirmed L5 – S1 disc herniation who later underwent lumbar discectomy; 2) to determine if there is any association between retrolisthesis and degenerative changes within the same vertebral motion segment; and 3) to determine the relation between retrolisthesis (alone or in combination with other degenerative conditions) and pre-operative low back pain, physical function, and quality of life. STUDY DESIGN/SETTING Cross-sectional study. PATIENT SAMPLE A total of 125 individuals were identified for incorporation into this study. All patients had confirmed L5-S1 disc herniation on MRI and later underwent L5-S1 discectomy. All patients were enrolled in the SPORT (Spine Patient Outcomes Research Trial) study; data was obtained from the multi-institutional database comprised of SPORT patients from across the United States. OUTCOME MEASURES Retrolisthesis, Degenerative change on MRI, Modic Changes. METHODS MRI scans of the lumbar spine were assessed at spinal level L5–S1 for all 125 patients. Retrolisthesis was defined as posterior subluxation of 8% or more. Disc degeneration was defined as any loss of disc signal on T2 imaging. Modic changes were graded 1 – 3 and collectively classified as vertebral endplate degenerative changes. The presence of facet arthropathy and ligamentum flavum hypertrophy were classified jointly as posterior degenerative changes. RESULTS The overall incidence of retrolisthesis at L5-S1 in our study was 23.2%. Retrolisthesis combined with posterior degenerative changes, degenerative disc disease, or vertebral endplate changes had incidences of 4.8%, 16%, and 4.8% respectively. The prevalence of retrolisthesis did not vary by sex, age, race, smoking status, or education level when compared to individuals with normal sagittal alignment. However, individuals with retrolisthesis were more likely to be receiving worker compensation than those without retrolisthesis. Increased age was found to be associated with individuals having vertebral endplate degenerative changes (both alone and in conjunction with retrolisthesis) and degenerative disc disease. Individuals who had retrolisthesis with concomitant vertebral endplate degenerative changes were more often smokers and had no insurance. The presence of retrolisthesis was not associated with an increased incidence of having degenerative disc disease, posterior degenerative changes, or vertebral endplate changes. No statistical significance was found between the presence of retrolisthesis on the degree of patient pre-operative low back pain and physical function. Patients with degenerative disc disease were found to have increased leg pain compared to those patients without degenerative disc changes. CONCLUSIONS We found no significant relationship between retrolisthesis in patients with L5-S1 disc herniation and worse baseline pain or function. It is possible that the contribution of pain or dysfunction related to retrolisthesis was far overshadowed by the presence of symptoms due to the concomitant disc herniation. It remains to be seen whether retrolisthesis will affect outcome following discectomy in these patients.
Shen, Michael; Razi, Afshin; Lurie, Jon D.; Hanscom, Brett; Weinstein, Jim
Lumbar disc herniation very rarely occurs in adolescence. The aim of this study was to assess the radiological, clinical and surgical features and case outcomes for adolescents with lumbar disc herniation, and to compare with adult cases. The cases of 17 adolescents (7 girls and 10 boys, age range 13–17 years) who were surgically treated for lumbar disc herniation in
Serdar Ozgen; Deniz Konya; O. Zafer Toktas; Adnan Dagcinar; M. Memet Ozek
Study Design A retrospective study. Purpose To examine the effectiveness of using an electrodiagnostic technique as a new approach in the clinical diagnosis of extraforaminal stenosis at L5-S1. Overview of Literature We introduced a new effective approach to the diagnosis of extraforaminal stenosis at the lumbosacral junction using the existing electrophysiological evaluation technique. Methods A consecutive series of 124 patients with fifth lumbar radiculopathy were enrolled, comprising a group of 74 patients with spinal canal stenosis and a second group of 50 patients with extraforaminal stenosis at L5-S1. The technique involved inserting a pair of needle electrodes into the foraminal exit zone of the fifth lumbar spinal nerves, which were used to provide electrical stimulation. The compound muscle action potentials from each of the tibialis anterior muscles were recorded. Results The distal motor latency (DML) of the potentials ranged from 11.2 to 24.6 milliseconds in patients with extraforaminal stenosis. In contrast, the DML in patients with spinal canal stenosis ranged from 10.0 to 17.2 milliseconds. After comparing the DML of each of the 2 groups and at the same time comparing the differences in DML between the affected and unaffected side of each patient, we concluded there were statistically significant differences (p<0.01) between the 2 groups. Using receiver operating characteristic curve analysis, the cutoff values were calculated to be 15.2 milliseconds and 1.1 milliseconds, respectively. Conclusions This approach using a means of DML measurement enables us to identify and localize lesions, which offers an advantage in diagnosing extraforaminal stenosis at L5-S1.
Yoshida, Munehito; Yamada, Hiroshi; Hashizume, Hiroshi; Minamide, Akihito; Nakagawa, Yukihiro; Kawai, Masaki; Tsutsui, Shunji
Radiologic measurement of central spinal canal diameters is considered a static measurement and does not necessarily indicate active stenosis. A free intracanal space is detectable with CT scanning, i.e., a container/content difference expressing reserve capacity and implying a functional identity. The obliteration of this space may induce clinical symptomatology in the elderly and in persons with developmental or acquired lumbar spinal conditions. Normal and pathologic measurements are presented. PMID:6617005
Weisz, G M; Lee, P
Anal fissure is a common anorectal disorder resulting in anal pain and bleeding. Fissures can either heal spontaneously and be classified as acute, or persist for 6 or more weeks and be classified as chronic, ultimately necessitating treatment. Anal stenosis is a challenging problem most commonly resulting from trauma, such as excisional hemorrhoidectomy. This frustrating issue for the patient is equally as challenging to the surgeon. This article reviews these 2 anorectal disorders, covering their etiology, mechanism of disease, diagnosis, and algorithm of management. PMID:24280397
Shawki, Sherief; Costedio, Meagan
The lumbar spine is a less common location for chordoma. Here we describe a 44-year-old woman presenting with pain due to a L4 vertebral expansile lesion that caused significant canal stenosis and neural foraminal compromise. Vertebroplasty was performed and resulted in immediate pain relief. For patients with painful lumbar chordoma who are unwilling to undergo surgery, vertebroplasty can play a palliative role as in patients with other vertebral lesions. Treating pain and stabilizing vertebra by way of vertebroplasty in a case of chordoma has not yet been reported.
Chatterjee, Somenath; Bodhey, Narendra Kuber, E-mail: email@example.com; Gupta, Arun Kumar; Periakaruppan, Alagappan [Sree Chitra Tirunal Institute for Medical Sciences and Technology, Department of Imaging Sciences and Interventional Radiology (India)
Lumbar hernia is one of the rare cases that most surgeons are not exposed to. Hence the diagnosis can be easily missed. This leads to delay in the treatment causing increased morbidity. We report a case of lumbar hernia in a middle-aged woman. It was misdiagnosed as lipoma by another surgeon. It was a case of primary acquired lumbar hernia in the superior lumbar triangle. Clinical and MRI findings were correlated to reach the diagnosis. We also highlight the types, the process of diagnosis and the surgical repair of lumbar hernias. We wish to alert our fellow surgeons to keep the differential diagnosis of the lumbar hernia in mind before diagnosing any lumbar swelling as lipoma. PMID:24810439
Ahmed, Syed Tausif; Ranjan, Rajeeva; Saha, Subhendu Bikas; Singh, Balbodh
Background Relationships between patient satisfaction with nursing and patient clinical data have not been fully resolved in a Polish sample. Our objectives were to determine clinical factors associated with patient satisfaction with nursing and investigate differences between patients treated surgically for cervical or lumbar discopathy and degenerative changes. Material/Methods This prospective and cross-sectional study included 63 consecutively selected patients treated surgically for lumbar discopathy and degenerative spine disease and 41 patients undergoing surgery for cervical discopathy and degenerative spine disease from 1st June 2009 to 31st September 2010 in the Department of Neurosurgery and Neurotraumatology of Poznan University of Medical Sciences. In the first stage of this study, socio-demographic data, medical history, and clinical patient characteristics were collected. A minimum 12-month follow-up formed the second part. Nineteen patients with lumbar discopathy were excluded because they were unable to answer the questionnaire. Finally, 44 consecutively selected patients treated surgically for lumbar discopathy and 41 patients undergoing surgery due to cervical discopathy were evaluated with the Polish version of the Newcastle Satisfaction with Nursing Scale (NSNS-PL). Results In patients with cervical and lumbar discopathy, the average Experiences of Nursing Care Subscale (ENCS) scores were 82.0 (SD 15.1) and 79.0 (SD 13.5), respectively, whereas the average Satisfaction with Nursing Care Subscale (SNCS) scores were 75.6 (SD 18.1) and 74.4 (SD 16.8), respectively. The study groups did not differ in regards to NSNS subscales. Associations between ENCS and SNCS scores were confirmed in both patient groups (rS=.73, p<0.001 and rS=.73, p<0.001, respectively). Conclusions Our study highlights the importance of assessing the association between patient characteristics and patient perception of quality of nursing care. Satisfaction with treatment outcome and conviction about undergoing the same treatment affected experiences and satisfaction with nursing in the cervical group only.
Garczyk, Danuta; Jankowski, Roman; Misterska, Ewa; Glowacki, Maciej; Zukiel, Ryszard; Kowalska, Anna M.
The authors describe two cases of pseudomeningocele after surgery for herniated lumbar disc. In order to prevent this rare complication, they suggest to suture the dura and to put on it oxycel or gelfoam every time there is a fluid leakage. The patient has to be placed in Trendelenburg's position for about seven days. PMID:3564761
Rocca, A; Turtas, S; Pirisi, A; Agnetti, V
Calcific aortic valve disease is associated with increased morbidity and mortality, especially in the elderly. To date, pharmacological therapies have not proven as effective as surgical intervention. Here, we used a hyperlipidemic rabbit model to investigate the potential effects of selective aldosterone inhibition on the early stages of aortic valve calcification, a pharmacological strategy that has not yet been tested.
Spyridon Gkizas; Dimitra Koumoundourou; Xara Sirinian; Stamatina Rokidi; Dimosthenis Mavrilas; Petros Koutsoukos; Apostolos Papalois; Efstratios Apostolakis; Dimitrios Alexopoulos; Helen Papadaki
Calcific aortic valve disease is associated with increased morbidity and mortality, especially in the elderly. To date, pharmacological therapies have not proven as effective as surgical intervention. Here, we used a hyperlipidemic rabbit model to investigate the potential effects of selective aldosterone inhibition on the early stages of aortic valve calcification, a pharmacological strategy that has not yet been tested. Forty New Zealand male rabbits fed a standard diet for 4 weeks were separated into three groups: (1) control (n=10), fed a standard diet; (2) vehicle (n=15), fed a hyperlipidemic diet (cholesterol 1%) plus vehicle; and (3) eplerenone (n=15), fed a hyperlipidemic diet plus 100 mg/kg/d eplerenone (last 4 weeks). After 8 weeks, animals were sacrificed and prepared aortic valve sections were examined with Von Kossa silver stain and by immunostaining for mineralocorticoid receptor, macrophages and angiotensin-converting enzyme. The presence of calcium deposits was confirmed by scanning electron microscopy. Eplerenone increased aldosterone levels but did not affect blood pressure, cholesterol or potassium levels. Hyperlipidemia induced macrophage accumulation and angiotensin-converting enzyme expression, as well as calcium deposition in the leaflets. All markers were decreased by eplerenone treatment. Immunohistochemistry for mineralocorticoid (aldosterone) receptors revealed similar expression in the leaflets of both control and hyperlipidemic groups. Collectively, these results indicate that aldosterone receptors are present in rabbit aortic valve leaflets and their selective blockade with eplerenone inhibits formation of the sclerotic lesions induced by a high fat diet. PMID:20553922
Gkizas, Spyridon; Koumoundourou, Dimitra; Sirinian, Xara; Rokidi, Stamatina; Mavrilas, Dimosthenis; Koutsoukos, Petros; Papalois, Apostolos; Apostolakis, Efstratios; Alexopoulos, Dimitrios; Papadaki, Helen
Intracranial arterial stenosis (IAS) is usually attributable to atherosclerosis and corresponds to the most common cause of stroke worldwide. It is very prevalent among African, Asian, and Hispanic populations. Advancing age, systolic hypertension, diabetes mellitus, high levels of low-density lipoprotein cholesterol, and metabolic syndrome are some of its major risk factors. IAS may be associated with transient or definite neurological symptoms or can be clinically asymptomatic. Transcranial Doppler and magnetic resonance angiography are the most frequently used ancillary examinations for screening and follow-up. Computed tomography angiography can either serve as a screening tool for the detection of IAS or increasingly as a confirmatory test approaching the diagnostic accuracy of catheter digital subtraction angiography, which is still considered the gold (confirmation) standard. The risk of stroke in patients with asymptomatic atherosclerotic IAS is low (up to 6% over a mean follow-up period of approximately 2 years), but the annual risk of stroke recurrence in the presence of a symptomatic stenosis may exceed 20% when the degree of luminal narrowing is 70% or more, recently after an ischemic event, and in women. It is a matter of controversy whether there is a specific type of treatment other than medical management (including aggressive control of vascular risk factors and antiplatelet therapy) that may alter the high risk of stroke recurrence among patients with symptomatic IAS. Endovascular treatment has been thought to be helpful in patients who fail to respond to medical treatment alone, but recent data contradict such expectation. PMID:23850084
Carvalho, Marta; Oliveira, Ana; Azevedo, Elsa; Bastos-Leite, António J
Alkaptonuria is a rare metabolic disorder of tyrosine catabolism in which homogentisic acid (HGA) accumulates and is deposited throughout the spine, large joints, cardiovascular system, and various tissues throughout the body. In the cardiovascular system, pigment deposition has been described in the heart valves, endocardium, pericardium, aortic intima and coronary arteries. The prevalence of cardiovascular disease in patients with alkaptonuria varies in previous reports . We present a series of 76 consecutive adult patients with alkaptonuria who underwent transthoracic echocardiography between 2000 and 2009. A subgroup of 40 patients enrolled in a treatment study underwent non-contrast CT scans and these were assessed for vascular calcifications. Six of the 76 patients had aortic valve replacement. In the remaining 70 patients, 12 patients had aortic sclerosis and 7 patients had aortic stenosis. Unlike degenerative aortic valve disease, we found no correlation with standard cardiac risk factors. There was a modest association between the severity of aortic valve disease and joint involvement, however, we saw no correlation with urine HGA levels. Vascular calcifications were seen in the coronaries, cardiac valves, aortic root, descending aorta and iliac arteries. These findings suggest an important role for echocardiographic screening of alkaptonuria patients to detect valvular heart disease and cardiac CT to detect coronary artery calcifications.
Hannoush, Hwaida; Introne, Wendy J.; Chen, Marcus Y.; Lee, Sook-Jin; O'Brien, Kevin; Suwannarat, Pim; Kayser, Michael A.; Gahl, William A.; Sachdev, Vandana
Background The sagittal alignment of the spine changes depending on body posture and degenerative changes. This study aimed to observe changes in sagittal alignment of the lumbar spine with different positions (standing, supine, and various sitting postures) and to verify the effect of aging on lumbar sagittal alignment. Methods Whole-spine lateral radiographs were obtained for young volunteers (25.4?±?2.3 years) and elderly volunteers (66.7?±?1.7 years). Radiographs were obtained in standing, supine, and sitting (30°, 60°, and 90°) positions respectively. We compared the radiological changes in the lordotic and segmental angles in different body positions and at different ages. Upper and lower lumbar lordosis were defined according to differences in anatomical sagittal mobility and kinematic behavior. Results Lumbar lordosis was greater in a standing position (52.79° and 53.90° in young and old groups, respectively) and tended to decrease as position changed from supine to sitting. Compared with the younger group, the older group showed significantly more lumbar lordosis in supine and 60° and 90° sitting positions (P?=?0.043, 0.002, 0.011). Upper lumbar lordosis in the younger group changed dynamically in all changed positions compared with the old group (P?=?0.019). Lower lumbar lordosis showed a decreasing pattern in both age groups, significantly changing as position changed from 30° to 60° (P?=?0.007, 0.007). Conclusions Lumbar lordosis decreases as position changes from standing to 90°sitting. The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties. Changes in lumbar lordosis were concentrated in the lower lumbar region in the older group in sitting positions.
Study design:?Comparative effectiveness review. Study rationale:?Spinal fusion is believed to accelerate the degeneration of the vertebral segment above or below the fusion site, a condition called adjacent segment disease (ASD). The premise of dynamic stabilization is that motion preservation allows for less loading on the discs and facet joints at the adjacent, non-fused segments. In theory, this should decrease the rate of ASD. However, clinical evidence of this theoretical decrease in ASD is still lacking. We performed a systematic review to evaluate the evidence in the literature comparing dynamic stabilization with fusion. Clinical question:?In patients 18 years or older with degenerative disease of the cervical or lumbar spine, does dynamic stabilization lead to better outcomes and fewer complications, including ASD, than fusion in the short-term and the long-term? Methods:?A systematic search and review of the literature was undertaken to identify studies published through March 7, 2011. PubMed, Cochrane, and National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two individuals independently reviewed articles based on inclusion and exclusion criteria which were set a priori. Each article was evaluated using a predefined quality-rating scheme. Results:?No significant differences were identified between fusion and dynamic stabilization with regard to VAS, ODI, complications, and reoperations. There are no long-term data available to show whether dynamic stabilization decreases the rate of ASD. Conclusions:?There are no clinical data from comparative studies supporting the use of dynamic stabilization devices over standard fusion techniques.
Chou, Dean; Lau, Darryl; Skelly, Andrea; Ecker, Erika
Background contextPosterior lumbar interbody fusion (PLIF) is a popular method of arthrodesis for surgical treatment of instabilities and degenerative conditions of the spine. With the introduction of threaded titanium cage devices, surgeons began performing PLIF procedures using these cages as stand-alone devices. Complications have been reported, however, including pseudarthrosis with persistent pain. Outcomes after revision surgical treatment for these patients
Ezequiel H. Cassinelli; Corey Wallach; Brett Hanscom; Molly Vogt; James D. Kang
Little information is available regarding the long-term effects, if any, of running on the musculoskeletal system. The authors compared the prevalence of degenerative joint disease among 17 male runners with 18 male nonrunners. Running subjects (53% marathoners) ran a mean of 44.8 km (28 miles)/wk for 12 years. Pain and swelling of hips, knees, ankles and feet and other musculoskeletal complaints among runners were comparable with those among nonrunners. Radiologic examinations (for osteophytes, cartilage thickness, and grade of degeneration) also were without notable differences among groups. They did not find an increased prevalence of osteoarthritis among the runners. Our observations suggest that long-duration, high-mileage running need to be associated with premature degenerative joint disease in the lower extremities.
Panush, R.S.; Schmidt, C.; Caldwell, J.R.; Edwards, N.L.; Longley, S.; Yonker, R.; Webster, E.; Nauman, J.; Stork, J.; Pettersson, H.
One of the most important sequelae affecting long-term results is adjacent-segment degeneration (ASD) after posterior lumbar interbody fusion (PLIF). Although several reports have described the incidence rate, there have been no reports of repeated ASD. The purpose of this report was to describe 1 case of repeated ASD after PLIF. A 62-year-old woman with L-4 degenerative spondylolisthesis underwent PLIF at L4-5. At the second operation, L3-4 PLIF was performed for L-3 degenerative spondylolisthesis 6 years after the primary operation. At the third operation, L2-3 PLIF was performed for L-2 degenerative spondylolisthesis 1.5 years after the primary operation. Vertebral collapse of L-1 was detected 1 year after the third operation, and the collapse had progressed. At the fourth operation, 3 years after the third operation, vertebral column resection of L-1 and replacement of titanium mesh cages with pedicle screw fixation between T-4 and L-5 was performed. Although the patient's symptoms resolved after each operation, the time between surgeries shortened. The sacral slope decreased gradually although each PLIF achieved local lordosis at the fused segment. PMID:24654745
Okuda, Shinya; Oda, Takenori; Yamasaki, Ryoji; Maeno, Takafumi; Iwasaki, Motoki
Treatment of motor symptoms of degenerative cerebellar ataxia remains difficult. Yet there are recent developments that are likely to lead to significant improvements in the future. Most desirable would be a causative treatment of the underlying cerebellar disease. This is currently available only for a very small subset of cerebellar ataxias with known metabolic dysfunction. However, increasing knowledge of the pathophysiology of hereditary ataxia should lead to an increasing number of medically sensible drug trials. In this paper, data from recent drug trials in patients with recessive and dominant cerebellar ataxias will be summarized. There is consensus that up to date, no medication has been proven effective. Aminopyridines and acetazolamide are the only exception, which are beneficial in patients with episodic ataxia type 2. Aminopyridines are also effective in a subset of patients presenting with downbeat nystagmus. As such, all authors agreed that the mainstays of treatment of degenerative cerebellar ataxia are currently physiotherapy, occupational therapy, and speech therapy. For many years, well-controlled rehabilitation studies in patients with cerebellar ataxia were lacking. Data of recently published studies show that coordinative training improves motor function in both adult and juvenile patients with cerebellar degeneration. Given the well-known contribution of the cerebellum to motor learning, possible mechanisms underlying improvement will be outlined. There is consensus that evidence-based guidelines for the physiotherapy of degenerative cerebellar ataxia need to be developed. Future developments in physiotherapeutical interventions will be discussed including application of non-invasive brain stimulation. PMID:24222635
Ilg, W; Bastian, A J; Boesch, S; Burciu, R G; Celnik, P; Claaßen, J; Feil, K; Kalla, R; Miyai, I; Nachbauer, W; Schöls, L; Strupp, M; Synofzik, M; Teufel, J; Timmann, D
Stenosis is one of the most common causes for spinal surgery. Laminectomy decompression and fusion are surgical procedures prescribed for this condition. The intention of this work was to investigate the effects of a laminectomy decompression, followed by fusion, on a lumbar functional spinal unit (FSU) through in vitro dynamic (±8Nm at 0.125Hz) and quasi-static (±7.5Nm at 0.1Hz) biomechanical tests,
Sabrina Alejandra Gonzalez Blohm
BACKGROUND: Although several authors have reported the use of endoscopic techniques to treat lumbar foraminal stenosis, the practical application of these techniques has been limited to soft disc herniation. OBJECTIVE: To describe the details of the percutaneous endoscopic lumbar foraminotomy (ELF) technique for bony foraminal stenosis and to demonstrate the clinical outcomes. METHODS: Two years of prospective data were collected from 33 consecutive patients with lumbar foraminal stenosis who underwent ELF. The surgical outcomes were assessed using the visual analog scale, Oswestry Disability Index, and modified MacNab criteria. The procedure begins at the safer extraforaminal zone rather than the riskier intraforaminal zone. Then, a full-scale foraminal decompression can be performed using a burr and punches under endoscopic control. RESULTS: The mean age of the 18 female and 15 male patients was 64.2 years. The mean visual analog scale score for leg pain improved from 8.36 at baseline to 3.36 at 6 weeks, 2.03 at 1 year, and 1.97 at 2 years post-surgery (P < .001). The mean Oswestry Disability Index improved from 65.8 at baseline to 31.6 at 6 weeks, 19.7 at 1 year, and 19.3 at 2 years post-surgery (P < .001). Based on the modified MacNab criteria, excellent or good results were obtained in 81.8% of the patients, and symptomatic improvements were obtained in 93.9%. CONCLUSION: Percutaneous ELF under local anesthesia could be an efficacious surgical procedure for the treatment of foraminal stenosis. This procedure may offer safe and reproducible results, especially for elderly or medically compromised patients. ABBREVIATIONS: ELF,endoscopic lumbar foraminotomy ODI, Oswestry Disability Index VAS, visual analog scale
Oh, Hyun-Kyong; Kim, Ho; Lee, Sang-Ho; Lee, Haeng-Nam
BACKGROUND: Outcomes of surgical intervention for lumbar synovial cysts have been evaluated in the short and intermediate term. Concerns regarding cyst recurrence, the development of late instability at the involved level, and instability\\/stenosis at adjacent levels (when concomitant) fusion is performed suggest that long term follow-up is needed. This study aims to fill that void. METHODS: Forty-six patients operated by
Bradley K Weiner; Joel Torretti; Michael Stauff
Congenital lumbar hernia (CLH) is a rare anomaly with only 45 cases reported in the English-language literature. This paper describes nine patients with CLH treated in our unit. Unusual features included the relatively high incidence of inferior lumbar hernia, presentation at the age of 6 years in one case, and an association with hydrometrocolpos and anorectal malformation, which is hitherto unreported. In seven patients the hernia could be repaired successfully. One patients' parents refused surgery for the CLH after treatment of a hydrometrocolpos and another died of fulminant pneumonia before the operation. Early operation is the treatment of choice, and repair with local tissues is preferable. The need for prosthetic material arises when the size of the defect is large. A successful operation offers a good quality of life. PMID:10663870
Wakhlu, A; Wakhlu, A K
Intraspinal and extradural cysts in the cervical spine are rare disorders that may cause myelopathy or radiculopathy. A synovial cyst or ganglion derived from the facet joint and that from a ligamentum flavum have been reported. We report a surgical case of degenerative intraspinal cyst, causing cervical myelopathy. MRI of a case revealed cystic lesion at C4-5. Spinal cord was compressed by cyst and symptoms of myelopathy were also observed. The patient with cervical spinal canal stenosis underwent laminoplasty and excision of the cyst. The patient recovered well immediately after the surgery. Literature review showed that 133 patients have been reported, including the present case. Previous reports indicated that most cysts occurred in old patients and at the atlanto-axial or C7-T1 junction, and laminectomy or laminoplasty with excision of the cyst gave good results in most cases. PMID:23195823
Machino, Masaaki; Yukawa, Yasutsugu; Ito, Keigo; Kato, Fumihiko
Biomedical advances in vision research have been greatly facilitated by the clinical accessibility of the visual system, its ease of experimental manipulation, and its ability to be functionally monitored in real time with noninvasive imaging techniques at the level of single cells and with quantitative end-point measures. A recent example is the development of stem cell-based therapies for degenerative eye diseases including AMD. Two phase I clinical trials using embryonic stem cell-derived RPE are already underway and several others using both pluripotent and multipotent adult stem cells are in earlier stages of development. These clinical trials will use a variety of cell types, including embryonic or induced pluripotent stem cell-derived RPE, bone marrow- or umbilical cord-derived mesenchymal stem cells, fetal neural or retinal progenitor cells, and adult RPE stem cells-derived RPE. Although quite distinct, these approaches, share common principles, concerns and issues across the clinical development pipeline. These considerations were a central part of the discussions at a recent National Eye Institute meeting on the development of cellular therapies for retinal degenerative disease. At this meeting, emphasis was placed on the general value of identifying and sharing information in the so-called "precompetitive space." The utility of this behavior was described in terms of how it could allow us to remove road blocks in the clinical development pipeline, and more efficiently and economically move stem cell-based therapies for retinal degenerative diseases toward the clinic. Many of the ocular stem cell approaches we discuss are also being used more broadly, for nonocular conditions and therefore the model we develop here, using the precompetitive space, should benefit the entire scientific community. PMID:24573369
Bharti, Kapil; Rao, Mahendra; Hull, Sara Chandros; Stroncek, David; Brooks, Brian P; Feigal, Ellen; van Meurs, Jan C; Huang, Christene A; Miller, Sheldon S
Study Design. This was a prospective clinical study that took place in an outpatient spine clinic. Objective. To demonstrate the short-/long-term outcomes from a large cohort of patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF). Summary of Background Data. Long-term prospective outcomes in patients undergoing minimally invasive spinal fusion for debilitating back pain has not been well studied. Methods. Presenting diagnosis was determined from clinical findings and radiographical (radiograph, magnetic resonance image, computed tomographic scan) evaluations preoperatively. Patients were assessed with outcome measures preoperatively, and postoperatively at 2 weeks, 3 months, 6 months, 12 months, 24 months, and annually 2 to 7 years (mean follow-up: 47 mo) final follow-up. The rate of postoperative complications and reoperations at the initial level of MITLIF and adjacent level(s) were followed. Fusion rates were assessed blinded and independently by radiograph. Results. Visual analogue scale scores decreased significantly from 7.0 preoperatively to 3.5 at mean 47-month follow-up. Oswestry Disability Index scores declined from 43.1 preoperatively to 28.2 at mean 47-month follow-up. Short-Form 36 mental component scores increased from 43.8 preoperatively to 49.7 at 47-month follow-up. Short-Form 36 physical component scores increased from 30.6 preoperatively to 39.6 at 47-month follow-up (P < 0.05). Conclusion. This prospectively collected outcomes study shows long-term statistically significant clinical outcomes improvement after MITLIF in patients with clinically symptomatic spondylolisthesis and degenerative disc disease with or without stenosis. MITLIF resulted in a high rate of spinal fusion and very low rate of interbody fusion failure and/or adjacent segment disease requiring reoperation while reducing postoperative complications. Level of Evidence: 3
Hussain, Namath S.; White, G. Zachary; Begun, Evan M.; Collins, Robert A.; Fahim, Daniel K.; Hiremath, Girish K.; Adbi, Fadumo M.; Yacob, Sammy A.
Degenerative scoliosis is a prevalent issue among the aging population. Controversy remains over the role of surgical intervention in patients with this disease. The authors discuss a suitable approach to help guide surgical treatment, including decompression, instrumented posterior spinal fusion, anterior spinal fusion, and osteotomy. These treatment options are based on clinical analysis, radiographic analysis of the mechanical stability of the deformity, given pain generators, and necessary sagittal balance. The high potential complication rates appear to be outweighed by the eventual successful clinical outcomes in patients suitable for operative intervention. This approach has had favorable outcomes and could help resolve the controversy. PMID:20192655
Silva, Fernando E; Lenke, Lawrence G
To assess the normal dimensions of the lumbar spinal canal, 100 normal healthy subjects of either sex between 25 and 45 years age were x-rayed for lumber vertebral column in both posteroanterior and lateral views and the canal was measured by Jones and Thomson method. The lumbar spinal canal showed constant dimensions in both sexes in all age groups when studied separately in the male and female subjects. However, no change in relative dimensions was observed between 25 and 45 years. The canal showed gradual decrease in measurement from L1 to L5 vertebral levels in both sexes but relative width of the canal was more in the females than in the males of the same age group. The normal values of the canal to vertebral body ratio (C/B) varies between 1:2.0 and 1:5.0. The ratio 1:2.0 indicates a wider canal whereas any ratio beyond 1:5.0 would be conclusive of stenosis of the lumbar vertebral canal. PMID:2513423
Janjua, M Z; Muhammad, F
Fifteen asymptomatic volunteers and 19 patients with current CT (GE 8800 CT/T) scans demonstrating either thecal sac contour distortion or nerve root displacement from disc rupture or spinal stenosis of the L4-L5 or L5-S1 levels judged to be at least moderate in severity underwent lumbar thermography. All patients were studied with an infrared telethermographic unit (AGA model 720M) employing the technical standards recommended by the Academy of Neuromuscular Thermography. The thermographic exams were interpreted independently and in a blind fashion by two radiologists. Of the 15 exams of asymptomatic patients, six were interpreted as positive and consistent with nerve fiber irritation. Of the 19 exams of patients with demonstrated CT abnormalities, all had positive thermograms for nerve fiber irritation (specificity 60%, sensitivity 100%). It is concluded that lumbar thermography is a sensitive examination for detecting those patients who will demonstrate lumbar spinal CT abnormalities and should play an important role in the diagnostic screening of low-back pain syndrome patients. PMID:2973135
Chafetz, N; Wexler, C E; Kaiser, J A
Purpose of study: Recombinant human bone morphogenetic protein (rhBMP)-2 has been demonstrated to form bone in various spine fusion applications as effectively as autologous iliac crest bone, without the morbidity of the graft harvest. Posterior lumbar interbody fusion (PLIF) constructs are commonly used in the treatment of degenerative spinal disease. This study evaluates the use of rhBMP-2 in a PLIF
Joseph Alexander; Charles Branch
Synovial spinal cysts are typically found in the lumbar spine, most often at the L4-L5 level. Magnetic resonance imaging is the diagnostic imaging of choice in the workup of suspected synovial cysts. This study consisted of 24 patients with lumbar synovial cysts treated by cyst excision and nerve root decompression through partial or complete facetectomy and primary posterolateral fusion. The most common location of the cysts was the L4-L5 segment. Synovial tissue was found in histological sections of 18 cysts. At a mean follow-up of 12 (range, 8 to 24) months, 20 patients (83%) had excellent or good results; two patients (8.3%) had fair and two patients (8.3%) had poor improvement. Operative complications included dural tear in two patients and postoperative wound dehiscence in one patient, which were treated accordingly. To eliminate the risk of recurrence synovial cyst excision through partial or complete facetectomy is required. In addition, since synovial cysts reflect disruption of the facet joint and some degree of instability, primary spinal fusion is recommended. PMID:23327848
Mavrogenis, Andreas F; Papagelopoulos, Panayiotis J; Sapkas, George S; Korres, Demetrios S; Pneumaticos, Spyridon G
Introduction The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic\\u000a curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis\\u000a of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.\\u000a \\u000a \\u000a \\u000a Materials and methods We conducted a
Rahul Kakkar; P. B. R. Sirigiri; A. Howieson; A. Siva Raman; R. J. Crawford
Study Design This is a retrospective study that was done according to clinical and radiological evaluation. Purpose We analyzed the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody single level fusion. Overview of Literature Minimally invasive transforaminal lumbar interbody fusion is effective surgical method for treating degenerative lumbar disease. Methods The study was conducted on 56 patients who were available for longer than 2 years (range, 24 to 45 months) follow-up after undergoing minimally invasive transforminal lumbar interbody single level fusion. Clinical evaluation was performed by the analysis of the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) and the Kirkaldy-Willis score. For the radiological evaluation, the disc space height, the segmental lumbar lordotic angle and the whole lumbar lordotic angle were analyzed. At the final follow-up after operation, the fusion rate was analyzed according to Bridwell's anterior fusion grade. Results For the evaluation of clinical outcomes, the VAS score was reduced from an average of 6.7 prior to surgery to an average of 1.8 at the final follow-up. The ODI was decreased from an average of 36.5 prior to surgery to an average of 12.8 at the final follow-up. In regard to the clinical outcomes evaluated by the Kirkaldy-Willis score, better than good results were obtained in 52 cases (92.9%). For the radiological evaluation, the disc space height (p = 0.002), and the whole lumbar lordotic angle (p = 0.001) were increased at the final follow-up. At the final follow-up, regarding the interbody fusion, radiological union was obtained in 54 cases (95.4%). Conclusions We think that if surgeons become familiar with the surgical techniques, this is a useful method for minimally invasive spinal surgery.
Chung, Hung-Tae; Kim, Dong-Jun; Kim, Sang-Hyuk; Jeon, Sang-Ho
Study Design. Prospective clinical studyObjective. Compare fusion rates between rhBMP-2 and iliac crest autograft (ICBG) to rh-BMP-2 with local bone graft (+/-bone graft extenders) in posterolateral fusion (PLF).Summary of Background Data. Previous reports have shown higher fusion rates when adding rhBMP-2 to ICBG in lumbar PLF, compared to ICBG alone. We compared the fusion success rates between rhBMP-2 delivered with ICBG versus that with local bone graft.Methods. Fusion rates were compared in patients with degenerative spondylolisthesis (1-2 levels) with accompanying lumbar stenosis. RhBMP-2 (InFuse, Medtronic) was delivered on an absorbable collagen sponge (6 mg/side @ 1.5 mg/mL) with ICBG alone or with local bone graft wrapped inside the sponge. Thin slice CT scans were assessed at 6, 12, and 24 months.Results. In a consecutive series, sixteen patients (30 levels) received ICBG with rhBMP-2 and 35 patients (49 levels) received local bone graft with rhBMP-2. For the ICBG cohort, 80.0%, 93.4%, 96.7% of levels were fused at 6, 12, and 24 months. In contrast, for the local bone with rhBMP-2 cohort, 87.7%, 98.0%, and 98.0% were fused at 6, 12, and 24 months. There was no statistically significant difference in fusion success rates between the two groups at any time point. As for fusion quality, the fusion mass showed superior quality in ICBG group than in the local bone group at each time point.Conclusion. This study validates the high fusion success rates previously reported by adding rhBMP-2 to ICBG and shows that local bone may be safely substituted for ICBG in 1-2 level PLF. The fusion rates were comparable. The avoidance of ICBG harvest has implications for operative time, blood loss, and morbidity. Lastly, this is the first study that directly compares the fusion success rate and quality using local bone with rhBMP-2 versus ICBG with rhBMP-2 at various times. PMID:23474598
Park, Daniel K; Kim, Sung S; Thakur, Nikhil; Boden, Scott D
This publication contains general information about spinal stenosis. It describes the conditions causes, symptoms, diagnosis, and treatments. At the end is a list of additional resources. Spinal stenosis is a narrowing of spaces in the spine (backbone) th...
ABSTRACT: Study Design. A descriptive CT study of lumbar facet joint (FJ) arthrosis in general and spinal stenosis populations.Objective. To reveal the prevalence of FJ arthrosis in general and stenosis populations and to establish its relationship to age and gender.Summary of Background Data. FJ arthrosis is a common radiographic finding and has been suggested as a cause of low back and lower extremity pain. It is also considered a dominant player in the genesis of lumbar spinal stenosis. Although it is well accepted that FJ arthrosis is an age dependent phenomenon, controversies still exist as to its association with gender and its prevalence at different spine levels. Additionally, data on FJ arthrosis frequency in spinal stenosis population are missing.Methods. Two groups were studied. The first included 65 individuals with LSS (mean age 66 ± 10 years) and the second, 150 individuals (mean age 52 ± 19 years) without LSS related symptoms. Both left and right FJ arthrosis for each vertebral level (L3 to S1) were evaluated on CT images (Brilliance 64, Philips Medical System, Cleveland Ohio). Chi-Square, Linear-by-Linear Association and McNemar test were carried out to reveal the correlation between FJ arthrosis and demographic factors (age, gender) and prevalence at different lumbar levels in both stenosis and non-stenosis groups. Additionally, a 2-way ANOVA was used to determine the association between BMI and FJ arthrosis.Results. The rate of FJ arthrosis at L3-4 and L4-5 were significantly higher (P<0.001) in the stenotic group compared to the control. In the control group the prevalence of FJ arthrosis increases cephalo-caudally (L3-L4 = 16%, L4-L5 = 28%, L5-S1 = 55%), whereas in the stenotic group there is a sharp increase from L3-4 (27%) to L4-5 (58%), but not from L4-5 to L5-S1 (55%). No association between FJ arthrosis and gender was noted. Although, mean BMI was significantly smaller in the control group compared to the stenotic group, no association between BMI and facet arthrosis was found. In the general population the prevalence of FJ arthrosis at all three levels was greater for the right side; however, significant difference (P = 0.004) was obtained only for L3-4. In all joints studied, the prevalence of FJ arthrosis increases considerably from the young age cohort (18-39) to the old age cohort (>60). Nevertheless, 10% of the young individuals (18-39) have already manifested FJ arthrosis at L5-S1. No arthrosis at that age was observed at L3-4.Conclusion. FJ arthrosis is an age-dependent and BMI and gender-independent phenomenon. In the general population, the prevalence of FJ arthrosis increases cephalo-caudally with the highest frequency at L5-S1. In the stenotic group, the highest frequency was observed at the two caudal levels; L4-5 and L5-S1. The prevalence of FJ arthrosis was greater for the right side. PMID:21270678
J, Abbas; K, Hamoud; S, Peleg; H, May; Y, Masharawi; H, Cohen; N, Peled; I, Hershkovitz
Background. The minimally invasive lateral interbody fusion (MIS LIF) in the lumbar spine can correct coronal Cobb angles, but the effect on sagittal plane correction is unclear. Methods. A retrospective review of thirty-five patients with lumbar degenerative disease who underwent MIS LIF without supplemental posterior instrumentation was undertaken to study the radiographic effect on the restoration of segmental and regional lumbar lordosis using the Cobb angles on pre- and postoperative radiographs. Mean disc height changes were also measured. Results. The mean follow-up period was 13.3 months. Fifty total levels were fused with a mean of 1.42 levels fused per patient. Mean segmental Cobb angle increased from 11.10° to 13.61° (P < 0.001) or 22.6%. L2-3 had the greatest proportional increase in segmental lordosis. Mean regional Cobb angle increased from 52.47° to 53.45° (P = 0.392). Mean disc height increased from 6.50?mm to 10.04?mm (P < 0.001) or 54.5%. Conclusions. The MIS LIF improves segmental lordosis and disc height in the lumbar spine but not regional lumbar lordosis. Anterior longitudinal ligament sectioning and/or the addition of a more lordotic implant may be necessary in cases where significant increases in regional lumbar lordosis are desired.
Le, Tien V.; Vivas, Andrew C.; Dakwar, Elias; Baaj, Ali A.; Uribe, Juan S.
Study Design Retrospective review. Purpose This study aims to define the role of lumbar fusion for persistent back pains after the lumbar disc replacement. Overview of Literature Little is written about lumbar fusion after optimally placed lumbar arthroplasty in patients with persistent lower back pains. Methods Retrospective review of cases of lumbar artificial disc requiring subsequent fusion because of persistent back pains despite optimally placed artificial discs. Outcomes were evaluated using Oswestry Disability Index (ODI) and visual analogue scale (VAS). Clinical improvements indicated 25% improvement in ODI and VAS values. Results Five patients met the study criteria. The mean baseline ODI for the five patients was 52. The mean baseline VAS scores for back and leg pains were 76 and 26, respectively. All the five patients had optimally placed prosthesis. The indication for surgery was the constant low back pains found in all the patients. Revision surgery involved disc explantation and fusion in two of the patients and posterolateral fusion without removing the prosthesis in three. None of the patients achieved adequate pain control after the revision surgery despite the solid bony fusion documented by postoperative computed tomography. The mean ODI value after the fusion was 55. The mean values for back and leg pains VAS were 72 and 30, respectively. Conclusions Lack of good pain relief after successful lumbar artifical disc replacements may indicate different etiology for the back pains. The spine-treating surgeons should have a high threshold level to perform salvage fusion at that level.
Congenital bony nasal stenosis (CBNS) is a rare condition that causes respiratory distress in neonates. Between 1986 and 1996, we encountered 13 cases of CBNS. Recently, CT measurements have been used to evaluate the features of this type of stenosis, but no satisfactory investigation of the severity of bony nasal stenosis has been reported. We compared the nasal width (NW),
Keijiro Koga; Nobuko Kawashiro; Akio Araki; Nobuaki Tsuchihashi; Makoto Sakai
Information regarding the precise dimensions of the lumbar vertebrae is essential for spinal surgery and instrumentation. When stenosis of the vertebral canal or the intervertebral foramen exists, the neural structures in them can be affected and cause symptoms such as low back or radicular pain. Accurate and comprehensive spinal canal measurements in the lumbar vertebrae are incomplete. The purpose of this study was to collect data on the dimensions of the lumbar spinal canal from computed tomography scans. Three hundred patients (162 men and 138 women) were studied. Computed tomography scans were obtained to determine the normal values of the midsagittal diameter, interpedicular distance, and lateral recess depth in the normal Egyptian population. The narrowest level was L3. The range of the midsagittal diameter was 11.07 to 26.07 mm at all levels. The range of the interpedicular distance was 17.00 to 43.41 mm at all levels. In all patients at all levels, mean lateral recess depth was 6.7 mm (range, 4-14 mm). The narrowest lateral recess depth was at L5. Few patients (3.3%) had a statistically stenotic midsagittal diameter measurement. The canal shape was not uniform along the 5 lumbar vertebrae; it ranged from being circular or rounded in the upper lumbar vertebrae to triangular in the midlumbar vertebrae to trefoil in the lower lumbar vertebrae, especially at L5. Trefoil canals existed mainly in the lower lumbar vertebrae at L5, followed by L4. Data from computed tomography scans combined with accurate measurements are the basis for anatomical studies, clinical research, and the development of implants suitable for a group of patients with measurements different from the population standard. PMID:23383623
Aly, Tarek; Amin, Osama
A patient who died of Whipple's disease had moderate mitral stenosis with large firm yellow vegetations on the contact area of the mitral leaflets. Light microsocopy showed PAS positive macrophages within the thickened cusps and overlying vegetations. Negative images of rod-shaped bodies were visible in the cytoplasm of the histiocytes. No Aschoff bodies were seen, and there was no history
A G Rose
Load and activity changes of the spine typically cause symptoms of nerve root compression in subjects with spinal stenosis.\\u000a Protrusion of the intervertebral disc has been regarded as the main cause of the compression. The objective was to determine\\u000a the changes in the size of the lumbar spinal canal and especially those caused by the ligamentum flavum and the disc
Tommy Hansson; Nobuyuki Suzuki; Hanna Hebelka; Arne Gaulitz
Upper and lower lumbar disc herniation apparently have different background, symptoms, and operative results. This retrospective study reviewed the clinical records of 403 patients (409 discs) who underwent lumbar microdiscectomy performed by different surgeons at our institute between 1999 and 2009. The 290 male (72.0%) and 113 female (28.0%) patients were aged from 19 to 77 years (mean 44 years). Demographics, symptoms, and static and dynamic radiographic and magnetic resonance images obtained at the L1-2, L2-3, L3-4, L4-5, and L5-S1 intervertebral levels were analyzed. Of the 409 herniations, 3 were at L1-2, 9 at L2-3, 21 at L3-4, 166 at L4-5, and 210 at L5-S1. The mean age at herniation at L1-2 and L2-3 levels was 55.7 years. Patients with herniation of discs at L3-4 or above were significantly older than patients who suffered herniation at L4-5 or below (p < 0.0001), and the incidence of urinary disturbance was significantly higher in patients with herniation at L1-2 and L2-3 levels (p = 0.0013). The incidence of degenerative scoliosis was significantly higher in patients with herniation at L1-2 and L2-3 than in those with herniated discs at L3-4 or below (p < 0.0001). Patients with upper lumbar disc herniation were older and manifested a higher incidence of urinary disturbance. A high incidence of degenerative scoliosis was noted in the course of prolonged degenerative processes. PMID:21701105
Iwasaki, Motoyuki; Akino, Minoru; Hida, Kazutoshi; Yano, Shunsuke; Aoyama, Takeshi; Saito, Hisatoshi; Iwasaki, Yoshinobu
We studied 117 adult patients undergoing posterior lumbar spinal fusion and instrumentation using bone grafts from the iliac crest between February 1999 and January 2001. All patients had degenerative disease of the lumbar spine, and all were operated upon by the same surgeon. Patients were randomized to have the iliac bone graft harvested either through a separate incision (traditional approach) or utilizing the same midline incision as used for the spinal surgery (intrafascial approach). Total volume of harvested graft, blood loss, pain, complications, and patient satisfaction were evaluated with a minimum of 2-year follow-up. There were no infections. The average volume of harvested bone was 17.2 cc versus 14.7 cc; total blood loss was 168 cc versus 96 cc; total complication rate was 20% versus 8%, and overall satisfaction rate was 81% versus 96%, respectively. The intrafascial graft harvesting technique minimizes morbidity and increases patient satisfaction compared with the traditional bone harvesting technique. PMID:15490164
Bezer, Murat; Kocao?lu, Bari?; Aydin, Nuri; Güven, Osman
Most chronic low back pain is the result of degeneration of the lumbar intervertebral disc. Ligustrazine, an alkaloid from Chuanxiong, reportedly is able to relieve pain, suppress inflammation, and treat osteoarthritis and it has the protective effect on cartilage and chondrocytes. Therefore, we asked whether ligustrazine could reduce intervertebral disc degeneration. To determine the effect of ligustrazine on disc degeneration, we applied a rat model. The intervertebral disc degeneration of the rats was induced by prolonged upright posture. We found that pretreatment with ligustrazine for 1 month recovered the structural distortion of the degenerative disc; inhibited the expression of type X collagen, matrix metalloproteinase (MMP)-13, and MMP3; upregulated type II collagen; and decreased IL-1?, cyclooxygenase (COX)-2, and inducible nitric oxide synthase (iNOS) expression. In conclusion, ligustrazine is a promising agent for treating lumbar intervertebral disc degeneration disease.
Liang, Qian-Qian; Ding, Dao-Fang; Xi, Zhi-Jie; Chen, Yan; Li, Chen-Guang; Liu, Shu-Fen; Lu, Sheng; Zhao, Yong-Jian; Shi, Qi; Wang, Yong-Jun
A retrospective analysis of adults treated with long instrumented fusion for scoliosis from the thoracic spine proximally to L4 or L5. To evaluate the long-term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome. A total of 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21-68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre- and post-operatively as well as at the most recent follow up--mean 9.3 years (range 7-19). A total of 62% of patients had a good or excellent outcome. Eleven had a poor outcome of which ten underwent extension of fusion--five for pain alone, three for pain with stenosis and two for pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (P < 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F = 14.285, P < 0.001) and the most recent lordosis (Anova F = 4.057, P = 0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration, respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion. Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa, i.e. sagittal imbalance causing degeneration. Immediate post-operative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter. PMID:17990008
Harding, Ian J; Charosky, Sebastian; Vialle, Raphael; Chopin, Daniel H
A retrospective analysis of adults treated with long instrumented fusion for scoliosis from the thoracic spine proximally to L4 or L5. To evaluate the long-term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome. A total of 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21–68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre- and post-operatively as well as at the most recent follow up—mean 9.3 years (range 7–19). A total of 62% of patients had a good or excellent outcome. Eleven had a poor outcome of which ten underwent extension of fusion—five for pain alone, three for pain with stenosis and two for pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (P < 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F = 14.285, P < 0.001) and the most recent lordosis (Anova F = 4.057, P = 0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration, respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion. Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa, i.e. sagittal imbalance causing degeneration. Immediate post-operative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter.
Charosky, Sebastian; Vialle, Raphael; Chopin, Daniel H.
The authors report three cases of neurinoma of the cauda equina initially misdiagnosed as prolapsed lumbar disk. Computed Tomography failed to reveal the tumour, while showing evidence of disk-degenerative patology and being thus misleading. Similar cases are reported in literature. After a thorough analysis of the causes of such an apparently gross error, it is concluded that the main source of pitfalls arises from neglecting those typical clinical features differentiating prolapsed disk from oncogenetic sciatica. When oncogenetic sciatica is suspected Computed Tomography is inappropriate and even misleading, while the elective investigation is Magnetic Resonance. PMID:7782865
Palma, L; Mariottini, A; Muzii, V F; Bolognini, A; Scarfò, G B
OBJECTIVES--To record the extent and location of lumbar apophyseal cartilage damage, and to ascertain if the extent of damage is correlated with the grade of disc degeneration, age, or both. METHODS--The extent and location of fibrillated areas of the apophyseal cartilage of the joint surfaces of 29 lumbar motion segments were examined using computer aided image processing of Indian ink stained areas, and degeneration of the associated intervertebral discs graded using the method of Nachemson. RESULTS--It was found that these joints showed a greater extent and prevalence of cartilage fibrillation than the knee, hip or ankle, with significant damage in specimens younger than 30 years. Damage was predominantly located peripherally, superiorly, and posteriorly in the concave superior apophyseal surfaces, and was predominantly peripheral and posterior in the inferior surfaces, with a tendency to be located inferiorly. There was a weak correlation between apophyseal joint damage and the intervertebral disc degenerative grade, but this was inconclusive, as both increased with age. CONCLUSIONS--The pattern of damage exhibited by superior joint surfaces is most probably caused by tension on collagenous joint capsule fibres which insert into the surfaces posteriorly, so producing an area of fibrocartilage unsuited to loadbearing. Tension on such fibres would be greatest during spinal flexion. The pattern of damage of the inferior surfaces lends some support to the hypothesis that their apices impact the laminae of the lumbar vertebra inferior to them, consequent upon the degeneration and narrowing of the associated intervertebral disc. The predominantly peripheral location of fibrillation of both superior and inferior surfaces may be associated with inadequate mechanical conditioning of marginal joint areas. Disc degeneration cannot be the initial cause of apophyseal fibrillation in most specimens. The study indicates a need for regular spinal exercise, starting at a young age.
Swanepoel, M W; Adams, L M; Smeathers, J E
This article describes a complex bilateral variation in the formation of lumbar plexus in a 32 year old male cadaver. On the left side the plexus was postfixed and located posterior to the psoas major muscle. The femoral nerve was formed by the union of anterior rami of the second, third, fourth and fifth lumbar spinal nerves. On the right side, the lumbar plexus was prefixed. The lateral cutaneous nerve of the thigh was formed by the union of the anterior rami of the first and second lumbar spinal nerves. The femoral nerve formed by branches from the first, second, third and fifth lumbar spinal nerves while the obturator nerve was formed by the union of the first, second and third lumbar spinal nerves. The right lumbar plexus was located in the substance of the psoas major muscle. In the present case, the formation of branches of the lumbar plexus were different from the previous data present in the literature. PMID:10409846
Erbil, K M; Ondero?lu, S; Ba?ar, R
This article describes a complex bilateral variation in the formation of lumbar plexus in a 32 year old male cadaver. On the left side the plexus was postifixed and located posterior to the psoas major muscle. The femoral nerve was formed by the union of anterior rami of the second, third, fourth and fifth lumbar spinal nerves. On the right side, the lumbar plexus was prefixed. The lateral cutaneous nerve of the thigh was formed. By the union of the anterior rami of the first and second lumbar spinal nerves. The femoral nerve formed by branches from the first, second, third and fifth lumbar spinal nerves while the obturator nerve was formed by the union of the first, second and third lumbar spinal nerves. The right lumbar plexus was located in the substance of the psoas major muscle. In the present case, the formation of branches of the lumbar plexus were different from the previous data present in the literature. PMID:10437316
Mine Erbil, K; Ondero?lu, S; Ba?ar, R
Eighty-two patients with mitral stenosis underwent cardiac catheterization with coronary angiography. Twenty-one patients (26 percent) had coronary artery disease. Characteristics of the mitral valve area, cardiac output, pulmonary artery pressure, pulmonary vascular resistance, left ventricular end-diastolic pressure, left ventricular ejection fraction, and atypical chest pain did not correlate with findings of angina pectoris or of coronary artery disease; however, there was correlation with sex, age, and angina. Coronary artery disease occurred only after the age of 40 years and was more frequent in males with angina. Coronary artery disease could not be ruled out in patients with mitral stenosis, especially those over age 40, without coronary arteriography. PMID:7053940
Chun, P K; Gertz, E; Davia, J E; Cheitlin, M D
A 15-year-old boy presented with chest pain and a new heart murmur. The clinical diagnosis of pulmonary stenosis was confirmed by two-dimensional and Doppler echocardiographic examinations. A large, encapsulated, partly solid and partly cystic tumor in the anterior mediastinum, visualized by ultrasonography, was compressing the main pulmonary artery and producing the right ventricular outflow tract obstruction. The tumor was removed
B. N. Agarwala; L. E. Thomas; J. D. Waldman
A 63-year-old male patient with subaortic stenosis (Pmax 105 mmHg, Pmean 55 mmHg) and an aneurysm of the ascending aorta was referred to our hospital due to progressive angina pectoris. Transesophageal echocardiography demonstrated high and turbulent subaortic flow velocities. A calcified subaortic membrane was identified. The membrane was removed and the aneurysm was treated with a Bentall procedure. The patient recovered smoothly from surgery and was doing well 6 months after discharge. PMID:23196660
Weymann, Alexander; Schmack, Bastian; Rosendal, Christian; Karck, Matthias; Szabó, Gábor
Hemodialysis-associated subclavian vein stenosis. This study was undertaken to evaluate hemodialysis-associated subclavian vein stenosis (SVS) and to clarify treatment of this condition. Forty-seven patients underwent upper arm venography to evaluate fistula dysfunction. Subclavian vein stenosis was documented in 12. Eleven of 12 had elevated venous dialysis pressure (196 ± 8.9 mm Hg), and six had arm edema. All 12 had
Steve J Schwab; L Darryl Quarles; John P Middleton; Richard H Cohan; Moshin Saeed; Vincent W Dennis
A primigravida with idiopathic hypertrophic subaortic stenosis, New York Heart Association Classification III, developed acute chest pain with significant ST segment depression together with a new Q-wave in chest lead V6 on the electrocardiograph following delivery under lumbar epidural analgesia. An intrapartum myocardial infarct was suspected because serial creatine phosphokinase and its muscle-brain isoenzyme levels were elevated in the postpartum
M. C. Vallejo; S. Ramanathan; S. A. Ward; G. L. Mandell
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localisation to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was more quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localisation to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was more quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies. PMID:21247412
Carstensen, Michael H; Al-Harbi, Mashael; Urbain, Jean-Luc; Belhocine, Tarik-Zine
The objective is to evaluate the geometric parameters of vertebral bodies and intervertebral discs in spinal segments adjacent to spondylolysis and spondylolisthesis. This pilot cross-sectional study was an ancillary project to the Framingham Heart Study. The presence of spondylolysis and spondylolisthesis as well as measurements of spinal geometry were identified on CT imaging of 188 individuals. Spinal geometry measurements included lordosis angle, wedging of each lumbar vertebra and intervertebral disc. Last measurements were used to calculate ?B, the sum of the lumbar L1-L5 body wedge angles; and ?D, the sum of the lumbar L1-L5 intervertebral disc angles. Using Wilcoxon-Mann-Whitney test we compared the geometric parameters between individuals with no pathology and ones with spondylolysis (with no listhesis) at L5 vertebra, ones with isthmic spondylolisthesis at L5-S1 level, and ones with degenerative spondylolisthesis at L5-S1 level. Spinal geometry in individuals with spondylolysis or listhesis at L5 shows three major patterns: In spondylolysis without listhesis, spinal morphology is similar to that of healthy individuals; In isthmic spondylolisthesis there is high lordosis angle, high L5 vertebral body wedging and very high L4-5 disc wedging; In degenerative spondylolisthesis, spinal morphology shows more lordotic wedging of the L5 vertebral body, and less lordotic wedging of intervertebral discs. In conclusion, there are unique geometrical features of the vertebrae and discs in spondylolysis or listhesis. These findings need to be reproduced in larger scale study. PMID:21181481
Been, Ella; Li, Ling; Hunter, David J; Kalichman, Leonid
The prevalence of lumbar disc syndrome (herniated disc or typical sciatica) and its consequences in terms of disability, handicap, and need for medical care were studied as part of the Mini-Finland Health Survey. A sample of 8000 persons representative of the Finnish population aged 30 or over was asked to come for examination, and 7217 (90%) participated. A diagnosis of
M Heliövaara; O Impivaara; K Sievers; T Melkas; P Knekt; J Korpi; A Aromaa
A two month old Thoroughbred filly was presented with signs of depression, grinding of the teeth, frothing of the mouth and abdominal pain. These signs had persisted for two weeks despite treatment with mineral oil, dioctyl sodium sulfosuccinate, meperidine and antibiotics. A variety of diagnostic tests were done, the only abnormal finding was a stress leukon. On exploratory laparotomy the stomach was dilated with fluid and gas and the pyloric canal was constricted. Pyloroplasty resulted in correction of the condition. The etiological possibilities are discussed. This is believed to be the first report of pyloric stenosis in the horse. PMID:7427855
Barth, A D; Barber, S M; McKenzie, N T
Study Design A cross-sectional imaging study. Purpose The objective was to assess the degree of degeneration and the associated factors through imaging studies of the lesion segment and the adjacent superior and inferior segments of isthmic and degenerative spondylolisthesis. Overview of Literature Few articles existed for degeneration and related factors in isthmic and degenerative spondylolisthesis. Methods The subjects were 95 patients diagnosed with spondylolisthesis. Simple plain radiographs including flexion and extension and magnetic resonance imaging were used to investigate the degree of translation, disc degeneration, high intensity zone (HIZ) lesion, Schmorl's node (SN) and Modic changes. Results Advanced disc degeneration, grade 5, was shown to be significant in the index segment of the isthmic type (p=0.034). Overall, type 2 Modic change was most common in both groups and also, it was observed more in the isthmus group, specifically, the index segment compared to the degenerative group (p=0.03). For the SN, compared to the degenerative type, the isthmus type had a significantly high occurrence in the index segment (p=0.04). For the HIZ lesions, the isthmus type had a higher occurrence than the degenerative type, especially in the upper segment (p=0.03). Conclusions Most advanced disc degeneration, fifth degree, SN and Modic change occurred more frequently in the lesions of the isthmus type. HIZ lesions were observed more in the isthmus type, especially in the segment superior to the lesion.
Jeong, Hyun-Yoon; Sohn, Hong-Moon; Park, Sang-Ha
This report describes the first successful treatment of tricuspid stenosis by percutaneous double balloon valvotomy. There was a dramatic reduction of the tricuspid valve gradient, with an increase in calculated valve area, together with an increase in resting cardiac output and symptomatic relief. The feasibility of the non-surgical treatment of severe tricuspid stenosis was demonstrated unequivocally. Images Fig 1 Fig 2
Al Zaibag, M; Ribeiro, P; Al Kasab, S
Although the incidence of post-intubation tracheal stenosis has markedly decreased with the advent of large volume, low pressure endotracheal tube cuffs, it still occurs, commonly in patients after prolonged intubation. We report a case of tracheal stenosis that developed after a brief period of endotracheal intubation, and that was misdiagnosed and treated as asthma and panic attacks. PMID:23345469
Barreiro, Timothy J; Ghattas, Christian; Valino, Cherry Ann
This study is to compare the therapeutic effect of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation on treatment in adult degenerative spondylolisthesis. A retrospective analysis of 187 patients to compare the complications and associated predictive factors of the two techniques of one level lumbar fusion. Ninety-one had PLIF with two cages and pedicle fixation (group 1), and ninety-six had TLIF with one cage and pedicle fixation (group 2). The two groups had similar age and sex distribution, and level of pain. Inclusion criteria and outcome measurements were identical in both groups. The two groups were operated on with autograft and cage with pedicle fixation. Before surgery and at the 2-year follow-up, pain (VAS) and functional disability (JOA) were quantified. The results showed there were no intraoperative deaths in our study. In the end 176 cases had 2-year follow-up while 11 cases were lost to follow-up. The follow-up rate was 93.4% (85/91) in the PLIF group and 94.8% (91/96) in the TLIF group. All patients had bone fusion, and there were no cases of cage extrusion. The pain index improved from 7.08 ± 1.13 to 2.84 ± 0.89 in PLIF patients and improved from 7.18 ± 1.09 to 2.84 ± 0.91 in TLIF patients (P < 0.001). There were 42 cases of excellent, 29 cases of good, 11 cases of general, and 3 cases of poor results in PLIF group. There were 46 cases of excellent, 31 case of good, 12 case of general, and 2 cases of poor results in TLIF group. The JOA score in all patients was 84.1% of good or excellent (83.5% in PLIF and 84.6% in TLIF, P > 0.05). The average preoperative slip was 30.1 ± 7.2% in PLIF group while in the TLIF it was 31.4 ± 8.3%. Immediately post operatively it was reduced to 7.3 ± 2.1% and 7.4 ± 2.7% and at last F/U it was 8.1 ± 2.8% and 8.2 ± 2.6%, respectively. The average of reduction rate was 75.2 ± 6.4% in PLIF and 75.4 ± 6.2 in TLIF on the initial post operatively X-ray, and 72.6 ± 5.2% and 72.4 ± 5.4% on the follow-up. The percentage rate, reduction rate and lost of reduction rate between the two groups was similar (P > 0.05). The average pre operative disk and foramen height in the PLIF group improved from 6.8 ± 2.3 and 14.2 ± 1.7 preoperatively to 11.6 ± 1.5 and 18.7 ± 1.8 post operatively, respectively. At last follow up there was minimal lost of correction down to 11.24 ± 1.2 and 18.1 ± 1.8, respectively. Similarly in the TLIF group, pre operative disk and foramen height were improved from 6.7 ± 1.7 and 14.1 ± 1.8 to 11.4 ± 1.6 and 18.5 ± 1.6 immediately post operative. At last follow up minimal lost of correction was noted with average disc height of 11.3 ± 1.4 and 18.2 ± 1.7. Both techniques achieve statistical significance in restoration of disc and foraminal (P < 0.01); however, there was no statistical difference between the two techniques. In conclusion, interbody fusion with either a PLIF technique or a TLIF technique provides good outcomes in the treatment of adult degenerative spondylolisthesis. The TLIF procedure is simpler and is as safe and effective as the PLIF technique.
Pei, Fu-xing; Li, Jian; Soo, Cheng-long
Models of the dynamic response of the lumbar spine have been used to examine vertebral fractures (VFx) during falls and whole body vibration transmission in the occupational setting. Although understanding the viscoelastic stiffness or damping characteristics of the lumbar spine are necessary for modeling the dynamics of the spine, little is known about the effect of intervertebral disk degeneration on these characteristics at high loading rates. We hypothesize that disk degeneration significantly affects the viscoelastic response of spinal segments to high loading rate. We additionally hypothesize the lumbar spine stiffness and damping characteristics are a function of the degree of preload. A custom, pendulum impact tester was used to impact 19 L1–L3 human spine segments with an end mass of 20.9?kg under increasing preloads with the resulting force response measured. A Kelvin–Voigt model, fitted to the frequency and decay response of the post-impact oscillations was used to compute stiffness and damping constants. The spine segments exhibited a second-order, under-damped response with stiffness and damping values of 17.9–754.5?kN/m and 133.6–905.3?Ns/m respectively. Regression models demonstrated that stiffness, but not damping, significantly correlated with preload (p?0.001). Degenerative disk disease, reflected as reduction in magnetic resonance T2 relaxation time, was weakly correlated with change in stiffness at low preloads. This study highlights the need to incorporate the observed non-linear increase in stiffness of the spine under high loading rates in dynamic models of spine investigating the effects of a fall on VFx and those investigating the response of the spine to vibration.
Wilson, Sara E.; Alkalay, Ron N.; Myers, Elizabeth
Calcific aortic valve stenosis (CAVS) is a major health problem facing aging societies. The identification of osteoblast-like and osteoclast-like cells in human tissue has led to a major paradigm shift in the field. CAVS was thought to be a passive, degenerative process, whereas now the progression of calcification in CAVS is considered to be actively regulated. Mechanistic studies examining the contributions of true ectopic osteogenesis, non-osseous calcification, and ectopic osteoblast-like cells (that appear to function differently from skeletal osteoblasts) to valvular dysfunction have been facilitated by the development of mouse models of CAVS. Recent studies also suggest that valvular fibrosis, as well as calcification, may play an important role in restricting cusp movement, and CAVS may be more appropriately viewed as a fibrocalcific disease. High resolution echocardiography and magnetic resonance imaging have emerged as useful tools for testing the efficacy of pharmacological and genetic interventions in vivo. Key studies in humans and animals are reviewed that have shaped current paradigms in the field of CAVS, and suggest promising future areas for research.
Miller, Jordan D.; Weiss, Robert M.; Heistad, Donald D.
Retinal degenerative diseases that target photoreceptors or the adjacent retinal pigment epithelium (RPE) affect millions of people worldwide. Retinal degeneration (RD) is found in many different forms of retinal diseases including retinitis pigmentosa (RP), age-related macular degeneration (AMD), diabetic retinopathy, cataracts, and glaucoma. Effective treatment for retinal degeneration has been widely investigated. Gene-replacement therapy has been shown to improve visual function in inherited retinal disease. However, this treatment was less effective with advanced disease. Stem cell-based therapy is being pursued as a potential alternative approach in the treatment of retinal degenerative diseases. In this review, we will focus on stem cell-based therapies in the pipeline and summarize progress in treatment of retinal degenerative disease.
Huang, Yiming; Enzmann, Volker; Ildstad, Suzanne T.
The use of biological technologies for the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. BMP strategies have gained wide support for an inherent potential to improve the ossification process. It has been extensively studied in combination with various techniques for spinal stabilisation from both anterior and posterior approach. We studied the fusion process after implantation of rhBMP-2 in 17 patients with degenerative lumbar spine diseases in combination with dorsal fixation with pedicle screws and poly-ether-ether-ketone (PEEK) interbody cages. We used 12 mg rhBMP-2 carried by collagen sponge, 6 mg in every cage. Patient follow up consisted of pre-operative radiographic and clinical evaluation. Similar post-operative evaluations were performed at 3 and 6 months. Clinical assessment demonstrated clear improvement in all patients despite evidence of vertebral endplate osteoclastic activity in the 3-month radiographs. The 6-month radiograph, however, confirmed evidence of fusion, and no untoward results or outcomes were noted. While previous studies have shown exclusively positive results in both fusion rates and process, our study demonstrated an intermediate morphology at 3 months during the ossification process using Induct Os in combination with peek-cages using a PLIF-technique. The transient resorption of bone surrounding the peek cage did not result in subsidence, pain or complication, and fusion was reached in all cases within a 6-month-controlled evaluation. Although there was no negative influence on clinical outcome, the potential for osteoclastic or metabolic resorption bears watching during the post-surgical follow up.
Schnoring, Mark; Hohaus, Christian; Minkus, Yvonne; Beier, Andre; Ganey, Timothy; Mansmann, Ulrich
Degenerative ocular conditions, such as age-related macular degeneration, diabetic retinopathy, retinal vein occlusions, and myopic degeneration, have become a major public health problem and a leading cause of blindness in developed countries. Anti-vascular endothelial growth factor (VEGF) drugs seem to be an effective and safe treatment for these conditions. Ranibizumab, a humanized monoclonal antibody antigen-binding fragment, which inhibits all biologically active isoforms of VEGF-A, is still the gold standard treatment for the majority of these pathological entities. In this review, we present the results of the most important clinical trials concerning the efficacy and safety of ranibizumab for the treatment of degenerative ocular conditions.
Triantafylla, Magdalini; Massa, Horace F; Dardabounis, Doukas; Gatzioufas, Zisis; Kozobolis, Vassilios; Ioannakis, Konstantinos; Perente, Irfan; Panos, Georgios D
This study aimed to determine the risk factors for developing adjacent segment disease (ASDz) after anterior cervical arthrodesis for the treatment of degenerative cervical disease by analyzing patients treated with various fusion methods. We enrolled 242 patients who had undergone anterior cervical fusion for degenerative cervical disease, and had at least 5years of follow-up. We evaluated the development of ASDz and the rate of revision surgery. To identify the risk factors for ASDz, the sagittal alignment, spinal canal diameter, range of motion of the cervical spine, number of fusion segments, and fusion methods were evaluated. The patients were divided into three groups according to the fusion method: Group A contained patients who had received autogenous bone graft only (53 patients), Group B contained patients who received autogenous bone graft and plate augmentation (62 patients), and Group C contained patients who underwent cage and plate augmentation (127 patients). ASDz occurred in 33 patients, of whom 19 required additional surgery. The risk of developing ASDz was significantly higher in male patients (p=0.043), patients whose range of motion of the cervical spine was >30° (p=0.027), and patients with spinal canal stenosis (p=0.010). The rate of development of ASDz was not different depending on the number of fusion segments. The rate of development of ASDz was 41.5% in Group A, 9.6% in Group B, and 5.51% in Group C (p=0.03). In patients who underwent anterior cervical arthrodesis for degenerative disease, the occurrence of ASDz was related to age, the cervical spine range of motion, and spinal canal stenosis. Additional plate augmentation for anterior cervical arthrodesis surgery can lower the rate of ASDz development. PMID:24331625
Song, Ji-Soo; Choi, Byung-Wan; Song, Kyung-Jin
Background To investigate how unilateral cage-instrumented posterior lumbar interbody fusion (PLIF) affects the three-dimensional flexibility in degenerative disc disease by comparing the biomechanical characteristics of unilateral and bilateral cage-instrumented PLIF. Methods Twelve motion segments in sheep lumbar spine specimens were tested for flexion, extension, axial rotation, and lateral bending by nondestructive flexibility test method using a nonconstrained testing apparatus. The specimens were divided into two equal groups. Group 1 received unilateral procedures while group 2 received bilateral procedures. Laminectomy, facectomy, discectomy, cage insertion and transpedicle screw insertion were performed sequentially after testing the intact status. Changes in range of motion (ROM) and neutral zone (NZ) were compared between unilateral and bilateral cage-instrumented PLIF. Results Both ROM and NZ, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF, transpedicle screw insertion procedure did not revealed a significant difference between flexion-extension, lateral bending and axial rotation direction except the ROM in the axial rotation. The bilateral group's ROM (-1.7 ± 0. 8) of axial rotation was decreased significantly after transpedicle screw insertion procedure in comparison with the unilateral group (-0.2 ± 0.1). In the unilateral cage-instrumented PLIF group, the transpedicle screw insertion procedure did not demonstrate a significant difference between right and left side in the lateral bending and axial rotation direction. Conclusions Based on the results of this study, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF have similar stability after transpedicle screw fixation in the sheep spine model. The unilateral approach can substantially reduce exposure requirements. It also offers the biomechanics advantage of construction using anterior column support combined with pedicle screws just as the bilateral cage-instrumented group. The unpleasant effect of couple motion resulting from inherent asymmetry was absent in the unilateral group.
Current clinical evaluations often rely on static anatomic imaging modalities for diagnosis of mechanical low back pain, which provide anatomic snapshots and a surrogate analysis of a functional disease. Three dimensional in vivo motion is available with the use of digital fluoroscopy, which was used to capture kinematic data of the lumbar spine in order to identify coefficients of motion that may assist the physician in differentiating patient pathology. 40 patients distributed among 4 classes of lumbar degeneration, from healthy to degenerative, underwent CT, MRI, and digital x-ray fluoroscopy. Each patient underwent diagnosis by a neurosurgeon. Fluoroscopy was taken as the patient performed lateral bending (LB), axial rotation (AR) and flexion-extension (FE). Patient specific models were registered with the fluoroscopy images to obtain in vivo kinematic data. Motion coefficients, CLB, CAR, CFE, were calculated as the ratio of in-plane motion to total out-of-plane motion. Range of motion (ROM) was calculated about the axis of motion for each exercise. Inter- and Intra- group statistics were examined for each coefficient and a flexible Bayesian classifier was used to differentiate patients with degeneration. The motion coefficients CLB and CFE were significantly different (p < 0.05) in 4 of 6 group comparisons. In plane motion, ROMLB, was significantly different in only 1 of 6 group comparisons. The classifier achieved 95% sensitivity and specificity using (CFE, CLB, ROMLB) as input features, and 40% specificity and 80% sensitivity using ROM variables. The new coefficients were better correlated with patient pathology than ROM measures. The coefficients suggest a relationship between pathology and measured motion which has not been reported previously.
Johnson, J. Michael; Mahfouz, Mohamed; Battaglia, Nicholas V.; Sharma, Adrija; Cheng, Joseph S.; Komistek, Richard D.
Lumbar interbody fusion is a common procedure owing to the high prevalence of degenerative spinal disorders. During such procedures, carbon fiber-reinforced polymer (CFRP) cages are frequently utilized to fill the void created between adjacent vertebral bodies, to provide mechanical stability, and to carry graft material. Failure of such implants can lead to significant morbidity. We discuss the possible causes leading to the failure of a CFRP cage in a patient with rheumatoid arthritis. Review of a 49-year-old woman who underwent revision anterior lumbar interbody fusion 2 years after posterior instrumentation and transforaminal lumbar interbody fusion at L4-L5 and L5-S1. The patient developed pseudarthrosis at the two previously fused levels with failure of the posterior instrumentation. Revision surgery reveled failure with fragmentation of the CFRP cage at the L5-S1 level. CFRP implants can break if mechanical instability or nonunion occurs in the spinal segments, thus emphasizing the need for optimizing medical management and meticulous surgical technique in achieving stability. PMID:24436878
Sardar, Zeeshan; Jarzem, Peter
This paper reviews the current published data regarding open transforaminal lumbar interbody fusion (TLIF) in relation to minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Introduction. MI-TLIF, a modern method for lumbar interbody arthrodesis, has allowed for a minimally invasive method to treat degenerative spinal pathologies. Currently, there is limited literature that compares TLIF directly to MI-TLIF. Thus, we seek to discuss the current literature on these techniques. Methods. Using a PubMed search, we reviewed recent publications of open and MI-TLIF, dating from 2002 to 2012. We discussed these studies and their findings in this paper, focusing on patient-reported outcomes as well as complications. Results. Data found in 14 articles of the literature was analyzed. Using these reports, we found mean follow-up was 20 months. The mean patient study size was 52. Seven of the articles directly compared outcomes of open TLIF with MI-TLIF, such as mean duration of surgery, length of post-operative stay, blood loss, and complications. Conclusion. Although high-class data comparing these two techniques is lacking, the current evidence supports MI-TLIF with outcomes comparable to that of the traditional, open technique. Further prospective, randomized studies will help to further our understanding of this minimally invasive technique.
Habib, Ali; Smith, Zachary A.; Lawton, Cort D.; Fessler, Richard G.
Lumbar spine radiographs of 28 patients with Marfan syndrome and a gender and age-matched control group were evaluated for scoliosis and morphologic changes of the L2, L3, and L4 vertebrae. No patient or control subject had any serious low back problems. The Marfan patients showed a high incidence of scoliosis (64%). The incidence of lumbosacral transitional vertebra was also high
K. Tallroth; A. Malmivaara; M.-L. Laitinen; A. Savolainen; A. Harilainen
BackgroundPosterolateral lumbar fusion (PLF) is the most popular technique for stabilizing the lumbar spine. Biomechanically, PLF decreases segmental motion in the posterior column, which presumably reduces facet joint pain. Posterior lumbar interbody fusion (PLIF) may decompress nerve roots by distracting the collapsed disc space, and achieving optimal fusion in relation to load-bearing capacity. The purpose of the study was to
Zvi Lidar; Andrew Beaumont; Jason Lifshutz; Dennis J. Maiman
Load and activity changes of the spine typically cause symptoms of nerve root compression in subjects with spinal stenosis. Protrusion of the intervertebral disc has been regarded as the main cause of the compression. The objective was to determine the changes in the size of the lumbar spinal canal and especially those caused by the ligamentum flavum and the disc during loaded MRI. For this purpose an interventional clinical study on consecutive patients was made. The lumbar spines in 24 supine patients were examined with MRI: first without any external load and then with an axial load corresponding to half the body weight. The effect of the load was determined through the cross-sectional areas of the spinal canal and the ligamentum flavum, the thickness of ligamentum flavum, the posterior bulge of the disc and the intervertebral angle. External load decreased the size of the spinal canal. Bulging of the ligamentum flavum contributed to between 50 and 85% of the spinal canal narrowing. It was concluded that the ligamentum flavum, not the disc had a dominating role for the load induced narrowing of the lumbar spinal canal, a finding that can improve the understanding of the patho-physiology in spinal stenosis.
Suzuki, Nobuyuki; Hebelka, Hanna; Gaulitz, Arne
Patch angioplasty has been reported as a suitable surgical option for patients with isolated coronary ostial stenosis, but controversy still exists concerning its effectiveness. We report the cases of 4 additional patients in whom this procedure was performed, including that of a patient with bilateral ostial stenosis; and we review the literature pertaining to bilateral ostial stenosis. Four patients, 3 with isolated stenosis of the left main coronary ostium and 1 with bilateral ostial stenosis, had direct surgical ostioplasty from January through November 1994. We considered the cause of ostial stenosis to be aortitis (of suspected syphilitic origin) in 1 patient, atherosclerotic plaque in 2 patients, and a fibrous membrane in the 4th. Ostioplasty was performed with a patch of autologous pericardium in 3 patients (fresh pericardium in 2 and glutaraldehyde-fixed in 1) and a patch of saphenous vein in 1. There were no operative deaths. One patient underwent successful reoperation for left main coronary artery restenosis after 3 months. All other patients are asymptomatic at 16, 18, and 24 months postoperatively. In the patient who underwent bilateral ostioplasty, coronary angiography showed patent ostia at 1 year. Surgical ostioplasty should be considered in the treatment of patients who have isolated ostial stenosis but no distal coronary disease. Careful patient selection seems to be a prerequisite for surgical success. Images
Bortolotti, U; Milano, A; Balbarini, A; Tartarini, G; Levantino, M; Borzoni, G; Magagnini, E; Mariani, M
Lumbar hernias are rare posterolateral abdominal wall defects that may be congenital or acquired. There are two types of lumbar hernia, the superior lumbar hernia through Grynfeltt triangle, and the inferior lumbar hernia through Petit triangle. Many techniques have been described for the surgical repair of lumbar hernias including primary repair, local tissue flaps, and conventional mesh repair. But these open techniques require a large skin incision. We report a case of superior lumbar hernia, which was successfully repaired using a laparoscopic approach.
Nam, Soon Young; Kee, Se Kook
Intraradicular lumbar disc herniation is a rare complication of disc disease that is generally diagnosed only during surgery. The mechanism for herniated disc penetration into the intradural space is not known with certainty, but adhesion between the radicular dura and the posterior longitudinal ligament was suggested as the most important condition. The authors report the first case of an intraradicular lumbar disc herniation without subdural penetration; the disc hernia was lodged between the two radicular dura layers. The patient, a 34-year-old soldier, was admitted with a 12-month history of low back pain and episodic left sciatica. Neurologic examination showed a positive straight leg raising test on the left side without sensory, motor or sphincter disturbances. Spinal CT scan and MRI exploration revealed a left posterolateral osteophyte formation at the L5-S1 level with an irregular large disc herniation, which migrated superiorly. An intradural extension was suspected. A left L5 hemilaminectomy and S1 foraminotomy were performed. The exploration revealed a large fragment of disc material located between the inner and outer layers of the left S1 radicular dura. The mass was extirpated without cerebrospinal fluid outflow. The postoperative course was uneventful. Radicular interdural lumbar disc herniation should be suspected when a swollen, hard and immobile nerve root is present intraoperatively. PMID:19888608
Akhaddar, Ali; Boulahroud, Omar; Elasri, Abad; Elmostarchid, Brahim; Boucetta, Mohammed
Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.
Beazell, James R; Mullins, Melise; Grindstaff, Terry L
Lumbar hernia is a rare surgical entity without a standard method of repair. With advancements in laparoscopic techniques, successful lumbar herniorrhaphy can be achieved by the creation of a completely extraperitoneal working space and secure fixation of a wide posterior mesh. We present a total extraperitoneal laparoendoscopic repair of lumbar hernia, which allowed for minimal invasiveness while providing excellent anatomical identification, easy mobilization of contents and wide secure mesh fixation. A total extraperitoneal method of lumbar hernia repair by laparoscopic approach is feasible and may be an ideal option.
Lim, Man Sup; Lee, Hae Wan; Yu, Chang Hee
In a longitudinal study, the dose-response relationships between long term occupational exposure to whole-body vibration and degenerative processes in the lumbar spine caused by the lumbar disks were examined. From 1990 to 1992, 388 vibration-exposed workers from different driving jobs were examined medically and by lumbar X-ray. For each individual, a history of all exposure conditions was recorded, and a cumulative vibration dose was calculated allowing comparisons between groups of low, middle, and high intensity of exposure. 310 subjects were selected for a follow-up four years later, of whom 90·6% (n=281) agreed to participate. In comparing the exposure groups, the results indicate that the limit value ofazw(8h)=0·8 m/s2should be reviewed. The best fit between the lifelong vibration dose and the occurrence of a lumbar syndrome was obtained by applying a daily reference ofazw(8h)=0·6 ms2as a limit value. The results became more distinct still when only those subjects were included in the statistical analysis who had had no lumbar symptoms up to the end of the first year of exposure. The prevalence of lumbar syndrome is 1·55 times higher in the highly exposed group when compared to the reference group with low exposure (CI95%=1·24/1·95). Calculating the cumulative incidence of new cases of lumbar syndrome in the follow-up period yields a relative risk ofRRMH=1·37 (CI95%=0·86/2·17) for the highly exposed group. It is concluded that the limit value for the calculation of an individual lifelong vibration dose should be based on a daily reference exposure ofazw(8h)=0·6 m/s2. With increasing dose it is more and more probable that cases of lumbar syndrome are caused by exposure to vibration.
Schwarze, S.; Notbohm, G.; Dupuis, H.; Hartung, E.
Aortic valve stenosis is known to be associated with loss of high molecular von Willebrand multimers. This can lead to gastrointestinal bleeding in patients with gastrointestinal angiodysplasia, the Heyde syndrome. Here we present a case of anaemia and severe epistaxis associated with acquired von Willebrand syndrome. Gastrointestinal endoscopy revealed no bleeding source. Calcifying aortic stenosis was confirmed by echocardiography. Loss of high molecular weight multimers of von Willebrand factor in our patient was shown by immunoblot analysis. If severe epistaxis occurs in the context of symptomatic aortic valve stenosis, it might be an additional reason to recommend valve replacement surgery to the patient. PMID:17150267
Schödel, Johannes; Obergfell, Achim; Maass, Alexander H
Background: Oculomotor abnormalities have been re- ported in patients with degenerative ataxic disorders. Objective: To assess the diagnostic sensitivity and speci- ficity of oculomotor deficits in patients with Friedreich ataxia (FA), cerebellar atrophy (CA), and olivoponto- cerebellar atrophy (OPCA). Setting: Neurology clinic at a university hospital in Lu ¨- beck, Germany. Patients: Seven patients with FA, 9 with CA, and
Karl Wessel; Carsten Moschner; Klaus-Peter Wandinger; Deflef Kompf; Wolfgang Heide
Many age-related degenerative diseases, including Alzheimer's, Parkinson's, Huntington's diseases and type II diabetes, are associated with the accumulation of amyloid fibrils. The protein components of these amyloids vary widely and the mechanisms of pathogenesis remain an important subject of competing hypotheses and debate. Many different mechanisms have been postulated as significant causal events in pathogenesis, so understanding which events are
Charles G. Glabe
By investigating three patients with progressive agraphia, we explored the possibility that this entity is an early sign of degenerative dementia. Initially, these patients complained primarily of difficulties writing Kanji (Japanese morphograms) while other language and cognitive impairments were relatively milder. Impairments in writing Kana…
Fukui, Toshiya; Lee, Eiyai
Background:Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. Objective: This study was undertaken to identify factors influencing the durability of mitral valve repair. Patients and methods: Between 1985 and 1997, 1072 patients underwent primary
A. Marc Gillinov; Delos M. Cosgrove; Eugene H. Blackstone; Ramon Diaz; John H. Arnold; Bruce W. Lytle; Nicholas G. Smedira; Joseph F. Sabik; Patrick M. McCarthy; Floyd D. Loop
Imbalanced Protein Expression Patterns of Anabolic, Catabolic, Anti-Catabolic and Inflammatory Cytokines in Degenerative Cervical Disc Cells: New Indications for Gene Therapeutic Treatments of Cervical Disc Diseases
Degenerative disc disease (DDD) of the cervical spine is common after middle age and can cause loss of disc height with painful nerve impingement, bone and joint inflammation. Despite the clinical importance of these problems, in current publications the pathology of cervical disc degeneration has been studied merely from a morphologic view point using magnetic resonance imaging (MRI), without addressing the issue of biological treatment approaches. So far a wide range of endogenously expressed bioactive factors in degenerative cervical disc cells has not yet been investigated, despite its importance for gene therapeutic approaches. Although degenerative lumbar disc cells have been targeted by different biological treatment approaches, the quantities of disc cells and the concentrations of gene therapeutic factors used in animal models differ extremely. These indicate lack of experimentally acquired data regarding disc cell proliferation and levels of target proteins. Therefore, we analysed proliferation and endogenous expression levels of anabolic, catabolic, ant-catabolic, inflammatory cytokines and matrix proteins of degenerative cervical disc cells in three-dimensional cultures. Preoperative MRI grading of cervical discs was used, then grade III and IV nucleus pulposus (NP) tissues were isolated from 15 patients, operated due to cervical disc herniation. NP cells were cultured for four weeks with low-glucose in collagen I scaffold. Their proliferation rates were analysed using 3-(4, 5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide. Their protein expression levels of 28 therapeutic targets were analysed using enzyme-linked immunosorbent assay. During progressive grades of degeneration NP cell proliferation rates were similar. Significantly decreased aggrecan and collagen II expressions (P<0.0001) were accompanied by accumulations of selective catabolic and inflammatory cytokines (disintegrin and metalloproteinase with thrombospondin motifs 4 and 5, matrix metalloproteinase 3, interleukin-1?, interleukin-1 receptor) combined with low expression of anti-catabolic factor (metalloproteinase inhibitor 3) (P<0.0001). This study might contribute to inhibit inflammatory catabolism of cervical discs.
Mern, Demissew S.; Beierfu?, Anja; Fontana, Johann; Thome, Claudius; Hegewald, Aldemar A.
The relationship between the formation of a solid arthrodesis and electrical and electromagnetic energy is well established; most of the information on the topic, however, pertains to the healing of long bone fractures. The use of both invasive and noninvasive means to supply this energy and supplement spinal fusions has been investigated. Three forms of electrical stimulation are routinely used: direct current stimulation (DCS), pulsed electromagnetic field stimulation (PEMFS), and capacitive coupled electrical stimulation (CCES). Only DCS requires the placement of electrodes within the fusion substrate and is inserted at the time of surgery. Since publication of the original guidelines, few studies have investigated the use of bone growth stimulators. Based on the current review, no conflict with the previous recommendations was generated. The use of DCS is recommended as an option for patients younger than 60 years of age, since a positive effect on fusion has been observed. The same, however, cannot be stated for patients over 60, because DCS did not appear to have an impact on fusion rates in this population. No study was reviewed that investigated the use of CCES or the routine use of PEMFS. A single low-level study demonstrated a positive impact of PEMFS on patients undergoing revision surgery for pseudarthrosis, but this single study is insufficient to recommend for or against the use of PEMFS in this patient population. PMID:24980594
Kaiser, Michael G; Eck, Jason C; Groff, Michael W; Ghogawala, Zoher; Watters, William C; Dailey, Andrew T; Resnick, Daniel K; Choudhri, Tanvir F; Sharan, Alok; Wang, Jeffrey C; Dhall, Sanjay S; Mummaneni, Praveen V
Congenital esophageal stenosis (CES) is associated with oesophageal atresia and tracheoesophageal fistula (EA-TEF). Tracheobronchial (cartilaginous) rests are typically found within the area of stenosis. The authors present a case report of EA-TEF associated with CES and present a modification of a novel technique to facilitate the management of CES. The impact of gastro-oesophageal reflux disease is discussed in this unique entity. Finally, the literature is reviewed for this unique entity. PMID:23696146
Escobar, Mauricio Antonio; Pickens, Michael K; Holland, Randall M; Caty, Michael G
A three year old girl with severe congenital mitral stenosis was successfully treated by percutaneous balloon dilatation of the mitral valve. Cardiac catheterisation and cross sectional and Doppler echocardiography indicated that the orifice of the mitral valve had doubled in area. A small atrial septal defect was found at follow up cardiac catheterisation and angiography. Balloon dilatation of the mitral valve is a reasonable alternative to surgical treatment for typical congenital mitral stenosis even in young children. Images Fig 1 Fig 2
Alday, L E; Juaneda, E
Intraspinal metallomas are rare. The authors present a case after implantation of two titanium threaded interbody cages at the L4L5 level, without posterior instrumentation. To their knowledge this is the first case due to intervertebral cages. The lack of additional instrumentation had probably allowed the cages to make contact. Subsequently, friction generated wear debris, which led to the formation of a granuloma, responsible for compression of the dural sac. Intraspinal metallosis should be kept in mind as an infrequent cause of delayed neurological symptoms after spinal surgery with metallic instrumentation. PMID:23409582
Fernández-Baíllo, Nicomedes; Sánchez Marquez, José Miguel; Conde Gallego, Esther; Martín Esteban, Ana
Microendoscopic discectomy (MED), which combines traditional lumbar microsurgical techniques with endoscopy, is being used as a minimally invasive procedure for lumbar disc herniation. We reviewed 30 patients who underwent MED at our institution and compared their outcome with that of patients subjected to the conventional method. Laboratory data suggested that MED was less invasive surgery. Moreover, MED allowed an early
Hiroyuki Nakagawa; Mikio Kamimura; Shigeharu Uchiyama; Kenji Takahara; Toshiro Itsubo; Tadaatsu Miyasaka
In hemodialysis access, the brachiocephalic or upper-arm fistula has less than optimal functional rates. The cause of this reduced patency is stenosis due to intimal hyperplasia in the cephalic vein. Stenosis typically leads to thrombosis and ultimately failure of the fistula. To increase our understanding of this process, numerical simulations of the unsteady, two-dimensional, incompressible Navier-Stokes equations are solved for the flow in an infinite channel having curvature and stenosis. Physiologically relevant Reynolds numbers ranging from 300 to 1500 and stenosis percentages of 0, 25, 50, and 75 are modeled. The post-stenotic flow is characterized by strong shear layers and recirculation regions. The largest shear stresses are found just upstream of the stenosis apex. The maximum shear stress increases with increasing Reynolds number and percent stenosis. The results indicate that hemodynamic conditions in the vein after fistula creation combined with curvature of the cephalic arch lead to shear stresses that exceed normal physiological values (both minimum and maximum). In some cases, the shear stresses are sufficiently large to cause damage to the endothelium and possibly denudation.
Boghosian, Michael E.; Cassel, Kevin W.
Background Decompressive laminotomy is the standard surgical procedure in the treatment of patients with canal stenosis related intermittent neurogenic claudication. New techniques, such as interspinous process implants, claim a shorter hospital stay, less post-operative pain and equal long-term functional outcome. A comparative (cost-) effectiveness study has not been performed yet. This protocol describes the design of a randomized controlled trial (RCT) on (cost-) effectiveness of the use of interspinous process implants versus conventional decompression surgery in patients with lumbar spinal stenosis. Methods/Design Patients (age 40-85) presenting with intermittent neurogenic claudication due to lumbar spinal stenosis lasting more than 3 months refractory to conservative treatment, are included. Randomization into interspinous implant surgery versus bony decompression surgery will take place in the operating room after induction of anesthesia. The primary outcome measure is the functional assessment of the patient measured by the Zurich Claudication Questionnaire (ZCQ), at 8 weeks and 1 year after surgery. Other outcome parameters include perceived recovery, leg and back pain, incidence of re-operations, complications, quality of life, medical consumption, absenteeism and costs. The study is a randomized multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 1 year. Discussion Currently decompressive laminotomy is the golden standard in the surgical treatment of lumbar spinal stenosis. Whether surgery with interspinous implants is a reasonable alternative can be determined by this trial. Trial register Dutch Trial register number: NTR1307
Introduction: L5 radiculopathy has characteristic clinical and electrodiagnostic features including: radicular pain; weakness or denervation of hip abductors, ankle dorsiflexors, and inverters; and pre-ganglionic dorsal foot sensory loss. It is unknown how often patients with this distinctive clinical-electrodiagnostic presentation have isolated L5-root compression on neuroimaging or more widespread, possibly age-related, lumbar neuroforaminal or spinal stenosis. Methods: A study-blinded neuroradiologist quantitated lumbosacral neuroforaminal, lateral recess, and spinal stenosis in 26 consecutive patients with unilateral, clinically and EMG-ascertained L5 monoradiculopathy, and quantitated a global neuroforaminal and spinal stenosis score (SSS). Results: Only 9 patients (35%) had isolated L5-root compression, 14 (54%) had multi-root compression, and 3 (12%) had normal neuroimaging. Increasing age correlated with SSS, and the 9 patients with isolated L5-root compression were significantly younger than patients with multi-root involvement. Conclusions: This study underscores the role of clinical and electrodiagnostic data when interpreting lumbosacral neuroimaging, particularly in older patients. Muscle Nerve 50: 135-137, 2014. PMID:24402913
Botez, Stephan A; Zynda-Weiss, Andrea M; Logigian, Eric L
Renal artery stenosis (RAS) is a common form of peripheral arterial disease. The most common cause of RAS is atherosclerosis. It is predominantly unilateral. The pathophysiologic mechanism stems from renal underperfusion resulting in the activation of the renin- angiotensin-aldosterone pathway. Even though the majority of patients with RAS are asymptomatic, it can clinically present with hypertension, nephropathy and congestive heart failure. This progressive disease can lead to resistant hypertension and end stage kidney failure. Screening patients for RAS with either Doppler ultrasonography, computed tomographic angiography, or magnetic resonance angiography is preferred. Adequate blood pressure control, goal-directed lipid-lowering therapy, smoking cessation, and other preventive measures form the foundation of management of patients with RAS. Catheter-based percutaneous revascularization with angioplasty and stenting showed modest clinical benefit for patients in small retrospective studies, but data from randomized clinical trials failed to confirm these beneficial results. The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial may provide more concrete data regarding the role of stenting in RAS. Surgical revascularization is considered only if catheter-based revascularization is unsuitable or unsuccessful. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with RAS provide the framework for determining individualized assessment and treatment plans for patients with RAS. PMID:24113662
Sattur, Sudhakar; Prasad, Hari; Bedi, Updesh; Kaluski, Edo; Stapleton, Dwight D
Cricket fast bowlers have a high incidence of serious lumbar injuries, such as lesions in the pars interarticularis. As lumbar loading is the causal mechanism of such injuries, the purpose of this study was to find relationships between lumbar spine kinetics, selected kinematic variables and the subsequent development of lumbar spine injury. At the beginning of the cricket season, the
René E D Ferdinands; Max Stuelcken; Andy Greene; Peter Sinclair; Richard Smith
In this review we discuss insights into therapeutic stratagems that can selectively target the choroid, retinal cells and vitreoretinal space for the treatment of vision-threatening vascular degenerative disorders of the posterior eye. Despite the relative success of these novel drugs, new problems related to its delivery remain. Systems carrying drugs to the target site, such as nanoparticles, liposomes, vectosomes, spanlastics, micelles, dendrimers and implants are also discussed. Further, we also consider drug penetration enhancement approaches along with cutting-edge strategies for regaining vision during vision-threatening vascular degenerative disorders of the eye. Finally, challenges, such as ocular or even systemic complications associated with use of prolonged therapies and future prospects, such as combination of approaches with multidisciplinary integration to optimize delivery to the posterior eye are also addressed. PMID:22504325
Jain, Gaurav K; Warsi, Musarrat H; Nirmal, Jayabalan; Garg, Vaidehi; Pathan, Shadab A; Ahmad, Farhan J; Khar, Roop K
With the development of stem cell technology, stem cell-based therapy for retinal degeneration has been proposed to restore\\u000a the visual function. Many animal studies and some clinical trials have shown encouraging results of stem cell-based therapy\\u000a in retinal degenerative diseases. While stem cell-based therapy is a promising strategy to replace damaged retinal cells and\\u000a ultimately cure retinal degeneration, there are
Ian Yat-Hin Wong; Ming-Wai Poon; Rosita Tsz-Wai Pang; Qizhou Lian; David Wong
Retinal degenerative diseases that target photoreceptors or the adjacent retinal pigment epithelium (RPE) affect millions\\u000a of people worldwide. Retinal degeneration (RD) is found in many different forms of retinal diseases including retinitis pigmentosa\\u000a (RP), age-related macular degeneration (AMD), diabetic retinopathy, cataracts, and glaucoma. Effective treatment for retinal\\u000a degeneration has been widely investigated. Gene-replacement therapy has been shown to improve visual
Yiming Huang; Volker Enzmann; Suzanne T. Ildstad
The syndrome of degenerative leiomyopathy (DL) causing intestinal obstruction clinically manifests in young indigenous African children as massive megacolon without aganglionosis. We report on a clinico-pathologic study of 18 children seen over a 15-year period. All patients came from the same geographic area. Mean age at presentation was 9.5 years with mean duration of symptoms 4.3 years. The youngest infant
H. Rode; S. W. Moore; R. O. C. Kaschula; R. A. Brown; S. Cywes
Abstract Context: Isolated lumbar paraspinal muscle fatigue causes lower extremity and postural control deficits. Objective: To describe the change in body position during gait after fatiguing lumbar extension exercises in persons with recurrent episodes of low back pain compared with healthy controls. Design: Case-control study. Setting: Motion analysis laboratory. Patients or Other Participants: Twenty-five recreationally active participants with a history of recurrent episodes of low back pain, matched by sex, height, and mass with 25 healthy controls. Intervention(s): We measured 3-dimensional lower extremity and trunk kinematics before and after fatiguing isometric lumbar paraspinal exercise. Main Outcome Measure(s): Measurements were taken while participants jogged on a custom-built treadmill surrounded by a 10-camera motion analysis system. Results: Group-by-time interactions were observed for lumbar lordosis and trunk angles (P < .05). A reduced lumbar spine extension angle was noted, reflecting a loss of lordosis and an increase in trunk flexion angle, indicating increased forward trunk lean, in healthy controls after fatiguing lumbar extension exercise. In contrast, persons with a history of recurrent low back pain exhibited a slight increase in spine extension, indicating a slightly more lordotic position of the lumbar spine, and a decrease in trunk flexion angles after fatiguing exercise. Regardless of group, participants experienced, on average, greater peak hip extension after lumbar paraspinal fatigue. Conclusions: Small differences in response may represent a necessary adaptation used by persons with recurrent low back pain to preserve gait function by stabilizing the spine and preventing inappropriate trunk and lumbar spine positioning.
Hart, Joseph M.; Kerrigan, D. Casey; Fritz, Julie M.; Ingersoll, Christopher D.
The causes of nasolacrimal duct stenosis in adults can vary greatly. In general, the symptoms can also vary, but most cases share a tendency toward recurring inflammations in the prestenotic area. The treatment of these disorders is limited to either conservative therapy to control inflammation or surgically invasive measures. By using balloon catheters, usually applied in percutaneous transluminal coronary angioplasty (PTCA), dilation of the relative postsaccal stenosis can be performed under radiographic control. An exact diagnosis using various testing methods, including digital dacryocystography for detailed localization and documentation of any pathologic changes, is decisive to success. Only in cases of incomplete postsaccal stenosis is retrograde balloon dilation of the distal nasolacrimal duct indicated. A guide wire, designed for the PTCA balloon catheter set, is introduced via the canaliculus to the nasal cavity antegradely and caught with a thin hook and pulled from the naris, under visual control with an image converter. The balloon catheter is retrogradely threaded over the guide wire. The baloon is then placed at the site of the pathologic stenosis under radiographic control and dilated with high pressure. To ensure the permeability of the system, monocanalicular silicone intubation has to be performed immediately afterwards. This procedure has been performed successfully on 6 patients with a follow-up of 6 to 27 months. These initial results give rise to the hope that this minimally invasive, interdisciplinary technique represents a new alternative in the treatment of incomplete postsaccal lacrimal stenosis. PMID:8311386
Steinkogler, F J; Huber, E; Kuchar, A; Karnel, F
Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction. A radioanatomic analysis of the nondiskal structures of the spinal column and perispinal soft tissues.
In earlier evolutionary times, mammals were primarily quadrupeds. However, other bipeds have also been represented during the course of the Earth's several billion year history. In many cases, either the bipedal stance yielded a large tail and hypoplastic upper extremities (e.g., Tyrannosaurus rex and the kangaroo), or it culminated in hypoplasia of the tail and further development and specialization of the upper extremities (e.g., nonhuman primates and human beings). In the human species this relatively recently acquired posture resulted in a more or less pronounced lumbosacral kyphosis. In turn, certain compensatory anatomic features have since occurred. These include the normal characteristic posteriorly directed wedge-shape of the L5 vertebral body and the L5-S1 intervertebral disk; the L4 vertebral body and the L4-L5 disk may be similarly visibly affected. These compensatory mechanisms, however, have proved to be functionally inadequate over the long term of the human life span. Upright posture also leads to increased weight bearing in humans that progressively causes excess stresses at and suprajacent to the lumbosacral junction. These combined factors result in accelerated aging and degenerative changes and a predisposition to frank biomechanical failure of the subcomponents of the spinal column in these spinal segments. One other specific problem that occurs at the lumbosacral junction that predisposes toward premature degeneration is the singular relationship that exists between a normally mobile segment of spine (i.e., the lumbar spine) and a normally immobile one (i.e., the sacrum). It is well known that mobile spinal segments adjacent to congenitally or acquired fused segments have a predilection toward accelerated degenerative changes. The only segment of the spine in which this is invariably normally true is at the lumbosacral junction (i.e., the unfused lumbar spine adjoining the fused sacrum). Nevertheless, biomechanical failures of the human spine are not lethal traits; in most cases today, mankind reaches sexual maturity before spinal biomechanical failure precludes sexual reproduction. For this gene-preserving reason, degenerative spinal disorders will likely be a part of modern societies for the foreseeable eternity of the race. The detailed alterations accruing from the interrelated consequences of and phenomena contributing to acquired degenerative changes of the lumbosacral intervertebral segments as detailed in this discussion highlight the extraordinary problems that are associated with degenerative disease in this region of the spine. Further clinicoradiologic research in this area will progressively determine the clinical applications and clinical efficacy of the various traditional and newer methods of therapy in patients presenting with symptomatic acquired collapse of the intervertebral disks at and suprajacent to the lumbosacral junction and the interrelated degenerative alterations of the nondiskal structures of the spine. PMID:11221507
Jinkins, J R
Lumbar disk lesions in 47 cases were initially diagnosed using MRI investigation, then, after surgery, biological and histopathological aspects of intervertebral disks were revealed. Pieces from intervertebral disks were used for electron microscopy studies in order to determine collagen in the components of the intervertebral disk. The aim of the present study was to highlight the correspondence between the MRI aspect in cases with clinically manifest lumbar hernia, staged according to MRI Modic classification, and the histopathological aspect in patients with surgical interventions on the intervertebral disks. 4/5 of the analyzed disks had advanced forms of degenerescence of the intervertebral disks: hyalinized disk cartilage ± intradiskal calcification or ossification zones, chronic inflammatory infiltrate at the disk cartilage level. Electron microscopy studies made on disk fragments obtained by discectomy revealed quantitative and qualitative changes of all types of collagen at the level of the three anatomical structures of the intervertebral disks, which correspond to the MRI changes. PMID:21424071
Cevei, Mariana; Ro?ca, Elena; Liviu, L; Mu?iu, Gabriela; Stoic?nescu, Dorina; Vasile, Liliana
Herniated lumbar disc may be asymptomatic or associated with lower limb radiculopathy. Most spinal surgeons would offer surgery following a period of conservative measures if the radiological and clinical findings correlate. However, the existing dictum that lumbar radiculopathy should correlate with ipsilateral lumbar disc herniation may not be accurate as it can rarely present with contralateral sciatica. Literature regarding this phenomenon is scarce. Therefore, we report a patient with herniated lumbar disc presenting with predominantly contralateral motor weakness radiculopathy, which resolved after discectomy. PMID:24811105
Abdul Jalil, Muhammad Fahmi; Lam, Miu Fei; Wang, Yi Yuen
Calcific aortic valve stenosis is the most common valvular disease in developed countries, and the major reason for operative valve replacement. In the US, the current annual cost of this surgery is approximately 1 billion dollars. Despite increasing morbidity and mortality, little is known of the cellular basis of the calcifications, which occur in high-perfusion zones of the heart. The case is presented of a patient with calcific aortic valve stenosis and colonies of progressively mineralized nanobacteria in the fibrocalcific nodules of the aortic cusps, as revealed by transmission electron microscopy. Consistent with their outstanding bioadhesivity, nanobacteria might serve as causative agents in the development of calcific aortic valve stenosis. PMID:17315391
Jelic, Tomislav M; Chang, Ho-Huang; Roque, Rod; Malas, Amer M; Warren, Stafford G; Sommer, Andrei P
Introduction The aim of this study is to report our 6-year single-center experience with L5–S1 axial lumbar interbody fusion (AxiaLIF). Methods A total of 131 patients with symptomatic degenerative disc disease refractory to nonsurgical treatment were treated with AxiaLIF at L5–S1, and were followed for a minimum of 1 year (mean: 21 months). Main outcomes included back and leg pain severity, Oswestry Disability Index score, working status, analgesic medication use, patient satisfaction, and complications. Computed tomography was used to determine postoperative fusion status. Results No intraoperative complications, including vascular, neural, urologic, or bowel injuries, were reported. Back and leg pain severity decreased by 51% and 42%, respectively, during the follow-up period (both P < 0.001). Back function scores improved 50% compared to baseline. Clinical success, defined as improvement ?30%, was 67% for back pain severity, 65% for leg pain severity, and 71% for back function. The employment rate increased from 47% before surgery to 64% at final follow-up (P < 0.001). Less than one in four patients regularly used analgesic medications postsurgery. Patient satisfaction with the AxiaLIF procedure was 83%. The fusion rate was 87.8% at final follow-up. During follow-up, 17 (13.0%) patients underwent 18 reoperations on the lumbar spine, including pedicle screw fixation (n = 10), total disc replacement of an uninvolved level (n = 3), facet screw fixation (n = 3), facet screw removal (n = 1), and interbody fusion at L4–L5 (n = 1). Eight (6.1%) reoperations were at the index level. Conclusion Single-level AxiaLIF is a safe and effective means to achieve lumbosacral fusion in patients with symptomatic degenerative disc disease.
Zeilstra, Dick J; Miller, Larry E; Block, Jon E
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.
Pusat, Serhat; Kural, Cahit; Aslanoglu, Atilla; Kurt, Bulent
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots. PMID:23741553
Pusat, Serhat; Kural, Cahit; Aslanoglu, Atilla; Kurt, Bulent; Izci, Yusuf
Stenosis of anterior nares may be congenital or acquired. Acquired stenosis may be caused by the diseases which cause destruction of skin or normal cartilage. The various causes of acquired stenosis of anterior nares are burns, trauma, infections, etc. Iatrogenic stenosis of anterior nares is a rare condition. Doing simple excision of fibrosed tissue, with septoplasty and endoscopic adenoidectomy in a 5-year child, improved nasal breathing. Use of Mitomycin-C topical solution prevents recurrence of fibrosis, with good outcome.
Garag, Santosh S.; Anchan, Shibani
The implantation of lumbar disc prostheses based on different design concepts is widely accepted. This paper reviews currently\\u000a available literature studies on the biomechanics of TDA in the lumbar spine, and is targeted at the evaluation of possible\\u000a relationships between the aims of TDA and the geometrical, mechanical and material properties of the various available disc\\u000a prostheses. Both theoretical and
Fabio Galbusera; Chiara M. Bellini; Thomas Zweig; Stephen Ferguson; Manuela T. Raimondi; Claudio Lamartina; Marco Brayda-Bruno; Maurizio Fornari
The posteroanterior view of the lumbar spine has important features including radiation protection and image quality; these have been studied by various investigators. Investigators have shown that sensitive tissues receive less radiation dosage in the posteroanterior view of the spine for scoliosis screening and intracranial tomography without altering the image quality. This paper emphasizes the importance of the radiation safety aspect of the posteroanterior view and shows the improvement in shape distortion in the lumbar vertebrae.
Tsuno, M.M.; Shu, G.J. (Cleveland Chiropractic College, Los Angeles, CA (USA))
Symptomatic lumbar synovial cysts (LSCs) are a rare cause of degenerative narrowing of the spinal canal, with thecal sac or nerve root compression. True synovial cysts have a thick wall lined by synovial cells, containing granulation tissue, numerous histiocytes, and giant cells. In contrast, pseudo-cysts lack specialized epithelium, have a collagenous capsule filled with myxoid material, and may be classified into ganglion cysts, originating from periarticular fibrous tissues, and ligamentous cysts, arising from the ligamentum flavum or even from the posterior longitudinal ligament. Here we present the surgical series of the Chair of Neurosurgery at the University of Cagliari (Italy) including a total of 17 LSCs. Surgical technique consisted of facet sparing excision of LSC, achieved by simple hemilaminectomy/laminectomy, and diagnosis was always confirmed by histological specimen examination, which detected the typical synovial epithelium, the intracystic presence of hemosiderin, histiocytes, and calcifications. Further immunohistochemical investigation revealed positive staining for cytokeratin: CK5, CK6, and AE1/AE3. Clinically, our cohort experienced rapid and complete resolution of symptoms, without perioperative complications, or recurrence of cysts or vertebral instability at a median follow up of 28 months, when the MacNab score was generally excellent. A review of the literature, retrieving articles published from 1973, collected a total of 101 articles concerning all the cases of LSC scientifically described to date. Both clinical and histological findings described in our study support the theory of degenerative microtraumatic pathogenesis of synovial cysts. PMID:23438660
Ganau, Mario; Ennas, Franco; Bellisano, Giulia; Ganau, Laura; Ambu, Rossano; Faa, Gavino; Maleci, Alberto
The authors describe a new minimally invasive technique for posterior supplementation using percutaneous translaminar facet screw (TFS) fixation with computed tomography (CT) guidance. Oblique axial images were used to determine facet screw fixation sites. After the induction of local anesthesia and conscious sedation, a guide pin was inserted and guided with a laser mounted on the CT gantry. Cannulated TFSs were placed via a percutaneous approach. From December 2002 to August 2003, 18 patients underwent CT-guided TFS. In 17 of these patients this procedure was supplementary to anterior lumbar interbody fusion, which had been performed several days earlier; in the remaining patient, CT-guided TFS fixation was undertaken as the primary therapy. Twelve patients had painful degenerative disc disease or unstable degenerative spondylolisthesis, three had infections, and three had deformities. All screws were inserted accurately and there were no complications. This new minimally invasive surgical technique may offer an alternative to pedicle screw fixation as a method of posterior supplementation. PMID:17633496
Kang, Ho Yeong; Lee, Sang-Ho; Jeon, Sang Hyeop; Shin, Song-Woo
The artificial disc is a mobile implant for degenerative disc replacement that attempts to lessen the degeneration of the adjacent elements. However, inconsistent biomechanical results for the neighboring elements have been reported in a number of studies. The present study used finite element (FE) analysis to explore the biomechanical differences at the surgical and both adjacent levels following artificial disc replacement and interbody fusion procedures. First, a three-dimensional FE model of a five-level lumbar spine was established by the commercially available medical imaging software Amira 3.1.1, and FE software ANSYS 9.0. After validating the five-level intact (INT) model with previous in vitro studies, the L3/L4 level of the INT model was modified to either insert an artificial disc (ProDisc II; ADR) or incorporate bilateral posterior lumbar interbody fusion (PLIF) cages with a pedicle screw fixation system. All models were constrained at the bottom of the L5 vertebra and subjected to 150N preload and 10Nm moments under four physiological motions. The ADR model demonstrated higher range of motion (ROM), annulus stress, and facet contact pressure at the surgical level compared to the non-modified INT model. At both adjacent levels, ROM and annulus stress were similar to that of the INT model and varied less than 7%. In addition, the greatest displacement of posterior annulus occurred at the superior-lateral region. Conversely, the PLIF model showed less ROM, less annulus stress, and no facet contact pressure at the surgical level compared to the INT model. The adjacent levels had obviously high ROM, annulus stress, and facet contact pressure, especially at the adjacent L2/3 level. In conclusion, the artificial disc replacement revealed no adjacent-level instability. However, instability was found at the surgical level, which might accelerate degeneration at the highly stressed annulus and facet joint. In contrast to disc replacement results, the posterior interbody fusion procedure revealed possibly accelerative degeneration of the annulus and facet joint at both adjacent levels. PMID:18760654
Chen, Shih-Hao; Zhong, Zheng-Cheng; Chen, Chen-Sheng; Chen, Wen-Jer; Hung, Chinghua
Prospective study. To study the validity of Hybrid construction (Anterior Lumbar Interbody Fusion) ALIF at one level and total disc arthroplasty (TDA) at adjacent, for two levels disc disease in lumbar spine as surgical strategy. With growing evidence that fusion constructs in the treatment of degenerative disc disease (DDD) may alter sagittal balance and contribute to undesirable complications in the long-term, total disc arthroplasty (TDA) slowly becomes an accepted treatment option for a selected group of patients. Despite encouraging early and intermediate term results of single-level total disc arthroplasty reported in the literature, there is growing evidence that two-level arthroplasty does not fare as well. Hybrid fusion is an attempt to address two-level DDD by combining the advantages of a single-level ALIF with those of a single-level arthroplasty. 42 patients (25 females and 17 males) underwent Hybrid fusion and had a median follow-up of 26.3 months. The primary functional outcomes were assessed before and after surgery with Oswestry Disability Index and the visual analogue score of the back and legs. Patients were divided into four groups according to the percentage improvement between preop and postop ODI scores. A total of 42 patients underwent a hybrid fusion as follows: 35 L5-S1 ALIF/L4-5 prosthesis, 3 L4-5 ALIF/L3-4 prosthesis, 2 L5-S1 ALIF/L4-5 prosthesis/L3-4 prosthesis, 1 L5-S1 prosthesis/L4-5 ALIF, and 1 L5-S1 ALIF/L4-5 ALIF/L3-4 prosthesis. At 2-years clinical outcomes, mean reduction in ODI is 24.9 points (53.0% improvement compared to preop ODI). The visual analogue score for the back is 64.6% improvement. At 2-year clinical outcomes, Hybrid fusion is a viable surgical alternative for the treatment of two-level DDD in comparison with two-level TDA and with two-level fusion. PMID:19888610
Aunoble, Stephane; Meyrat, Robert; Al Sawad, Yasser; Tournier, C; Leijssen, Philip; Le Huec, Jean-Charles
Lumbar disc prostheses have been used in treating symptomatic degenerative disc diseases. A few prostheses of the ball-socket design are currently available for clinical use, the joint mechanism being materialized either with a hard polymer core or a metal-to-metal couple. Other prostheses of "shock absorber" design were not available at the time of the study. The objective of this work was to establish whether there was a difference in the shock absorption capacity between a device having an ultra-high-molecular-weight polyethylene center core and a device having a metal-on-metal bearing. Vibration and shock loading were applied to two lumbar total disc prostheses: PRODISC, manufactured by Spine Solutions, and MAVERICK Total Disc Replacement, manufactured by Medtronic Sofamor Danek. The shock absorption capacity of the device was evaluated by comparing the input and the output force measurements. The disc prosthesis was mounted onto a test apparatus. Each side of the device was equipped with a force sensor. The input shock load and the output resulting forces were simultaneously measured and recorded. The loading force pattern included 1). a static preload of 350 N plus an oscillating vibration of 100 N with frequency sweeping from 0 to 100 Hz and 2). a sudden shock load of 250 N applied over a 0.1-second interval. Both input and output signal data were processed and were transformed into their frequency spectrums. The vibration and shock transmissibility of the device, defined as the ratio of the output spectrum over the input spectrum, were calculated in sweeping the frequency from 0 to 100 Hz. The phase deviation was calculated to characterize the shock absorber effects. For both tested devices under vibration and shock loading, the phase angle displacement between the input and the output signals was 10 degrees. Under oscillating vibration loading, both tested devices had a transmission ratio higher than 99.8%. Over the frequency interval 1-100 Hz, the difference in transmission ratio between the two devices was <0.3%. Under sudden shock loading, both tested devices had a transmission ratio higher than 98%. The difference between the two devices was <0.8%. Both tested devices have identical vibration and shock transmissibility. PMID:12902950
LeHuec, J C; Kiaer, T; Friesem, T; Mathews, H; Liu, M; Eisermann, L
Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective. In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques. These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques. While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma. PMID:24981899
Koreckij, Theodore; Park, Daniel K; Fischgrund, Jeffrey