Aims. The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral
The management of
To assess the effectiveness of dynamic stabilisation as a treatment for
Objective. To assess the effectiveness of dynamic stabilisation as a treatment for
Introduction: Recent cadaveric studies have identified neovascularisation and neoneuralisation as probable mechanisms in the causation of
Anterior lumbar interbody fusion (ALIF) is an accepted surgical treatment for disabling
Objectives: To examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits and other hisotological features in the disc and
Summary. Cytokines produced within the degenerate disc induce expression of neurotrophic factors and pain related peptides which could be important in nerve ingrowth and pain sensitisation leading to low back pain. The intervertebral disc (IVD) is considered the largest aneural and avascular structure within the human body, yet during degeneration vascularisation of the IVD is seen to be accompanied by nociceptive nerves. Low back pain is a highly debilitating condition affecting around 80% of the population, 40% of which are attributed to IVD degeneration.
Persistent back pain in the presence of an intact posterior fusion is commonly seen and is often regarded as being psychogenic in origin. This paper discusses five patients, all of whom were chronically disabled by such pain; all five had a confirmed posterior and/or lateral fusion. In each case lateral discography identified the disc within the fused segment as the source of symptoms and pain relief was obtained with an anterior interbody fusion. This source of pain should be considered as a possibility in similar cases of failed back surgery.
Purpose: The purpose of this prospective study is to evaluate the benefits of this treatment for
The afferent pathways of
Study Design: A retrospective study of the clinical outcome of patients with lumbar
Purpose of Study. To review the medium-term results of the Dynesys stabilisation system used in 113 consecutive patients with
There was no apparent difference between the clinical improvement in VAS and LBOS (p=0.91 and p=0.45 respectively) for each group. Analysis of the power of the comparison showed an 86% power for comparison of VAS improvement using a clinically important difference (delta) of 1 VAS point and there was 98% power for the LBOS improvement comparison using a clinically important difference (delta) of 10 LBOS points. Complications appeared higher in the arthroplasty group with foraminal encroachment requiring revision in 3 cases and one case of polyethylene failure in the Charité group at 3 years. This case occurred with an 8mm polyethylene insert (since removed from inventory by the manufacturer)
Intervertebral disc (IVD) degeneration is a pathological process often associated with chronic back pain and considered a leading cause of disability worldwide. 1. During degeneration, progressive structural and biochemical changes occur, leading to blood vessel and nerve ingrowth and promoting
Lumbar fusion remains the gold standard for the treatment of
Introduction: Lumbar total disc replacement (TDR) is intended to address
Aim: To investigate the use of the Graf Dynamic Stabilisation System for the treatment of multi-level
The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed. Research in the 1980s suggested that pain sensation was conducted in part via the sympathetic system. These sensory pathways have now been clarified using sophisticated experimental and histochemical techniques confirming a dual pattern. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry through the thoracolumbar white rami communicantes. Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission. The nature and mechanism of
Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of
Posterior fixation of intervertebral discs is used to treat, and occasionally diagnose,
Intervertebral discs (IVDs) degeneration is one of the major causes of back pain. Upon degeneration, the IVDs tissue become inflamed, and this inflammatory microenvironment may cause
Introduction The aim of the study was to determine the prevalence of different causes of neck pain in a private practice clinic by a retrospective audit of records. Methods The study included all consecutive patients attending a private spine pain clinic in the state of Washington, USA, seen between January 2003 and January 2005, in whom a diagnosis of neck pain was made. The records of all patients were examined to determine the prevalence of various diagnostic entities determined by history, examination, and invasive tests such as controlled diagnostic blocks and provocation discography. Using different denominators, the prevalence of various conditions was determined in all patients who presented with neck pain, in patients in whom investigations were undertaken, and in patients who completed investigations. Results A large proportion of patients (35%) did not pursue investigations, which diluted the crude prevalence of various conditions. A further 17% deferred completing investigations. Amongst the 48% of patients who completed investigations, the prevalence of zygapophysial joint pain was 55%,
Introduction: The role of discography before lumbar fusion had been discussed in the literature. No study discussed its role before total lumbar disc replacement (TDR). Degenerate discs are not necessarily painful, even if they show Modic changes or HIZ. Moreover,
Disc degeneration in the human spine is characterised by progressive fraying and dehydration of the nucleus pulposus associated with formation of clefts within the annulus fibrosus. These have been classified on the basis of autopsy studies into radiating, circumferential and peripheral tears (rim lesions). Outer tears allow neovascularisation of the outer third of the annulus fibrosus and ingrowth of nerve fibres. Correlation with discographic findings had suggested the relevance of peripheral defects in the pathogenesis of
Introduction: Biacuplasty is an innovative intervention for the treatment of
Background. Fissures in the anulus fibrosus are common in disc degeneration, and are associated with
Introduction. Lumbar spinal pain can be a consequence of
Lumbar Total Disc Replacement (LTDR) is an alternative to fusion for the surgical management of
Cite this article:
Purpose of this study is to compare the reduction of
Introduction. Risk factors for disc degeneration depend on how the condition is defined, i.e. on the specific disc degeneration “phenotype”. We present evidence that there are two major and largely-distinct types of disc degeneration. Methods. The relevant research literature was reviewed and re-interpreted. Evidence. In the . upper. lumbar and thoracic spine, disc degeneration is closely associated with endplate defects and with inflammatory changes in the vertebral bodies. It has a relatively high heritability (i.e. a strong genetic influence), and its incidence does not increase markedly with age. In the . lower. lumbar spine, disc degeneration is closely associated with radial fissures and nucleus herniation. Here it has a relatively low heritability, and a correspondingly stronger association with mechanical loading, and its incidence increases steadily throughout life. Mechanical experiments on cadaveric spines show that endplate fracture and nucleus herniation can be caused by compressive loading, and by bending combined with compression, respectively. Both lesions cause an immediate decompression of the nucleus, so that it becomes difficult to create subsequently the other lesion in the same disc. This suggests distinct phenotypes. Interpretation. The two types of disc degeneration are not entirely distinct, because disc herniation sometimes occurs at upper lumbar levels. Nevertheless, it may be useful to recognise two phenotypes when it comes to explaining and treating
Introduction.
Purposes. To develop disease-specific quality indicators for patients with low-back-pain presenting to Danish chiropractic clinics. Methods and results. A cross-disciplinary group of healthcare providers (the indicatorgroup) prioritized nine evidensbased indicators and standards in a systematic consensus process. A pilot test including 206 low-back-pain patients was carried out in eight chiropractic clinics. An audit meeting with the test-clinics was conducted after the test-period, and the indicatorgroup designed the final set of indicators. The indicator domains were: Anamnesis, test for
Background: Severe and chronic back pain often originates from degenerated intervertebral discs, probably from lesions in the outer posterior anulus. Unlike the nucleus, the outer anulus has a high cell density and adequate metabolite transport. The outer annulus can heal after injury in small and young experimental animals, but little is known about the healing potential of adult human discs. Purpose: We seek evidence that healing of the human outer anulus follows the three stages of tendon healing: inflammation, repair, remodelling. If so, then manual therapy and self-treatment techniques known to facilitate tendon healing could be adapted to treat
We studied 135 lumbar discs from 27 spines removed post-mortem from subjects of an average age of 31.5 years. Defects of the annulus fibrosus were classified as peripheral, circumferential or radiating; the nucleus pulposus as normal, moderately or severely degenerate. Peripheral tears were more frequent in the anterior annulus, except in the L5-S1 disc. Circumferential tears were equally distributed between the anterior and the posterior annulus. Almost all the radiating tears were in the posterior annulus, and closely related to the presence of severe nuclear degeneration. Histology suggested that peripheral tears were due to trauma rather than biochemical degradation, and that they developed independently of nuclear degeneration. The association of peripheral annular lesions with low back pain is uncertain but our study suggests that they may have a role in the pathogenesis of
It has been thought that lumbar intervertebral discs were innervated segmentally. We have previously shown that the L5-L6 intervertebral disc in the rat is innervated bilaterally from the L1 and L2 dorsal root ganglia through the paravertebral sympathetic trunks, but the pathways between the disc and the paravertebral sympathetic trunks were unknown. We have now studied the spines of 17 rats to elucidate the exact pathways. We examined serial sections of the lumbar spine using immunohistochemistry for calcitonin gene-related peptide, a sensory nerve marker. We showed that these nerve fibres from the intervertebral disc ran through the sinuvertebral nerve into the rami communicantes, not into the corresponding segmental spinal nerve. In the rat, sensory information from the lumbar intervertebral discs is conducted through rami communicantes. If this innervation pattern applies to man, simple decompression of the corresponding nerve root will not relieve
Introduction. Severe ‘discogenic’ back pain may be related to the ingrowth of nerves and blood vessels, although this is controversial. We hypothesise that ingrowth is greater in painful discs, and is facilitated in the region of annulus fissures. Methods. We compared tissue removed at surgery from 22 patients with
The purpose of this prospective study is to evaluate the benefits of intra discal electrothermal treatment (IDET) for
The multiplicity of factors that influence the clinical evolution of discopathies, determine a great diversity in its presentation. The barely known genetic predisposition, the individual morphological aspects, the age and sex, the associated co-morbidities as well as the patient environment define in its all an individual context that influences decisively the treatment for each patient. On the other hand, the identification in each case of the different stages of the multilevel DDD, causes doubts regarding the involvement of each segment in the respective clinical condition. To singly identify all sources of pain, and not only each painful level, is the main challenge poised to the spine surgeon when defining the treatment strategy. The diagnosis aggressiveness must be proportional to its doubts, and the discography, the disco-scanner and the facet blocks are fundamental when the conventional clinical investigation is inconclusive. The use of minimal invasive techniques such as IDET or Coblation can be considerate as alternatives, especially in the early stages of single-level DDD. The nucleoplasthy – nuclear prosthesis- is an interesting alternative in the intermediate stages of the
INTRODUCTION: Although it is well recognised that the outer annulus is innervated, the relative densities of innervation of different regions of the disc have not been quantitated. We present here the first comparative analysis of the innervation of the innervation of different regions of the lumbar intervertebral disc. METHODS: A sheep model was used allowing evaluation of the whole motion segment. Four sheep spines were used. One was processed for PGP 9.5 immunofluorescence and three were processed for PGP 9.5 immunoperoxidase histochemistry. Serial sagittal sections were obtained and a count was made of the densities of innervation of different regions of the endplate and annulus. These were compared to identify which areas of the disc and endplate are most innervated. RESULTS: The endplate innervation is concentrated centrally adjoining the nucleus. The mean density of innervation of the central endplate was 0.44 (SEM 0.07) nerves/mm2 while the mean density of the peripheral endplate was 0.10 (SEM 0.03) nerves/ mm. 2. (p= 0.0001). There was no significant difference between the overall endplate and annulus innervation densities 0.52 (SEM 0.1) v 0.37 (SEM 0.07) p=0.2. But the peri-annular connective tissue, external to the outer annulus contained the densest innervation of any region in the motion segment 1.05 (SEM 0.16). DISCUSSION: The lumbar intervertebral disc has a meagre innervation. This is concentrated in the peri-annular connective tissue and the central endplate. While receptor threshold is more closely related to noci-ceptive function than innervation density, these findings have important implications for any treatment of
Background: Lumbar disc replacement is a good alternative to fusion in young patients with degenerative disc disease or
Introduction: Eighty percent of individuals experience low back pain in their lifetime. This is often due to disc injury or degeneration. Conservative treatment of
Introduction: Although it is well recognized that the outer annulus is innervated, the relative densities of innervation of different regions of the disc have not been quantitated. We present here the first comparative analysis of the innervation of the innervation of different regions of the lumbar intervertebral disc. Methods: A sheep model was used allowing evaluation of the whole motion segment. Four sheep spines were used. One was processed for PGP 9.5 immunoflourescence and three were processed for PGP 9.5 immunoperoxidase histochemistry. Serial sagittal sections were obtained and a count was made of the densities of innervation of different regions of the endplate and annulus. These were compared to identify which areas of the disc and endplate are most innervated. Results: The endplate innervation is concentrated centrally adjoining the nucleus. The mean density of innervation of the central endplate was 0.44 (SEM 0.07) nerves/ mm. 2. while the mean density of the peripheral endplate was 0.10 (SEM 0.03) nerves/ mm. 2. (p= 0.0001). There was no significant difference between the overall endplate and annulus innervation densities 0.52 (SEM 0.1) v 0.37 (SEM 0.07) p=0.2. But the peri-annular connective tissue, external to the outer annulus contained the densest innervation of any region in the motion segment 1.05 (SEM 0.16). Discussion: The lumbar intervertebral disc has a meagre innervation. This is concentrated in the peri-annular connective tissue and the central endplate. While receptor threshold is more closely related to nociceptive function than innervation density, these findings have important implications for any treatment of
Purposes of the study and background: Diagnostic interventional procedures are often performed on patients who suffer from cervical facet joint
Introduction We report the two-year clinical outcome of a prospective randomised trial comparing Femoral Ring Allograft (FRA) to a Titanium Cage (TC) in circumferential lumbar spinal fusion. Methods 83 patients recruited to the study fulfilled strict entry requirements (>
6 months chronic discogenic low back pain, failure of conservative treatment, one or two-level discographically proven
Background: Over several decades, investigators have been trying to identify the painful degenerate disc. Their work included two main methods. The first was to set criteria on the radiological investigations, mainly the MRI scan, to describe the severity of the degenerative disc disease (DDD); and the second was to perform discographies. Neither of these two methods precluded the need for the other. Purpose: Using Pfirrmann’s classification, we correlated static MRI images, for the severity of segmental disc degeneration, with dynamic lumbar discography, with the aim to improve the identification of painful ‘disco-genic’ intervertebral segments. Study design: Prospective cohort study. Inclusion criteria included patients with mechanical low back pain who exhausted the conservative measures and required surgical treatment. Patient Sample and Methods: We investigated 69 patients (45 females, 24 males). The average age was 38.9 years (range 20–56). All patients had degenerative disc disease (DDD) on lumbar MRI scans. Provocative discographies were performed in all cases as a routine investigation to identify painful levels prior to fusion or disc replacement surgery. The severity of DDD was graded using Pfirrmann’s classification. A total of 162 discographies were performed using the ‘miss the facet joint, double needle technique’. Outcome measures: During discography typical or concordant pain only was regarded as positive. Among each of the five Pfirrmann grades, the percentage of positive discographies was calculated. Significance and correlation then were investigated using the Chi-squared and Spearman’s correlation tests. Results: 24 discs were classified as Pfirrmann grade I, 33 grade II, 63 grade III, 27 grade IV and 15 grade V. The percentages of positive provocative discography for concordant pain among these groups were 0%, 9.1%, 71.4%, 100% and 100% respectively. Statistical analysis showed a high correlation between the severity of DDD on MRI scan and the result of the provocative discography (Chi2 = 32.96, P <
0.001 and correlation coefficient = 0.756). Conclusion: The higher the grade of segmental DDD, the more likely it will be painful on discography. All discs showing Pfirmann grade IV and V disease were painful on discography. We strongly recommend the Pfirrmann classification for use in grading the severity of lumbar DDD especially when assessing for its association with
Study Design: The effects of heat on porcine intertvertebral disc were studied experimentally. Objective: To assess the effects of in-vitro heating of porcine nucleus pulposus on expression of inducible heat shock protein 70 and subsequent modification of biochemical responses to an inflammatory insult in the heated intervertebral disc tissue. Subjects: Lumbar spines were harvested from six pigs. The nucleus pulposus was dissected from each intervertebral disc, divided into control (37°C) and heat shocked (42°C) groups then cultured in medium for one hour. All samples were then cultured at 37 C for a further two hours. After three hours tissue and supernatant were harvested from one third of the samples and the expression of inducible heat shock protein 70 (HSP70) was quantified via Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA). The remaining samples were cultured either in normal medium or altered (pro-inflammatory) medium containing 5ug/ml bacterial lipopolysaccharide (LPS). At 24 hours the supernatant from these samples was analysed for both interleukin-8 (IL-8) and prostaglandin E2 (PGE2) secretion using ELISA. Outcome Measures: Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA) for heat shock protein 70. ELISA for interleukin-8 (IL-8) and prostaglandin E2 (PGE2). Results: HSP70 expression was significantly increased in the heat shocked specimens. IL-8 and PGE2 secretion were significantly increased in nucleus pulposus exposed to LPS at both temperatures. The concentrations of IL-8 and PGE2 secreted in the heat shocked samples were significantly less than controls, particularly after exposure to LPS (p<
0.05, paired students t test). Conclusions: In vitro heating of porcine nucleus pulposus causes overexpression of HSP70. This heat shock effect can alter aspects of the biochemical response of the intervertebral disc tissue to an inflammatory insult. Intradiscal electrothermal therapy (IDET) may, in theory, reduce
Purpose: In this prospective study we present the intermediate results of our experience using the Prodisc disc replacement for lumbar degenerative disc disease. Methods and Results: A total of 29 patients underwent Prodisc disc replacement by the senior author(AAH). There were 9 males and 20 females with a mean age of 39 years(Range 28–60 years). 18 patients had a single level disc replacement (L5/S1-- 14 patients, L4/5-- 4 patients). 11 patients had double level disc replacement (L4/5&
L5/S1--7 patients, L3/4&
L4/5--3 patients, L2/3&
L3/4--1 patient). All patients were assessed pre-operatively with clinical examination, plain films, MRI scans and discography. The indication for surgery was
Introduction: Anterior lumbar interbody fusion has become a frequently utilised procedure. The trend has been towards less invasive techniques including laparascopic and mini-open techniques. This report examines the results of one procedure and suggests appropriate tools to decrease the learning curve. Methods: Twenty-two patients with a mean age of 41 (17–78) underwent mini-open ALIF with threaded cortical bone dowels. The same senior surgeon performed all procedures (RFD). Indication for the procedure was
Purpose/introduction: 80% of individuals experience low back pain in their lifetime. This is often due to disc injury or degeneration. Conservative treatment of
A prospective study to evaluate the design, outcome and complications of the AcroFlex titanium/polyolefin artificial lumbar disc replacement. 11 subjects with single-level discographically proven
Introduction Historically, lumbar discography has been one of the most controversial subjects in the management of discogenic low back pain. The diagnostic value of normal psychometric specific pain provocation by disc pressurization has emerged. The sensitivity, specificity and accuracy of discography as a diagnostic test are not in doubt. In clinical discography pain reproduction and location are essential elements. There is an accepted rate of 0–10% false positives. This rate is influenced by occupational disability and abnormal psychometric profiles. By contrast, little attention has been given to false negative results and their outcomes if surgically treated. Traditionally, whether or not the test is considered to be positive or negative is determined immediately after completion of the diagnostic procedure. This study shows that patient’s pain reproduction may occur up to 24 hours after the discogram which often initially interpreted as a true negative when it is actually a false negative result. This study verifies the existence and significance of a false negative through the patients’ treatment and outcomes. Methods In this study, 150 patients underwent discography for investigation of chronic persistent low back pain (CPLBP). All patients had a control (morphologically normal) discogram at the level above the degenerative segment. No patients with abnormal psychometric profiles or compensation were included. All patients were followed up 24 hours post discogram by the radiologist to further assess their clinical status. Ten of the patients (7.5%) were considered to have a false negative discogram, as per the Dallas Discogram Scale. The surgeon correlated the delayed response on the subsequent follow-up. These ten patients were diagnosed as having a positive response and were treated surgically for their
Many pathological disease processes are manifested by abnormalities in cellular signalling caused by altered protein expression. Our aims, therefore, were to determine whether ‘’degenerative disc disease’’ results in 1) altered proteome expression and 2) such changes might be used as a marker for the disease process. Using gel electrophoresis, we analysed the proteome expression of nucleus pulposus (NP) derived from patients with scoliosis (‘normal’) compared to degenerate samples from patients with 1) back pain undergoing spinal fusion (DDD) and 2) sciatica undergoing discectomy (herniated nucleus pulposus or HNP). Normal NP tissue was also obtained from organ donor patients with no previous history of back pain. All samples were investigated in duplicate. Protein concentrations were measured qualitatively by visual analysis in a blinded manner and categorised into high, medium, low or absent. The Kruskal-Wallis analysis of variance was sued to analyse the data. Subsequent proteins of interest were determined on N-terminal protein sequencing. 15 samples each were collected each from scoliosis, DDD, and HNP, but only 4 samples from the organ donor groups. One major protein band difference was observed whose molecular weight was 15 kDa and N-terminal sequence homologous with lysozyme C (lysozyme-C-like-protein - LCLP). DDD and HNP samples exhibited significantly reduced levels of LCLP compared to scoliosis (P<
0.0001). All NP from donor patients exhibited high levels of LCLP, but numbers were too small for statistical analysis. No statistical correlation existed between age and LCLP levels. The true physiological roles of Lysozyme C remains unclear, but it is a known ubiquitous secretory and hydrolytic protein found in saliva, milk, cerebrospinal fluid and synovial liquid, and thought to function in primary immunity. LCLP loss in degenerate disc tissue might be due to 1) lack of production, 2) increased breakdown through a specific ubiquitin-linked pathway, or 3) polymerisation with tissue-specific amyloid deposition. The inflammatory effects within the NP related to localised LCLP-amyloid deposition offers a plausible hypothesis for patho-physiology of disc degeneration and
Introduction: While anterior cervical decompression and fusion has been shown to be clinically effective in cases of myelopathy or radiculopathy, several studies have suggested an increased risk of development of adjacent segment degeneration. The Bryan Cervical Disc Pros-thesis was developed to address this complication and was fi rst used clinically in Europe in January 2000. The author began to use the device in June of 2001 and since that time has implanted 30 prostheses in 22 patients. The present prospective study was commenced at the time (concurrently with an ASERNIPS study) with a view to examine the clinical efficacy and safety of this device. The results in the author’s first 14 patients are reported, all with a minimum follow-up of 12 months (mean 20 months). Methods: An observational audit of 14 consecutive patients with cervical radiculopathy (6 patients), myelopathy (6 patients) or
Mechanical function and failure of intervertebral discs. In a healthy disc, the nucleus pulposus acts like a pressurised fluid which is restrained by tensile stress within the annulus. With increasing age, the nucleus becomes more fibrous, and biochemical changes cause the whole disc to become less elastic, and more yellow in colour. Mechanically, the hydrostatic nucleus shrinks with age, and concentrations of compressive stress appear in the posterior annulus. Experiments on cadaveric spines have shown that healthy discs can prolapse when loaded severely or repetitively in bending and compression, and that internal disruption of the disc probably follows damage to the vertebral endplates. However, mechanical loading is not necessarily harmful to living discs: on the contrary, moderate repetitive loading may lead to disc hypertrophy rather than injury. Disc degeneration. Degeneration represents some mechanical or biological “insult” superimposed on normal ageing. A defining feature of “degeneration” should be structural failure of the annulus or endplate, because all degenerated discs exhibit structural failure whereas many old discs do not. Degeneration creates high stress concentrations within the annulus. Paradoxically, severe degeneration can lead to gross disc narrowing and reduced stresses in the annulus, presumably because it is “stress shielded” by the apophyseal joints. Animal experiments show that disc degeneration always follows mechanical disruption. In some cases, it may possibly precede it. Disc degeneration and back pain. Pain-provocation studies have shown that severe and chronic back pain often originates in the posterior annulus fibrosus, and can be elicited by relatively moderate mechanical pressure. Anatomical studies indicate that the outer annulus is supplied with complex and free nerve endings from the mixed sinuvertebral nerve. MRI and discographic studies show that back pain is closely correlated with structural features of disc degeneration such as radial fissures and prolapse, although age-related changes in composition are clinically irrelevant. The stress-shielding of severely degenerated discs (see above) suggests that
Our study aims to evaluate the efficacy of Wallis implant in management of
Objectives: The purpose of this study was to assess the effect of different types of posterior stabilisation on the fusion rate of anterior lumbar interbody fusion (ALIF). Thin section CT scanning has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiological modalities. Cadaveric studies have demonstrated that posterior stabilisation would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. The results of thin section CT scanning of ALIF, with and without posterior stabilisation, has not been reported previously. Methods: Patients with
Introduction: Intervertebral disc (IVD) cell transplantation is used to treat back pain. However, IVD cell activity may also contribute to pathology, e.g. IVD cells can undergo senescence or promote nerve growth, which in the IVD is associated with
Introduction and Aims: Outcome studies in select patient groups in a research environment risk reporting findings that may not be relevant to the large percentage of patients undergoing surgery in private practice in the community. This paper reports an audit of outcomes improvement in Lumbar Fusion patients using the Modified Rowland Questionnaire (MRQ). Method: Two hundred and sixteen patients undergoing lumbar fusion procedures, over a five-year period, completed the MRQ prior to surgery and at the routine one-year follow-up. Changes to the score were documented and analysed in relation to diagnosis, third party compensation coverage, and revision procedures. The MRQ is a validated responsive disease specific functional questionnaire. It ranges from 23 points (maximum disability) to zero (no disability). A four-point improvement is considered clinically significant. Results: Data completion was 88%. Median disability improvement was 10 points on the MRQ (p<
0.0001). Benefit occurred in 80% of patients. Although improvements in degenerative spondylolisthesis and isthmic spondylolisthesis were greater than in fusions for
This is to report an audit of outcomes improvement in Lumbar Fusion patients in a private practice setting using routine application of a robust functional outcomes instrument – the Modified Rowland Questionnaire (MRQ). The MRQ is a validated responsive disease specific functional questionnaire. It ranges from 23 points (maximum disability) to zero (no disability). Potential changes in score are 46 points (−23 to 23). A 4 point improvement is clinically significant. Two hundred and sixteen patients undergoing lumbar fusion procedures, over a five year period completed an MRQ prior to surgery and at the routine one-year follow up. Changes to the score were documented and analysed in relation to diagnosis, Accident Compensation corporation (ACC) coverage, and revision procedures. Data completion was 88%. Median disability improvement was 10 points on the MRM questionnaire. Benefit occurred in 80.0% of patients. Improvements were more marked in degenerative spondylolisthesis and isthmic spondylolisthesis than fusions for
The clinical and radiological outcome of 34 patients who were treated with PDN-Solo and PDN-Solo XL devices for symptomatic degenerative lumbar discs is described. 34 patients had PDNs implanted in their lumbar spines between September 2002 and August 2004. Suitable patients, with proven
Introduction: This paper reports an audit of outcomes improvement in lumbar fusion patients in a private practice setting using routine application of a robust functional outcomes instrument – the Modified Roland Questionnaire (MRQ). The MRQ is a validated responsive disease specific functional questionnaire. It ranges from 23 points (maximum disability) to zero (no disability). Potential changes in score are 46 points (−23 to 23). A 4 point improvement is clinically significant. Methods: 216 patients undergoing lumbar fusion procedures, over a 5 year period completed an MRQ prior to surgery and at the routine one-year follow-up. Changes to the score were documented and analysed in relation to diagnosis, ACC coverage, and revision procedures. Results: Data completion was 88%. Median disability improvement was 10 points on the MRQ questionnaire. Benefit occurred in 80.0% of patients. Improvements were more marked in degenerative spondylolisthesis and isthmic spondylolisthesis than fusions for
Aims: The aim of our study was assess the outcome following intradiscal electrothermal therapy in patients with chronic
Introduction: Intradiscal electrothermal therapy (IDET) is a novel minimally invasive treatment for
Introduction: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of
INTRODUCTION: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of
Recently there has been considerable interest in the role of inflammatory mediator production by herniated degenerate discs. Modic has described MR endplate changes which have an inflammatory appearance and have been linked with
The role of nucleus pulposus (NP) biology in the genesis of sciatica is being increasingly investigated. The aim of this study was to examine the ability of control and degenerate human nucleus pulposus to respond to an exogenous pro-inflammatory stimulus. Control disc material was obtained from surgical procedures for scoliosis and degenerate disc tissue from surgical procedures for sciatica and low back pain. Disc specimens were cultured using a serumless technique under basal and lipopolysaccharride (LPS) stimulated conditions and the media harvested, aliquoted and stored at –80°C for subsequent analysis. Levels of IL-1β,TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits. Neither basal nor LPS stimulated control or degenerate NP produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. Control disc IL-8 secretion increased significantly with LPS stimulation, p<
.018. Degenerate disc IL-6, IL-8 and PGE2 production increased significantly with LPS stimulation, p<
.01, p<
.001 and p<
.005 respectively. LPS stimulated degenerate NP secreted significantly more IL-6, IL-8 and PGE2 than LPS stimulated control NP, p <
0.05, 0.02 and 0.003 respectively. LPS induces an increase in both control and degenerate NP mediator production demonstrating the ability of human NP to react to a noxious stimulus by producing pro-inflammatory mediators. The difference in levels of basal and LPS stimulated mediator production between control and degenerate discs show that as a disc degenerates it increases both its level of inflammatory mediator production and its ability to react to a pro-inflammatory stimulus. The increased sensitivity of degenerating human NP to noxious stimuli and increased ability to respond with inflammatory mediator production support the role of NP as an active participant in the genesis of lumbar radiculopathy and
To investigate the efficacy of the navigable intradiscal catheter in the treatment and relief of lumbar
Introduction: Abnormal pain drawings have been shown in some studies to correlate well with psychological characteristics predicting poor outcome in spinal procedures. Our study evaluated whether pain drawings are a useful predictive tool for outcome following Intradiscal Electrothermal Therapy (IDET). Method: 56 Patients underwent IDET for chronic
Introduction: Intradiscal electrothermal therapy (IDET) is a novel treatment for
Introduction: Europe has no equivalent of the US Food and Drug Administration (FDA). As a result, spinal implants can be adopted into clinical use in Europe earlier than in the US with a lesser regulatory burden. This may benefit patients, but if a device fails due to design changes that are not fully evaluated, outcomes can be compromised. The classic example in the past was the Capital Hip. If Europe had an equivalent to the FDA, oversight of implant design and design changes might prevent such occurrences. The Prosthetic Disc Nucleus (PDN) is an implant designed to replace the nucleus of the lumbar disc in early stage symptomatic disc degeneration. The PDN originally was a paired device. Due to technical difficulties encountered by surgeons these were converted to a single implant (PDN Solo range). Mechanical testing suggested the new device would function as well as the original paired device. However, the implant was introduced into clinical practice, outside of the US, without any clinical evaluation. Study Design: Prospective cohort study with 3 to 5 year clinical and radiological follow-up. Objective of Study: To review the outcome of PDN Solo implanted anteriorly in the lumbar spine, define the mode of failure and describe revision strategies. Patients and Methods: PDN Solo was used in 35 patients from September 2002 to January 2005 with a median follow-up of 49 months. Patients with
Introduction: Intervertebral disc degeneration occurs with ageing and is often associated with back pain. During such degeneration, gross morphological differences between the central nucleus pulposus (NP) and outer annulus fibrosus (AF) are lost and the disc loses hydration and height due to decreased proteoglycan content. The cartilage endplate may also become calcified and this blocks the passage of nutrients into the disc, causing cell death and further degeneration. A potential therapy of degeneration is “re-inflation” of the disc with the use of hydrogels seeded with autologous disc cells. In this study, we have assessed the ability of a variety of hydrogels to support intervertebral disc cell growth. Method: Intervertebral disc cells were isolated enzymatically from bovine tails and cultured as a monolayer in 10% foetal calf serum in DMEM containing antibiotics and ascorbic acid. This stimulates the cells to proliferate and thereby produces increased cell numbers. The cells were then seeded onto various hydrogels including hyaluronic acid (HA), 2-hydroxyethyl methacrylate (HEMA), N’N’ dimethyl methacrylate (NNDMA) and polyacryloyl morpholine (AMO) before harvesting at set time points of 1, 3, 6 and 9 days for hyaluronic acid and 1, 7, 14, 21, and 28 days for the other hydrogels. Cell number, morphology, viability and adherence to or migration into the hydrogels were assessed. Cell proliferation was also determined by immunostaining for the Ki67 antigen. Results: Disc cells became incorporated in the HA gel, adopted a spherical morphology and remained viable for up to nine days. However, after a few days, a large proportion of the cells began to migrate through the gel to form a monolayer on the bottom of the tissue culture well. These monolayered cells became fibroblastic and proliferated. NP cells appeared to proliferate to a greater extent than AF cells both in monolayer and in suspension. Ki67 antigen immunostaining confirmed cell proliferation. On the non-porous HEMA, NNDMA and AMO, both cell types adhered and adopted a fibroblast-like morphology. Cell adhesion was greatest to the HEMA. NNDMA and AMO had lower levels of cell adherence. Both cell types became incorporated into the porous materials and adopted a rounded morphology. Cell incorporation appeared to be greatest into porous HEMA. Conclusion: These initial studies show that intervertebral disc cells will adhere to or migrate into a variety of hydrogels and remain viable. The morphology and proliferative capacity of cells derived from both the AF and NP were responsive to the structure of the hydrogel with which they were cultured. Thus, cells were able to become fibroblastic or chondrocytic. Further analyses will reveal whether matrix synthesis by disc cells is similarly responsive to the hydrogel format. The results of these experiments suggest that the hydrogels tested have potential as support matrices in intervertebral disc repair to provide relief from
This short contribution aims to explain how intervertebral disc ‘degeneration’ differs from normal ageing, and to suggest how mechanical loading and constitutional factors interact to cause disc degeneration and prolapse. We suggest that disagreement on these matters in medico-legal practice often arises from a misunderstanding of the nature of ‘soft-tissue injuries’.
To clarify the pathomechanisms of discogenic low back pain, the sympathetic afferent discharge originating from the L5-L6 disc via the L2 root were investigated neurophysiologically in 31 Lewis rats. Sympathetic afferent units were recorded from the L2 root connected to the lumbar sympathetic trunk by rami communicantes. The L5-L6 discs were mechanically probed, stimulated electrically to evoke action potentials and, finally, treated with chemicals to produce an inflammatory reaction. We could not obtain a response from any units in the L5-L6 discs using mechanical stimulation, but with electrical stimulation we identified 42 units consisting mostly of A-delta fibres. In some experiments a response to mechanical probing of the L5-L6 disc was recognised after producing an inflammatory reaction. This study suggests that mechanical stimulation of the lumbar discs may not always produce pain, whereas inflammatory changes may cause the disc to become sensitive to mechanical stimuli, resulting in nociceptive information being transmitted as discogenic low back pain to the spinal cord through the lumbar sympathetic trunk. This may partly explain the variation in human symptoms of degenerate discs.
Little information is available about the incidence
and outcome of incidental dural tears associated with microendoscopic
lumbar decompressive surgery. We prospectively examined the incidence
of dural tears and their influence on the outcome six months post-operatively
in 555 consecutive patients (mean age 47.4 years (13 to 89)) who
underwent this form of surgery. The incidence of dural tears was
5.05% (28/555). The risk factors were the age of the patient and
the procedure of bilateral decompression via a unilateral approach.
The rate of recovery of the Japanese Orthopaedic Association score
in patients with dural tears was significantly lower than that in
those without a tear (77.7% Cite this article:
Interleukin 18 (IL-18) is a regulatory cytokine that degrades the disc matrix. Bone morphogenetic protein-2 (BMP-2) stimulates synthesis of the disc extracellular matrix. However, the combined effects of BMP-2 and IL-18 on human intervertebral disc degeneration have not previously been reported. The aim of this study was to investigate the effects of the anabolic cytokine BMP-2 and the catabolic cytokine IL-18 on human nucleus pulposus (NP) and annulus fibrosus (AF) cells and, therefore, to identify potential therapeutic and clinical benefits of recombinant human (rh)BMP-2 in intervertebral disc degeneration. Levels of IL-18 were measured in the blood of patients with intervertebral disc degenerative disease and in control patients. Human NP and AF cells were cultured in a NP cell medium and treated with IL-18 or IL-18 plus BMP-2. mRNA levels of target genes were measured by real-time polymerase chain reaction, and protein levels of aggrecan, type II collagen, SOX6, and matrix metalloproteinase 13 (MMP13) were assessed by western blot analysis.Objectives
Methods
In a study on ten fresh human cadavers we examined the change in the height of the intervertebral disc space, the angle of lordosis and the geometry of the facet joints after insertion of intervertebral total disc replacements. SB III Charité prostheses were inserted at L3-4, L4-5, and L5-S1. The changes studied were measured using computer navigation sofware applied to CT scans before and after instrumentation. After disc replacement the mean lumbar disc height was doubled (p <
0.001). The mean angle of lordosis and the facet joint space increased by a statistically significant extent (p <
0.005 and p = 0.006, respectively). By contrast, the mean facet joint overlap was significantly reduced (p <
0.001). Our study indicates that the increase in the intervertebral disc height after disc replacement changes the geometry at the facet joints. This may have clinical relevance.
Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.
We carried out a prospective study to determine whether the addition of a recombinant human bone morphogenetic protein (rhBMP-2) to a machined allograft spacer would improve the rate of intervertebral body fusion in the spine. We studied 77 patients who were to undergo an interbody fusion with allograft and instrumentation. The first 36 patients received allograft with adjuvant rhBMP-2 (allograft/rhBMP-2 group), and the next 41, allograft and demineralised bone matrix (allograft/demineralised bone matrix group). Each patient was assessed clinically and radiologically both pre-operatively and at each follow-up visit using standard methods. Follow-up continued for two years. Every patient in the allograft/rhBMP-2 group had fused by six months. However, early graft lucency and significant (>
10%) subsidence were seen radiologically in 27 of 55 levels in this group. The mean graft height subsidence was 27% (13% to 42%) for anterior lumbar interbody fusion, 24% (13% to 40%) for transforaminal lumbar interbody fusion, and 53% (40% to 58%) for anterior cervical discectomy and fusion. Those who had undergone fusion using allograft and demineralised bone matrix lost only a mean of 4.6% (0% to 15%) of their graft height. Although a high rate of fusion (100%) was achieved with rhBMP-2, significant subsidence occurred in more than half of the levels (23 of 37) in the lumbar spine and 33% (6 of 18) in the cervical spine. A 98% fusion rate (62 of 63 levels) was achieved without rhBMP-2 and without the associated graft subsidence. Consequently, we no longer use rhBMP-2 with allograft in our practice if the allograft has to provide significant structural support.
Posterior lumbar interbody fusion (PLIF) is indicated
for many patients with pain and/or instability of the lumbar spine.
We performed 36 PLIF procedures using the patient’s lumbar spinous
process and laminae, which were inserted as a bone graft between
two vertebral bodies without using a cage. The mean lumbar lordosis
and mean disc height to vertebral body ratio were restored and preserved
after surgery. There were no serious complications. These results suggest that this procedure is safe and effective.
The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p <
0.001). Both chromium levels were also significantly lower after TDR These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.
Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.