Infection after intradiscal injections has been recognised as a distinct entity, but discitis after
Introduction Historically, lumbar
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 discogenic pain through the analysis of clinical data and finite element modelling (FEM). Methods. Retrospective analysis was conducted on clinical data, with a specific focus on the spinal units displaying facet tropism, utilizing FEM analysis for motion simulation. We studied 318 intervertebral levels in 156 patients who had undergone provocation
In a prospective study we attempted to define the role of lumbar
Discitis after
We attempted to correlate the findings of MRI and
Prospective match cohort study of disc degeneration progression over ten years with and without baseline
Introduction: The role of
This prospective study was carried out to correlate findings of magnetic resonance imaging (MRI) and
Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal.
We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent
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
The lumbar spines of 22 patients were examined for disc degeneration by magnetic resonance imaging (MRI) and by
Introduction: Recent cadaveric studies have identified neovascularisation and neoneuralisation as probable mechanisms in the causation of discogenic pain. Calcium pyrophosphate deposits have been observed in discs in several studies. Their significance in the causation of discogenic pain is unclear. Direct correlation between the pain site and histological features can be verified by aware state endoscopic visualisation. Aim and Objectives: The study aims to examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits in the disc, and discogenic pain by spinal probing and
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
Introduction. Degenerative disc disease results from mechanical alteration of the intervertebral disc. Biochemical modifications of the nucleus matrix are also incriminated. Furthermore, genetic predispositions as well as vascular factors have been advocated in the process of disc degeneration. A relationship between sciatica and Propionibacterium acnes has been described. However, it remains unclear if the hypothesis of a subclinical spondylodiscitis might play a role in the pathophysiology of degenerative disc disease. The purpose of this study was to analyze the possible presence of bacteria in lumbar discs of patients with degenerative disc disease. Methods. We prospectively analyzed the presence of bacteria in 83 patients (34 males and 49 females, average age 41 years) treated by lumbar disc replacement at L3-L4, L4-L5 or L5-S1. An intraoperative biopsy and microbiological culture were performed for each disc to determine if intradiscal bacteria were present. Great care was taken to avoid any source of contamination during the conditioning process of the biopsy. Microbiological results were compared to the magnetic resonance stages of disc degeneration according to the Pfirrmann and Modic classifications. Possible sources of previous iatrogenic disc contamination after
Objectives: To examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits and other hisotological features in the disc and discogenic pain established by spinal probing and
Problem Chronic disabling pain in the sacrococcygeal region is regarded by clinicians with great dismay because of unpredictability of the treatment outcome. The subject is under- represented in the literature. Method Thirty eight patients with intractable coccydynia had imaging investigations for the spine other than X-rays. Six of these patients were also investigated by means of sacrococcygeal and intercoccygeal
Purpose. By systematic literature review, to quantify the association between vertebral endplate signal changes (VESC) and non-specific low back pain (NSLBP). Materials and methods. MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to June 2009. Articles were included which investigated the association between VESC and NSLBP and reported sufficient data to construct two-by-two tables. Articles on specific low back pain conditions were excluded. A standardised data collection and quality assessment were performed. To estimate the association between VESC and NSLBP, two-by-two tables were created and exact odds ratios were calculated with 95% confidence intervals (CI). Meta-analysis was performed on homogeneous studies. Results. Fourteen articles met the inclusion criteria. A statistically significant positive association between VESC and NSLBP was found in 10 of 14 studies from the general, working, and clinical populations with odds ratios ranging from 2.0 to 27.9. Two of the other four studies showed positive associations, one study a neutral association and the other a negative association but all these results were not statistically significant. Meta-analysis of the eight
Aim: To assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electro thermal therapy (IDET). Design: A prospective longitudinal study. Subjects: Patients undergoing IDET in our unit between April 2000 and October 2007 were included in the study after assessment with
There are many difficulties associated with the localisation of the symptomatic segment in patients presenting with cervicobrachial pain with no evidence of impaired conduction in the nerve root. Ancillary radiological investigations such as myelography, epidural phlebography, and epidural myelograms are of unreliable diagnostic value. However,
We report a series of 98 patients with back pain and sciatica in whom the MRI scan was reported as normal. The patients were referred by their General Practitioners and the MRI was the first and only investigation. The patients were subsequently subjected to plain radiographs including weight-bearing spot laterals of the lumbo-sacral spine, and
Magnetic resonance imaging (MRI) of the spine produces images which reflect the chemical composition of the intervertebral disc. We have conducted a prospective study of the serial changes in the MRI appearance of the intervertebral disc after chemonucleolysis with the enzyme chymopapain. Fourteen patients were studied after single-level chemonucleolysis and the results compared with a control group of 17 discs in six patients who had diagnostic
Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of discogenic back pain after two years. Introduction:
Aims: MRI changes to the symptomatic intervertebral disc following Intradiscal Electrothermal Therapy (IDET), in particular those relating to the Ç High Intensity Zone È (HIZ) in the posterior annulus, were determined in this prospective study. Methods: MRI images before the IDET procedure were compared to those taken at six months post procedure in 10 patients. The presence and absence of an HIZ, the disc height and hydration, and Modic changes, were determined from the images. Two of the patients also had
Introduction: We report a series of 10 cases from a cohort of 421 Dynesys procedures in which evidence of Accelerated Adjacent Disc Disease (AASDD). Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys. Method: Ten patients developed new and symptomatic disc disease within segments adjacent to Dynesys. The average age of patients was 49 year with range between 36–70 years. Average post Dynesys to secondary surgery for ASD was 24.7 months. Previous
Objective: MRI changes to the symptomatic intervertebral disc following Intradiscal Electrothermal Therapy (IDET), in particular those relating to the “High Intensity Zone” (HIZ) in the posterior annulus, were determined in this prospective study. Material and Methods: MRI images before the IDET procedure were compared to those taken at six months post procedure in 10 patients. The presence and absence of an HIZ, the disc height and hydration, and Modic changes, were determined from the images. Two of the patients also had
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
Thirteen patients with symptomatic disc herniation in the cervical spine were treated with percutaneous laser disc decompression (PLDD). Patients included 10 males and 3 females with a mean age of 41.4 (range, 24–60) years old. Preoperative symptom was divided into 2 types; myelopathy in 8 and radiculopathy in 5 patients. The level of the treated disc, which was diagnosed from the provoked cervicobrachial neuralgia during
Study Design: Prospective cohort study. Summary of Background data: A definite link between Modic end plate changes and discogenic low back pain has yet to be established. However, current prospective data indicates that Modic changes strongly correlate with the pain provocation of lumbar
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
Routine use of Computed Tomography (CT) to evaluate discogram morphology is time consuming, costly and incurs additional radiation hazards. In our spinal unit,
Introduction and Objectives: This is a retrospective study on the treatment of lumbar degenerative disk disease (LDDD) using intervertebral arthroplasty. The lack of uniformity in the treatment of LDDD, persistence of pain even with solid fusion, and the possibility of changes over the fusion site have encouraged us to seek other solutions for this condition. Total intervertebral arthroplasty has been proposed as a possible alternative for selected cases of LDDD. Materials and Methods: Between November 1999 and July 2002, 16 patients with LDDD were treated surgically using third-generation total intervertebral arthroplasty (Link SB Charité III) with a chromium-cobalt alloy and ultra-high molecular weight (UHMW) poly-ethylene. Average follow-up time was 14 months (6-36 months), and average age was 42 years (35–52). There were 11 females and 5 males. All patients underwent radi-olographic studies, CT scan, MRI, and
Purpose of the study: The endoscopic transforaminal approach to the lumbar disc proposed by A.T. Yeung has achieved world-wide acceptance. The Yeung endoscopic spinal system (YESS) used with a specific instrument set enables direct magnified optical control of discectomy performed under local anesthesia and neurolepanalgesia in the outpatient setting. We began our experience in 2003 and report here the results obtained in a consecutive series of 100 patients reviewed retrospectively. Material and methods: The inclusion criteria were patients with lumbar disc herniation-related lumbosciatic or crural pain non-responsive to well conducted medical care (including epidural or periradicular injections) for at least three months. The patients also had to display a concordant clinical and radiographic picture with confirmation of the symptomatic level by
The management of discogenic pain continues to be controversial. The results for operative and non-operative management are variable. This study aims to look at the results of interbody fusion versus dynamic stabilisation in patients with discogenic pain. Diagnosis was made by use of MRI and provocative
To assess the effectiveness of dynamic stabilisation as a treatment for discogenic pain compared to standard treatment of interbody fusion. All patients were referred for a 2 year back-pain management programme. Patients with continued pain following conservative treatment underwent
Objective. To assess the effectiveness of dynamic stabilisation as a treatment for discogenic pain compared to standard treatment of interbody fusion. Study Design & Subjects. All patients were referred for a 2 year back-pain management programme. Patients with continued pain following conservative treatment underwent
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
Introduction: We report the outcome two years following Dynesys for the treatment of Spinal Canal Stenosis. In both the FDA trial and the European multicentre study, stenosis was invariably combined with decompression, invalidating conclusions on the results of Dynesys alone. Method: Eighteen patients had symptomatic Spinal Canal Stenosis with root claudication sufficient to justify surgical intervention. Average age of patients was 68 with a range between 44–86 years. Dynesys was applied for the treatment of a single level in 4, two levels in 8, and more than two levels in 6. Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning &
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 discogenic back pain confirmed by
Introduction: The results of the FDA trial for Dynesys stabilisation implied that the procedure was effective as a method of treatment for this condition. However, all the American cases had adjunct decompressive treatment. In this study we report the outcome of the first two years following DYNESYS for Spondylolisthesis in two groups of patients; Dynesys alone and Dynesys with fusion. Method: Fifty five patients had Dynesys for symptomatic Spondylolisthesis which was indicated for surgical treatment. Average age for group 1 was 51 years with range of 36–85 years whereas in group 2, average age was 59 years with range of 31–79 years. Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning &
Thirty-three patients who had undergone anterior cervical fusion for degenerative disc disease were reviewed to determine the efficacy of the procedure. Only patients who were available for examination and who had undergone operation at least one year previously were included in the review. Nearly all had had arm pain and three-quarters neck pain. Diminished neck movement and neurological abnormalities in the arms had been frequent findings. Diagnosis from the clinical features and plain radiographs is described. Myelography was not used routinely and
Introduction. We report the outcomes of minimally invasive technique for posterior lumbar interbody fusion (PLIF) procedure using Hollow Modular Anchorage (HMA) screws supplemented by routine pedicle screw fixation (Dynesis). Patients and Methods. Seventy-nine patients, who had undergone PLIF procedure using HMA screws supplemented by pedicle screw fixation, were included. Patients deemed suitable for surgery following
Background: Spinal fusion for degenerative disc disease remains a controversial issue due to adjacent segment disease. Several alternatives have been evaluated; including Dynamic Neutralisation System for Spine and artificial disc arthroplasty. In our cohort study, we are highlighting advantages of DYNESYS over TDA and fusion as being a simple and reversible procedure if removal of implants is necessary. Materials and Methods: Prospective cohort study on 415 patients underwent DYNESYS. The implant has to be removed in 43 patients. Patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain imaging and MRI scanning. Preoperative
Background: Spinal fusion for degenerative disc disease remains a controversial issue due to adjacent segment disease. Several alternatives have been evaluated; including Dynamic Neutralisation System for Spine and artificial disc arthroplasty. In our cohort study, we are highlighting advantages of DYNESYS over TDA and fusion as being a simple and reversible procedure if removal of implants is necessary. Material &
Methods: Prospective cohort study on 415 patients underwent DYNESYS. The implant has to be removed in 43 patients. Patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain imaging and MRI scanning. Preoperative
Anterior lumbar interbody fusion (ALIF) is an accepted surgical treatment for disabling discogenic pain. Additional posterior fixation has been advocated. This is a prospective clinic al study evaluating a stand-alone anterior fusion cage with an integrated titanium plate and four divergent locking screws. Patients who had failed conservative management for lumbar discogenic pain were recruited into the study. All underwent diagnostic
Purpose And Background: In patients with chronic low back pain (LBP), selective injection procedures (provocative
Aim: To investigate the use of the Graf Dynamic Stabilisation System for the treatment of multi-level discogenic pain associated with symptoms of ‘instability’. Introduction: Indications for the use of the Graf Ligament system remain controversial. There is a small group of patients who present with severely disabling pain with failed conservative treatment, of discogenic origin at more than one level, and associated with symptoms of so-called ‘instability’ (acute pain related to position and movement), for whom treatment is extremely difficult. Methods: Twenty-two consecutive adult patients of working age with this clinical picture, with discogenic pain at two or three levels confirmed by
Primary disc space infections are thought to occur in children because of the abundant vascularity of the disc prior to skeletal maturity, and while they generally resolve with treatment, little is known about the long-term consequences on the spine. An ovine model of discitis was used to investigate the effects of discitis on spinal development in the growing sheep. Six-week-old lambs underwent lumbar
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
The fourth lumbar vertebrae and L4-5 discs from six cadaveric lumbar spines were subjected to detailed strain gauge analysis under conditions of controlled loading. With central compression loads, maximal compressive strain was found to occur near the bases of the pedicles and on both superficial and deep surfaces of the pars interarticularis, which emphasises the importance of the posterior elements of lumbar vertebrae in transmitting load. Radial bulge and tangential strain of the disc wall were maximal at the posterolateral surface, in agreement with the fact that disc degeneration and prolapse commonly occur there. Under posterior offset loads simulating extension, both compressive and tensile strains were found to be increased on both surfaces of the pars interarticularis, which suggests that hyperextension may lead to stress fractures and spondylolisthesis. Posterior offset loads also increased the radial bulge of the posterior disc wall and tangential strain at the anterior surface of the disc. Anterior offset loads simulating flexion increased the radial bulge of the anterior disc wall and tangential strain at the posterior surface of the disc. These findings are compatible with movement of the nucleus pulposus within the disc during flexion and extension. This hypothesis was supported by post-mortem
Background: Back pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc. Objective: To form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’. Methods: This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with lysis block and
Defects in annulus fibrosus induced by needle puncture can compromise mechanical integrity of the disc and lead to degeneration in animal models. This study examined the immediate and short-term mechanical and biological response to annulus injury through needle puncture using small and large gauge needles in a bovine organ culture system. Bovine caudal intervertebral discs were harvested, assigned to one of two needle puncture groups (small = 25G, N=11; large = 14G, N=12) or an unpunctured control group (N=10), and cultured in organ culture for 6 days. After measuring initial heights, diameters, and wet weights, discs were placed in an organ culture chamber and incubated with constantly circulating media in standard culture conditions under a 0.2 MPa static load. Discs underwent a daily dynamic compression loading protocol for five days from 0.2 – 1 MPa at 1 Hz for one hour. Disc structure and function were assessed with measurements of dynamic modulus, creep, height loss, water content, proteoglycan loss to the culture medium, cell viability and histology. Needle insertion caused a rapid decrease in dynamic modulus and increase in creep during one hour of loading, although no changes were detected in water content, disc height, or proteoglycan lost to the media. Cell viability was maintained except for localised cell death at the needle insertion site. An increase in cell number and possible remodelling response was seen in the insertion site in the nucleus pulposus. Relatively minor disruption in the disc from needle puncture had immediate and progressive mechanical and biological consequences with important implications for the use of needle puncture in
Objective A prospective longitudinal study with a mean 22 month follow up (range 6–36 months) to assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electrothermal therapy (IDET). Method Patients with a discogenic origin of their back pain confirmed by diagnostic imaging and
Study Design: Prospective study with a 2-year follow-up. Background: Intradiscal electrothermal therapy (IDET) was developed as an intermediate stage between conservative measures (analgesia, physiotherapy and injections) and radical surgery (fusion and disc replacement) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this treatment. Objective: To assess the long-term outcome of patients with discogenic low back pain (≥ 6 months duration) treated with IDET who had previously failed to improve with nonoperative treatment. Methods: Forty patients with IDD determined by pre-operative provocative
Introduction The Dynesys device uses transpedicular screws linked by a cord and spacers. It is claimed that the advantage is that it allows some motion, in all directions, in the operative levels. In vitro laboratory biomechanical studies show that the movement permitted is similar to rigid fusions. This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device. Material-method In our study 20 patients with dominant low back pain, with or without leg pain, were treated with Dynesys system. Stress
Introduction: Although several studies have reported on outcomes following heating of annular tears with a thermo-resistive catheter (SpineCATH), little data is available on the efficacy of thermal treatment with a flexible radiofrequency electrode (discTRODE). The aim of this prospective case-control study was to determine the efficacy of radiofrequency heating of painful annular tears in the lumbar spine. Methods: After at least six months of conservative treatment, 46 patients were studied for the presence of single level painful annular tears with MRI and provocative
Purpose: To report the clinical and radiographic prospective results of a consecutive series of patient with a minimum two year follow-up with the Charite Total Disc Arthroplasty (TDA). Method: Between 2001 and 2005, sixty patients underwent a Charite TDA (Depuy Spine, Raynham, MA) at either L4-5 or L5-S1. The primary indication for surgery was discogenic low back pain confirmed by provocative
To compare the effectiveness of ALIF, using the Hartshill Horseshoe cage, and Graf ligamentoplasty for stabilisation of comparable severity of degenerative disc disease. Between 1995 and 1997, 27 patients who had single level ALIF with Hartshill Horseshoe cage [group A], and 28 patients who had single level Graf ligamentoplasty [group B] were assessed by Oswestry disability index, a subjective score, Zung Depression Scale [ZDS], and Modified Somatic Perception Questionnaire [MSPQ]. The two groups were similar in age and sex distribution. The patients were randomized, and procedures were all undertaken primarily for symptoms of back pain, although some patients in each group reported some leg pain. No patients with the ALIF group had any MRI evidence of neurological compromise. Where there was any degeneration at more than 1 level,
Study Design: A retrospective cross sectional cohort study of degeneration of the lumbar spine, using pre- and post-discography MRI scans of 28 patients, as compared to two consecutive MRI scans of an age and sex matched control group of 32 patients. Objective: To determine whether injection of steroid into a lumbar intervertebral disc causes degeneration, as assessed by magnetic resonance imaging (MRI). Methods: Twenty-eight patients with chronic discogenic low back pain were selected. Each had been investigated with an MRI,
Purpose of the study: Indications for disc prosthesis is generally established on the basis of the MRI findings (MODIC classification) and the
Aims: The aim of our study was assess the outcome following intradiscal electrothermal therapy in patients with chronic discogenic back pain. Methods: 57 patients underwent IDET. All patients had an MRI and provocative
Purpose Of The Study: This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device. Material-Method-Results: All the 25 patients, with chronic back pain, had
Surgical treatment of degenerative disc disease (DDD) has been widely modified in the last decade. The clinical evaluation of back pain has been improved by the use of functional scores and VAS. The
A prospective series of patients undergoing intradiscal electrothermal therapy for treatment of lower back pain refractory to physiotherapy. 33 patients with a mean follow up of 16 months were assessed pre- and postoperatively at Mayday University Hospital between 1999–2001 using visual analogue scores and SF-36. These patients failed to show an improvement with physiotherapy and had no evidence of a significant disc prolapse according to MRI with their back pain being reproduced at one or more disc levels on provocative
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 discogenic pain. Outer annular tears are likely to be linked to tensile strain onto the collagen fibres and, therefore, may have a mechanical aetiology. In the animal model, peripheral tears of the outer annulus were proven to induce degenerative changes within the inner annulus and the nucleus pulposus. The increased understanding of the role of discrete peripheral defects of the annulus in discogenic pain may support the potential therapeutic effects of thermal treatment using radiofrequency waves and specially designed probes. At present, however, no in vivo studies have been able to demonstrate healing of outer annulus defects and reversibility of mechanical lesions to the intervertebral discs by thermal therapy. While it is highly likely that discrete defects of the outer annulus may be responsible for acute episodes of self-limiting low back pain, it is unclear if annular pathology may be as relevant for chronic disabling back pain. Recent studies using
Purpose of study. To compare the cost and outcome of Intradiscal Elecrothermal Therapy (IDET) with fusion (anterior lumbar interbody fusion with posterior translaminar screws) at one year, in single level lumbar disc disease. Methods. 49 patients were prospectively enrolled for IDET. The 49 fusion group patients had either a Syncage or Femoral Ring Allograft. All patients had at least 6 months of LBP with single level disease on MRI or positive
Purpose: To report the clinical and radiographic prospective results of a consecutive series of patient with a minimum two year follow-up with the Charite Total Disc Arthroplasty (TDA). Methods: Between 2001 and 2005 sixty patients underwent a Charite TDA (Depuy Spine, Raynham, MA) at either L4–5 or L5-S1. The primary indication for surgery was discogenic low back pain confirmed by provocative
Objectives: To evaluate the clinical and radiological outcome following anterior interbody fusion using a femoral cortical allograft packed in the centre with autogenous iliac graft combined with posterior pedicle fixation. Design: A prospective study of 30 consecutive adult patients diagnosed with lumbar degenerative disc disease. Summary of background data: Various fusion options have been described in the literature with various clinical and radiological outcomes. Narrowing of the disc space is thought to be the primary cause of all the potential secondary spondylotic changes; the ideal corrective surgery would be one that reconstitutes the disc space interval. A hybrid graft consisting of a femoral cortical allograft (FCA) ring packed in the centre with autogenous cancellous iliac graft seems to be an ideal option as one should capitalize on the mechanical strength of the cortical ring and the biological strength of the cancellous autogenous graft. Methods: 15 patients with failed back surgery, 15 patients with primary degenerative disc disease. Mean age was 43 years. All patients had preoperative radiographs, MRI scanning,
Purposes Of The Study-Background Data: Dynesys is claimed that allows motion in the operative levels. This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device. Thirty patients with were treated with Dynesys system. All had
Study Design: Prospective longitudinal study with a 2-year follow-up. Background: Intradiscal electrothermal therapy (IDET) was introduced to bridge the gap between conservative measures (analgesia, physiotherapy and standard injection therapy) and radical surgery (disc replacement and fusion) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this so called less invasive treatment technology. Objective: To assess the long-term outcome of patients with chronic discogenic low back pain (<
6 months duration) treated with IDET who had previously failed to improve with comprehensive nonoperative treatment. Methods: Forty patients with IDD determined by provocative
Introduction: The purpose of this study was to evaluate the design of a titanium/polyolefin artificial disc, assess its safety and measure outcome to determine if a RCT is justified. Methods: All subjects entered this pilot study with one or two-level disc disruption at l4/l5 and/or l5/s1 and had disabling low back pain for at least 12 months. The diagnosis was confirmed by
Isthmic spondylolisthesis with pars interarticularis defect is a “ fatigue” fracture. In most cases there is no instability and moderate pain, with no need for treatment. Twenty per cent of the patients have severe back pain, and some also radicular pain, while some young patients have progressive lumbosacral kyphosis and instability with high grade spondylolisthesis. The sacral deformity and kyphosis result from the fracture and could be avoided by healinfg of the defect. Histological studies have shown that the pars defect can be a source of pain. Patients with severe back pain and some with radicular pain or increasing deformity are candidate to surgery. Since many years, the only treatment was fusion with or without instrumentation and with or without correction of the deformity, by anterior or posterior approach. Fusion was mandatory in case of associated disc degeneration, including all the pathological discs into the fusion area. Isthmic repair has been done since many years using several techniques, but only in the absence of olisthesis and disc degeneration. However, it is known that many adult or senile subjects have degenerated discs and no back pain. Thus, what is the rationale to perform fusion in all patients with spondylolisthesis? The problem is to know the source of pain and to treat patients rather than x-rays. This can be achieved by anaesthetic injection of the lytic zone, MRI and
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 discogenic back pain. To date there has been no biomechanical investigation of discs with associated Modic changes. The aim of this study is to determine if degenerate discs with associated Modic changes have higher levels of pro-inflammatory mediator production than those without Modic changes. Intervertebral disc tissue was obtained from 52 patients undergoing spinal surgery for sciatica [40] and discogram proven discogenic low back pain [12]. The tissue was cultured and the medium analysed for interleukin-6, interleukin-8 and prostaglandin E2 using an enzyme linked immunoabsorbetn assay method. Preoperative MR images of the patients were examined by a double blinded radiologist to determine the Modic status of the cultured disc level. Forty percent of patients undergoing surgery for discogenic low back pain had a Modic 1 change compared to only 12.5% of patients undergoing surgery for sciatica [p<
.05] There was a statistically significant difference between levels of IL-6, IL-8 and PGE2 production by both the Modic1 [M1] and Modic2 [M2] groups compared to the Modic negative [NEG] group. IL-6:NEGvM1 p<
.001, NEG v M2 p<
.05, IL-8: NEG v M1 p<
.01, NEG v M2 p>
.05, PGE2: NEG v M1 p<
01, NEG v M2 p<
.05. Modic changes have been associated with positive provocative
To investigate the efficacy of the navigable intradiscal catheter in the treatment and relief of lumbar discogenic back pain. Twenty-three (23) consecutive patients, at this site, were enrolled into the study by this investigator from normal practice. Inclusion criteria included presentation with predominant low back pain with or without referral leg pain lasting longer than 6 months, diagnosis of DDD or IDD confirmed by plain x-rays, MRI, and positive, low pressure
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 discogenic pain verified by concordant
Introduction: Biacuplasty is an innovative intervention for the treatment of discogenic pain. It involves inserting electrodes bilaterally into the posterolateral corner of the anulus fibrosus. Radiofrequency current is passed between the electrodes, but each electrode is water-cooled. This prevents coagulation occurring around the surface of the electrode, which allows a three-dimensional lesion to develop between the electrodes. Theoretically this lesion would seal radial and circumferential fissures, and coagulate nerve endings throughout the posterior anulus. Methods: As part of a multi-centre, limited release of biacuplasty, a prospective audit of outcomes was undertaken in 8 patients with chronic low back pain, in whom
Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomized controlled trials assessing efficacy when compared to a placebo group. Ethical Committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered for the study. Subjects had one or two level symptomatic disc degeneration as determined by provocative CT/
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 discogenic lumbar pain as demonstrated by MRI and provocative
Purpose and Background: We have previously reported our investigations of nerve ingrowth into intervertebral discs (IVD) from patients with mechanical low back pain. We have shown that in discs that are painful on
Background Context: One of the main postulated basic principles of total disc replacement (TDR) is the preservation of flexion/extension ability. In neutral position the ideal disc prosthesis should not stay in maximal possible extension which would imply an impingement of the prosthesis. An impingement would cause shear strains on the prosthesis endplates which probably accelerate loosening. Moreover an additional extension ability from the neutral position would indicate no impingement in the facet joints in neutral position and a physiological movement capability. Purpose: The purpose of study was to evaluate a possible impingement of the prosthesis or facet joints after TDR in neutral position. Study design: Prospective evaluation of radiological outcome measures after total disc replacement. Patient sample: The patients (19 female, 10 male) ranged from 29 to 56 years of age (mean: 42.46.5 years). The mean follow up interval averaged 13.2 months (range: 6 – 35 months). The diagnosis of degenerative disc disease was confirmed by MRI (black disc) and
Introduction: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but there are no published randomized controlled trials assessing efficacy against a placebo group. Methods: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed conservative treatment were considered for the study. Inclusion criteria included one or two level symptomatic internal disc disruption as determined by provocative CT/
Introduction: Intradiscal electrothermal therapy (IDET) is a controversial, new treatment for low back pain, whose efficacy has not been tested in randomized trials. The present study was undertaken to compare the efficacy of IDET with that of a placebo treatment. Methods: Patients were recruited by referral and by advertising in the media. Of 4,530 individuals who enquired, 1,360 were prepared to submit to randomization. Of these, 260 were found potentially eligible after clinical examination, and 64 became eligible after
INTRODUCTION: Intradiscal electrothermal therapy (IDET) is a controversial, new treatment for low back pain, whose efficacy has not been tested in randomised trials. The present study was undertaken to compare the efficacy of IDET with that of a placebo treatment. METHODS: Patients were recruited by referral and by advertising in the media. Of 4,530 individuals who enquired, 1,360 were prepared to submit to randomisation. Of these, 260 were found potentially eligible after clinical examination, and 64 became eligible after
Introduction: Surgical management of discogenic low back pain has in the past been limited to spinal fusion. Recently disc arthroplasty has become available. The rationale for disc arthroplasty is that it may avoid the long term consequences of adjacent segment degeneration. Avoidance of long term consequences is of no value unless the short term outcome is at least equivalent between fusion and arthroplasty. Methods: A series of patients with chronic low back pain with concordant lumbar
Introduction Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomized controlled trials assessing efficacy versus a placebo group. Methods Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or postero-lateral annular tears as determined by provocative CT/
Introduction: Infection can occur after any spinal procedure that involves entry into the disc and although it is not common, the potential consequences are serious. Treatment usually requires identification of the bacteria followed by a course of antibiotics. This treatment remains controversial since it is not clear whether antibiotics actually penetrate the disc and if so, whether they are effective, or even if the outcome would be the same without antibiotics. For an antibiotic to be effective against the infecting organism it must diffuse through the disc matrix. Blood vessels that surround the disc facilitate the diffusion process, but with age this vascularity decreases and may impede diffusion. The aims of the pilot study were to assess the effectiveness of antibiotic in treating infection in both normal and degenerate sheep discs and to measure the concentration of antibiotic in non-operated discs at varying ages. Methods: In each of six Merino wethers aged 12 weeks (n=3) and 24 months (n=3), two lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade. After four weeks all animals had
Introduction: Recent evidence from the Swedish Lumbar Spine Group has confirmed the anecdotal opinions of many spinal surgeons that fusion for persistent back pain can be a very effective treatment. However, it is clear that many more variables operate in determining clinical success than just radiological evidence of solid fusion. The very careful selection of patients for low back surgery is, in the opinion of the authors, the most important predictor of success. This paper addresses this issue and presents data to show why clinical failure can coexist with radiological success. Methods: Between October 1997 and January 2001, 3600 spinal fusion using Diapason pedicle screw instrumentation and Brantigan anterior interbody fusion cages was performed on 25 patients. During this period 5,850 new outpatients with back pain were assessed in the low back clinic. Patients were selected by the following criteria: Low back pain of two years or more duration; Pain resistant to all non-operative and minimally invasive treatments; Normal psychosocial profile; Normal body mass index; Non-Smokers; Single or two level disease on MRI proven to be painful by provocative
Introduction: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomized controlled trials assessing efficacy versus a placebo group. Methods: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered for the study. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or posterolateral annular tears as determined by provocative CT/
INTRODUCTION: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomised controlled trials assessing efficacy versus a placebo group. METHODS: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered for the study. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or posterolateral annular tears as determined by provocative CT/
INTRODUCTION: Infection can occur after any spinal procedure that involves entry into the disc and although it is not common, the potential consequences are serious. Treatment usually requires identification of the bacteria followed by a course of antibiotics. This treatment remains controversial since it is not clear whether antibiotics actually penetrate the disc and if so, whether they are effective, or even if the outcome would be the same without antibiotics. For an antibiotic to be effective against the infecting organism it must diffuse through the disc matrix. Blood vessels that surround the disc facilitate the diffusion process, but with age this vascularity decreases and may impede diffusion. The aims of the pilot study were to assess the effectiveness of antibiotic in treating infection in both normal and degenerate sheep discs and to measure the concentration of antibiotic in non-operated discs at varying ages. METHODS: In each of six Merino wethers aged 12 weeks (n=3) and 24 months (n=3), two lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade. After four weeks all animals had
INTRODUCTION: Recent evidence from the Swedish Lumbar Spine Group has confirmed the anecdotal opinions of many spinal surgeons that fusion for persistent back pain can be a very effective treatment. However, it is clear that many more variables operate in determining clinical success than just radiological evidence of solid fusion. The very careful selection of patients for low back surgery is, in the opinion of the authors, the most important predictor of success. This paper addresses this issue and presents data to show why clinical failure can coexist with radiological success. METHODS: Between October 1997 and January 2001, 360° spinal fusion using Diapason pedicle screw instrumentation and Brantigan anterior interbody fusion cages was performed on 25 patients. During this period 5,850 new outpatients with back pain were assessed in the low back clinic. Patients were selected by the following criteria: Low back pain of two years or more duration; Pain resistant to all non-operative and minimally invasive treatments; Normal psycho-social profile; Normal body mass index; Non-Smokers; Single or two level disease on MRI proven to be painful by provocative
Introduction The Dynesys® stabilisation system (Zimmer Spine) uses transpedicular screws linked by a cord and spacers; the advantage claimed is that it allows some motion, in all directions, in the operated levels. In vitro laboratory biomechanical studies show that the movement permitted is similar to rigid fixation systems. This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device. Methods In our study 25 patients with dominant low back pain, with or without leg pain, were treated with Dynesys system, 14 females and 11 males with mean age 43.5 yrs.
Introduction: Although prophylactic antibiotic administration is common in spinal surgery, the choice of drug, dose, and timing of administration often varies. Little is known about the activity of antibiotics in the spine and indeed if they are distributed throughout the disc and if the time intervals are optimal. Because infections that produce iatrogenic discitis generally arise within the disc, the antibiotic concentration of the disc is more relevant than serum concentrations. The aims of the study were to determine if a 2g dose of cephazolin was effective at preventing discitis over a four-hour period in immature ovine discs that were both non-degenerate and degenerate; and also to determine the concentration of cephazolin in serum and disc tissue. Methods: In 10 Merino wethers aged 12 weeks, three lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade and using ronguers, removing the bulk of the nucleus pulposus. After 12 weeks nine animals were anaesthetised and given a 2g dose of cephazolin (David Bull Laboratories, Australia) at predetermined time intervals over a four-hour period. The antibiotic was chosen for effectiveness against Staphylococcus aureus a common discitis-causing organism. One sheep (control) did not receive any antibiotics to follow the natural progression of infection. All animals had
This is a preliminary retrospective report on a novel technique for achieving fusion at the lumbo-sacral disc. Current methods of complete discectomy and instrumented fusion involve either a posterior approach and the insertion of cages or an anterior approach. Both methods involve quite extensive dissections with potential stabilising muscle stripping. They also require significant post operative analgesia, inpatient stay and post operative recovery. There are attendant risks of nerve injury, blood loss and thrombosis. A novel method of approach from the sacrum via a ‘safe zone’, described by Yuan et al., is presented. The technique along with the anatomical considerations is described. The operation basically consists of a posterior sacrococcygeal incision and an x-ray guided approach to the anterior surface of the S1/S2 junction with blunt obturators. The L5/S1 disc is then accessed by drilling through the sacrum. The disc is then removed from within with shaped tools leaving the bulk of the annulus. The void created is filled with bone graft and the L5 vertebra fixed to the sacrum via a bolt. The initial results of the first 20 patients are presented. 21 patients have been operated upon but one has been lost to follow up due to a psychological disorder. That patients details have been excluded. The patients underwent surgery between 4/7/06 and 8/10/07. All operative procedures were completed without complication, the operative time improving from 60 minutes to a ‘standard’ 45 minutes. There were no post operative complications. Two patients underwent additional procedures. One was an L4/5 Wallis ligament the other an inter-transverse non instrumented fusion. Several patients required a further pain control procedure, 3 caudal epidurals, 2 facet blocks and 2 coccyx injections. One patient required an L4/5 PLIF 12 months after the first procedure and two patients required posterior stabilisation at the same level. One after 4 months the other at 18 months. The indications for surgery are the same as for a standard fusion procedure. In this group there were 12 degenerative discs with mechanical LBP, 3 spondylolistheses, 2 previous failed posterior fusions and 3 post discectomy patients.
Introduction Current evidence suggests that, in the short and medium term, total disc arthroplasty (TDA) is at least as good as fusion for the management of discogenic low back pain. The optimum kinematic design of TDA, however, at this stage has not been identified. This paper compares the clinical outcomes of two TDA prostheses with different kinematic properties. Methods A randomised comparative clinical study with prospective data collection was performed. Two groups of patients with low back pain who were treated surgically with TDA were compared. All patients had primary symptoms of low back pain without significant facet degeneration. All patients had MRI evidence of disc degeneration and positive
The National Institute for Health and Care Excellence
has issued guidelines that state fusion for non-specific low back
pain should only be performed as part of a randomised controlled
trial, and that lumbar disc replacement should not be performed.
Thus, spinal fusion and disc replacement will no longer be routine
forms of treatment for patients with low back pain. This annotation
considers the evidence upon which these guidelines are based. Cite this article: