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
Background: Lumbar disc replacement is a good alternative to fusion in young patients with degenerative disc disease or
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
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