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 discogenic pain. Until we determine the true nature and function of LCLP, we are no further in understanding the patho-mechanisms of disc degeneration. Moreover, LCLP loss in the NP of degenerate discs may provide a potential diagnostic marker for degenerative disc disease.
Routine use of Computed Tomography (CT) to evaluate discogram morphology is time consuming, costly and incurs additional radiation hazards. In our spinal unit, discography is routinely performed without the aid of CT. Discogram morphology for different stages of disc degeneration is evaluated using the modified Adam’s grading system on images obtained on fluoroscopy. Our aims were to assess the validity of the modified Adam’s grading system of discogram morphology, by assessing its inter- and intra-observer agreement. We reviewed the discographic images (133 intervertebral levels) of 71 patients with chronic low back pain undergoing discography as part of a preoperative assessment between 1995 and 1997. Using the modified Adam’s grading system, three independent surgeon observers of three levels of experience (Senior Fellow, Senior and Junior residents) retrospectively evaluated the morphological appearance of each disc level in a randomized and blinded manner. Each observer was supplied with descriptions and illustrations of the 5 grades1, and each level was classified accordingly. The exercise was repeated three weeks later. The respective inter- and intra-observer agreements were calculated using the kappa statistic (Fleiss 1971) and generalized kappa statistic (Landis and Koch 1977). The inter-observer agreement was excellent (kappa = 0.77; standard error = 0.054). The intra-observer agreement for each of the three observers was also excellent (kappa = 0.8, 0.8, and 0.85 with respective standard errors = 0.046, 0.049 and 0.042). Significance and conclusions: The inter- and intra-observer agreement and therefore the reliability of the modified Adam’s grading system is excellent. This classification is easy to apply and has a high degree of reproducibility amongst observers with different levels of spinal experience. In view of the high reproducibility, we recommend the Adam’s classification for the grading of discogram morphology. The routine use of computed tomography with the concomitant radiation exposure and additional cost would seem not to be justified.
Three developments in the last 10 to 15 years have made it necessary to review how we ensure rapid access to treatment of patients with disabling low back pain. Firstly, there would appear to be an increase in the numbers of patients seeking medical help for low back pain, whether due to increased patient expectation, or better reporting, or a true increase associated with the increasing sedentary nature of life, is uncertain. Secondly, there is the realisation that amongst the factors that encourage acute back pain to become chronic is being off work, and the sooner a diagnosis and treatment is started the more likely that chronicity will be prevented, so a long waiting time to be seen in a clinic is productive of disability. Thirdly, reorganisation of consultant services has created the spinal surgeon, who in return for being allowed to practice spinal surgery almost exclusively undertakes the load of patients referred with back pain, amongst whom lurk those with a surgically remediable problem. The effect has been that although waiting times for general orthopaedic patients have dropped, as general orthopaedic, or other specialist orthopaedic surgeons no longer see spinal cases, the specialist spinal surgeon is overwhelmed by a large group of patients with back pain for whom there is not a surgical solution. Unfortunately, there is a shortage of spinal surgeons, which is likely in the UK at any rate to get worse. Being overwhelmed with non-surgical back pain interferes with their ability to deal with surgical problems. It also does create a recruitment problem, as back pain is not seen as a rewarding or satisfying problem to treat. Triage is a method of screening patients into groups at an early stage, identifying those who might benefit from surgery, and fast tracking them, identifying those who will benefit from other management and tracking them accordingly. Pioneered in general orthopaedics by Robin Ling in Exeter, it has been developed in the hospital setting somewhat randomly, by dedicated enthusiasts, many of whom will be speaking today. The purpose of this meeting today is to hear about the various systems, their funding and organisation and location, the triage staff used, the investigations used in primary triage and the effect on hospital specialist waiting times, the safety and patient satisfaction. Is a multiplicity of systems best, is one better than another, why have some units achieved no waiting times for MRI, and others six months etc? In 1994, the Clinical Standards Advisory Group produced two books, An epidemiological Review, largely the work of Gordon Waddell, and a second book on Back Pain, chaired by Professor Michael Rosen with, I suspect, considerable input from Professor Waddell and others. Many of us met them when they toured the country collecting facts about the treatment and management of back pain. It discusses back pain triage, and suggests that it can be done within the average GP Consultation time of 9 minutes. It deals with simple back ache, “red flags”, (we now have “yellow flags” denoting the psycho-social factors) nerve root pain, cauda equina and inflammatory disorders. It is to be noted that chronic back pain, is not alluded to in the diagnostic triage, but it is stated that 90% of simple back ache recovers in six weeks. Their management guidelines emphasise the value of physical therapy (manipulation and active exercises), but it will be noted that they are addressed to a group of patients, 90% of whom will recover in six weeks. Sadly, therefore, the effect of this very sensible document, in ignoring in the triage system the chronic patient, has in many cases directed therapy in general practice towards open access for patients who in any event will improve spontaneously. We must therefore address where triage should be, hospital, or GP level. Certainly a GP gatekeeper will remove the acute back pains that are going to get better soon anyway from attending hospital and in certain units, a separate fast track is provided for acute radicular problems (Acute Sciatic Clinics). Any successful triage system involving chronic back pain must be associated with treatment possibilities, and I shall briefly discuss these, although the main thrust of the afternoon will be the triage organisation itself. The session is designed to allow considerable audience participation, as it is hoped that information, comments and criticisms from the audience will allow us to subsequently produce a booklet, hopefully with support from our Professional Societies, describing what we feel is Best Practice in Back Pain Triage, which we hope, after appropriate circulation, will encourage Trusts and Community Health Groups to develop such units and ensure that back pain patients get a better deal.
The Short Form-36 (SF-36) health questionnaire has been put forward as a general measure of outcome in health care and has been evaluated in several recent studies in the UK. We report its use in three groups of patients after spinal operations and have compared it with the Oswestry and Low Back Pain disability scales. There was a significant correlation between all variables of the SF-36 and the low-back scores. The mental-health items had the weakest correlation. Our study shows that the SF-36 questionnaire is valid and has internal consistency when applied to these patients.
We treated 137 patients with symptomatic lumbar disc prolapse by automated percutaneous lumbar discectomy (APLD). Seventeen (12%) required further operation. At a mean follow-up of 55 months, the success rate was 45%. Of those who had APLD alone, 52% were graded as either excellent or good. In this group, 76% were employed, and the mean Oswestry score was 28.2%. One-third of those patients initially rated as successful had deterioration in symptoms and increased disability from back pain. The Short Form 36 health survey questionnaire revealed that these patients had a chronic ill-health profile.
Forty-two consecutive patients with suspected lumbar disc protrusions were studied prospectively to compare the diagnostic accuracy of low-field strength MRI with that of radiculography. Thirty patients subsequently underwent surgical exploration at 33 levels and the operative findings were compared to both methods of diagnostic imaging. All patients had MRI studies, whilst 29 patients also had radiculography. Both studies were evaluated without prior knowledge of the clinical signs, operative findings or the results of other imaging techniques. MRI predicted the correct diagnosis in 29 of the 33 levels explored, an accuracy of 88%. All discs proven to be abnormal demonstrated a reduced signal from the nucleus pulposus. There were two false positive results and two doubtful cases but no false negatives. Radiculography predicted the correct diagnosis in 24 of 32 levels explored, an accuracy of 75%. There were two false positive results, five doubtfuls and one false negative. The overall accuracy when both tests were considered rose to 94%. Of the remaining 12 patients all except one showed good correlation between the MRI and radiculographic findings. These results indicate that low field strength MRI is slightly better than radiculography in diagnosing lumbar disc protrusions.
Magnetic resonance imaging (MRI) was used to compare the appearance of the spine in 20 adolescents with proven symptomatic intervertebral disc herniations with that in 20 asymptomatic patients who acted as controls. Abnormality in the signal from the nucleus pulposus of one or more discs was present in all patients, while only four of the 20 controls had any abnormal signals. In all the patients the symptomatic disc produced an abnormal signal and in most a herniated fragment of the nucleus pulposus was identified. Fifteen of the 20 patients had multiple-disc abnormality: six had three abnormal discs and nine had two. This suggests there was an underlying diathesis in patients who later developed disc herniation.
Surgical treatment of hydatid bone disease is rarely completely successful because radical excision is only possible at certain sites and secondary infection frequently occurs. Antihelmintic drugs have in the past been only palliative due to poor absorption and consequent low concentration in serum or cysts. We report five patients with Echinococcus granulosus infestation treated with a new chemotherapeutic agent albendazole; in two it was given postoperatively, in two pre-operatively and one child is being followed expectantly. We believe that a combination of chemotherapy and surgery may be efficacious in the treatment of hydatid bone disease.
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 discography without enzyme insertion. A consistent pattern of gradual loss of signal from the nucleus pulposus culminating in complete loss of nuclear signal was seen in all cases after chemonucleolysis. Chymopapain therefore produced MRI changes analogous with premature gross disc degeneration. The rate at which this occurred varied; complete loss of signal took at least six weeks. Transitory minor end-plate changes were present in five patients, probably representing a mild chemical discitis. No similar changes were seen in the discography group.
The lumbar spines of 22 patients were examined for disc degeneration by magnetic resonance imaging (MRI) and by discography. The results from 50 intervertebral discs visualised by both techniques were independently assessed and graded on a five-point scale from normality to gross degeneration and then compared. In 44 discs the results agreed. Of the six discs which gave differing results, four discrepancies were due to observer error and two to incorrect placement of the discographic needle. MRI was shown to be more accurate than discography in the diagnosis of disc degeneration. It has several major advantages, which should make it the investigation of choice.
The use of nuclear magnetic resonance (NMR) in the diagnosis of radicular pain due to lateral canal stenosis in 21 patients is reported. NMR was able to distinguish normal intervertebral discs from degenerate discs, and NMR evidence of reduction of epidural fat was more reliable than radiculography in identifying lateral root entrapment. NMR is an important advance in the investigation of lumbar radiculopathies.
A study of cadaveric vertebral biopsy and a review of 100 clinical biopsies has shown that needles and trephines producing tissue specimens of two millimetres or more in diameter can be expected to give a high degree of diagnostic accuracy. The erythrocyte sedimentation rate was a more useful screening investigation than were estimations of serum alkaline phosphatase. The complications are described. It is suggested that patients with painful thoracic metastases and evidence of progressive cord compression should have early decompression after open biopsy if further neurological compromise is to be prevented.
Modern anthropometric techniques were used to investigate two groups of subjects, one with various syndromes associated with pain in the lower back and the other a control group. Analysis confirmed previous reports that people prone to pain in the back have a greater standing height than people who are not. To investigate this further two new components of height, namely pelvic height and suprapelvic height, were calculated in addition to the established calculation of subischial height. Consecutive components, namely suprapelvic height, pelvic height and subischial height, together constituted the standing height of a subject. The main finding of this investigation was that the relatively large standing height of the subject prone to back pain was due only to the pelvic component.
