Introduction

Discogenic pain is associated with ingrowth of blood vessels and nerves, but uncertainty over the extent of ingrowth is hindering development of appropriate treatments. We hypothesise that adult human annulus fibrosus is such a dense crosslinked tissue that ingrowth via the annulus is confined to a) peripheral regions, and b) fissures extending into the annulus.

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.

The purpose of the study was, to investigate how often the diagnosis of “Scheuermann’s disease” was made in radiological reports to General Practitioners, to determine the precise nature of the disease being described, and to evaluate the management of patients by GP’s who receive such radiological reports.

A computerised search of radiological reports to local GP’s revealed fifty reports over a two and a half period which included the diagnosis of “Scheuermann’s disease”. Assessment of these radiographs by a Consultant Radiologist indicated that ten of these patients had classical Scheuermann’s (abnormal thoracic kyphosis associated with disc and end plate irregularities), and forty had so called lumbar/type two Scheuermann’s (disc and end plate irregularities of the thoraco lumbar spine without deformity).

A questionnaire was sent out to GP’s which consisted a case history of a middle aged patient with typical symptoms of degenerative low back pain without deformity, including a radiological report indicating the “possibility of Scheuermann’s disease”, on the basis of features typical of Scheuermann’s lumbar/type two.

86% of GP’s indicated that they would inform their patients that they had “Scheuermann’s disease” using that term, but 48% did not appreciate the meaning of the term in the context of the case history.

We conclude that the majority of radiological reports to GP’s which include the diagnosis “Scheuermann’s disease” relate to lumbar/type two Scheuermann’s, and that the nature of the radiological diagnosis, invariably passed on to the patient, is often misunderstood by the GP. This may well result in patients presenting to spinal clinicians with unnecessary anxiety due to concerns of possible serious pathology.

We would recommend that spinal clinicians encourage their radiological colleagues to avoid the use of the words “Scheuermann’s disease” in radiological reports to GP’s except when describing classical adolescent thoracic kyphosis.

Restriction of straight leg raising (SLR) is usually associated with patients suffering leg pain due to a postero-lateral disc protrusion.

We report a group of twelve patients presenting with acute mechanical low back pain only, and no leg pain, who also demonstrated similar restriction of SLR.

The MRI scans of these patients, when compared with the scans of patients suffering typical sciatic pain, revealed that the disc protrusions in the back pain group were more likely to be smaller, central and at a higher lumbar level than the leg pain group.

Anatomical considerations would suggest that the source of back pain was the anterior theca being compressed by a central disc protrusion.

Twelve patients presenting with acute low back pain only and demonstrating intensification of low back pain during passive straight leg raising were investigated with CT or MRI scanning. None of these patients had leg pain. The painful and reduced passive SLR was accompanied by further increase in pain on dorsiflexion of the foot and reduction in pain on knee flexion, findings normally associated with sciatic pain due to acute nerve root compression following disc protrusion.

Imaging demonstrated significant central disc prolapses at L4/5 or L3/4 in all patients. In those who showed unilateral restriction of passive straight leg raising, the scans revealed central disc protrusions with a disposition to the affected side. None of these patients had neurological deficits effecting the leg, bladder bowels.

The clinical presentation, imaging and anatomy of the spinal canal would clearly implicate the anterior dura as being the source of the pain, being compressed by a central disc protrusion. The nerve supply of the anterior dura as opposed to the posterior dura is substantial.

The dura as an origin of acute low back pain has received some but not widespread attention in the medical literature.

The clinical outcome of these patients typically mimicked those who present with acute sciatica. The majority improved spontaneously and only a small proportion continued to have significant pain some months after the onset of symptoms.

Diagnosis of this clinical syndrome, which has not been fully described before, may give some focal point for an explanation of the pain source to the patient and give some lead to further investigations.

Chronic pain at the donor site was reported by 25% of 290 patients who had undergone anterior lumbar spine fusion for low back pain. Donor site pain has characteristic clinical features, may be severely disabling and is stubbornly resistant to treatment. The highest prevalence was in patients who had a tricortical full thickness graft taken through a separate incision overlying the iliac crest. Patients with a clinically unsatisfactory result from the spine fusion also had a significantly higher prevalence of donor site pain.

Shelf operations performed on 24 patients (27 hips) for late presentation of congenital hip dysplasia were evaluated. The mean age at operation was 14 years 9 months and the mean follow-up 16 years 8 months. Two-thirds of the hips had good clinical results at follow-up. Patients operated on under the age of 20 years and with little or no radiological evidence of degenerative joint changes had the highest likelihood of success. The shelf operation was found to provide good cover of the femoral head and, should failure occur, also provides adequate superior support for the seating of an acetabular prosthesis.