It has been proposed that
Our study establishes a rabbit model of disc degeneration which requires neither a chemical nor physical injury to the disc. Disc degeneration similar to that seen in man was created at levels proximal (L4-L5) and caudal (L7-S1) to a simulated lumbar fusion and was studied for up to nine months after arthrodesis. Loss of the normal parallel arrangement of collagen bundles within the annular lamellae was observed in intervertebral discs adjacent to the fusion at three months. By six months there was further disorganisation as well as loss of distinction between the lamellae themselves. By nine months the structure of the disc had been replaced by disorganised fibrous tissue, and annular tears were seen. There was an initial cellular proliferative response followed by loss of chondrocytes and notochordal cells in the nucleus pulposus. Degeneration was accompanied by a decrease in the monomer size of proteoglycans. Narrowing of the disc space, endplate sclerosis and the formation of osteophytes at adjacent disc spaces were observed radiologically.
We studied 52 patients, each with a lumbosacral transitional vertebra. Using MRI we found that the lumbar discs immediately above the transitional vertebra were significantly more degenerative and those between the transitional vertebrae and the sacrum were significantly less degenerative compared with discs at other levels. We also performed an anatomical study using 70 cadavers. We found that the iliolumbar ligament at the level immediately above the transitional vertebra was thinner and weaker than it was in cadavers without a lumbosacral transitional vertebra. Instability of the vertebral segment above the transitional vertebra because of a weak iliolumbar ligament could lead to subsequent disc degeneration which may occur earlier than at other disc levels. Some stability between the transitional vertebra and the sacrum could be preserved by the formation of either an articulation or by bony union between the vertebra and the sacrum through its transverse process. This may protect the disc from further degeneration in the long term.
We attempted to correlate the findings of MRI and discography in patients with low back pain, examining 108 lumbar intervertebral discs in 33 consecutive patients. MRI results were assessed from the intensity and shape of the signal obtained from the central part of the disc. Discography was classified according to the pattern of contrast material, the pressure accepted and the pain reproduced. All discs which were abnormal on MRI had altered patterns on discography, but 18 of the 60 discs with normal MRI had abnormal discograms. Of 39 asymptomatic discs, 33 had normal MRI signals and 24 had normal discograms. None of the 15 discs showing severe degeneration on MRI sustained high levels of intradiscal pressure, but only six of the 60 discs giving normal MRI had low pressure. With current techniques, discography is more accurate than MRI for the detection of annular pathology: a normal MRI does not exclude significant changes in the peripheral structure of the intervertebral disc which can produce low back pain.
We investigated the relationship between spinopelvic
parameters and disc degeneration in young adult patients with spondylolytic
spondylolisthesis. A total of 229 men with a mean age of 21 years
(18 to 26) with spondylolytic spondylolisthesis were identified.
All radiological measurements, including pelvic incidence, sacral
slope, pelvic tilt, lumbar lordosis, sacral inclination, lumbosacral
angle (LSA), and sacrofemoral distance, were calculated from standing
lateral lumbosacral radiographs. The degree of intervertebral disc
degeneration was classified using a modified Pfirrmann scale. We
analysed the spinopelvic parameters according to disc level, degree
of slip and disc degeneration. There were significant positive correlations between the degree
of slip and pelvic incidence (p = 0.009), sacral slope (p = 0.003)
and lumbar lordosis (p = 0.010). The degree of slip and the LSA
were correlated with disc degeneration (p <
0.001 and p = 0.003,
respectively). There was also a significant difference between the
degree of slip (p <
0.001) and LSA (p = 0.006) according to the
segmental level of disc degeneration. Cite this article:
In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p <
0.001). The prevalence of
The action of fast bowling in the game of cricket is known to cause injuries to the lumbar spine. We studied a group of 16- to 18-year-old fast bowlers, selected for special training in Western Australia. All 24 had MR scans of the spine, 22 had radiographs and CT scans; in 20 the bowling technique was analysed biomechanically. There was a high incidence of back pain and this was always associated with a radiological abnormality. Pars interarticularis defects were diagnosed in 54% and
The pathophysiology of
1. At the present stage of our experience, when 150 patients have been analysed over a period of five years, the conclusion has been reached that anterior interbody fusion in the lower lumbar spine is a procedure which should be added to our surgical armamentarium for use in selected cases. 2. Patients suffering from chronic
1. In this series of posterior onlay grafting with fresh autogenous bone and without internal fixation, in the treatment of non-infective structural lesions in the lumbo-sacral area, 71 per cent of the patients were relieved of their symptoms, but bony fusion was obtained in only 60 per cent. 2. It is probable that with this technique twelve weeks' immobilisation in a plaster bed is required. 3. Some failures are ascribed to the use of an insufficient quantity of bone or to poor apposition of the graft to its bed. 4. It is evident that the more vertebrae one attempts to fuse the more difficult it is to succeed. When the diseased area is successfully fused but an unnecessarily long graft has been used, a pseudarthrosis above the level of the pre-operative pathology may be the cause of persisting backache. For these reasons we believe that one should not attempt to graft more vertebrae than is necessary to stabilise the local lesion. 5. The complication rate, particularly from deep vein thrombosis, was high. This major complication could perhaps be overcome by using banked bone. 6. The indications for the operation are assessed as follows. It should be done for low back pain only when there is a definite diagnosis and a limited extent of structural pathology; one can then expect excellent results when successful fusion is achieved and also an appreciably high proportion of satisfied patients even when bony fusion has not been obtained, presumably because there is a fibrous union strong enough to stabilise the affected spine. It is inadvisable to undertake lumbar-lumbo-sacral fusion for
The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position. A total of 161 patients were considered for inclusion. Patients had a mean age of the remaining 61 years (Aims
Patients and Methods
Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion.
Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.
Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.