In a prospective study we attempted to define the role of lumbar discography in the investigation of patients with low back pain with or without non-dermatomal pain in the lower limb. The records of 195 patients were studied at least two years after a technically successful operation. Of 137 patients in whom discography had revealed disc disease and provoked symptoms, 89% derived significant and sustained clinical benefit from operation. Of 25 patients whose discs showed morphological abnormality but had no provocation of symptoms on discography only 52% had clinical success. These findings support the continued use of lumbar discography for the investigation of this particular group of patients.
In the search for a simple method of assessing the therapeutic efficacy of sodium fluoride, a prospective study of vertebral radiography during such treatment was carried out. Treatment of osteoporosis with sodium fluoride, calcium and vitamin D was found to enhance the vertical markings of the vertebral trabecular pattern in 69% of patients. This response was graded 1 (failure), 2 (good) and 3 (excellent); Grade 2 or 3 was attained after a mean treatment period of 31.7 months. Subsequent analysis of the vertebral fracture rate revealed that new vertebral fractures had occurred only in patients with Grade 1 and not in those with Grade 2 or 3. We recommend that treatment should aim at increasing the vertebral trabecular pattern to Grade 2 or 3 and that the duration of therapy should be approximately 30 months.
The results of the use of Harrington rods in the treatment of spinal fractures were reviewed. It was found that with burst fractures where the anterior pillar was deficient there was a significant incidence of loss of reduction. Anterior bone supplementation is recommended in these fractures when major loss of height or angulation occurs. Several technical faults were detected which, in most cases, also led to a loss of reduction. Almost all patients with an anatomical reduction were free of pain. There was no correlation between the loss of reduction and the lapse of time before operation, the levels of instrumentation, the length of the fusion, the severity of the initial deformity, the degree of initial correction or the presence or absence of a neurological deficit.
Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption.
Scintigraphy using technetium-labelled methylene diphosphonate was performed on 110 scoliotic patients six months after an attempted fusion and the findings compared with those at exploration to detect the possible sites of pseudarthroses. The majority of patients (65 per cent) had a uniform uptake of isotope over the fused area and all but one had a solid fusion. A second group (35 per cent) had a more patchy uptake and eight of the nine patients with pseudarthroses were in this group. Pseudarthroses were detected as localised areas of increased uptake but there were also a number of false positives and scans that were difficult to interpret due to continuing new bone formation in immature fusions. In those scans performed after one year the pseudarthroses which had been missed were seen more clearly in contrast to the diminished generalised activity in the fused area.
1. A review of nineteen cases of malignant spinal tumour treated surgically is presented. 2. Four cases are presented in detail. 3. The results in terms of survival are not assessed, because the effect of operation on survival cannot be estimated in a small series without controls. However, if the patient does survive for a considerable time, the value of operation can be assessed in terms of its contribution to the quality of survival, in relieving pain or improving or protecting neurological function. 4. The limitations of laminectomy are compared with the possible advantages of anterior approaches.
1. A left-sided, paravertebral, hour-glass tumour causing destruction of the neural arches of the third and fourth thoracic vertebrae with evidence of spinal cord compression, is described. The tumour presented the typical histological appearance of a chondroblastoma. 2. The intraspinal part of the tumour was excised and the mediastinal part curetted. Post-operative radiotherapy was given. The patient was symptomless two years after operation. 3. No example of Codman's tumour with similar features and in such a situation has been described before in the literature. Pathological, clinical and radiological aspects of chondroblastomata are briefly discussed and some remarks concerning their treatment are added.
A case of extensive spinal actinomycosis, undiagnosed for nearly five years, responded dramatically to large doses of penicillin, which was later supplemented by streptomycin.
1. The pathology of actinomycosis is briefly summarised, especially its method of invading bone by direct spread. 2. The manifestations, diagnosis and treatment of spinal involvement are considered. 3. The literature is brought up to date with
We have studied the intervertebral discs adjacent to fractured vertebral bodies using MRI in 63 patients at a minimum of 18 months after injury. There were 75 thoracolumbar fractures of which 26 were treated conservatively and 37 by posterior reduction and fusion with an AO internal fixator. We identified six different types of disc using criteria based on the morphology and the intensity of the MRI signal. The inter- and intraobserver variability of this system was good. Most of the discs showed predominantly morphological changes with no variation in signal intensity. Some disc types were associated with progressive kyphosis in patients treated conservatively. In those managed by operation, recurrent kyphosis appeared to result from creeping of the disc in the central depression of the bony endplate rather than from disc degeneration. Changes in the disc space after posterior fixation should not be seen as a form of chronic instability but as a redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate.
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.
