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The occurrence of calcified discs with large calcified masses protruding into the spinal canal in two children is reported. The discs affected had increased height in the acute stage. Air myelogram, performed in one case with muscular weakness in the hand demonstrated compression of the spinal cord. The condition improved on conservative treatment without sequelae in both cases.
The procedures used in the investigation of low back pain and sciatica have been subjected to a double statistical analysis to determine their diagnostic accuracy, since contradictory opinions have been expressed in the literature. It was found that only lumbar phlebography was more accurate than the most simple procedure, the clinical examination. Myelography is more accurate than clinical examination only in making a positive diagnosis. In this case, it equals the reliability of lumbar phlebography, but so does plain film radiography which however leads to a positive diagnosis less constantly. Lumbar phlebography is the most accurate procedure for making a negative diagnosis, mainly by avoiding a false negative conclusion. A comparison is made with the statements in the literature and the complementary use of the different procedures is proposed for the investigation of low back pain and sciatica.
Anterior lumbar disc herniations can easily and clearly be evidented by discography. The morbidity and, especially, the clinical importance of this entity, however, has been described by some authors only. According to our own experience with discography, ventral lumbar disc herniation seems to be correlated with a painful syndrome consisting of both a typical and circumscribed backache and pain radiating into the abdominal cavity and genital area along the lateral aspect of the lumbar region.
Fusion of the lumbosacral spine was carried out on 44 patients. A modification of the standing H-graft technique was used in 41 of the patients. The operative diagnosis was degeneration of the lumbosacral spine in nearly two-thirds of the cases and spondylolisthesis in about one-third. Operations for low back or sciatic pain had previously been performed on 17 patients. The duration of postoperative bed rest ranged from one to six weeks; a lumbosacral corset was used at least for six weeks postoperatively. The average stay in hospital was 52 days. Complications occurred in five cases. The operative results of 40 patients were evaluated on the basis of a follow-up examination performed on average 3.6 years after operation. Nearly half the patients with radiologically successful fusions had a good subjective improvement and about one-fourth had returned to their previous or corresponding occupations. The operative result was at least fair in about half the patients, assessed by a measure of the patients' subjective improvement and working capacity. In the non-fusion group (six cases) the operative results were exclusively poor. Age over 40 years, long-standing preoperative disability and previous back operations proved prognostic factors for poor results. Assessed from functional radiographs, 63% of two-segment fusions and 95% of one-segment fusions were successful. The operative technique appeared simple and suitable for fusions of one spinal segment, but the value of the lumbosacral fusion in the treatment of low back pain seemed doubtful because of the great proportion of poor clinical results even following technically successful fusions.
In epidural venography systematic use of two catheters and simultaneous injection of contrast medium does improve the opacification of the entire lumbar epidural venous system and the reliability of the X-rays. The combined catheterization offers the possibility of over 20 different procedures. The position of the catheters can be chosen according to diagnostic problems or technical catheterization problems during the examination. The method should be regarded as extremely reliable in diagnosing lumbar disc herniation. A small straight vein, which has not been described before, is often shown in the middle of the vertebral canal. Metrizamide may be used as a contrast agent.
1. The literature concerning intrathecal herniation of intervertebral discs is briefly reviewed. 2. A case of an intrathecal herniation of a cervical disc with transitory paraplegia and a following Brown-Sequard-Syndrome is reported. 3. Laminectomy disclosed a rotation of the cord and a sequestrated disc embedded in the anterior substance of the cord. 4. A trauma of the cervical spine 8 years ago seem to be responsible for the progredient protrusion of the cervical disc. 5. Adhaesions between the dura mater and posterior longitudinal ligament in this case are regarded as origin of intrathecal herniation.
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Intrathecal instillation of corticosteroid was used in treatment of 188 patients with persistent sciatica or lumbar pain caused by disc hernia or osteochondrosis and recurrent sciatica or lumbar pain after disc operation. 88 of 122 own patients were followed up. Indication, mechanism of steroid action, technic, complications and results are discussed. According to the good results in part of the patients, still after years, the authors believe, that intrathecal corticosteroid administration is a further useful method of conservative treatment of degenerative lumbar disc affections. This therapy can also be used in patients with recurrent, persistent lumbar or leg pain after disc operation.
The routinelike employment of myelography is attached and as follows established. 1. Primum non nocere! This old medical axiom also here has its validity, there are enough examples of incidents and late damages in employment of this method. 2. The myelography is not reliable. Errors are described. 3. Superfluous painful examinations should be spared for the patient: operation and myelography are two interventions. 4. The myelography costs time and prolongs staying in hospital.
The terminal plate fracture of human vertebrae was studied morphologically on midsagittal specimens from 92 autopsy cases which included 82 patients over 60 years. 1. Histologically, the terminal plate fracture was classified into three types by its representative histology. (a) Fracture with intervertebral disk (ID) prolapse: a healed fracture characterized by the presence of the prolapsed ID at the fractured site. ID prolapse in the marrow cavity may or may not be present. The group includes the typical case of the Schmorl's nodule. (b) Fracture with the granulation tissue: The fracture site was embedded by the granulation tissue. Callus and ID prolapse, if any, were insignificant. (c) Diffuse replacement of the hyaline cartilage layer by osteoid tissue: The alteration is seen often at a concaved surface of the terminal plate of significantly deformed vertebrae. 2. The fracture may be classified by the depth of the ID prolapse. (a) Grade 1: ID prolapse may be seen within the fracture aperture, but, not in the marrow cavity. (b) Grade 2: ID prolapse is confined to a labyrinth of subcortical trabeculae. (c) Grade 3: ID prolapse extends to a deep marrow space. The typical Schmorl's nodule belongs to this group. 3. In the present study, the terminal plate fracture was noted in 78% of the patients over 60 years. The female group was affected more often (68% in male, 86% in female). Grade 2 was more often seen in atrophic vertebrae than Grade 1. However, in Grade 3, the fracture appeared unrelated to the atrophy of the vertebrae. 4. The terminal plate fracture was more often seen in the lower deck than the upper deck at the site of two-thirds dorsal from the ventral edge of the vertebral body. The site corresponds roughly to the nucleus pulposus. 5. Histologic variations of the terminal plate fracture and of ID prolapse may relate to senescence of both vertebrae and ID.
The aim of this study was to evaluate the long-term results of Cloward's anterior interbody fusion of the cervical spine and to identify the factors influencing them. The series consisted of 29 patients operated on in 1968--75. The indication for operation was in 12 cases intensive radicular symptoms, not responding to conservative treatment, in connection with considerable degeneration of the corresponding spinal segment only, and in 17 cases instability of the cervical spine caused by traumatic injury followed by dislocation and radicular or medullary symptoms enhancing in spite of conservative treatment by skull traction or collar. Twenty-five patients (86%) attended follow-up after an average time lapse of 6.5 years from operation. The operative result was evaluated considering objective neurological improvement, subjective improvement, present symptoms and working capacity. The operative result was at least fair in 7/11 in the degeneration group and in 12/14 in the traumatic injury group. All fusions were radiologically successful. Adequate correction of a primary flexion deformity of more than 15 degrees was not achieved. Age over 35 years and motor defect preoperatively proved to be statistically significant prognostic factors for a poor operative result in the traumatic injury group. Preoperative sick-leaves and a duration of preoperative symptoms exceeding six months proved to be prognostic factors for a poor result in the degeneration group. In spite of the relatively good clinical results obtained, this study does not justify any conclusions concerning the value of Cloward's procedure compared to other methods of treatment, since no control material was available.
An experimental study was undertaken to determine the origin of lumbar pain associated with degeneration of lumbar intervertebral disc by examining their innervation, vascularization, and stages of evolution. The study included the comparison of discography on patients with an experimental reproduction of this examination on cadavers.
Four boys with anterior lumbar disc herniations probably secondary to chronic trauma are reported. Anterior disc herniations may appear as separate lesions-as in our patients-or coexist with Scheuermann's disease. Although Scheuermann's disease, discitis and tuberculosis are regarded as the most common causes of intervertebral disc lesions in childhood, trauma should be excluded as a possible cause in all children with chronic back pain who show localised radiographic signs of narrowed disc spaces with erosive and sclerotic changes in the adjacent vertebrae. Localised mild platyspondly may be the result of abnormal, prolonged stress and early osteoarthritic changes are to be expected.
The clinical findings and operation results in two series of patients with medial prolapse of an intervertebral disc with total or partial occlusion of the spinal canal are reported. In one of the series (30 patients) symptoms of cauda equina compression, with bladder and rectal disturbances, were present, and in the other series (28 patients) these symptoms were absent. The observation period was five years (median value). The late results are evaluated in relation to the time interval between the onset of symptoms and operation. In the series with caudal compression syndrome, sphincter disturbances persisted in 10 patients, six of whom underwent operation during the first week after the onset of symptoms. The prognosis was most favourale when the symptoms developed slowly. Seventeen patients have returned to work. The importance of early operation in patients with classical compression syndrome of the cauda equina is emphasized. In the series without caudal compression syndrome, the symptomatalogy varied. The duration of symptoms was strikingly long. Only 19 patients are able to work. The others are prevented from working by persistent backache and leg pains, and in four cases by pareses of the extremities. In these cases also the importance of early operation is stressed.
The operative results in 37 consecutive patients suffering from developmental stenosis of the lumbar spinal canal, compared with those in spondylosis and disc herniations, are discussed. The diagnostic certainty of stenosis, suspected on the bases of clinical and radiographic data, is reached only at the operating table. To judge the usefulness of the operation we have considered not only the patients' verdicts, but also the improvements in neurological signs and the appearance of new deficits. Satisfactory results are around 80%, slightly less good with stenosis than with the other causes of lumbar syndrome. Radiographic study with contrast medium is mandatory. Dimer-X has been used with very clear radiographic findings and very few complications. Operating technique is also described: a wide laminectomy with facetectomy is advised. The great importance of early physiotherapy is emphasized.
Eight consecutive cases of ventriculitis detected and treated during a four year period are reviewed. This complication represented 7.9% of all cases of spina bifida treated surgically, and 5.4% of all shunt precedures performed during the study period. Prophylactic antibiotic treatment did not reduce the incidence of ventriculitis, and in fact seemed to produce resistant strains, which led to difficulties in treatment and a worse prognosis. The presence of an intraventricular foreign body precludes permanent sterilization of the ventricular fluid. Finally, in those cases in which the antibiotic of choice penetrates poorly into the cerebrospinal fluid; intraventricular as well as systemic administration of the drug is indicated. With Gram negative organisms, Gentamicin is currently the drug of choice.
Myelotomography is of considerable help in the preoperative diagnosis of lumbo-sacral intervertebral disc prolapses. Contrast views and new water-soluble media make the technique very useful. On the basis of 550 myelographies, indications for myelotomography are discussed. The examination should be performed in patients with clear clinical symptoms of intervertebral disc prolapse but negative routine myelograms. The introduction of myelotomography has reduced the incidence of false negative preoperative radiological investigations.
Recent anatomic and physiologic work suggests that there may be substantial numbers of unmyelinated sensory axons in the ventral roots. The cell bodies of origin for these unmyelinated axons would presumably be located in the dorsal ganglion. We have performed 18 microsurgical lumbosacral ganglionectomies over the past two years for chronic lumbosacral pain syndromes. In spite of preoperative nerve block trials, good results were obtained in only 10 of 18 patients. Four patients obtained some pain relief, and four patients no pain relief whatsoever. Microganglionectomy in the lumbosacral area is probably easier technically than the more traditional intradural rhizotomy, but may not yield any better results.