Thursday
Intervertebral disk degeneration related to reduced vertebral marrow perfusion at dynamic contrast-enhanced MRI.
AJR Am J Roentgenol. 2009 Apr; 192(4): 974-9Liu YJ, Huang GS, Juan CJ, Yao MS, Ho WP, Chan WPOBJECTIVE: The purpose of this study was to use dynamic contrast-enhanced MRI to ascertain the relation between intervertebral disk degeneration and lumbar vertebral marrow blood perfusion. SUBJECTS AND METHODS: We recruited 25 patients (50 vertebral bodies) who underwent dynamic contrast-enhanced MRI of the lumbar spine. The peak signal enhancement of each vertebral body was calculated from the time signal after curve fitting of a pharmacokinetic model. We controlled for other variables that might have affected blood perfusion by assessing two vertebral bodies in each patient. The 25 patients were divided into three groups. In group 1, one of the vertebral bodies (L1 or L3) evaluated was between two adjacent normal disks and the other was between two adjacent degenerated disks. In group 2, each of the two vertebral bodies evaluated was between two normal disks. In group 3 each of the two vertebral bodies evaluated was between two degenerated disks. RESULTS: Without normalization by minimization of other variables, there were no statistically significant differences in original peak enhancement values among groups 1, 2, and 3 (p = 0.179). After normalization, the peak enhancement in group 1 (0.846 +/- 0.060) was significantly lower than that in group 2 (0.988 +/- 0.047) (p = 0.003) or group 3 (0.973 +/- 0.081) (p = 0.008). CONCLUSION: After normalization, lumbar vertebral marrow perfusion correlated well with intervertebral disk degeneration evaluated with dynamic contrast-enhanced MRI. Blood perfusion was 14% less in the vertebral body marrow between two degenerated disks than in vertebral marrow between two normal disks.
[Efficacy and safety of AirWay Scope in using a bronchofiberscope in patients with difficult airway]
Masui. 2009 Mar; 58(3): 346-8Nakasuji M, Tanaka M, Imanaka N, Nakamura M, Higuchi M, Nomura M, Kawashima HCase 1: A 41-year-old woman was scheduled for pinning of fractured finger and repair of a ligamentum. Preoperative problems did not exist except mandibular hypoplasia. General anesthesia was induced and Cormack classification was grade III in laryngeal view by laryngoscope and we tried a new videolaryngoscope PENTAX-AirWay Scope (AWS). We did not catch the epiglottis directly by Intlock and the target mark was not located at the middle of the vocal cord. Bronchofiberscope was guided to the vocal cord through a tracheal tube attached to AWS by another anesthesiologist and the patient was successfully intubated. Case 2: A 46-year-old man was scheduled for anterior screw-plate fixation due to C3/4 herniated disc. AWS using bronchofiberscope procedure was tried to keep the neutral position of the neck. The patient was successfully intubated. We did not view the bronchofiberscope and used it just as a flexible bougie. Case 3: A 56-year-old man was scheduled for free radial forearm flap reconstruction of a diabetic necrotic toe. Ten minutes were needed to finish intubation due to difficult airway (Cormack classification grade III) when free latissimus dorsi flap reconstruction was perfomed two month before. Hence, AWS using a bronchofiberscope procedure was tried first and 39 seconds were needed to intubate. We concluded that AWS using bronchofiberscope procedure was useful for patients with difficult airway, though two anesthesiologist, one keeping AWS and the other using a bronchofiberscope, were needed.
Wednesday
Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis.
Clin J Pain. 2009 Mar-Apr; 25(3): 206-10Lee JH, An JH, Lee SHOBJECTIVES: The purpose of this study is to compare the effectiveness of interlaminar (IL) and bilateral transforaminal (TF) epidural steroid injections (ESIs) for pain reduction in patients with axial back pain resulting from herniated intervertebral disc (HIVD) and spinal stenosis (SS). METHODS: Patients reporting axial back pain without radiation continuing over 3 months, which resulted from lumbosacral SS or HIVD were recruited and assigned to either the IL or TF technique group. The degree of pain and patient satisfaction were evaluated by the Numerical Rating Scale (NRS), the Patient Satisfaction Index (PSI), and the Roland 5-point pain score, which were administered at pretreatment, 2 weeks, 2 months, and 4 months after ESI. RESULTS: Both the TF and IL ESIs accomplished significant pain reduction in HIVD and SS from 2 weeks to 4 months after treatment. SS showed a more significant reduction in the Roland 5-point pain score and obtained more successful NRS results using the TF technique as compared with the IL technique. HIVD did not show any differences between the techniques. DISCUSSION: Bilateral TF epidural injection allowed the higher concentration of injectates to be delivered into ventral epidural space bilaterally. The IL approach can be more affected by tissue fibrosis, scarring, or hypertrophy, which is more prominently featured in SS than in HIVD; these prevent the injectate delivered via the posterior route from spreading to the ventral epidural space. Consequently, in patients with SS, bilateral TF produces better results than IL.
Giant calcified thoracic herniated disc: considerations aiming a proper surgical strategy.
J Neurosurg Sci. 2009 Mar; 53(1): 19-26Barbanera A, Serchi E, Fiorenza V, Nina P, Andreoli AAIM: Giant herniated thoracic disc (HTD) is a rare disease that, unlike other thoracic disc herniations of different size, need a different surgical management. The copresence of ''giant'' volume and calcification of the herniated disc heavily affects the surgical difficulty and is not elsewhere described. METHODS: Seven cases of surgically treated giant calcified HTDs were considered in this study. Five of them were females and two males, age range 18-63 years. Before and after surgery, all patients underwent computed tomography myelography, magnetic resonance imaging or both pre-and postoperatively. Functional outcomes were assessed using the Asia grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The mean overall follow-up period was 36 months. All patients presented with various grades of myelopathy: according to the Asia impairment scale, two were grade B, four were grade C and one were grade D. Six patients underwent an anterior approach, i.e. thoracotomy, and one patients underwent a posterolateral approach, i.e. peduncolocostotrasversectomy. RESULTS: Based on an analysis of the long-term follow-up data, the Asia grade improved in five patients (71.4%), stabilized (no grade change) in one (14.3%), and worsened in one (14.3%). CONCLUSIONS: Giant calcified HTDs are particularly challenging surgical lesions and their volume and consistency are additional elements of difficulty. This article presents authors' personal experience on a small but extraordinary series of giant and calcified thoracic herniated discs and the problems encountered in the management of this peculiar pathology since an accurate surgical planning leads to better clinical RESULTS:
Foot drop due to lumbar degenerative conditions: mechanism and prognostic factors in herniated nucleus pulposus and lumbar spinal stenosis.
J Neurosurg Spine. 2009 Mar; 10(3): 260-4Iizuka Y, Iizuka H, Tsutsumi S, Nakagawa Y, Nakajima T, Sorimachi Y, Ara T, Nishinome M, Seki T, Shida K, Takagishi KOBJECT: The aim of this study was to analyze the mechanism and prognostic factors of foot drop caused by lumbar degenerative conditions. METHODS: The authors retrospectively reviewed the charts of 28 patients with foot drop due to a herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS), scoring between 0 and 3 on manual muscle testing for the tibialis anterior muscles. They analyzed the mechanism of foot drop and whether the duration before the operation, preoperative tibialis anterior and extensor hallucis longus strength, age, gender, and diabetes mellitus were all found to be prognostic factors for postoperative tibialis anterior recovery. They also investigated whether the diagnosis had any influence on the prognosis. RESULTS: The compression of double roots and a sequestrated fragment were observed, respectively, in 9 and 13 of 16 patients with HNP. Multiple levels including the L4-5 segment were decompressed in 8 of 12 patients with LSS. Analysis did not demonstrate any prognostic factor in surgically treated HNP, but significant associations with prognosis were observed with respect to preoperative tibialis anterior (p = 0.033) and extensor hallucis longus (p = 0.020) strength in patients with LSS. In addition, the postoperative muscle recovery in patients with HNP was significantly superior to that in patients with LSS (p = 0.011). CONCLUSIONS: Double root compression was the most common condition associated with foot drop due to HNP. The diagnosis and preoperative tibialis anterior and extensor hallucis longus strength in LSS were factors that influenced recovery following an operation.
Ultrastructural analysis on lumbar disc herniation using surgical specimens: role of neovascularization and macrophages in hernias.
Spine. 2009 Apr 1; 34(7): 655-62Kobayashi S, Meir A, Kokubo Y, Uchida K, Takeno K, Miyazaki T, Yayama T, Kubota M, Nomura E, Mwaka E, Baba HSTUDY DESIGN: The mechanisms responsible for the spontaneous regression of lumbar disc herniation (LDH) were studied by examining herniated tissue collected at operation from patients with LDH. OBJECTIVE: The aim of the present study was to investigate the role of neovascularization and macrophages in hernias when spontaneous regression of LDH occurred. SUMMARY OF BACKGROUND DATA: Spontaneous regression of LDHs has already been demonstrated by diagnostic imaging with tools such as magnetic resonance imaging. However, there have been few studies on the mechanisms of spontaneous regression based on pathologic examination of herniated tissue. In particular, there has been no detailed work on the role of macrophages, which are thought to be closely associated with spontaneous regression. METHODS: The magnetic resonance imaging and operative findings of 73 patients who underwent surgery were investigated, and specimens collected during surgery were examined by light and transmission electron microscopy. RESULTS: Capillaries that invade the hernia and macrophages derived from monocytes migrating out of these capillaries are considered to be important factors in the regression of the herniated disc. Macrophages contain lysosomes filled with collagen-degrading enzymes that break down substances after phagocytosis, whereas primary lysosomes are secreted by these cells and break down intercellular substances such as collagen. Both of these mechanisms are closely involved in the regression of herniation. CONCLUSION: The inflammatory response that occurs around hernia tissue in the epidural space is believed to play an important role in herniated disc resorption, although it may also have a harmful effect on the adjacent nerve root. Therefore, control of the inflammatory reaction is an important challenge when treating patients with disc herniation.
Tuesday
Detection of Residual Disc Hernia Material and Confirmation of Nerve Root Decompression at Lumbar Disc Herniation Surgery by Intraoperative Ultrasound.
Ultrasound Med Biol. 2009 Apr 17; Aoyama T, Hida K, Akino M, Yano S, Iwasaki YThe aim of lumbar disc herniation surgery is the removal of herniated disc material (HDM) and complete decompression of the nerve root. As some patients present with residual HDM, we examined the ability of intraoperative ultrasound (IOUS) to detect this material. Between February 2006 and June 2007, we used IOUS in 30 patients undergoing surgery for lumbar disc herniation. They were 17 men and 13 women; their ages ranged from 22 to 63 y (mean 44.0 y). The level surgically addressed was L3/4 in 1, L4/5 in 14 and L5/S1 in 15 patients; they were operated in the prone position. After placing a 3-4 cm midline skin incision, partial hemi-semilaminotomy was performed. HDM was removed through a bone window; a surgical microscope was used during the operation. After removal was judged as adequate, IOUS was performed; 17 patients also underwent IOUS before removal of the herniated disc. For the acquisition of IOUS images, we used LOGIQ 9 and 8c microconvex probes (GE Healthcare, Wauwatosa, WI, USA). The normal anatomical structures were well visualized. HDM was iso- to hyperechoic compared with normal nerve tissue. In three of 17 patients, the dural sac and nerve root could not be distinguished from HDM before removal, although in all 30, the decompressed dural sac, intradural cauda equina and nerve root were well visualized. We posit that the echogenicity of nerve tissue was raised due to compression, rendering it similar to that of the herniated disc. In two patients, IOUS detected residual disc material; the surgical procedure was resumed and sufficient removal was accomplished. IOUS monitoring is safe, convenient and inexpensive. It is also highly useful for the detection of residual HDM and the confirmation of adequate nerve root decompression. (E-mail: taoya@sirius.ocn.ne.jp).
PET imaging in patients with Modic changes.
Nuklearmedizin. 2009 Mar 23; 48(3): Albert H, Pedersen H, Manniche C, Høilund-Carlsen PFThe aim of this study was via PET imaging to reveal if any highly metabolic processes were occurring in Modic changes type 1 and/or in the adjacent discs. Modic changes (MC) are signal changes in the vertebral endplate and body visualised by magnetic resonance imaging (MRI). MC are strongly associated with low back pain (LBP). MC type 1 appear to be inflammation on MRI, and histological and biochemical findings make it highly likely that an inflammation is present. Though MC is painful no known treatment is available, and it is unknown which entities affect the progress or regress of MC. The changes observed on MRI are slow and take months to develop, but faster changes in the metabolism might provide a platform for monitoring patients. Patients, methods: Patients from The Back Centre Funen, with low back pain in the area of L1 to S1, MC type 1 in L1 to L5, and a previous herniated lumbar disc. All patients had a PET scan using FDG (18F-fluorodeoxyglucose) as tracer. Results: Included in the study were 11 patients, 4 women and 7 men, mean age 48.1 year (range 20-65). All MC were situated in the vertebrae both above and below the previously herniated disc/discs. Ten patients had MC at 1 level, and 1 had MC at 2 levels. The affected levels were 1 at L2/L3, 6 at L4 /L5, and 5 at L5/S1. All had a previous disc herniation and MC larger than 4 mm in diameter. Technically satisfactory PET scans were obtained. However, PET imaging showed no increases in metabolism in any vertebra or disc of any patient. Conclusion: Modic type 1 changes do not reveal themselves by showing increased metabolism with ordinary FDG PET imaging. PET tracers illuminating inflammation are being developed and hopefully may become more successful.
A comparison of angled sagittal MRI and conventional MRI in the diagnosis of herniated disc and stenosis in the cervical foramen.
Eur Spine J. 2009 Mar 18; Shim JH, Park CK, Lee JH, Choi JW, Lee DC, Kim DH, Kim JK, Hwang JHThe object of this study is to demonstrate that angled sagittal magnetic resonance imaging (MRI) enables the precise diagnosis of herniated disc and stenosis in the cervical foramen, which is not available with conventional MRI. Due to both the anatomic features of the cervical foramen and the limitations of conventional MR techniques, it has been difficult to identify disease in the lateral aspects of the spinal canal and foramen using only conventional MRI. Angled sagittal MRI oriented perpendicular to the true course of the foramina facilitates the identification of the lateral disease. A review of 43 patients, who underwent anterior cervical discectomy and interbody fusion, is presented with a herniated disc and/or stenosis in the cervical foramen. They all had undergone conventional MRI and angled sagittal MRI. Fifty levels were surgically explored for evidence of foraminal herniated disc and stenosis. The results of each test were correlated with what was found at each explored surgical level. The sensitivity, specificity, and accuracy of both examinations for making the diagnosis of foraminal herniated disc and stenosis were compared. During the diagnosis of foraminal herniated disc, the sensitivity, specificity, and accuracy of angled sagittal MRI were 96.7, 95.0, and 96.0%, respectively, compared with 56.7, 85.0, and 68.0% for conventional MRI. In making the diagnosis of foraminal stenosis, the sensitivity, specificity, and accuracy of angled sagittal MRI were 96.3, 95.7, and 96.0%, respectively, compared with 40.7, 91.3, and 66.0% for conventional MRI. In the above groups, the difference between the tests for making the diagnosis of both foraminal herniated disc and stenosis was found to be statistically significant in sensitivity and accuracy. Angled sagittal MRI was a more accurate test compared to conventional MRI for making the diagnosis of herniated disc and stenosis in the cervical foramen. It can be utilized for the precise diagnosis of foraminal herniated disc and stenosis difficult or ambiguous in conventional MRI.
Monday
Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline.
Spine. 2009 Apr 9; Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JDSTUDY DESIGN.: Systematic review. OBJECTIVE.: To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. SUMMARY OF BACKGROUND DATA.: Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions. METHODS.: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS.: For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms. CONCLUSION.: Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.
A pyogenic discitis at c3-c4 with associated ventral epidural abscess involving c1-c4 after intradiscal oxygen-ozone chemonucleolysis: a case report.
Spine. 2009 Apr 15; 34(8): E298-304Bo W, Longyi C, Jian T, Guangfu H, Hailong F, Weidong L, Haibin TSTUDY DESIGN: A case report and clinical discussion. OBJECTIVE: To describe an unique case of purulent discitis at C3-C4 and an anterior C1-C4 epidural abscess secondary to oxygen-ozone therapy for the herniated cervical discs. SUMMARY OF BACKGROUND DATA: Previously reported complications secondary to ozone therapy are rarely documented. No cases of pyogenic discitis with associated epidural abscess after oxygen-ozone therapy have been reported to date. To our knowledge, this is the first such case reported in literature. METHODS: A 57-year-old female patient with nuchal stiffness was previously treated with ozone therapy at the discs of C3-C4, C4-C5, and C6-C7. Five days later, she presented with an attack of neck pain and fever followed by progressive quadriplegia with sudden onset of dyspnea and was referred to our hospital. On admission, physical examination revealed a temperature of 38.8 degrees C, evident neck tenderness, marked global weakness (grade 1-2/5 MRC) in bilateral upper-limb, and a modest global weakness in bilateral lower-limb (grade 4/5 MRC). Laboratory findings showed a significantly elevated WCC, ESR, and CRP. Blood culture was negative. Enhanced-MR imaging demonstrated a purulent discitis at C3-C4 and a ventral C1-C4 epidural abscess with homogenous enhancement indicative of a solid phlegmonous granulation tissue. RESULTS: We formulated a 3-stage treatment involving C1-C4 multilevel decompressive laminectomies, subtotal unilateral C3-C4 facetectomies, and tissue sampling for culture with application of a corset after surgery, followed by a delayed secondary posterior thorough drainage of epidural liquid pus using a suction-irrigation drainage, after the abscess had turned to a necrotic liquid abscess, on the basis of findings of enhanced-MR imaging, by 10-day duration of intravenously antibiotic therapy tailored to Streptococcus bovis isolated from infected tissue. Over the next few weeks, the patient made an excellent neurologic recovery. However, she did not consent to undergo further occipitocervical fusion until the follow-up MR imaging at 8 months demonstrated postlaminectomy kyphosis. After surgery, the patient remained clinically satisfactory in neurology without evidence of a recurrence of spinal infection. A slight improvement in the cervical spine curve was demonstrated in the follow-up radiograph at nearly 4-month postoccipitocervical fusion. CONCLUSION: This case report illustrates a rare but life-threatening complication of oxygen-ozone therapy for the cervical disc herniation. Infection is a common risk for any invasive spinal techniques involving puncture, so attention should be paid to the sterility during the procedures. A high index of suspicion along with reliance on enhanced-MRI is essential to diagnose the condition and institute appropriate treatment on an individual basis.
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