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Nișcoveanu C, Refi D, Obada B, Dragosloveanu S, Scheau C, Baz RO. Beyond the Bony Fragment: A Review of Limbus Vertebra. Cureus 2024; 16:e60065. [PMID: 38746486 PMCID: PMC11093693 DOI: 10.7759/cureus.60065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 05/16/2024] Open
Abstract
Vertebral limbus is a condition characterized by the intraspongious herniation of a portion of the nucleus pulposus. It is often asymptomatic, but it can sometimes cause nonspecific symptoms such as local pain and muscle spasm, or, in rare cases, radiculopathies, which is why it can be confused with vertebral fractures, spondyloarthropathies, infectious or tumoral processes. Early recognition of this pathology is preferable for a correct diagnosis and adequate treatment, the latter ranging from conservative approaches (such as personalized exercise programs and physical therapy) to surgical interventions reserved for severe cases with nerve compression.
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Affiliation(s)
- Cosmin Nișcoveanu
- Department of Radiology, Sf. Apostol Andrei County Hospital, Constanta, ROU
- Department of Radiology and Medical Imaging, Faculty of Medicine, Ovidius University, Constanta, ROU
| | - Deria Refi
- Department of Radiology, Sf. Apostol Andrei County Hospital, Constanta, ROU
| | - Bogdan Obada
- Department of Orthopaedics and Traumatology, Sf. Apostol Andrei County Hospital, Constanta, ROU
| | - Serban Dragosloveanu
- Department of Orthopaedics, Foisor Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, Bucharest, ROU
- Department of Orthopaedics and Traumatology, The Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Cristian Scheau
- Department of Radiology and Medical Imaging, Foisor Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, Bucharest, ROU
- Department of Physiology, The Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Radu Octavian Baz
- Department of Radiology, Sf. Apostol Andrei County Hospital, Constanta, ROU
- Department of Radiology and Medical Imaging, Faculty of Medicine, Ovidius University, Constanta, ROU
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Zhang B, Chen P, Zhong J, To MKT, Cheung KMC, Wu J. Percutaneous endoscopic lumbar discectomy in lumbar disc herniation with posterior ring apophysis fracture: A case report in a 15-year-old child. Medicine (Baltimore) 2023; 102:e36213. [PMID: 38206687 PMCID: PMC10754556 DOI: 10.1097/md.0000000000036213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/30/2023] [Indexed: 01/13/2024] Open
Abstract
RATIONALE Lumbar disc herniation (LDH) with posterior ring apophysis fracture (PRAF) is rather rare in children, and in all age-stratified LDH patients, the incidence of RAF was 5.3% to 7.5%. Interestingly, the incidence of LDH with RAF in children (15%-32%) is several times higher than in adults, the mis-diagnosis of which may lead to delayed treatment. PATIENT CONCERNS Here, we report a 15-year-old schoolboy who suffered from sudden low back pain and radiating pain in both lower limbs after sport activities. Symptoms persisted after 3 months of conservative treatment. Computer radiography and magnetic resonance imaging indicated central disc herniation with PRAF at L4-5. DIAGNOSIS LDH with PRAF. INTERVENTIONS The herniated disc and epiphyseal fragments were successfully excised by the percutaneous endoscopic lumbar discectomy minimal-invasive technique. OUTCOMES Surgery was successful. Symptoms were immediately relieved postoperatively with a wound of only about 7.0 mm. Discharged on the next day. No perioperative complications occurred. Moreover, the imaging and clinical outcomes were also more satisfactory during the post-operative 15 months outpatient follow-up. LESSONS Pediatric LDH with PRAF is extremely uncommon, and there is a lack of training among physicians for such cases, which may lead to delayed diagnosis and treatment. Once a diagnosis for LDH with PRAF is established, percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive treatment to be considered, and we hope that this technique can provide more assistance in the future.
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Affiliation(s)
- Baode Zhang
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
| | - Peikai Chen
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
- School of Biomedical Sciences, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jiaquan Zhong
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
| | - Michael Kai-Tsun To
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
- Department of Orthopedics and Traumatology, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Kenneth Man-Chee Cheung
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
- Department of Orthopedics and Traumatology, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jianbin Wu
- Department of Orthopedics and Traumatology, The University of Hong Kong – Shenzhen Hospital (HKU-SZH), Shenzhen, Guangdong, China
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de Reuver S, van der Linden PP, Kruyt MC, Schlösser TPC, Castelein RM. The role of sagittal pelvic morphology in the development of adult degenerative scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2467-2472. [PMID: 34292371 DOI: 10.1007/s00586-021-06924-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/15/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Pelvic morphology dictates the alignment and biomechanics of the spine. Recent observations in different types of adolescent idiopathic scoliosis indicate that individual pelvic morphology is related to the spinal levels in which scoliosis develops: primary lumbar adolescent scoliosis is associated with a higher pelvic incidence (PI) than thoracic scoliosis and non-scoliotic controls. We hypothesize that adult degenerative scoliosis (ADS) of the lumbar spine follows the same mechanical principles and is associated with a high PI. METHODS This study used an existing CT-scan database, 101 ADS patients were sex and age matched to 101 controls. The PI was measured by two observers with multi-planar reconstruction, perpendicular to the hip-axis according to a previously validated technique. RESULTS The PI was 54.1° ± 10.8° in ADS patients and 47.7° ± 10.8° in non-scoliotic controls (p < 0.001). The median ADS curve apex was the disc L2-3 and median curve length was 4 vertebral levels. The mean supine Cobb angle was 21° ± 8° (ranged 10°-47°). There was no significant correlation between PI and the apex level (p = 0.883), the curve length (p = 0.418) or the Cobb angle (p = 0.518). CONCLUSIONS ADS normally develops de novo in the lumbar spine of patients with a higher PI than controls, similar to primary lumbar adolescent idiopathic scoliosis. This suggests a shared mechanical basis of both deformities. Pelvic morphology dictates spinal sagittal alignment, which determines the segments of the spine that are prone to develop scoliosis.
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Affiliation(s)
- Steven de Reuver
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Philip P van der Linden
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Moyo C Kruyt
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Tom P C Schlösser
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - René M Castelein
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Ossification and Fusion of the Vertebral Ring Apophysis as an Important Part of Spinal Maturation. J Clin Med 2021; 10:jcm10153217. [PMID: 34362001 PMCID: PMC8347734 DOI: 10.3390/jcm10153217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/22/2022] Open
Abstract
In scoliosis, most of the deformity is in the disc and occurs during the period of rapid growth. The ring apophyses form the insertion of the disc into the vertebral body, they then ossify and fuse to the vertebrae during that same crucial period. Although this must have important implications for the mechanical properties of the spine, relatively little is known of how this process takes place. This study describes the maturation pattern of the ring apophyses in the thoracic and lumbar spine during normal growth. High-resolution CT scans of the spine for indications not related to this study were included. Ossification and fusion of each ring apophysis from T1 to the sacrum was classified on midsagittal and midcoronal images (4 points per ring) by two observers. The ring apophysis maturation (RAM) was compared between different ages, sexes, and spinal levels. The RAM strongly correlated with age (R = 0.892, p < 0.001). Maturation differed in different regions of the spine and between sexes. High thoracic and low lumbar levels fused earlier in both groups, but, around the peak of the growth spurt, in girls the mid-thoracic levels were less mature than in boys, which may have implications for the development of scoliosis.
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Gavira N, Amelot A, Cook AR, Hamel A, Buffenoir K, Cristini J. Thoracolumbar spinal fracture in children: Conservative or surgical treatment? Neurochirurgie 2021; 68:309-314. [PMID: 34246661 DOI: 10.1016/j.neuchi.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Spinal thoracolumbar fractures represent 10-14% of pediatric fractures. Most children concerned by such fractures are above 10 years of age. No guidelines presently exist. Analysis of spine pathophysiology and of the various common therapeutic attitudes led us to conduct a review of the different therapeutic approaches in pediatric thoracolumbar fracture. METHODS A review of the literature was carried out using the Medline and Embase databases with the search-term "pediatric thoracic lumbar spine fractures". RESULTS The systematic review identified 44 studies, 24 of which were selected, and 19 were included for analysis. Physiological age was categorized on Risser's classification. In Risser 1 with Magerl A1 fracture, surgical treatment was not necessary and functional (rest and analgesics) or conservative treatment (bracing for 6 weeks) was sufficient. In Risser 1 with Magerl A2, A3 or B fracture, conservative treatment (bracing for 3 months) was the first-line option. In Risser 2-4, conservative treatment with bracing for 3 months was possible in the absence of instability, with kyphosis>20° and canal compression>33%; otherwise, treatment should be surgical. Subsequently, in case of onset of secondary instability, surgical treatment can be proposed. We highlight the importance of MRI assessment for diagnosis of thoracolumbar fracture and associated lesions of the intervertebral discs and posterior ligament complex. Children classified as Risser 5 can undergo the same treatment as adults. CONCLUSION Two main parameters should be assessed in treatment decision-making for thoracolumbar fracture: the Risser scale and the Magerl classification.
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Affiliation(s)
- N Gavira
- Department of Pediatric Orthopaedic Surgery, CHU Hotel-Dieu, Nantes, France
| | - A Amelot
- Department of Neurosurgery, CHU Hotel-Dieu, Nantes, France; Department of Neurosurgery, CHU Bretonneau, 2, Boulevard de Tonnelle, 37000 Tours, France.
| | - A-R Cook
- Department of Neurosurgery, CHU Bretonneau, 2, Boulevard de Tonnelle, 37000 Tours, France
| | - A Hamel
- Department of Pediatric Orthopaedic Surgery, CHU Hotel-Dieu, Nantes, France
| | - K Buffenoir
- Department of Neurosurgery, CHU Hotel-Dieu, Nantes, France
| | - J Cristini
- Department of Neurosurgery, CHU Hotel-Dieu, Nantes, France
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Alagheband SJ, Clapp AD, Narducci DM, Cudahy R, Pujalte G. Limbus Vertebra. Cureus 2021; 13:e13954. [PMID: 33880290 PMCID: PMC8051534 DOI: 10.7759/cureus.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Athletes in their teenage years can present to clinics with back pain, without any history of trauma. Many sports require repetitive spinal extension, which may be pertinent to the evaluation of back pain as a chief complaint. Musculoskeletal and neurologic examinations are crucial in the evaluation of athletes presenting with back pain. Most back pain cases are caused by benign conditions that resolve with conservative treatment. However, radiographic imaging may be appropriate to look for possible spondylolysis in teenage athletes who perform repetitive extension in their sports, and who present with a positive stork test on examination. Limbus vertebra is a condition that can be seen in asymptomatic patients but can also be associated with back pain. Nevertheless, a conservative approach is still appropriate in these cases, with escalation to further testing or imaging only considered for recalcitrant pain. Limbus vertebra is not well known by clinicians and can be misdiagnosed. Therefore, early recognition is crucial to potentially prevent an unnecessary cascade of increasing expenses related to time, effort, medications, and resources to find the diagnosis when conservative treatment is preferred.
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Affiliation(s)
| | | | - Dusty M Narducci
- Department of Family Medicine, University of South Florida, Tampa, USA
| | - Ryan Cudahy
- Department of Family Medicine and Sports Medicine, Dignity Health Medical Group, San Francisco, USA
| | - George Pujalte
- Department of Family Medicine, Mayo Clinic, Jacksonville, USA
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Oichi T, Taniguchi Y, Oshima Y, Tanaka S, Saito T. Pathomechanism of intervertebral disc degeneration. JOR Spine 2020; 3:e1076. [PMID: 32211588 PMCID: PMC7084053 DOI: 10.1002/jsp2.1076] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 12/13/2022] Open
Abstract
Intervertebral disc degeneration (IDD) is the main contributor to low back pain, which is a leading cause of disability worldwide. Although substantial progress has been made in elucidating the molecular mechanisms of IDD, fundamental and long-lasting treatments for IDD are still lacking. With increased understanding of the complex pathomechanism of IDD, alternative strategies for treating IDD can be discovered. A brief overview of the prevalence and epidemiologic risk factors of IDD is provided in this review, followed by the descriptions of anatomic, cellular, and molecular structure of the intervertebral disc as well as the molecular pathophysiology of IDD. Finally, the recent findings of intervertebral disc progenitors are reviewed and the future perspectives are discussed.
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Affiliation(s)
- Takeshi Oichi
- Sensory & Motor System Medicine, Faculty of MedicineThe University of TokyoBunkyo‐kuTokyoJapan
- Department of Orthopedic SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
| | - Yuki Taniguchi
- Sensory & Motor System Medicine, Faculty of MedicineThe University of TokyoBunkyo‐kuTokyoJapan
| | - Yasushi Oshima
- Sensory & Motor System Medicine, Faculty of MedicineThe University of TokyoBunkyo‐kuTokyoJapan
| | - Sakae Tanaka
- Sensory & Motor System Medicine, Faculty of MedicineThe University of TokyoBunkyo‐kuTokyoJapan
| | - Taku Saito
- Sensory & Motor System Medicine, Faculty of MedicineThe University of TokyoBunkyo‐kuTokyoJapan
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8
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Peng C, Zhou C, Zhu K, Zhang H, Tu Q, Ma X, Liu L. Percutaneous Full Endoscopic Management of Lumbar Posterior Edge Separation in Adolescents. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 159:181-186. [PMID: 31830771 DOI: 10.1055/a-1039-1830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Lumbar posterior edge separation is a common disorder with lumbar disc herniation (LDH) in adolescents. Over the years, there has been a lack of an acknowledged assessment and plan. The purpose of this study was to elucidate the feasibility of all sufferers who have received percutaneous full endoscopic treatment for lumbar posterior edge separation in adolescents. METHODS Case series of sufferers with lumbar posterior edge separation who underwent surgery in the Affiliated Hospital Qingdao University between February 2017 and December 2018 were reviewed, including 15 males and 9 females. Preoperative and postoperative visual analogue scale (VAS) scores and the Korean Version of the Oswestry disability index (K-ODI) scores were used to evaluate the clinical outcomes. RESULTS All sufferers were followed up for 6 to 12 months, with an average time of 10.7 months. The postoperative VAS scores of low back pain and leg pain and ODIs were significantly different from the preoperative scores (p < 0.05). According to the modified Mac Nab criteria, the results were excellent in 17 cases and good in 7 cases. CONCLUSIONS Percutaneous full endoscopic treatment can effectively achieve neurological functional recovery in sufferers with favorable efficacy and safety.
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Affiliation(s)
- Chen Peng
- Qingdao University, Qingdao University, Qingdao, China
| | - Chuanli Zhou
- Qingdao University, Qingdao University, Qingdao, China
| | - Kai Zhu
- Qingdao University, Qingdao University, Qingdao, China
| | - Hao Zhang
- Qingdao University, Qingdao University, Qingdao, China
| | - Qihao Tu
- Qingdao University, Qingdao University, Qingdao, China
| | - Xuexiao Ma
- Department of Spine Surgery, Affiliated Hospital of Medical College Qingdao University, Qingdao, Cocos (Keeling) Islands
| | - Lei Liu
- Qingdao University, Qingdao University, Qingdao, China
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9
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Swärd Aminoff A, Agnvall C, Todd C, Jónasson P, Sansone M, Thoreson O, Swärd L, Karlsson J, Baranto A. The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes. Open Access J Sports Med 2018; 9:147-156. [PMID: 30123011 PMCID: PMC6084081 DOI: 10.2147/oajsm.s162675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Current knowledge of the effect of changes in posture and the way cam morphology of the hip joint may affect hip range of motion (ROM) is limited. Purpose To determine the effect of changes in pelvic tilt (PT) on hip ROM and with/without the presence of cam. Study design This was a cross-sectional study. Materials and methods The hip ROM of 87 subjects (n=61 young elite skiers, n=26 nonathletes) was examined using a goniometer, in three different seated postures (flexed, neutral, and extended). The hips of the subjects were further subgrouped into cam and no-cam morphology, based on the magnetic resonance imaging findings in the hips. Results There was a significant correlation between the hip ROM and the seated posture in both extended and flexed postures compared with the neutral posture. There was a significant decrease in internal hip rotation when the subjects sat with an extended posture with maximum anterior PT (p<0.0001). There was a significant increase in internal hip rotation when the subjects sat with a flexed posture with maximum posterior PT (p<0.001). External rotation was significantly decreased in an extended posture with maximum anterior PT (p<0.0001), but there was no difference in flexed posture with maximum posterior PT. The hips with cam morphology had reduced internal hip rotation in all three positions, but they responded to the changes in position in a similar manner to hips without cam morphology. Conclusion Dynamic changes in PT significantly influence hip ROM in young people, independent of cam or no-cam morphology.
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Affiliation(s)
- Anna Swärd Aminoff
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Cecilia Agnvall
- Sports Medicine Åre, Åre, Sweden.,Åre Ski Academy, Åre, Sweden
| | - Carl Todd
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | | | - Mikael Sansone
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Olof Thoreson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Leif Swärd
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Adad Baranto
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
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Rider SM, Mizuno S, Kang JD. Molecular Mechanisms of Intervertebral Disc Degeneration. Spine Surg Relat Res 2018; 3:1-11. [PMID: 31435545 PMCID: PMC6690117 DOI: 10.22603/ssrr.2017-0095] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/24/2018] [Indexed: 12/25/2022] Open
Abstract
Intervertebral disc degeneration is a well-known cause of disability, the result of which includes neck and back pain with associated mobility limitations. The purpose of this article is to provide an overview of the known molecular mechanisms through which intervertebral disc degeneration occurs as a result of complex interactions of exogenous and endogenous stressors. This review will focus on some of the identified molecular changes leading to the deterioration of the extracellular matrix of both the annulus fibrosus and nucleus pulposus. In addition, we will provide a summation of our current knowledge supporting the role of associated DNA and intracellular damage, cellular senescence's catabolic effects, oxidative stress, and the cell's inappropriate response to damage in contributing to intervertebral disc degeneration. Our current understanding of the molecular mechanisms through which intervertebral disc degeneration occurs provides us with abundant insight into how physical and chemical changes exacerbate the degenerative process of the entire spine. Furthermore, we will describe some of the related molecular targets and therapies that may contribute to intervertebral repair and regeneration.
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Affiliation(s)
- Sean M Rider
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shuichi Mizuno
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Kang
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Study of lesions of the lumbar endplate based on the stage of maturation of the lumbar vertebral body: the relationship between skeletal maturity and chronological age. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:183-187. [DOI: 10.1007/s00590-017-2032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
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12
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A Rare Case of Progressive Palsy of the Lower Leg Caused by a Huge Lumbar Posterior Endplate Lesion after Recurrent Disc Herniation. Case Rep Orthop 2016; 2016:5963924. [PMID: 27648326 PMCID: PMC5018346 DOI: 10.1155/2016/5963924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 11/21/2022] Open
Abstract
A lesion of the lumbar posterior endplate is sometimes identified in the spinal canal of children and adolescents; it causes symptoms similar to those of a herniated disc. However, the pathology of the endplate lesion and the pathology of the herniated disc are different. We present a rare case of a 23-year-old woman who developed progressive palsy of the lower leg caused by huge lumbar posterior endplate lesion after recurrent disc herniation.
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13
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Rodrigues SA, Thambyah A, Broom ND. How maturity influences annulus-endplate integration in the ovine intervertebral disc: a micro- and ultra-structural study. J Anat 2016; 230:152-164. [PMID: 27535364 DOI: 10.1111/joa.12536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2016] [Indexed: 01/08/2023] Open
Abstract
The annulus-endplate anchorage system plays a vital role in structurally linking the compliant disc to its adjacent much more rigid vertebrae. Past literature has identified the endplate as a region of weakness, not just in the mature spine but also in the immature spine. The aim of this structural study was to investigate in detail the morphological changes associated with annulus-endplate integration through different stages of maturity. Ovine lumbar motion segments were collected from two immature age groups: (i) newborn and (ii) spring lamb (roughly 3 months old); these were compared with a third group of previously analysed mature ewe samples (3-5 years). Sections from the posterior region of each motion segment were obtained for microstructural analysis and imaged in their fully hydrated state via differential interference contrast (DIC) optical microscopy. Selected slices were further prepared and imaged via scanning electron microscopy (SEM) to analyse fibril-level modes of integration. Despite significant changes in endplate morphology, the annular fibre bundles in all three age groups displayed a similar branching mechanism, with the main bundle splitting into several sub-bundles on entering the cartilaginous endplate. This morphology, previously described in the mature ovine disc, is thought to strengthen significantly annulus-endplate integration. Its prevalence from an age as young as birth emphasizes the critical role that it plays in the anchorage system. The structure of the branched sub-bundles and their integration with the surrounding matrix were found to vary with age due to changes in the cartilaginous and vertebral components of the endplate. Microscopically, the sub-bundles in both immature age groups appeared to fade into the surrounding tissue due to their fibril-level integration with the cartilaginous endplate tissue, this mechanism being particularly complex in the spring lamb disc. However, in the fully mature disc, the sub-bundles remained as separate entities throughout the full depth of their anchorage into the cartilaginous endplate. Cell morphology was also found to vary with maturity within the cartilaginous matrix and it is proposed that this relates to endplate development and ossification.
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Affiliation(s)
- Samantha A Rodrigues
- Experimental Tissue Mechanics Laboratory, Department of Chemical and Materials Engineering, The University of Auckland, Auckland, New Zealand
| | - Ashvin Thambyah
- Experimental Tissue Mechanics Laboratory, Department of Chemical and Materials Engineering, The University of Auckland, Auckland, New Zealand
| | - Neil D Broom
- Experimental Tissue Mechanics Laboratory, Department of Chemical and Materials Engineering, The University of Auckland, Auckland, New Zealand
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14
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Vo NV, Hartman RA, Patil PR, Risbud MV, Kletsas D, Iatridis JC, Hoyland JA, Le Maitre CL, Sowa GA, Kang JD. Molecular mechanisms of biological aging in intervertebral discs. J Orthop Res 2016; 34:1289-306. [PMID: 26890203 PMCID: PMC4988945 DOI: 10.1002/jor.23195] [Citation(s) in RCA: 240] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/03/2016] [Indexed: 02/04/2023]
Abstract
Advanced age is the greatest risk factor for the majority of human ailments, including spine-related chronic disability and back pain, which stem from age-associated intervertebral disc degeneration (IDD). Given the rapid global rise in the aging population, understanding the biology of intervertebral disc aging in order to develop effective therapeutic interventions to combat the adverse effects of aging on disc health is now imperative. Fortunately, recent advances in aging research have begun to shed light on the basic biological process of aging. Here we review some of these insights and organize the complex process of disc aging into three different phases to guide research efforts to understand the biology of disc aging. The objective of this review is to provide an overview of the current knowledge and the recent progress made to elucidate specific molecular mechanisms underlying disc aging. In particular, studies over the last few years have uncovered cellular senescence and genomic instability as important drivers of disc aging. Supporting evidence comes from DNA repair-deficient animal models that show increased disc cellular senescence and accelerated disc aging. Additionally, stress-induced senescent cells have now been well documented to secrete catabolic factors, which can negatively impact the physiology of neighboring cells and ECM. These along with other molecular drivers of aging are reviewed in depth to shed crucial insights into the underlying mechanisms of age-related disc degeneration. We also highlight molecular targets for novel therapies and emerging candidate therapeutics that may mitigate age-associated IDD. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1289-1306, 2016.
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Affiliation(s)
- Nam V. Vo
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert A. Hartman
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Prashanti R. Patil
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Makarand V. Risbud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dimitris Kletsas
- Laboratory of Cell Proliferation and Ageing, Institute of Biosciences and Applications, National Centre for Scientific Research “Demokritos”, Athens, Greece
| | - James C. Iatridis
- Leni & Peter W May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Judith A. Hoyland
- Centre for Tissue Injury and Repair, Faculty of Medical and Human Sciences, University of Manchester M13 9PT and NIHR Manchester Musculoskeletal Biomedical Research Unit, Manchester Academic Health Science Centre, Manchester, UK
| | - Christine L. Le Maitre
- Musculoskeletal and Regenerative Medicine Research Group, Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, S1 1WB, UK
| | - Gwendolyn A. Sowa
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James D. Kang
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Schroeder GD, Guyre CA, Vaccaro AR. The epidemiology and pathophysiology of lumbar disc herniations. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.semss.2015.08.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kim P, Kim SW, Ju CI, Kim HS. Lumbar Disc Herniation Combined with Posterior Apophyseal Ring Separation in a Young Child: A Case Report. KOREAN JOURNAL OF SPINE 2015; 12:143-5. [PMID: 26512269 PMCID: PMC4623169 DOI: 10.14245/kjs.2015.12.3.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/15/2015] [Accepted: 06/17/2015] [Indexed: 11/19/2022]
Abstract
Lumbar disc herniation in children aged 10 years or less is extremely uncommon and posterior apophyseal ring separation is not a common injury that usually occurs in adolescents or young adults after a sports-related microtraumatism. The authors report an unique case of 10-year-old boy who presented with low back pain and radiating pain on both legs. The boy received conservative treatment, which included anti-inflammatory medication, muscle relaxants, and physical therapy, but symptoms were not improved. Computed tomography and magnetic resonance imaging revealed a huge central disc herniation combined with posterior apophyseal ring separation. Microscopic lumbar discectomy with the removal of apophyseal ring separation was performed due to the intractable pain. At six months after surgery, the child was symptom free.
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Affiliation(s)
- Pius Kim
- Department of Neurosurgery, Chosun University College of Medicine, Gwangju, Korea
| | - Seok Won Kim
- Department of Neurosurgery, Chosun University College of Medicine, Gwangju, Korea
| | - Chang Il Ju
- Department of Neurosurgery, Chosun University College of Medicine, Gwangju, Korea
| | - Hyeun Sung Kim
- Department of Neurosurgery, Sun Han Hospital, Gwangju, Korea
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Vo N, Niedernhofer LJ, Nasto LA, Jacobs L, Robbins PD, Kang J, Evans CH. An overview of underlying causes and animal models for the study of age-related degenerative disorders of the spine and synovial joints. J Orthop Res 2013; 31:831-7. [PMID: 23483579 PMCID: PMC3628921 DOI: 10.1002/jor.22204] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 07/10/2012] [Indexed: 02/04/2023]
Abstract
As human lifespan increases so does the incidence of age-associated degenerative joint diseases, resulting in significant negative socioeconomic consequences. Osteoarthritis (OA) and intervertebral disc degeneration (IDD) are the most common underlying causes of joint-related chronic disability and debilitating pain in the elderly. Current treatment methods are generally not effective and involve either symptomatic relief with non-steroidal anti-inflammatory drugs and physical therapy or surgery when conservative treatments fail. The limitation in treatment options is due to our incomplete knowledge of the molecular mechanism of degeneration of articular cartilage and disc tissue. Basic understanding of the age-related changes in joint tissue is thus needed to combat the adverse effects of aging on joint health. Aging is caused at least in part by time-dependent accumulation of damaged organelles and macromolecules, leading to cell death and senescence and the eventual loss of multipotent stem cells and tissue regenerative capacity. Studies over the past decades have uncovered a number of important molecular and cellular changes in joint tissues with age. However, the precise causes of damage, cellular targets of damage, and cellular responses to damage remain poorly understood. The objectives of this review are to provide an overview of the current knowledge about the sources of endogenous and exogenous damaging agents and how they contribute to age-dependent degenerative joint disease, and highlight animal models of accelerated aging that could potentially be useful for identifying causes of and therapies for degenerative joint diseases.
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Affiliation(s)
- Nam Vo
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA,Ferguson Laboratory for Orthopaedic Research, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219
| | - Laura J. Niedernhofer
- Department of Microbiology and Molecular Genetics, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219,University of Pittsburgh Cancer Institute, Hillman Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15213-1863, U.S.A
| | - Luigi Aurelio Nasto
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA,Ferguson Laboratory for Orthopaedic Research, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219
| | - Lloydine Jacobs
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA,Ferguson Laboratory for Orthopaedic Research, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219
| | - Paul D. Robbins
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA,Department of Microbiology and Molecular Genetics, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219,University of Pittsburgh Cancer Institute, Hillman Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15213-1863, U.S.A
| | - James Kang
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA,Ferguson Laboratory for Orthopaedic Research, 523 Bridgeside Point II. 450 Technology Drive, Pittsburgh, PA 15219
| | - Christopher H. Evans
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, RN-115, Boston, MA 02215, USA
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Bae JS, Rhee WT, Kim WJ, Ha SI, Lim JH, Jang IT. Clinical and radiologic analysis of posterior apophyseal ring separation associated with lumbar disc herniation. J Korean Neurosurg Soc 2013; 53:145-9. [PMID: 23634263 PMCID: PMC3638266 DOI: 10.3340/jkns.2013.53.3.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 12/27/2012] [Accepted: 02/25/2013] [Indexed: 12/02/2022] Open
Abstract
Objective We analyzed the clinical and radiologic features of posterior apophyseal ring separation (PARS) with lumbar disc herniation and suggest the proper management options according to the PARS characteristics. Methods We reviewed case series of patients with PARS who underwent surgery of lumbar disc herniation. Preoperative symptoms, neurologic status, Body Mass Index, preoperative and postoperative Visual Analogue Scale (VAS) and Korean-Oswestry Disability Index (K-ODI) scores, operation types were obtained. PARS size, locations, the degree of resection were assessed. Results PARS was diagnosed in 109 (7.5%) patients among 1448 patients given surgical treatment for single level lumbar disc herniation. There were 55 (50.5%) small PARS and 54 (49.5%) large PARS. Among the large PARS group, 15 (27.8%) had lower endplate PARS of upper vertebra at the level of disc herniation. Thirty-nine (72.2%) were upper endplate PARS of lower vertebra. Among the group with upper endplate PARS of lower vertebra, unresected PARS was diagnosed in 12 (30.8%) cases and resected PARS was diagnosed in 27 (69.2%) cases. VAS and K-ODI scores changes were 3.6±2.9 and 5.4±6.4 in the unresected PARS group, 5.8±2.1 and 11.3±7.1 in the resected PARS group. The group with upper endplate PARS of lower vertebra showed significant difference of VAS (p=0.01) and K-ODI (p=0.013) score changes between unresected and resected PARS groups. Conclusion The large PARS of upper endplate in lower vertebra should be removed during the surgery of lumbar disc herniation. High level or bilateral side of PARS should be widely decompressed and arthrodesis procedures are necessary if there is a possibility of secondary instability.
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Affiliation(s)
- Jung-Sik Bae
- Department of Neurosurgery, Nanoori Hospital, Seoul, Korea
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Nasto LA, Wang D, Robinson AR, Clauson CL, Ngo K, Dong Q, Roughley P, Epperly M, Huq SM, Pola E, Sowa G, Robbins PD, Kang J, Niedernhofer LJ, Vo NV. Genotoxic stress accelerates age-associated degenerative changes in intervertebral discs. Mech Ageing Dev 2012; 134:35-42. [PMID: 23262094 DOI: 10.1016/j.mad.2012.11.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 11/19/2012] [Accepted: 11/24/2012] [Indexed: 01/09/2023]
Abstract
Intervertebral disc degeneration (IDD) is the leading cause of debilitating spinal disorders such as chronic lower back pain. Aging is the greatest risk factor for IDD. Previously, we demonstrated IDD in a murine model of a progeroid syndrome caused by reduced expression of a key DNA repair enzyme. This led us to hypothesize that DNA damage promotes IDD. To test our hypothesis, we chronically exposed adult wild-type (Wt) and DNA repair-deficient Ercc1(-/Δ) mice to the cancer therapeutic agent mechlorethamine (MEC) or ionization radiation (IR) to induce DNA damage and measured the impact on disc structure. Proteoglycan, a major structural matrix constituent of the disc, was reduced 3-5× in the discs of MEC- and IR-exposed animals compared to untreated controls. Expression of the protease ADAMTS4 and aggrecan proteolytic fragments was significantly increased. Additionally, new PG synthesis was reduced 2-3× in MEC- and IR-treated discs compared to untreated controls. Both cellular senescence and apoptosis were increased in discs of treated animals. The effects were more severe in the DNA repair-deficient Ercc1(-/Δ) mice than in Wt littermates. Local irradiation of the vertebra in Wt mice elicited a similar reduction in PG. These data demonstrate that genotoxic stress drives degenerative changes associated with IDD.
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Affiliation(s)
- Luigi A Nasto
- Ferguson Laboratory for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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Sakai DS, Tomlinson LA, Dormans JP. Distraction Phenomenon After Lengthening of Spinal Growing Rods: A Case Report. JBJS Case Connect 2012; 2:e45. [PMID: 29252543 DOI: 10.2106/jbjs.cc.l.00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Denis S Sakai
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, 2nd Floor, Wood Building, Philadelphia, PA 19104. . .
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21
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Huang PY, Yeh LR, Tzeng WS, Tsai MY, Shih TTF, Pan HB, Chen CKH. Imaging features of posterior limbus vertebrae. Clin Imaging 2012; 36:797-802. [PMID: 23154012 DOI: 10.1016/j.clinimag.2012.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 01/24/2012] [Indexed: 10/28/2022]
Abstract
Posterior limbus vertebra (PLV) is the retropulsion of the vertebral ring apophysis resulting from disc herniation through posterior ring physis. Large PLV can cause spinal stenosis, and small PLV can be mistaken as intraspinal disc herniation. Although the clinical presentations were similar, the surgery was quite different. We had experienced preoperative misdiagnosed cases and the surgery could not be finished. Therefore we analyzed the imaging features of PLV in 34 patients in order to prompt appropriate preoperative diagnosis and surgical planning.
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Affiliation(s)
- Pei-Yu Huang
- Department of Radiology, Fenglin Veterans Hospital, Taiwan.
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Higashino K, Sairyo K, Katoh S, Takao S, Kosaka H, Yasui N. Long-term outcomes of lumbar posterior apophyseal end-plate lesions in children and adolescents. J Bone Joint Surg Am 2012; 94:e74. [PMID: 22637214 DOI: 10.2106/jbjs.k.00343] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A lesion of the lumbar posterior apophyseal end plate in children and adolescents causes symptoms similar to those associated with a herniated disc. However, the end-plate lesion and the herniated disc differ in terms of pathology. The purpose of this study was to clarify the long-term clinical and radiographic outcomes in children and adolescents who were treated either surgically or conservatively for a lumbar posterior apophyseal end-plate lesion. METHODS We identified twenty-four consecutive patients who had been treated in the sports clinic of our hospital. The mean age at the first medical examination was 14.5 years. The mean follow-up time was 13.8 years. The mean age at the time of final follow-up was 28.4 years. All twenty-four patients had symptomatic low back pain with sciatica. All but two were active in sports. Sixteen patients were treated conservatively, and eight patients underwent surgical intervention. Skeletal maturity was evaluated on the basis of the appearance of the secondary ossification center of L3. RESULTS The apophyseal stage ("A" stage), which was assigned when the secondary ossification center of the vertebral body was visible on radiographs, was seen most frequently. Both the surgically treated group and the conservatively treated group demonstrated progressive disc degeneration at the involved level. The average Roland-Morris Disability Questionnaire (RDQ) score was 1.3 for the patients treated conservatively and 1.8 for those treated surgically, a nonsignificant difference. One patient developed spinal stenosis after twelve years of conservative treatment. One patient treated surgically demonstrated severe lumbar instability. There were no significant associations between the magnetic resonance imaging (MRI) findings and RDQ scores. Histological examination of surgical specimens showed irregular alignment of the anulus fibrosus, with degenerative matrix and chondrocytes without a nucleus. CONCLUSIONS The long-term outcome for patients with a posterior end-plate lesion is favorable, regardless of whether it is treated surgically or nonsurgically.
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Affiliation(s)
- Kosaku Higashino
- Department of Orthopedics, University of Tokushima, Graduate School, Institute of Health Biosciences, 3-18-15 Kuramoto, Tokushima 770-8503, Japan.
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Akhaddar A, Belfquih H, Oukabli M, Boucetta M. Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases. J Neurosurg Spine 2011; 14:475-83. [PMID: 21294611 DOI: 10.3171/2010.11.spine10392] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The association of posterior ring apophysis separation (PRAS) with lumbar disc herniation (LDH) is uncommon and represents a true subgroup of disc herniation mainly seen in the adolescent population. The objective of this study was to describe a decade of experience in the care of adult patients with PRAS with LDH, giving particular attention to its diagnosis, surgical treatment, and outcome. METHODS This retrospective study focuses on a case series of adult patients with PRAS associated with LDH who underwent surgery for lumbar disc disease in the author's neurosurgical department between 1999 and 2008. Posterior ring apophysis separation was diagnosed in 87 (5.35%) of 1625 patients surgically treated for LDH; these patients made up the PRAS group. During a 6-month period in 2005, LDH without PRAS was diagnosed in 89 consecutive patients at the same facility; these patients constituted the control group. Presenting symptoms, physical examination findings, and preoperative imaging results were obtained from medical records. Immediate operative results were assessed, as were complications, long-term outcome, and the need for repeat surgery. RESULTS This study is the first to document the distinguishing features between adult patients with and those without PRAS. The difference in average age was statistically significant (p < 0.001) between the study group (36.22 years) and the control group (44.30 years), as was the incidence of male patients (86.20% vs 71.91%, p = 0.020), incidence of military patients (74.71% vs 57.30%, p = 0.015), average duration of symptoms (16.13 vs 8.4 months, p = 0.016), and incidence of reactive scoliosis (19.54% vs 4.49%, p = 0.002). The most common anatomical location of disc herniation in the PRAS group was L5-S1 (51.72%) versus L4-L5 (53.93%) in the control group (p = 0.017). In terms of previous injury, motor deficits, back and/or leg pain, lateral or central location of LDH, mean anteroposterior diameter of disc herniation, hard or soft discs, and surgical complications, there was no statistical difference between the 2 patient groups. Similarly, there was no difference in recurrence rates and clinical outcomes between the patients with or without PRAS. CONCLUSIONS Posterior ring apophysis separation with LDH is probably more common in adults than is generally recognized. It must be suspected when young male patients with persistent sciatic scoliosis and no history of injury show signs of calcified LDH. Computed tomography scanning with sagittal reconstructions is the procedure of choice for diagnosing. The L5-S1 intervertebral disc level is most commonly affected, especially the superior endplate of S-1. This condition needs more extensive surgical exposure and resection to relieve the nerve impingement. The occurrence of an apophyseal lesion was not associated with recurrent disc herniation or a fair outcome.
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Affiliation(s)
- Ali Akhaddar
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V Souissi University, Rabat, Morocco.
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Comparison of the immature sheep spine and the growing human spine: a spondylometric database for growth modulating research. Spine (Phila Pa 1976) 2010; 35:E1262-72. [PMID: 20938392 DOI: 10.1097/brs.0b013e3181e24196] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A comparative study on growth of the sheep and human spine. OBJECTIVE To validate the immature sheep spine as model for the growing human spine and to yield a database for planning and interpretation of future animal experiments. SUMMARY OF BACKGROUND DATA With the current change of paradigm to nonfusion strategies for pediatric spine deformities, experimental surgery on spines of growing goats, sheep, and pigs has gained importance as preclinical proof-of-concept test. However, despite the proceeding use of animals, there is a lack of knowledge regarding the growth of the sheep spine and the relation to the human spine. METHODS Thoracic and lumbar cadaver spines were harvested from 50 Swiss alpine sheep. Specimens were obtained from newborn, 1, 3, 6, 9 and 12, 15 and 18 months old female sheep. Direct spondylometry yielded vertebral body heights, widths, and depths and spinal canal size, which were compared to pooled data on human spine growth retrieved from the literature. RESULTS Sheep spine growth ceases at age 15 to 18 months, which corresponds to a time-lapse model of human growth. Main growth occurs within the first 3 to 6 months of life, as opposed to human spines with maximal growth during the first 4 years and puberty. The relation between sheep and human vertebral shape is continuously changing with growth: at birth, sheep vertebrae are twice as tall, but equally wide and deep. At skeletal maturity, height is 15% to 25% bigger in sheep, but width 15% to 30% and depth 30% to 50% are smaller. CONCLUSION The immature sheep spine offers fast effects if growth-modulating interventions are performed within the first 3 to 6 months of age. The differences in vertebral shapes and further distinctions between human and sheep spines such as biomechanics, facet anatomy, and rib cage morphology have to be considered when interpreting results after experimental surgery.
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Roberts S, Evans H, Trivedi J, Menage J. Histology and pathology of the human intervertebral disc. J Bone Joint Surg Am 2006; 88 Suppl 2:10-4. [PMID: 16595436 DOI: 10.2106/jbjs.f.00019] [Citation(s) in RCA: 385] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The intervertebral disc is a highly organized matrix laid down by relatively few cells in a specific manner. The central gelatinous nucleus pulposus is contained within the more collagenous anulus fibrosus laterally and the cartilage end plates inferiorly and superiorly. The anulus consists of concentric rings or lamellae, with fibers in the outer lamellae continuing into the longitudinal ligaments and vertebral bodies. This arrangement allows the discs to facilitate movement and flexibility within what would be an otherwise rigid spine. At birth, the human disc has some vascular supply within both the cartilage end plates and the anulus fibrosus, but these vessels soon recede, leaving the disc with little direct blood supply in the healthy adult. With increasing age, water is lost from the matrix, and the proteoglycan content also changes and diminishes. The disc-particularly the nucleus-becomes less gelatinous and more fibrous, and cracks and fissures eventually form. More blood vessels begin to grow into the disc from the outer areas of the anulus. There is an increase in cell proliferation and formation of cell clusters as well as an increase in cell death. The cartilage end plate undergoes thinning, altered cell density, formation of fissures, and sclerosis of the subchondral bone. These changes are similar to those seen in degenerative disc disease, causing discussion as to whether aging and degeneration are separate processes or the same process occurring over a different timescale. Additional disorders involving the intervertebral disc can demonstrate other changes in morphology. Discs from patients with spinal deformities such as scoliosis have ectopic calcification in the cartilage end plate and sometimes in the disc itself. Cells in these discs and cells from patients with spondylolisthesis have been found to have very long cell processes. Cells in herniated discs appear to have a higher degree of cellular senescence than cells in nonherniated discs and produce a greater abundance of matrix metalloproteinases. The role that abnormalities play in the etiopathogenesis of different disorders is not always clear. Disorders may be caused by a genetic predisposition or a tissue response to an insult or altered mechanical environment. Whatever the initial cause, a change in the morphology of the tissue is likely to alter the physiologic and mechanical functioning of the tissue.
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Affiliation(s)
- Sally Roberts
- Centre for Spinal Studies, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, Shropshire SY10 7AG, United Kingdom.
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26
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Wang X, Dumas GA. Evaluation of effects of selected factors on inter-vertebral fusion—a simulation study. Med Eng Phys 2005; 27:197-207. [PMID: 15694602 DOI: 10.1016/j.medengphy.2004.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Revised: 09/06/2004] [Accepted: 10/12/2004] [Indexed: 11/26/2022]
Abstract
This study simulated the effects of inter-vertebral disc degeneration and bone density distribution on the structural stiffness and strength provided by inter-vertebral fusion. Based on the original and redistributed bone density distributions, the effects of selected factors, including contact area between device/graft and vertebral endplates, endplate conditions, and bone growth capacity were evaluated using a factorial design of experiment. The simulation results suggested that the degeneration of inter-vertebral disc significantly affected the bone density and density distribution in adjacent vertebrae. The mechanical strength immediately after instrumentation is the worst case of device/graft subsidence. After that procedure, bone will adapt itself to the changed loading conditions and therefore reduce the risk of subsidence. A deficiency in structural stiffness immediately after instrumentation could be the "worst-case scenario" depending on the combinations of selected factors. The simulation results demonstrated that the contact area and initial bone density distribution should be considered jointly while estimating the risk of device/graft subsidence. The endplate condition is a secondary factor on the subsidence risk, compared with the contact area and initial bone density distribution.
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Affiliation(s)
- Xiaobo Wang
- Department of Mechanical Engineering Queen's University, Kingston, Ont., Canada K7L 3N6.
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Abstract
BACKGROUND CONTEXT Although it has been well documented that slippage in patients with spondylolysis is most prevalent during the growth period, the exact time when slippage initiates and halts during the growth period is still unknown. Moreover, the contribution of spinal deformities, such as wedging of the vertebral body to the slippage, remains controversial. PURPOSE To clarify when slippage in pediatric spondylolysis initiates and halts. STUDY DESIGN Retrospective study. PATIENT SAMPLE We radiographically examined 46 athletes under 18 years of age with spondylolysis at the fifth lumbar vertebra (L5). The mean age at the first consultation was 13.3 years. The average follow-up period was 6.0 years. OUTCOME MEASURES Longitudinal observation of slippage at L5 on radiogram in correlation with the maturity of the lumbar spine. METHODS From a lateral radiogram of each patient, percent slippage, lumbar index (LI), and skeletal age of the affected vertebra were measured. Changes in the percent slippage over time were investigated, and the correlation between the percent slippage and LI was analyzed. RESULTS From the cartilaginous stage to the apophyseal stage, the slippage increased in 80.0% of the patients (16 of 20). From the cartilaginous stage to the epiphyseal stage, slippage increased in 11.1% of the patients (3 of 27). None of the patients (0 of 22) showed an increase after the epiphyseal stage. In 20 patients in whom slippage increased during the follow-up period, the percent slippage at the final consultation and the LI at the first consultation showed no significant correlation; however, the percent slippage and the LI at the final consultation were significantly (p<.01) correlated. CONCLUSION In conclusion, slippage was more prevalent in individuals of a younger skeletal age whose lumbar spine was immature, and it halted during the epiphyseal stage when the growth period was over and the vertebra matured. Furthermore, the results suggest that wedge deformity of an affected vertebra might be the result rather than the cause of slippage.
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Affiliation(s)
- K Sairyo
- Department of Orthopedic Surgery, The University of Tokushima, 3-8-15, Kuramoto-cho, Tokushima 770-8502, Japan
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Edwards WT, Zheng Y, Ferrara LA, Yuan HA. Structural features and thickness of the vertebral cortex in the thoracolumbar spine. Spine (Phila Pa 1976) 2001; 26:218-25. [PMID: 11154545 DOI: 10.1097/00007632-200101150-00019] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The thickness and structure of the vertebral body cortex were examined from sections of human cadaveric vertebrae. OBJECTIVES The objectives were to identify the principal structural features of the cortex, to directly measure the minimum and maximum thicknesses of the cortex in the thoracolumbar spine, and to compare regional variations in the structure of the cortex. SUMMARY OF BACKGROUND DATA The thickness of the vertebral cortical shell contributes to the compressive strength of the vertebral body. There is little consensus concerning the thickness and morphology of vertebral shell and endplate along the spine in existing data. METHODS Human T1, T5, T9, L1, and L5 vertebral bodies (mean age 70.4 years) from 20 cadaveric spines were sectioned and photographed. The minimum and maximum cortical thickness of the shells and endplates in the midsagittal plane were measured from magnified images. RESULTS The anterior shell thickness was significantly greater than the posterior shell and both endplates. Endplate thickness was greatest in the lower lumbar vertebrae. There was a significant decrease in cortex thickness over the central portion of endplates and shells, with a mean minimum thickness of 0.40 mm and a mean maximum thickness of 0.86 mm, with an overall mean of 0.64 +/- 0.41 mm. Increased porosity was also observed along the central regions of the cortical shells. In the lower thoracic and lumbar spine, a double-layered endplate structure was observed. CONCLUSIONS Invasive techniques provide the only means to directly resolve the thickness and distribution of bone in the vertebral cortex. The cortex thickness and structure varies along the endplates and the anterior and posterior surfaces of the vertebral body. The implications of the so called double-layered endplate structure are unknown, but indicate the need for further study.
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Affiliation(s)
- W T Edwards
- Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University, Syracuse, New York 13210, USA.
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Steffen T, Tsantrizos A, Aebi M. Effect of implant design and endplate preparation on the compressive strength of interbody fusion constructs. Spine (Phila Pa 1976) 2000; 25:1077-84. [PMID: 10788851 DOI: 10.1097/00007632-200005010-00007] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A human cadaveric study on the compressive strength of different lumbar interbody fusion implants and endplate preparation techniques was performed. OBJECTIVES To assess the axial compressive strength of an implant with peripheral endplate contact as opposed to full surface contact, and to assess whether removal of the central bony endplate affects the axial compressive strength. SUMMARY OF BACKGROUND DATA The compressive strength of interbody fusion constructs has been compared between implants and bone grafts. Neither implant design nor endplate preparation has been shown to affect strength. Removal of the central bony endplate for bone grafts was noted to improve graft incorporation but also to facilitate subsidence. METHODS A total of 44 vertebrae were tested in four experimental groups by combining two interbody implants (full-surface vs peripheral surface support) with two endplate preparation techniques (intact bony endplate vs removal of the central bony endplate). Specimens were tested to ultimate compressive failure using a 50 N/second ramped load. Yield strength and ultimate compressive strength were compared between groups using two-factor analysis of covariance. A P value less than 0.05 was considered significant. Stepwise linear regressions assessed the predictive power of age, bone mineral content, and the implant's normalized endplate coverage on yield strength and ultimate compressive strength. RESULTS Neither implant design nor endplate preparation technique affected yield strength or ultimate compressive strength. Age, bone mineral content, and the normalized endplate coverage were strong predictors of yield strength (P < 0. 0001; r2 = 0.459) and ultimate compressive strength (P < 0.0001; r2 = 0.510). CONCLUSIONS An implant with only peripheral support resting on the apophyseal ring offers axial mechanical strength similar to that of an implant with full support. Neither supplementary struts nor a solid implant face has any additional mechanical advantage, but reduces graft-host contact area. Removal of the central bony endplate is recommended because it does not affect the compressive strength and promotes graft incorporation.
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Affiliation(s)
- T Steffen
- Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, Canada
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Kasai T, Ikata T, Katoh S, Miyake R, Tsubo M. Growth of the cervical spine with special reference to its lordosis and mobility. Spine (Phila Pa 1976) 1996; 21:2067-73. [PMID: 8893429 DOI: 10.1097/00007632-199609150-00003] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN The cervical spine of the healthy Japanese children aged between 1 year and 18 years was radiographically examined. OBJECTIVES To examine the correlation between growth of the cervical vertebral body and the facet joint and the development of the cervical lordosis and intervertebral motion. SUMMARY OF BACKGROUND DATA Although the growth of body height and facet angle have been well documented, their correlation with curvature or mobility has not been elucidated. METHODS We evaluated plain lateral radiographs of 180 boys and 180 girls regarding diameters and central heights of the cervical vertebra, the anterior and posterior vertebral height ratio, body height index, the facet joint angles, and tilting and sliding motions. Cervical length as the summation of the central height from C3 to C7 and the cervical lordosis angle (C3-C7 angle) were also measured. RESULTS The mean C3-C7 angle and body height index gradually decreased until 9 years of age and then increased. The C3-C7 angle showed a significant correlation with cervical length, body height index, and facet joint angles before 9 years of age, and with cervical length and body height index after 9 years of age but not with facet joint angles. Facet joint angle decreased until 10 years of age and remained almost unchanged thereafter. Total sliding showed a significant age-related decrease and showed a significant correlation with facet joint angle. CONCLUSION Although the lordosis angle showed a significant correlation with the other values, cervical length, body height index, and facet joint angle, the determinants of the lordosis could not be elucidate in the present study. As for the mobility of the cervical spine, changes of tilting motion were small, whereas changes of sliding motion were restricted by the change of orientation of the facet joints.
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Affiliation(s)
- T Kasai
- Department of Orthopedic Surgery, School of Medicine, University of Tokushima, Japan
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Oxland TR, Panjabi MM, Southern EP, Duranceau JS. An anatomic basis for spinal instability: a porcine trauma model. J Orthop Res 1991; 9:452-62. [PMID: 2010850 DOI: 10.1002/jor.1100090318] [Citation(s) in RCA: 123] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To determine the anatomic basis for spinal instabilities, 16 porcine cervical spine specimens were subjected to a well-defined sagittal plane trauma. The multidirectional instability of each specimen was measured before and after trauma. Detailed anatomic dissections were performed on each traumatized specimen to quantitate the extent of injury to several distinct anatomic structures and columns. Multiple regression models were constructed to determine which anatomic structures and columns correlated best with each multidirectional instability. Flexion instability correlated best with injury to the interspinous/supraspinous ligaments and the ligamentum flavum. Extension instability correlated best with anterior longitudinal ligament and pedicle injury. Axial rotation instability correlated best with anterior disc-end-plate and capsular ligament injuries, while lateral bending instability correlated best with posterior disc-end-plate injuries. Anterior column injuries correlated best with extension, axial rotation, and lateral bending instabilities, while posterior column injuries correlated best with flexion instability. Finally, individual anatomic structural injuries had higher correlations with multidirectional instabilities than did the injuries defined by the anatomic columns.
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Affiliation(s)
- T R Oxland
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut 06510
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Albeck MJ, Madsen FF, Wagner A, Gjerris F. Fracture of the lumbar vertebral ring apophysis imitating disc herniation. Acta Neurochir (Wien) 1991; 113:52-6. [PMID: 1799144 DOI: 10.1007/bf01402115] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Three cases of fracture of the lumbar ring apophysis representing type I, II, and III are described in detail and the natural history of these fractures is discussed. The symptoms of apophyseal fractures are usually low back pain, sciatica, tension signs, and neurological deficits, thus imitating the symptoms of lumbar disc herniation. Plain radiography and magnetic resonance are often inconclusive and computed tomography is essential for the true diagnosis. An explanation of the different types of fractures, based on the osteogenesis of the human vertebra, is proposed. Recognition of these fractures is essential for proper planing of surgery, and apophyseal ring fractures must be suspected when children and young adults show signs of lumbar disc herniation.
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Affiliation(s)
- M J Albeck
- University Clinic of Neurosurgery, Copenhagen, Denmark
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Anderson SJ. Assessment and Management of the Pediatric and Adolescent Patient with Low Back Pain. Phys Med Rehabil Clin N Am 1991. [DOI: 10.1016/s1047-9651(18)30734-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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