Terms used for diagnosis by English speaking spine surgeons

Lumbar disc nomenclature: version 2.0: recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology

STUDY DESIGN

This article comprises a review of the literature pertaining to the normal and pathological lumbar disc and the compilation of a standardized nomenclature.

OBJECTIVE

To provide a resource that promotes a clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers.

SUMMARY OF BACKGROUND DATA

The article "Nomenclature and Classification of Lumbar Disc Pathology. Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology and American Society of Neuroradiology" was published in 2001 in Spine © Lippincott, Williams and Wilkins and formally endorsed by the 3 boards. Its purpose, which it served for well over a decade, was to promote greater clarity and consistency of usage of spine terminology. Since 2001, there has been sufficient evolution in our understanding of the lumbar disc to suggest the need for revision and updating. The document represents the consensus recommendations of the current combined task forces and reflects changes consistent with current concepts in radiological and clinical care.

METHODS

A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. It was then reviewed by the governing boards of the American Society of Spine Radiology, the American Society of Neuroradiology, and the North American Spine Society. After further revision based on their feedback, the paper was approved for publication.

RESULTS

The article provides a discussion of the recommended diagnostic categories and a glossary of terms pertaining to the lumbar disc, a detailed discussion of the terms and their recommended usage, as well as updated illustrations and literature references.

CONCLUSION

We have revised and updated a document that, since 2001, has provided a widely accepted nomenclature that helps maintain consistency and accuracy in the description of the properties of the normal and abnormal lumbar discs and that serves as a system for classification and reporting built upon that nomenclature.

[Standardized terminology for disc disease]

This article reviews the terminology used to describe morphological alterations in the intervertebral discs. Radiologists must be able to communicate information about the type, location, and severity of these alterations to medical and surgical clinicians. It is crucial to use simple, standard, and unified terminology to ensure comprehension not only among radiologists but also with professionals from the different specialties for whom the radiology reports are written (fundamentally traumatologists and neurosurgeons). This terminology will help ensure a more accurate diagnosis and better patient management.

A systematic review of the passive straight leg raising test as a diagnostic aid for low back pain (1989 to 2000)

STUDY DESIGN

A systematic review.

OBJECTIVES

This systematic review sought papers (January 1989-January 2000) on the passive straight leg raising test (PSLR) as a diagnostic component for low back pain (LBP) to identify, summarize, and assess developments in the test procedure, the factors influencing PSLR outcome, and the clinical significance of that outcome.

SUMMARY OF BACKGROUND DATA

Previous studies suggested that the PSLR tractioned the sciatic nerve and that diminished leg elevation with reproduced pain indicated low lumbar intervertebral disc pathology.

METHODS

Searches on six computerized bibliographic databases identified publications written about the PSLR. Papers were excluded if they were published before January 1989, were non-English language papers, or employed either an active SLR or a PSLR for purposes other than LBP diagnosis. The references of qualifying papers (and the references of references) were searched. Contact with primary authors, and others known to be active in this field, was attempted.

RESULTS

The PSLR procedure remains unchanged. The influence of hip rotation during the PSLR was discussed without consensus. Biomechanical devices improved intra- and interobserver reliability and so increased test reproducibility. Hamstrings were found to have a defensive role in protecting nerve roots by limiting PSLR range in cases of nerve root inflammation. A small diurnal variation in the PSLR may imply a poorer prognosis. A positive PSLR at 4 months after lumbar intervertebral disc surgery predicted poor reoperative outcome, and a negative 4-month PSLR predicted excellent outcome. The influence of psychosocial factors was not discussed, neither was the diagnostic significance of a negative PSLR outcome.

CONCLUSIONS

There remains no standard PSLR procedure, no consensus on interpretation of results, and little recognition that a negative PSLR test outcome may be of greater diagnostic value than a positive one. The causal link between LBP pathology and hamstring action remains unclear. There is a need for research into the clinical use of the PSLR; its intra- and interobserver reliability; the influences of age, gender, diurnal variation, and psychosocial factors; and its predictive value in lumbar intervertebral disc surgery.

Low back pain

The communication between radiologists and their surgical colleagues is particularly important in the setting of back pain. This common disorder often does not have a definable cause, even when the imaging findings are abnormal. A shared understanding of the various causes of back pain, the appropriate terminology, and the needs of the surgeon is vital to proper patient treatment. Unfortunately, little standardization in the terminology for and management of back pain syndromes exists. This article elucidates the approaches to problems of back pain used in one clinical setting.

Classification, diagnostic imaging, and imaging characterization of a lumbar herniated disk

The absence of universal nomenclature standardization with respect to the definition of a disk herniation and its different categories, especially regarding type and location, is still a major problem that will only be overcome when major national or international scientific societies join efforts to support a particular scheme. Meanwhile, it is important to realize that the two models that are currently most used are based on a different [figure: see text] perspective. Trying to straddle the two by opposing, for instance, bulging disk and herniation is doomed to failure because this exercise defies formal logic. MR imaging is currently the most accurate noninvasive imaging modality to diagnose a disk herniation and to determine its exact location. The determination of some pathoanatomic characteristics of herniated disks (type and composition) may require the use of CT, diskography, or CT diskography.

A survey of the causes of sudden death in sport in the Republic of Ireland

BACKGROUND

Sudden death in sport is rare, but when it occurs the effects are devastating. There have not been any reports to date describing the frequency and causes of sudden death in sport in the Republic of Ireland.

AIM

To describe the incidence, possible causes, associated factors, and pathological findings in people who died while exercising in the Republic of Ireland in the 10 year period from January 1987 to December 1996.

METHODS

All 49 regional coroners in the Republic of Ireland were approached and details on all cases of sudden death in sport from 1 January 1987 to 31 December 1996 were requested. A questionnaire was used to document age, sex, participating sport, previous symptoms, previous medical investigations, circumstances of death, and main pathological finding in all reported cases.

RESULTS

Of the 49 coroners surveyed, 45 replied. A total of 51 cases of sudden death in sport were identified. The median age was 48 (range 15-78). Fifty of the deaths were of men. Golf was the most popular participating sport. In 42 cases, the pathological cause of death was atherosclerotic coronary artery disease.

CONCLUSIONS

This is the first time the incidence of sudden death in sport in the Republic of Ireland has been described. The main cause of death in all age groups was atherosclerotic coronary artery disease.

Magnetic resonance imaging of the musculoskeletal system. Part 8. The spine, section 2

Magnetic resonance imaging has revolutionized the noninvasive evaluation of degenerative disc disease and its complications. Compared with computed tomography and computed tomographic myelography, magnetic resonance allows specific determination of the nature of disc protrusions and other degenerative related soft tissues about the spine. Magnetic resonance offers the most complete evaluation of specific degenerative disorders including degenerative facet disease, spondylolysis, spondylolisthesis, spontaneous lumbar epidural hematomas, and juvenile discogenic disease.

A system for reporting the size and location of lesions in the spine

STUDY DESIGN

A description of a method for standardizing the nomenclature used in reporting the size and location of lesions in the lumbar or thoracic spine is presented.

OBJECTIVES

To make the reporting of findings on computed tomography or magnetic resonance imaging scans simpler and more accurate.

SUMMARY OF BACKGROUND DATA

Over the past 10 years, three other systems have been proposed, and parts of each have been incorporated in this system.

METHODS

This is a multicenter report. A group of 12 prominent physicians, including radiologists, neurosurgeons, orthopedic surgeons, and physiatrists, at 11 centers collaborated in the formulation of this system.

RESULTS

In this system, areas in the axial plane, i.e., medial to lateral, are called "zones," and in the caudocranial direction, they are called "levels." The zones are the central canal zone, the subarticular zone, the foraminal zone, and the extraforaminal zone. In the caudocranial direction, the levels from above downward are the suprapedicle level, the pedicle level, the infrapedicle level, and the disc level. The size of a lesion can be rated by the descriptive words normal, mild, moderate, moderately severe, and severe, or by the numbers 1 to 5, with the number 1 indicating normal and the number 5 indicating severe.

CONCLUSIONS

The authors of the present study believe that all health care professionals who care for the spine will find this nomenclature valuable in communicating with each other, in writing medical reports, in presenting reports at meetings, or in writing scientific articles.

Interreader reliability for a new classification of lumbar disk disease

RATIONALE AND OBJECTIVES

The nomenclature that divides disk herniations into protrusions and extrusions may increase the specificity of magnetic resonance (MR) imaging for clinically important lesions. Our goal was to determine this terminology's interreader reliability.

METHODS

Three readers who were unaware of patients' histories independently read MR images of 34 consecutive patients with back pain. Readers classified disks at the lowest three lumbar levels as normal, bulging, protruded, or extruded. Kappa and weighted kappa values were the primary measures of agreement.

RESULTS

Weighted kappa values showed fair-to-moderate agreement. Kappas for the dichotomous decision of extrusion present or absent were more variable, ranging from 0 to .78. Major disagreements (greater than a single category) occurred with 6.2% of all comparisons and in 10 of 34 volunteers; five involved extrusions.

CONCLUSION

Overall, readers achieved moderate agreement for this new nomenclature. However, agreement for the presence or absence of an extrusion was less reliable.

Commented glossary for rheumatic spinal diseases, based on pathology

OBJECTIVES

To redefine and comment on terms on a pathological basis, in order to avoid the confusion due to the use of terms with different meanings, to standardise usage among clinicians, radiologists and pathologists, and to facilitate literature searches.

METHODS

Within the Committee of Pathology of the European League against Rheumatism, a study group was set up to analyse the medical literature and common practice concerning the nomenclature of rheumatic spinal diseases. The group tried to amalgamate the main trends in the field, to reconcile etymology, historical background, morphology, and common practice.

RESULTS

The group warns against use of the terms 'acquired hyperostosis syndrome', '(von) Bechterew's disease', 'Kümmel's disease', 'pseudospondylolisthesis', 'rheumatoid spondylitis', 'spondylarthropathy' in the sense of spondarthritis, and 'spondylosis'. It recommends intercorporal or interapophyseal rather than intervertebral (osteo) chondrosis, zygapophyseal diverticulum rather than cyst, disc hernia rather than prolapse, spondyloarthritis rather than spondyloarthropathy, marginal rather than anterior spondylitis, and discarthrosis. It proposes 'zygarthrosis' to designate zygapophyseal osteoarthrosis.

CONCLUSIONS

Knowledge of the pathological basis of diseases and an understanding of the original definitions given by those who coined new terms make it possible to avoid most of the confusion arising from improper use of spinal terms.

Anatomy of intervertebral disc and pathophysiology of herniated disc disease

This discussion reviews developments in normal and abnormal disc biology over the past decade. The anatomic and biochemical structure of the disc is reviewed. Emphasis is placed on recent neurochemical changes identified in disc degeneration and disc herniation. Biomechanical considerations for the normal disc are presented. Influence of mechanical factors on disc nutrition, disc degeneration and disc herniation is reviewed. Biologic events underlying the diagnostic methods used in evaluating disorders of the intervertebral disc are presented. The biologic consequences of iatrogenic disc injury in discectomy are also discussed.