Forestier's syndrome : a rare cause of dysphagia. A case report and review of the literature

We report a 72-year-old male with Forestier's syndrome suffering of dysphagia due to an anterior cervical calcification, unusually great in both volume and extent. Its resection by anterior approach allowed the immediate restoration of a normal swallowing. A bony resection is sufficient in case of Forestier's syndrome, but it must be associated with fixation in case of degenerative osteophyte with disc instability. Long-term follow-up is necessary because the recurrence of the calcification is slow but frequent.

Relationship between spinal osteoarthritis and vertebral fractures in men older than 50 years: data from the Camargo Cohort Study

Spinal osteoarthritis has been suggested as a risk factor for vertebral fractures. However, results are conflicting: most of the data are focused on the lumbar region, and referred to postmenopausal women, whereas data for men are scarce. The aim of this study is to assess the relationship between spinal osteoarthritis and vertebral fractures in men over 50 years of age. We conducted a cross-sectional study, nested in a prospective population-based cohort, including 507 community-dwelling men, 93 of them with at least one vertebral fracture. Vertebral fractures, osteophytosis, and disc space narrowing (DSN) were assessed by lateral thoracic and lumbar radiographs. Anthropometric, clinical, and densitometric variables were also analyzed. A multiple logistic regression model was performed. Eighty-five percent of vertebral fractures were located at the thoracic spine. Osteophytosis and DSN showed a bimodal distribution, with major frequency peaks at mid- and distal lumbar spine. The three distributions overlapped around the T9 vertebra. We did not find any relationship between lumbar osteoarthritis and vertebral fractures. Nevertheless, thoracic osteophytosis (OR, 1.84; 95 % CI, 1.05-3.17; p = 0.03) and DSN (OR, 2.52; 95 % CI, 1.43-4.46; p = 0.001) were found to be independently associated with prevalent vertebral fractures, after adjusting for confounders. Our results suggest a positive relationship between radiologic osteoarthritic changes at the thoracic spine and prevalent vertebral fractures in men more than 50 years of age. Osteoarthritis may act as a local risk factor, in addition to other mechanical factors, resulting in a greater propensity to fracture, especially at the mid-thoracic region.

[Ocular ochronosis. A case report]

Ochronosis or alkaptonuria is a rare inherited disease. It is characterized by the deposition of dark pigments in collagen-rich tissues, which leads to clinical manifestations such as arthropathy. The ochronotic pigment can be found in the sclera, the conjunctiva, and the limbic cornea. Vision is usually not affected. We report the case of 47-year-old patient who complained of lower back pain. Ophthalmologic examination showed dark pigments in the conjunctiva. The increased levels of homogentisic acid in urine confirmed the diagnosis of ochronosis.

[Clinical observation to adjacent-segment disease after anterior cervical discectomy and fusion]

OBJECTIVE

To probe the etiopathogenisis of adjacent-segment disease by analyzing the imageology data and clinical neurological function in patients with anterior cervical discectomy and fusion (ACDF) harvested by long-term follow-up.

METHODS

A retrospective study was performed on 52 patients who had undergone ACDF with perfect documents from January 1990 to April 2003. Of the patients, 45 were males and 7 were females with a mean age of 48.5 years (range from 25 to 72 years). There was the fusion of 10 one-levels, 38 two-levels and 4 three-levels. The cervical anterior-posterior and lateral X-ray, CT and MRI examination were performed before the operation. Clinical neurological function was recorded by the Nurick score, and this score at 6 weeks after the operation was compared with the later follow-up. In the radiological examination, the motion of adjacent vertebrae and osteophyte formation were reviewed on X-ray and CT, and were converted to the semi-quantitative degeneration score according to the Goffin method. The correlation between Nurick score or degeneration score and the age at operation or fusion levels was compared by Spearman correlation coefficients. The cervical canal sizes of adjacent level and remote level on MRI were reviewed and compared with each other by t test.

RESULTS

The follow-up period was 3 to 10 years, 6.9 years on average. There was difference in the Nurick score between the 6th week after operation (1.07 +/- 0.84) and the later follow up (1.92 +/- 1.28) by rank test (P < 0.05). There was no correlation between the Nurick score change and the age at operation (r = 0.21, P > 0.05) or fused levels(r = 0.30, P > 0.05) by Spearman correlation coefficients. There was obvious difference in degeneration score between the 6th week after operation (0.73 +/- 0.67) and the later follow up (1.58 +/- 1.06), (P < 0.01). There was no correlation between the degeneration score change and the age at operation (r = 0.35, P > 0.05) or fusion levels (r = 0.38, P > 0.05) by Spearman correlation coefficients. The cervical canal size reductions were (1.7 +/- 1.1) mm at superior adjacent level, (1.2 +/- 0.6) mm at inferior adjacent level and (0.30 +/- 0.68) mm at remote level. There was obvious difference between superior or inferior and remote level by t test (P < 0.01). The adjacent level developed prominent degeneration together with nerve function change after the fusion operation and displayed correlation between degeneration and nerve function change(r = 0.41, P < 0.05).

CONCLUSION

The adjacent-segment disease after interbody fusion is produced by multiple factors. The natural progression in adjacent disc, biomechanical natural change resulting from interbody fusion, destruction to ligament structure in front of cervical vertebrae by operation, and bone graft model are important factors not to be ignored.

Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management

Degenerative changes in the cervical spinal column are ubiquitous in the adult population, but infrequently symptomatic. The evaluation of patients with symptoms is facilitated by classifying the resulting clinical syndromes into axial neck pain, cervical radiculopathy, cervical myelopathy, or a combination of these conditions. Although most patients with axial neck pain, cervical radiculopathy, or mild cervical myelopathy respond well to initial nonsurgical treatment, those who continue to have symptoms or patients with clinically evident myelopathy are candidates for surgical intervention.

[Surgical treatment of cervical spondylotic amyotrophy]

OBJECTIVE

To investigate the clinical characteristics and treatment of cervical spondylotic amyotrophy.

METHODS

9 cervical spondylotic amyotrophy patients and 15 cervical radiculopathy, myelopathy spondylosis patients were included in this study. Their clinical manifestation, MRI image results and treatment were analysis. Of 9 cervical spondylotic amyotrophy patients, 7 cases were done with cervical discectomy, 2 cases were done with combined cervical anterior and posterior operation; of 15 radiculopathy, myelopathy spondylosis patients, 12 cases were done with cervical discectomy, 3 cases were done with combined cervical anterior and posterior operation.

RESULTS

Cervical spondylotic amyotrophy patients were followed up 6-36 months, muscle power of 9 patients were improved markedly, muscle power of 6 patients were improved from grade II preoperation to grade IV-V postoperation after operation 6 months, relief rate is 75%-100%, that of 2 patients were improved from grade III preoperation to grade IV-V postoperation, relief rate is 50% and 100% respectively, that of 1 patient (multiple segments) were improved from grade I preoperation to grade III postoperation, relief rate is 50%; 8 patients were followed up over 12 months, muscle power of 7 patients were improved to grade V, relief rate is 100%, that of 1 patient were improved to grade IV, relief rate is 80%. Cervical radiculopathy, myelopathy spondylosis patients were followed up 12-36 months, muscle power of 15 patients were improved respectively, muscle power of 15 patients were improved from grade II-IV preoperation to grade III-V postoperation after operation 6 months, relief rate is 20%-100%, all 15 patients were followed up over 12 months, muscle power of 11 patients were improved to grade V, relief rate is 100%, that of 3 patient were improved to grade IV, relief rate is 20%-50%, that of 1 case keep unchanged.

CONCLUSION

Cervical spondylotic amyotrophy is a rare type of cervical spondylotic disorder, it is easily misdiagnosed because it is confused with motor neuron disease. MRI and electromyography can help to diagnose. The mechanism of cervical spondylotic amyotrophy maybe is that compression of anterior horn of spinal cord or ischemic injury of spinal cord. Surgical treatment can help to improve muscle power, prognosis of single segment is better than that of multiple segments.

4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

In the future, there will be an increased number of cervical revision surgeries, including 4- and more-levels. But, there is a paucity of literature concerning the geometrical and clinical outcome in these challenging reconstructions. To contribute to current knowledge, we want to share our experience with 4- and 5-level anterior cervical fusions in 26 cases in sight of a critical review of literature. At index procedure, almost 50% of our patients had previous cervical surgeries performed. Besides failed prior surgeries, indications included degenerative multilevel instability and spondylotic myelopathy with cervical kyphosis. An average of 4.1 levels was instrumented and fused using constrained (26.9%) and non-constrained (73.1%) screw-plate systems. At all, four patients had 3-level corpectomies, and three had additional posterior stabilization and fusion. Mean age of patients at index procedure was 54 years with a mean follow-up intervall of 30.9 months. Preoperative lordosis C2-7 was 6.5 degrees in average, which measured a mean of 15.6 degrees at last follow-up. Postoperative lordosis at fusion block was 14.4 degrees in average, and 13.6 degrees at last follow-up. In 34.6% of patients some kind of postoperative change in construct geometry was observed, but without any catastrophic construct failure. There were two delayed unions, but finally union rate was 100% without any need for the Halo device. Eleven patients (42.3%) showed an excellent outcome, twelve good (46.2%), one fair (3.8%), and two poor (7.7%). The study demonstrated that anterior-only instrumentations following segmental decompressions or use of the hybrid technique with discontinuous corpectomies can avoid the need for posterior supplemental surgery in 4- and 5-level surgeries. However, also the review of literature shows that decreased construct rigidity following more than 2-level corpectomies can demand 360 degrees instrumentation and fusion. Concerning construct rigidity and radiolographic course, constrained plates did better than non-constrained ones. The discussion of our results are accompanied by a detailed review of literature, shedding light on the biomechanical challenges in multilevel cervical procedures and suggests conclusions.

Osteoporosis in a postpolio clinic population

OBJECTIVES

To determine (1) the frequency of osteoporosis at the hip and lumbar spine in a postpolio clinic population and (2) the association of lower-extremity muscle strength and other potential contributing factors to osteoporosis with bone density measured at the hip.

DESIGN

Cross-sectional study involving a chart review.

SETTING

A university-affiliated hospital postpolio clinic.

PARTICIPANTS

Patient charts (N=379) were reviewed; 164 (26%) were included, and 215 (74%) were not included primarily (74%) because of the unavailability of bone density results.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Bone density (in g/cm(2)) and T score were assessed at the femoral neck and lumbar spine. Muscle strength was evaluated by manual muscle testing in 7 bilateral lower-extremity muscles.

RESULTS

The occurrence of osteoporosis at the hip and lumbar spine was 20 (32%) of 62 and 6 (10%) of 61 in men, 3 (9%) of 33 and 2 (6%) of 32 in premenopausal women, and 18 (27%) of 67 and 7 (11%) of 65 in postmenopausal women, respectively. In a logistic regression model, the presence of osteoporosis at the hip was significantly associated with strength sum score in the same extremity in which the bone density was performed after adjusting for other important risk factors (age, body mass index, time since polio).

CONCLUSIONS

Osteoporosis occurred commonly at the hip in a postpolio clinic population. Hip bone density was associated with muscle strength in the same lower extremity.

Is there any relationship between proinflammatory mediator levels in disc material and myelopathy with cervical disc herniation and spondylosis? A non-randomized, prospective clinical study

The proinflammatory mediator (PIM) levels were assessed in surgically removed samples of herniated cervical intervertebral discs. The objective of this study was to investigate if there is a correlation between the levels of PIMs in disc material and myelopathy associated with cervical intervertebral disc herniation and spondylosis. The role of proinflammatory mediators in the degeneration of intervertebral disc and the inflammatory effects of disc herniations on radicular pain has been previously published. However, the possible relationship between PIMs and myelopathy related to cervical disc herniation and spondylosis has not been investigated before. Thirty-two patients undergoing surgery for cervical disc herniation and spondylosis were investigated. Surgically obtained disc materials, stored at 70 degrees C, were classified into two groups: cervical disc herniation alone or with myelopathy. Biochemical preparation and solid phase enzyme amplified sensitivity immunoassay (ELISIA) analysis of the samples were performed to assess the concentration of mediators in the samples. Very similar values of interleukin-6 were found in both groups whereas the concentrations of mediators were significantly higher in myelopathy group. This study has demonstrated that PIMs are involved in cervical intervertebral disc degeneration with higher concentrations in the samples associated with myelopathy.

[Non-infective inflammations of the vertebral spine]

Non-infective inflammations of the vertebral spine can be caused by seronegative spondylarthropathies or rheumatoid arthritis, respectively. Seronegative spondylarthropathies include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with inflammatory bowel diseases and undifferentiated arthritis. This review discusses etiology and pathogenesis, epidemiology, clinical features, diagnosis and differential diagnoses of these chronic inflammatory diseases with a special focus on vertebral involvement.

Segmental motion adjacent to anterior cervical arthrodesis: a prospective study

STUDY DESIGN

Prospective, observational study.

OBJECTIVE

The present study describes in a prospective setting the kinematics changes occurring at segments adjacent to a one-level cervical arthrodesis.

SUMMARY OF BACKGROUND DATA

The development of adjacent segment disease has been noticed by many clinicians. Whether symptoms develop due to fusion induced accelerated spondylosis or due to a natural development in a predisposed person is currently under debate. The motivation for introducing motion preservation procedures in the neck is primarily to protect the patients from developing symptomatic adjacent disc disease. To accept this rationale, it has to be demonstrated that a fusion creates an unfavorable biomechanical situation at adjacent levels.

METHODS

Forty-six patients underwent standard anterior cervical decompression and fusion using a cylindrical cage implant. Lateral radiographic views of the cervical spine in flexion and extension were obtained before surgery, and at 12 months of follow-up. Employing Distortion Compensated Roentgen Analysis, rotational and translational motion at adjacent levels was quantified prospectively.

RESULTS

Rotational and translational motion at adjacent cranial and caudal levels did not exhibit a significant change between the preoperative state and the state 12 months after the operation.

CONCLUSION

The assumption of an iatrogenically caused increased mobility by a one-level cervical fusion could not be confirmed 12 months after surgery.

Bony flexion-distraction injury of the lower lumbar spine treated with instrumentation without fusion and early implant removal: a method of treatment to preserve lumbar motion: two-year follow-up of a teenage patient

Most single level bony flexion-distraction injuries can be treated in a brace. Internal fixation is required, however, when a patient fails brace treatment. Instrumentation is routinely left in place for a year or more and in an unfused spine can lead to early degenerative changes of the facets and disks. Implant removal once healing has occurred can preserve motion segments in the lumbar spine and offer an advantage in a young patient over instrumentation and fusion. A case report is presented of a 17-year-old female treated successfully with internal fixation without fusion of a bony flexion-distraction injury of the lower lumbar spine with early implant removal and 2-year follow-up.

CERVICAL SPONDYLOSIS ANATOMY

CERVICAL SPONDYLOSIS IS the most common progressive disorder in the aging cervical spine. It results from the process of degeneration of the intervertebral discs and facet joints of the cervical spine. Biomechanically, the disc and the facets are the connecting structures between the vertebrae for the transmission of external forces. They also facilitate cervical spine mobility. Symptoms related to myelopathy and radiculopathy are caused by the formation of osteophytes, which compromise the diameter of the spinal canal. This compromise may also be partially developmental. The developmental process, together with the degenerative process, may cause mechanical pressure on the spinal cord at one or multiple levels. This pressure may produce direct neurological damage or ischemic changes and, thus, lead to spinal cord disturbances. A thorough understanding of the biomechanics, the pathology, the clinical presentation, the radiological evaluation, as well as the surgical indications of cervical spondylosis, is essential for the management of patients with cervical spondylosis.

ANTERIOR CERVICAL APPROACH FOR THE TREATMENT OF CERVICAL MYELOPATHY

COMPRESSION OF THE spinal cord by the degenerating cervical spine tends to lead to progressive clinical symptoms over a variable period of time. Surgical decompression can stop this process and lead to recovery of function. The choice of surgical technique depends on what is causing the compression of the spinal cord. This article reviews the symptoms and assessment for cervical spondylotic myelopathy (clinically evident compression of the spinal cord) and discusses the indications for decompression of the spinal cord anteriorly.

[Spondylarthrosis etiopathogenesis]

Spinal pain syndrome is a fast growing "pandemic" disease in highly civilised communities. Dealing with the etiopathogenesis of its most popular cause--spondylarthrosis--requires the knowledge of anatomy and physiology of the spine, and the explanation of biomechanic phenomena occurring in it. Many theories explaining the progress of spondylarthrosis are based on the assumption that the primary reason for pathology is degeneration of intervertebral discs, caused mainly by forced changes of spatial geometry of the spine; namely prolonged sitting or carrying weights in a bent position. The work presents Kapandji's hypothesis, attractive, among others, for its simplicity; explaining pathological mechanisms occurring within intervertebral disc. The hypothesis has also been advanced that the initiator of the process are degenerative changes in intervertebral joints, resulting from the so - called muscle dysbalance. They may occur earlier and only secondarily lead to disorders within the disc. The dynamics of progress of the disease varies, and the progression of pathological disorders is connected with the above - mentioned improper motor activity; first of all with the cumulation of effects of microtraumas, resulting from excessive sitting and bending, which may considerably accelerate this process, especially in patients genetically predisposed. In the work the progress of pathological process was presented from the stage of primary changes in nucleus pulposus to the phase of advanced adaptive--compensatory productive reactions in developed spondylosis.

Cervicogenic headache. Smith/Robinson approach in bilateral cases

The aim was to follow the postoperative fate of cervicogenic headache (CEH) patients with a hard-to-treat, bilateral headache, operated upon by the Smith/Robinson procedure, a stabilization and decompression operation in the cervical spine. CEH is a typically unilateral headache, but in this study, bilateral cases were deliberately selected (n=28). The patients were, otherwise, diagnosed according to the Cervicogenic Headache International Study Group (CHISG) CEH criteria. In most cases, the discs C(4-5), C(5-6) and C(6-7) were affected, and one or two discs were removed by anterior approach; an interbody fusion was carried out. Immediately postoperatively - up to 2-3 months - there was pain freedom. Secondary deterioration was reported to us in 10 patients, in nine of whom it occurred within three years. The remaining 18 patients were followed up for 2-100 months; the mean duration of improvement was 22.7 months. Bilateral, Smith/Robinson operated CEH patients seemed to fare as well as unilateral ones.

Cervical intervertebral disc degeneration induced by unbalanced dynamic and static forces: a novel in vivo rat model

STUDY DESIGN

Establishment of a novel in vivo animal model of cervical spondylosis.

OBJECTIVE

To investigate apoptotic, degenerative, and inflammatory changes occurring in the cervical intervertebral discs of rats.

SUMMARY OF BACKGROUND DATA

Cervical degeneration occurs as the result of imbalance of both static and dynamic spinal stabilizers. The disc degeneration that occurs is characterized by increased local inflammation and increased apoptosis of intervertebral disc cells.

METHODS

By excising the paraspinal musculature and posterior cervical spinal ligaments of rats, both static and dynamic cervical stabilizers were disrupted. The resultant biomechanical imbalance resulted in biochemical and histologic changes, which were characterized by light microscopy, electron microscopy, immunostaining, enzyme-linked immunosorbent assay, polymerase chain reaction, and in situ hybridization.

RESULTS

Histologic analysis showed characteristic degenerative changes of the intervertebral discs and vertebral endplates following surgery. Ultrastructural examination revealed apoptotic changes, which were verified by immunostaining. Instability also resulted in significant up-regulation of inflammatory factors, as shown by enzyme-linked immunosorbent assay, polymerase chain reaction, and in situ hybridization.

CONCLUSIONS

By creating static and dynamic posterior instability of the cervical spine, this novel model of cervical spondylosis results in rapid intervertebral disc degeneration characterized by increased apoptosis and local inflammation, such as that seen clinically.

[Evaluation on clinical therapeutic effect of needle-knife therapy on cervical spondylosis]

OBJECTIVE

To compare therapeutic effects of needle-knife therapy and acupuncture on cervical spondylosis.

METHODS

Multi-central clinical randomized controlled trial was adopted. The patients were divided into a needle-knife treatment group treated with needle-knife therapy at the upper and lower interspinal ligaments of the affected vertebral body and bilateral posterior joint capsules; and the acupuncture control group were treated with acupuncture at Laozhen, Ashi points and cervical Jiaji points, etc. The short-term and the long-term therapeutic effects were observed at the end of the therapeutic course and 6 months after the end of the therapeutic course.

RESULTS

The short-term therapeutic effect and the long-term therapeutic effect were 91.3% and 94.7% in the needle-knife treatment group and 59.4% and 56.6% in the acupuncture control group, respectively, with a very significant difference between the two groups (P < 0.01).

CONCLUSION

The needle-knife treatment in the therapeutic effect on cervical spondylosis is superior to acupuncture treatment.

Adjacent level degeneration after anterior cervical fusion: a clinical review

Anterior cervical discectomy and corpectomy for the treatment of cervical spondylosis,cervical disc herniation, and ossification of the posterior longitudinal ligament enjoy favorable rates of fusion and successful clinical outcomes. Although the complications from these procedures have been well described, the pathogenesis and clinical development of adjacent segment degeneration (ASD) are not fully understood. The definition of symptomatic ASD is the development of radicular or myelopathic signs and symptoms referable to a motion segment adjacent to prior cervical arthrodesis. The incidence, pathogenesis, prevalence, and potential treatment strategies for symptomatic ASD are discussed in this article.

[Degenerative disease of the lumbar spine. Clinical and magnetic resonance imaging correlation]

BACKGROUND

Low back pain often affects the economically active population with repercussions in world productivity. MRI defines the diagnosis easily with high specificity, allowing the most adequate treatment to be initiated. We undertook this study to confirm the diagnostic sensitivity and specificity of MRI in the evaluation of degenerative lumbosacral disease with facet joint participation.

METHODS

In a 6-month period we studied 358 patients with low back pain and/or sciatica due to degenerative disorders. We performed a basic evaluation on the clinical characteristics of pain. Plain sequences (T1 and T2) were used on axial, sagittal and coronal planes with MR equipment (0.5 T), evaluating the degenerative modifications of the lumbosacral region.

RESULTS

Discal degeneration associated with multidirectional bulging of annulus and extrusion and protrusion of discal material affected mostly L4-L5 and L5-S1 levels. The same levels showed most degenerative changes on facet joints. The most relevant result in our study was articular facet joint disease present in all cases regardless of the association with intervertebral osteochondrosis, discal hernia and spinal stenosis.

CONCLUSIONS

Diagnostic value of MRI in the study of low back pain offers a reliable evaluation with high sensitivity and specificity, in order to make appropriate therapeutic decisions.

Complementary and alternative medicine approaches to pain management

This article argues for and illustrates incorporating complementary and alternative medicine (CAM) interventions into pain treatment plans. Two CAM treatments, cranial electrotherapy stimulation (CES) and self-hypnosis training, are offered in a multidisciplinary pain treatment program. Because these interventions focus on pain relief, they may be of particular interest to patients who have chronic pain who begin treatment with a primary interest in pain reduction. Two cases that illustrate the clinical application of CES and self-hypnosis are presented. When effective, these interventions can help patients have greater confidence in treatments offered by psychologists for pain management and may help make them more open to participating in other psychological interventions that have established efficacy for pain management (e.g., cognitive-behavioral therapy). Because of their brevity, these treatments also can be offered alone to patients who may not have the resources or time to participate in more time-intensive treatment.

The numerical simulation of osteophyte formation on the edge of the vertebral body using quantitative bone remodeling theory

OBJECTIVES

To extend the quantitative prediction of the external shape of bone structure to the simulation of osteophyte formation on the edge of vertebral body.

METHODS

The high-order nonlinear equation of bone remodeling was used to control osteophyte formation process. The idea of topology optimization in engineering was imported to allow the outgrowth of osteophyte. Osteophyte on the edge of a vertebral body in its mid-sagittal plane was simulated numerically.

RESULTS

Osteophyte formation is an adaptive bone remodeling process in response to the progressive changes of mechanical environment, which were mainly caused by intervertebral disc degeneration.

CONCLUSION

The numerical simulation in this paper extended the structural simulation based on the quantitative bone remodeling theory to bone morphological abnormity in orthopaedics, which can help to better understand the relationship between bone morphological abnormity and the mechanical environment.

The effectiveness of calcitonin on chronic back pain and daily activities in postmenopausal women with osteoporosis

The aim of this study was to investigate the effect of nasal calcitonin on chronic back pain and disability attributed to osteoporosis. The study design involved three groups of osteoporotic postmenopausal women suffering from chronic back pain. Group I consisted of 40 women with vertebral fractures, group II of 30 women with degenerative disorders and group III of 40 patients with non specific chronic back pain and without abnormality on plain X-rays. Pain intensity was measured using a numerical rating scale (NRS) and disability due to back pain was measured using the Oswestry disability questionnaire. The patients were randomly assigned to receive, for three months, either 200 IU intranasal salmon calcitonin and 1,000 mg of oral calcium daily (groups IA, IIA, IIIA) or 1,000 mg of oral calcium daily (groups IB, IIB, IIIB). Repeated measures ANOVA showed that there were no significant time, group or interaction effects for pain intensity and disability in any of the groups studied. Mean Oswestry and NRS scores were reduced during the follow-up period in the groups IA, IIIA, but the differences between the two time points were not statistically significant. Intranasal calcitonin has no effect on chronic back pain intensity and functional capacity of osteoporotic women regardless of the presence of fractures, degenerative disorders or chronic back pain of non-specific etiology.

Cervical spondylotic myelopathy in athetoid cerebral palsy patients: about five cases

We herein report five cases of cerebral palsy athetosic patients with spondyloid cervical myelopathy. Four of them underwent decompressive surgery. The level of cervicarthrosis differs from a control population with a more frequent osteoarthritis on the lower cervical spine. The diagnosis of spondylotic cervical myelopathy is frequently overlooked because of the insidious progression of neurologic disorders and of the pre-existent neurological handicap. Depressive syndrome is often evoked in such a situation, and thus responsible for a delay of diagnosis. The presence of an hypersignal in T2 MRI sequences is still controversial. For some authors it is an indication for surgery, which is the treatment with the best functional results.

CONCLUSION

Cervical spondylotic myelopathy must be evoked in patients with athetoid cerebral palsy who complain about a decrease of their functional ability.

Acquired structural kyphoscoliosis in a captive adult female rhesus macaque (Macaca mulatta)

A female, wild-caught, rhesus macaque (Macaca mulatta), in captivity for 23 years and estimated to be older than 26 years, had an 8-year history of progressive spinal curvature. Scoliosis was initially noted 1 year after a therapeutic bilateral ovariectomy to treat endometriosis. Eight years after the initial diagnosis, the curvature had progressed to a structural (nonflexible), lumbar scoliosis with a curvature to the left and a structural thoracolumbar kyphosis. The spinal curvature was characterized radiographically by a severe, major lumbar curve to the left with vertebral rotation and severe thoracolumbar kyphosis. The Cobb method of measurement identified a major left lumbar curve of 80 degrees. When the animal's condition deteriorated, the animal was euthanized, and a necropsy with postmortem radiographic and microscopic examination was performed. Radiographically and grossly, multiple intervertebral disc spaces were narrowed along the entire spine with ventral bridging intervertebral spondylosis of the lumbar spine. Radiographically, vertebral bodies appeared to be less radiodense and multiple features of degenerative disc disease were present. No clinical evidence of concurrent neuromuscular or mesenchymal disease was noted, and development of lesions after bilateral ovariectomy suggested the kyphoscoliosis was secondary to osteopenia that developed as the result of a surgically induced estrogen deficiency.

[Magnetic resonance and traditional radiology in the spine localizations of alkaptonuric ochronotic arthropathy]

AIM

To study the spine alterations in alcaptonuria with traditional radiology and magnetic resonance (MR), comparing the results of the two techniques.

PATIENTS AND METHODS

Five patients (4 males, 1 female, mean age 51 years) underwent the examinations. For the study with X-rays we performed anteroposterior and lateral scan and the images have been studied making reference to a radiographic score; it examines the alterations of the joint space and the presence of calcifications. MR scan, oriented in the three spatial planes, were performed using spin echo T1-weighted and spin echo T2-weighted sequences.

RESULTS

Both MR and X-rays pointed out, in the cases with known diagnosis, the typical alterations of the ochronosis: narrowing of the articular spaces, even osseous ankylosis, calcifications of the discs, osteophytosis, multiple disc protrusions and reactive sclerosis of the articular surfaces, evident above all to dorso-lumbar tract; nevertheless MR has been more accurate than X-rays for individualizing the lesions and recognizing alterations, such as the thickness of the anterior longitudinal ligament. In the case of new diagnosis, the MR is fundamental to recognize typical signs of the ochronotic arthropathy not well detected by X-rays.

CONCLUSIONS

Imaging techniques, first of all the MR, are essential in the differential diagnosis of ochronosis vertebral lesions with other articular diseases.

An unusual cause of difficult intubation in a patient with a large cervical anterior osteophyte: a case report

This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, due to ankylosing spondylitis, resulted in distortion of the anatomy of the upper airway and difficult intubation. Ankylosing spondylitis (AS) is a progressive inflammatory disease, characterized by stiffening of the joints and ligaments. Stiffness of the cervical spine, atlanto-occipital, temporomandibular and cricoarytenoid joints may cause difficult intubation (1). This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, associated with AS, resulted in distortion of the anatomy of the upper airway and difficult intubation.

Superior sensitivity of motor over somatosensory evoked potentials in the diagnosis of cervical spondylotic myelopathy

Myelopathy secondary to cervical spondylosis is often a difficult clinical diagnosis. Furthermore, with the introduction of magnetic resonance imaging (MRI) an increasing number of patients are identified with spondylotic cervical spinal cord compression. We analyzed the value of functional assessment of the spinal cord by motor and sensory evoked potentials (MEP and SEP) in the detection of myelopathy, with special emphasis on the correlation of clinical and electrophysiological findings. Fifty-one patients with at least some degree of spinal cord compression because of cervical spondylosis, as shown by MRI, were included in the study, grouped according to clinical symptoms. We found that patients who had no clinical symptoms whatsoever indicating myelopathy (they were referred to MRI examination mostly because of cervical radiculopathy), had in the large majority normal MEP and SEP findings. Patients with slight, unspecific and non-confirmative symptoms without pyramidal signs had mostly abnormal MEP but normal SEP findings. This points to the superior sensitivity of MEP over SEP in detecting myelopathy in its early stages. Patients with obvious clinical signs of myelopathy, including pyramidal signs had both abnormal MEP and SEP findings. Altogether these findings may help clinicians in interpreting MRI signs of cervical spinal cord compression.

Degenerative changes following spinal fixation in a small animal model

OBJECTIVE

The objective of this study was to evaluate changes of the lumbar vertebral column following fixation.

DESIGN

Using an established small animal (rat) model of spinal fixation (hypomobility), 3 contiguous lumbar segments (L4, L5, L6) were fixed with a specially engineered vertebral fixation device. Spinal segments of control rats were compared with those of animals with 1, 4, or 8 weeks of fixation. Subgroups of these fixation animals subsequently had the fixation device removed for 1, 2, 4, 8, or 12 weeks to evaluate the effects of attempting to reestablish normal forces to the vertebral segments following hypomobility.

SETTING

This Institutional Animal Care and Use Committee (IACUC) approved study was conducted in a university animal facility.

ANIMALS

Eighty-seven animals (23 controls animals and 64 fixation animals) were used in this study. Main Outcome Measures Outcome measures were degenerative changes of the vertebral bodies (VBs) and intervertebral disks (IVDs), zygapophysial (Z) joint osteophyte formation, and Z joint articular surface degeneration (ASD). Changes found in vertebral segments that were fixed (hypomobile) were compared with changes in adjacent nonfixed vertebral segments, and changes among fixation animals were compared with nonfixed controls. Main Results Very few degenerative changes were identified on the VBs and IVDs. Z joint changes were significant, both for osteophyte formation (analysis of variance [ANOVA], P <.0001) and ASD (ANOVA, P <.0001). Fixed segments had more degenerative changes than nonfixed segments for all Z joint parameters (ANOVA, P <.0001). Osteophyte formation and ASD were directly dependent on duration of fixation.

CONCLUSIONS

These findings indicate that fixation (hypomobility) results in time-dependent degenerative changes of the Z joints.

Degenerative disease in lumbar spine of military parachuting instructors

Parachuting, be it static line or skydiving, places enormous stresses on the human spine. It is, therefore, important to determine the prevalence and severity of degenerative changes in the lumbar spine of subjects who practice this sport activity. Seventy four parachuting instructors, mean age 33 years and with an average of 410 static line and skydiving jumps, were included in the study. Past radiographs were examined and compared to current anterolateral and lateral views of the lumbar spine, in order to determine the prevalence of degenerative changes and document possible progression. Doubtful radiographic changes in the lumbar spine were identified in 47.4 percent of the parachuting instructors, mild degeneration in 9.6 percent, moderate degenerative disease in 10.9 percent and severe radiographic changes in 5.5 percent. Schmorll nodes were found in 8.1 percent of the subjects. Traction spurs--osteophytes were identified in 6.8 percent. The degenerative changes correlated with age and the number of jumps. Spondylolysis of L5-S1 and L3-L4 segments were observed in 12.2 and 1.4 percent respectively. Progressive spondylolisthesis was found in 2 subjects. No correlation was found between the severity of radiographic changes and either the prevalence and the severity of low back pain. The present findings provide a rational for considering repeated sheer stress as an etiology of degenerative changes in the spinal cord, and as a possible contributing factor to the pathogenesis of spondylolysis. Further study has to be done comparing parachuting instructors to a non-parachuting group, or equivalent physically active individuals, in order to assess the effect of sport-background on the development of degenerative changes.

Prediction of inter-segment stability and osteophyte formation on the multi-segment C2-C7 after unilateral and bilateral facetectomy

The objective of this study was to determine the intersegment stability, disc degeneration, and osteophytes formation on the multisegment cervical spine (C2-C7) after unilateral and bilateral facetectomy. A geometrically accurate non-linear three-dimensional model of the intact human cervical spine was created from the digitized coordinates of the dry vertebrae. The intact model was validated against the published results under physiological loading conditions. Eight surgically altered models were created from the intact model. The intact and surgical altered models were subjected to physiological loading. The inclusion of five levels in the present model allowed accurate determination of the intersegment responses and internal cortical bone and disc annulus stress in the adjacent spinal components. Results indicated that facetectomy performed on C5-C6 significantly affects the corresponding stress and intersegment motions at the corresponding C5-C6 levels. The maximum increases were 18 per cent for bilateral facetectomy and 7 per cent for unilateral facetectomy under lateral bending. Combined flexion-extension and axial rotation caused an approximately similar amount of increases after total facetectomy. In addition, adjacent segments (C4-C5 and C6-7) also experience a slight increase in the intersegment responses and internal stress after facetectomy. It has been shown that facetectomy of greater than 50 per cent resulted in segment hypermobility and substantial increase in the disc annulus and cortical bone stress. Increase in the stress may lead to osteophytes formation. This study revealed important information that will help clinicians identify the critical intersegment stability and to decide on the amount of facets resection.

Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain

OBJECTIVE

To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain.

DESIGN

Retrospective study with independent clinical review. A total of 15 patients who met specific physical examination or electrodiagnostic criteria and failed to improve clinically after at least 4 wks of physical therapy were included. Each patient demonstrated a positive response to a fluoroscopically guided cervical selective nerve root block. Therapeutic selective nerve root blocks were administered in conjunction with physical therapy. Outcome measures included visual analog scale pain scores, employment status, medication usage, and patient satisfaction.

RESULTS

Patients' symptom duration before diagnostic injection averaged 13.0 mos. An average of 3.7 therapeutic injections were administered. Follow-up data collection transpired at an average of 20.7 mos after discharge from treatment. An overall good or excellent outcome was observed in three patients (20.0%). Among those treated without surgery, a significant reduction (P = 0.0313) in pain score was observed at the time of follow-up. Six patients (40.0%) proceeded to surgery.

CONCLUSIONS

These initial and preliminary findings do not support the use of therapeutic selective nerve root block in the treatment of this challenging patient population with traumatically induced spondylotic radicular pain.

Cervical osteophyte causing perforation of the nasopharynx

Images

Late complications of adult idiopathic scoliosis primary fusions to L4 and above: the effect of age and distal fusion level

STUDY DESIGN A retrospective analysis of primary cases of adult idiopathic scoliosis treated with long instrumented fusions from the thoracic spine proximally to segments that range from T11 to L4 distally.

OBJECTIVE

To analyze whether patients requiring revision surgery had lower postoperative SRS-24 scores; age >or=40 years correlated with higher rates of revision surgery; disc degeneration below the fusion occurred more commonly with a more distal lowest instrumented vertebra or older patient age (>or=40 years); and whether smokers had higher rates of major complications or revision surgery.

SUMMARY OF BACKGROUND DATA

Few reports describe complications related to primary long fusions using modern 2+ rods, hook/pedicle screw instrumentation methods in the treatment of adult idiopathic scoliosis.

METHODS

Sixty-seven patients were analyzed with an average age of 38.8 years (range 21-61 years). The average clinical follow-up was 7.8 years (range 2-16 years): 42 patients had >5 years follow-up, including 23 patients with >10 years follow-up. Patients were categorized by age (< or >or=40 years) and level of the lowest instrumented vertebra (T11-L2 vs. L3-L4). Upright radiographs and postoperative SRS-24 questionnaires from the latest follow-up date were analyzed.

RESULTS

Patients requiring revision surgery had lower total score (average 72.0) than those that did not (total score = 94.2; P = 0.01). More specifically, patients with pseudarthrosis had lower total scores (average 74.7) than those without (average total score = 93.5; P = 0.02). When analyzing age, there were similar rates of pseudarthrosis, but higher rates of transition syndrome (2) and sagittal/coronal imbalance (1 each) in patients >or=40 years. Subsequent distal disc degeneration did not correlate significantly with more distal lowest instrumented vertebra or older patient age. Smokers did not have higher rates of major complications or revision surgery than nonsmokers.

CONCLUSIONS

Patients with adult idiopathic scoliosis and long fusions had similar pseudarthrosis rates, but higher rates of transition syndrome when lowest instrumented vertebra was L3-L4 relative to levels T11-L2. When categorized by age, complication rates were similar in each group. Patients with pseudarthroses or other diagnoses requiring revision surgery had lower SRS-24 total scores than those without (P = 0.02 and P = 0.01, respectively).

Cigarette smoking and appendectomy are risk factors for extraintestinal manifestations in ulcerative colitis

OBJECTIVE

Two common factors, cigarette smoking and appendectomy, have been found to play a role in ulcerative colitis (UC). Data on their role in the development of extraintestinal manifestations (EIM) are scarce.

METHODS

The relationship between cigarette smoking, appendectomy, and EIM was examined in a prospective study involving 535 (M/F = 319/216) consecutive UC patients followed up for 18 yr. We considered the major EIM: seronegative spondyloarthropathy, pyoderma gangrenosum/erythema nodosum, acute anterior uveitis, and primary sclerosing cholangitis. We excluded patients with a history of EIM or those colectomized before study entry, ex-smokers, and those who started to smoke during the course of UC.

RESULTS

In UC patients, seronegative spondyloarthropathy and dermatologic complications were found increased in smokers (p < 0.0001; p = 0.001) or in subjects with appendectomy (p = 0.0003; p = 0.02), while acute anterior uveitis and primary sclerosing cholangitis did not differ. The Kaplan-Meier analysis showed 18-yr rates for EIM of 71% in smokers and 45% in nonsmokers (log-rank test, p = 0.0001), and of 85% in patients with appendectomy and 48% in those without (p = 0.0001). Cox proportional-hazard model showed that cigarette smoking and appendectomy are independent factors promoting EIM. In smokers with appendectomy the adjusted hazard ratio (3.197, 95% CI 1.529-6.684) was higher than in patients with appendectomy alone (2.617, 95% CI 1.542-4.442) or smoking alone (1.947, 95% CI 1.317-2.879).

CONCLUSIONS

In UC patients, appendectomy and cigarette smoking are prognostic factors for the development of EIM. The unfavorable effect of cigarette smoking on EIM is additive to that of appendectomy.

[Epidural blood patch as a successful treatment of Barrè-Lièou syndrome: report of two cases]

Barrè-Lièou syndrome accompanies neurological symptoms after neck sprain, and is often difficult to treat. We describe two young men with various neurological symptoms after traffic accident, who were diagnosed with Barrè-Lièou syndrome. Both case 1 (41-year-old man) and case 2 (34-year-old man) showed no abnormal findings in head and cervical X-ray, CT-scan and MRI. Only radionuclide cisternography (RNC) showed cerebrospinal fluid (CSF) leak into epidural space at thoracolumbar level. Three months (case 1) and four years (case 2) had passed after each accident. Two patients underwent epidural blood patch (EBP) for total of three times. The average volumes of the blood used for EBP were 30 ml (case 1) and 24 ml (case 2). The procedure improved various symptoms except for neck stiffness and dizziness. EBP had led to low back pain, which disappeared within three days. CSF leak vanished in RNC after EBP. Severe complication, for example epidural infection or neurological disorders due to hematoma, was not noticed. While neural blockade did not relieve pain before EBP, we could get good effect from neural blockade for remaining symptoms after EBP. We consider that Barrè-Lièou syndrome is due to CSF leak and EBP may be one of the useful treatments.

[Peri-operative treatment with botulinum A toxin prior to posterior cervical decompression in a case with cervical spondylosis caused by spasmodic torticollis secondary to cerebral palsy]

Patients with spasmodic torticollis secondary to athetoid cerebral palsy may develop symptomatic degenerative cervical disc disease or spondylosis. In these cases, peri-operative stabilization of the cervical spine is considered to be difficult and recurrence occurs frequently. We reported a case with cervical spondylosis induced by athetoid cerebral palsy. A 44-year-old female with athetoid cerebral palsy had suffered from secondary spasmodic torticollis. 7 years previously, she had been admitted to our hospital for the first time with complaints of gait disturbance, dysesthesia and hypesthesia in all extremities. CT-myelography and MRI showed disc degeneration and spondylosis at the level of C4/5 and C5/6, compressing the spinal cord. She underwent C5 vertebrectomy and C4-6 anterior fusion. However, due to cervical dystonia, it was difficult for her to wear a Philadelphia collar, so she had to under go complete bed rest for postoperative neck stabilization. Her symptoms improved after the operation. 5 years after the first operation, she complained of gait disturbance and sensory disturbance, again. MRI showed compression of the spinal cord at C2-C4, rostral to the level of the previous surgical area. So we planned the second operation. Prior to the operation, we used botulinum A toxin to reduce the athetoid movement of the neck. And we performed C3-6 expansive laminoplasty and partial laminectomy of C2 and C7 laminae. After the second operation, she was able to wear the Philadelphia collar without trouble and her neurological condition improved again. Botulinum A toxin was very effective to control the spasmodic torticollis peri-operatively in this case with cervical dystonia.

Adjacent segment disease: an uncommon complication after cervical expansile laminoplasty: case report

OBJECTIVE AND IMPORTANCE

Adjacent segment disc disease is a well-described phenomenon that occurs after anterior cervical spinal fusion. One of the advantages of cervical laminoplasty over anterior approaches is that although the treated segments are stiffened, no formal fusion is performed. This is thought to reduce the biomechanical stresses placed on adjacent levels and thus decrease the likelihood of adjacent level degeneration.

CLINICAL PRESENTATION

A 62-year-old man presented with myelopathy attributable to cervical spondylosis and underwent a C3-C7 laminoplasty. Improvements in gait were followed 2 years later by symptomatic disc degeneration and spinal cord compression at T1-T2, which rendered him wheelchair bound.

INTERVENTION

The patient was treated with a laminectomy at the level of stenosis accompanied by posterior instrumentation and fusion from C5 to T3. This resulted in clinical improvement, and the patient was returned to his baseline ambulatory status.

CONCLUSION

Adjacent segment disease is an uncommon complication that occurs after laminoplasty. Careful attention to preserving facet joint motion in the cervical spine may minimize the stresses placed on adjacent motion segments.