Isthmic Lumbar Spondylolisthesis with Sciatica

Seventeen patients with sciatica and isthmic lumbar spondylolisthesis were studied with magnetic resonance (MR) imaging. In 13, myelography was also performed: 5 had dural sac deformation and root sleeve shortening, 2 had deformation with unilateral root sleeve shortening, one had bilateral root sleeve shortening only, and one had sac deformation only. In 4, myelography was normal. On sagittal MR examinations the neural foramen had an altered shape bilaterally with the long axis horizontal in all cases. In addition to altered shape the following was found in the 33 foramina evaluated. I: normal nerve (n = 8); II: compressed nerve (n = 16); III: disappearance of fat, nerve not possible to identify (n = 9). In patients with unilateral sciatica, the degree of foraminal stenosis correlated well with the side of symptoms. Coronal views showed the course of the nerve and pedicular kinking. Eight patients underwent decompressive surgery which revealed nerve compression by hypertrophic fibrous tissue and pedicular kinking, which correlated well with the findings on MR. Since the site of nerve compression often was peripheral to the root sleeves, myelography did not give complete information.

Outcome of surgical treatment of lumbar disc herniation in young individuals

Lumbar disc herniation (LDH) is uncommon in youth and few cases are treated surgically. Very few outcome studies exist for LDH surgery in this age group. Our aim was to explore differences in gender in pre-operative level of disability and outcome of surgery for LDH in patients aged ≤ 20 years using prospectively collected data. From the national Swedish SweSpine register we identified 180 patients with one-year and 108 with two-year follow-up data ≤ 20 years of age, who between the years 2000 and 2010 had a primary operation for LDH. Both male and female patients reported pronounced impairment before the operation in all patient reported outcome measures, with female patients experiencing significantly greater back pain, having greater analgesic requirements and reporting significantly inferior scores in EuroQol (EQ-5D-index), EQ-visual analogue scale, most aspects of Short Form-36 and Oswestry Disabilities Index, when compared with male patients. Surgery conferred a statistically significant improvement in all registered parameters, with few gender discrepancies. Quality of life at one year following surgery normalised in both males and females and only eight patients (4.5%) were dissatisfied with the outcome. Virtually all parameters were stable between the one- and two-year follow-up examination. LDH surgery leads to normal health and a favourable outcome in both male and female patients aged 20 years or younger, who failed to recover after non-operative management.

Initial clinical experience with a new biointegrative cement for vertebroplasty in osteoporotic vertebral fractures

SUMMARY

Polymethylmethacrylate, as a widely used material for vertebroplasty, has several drawbacks such as heat development and high allergenic potential. In order to avoid these drawbacks ceramic cement materials have been developed. The purpose of this study was to evaluate a new biointegrative material for vertebroplasty in osteoporotic vertebral fractures regarding pain relief, safety aspects and technical feasibility. The injectable bone substitute Cerament(TM) SpineSupport has been developed for vertebroplasty of osteoporotic vertebral fractures. The aim of the product is to provide mechanical stability by cured calcium sulfate dehydrate during a period of several weeks and to act as an osteoconductive support by hydroxyl apatite particles. Inclusion criteria were a stable single vertebral fracture at levels Th5 to L5, verified by CT and MRI, and not older than four weeks, in osteoporotic patients aged 60 years or older. Bipedicular vertebroplasty technique was used. Follow up included CT directly after treatment and after two month and pain assessment (VAS) pre and post procedure after two weeks and one month. Seven patients (age range 62 - 96 years, mean 73.9, five women, two men) were treated at levels T 8 (n=1), T 12 (n=4) and L1 (n=2). The average injected volume was 1.9 ml (range 0.2-4 ml). No material or procedure-related complications were observed. An average height loss of the treated vertebral bodies of 3.6 mm (range 1.5-5.4) was seen two months after treatment as compared to pre-treatment CT. Pain assessment by VAS resulted in an improvement from mean 69 prior treatment to 37 the day post treatment, 42 after two weeks and 30 after one month. Initial results indicate that Cerament(TM) SpineSupport is safe and effective in the treatment of acute osteoporotic vertebral body fractures. Further studies with long-term follow-up are needed to confirm these results and to prove the concept of osteoconduction with hydroxyl apatite particles.

Visual analog scales for interpretation of back and leg pain intensity in patients operated for degenerative lumbar spine disorders

STUDY DESIGN

A prospective observational study of visual analog scale (VAS) scores for pain in patients operated at one institution within the framework of a national registry.

OBJECTIVE

To describe the use of recording VAS for pain intensity in patients operated on for lumbar spine problems.

SUMMARY OF BACKGROUND DATA

There is no consensus regarding pain outcomes assessment in spine patients. Pain intensity, recorded on a VAS, is one of the most used measures. Still, many aspects of its interpretation are still debated or unclear.

METHODS

A total of 755 consecutive patients, mean age 50 years (range, 15-86 years), operated from 1993 to 1998 were included in the study; there were 420 males and 335 females. Diagnoses included herniated nucleus pulposus (45%), central stenosis (19%), lateral stenosis (14%), isthmic spondylolisthesis (9%), and degenerative disc disease (9%). Local pain, radiating pain, analgesic intake, and walking ability were recorded before surgery and at 4 and 12 months after surgery. The patients' opinions regarding the change in pain and satisfaction with the result were assessed separately. Correlation among variables reflecting perceived pain was sought.

RESULTS

Preoperative VAS mean values for local and radiating pain were significantly different in the five diagnostic groups. Significant but moderate correlation between different types of pain outcomes and with patient satisfaction was present in all cases.

CONCLUSIONS

Measuring pain intensity with VAS is a useful tool in describing spine patients. In the search for a standard in the evaluation of pain as an outcome, the differences between the various methods should be taken into account.

Is there increased intervertebral mobility in isthmic adult spondylolisthesis? A matched comparative study using roentgen stereophotogrammetry

STUDY DESIGN

By roentgen stereophotogrammetric technique, the intervertebral mobility of the spondylolytic segment in eight patients was measured and compared with the mobility of eight nonspondylolytic patients matched according to sex, afflicted segment, and grade of disc degeneration.

OBJECTIVES

To compare the intervertebral mobility of a spondylolytic segment with the mobility of a segment without spondylolysis in adult patients with back pain.

SUMMARY OF BACKGROUND DATA

Evidenced by the resulting olisthetic deformity and supported by the outcome from prior investigations, spondylolysis is assumed to induce spinal segmental instability/hypermobility.

METHODS

After percutaneous application of tantalum indicators for roentgen stereophotogrammetric technique, the intervertebral translations of the spondylolytic fifth lumbar vertebra were measured in eight adult patients with low back pain and low-grade olisthesis. Eight other patients without spondylolysis but with low back pain presumably on degenerative basis were chosen for comparison and had an identical measuring procedure using roentgen stereophotogrammetric technique. The two groups were matched in pairs according to sex, afflicted segment, and grade of disc degeneration.

RESULTS

No significant difference was registered considering the intervertebral mobility for matched pairs in the two groups neither along the sagittal nor the vertical axis. The transverse translations were mostly negligible in both groups.

CONCLUSION

The spondylolytic defect in pars interarticularis does not cause permanent instability/hypermobility detectable in the adult patient with low back pain and low-grade olisthesis.

Incomplete incorporation of morselized and impacted autologous bone graft: a histological study in 4 intracorporally grafted lumbar fractures

Morselized and impacted bone allografts are used successfully in hip and knee revisions, but experiments using bone chambers indicate that impaction actually can delay ingrowth of new bone into a graft. To understand the remodeling and incorporation process of morselized and impacted grafts, we studied the incorporation of morselized impacted autografts in lumbar fractures histologically. 4 patients were operated on for Th XII-LI fractures. The fractures were stabilized by VSP plates and transpedicular screws in the vertebrae above and below the fractured one. Autologous bone graft was packed into the fractured vertebral body through one of the pedicles. After 18-20 months, the plates were removed and biopsies were obtained from various locations in the fractured vertebra. All fractures were at this time clinically and radiographically healed. Histologically, in all cases, large areas of the autograft in the vertebral body were unvascularized and partially or entirely necrotic. As with morselized bone in hip revisions, evaluation of graft incorporation requires histological examination. Full osseous incorporation of a graft is not always necessary for a good clinical result.

Significance of a persistent positive straight leg raising test after lumbar disc surgery

OBJECT

Results of the straight leg raising (SLR) test provide the clinician with valuable information regarding possible causes of a patient's pain. In a previous study the results have also demonstrated a correlation between the outcome of the test and the severity of pain, as well as the prognostic value of the test; patients for whom the SLR test is persistently positive postoperatively appear to have a poorer short-term outcome. In a prospective study of 200 consecutive patients who underwent surgery for disc herniation, the authors evaluated the frequency of repeated surgery and outcome of surgery in patients with a persistent postoperative positive SLR test.

METHODS

The preoperative radiological evaluation included myelography, computerized tomography scanning, and/or magnetic resonance imaging. Preoperatively as well as 4, 12, and 24 months postoperatively, each patient was interviewed and examined using a standard protocol in which common symptoms and signs were described. The result of the SLR test was also classified into one of four categories: positive 0 to 30 degrees ; positive 30 to 60 degrees, positive greater than 60 degrees, or negative, and the surgical results were evaluated using a four-grade scale. Preoperatively, the SLR test was positive in 86% of patients. At 4 months postoperatively, 22% still had a positive SLR test. For the patients whose SLR test was positive 4 months postoperatively, the long-term outcome at all three follow-up examinations was inferior; this difference was statistically significant.

CONCLUSIONS

During the 2-year period, the reoperation rate was 18% (eight of 44) in patients with a positive postoperative SLR test compared with 4.5% (seven of 156) in patients whose postoperative SLR test was negative. A postoperative positive SLR test thus correlates to an unfavorable surgical outcome.

External pedicular fixation of the lumbar spine: outcome evaluation by functional tests

We analyzed the pain-relieving effect and the functional outcome during external pedicular fixation of the lumbar spine. Twenty patients were included, and the diagnoses were disc degeneration with or without facet joint arthrosis in eight patients, pain after decompression in six patients, spondylolysis/olisthesis in two patients, other types of lumbar anomalies in three patients, and pseudarthrosis after prior uninstrumented fusion in one patient. Before application of the external frame, the pain level on the Visual Analogue Scale was registered at rest, as a mean level for the preceding week, and at seven different functional tests. Maximum walking capacity and walking time needed for a standardized distance were also measured. The same test procedure was repeated 1 week postoperatively with the external frame applied in locked position. With stabilization, 11 patients reported pain relief at rest and 14 when approximating the mean pain level for the week. Both these measured levels correlated to the pain level at all of the seven functional tests. Thus, the patients selected for a subsequent fusion based on pain relief during extended functional provocation would not differ from the patients selected by using only the pain-relieving effect at rest. The patients reporting pain relief tended to increase their walking distance (p = 0.06, t test) but not the speed of walking.

Stability of lumbar fusion with transpedicular fixation determined by roentgen stereophotogrammetric analysis

STUDY DESIGN

An evaluation of the intervertebral stability of transpedicular instrumentation in posterolateral lumbar fusions by roentgen stereophotogrammetric analysis.

OBJECTIVES

To determine the in vivo intervertebral stability of posterolateral lumbar fusions augmented with transpedicular screws and plates.

SUMMARY OF BACKGROUND DATA

Transpedicular bone screw systems have been found to be as safe and clinically effective as other types of devices in stabilizing surgery of the spine. Many experimental studies have yielded basic data on the stabilizing implant effect in vitro, but the exact in vivo stabilizing effect on human lumbar vertebrae has not been presented previously.

METHODS

In 12 patients, the intervertebral stability of posterolateral fusion in the lower lumbar spine augmented with transpedicular screws and plates was evaluated by serial roentgen stereophotogrammetric analysis with the patients in supine and erect positions 1 year after surgery.

RESULTS

Screws in each fused vertebra yielded stable fixation or permitted sagittal intervertebral translations smaller than 1 mm induced by the positional change. A widely decompressed and destabilized vertebra without screw fixation yielded persisting intervertebral translations.

CONCLUSIONS

The current study demonstrated the adequacy of in vivo stability of lumbar fusions augmented with transpedicular screws and plates. Sagittal translation seems easier to elicit than movements along the other three-dimensional axes. A widely decompressed and destabilized vertebra without screw fixation increases the risk for persisting intervertebral translations. The roentgen stereophotogrammetric analysis technique described seems to be a good way of comparing the in vivo behavior of different implant systems.

Lumbar nerve root compression by intraspinal synovial cysts. Report of 8 cases

We evaluated the clinical appearance and results of surgical treatment in 8 patients with leg symptoms due to a lumbar intraspinal synovial cyst. The most frequent symptom was radicular leg pain due to unilateral single-root compression affecting the L5 or S1 nerve root. There were 2 cases with large cysts causing compression of the cauda equina, with spinal claudication as the main symptom. All cysts arose from arthrotic facet joints. Surgical excision gave good results and no recurrences have been noted 0.5-2 years postoperatively.

Assessment of sagittal plane segmental motion in the lumbar spine. A comparison between distortion-compensated and stereophotogrammetric roentgen analysis

STUDY DESIGN

Sagittal plane translatory and rotatory motion was measured in 15 lumbar motion segments of 8 patients by distortion-compensated and stereophotogrammetric Roentgen analysis.

OBJECTIVE

To compare measurement precision of the new distortion-compensated Roentgen analysis protocol with that of the established Roentgen stereophotogrammetric technique under realistic clinical conditions.

SUMMARY OF BACKGROUND DATA

Roentgen stereophotogrammetric analysis constitutes the most precise method available to assess segmental motion. Because of the invasive nature of the procedure, however, there is interest in alternative, noninvasive protocols suitable for studying larger patient cohorts.

METHODS

In 8 patients, segmental motion of 15 lumbar segments that had undergone previous spinal surgery was assessed from stereo views by using Roentgen stereophotogrammetric analysis. Sagittal plane segmental motion was assessed by distortion-compensated Roentgen analysis. Sagittal plane translatory and rotatory motion data obtained by both methods were compared.

RESULTS

With respect to Roentgen stereophotogrammetric analysis, sagittal plane rotation was determined by distortion-compensated Roentgen analysis with an error (standard deviation) of 1.4 degrees and a mean difference of less than 0.05 degree. Sagittal plane translation was determined by distortion-compensated Roentgen analysis, with an error of 1.25 mm and a mean difference 0.5 mm.

CONCLUSION

Measurement precision of distortion-compensated Roentgen analysis is slightly inferior to that of Roentgen stereophotogrammetric analysis but substantially higher than that of conventional protocols assessing lumbar segmental motion. If measurement precision is considered adequate and if a noninvasive technique is indicated, distortion-compensated Roentgen analysis can be used to provide reliable motion data required for epidemiologic and clinical studies.

Contained and noncontained lumbar disc herniation in the same patient. Two case reports

STUDY DESIGN

A case report containing description of symptoms, signs, and selected treatment in two patients with lumbar disc herniation where the type of herniation changed from contained to noncontained in less than 1 year.

OBJECTIVES

To demonstrate the difference in clinical appearance related to the type of herniation.

SUMMARY OF BACKGROUND DATA

The clinical appearance of lumbar disc herniation regarding onsets of symptoms, severity of pain, and clinical findings are related to the type of herniation, as is the treatment.

METHODS

Two cases reports are presented with description of anamneses, clinical findings, neuroradiographic findings, and treatment.

RESULTS

Both patients suffered from a transient left-side sciatica due to a contained lumbar disc herniation, improved by physiotherapy. After several months, both patients had an instantaneous increase in contralateral leg pain, and the recurrent, intense pain was caused by a sequestration of the previous contained herniation. The neurologic findings were more severe, and the patients were operated on, with subsequent improvement.

CONCLUSIONS

The case reports illustrate the difference in clinical appearance of disc herniation related to the type of herniation, with a more aggressive clinical appearance in conjunction with perforation of the posterior longitudinal ligament with extrusion of disc material.

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part II: Five-year follow-up by an independent observer

STUDY DESIGN

A prospective and consecutive study of surgical results obtained during serial follow-up investigations in patients who underwent surgery for central lumbar spinal stenosis.

OBJECTIVES

To evaluate the result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate these results with values for preoperative parameters; special interest was focused on the results in relation to the degree of constriction of the spinal canal.

SUMMARY OF BACKGROUND DATA

The outcome after surgery for spinal stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a meta-analysis of the literature on surgical results have demonstrated a wide variation of outcomes.

MATERIAL AND METHODS

In a prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet-preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade scale. The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical analysis was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient outcome. Logistic regression analysis was performed.

RESULTS

During the follow-up period, 19 patients underwent reoperation, consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive stenosis (n = 13), and repairs in response to surgical complications (n = 2). Follow-up results: The result, related to the recurrence of leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67% at 4-month and 2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between the constriction of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm or less at the narrowest site had significantly better results. The logistic regression analysis demonstrated a significant correlation between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward better results in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also associated with a pronounced constriction of the spinal canal.

CONCLUSION

The results after surgical decompression in patients with central spinal stenosis deteriorated with time. There was a significant correlation between good result and pronounced constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4 years and patients with no preoperative back pain tended to have better surgical outcomes. The reoperation rate was 18% within 5 years. When surgery for spinal stenosis is contemplated, these prognostic factors should be taken into consideration: The "ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain, no concomitant disease affecting walking ability, and a symptom duration of less than 4 years.

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings

STUDY DESIGN

A prospective study of consecutive patients undergoing surgery for central lumbar spinal stenosis.

OBJECTIVES

To evaluate symptoms and signs in patients undergoing surgery for central spinal stenosis and to correlate the findings to age, preoperative duration of symptoms, and radiographically detected constriction.

SUMMARY OF BACKGROUND DATA

The degree of constriction of the spinal canal considered to be symptomatic of lumbar canal stenosis is not clear, nor is the relation between the clinical appearance of the disease and the degree of radiographically verified constriction.

MATERIAL AND METHODS

One hundred five consecutive patients scheduled for decompression surgery were included in a prospective study. The day before surgery, all patients were interviewed and examined, using a defined protocol that included data on age, gender, preoperative duration of symptoms, walking ability, and occurrence of pain at rest and at night. Included were data recording straight leg raising test results, reflex disturbance, and extensor hallucis longus muscle weakness. All radiographs were examined by a neuroradiologist. The anteroposterior diameters at each site from L1-L2 to L5-S1 were recorded. For the computer analysis, the site of and width at the narrowest site was registered, as well as the number of sites with an anteroposterior diameter of less than 10 mm. A statistical analysis was performed using chi-square analysis, nonparametric tests, analysis of variance, and logistic regression.

RESULTS

Pain at rest and at night was reported by 68 and 60 patients, respectively, and was more common in younger patients (P = 0.065 and 0.015, respectively). A severe reduction of walking ability (< 0.5 km) was reported by 70 patients. The straight leg raising test results were negative in 70 patients, positive > 60 degrees in 16, positive 30-60 degrees in 14, and positive < 30 degrees in 5. Younger patients had a positive straight leg raising result (P = 0.028, analysis of variance) more often. Reflex disturbances correlated to patient age: Older patients had reflex disturbances more often. There was no correlation between preoperative duration and pain or neurologic disturbances: Patients with longer preoperative duration of symptoms did not demonstrate more severe symptoms. There was a total myelographic block of the spinal canal in 13 patients. The mean value of the antero-posterior diameter in the other patients was 6.8 mm (range, 4-11 mm). In patients younger than 70 years L4-L5 was the site for the most pronounced constriction, whereas L3-L4 was the narrowest site in the older patients. Degenerative spondylolisthesis was found in 32 patients, and they had a more pronounced constriction of the spinal canal (5.6 mm compared with 6.7 mm in those without displacement, P = 0.02). There was a (nonsignificant) tendency toward more walking disturbances in patients with a more pronounced constriction of the spine. There was no correlation between reflex disturbances or extensor hallucis longus weakness and radiographically detected constriction.

CONCLUSION

Pain was more intense and positive straight leg raising test results were more common in younger patients, whereas reflex disturbances were more common in the elderly. The vertebral site for the lowest anteroposterior value was higher with higher age. Preoperative duration did not affect the severity of symptoms or signs. Patients with more pronounced stenosis tended to have a more severe reduction of walking ability. There was no correlation between symptoms and signs and radiographically detected constriction.

Posterolateral lumbar fusion using facet joint fixation with biodegradable rods: a pilot study

Roentgen stereophotogrammetric analysis (RSA) was used to assess whether there is a potential for biodegradable rods crossing the denuded facet joints to increase the stability and healing rate of lumbar posterolateral fusions. Eleven consecutive patients with lumbosacral disc/facet joint degeneration had a posterolateral fusion augmented with 2- or 3.2-mm biodegradable rods passing perpendicularly through the center of the denuded facet joints. The patients were followed-up with RSA in supine and erect positions monthly from the 2nd to the 6th postoperative month, and again 1 year postoperatively. All seven L5-S1 fusions healed. Four cases were stable as defined by RSA within 3 months, two within 6 months, and one within 1 year. One L4-S1 fusion could not be evaluated by RSA. None of the remaining three L4-S1 fusions fully healed. In all three cases 1- to 3-mm intervertebral translations remained at 1 year. None of the 11 fusions showed any radiographic signs of osteolysis around the biodegradable rods. The promising results of this pilot study indicate that posterolateral L5-S1 fusion augmented with transarticular biodegradable rods crossing the denuded facet joints may yield rapid intervertebral stabilization and a high healing rate without any adverse rod effects. This may be due to enhanced initial fusion stabilization and/or increased ossification induced by the rods.

The spondylolytic vertebra and its adjacent segment. Mobility measured before and after posterolateral fusion

STUDY DESIGN

By using roentgen stereophotogrammetric analysis in six patients having tantalum indicators implanted at a preoperative external fixation test, the mobility in the spondylolytic lumbosacral level and its adjacent segment could be studied before fusion and during the course of postoperative fusion consolidation.

OBJECTIVE

To study the mobility effects on the segment adjacent to a lumbar fusion over time from the preoperative situation until fusion healing as defined by roentgen stereophotogrammetric analysis.

SUMMARY OF BACKGROUND DATA

In vitro studies indicate that the altered biomechanical situation after lumbar fusion increases the intradiscal pressure and changes the kinematics in the juxtafused segment.

METHODS

Six patients with low grade spondylolysisolisthesis were scheduled for fusion of the spondylolytic lumbosacral segment after a preoperative external fixation test. The latter procedure also included implantation of tantalum markers for spinal roentgen stereophotogrammetric analysis. Each patient was examined by roentgen stereophotogrammetric analysis at four separate occasions: before fusion (2 months after removal of the external frame) and 3, 6, and 12 months after surgery. The translatory movements of the L5 vertebra in relation to sacrum and of the L4 vertebra in relation to the L5 vertebra were calculated at each examination.

RESULTS

For the juxtafused L4-L5 level, increased and decreased mobility patterns could be identified. Transformation of the preoperative mobility in the lumbosacral segment to the adjacent segment during fusion consolidation was verified in two patients but was not a general phenomenon.

CONCLUSION

Fusion of the lumbosacral segment can alter the kinematics of the adjacent segment, redistributing the mobility toward relative hypermobility in the juxtafused segment.

Neurologic signs in lumbar disc herniation. Preoperative affliction and postoperative recovery in 150 cases

We studied prospectively 165 consecutive patients operated on for lumbar disc herniations. Neurologic examination was performed preoperatively and at 4, 12, and 24 months postoperatively according to a protocol. Preoperatively 69% of the patients showed a neurological disturbance corresponding to the level of disc herniation and 62% a corresponding sensory deficit. Recovery of the neurological deficit was seen in half of the cases at 2 years postoperatively, the main part of this improvement occurred within 4 months after the operation. Neurologic recovery correlated to a good surgical outcome, and a short history of disc herniation prior to the operation correlated to postoperative neurologic improvement. The straight leg raising test correlated to preoperative neurologic deficit, but not to postoperative recovery. Motor power disturbance of the extensor hallucis longus muscle recovered in more patients than reflex disturbances. Sensory disturbances had the lowest recovery rate. Our study demonstrates a correlation between routine postoperative neurologic findings and the patient's self-assessed outcome of surgery.

MR imaging as the primary modality for neuroradiologic evaluation of the lumbar spine. Effects on cost and number of examinations

PURPOSE

To evaluate the effects on cost, and number of primary and supplementary neuroradiologic examinations, after introducing MR imaging as the primary modality in the evaluation of the lumbar spine.

MATERIAL AND METHODS

Two 5-month periods were compared: period 1--before MR; and period 2--after introduction of a 2nd MR device. In period 1, patients were examined with myelography and/or CT after referral from specialists only, whereas in period 2 both specialists and general practitioners could refer patients for MR imaging. The direct cost (neuroradiologic methods and hospitalization) and indirect cost (sick-leave and estimated loss of production caused by the diagnostic procedure) were estimated.

RESULTS AND CONCLUSION

In period 1, investigations were started in 75 patients (62 myelographies and 13 CT examinations); in period 2, in 227 patients (198 MR, 21 CT, and 8 myelographies). The estimated total cost increased from SEK 825,000 to 1,265,000 (53%), the cost per investigated patient decreasing from 11,000 to 5565 (50%), and the cost of preoperative investigation per operated patient decreasing from 8616 to 5563 (35%). The number of supplementary examinations was unchanged.

Clinical characteristics of recurrent sciatica after lumbar discectomy

STUDY DESIGN

A prospective and consecutive study with preoperative collection of data using a standard protocol for data processing.

OBJECTIVES

The frequency of common symptoms and signs was determined in patients with recurrent disc herniation (n = 22), symptomatic postoperative epidural and periradicular fibrosis after a previous lumbar disc excision (n = 18) and compared with the same variables in primary disc herniation (n = 150). The ultimate diagnostic criterion was the finding at surgery.

SUMMARY OF BACKGROUND DATA

Surgical treatment of recurrent sciatica after disc excision is rewarding in most cases of recurrent herniation but not in fibrosis and scarring.

METHODS

Recorded were pain at rest, at night, and upon coughing. Three categories of analgesic use were collected: 1) none, 2) intermittent, and 3) regular. Walking capacity was determined as more than 5 km, 1-5 km, 0.5-1.0 km, or less than 0.5 km. the straight leg raising test was graded as positive 0 - 1.0 km, or less than 0.5 km. The straight leg raising test was graded as positive 0-30 degrees, positive 30-60 degrees, positive more than 60 degrees, or negative. The results from a standardized neurologic examination were collected.

RESULTS

Pain at rest and pain at night were equally common in all three patient groups, although pain upon coughing was more common in disc herniation (primary and recurrent) than in fibrosis, Severe reduction of walking capacity was reported more commonly by patients with dis herniation, whereas regular consumption of analgesics was reported most frequently by patients with fibrosis.

CONCLUSION

The symptoms and signs profiles show differences that may be of interest in differential diagnostic considerations after previous lumbar disc surgery.

Mechanics of the external fixation test in the lumbar spine. A roentgen stereophotogrammetric analysis

STUDY DESIGN

By implanting tantalum indicators percutaneously during application of pedicular screws, lumbosacral mobility could be studied with roentgen stereophotogrammetric analysis in seven patients having a diagnostic external fixation test.

OBJECTIVES

To determine the mechanical effects on the segmental mobility during an external fixation test of the lumbar spine.

SUMMARY OF BACKGROUND DATA

External pedicular fixation test of the lumbar spine has been reported a valuable prognostic instrument in fusion for low back pain.

METHODS

A Magerl external fixation device was applied in seven patients with low-grade spondylolysis-olisthesis. By using roentgen stereophotogrammetric technique, the intervertebral translations in the lumbosacral segment were determined. Each patient had three separate examinations; with the frame fixed, with the frame loosened, and without frame 6 weeks after screw removal.

RESULTS

With the external frame fixed, the sagittal intervertebral translations were significantly reduced, in three cases to a level beneath the accuracy of the measuring method. One patient had the same immobilizing effect even with the frame loosened while for the others loosening of the frame meant regained mobility of the segment.

CONCLUSION

The properties of the external fixator give an adequate mechanical basis for the prognostic external fixation test in lumbar fusion.

Clinical appearance of contained and noncontained lumbar disc herniation

In a prospective and consecutive study, we evaluated the incidence of common symptoms and neurologic disturbances in 200 patients operated on because of lumbar disc herniation by using a computer-coded protocol with pre- and perioperative registration. The preoperative occurrence of pain at rest, at night, and on coughing was registered. Use of analgesics and walking ability were registered as category data. At examination, a straight-leg-raising (SLR) test was graded in four categories, and results from neurologic findings were collected. At surgery, disc herniation was classified as extruded/sequestered herniation, prolapse, or focal protrusion. There were no significant differences concerning pain at rest or at night related to type of herniation. Pain on coughing was more common in extruded/sequestered herniations. Use of analgesics as well as severe reduction of walking capacity were significantly more common in patients with extrusion/sequestration. The highly restricted SLR test, as well as the crossed positive SLR test, were also significantly more common in patients with extruded/sequestered herniation, and this was also true for the incidence of relevant reflex/extensor hallucis longus (EHL) and sensory disturbance. In conclusion, the clinical appearance of lumbar disc herniation was most "aggressive" in extruded and sequestered disc herniation. The symptoms and signs in disc protrusion were less severe, whereas patients with prolapse had an "intermediate" appearance concerning symptoms and signs. The differences in incidence of common signs in noncontained versus contained herniation were statistically significant; these differences may be of clinical interest for patient selection and information as well as in pathophysiologic considerations.

Motor affliction of the L5 nerve root in lumbar nerve root compression syndromes

STUDY DESIGN

From a prospective and consecutive study on degenerative lumbar spine disorders containing 416 patients, all patients with a severely reduced or absent strength of the extensor hallucis longus muscle (n = 35) before surgery were identified.

OBJECTIVES

The incidence, diagnosis, and recovery after surgery of patients with L5 root compression syndromes and a severely reduced or absent power before surgery of the big toe extensor was evaluated.

SUMMARY OF BACKGROUND DATA

The L5 root is commonly involved in disc herniation and central and lateral spinal stenosis. Whether motor recovery occurs after root decompression is not fully known.

METHODS

All patients underwent a conventional radiologic evaluation before surgery including one or more myelography, computed tomography scan, and magnetic resonance imaging. At examination before surgery, extensor hallucis longus-power was graded as normal, reduced, or severely reduced/absent, and the latter group is presented here. Surgical findings were registered. Clinical investigation was performed after 4, 12-, and 24-month follow-up periods.

RESULTS

A pronounced extensor hallucis longus paresis was seen in disc herniation in 20 of 187 patients, in lateral spinal stenosis in 10 of 122 patients, and central spinal stenosis 5 of 107 patients. Improvement of the paresis after surgery was equally common in disc herniation (15 of 20 patients) and lateral spinal stenosis (7 of 10 patients). Complete restitution was more common in disc herniation. None of the five patients with central spinal stenosis improved concerning paresis at the follow-up period. Improvement was most common during the first 4 months after surgery. No correlation between age or preoperative symptom duration and recovery was noted in either group.

CONCLUSION

The incidence of pronounced extensor hallucis longus paresis in lumbar nerve root compression varied between 5-11%. Recovery after surgery was common in disc herniation and lateral spinal stenosis but did not occur in central stenosis. Complete recovery was most common in disc herniation, and recovery occurred mainly during the first 4 months after surgery.

Influence of age on symptoms and signs in lumbar disc herniation

In a prospective and consecutive study we evaluated the prevalence of pain-related symptoms, the results of the straight leg raising (SLR) test and neurological disturbances by age group in a total of 150 patients operated on due to lumbar disc herniation. On admission, all patients were interviewed, and pain at rest, at night and on coughing was recorded. Walking capacity was recorded under four categories: > 5 km, 1-5 km, 0.5-1 km and < 0.5 km. Results of the SLR test were also registered as category data: positive 0-30 degrees, positive 30-60 degrees, positive > 60 degrees or negative. Findings from examination of tendon reflexes and power of the extensor hallucis longus (EHL) muscle were registered, as were sensory disturbances. The above mentioned parameters were analysed separately for five different age groups: 20-29 years, 30-39 years, 40-49 years, 50-59 years and above 60 years of age. There was an age-related change in the prevalence of certain parameters. Highly restricted positive SLR test results and pain on coughing was most commonly found in the youngest patient group. With increasing age there was a decreasing prevalence of highly restricted positive SLR test results, while the prevalence of severe reduction of walking capacity increased. In short, the youngest patient group showed the most obvious clinical picture of disc herniation and, with increasing age, the clinical picture gradually changed towards the picture associated with spinal stenosis.

Orthosis as prognostic instrument in lumbar fusion: no predictive value in 50 cases followed prospectively

To evaluate pain relief in a lumbar orthosis as a predictor for good clinical results after solid fusion, all patients scheduled for such a surgical procedure were preoperatively encouraged to use an orthosis, soft or rigid, for 3 weeks. Grade of back pain relief as a percent using the orthosis was assessed by the patients and was registered before surgery. After surgery, at 1-year follow-up, patients with nonunion demonstrated radiographically were excluded from the series. Thus, 50 patients with solid fusion could be identified and followed for at least 2 years prospectively. At follow-up these 50 patients graded the pain relief induced by the fusion. In the preoperative corset test, 31 patients experienced significant back pain relief, meaning a reduction of at least 50%. No applicable correlation was found, however, between outcome in this corset test and the eventual clinical result expressed as improvement/no improvement after solid fusion. The two types of orthoses did not differ in this aspect. We conclude that the orthosis, rigid or soft, is not a useful instrument when selecting patients for lumbar fusion.

Serial MRI in the early postoperative period after lumbar discectomy

The aim of this study was to determine MRI findings in patients successfully operated upon for lumbar disc herniation. We investigated 20 patients with a successful outcome after L4-5 or L5-S1 disc operations clinically and with MRI preoperatively, and at 5 days, 6 weeks, and 4 months after surgery. Postoperatively, T1- and T2-weighted images were obtained. At 4 months gadolinium-enhanced images were added. Pronounced intraspinal MRI changes were seen during follow-up. Deformation of the dural sac was seen in 13 patients preoperatively, in 19 at 5 days after operation, in 15 at 6 weeks, and in 12 at 4 months. Nerve root involvement was seen in all cases both preoperatively and at 5 days after operation, in 17 at 6 weeks, and in 15 at 4 months. No correlation between symptoms or the straight leg raising test and the size or nature of the abnormal tissue in the spinal canal postoperatively could be demonstrated. It was concluded that early postoperative MRI after lumbar discectomy must be interpreted carefully, and that oedema and scar formation are probable reasons for difficulties in interpretation.

No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome. A study with contrast-enhanced magnetic resonance imaging in symptomatic and asymptomatic patients

STUDY DESIGN

Symptomatic patients were retrospectively analyzed and compared with a control group from an ongoing prospective and consecutive study.

OBJECTIVES

To determine the presence and extent of epidural fibrosis in patients with and without recurrent sciatic pain after previous lumbar discectomy, contrast-enhanced magnetic resonance images were evaluated and correlated with surgical findings in the symptomatic patients. Recurrent hernia and bony stenosis were ruled out as the probable causative agent, as well as any morphologic explanation other than fibrosis.

SUMMARY OF BACKGROUND DATA

Repeat surgical results for patients with the lumbar postdiscectomy syndrome with epidural fibrosis alone are often unfavorable. The pathogenic role of epidural fibrosis, however, has not been established.

METHODS

The magnetic resonance images of eight patients with recurrent or persistent sciatic pain after lumbar discectomy were compared with those of eight asymptomatic patients constituting a control group. All were examined with magnetic resonance imaging on a 0.3 T unit before and after intravenous injection of gadolinium-DTPA, and clinically, 6 months to 4 years after surgery. The symptomatic patients subsequently underwent reoperation.

RESULTS

Fourteen patients had focal or diffuse epidural fibrosis around the nerve root and/or the thecal sac at the operated level, whereas the postoperative findings for two patients were "normal," one in the operated and one in the control group. No difference between the groups regarding mass effect or affection of the nerve roots or thecal sac was noted. At reoperation of the eight symptomatic patients, fibrosis was the only pathologic finding in all cases except one, in which surgery confirmed the normal finding on magnetic resonance imaging. Six of the eight operated patients had recurrent or persistent symptoms within a year of the reoperation.

CONCLUSION

No differences regarding the presence and extent of epidural fibrosis between the symptomatic and asymptomatic patients could be demonstrated with contrast-enhanced magnetic resonance imaging. The role of epidural fibrosis as the causative agent in the lumbar postdiscectomy syndrome is questioned.

Heat generation and heat protection in methylmethacrylate cementation of vertebral bodies. A cadaver study evaluating different clinical possibilities of dural protection from heat during cement curing

For metastatic disease of the spine, anterior operations on the vertebral bodies often include methylmethacrylate cementation. The cement curing process may produce high temperatures in the surroundings, as demonstrated in joint replacement surgery, and there is a risk of thermal injury to the spinal nerves. In cadavers, we studied the heat arising during curing of cement on the dural sac, and the temperature of the cement surface was measured when the vertebral body was reconstructed using acrylic cement in the same way as in tumor surgery. The temperature increase on the surface of the dural sac during polymerization was between 4 degrees and 12 degrees C, depending on the amount of protection. Only a moderate temperature elevation was measured on the surface of the dural sac, provided that the posterior cortex of the vertebra was retained together with 0.5 cm of the spongious bone or a silicone membrane.

The straight leg raising test and the severity of symptoms in lumbar disc herniation. A preoperative evaluation

STUDY DESIGN

In a prospective, consecutive study, correlation between the straight leg raising and other pain-related symptoms in lumbar disc herniation was evaluated preoperatively and postoperatively.

OBJECTIVES

All patients were interviewed and examined preoperatively and at follow-up investigations 4 and 12 months postoperatively.

SUMMARY OF BACKGROUND DATA

One-hundred-and-fifty consecutive patients underwent lumbar disc surgery. Mean patient age was 42 years (range, 21-81 years). Eighty-nine patients were men and 61 were women. Two herniations occurred at L2-L3, seven at L3-L4, 61 at L4-L5, and 80 at L5-S1.

METHODS

Pain at rest, at night, and upon coughing was recorded. Consumption of analgesics was classified into three categories: 1) none, 2) intermittent, or 3) regular. Walking capacity was recorded as > 5 km, 1-5 km, 0.5-1 km, or < 0.5 km. The straight leg raising test was graded pos 0 degree-30 degrees, pos 30 degrees-60 degrees, pos > 60 degrees, or negative. At surgery, the herniation was classified as focal protrusion, subligamentous herniation, or perforation. The patient's assessment of outcome was graded into one of four categories.

RESULTS

There was an almost linear correlation between a positive straight leg raising test and pain at rest, pain at night, pain upon coughing, and reduction of walking capacity. Regular consumption of analgesics was more common in patients who had a very restricted positive straight leg raising test (30 degrees). A positive straight leg raising test early postoperatively correlated with inferior outcome of the surgical procedure.

CONCLUSION

The straight leg raising test as performed in clinical practice has a strong correlation with various parameters that signify the pain level of the patient. A positive straight leg raising test postoperatively correlates with inferior surgical outcome.

The European Spine Society AcroMed Prize 1994. Acute thermal nerve root injury

Bone cement is sometimes used for vertebral body reconstruction following tumor removal. During such procedures, the polymerization of the methyl-metacrylate in the bone cement generates heat. Such temperature increase might cause damage to the nerve roots within the spinal canal. In the present study, pig cauda equina nerve roots were subjected to controlled temperature increases by means of a heat-generating probe. A temperature of 40 degrees C applied for 5 min did not cause any changes in nerve root function. However, 70 degrees C resulted in a complete block of nerve root function within 5 min. Histological nerve fiber damage was seen after exposure to 60 degrees C and 70 degrees C. The present study provides basic knowledge of heat-resistance properties of spinal nerve roots that might be directly applicable as guidelines for safety margins during surgical spine reconstruction procedures using bone cement.

Decompression for lateral lumbar spinal stenosis. Results and impact on sick leave and working conditions

STUDY DESIGN

One hundred patients underwent lumbar nerve root decompression without fusion. All patients were registered preoperatively in a computer-coded protocol and followed at regular intervals: 4, 12, and 24 months after surgery. A number of subjective and objective variables were investigated including data on preoperative and postoperative working conditions and sick listing. Patients' opinions on pain relief were assessed using a 4-grade scale.

OBJECTIVES

Surgical results and impact on sick leave and working conditions in patients who underwent surgery for lateral spinal stenosis were evaluated in a prospective, consecutive study.

SUMMARY OF BACKGROUND DATA

Preoperatively, 81 of the patients were employed, 21 in sedentary work, 36 in moderately heavy work, and 24 in heavy work. The majority of the patients (78%) were off work (sick listed) with a mean duration of 13 months. Mean preoperative duration of sciatic pain was 2.5 years.

METHODS

Working conditions were classified into one of three categories: sedentary, moderately heavy, and heavy work. Distribution of working conditions preoperatively and postoperatively was assessed in conjunction with duration of sick leave. Change of work category postoperatively was evaluated and related to preoperative working conditions.

RESULTS

The effect of decompression for sciatica due to lateral spinal stenosis was gratifying in most cases with excellent results in 65% and fair in 23% of the patients concerning leg pain. The majority of patients employed preoperatively (73%) returned to work after a postoperative sick leave of 5.5 months. Patients who received disability pension postoperatively had significantly inferior surgical result concerning back pain and were also sick listed significantly longer preoperatively.

CONCLUSION

Thus, lateral spinal stenosis was improved in the majority of patients (88%) who underwent surgery, and the majority of patients who were employed before surgery returned to work after.

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after primary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.

Lumbar spine surgery in the elderly. Complications and surgical results

STUDY DESIGN

Diagnosis, postoperative complications, and surgical results in patients over 70 years old who underwent surgery for lumbar nerve root compression of a degenerative origin were evaluated in a prospective, consecutive study.

SUMMARY OF BACKGROUND DATA

Of the 50 patients investigated, 43 suffered from central spinal stenosis, four from disc herniation, and three from lateral spinal stenosis.

METHODS

All patients were investigated preoperatively and at 4, 12, and 24 months postoperatively. A number of subjective and objective variables were investigated and registered in a computer-coded protocol. Data gathered included intraoperative and postoperative complications, relevant diagnosis, and surgical results. Surgical procedures consisted of decompression with a facet-preserving technique in spinal stenosis and conventional open disc excision for disc herniation. Complications were classified as general (anesthetic, cardiopulmonary, and thromboembolic) and surgical. Patients' opinions on pain relief were assessed with a 4-grade scale.

RESULTS

No anesthetic, cardiopulmonary, or thromboembolic complications were seen. Three surgical complications occurred: 1) a patient with spondylitis, 2) a patient with dural leakage with spontaneous recovery, and 3) a patient with postoperative cauda equina syndrome that resulted from peridural hematoma. During follow-up, two patients died from unrelated diseases and cerebrovascular lesions developed in two patients. Among the remaining 46 patients, 37 had improved by the 2-year follow-up and nine were unchanged. No patient deteriorated after the operation.

CONCLUSION

Degenerative disorders of the lumbar spine in patients over 70 year old can be treated with no anesthetic complications and with 2-year results on par with those of decompressive surgery in younger patients.

Posterolateral lumbar fusion. Outcome of 71 consecutive operations after 4 (2-7) years

We report the outcome of 71 consecutive posterolateral lumbar fusions without spinal instrumentation. The indication for the operation was spondylolysis-olisthesis, degenerative disc disease/facet joint arthrosis, or pain after prior laminectomy. Concerning pain relief, 29/43 patients with spondylolysis-olisthesis were classified as good. The corresponding figures in the group with degenerative disc disease and/or facet joint arthrosis were 8/16 patients and in the group with pain post-laminectomy, 6/12 patients. No surgical complications were noted. In the total material 54 patients had a solid fusion, as defined by radiographic osseous trabecular bridging at all intended levels. One-level fusions tended to heal solidly in a higher frequency than two-level fusions. For the spondylolysis-olisthesis group, healed fusion correlated with a good clinical result. Such a correlation could not be verified for the other diagnostic groups. We conclude that non-instrumented posterolateral lumbar fusion is a valid method for treating low-grade spondylolysis-olisthesis, especially when the aim is to fuse a single level. Improved patient selection methods are required in fusion for degenerative disc disease and pain after laminectomy.

Repeat decompression of lumbar nerve roots. A prospective two-year evaluation

In a prospective, consecutive study 93 patients who had had previous lumbar spinal surgery underwent repeat decompression for persistent or recurrent back and leg pain. The previous operations had been discectomies in 65 patients and decompression for spinal stenosis in 28; two of the latter group had also had posterolateral fusion. At the repeat operation, disc herniation was found in 19 patients, lateral spinal stenosis in 19, central spinal stenosis in 20 and periradicular fibrosis in 35. Ninety-one patients were followed up for two years after surgery; the effect of the operation was recorded using a four-scale grading system. The results were significantly related to the diagnosis. Nerve-root compression due to recurrent disc herniation or to bony compression responded well to repeat decompression. In patients with a single nerve-root compression the results were similar to those obtained in primary operations. Sciatica due to nerve-root scarring was seldom improved by the repeat operation.

Lumbar orthosis with unilateral hip immobilization. Effect on intervertebral mobility determined by roentgen stereophotogrammetric analysis

To determine the additional stabilizing effect of unilateral hip fixation on external lumbar supports, nine patients with a posterolateral lumbosacral fusion without internal fixation were examined by roentgen stereophotogrammetric analysis. The roentgen stereophotogrammetric analysis was performed with the patients in supine and erect positions 1 month after surgery, that is, before fusion consolidation. Each patient was examined without lumbar support and with a molded, rigid thoracolumbosacral orthosis with extension to one thigh, thus immobilizing one hip. The additional hip immobilization had no consistent or significant stabilizing effect on the sagittal, vertical, or transverse intervertebral translations in the lower lumbar spine. This study using roentgen stereophotogrammetric analysis gave no support for including hip immobilization when using lumbar orthoses after spinal fusion in patients adequately cooperating to minimize gross body motions.

Symptoms and signs in degeneration of the lumbar spine. A prospective, consecutive study of 300 operated patients

In a prospective, consecutive study we determined the frequency of common symptoms and signs in 300 patients with lumbar nerve-root compression syndromes. We compared 100 patients with disc herniation (mean age 43 years), 100 with lataral spinal stenosis (41 years) and 100 with central spinal stenosis (65 years), using a standard protocol of common signs and symptoms. The diagnoses were established by one or more of myelography, CT, MRI and nerve-root block, and all were confirmed at operation. The preoperative duration of symptoms was significantly shorter in patients with disc herniation. Pain at rest, at night, and on coughing was as common in lateral stenosis as in disc herniation, but regular consumption of analgesics was more common in patients with disc herniation. Positive straight-leg-raising tests were more common in disc herniation than in lateral stenosis and were uncommon in central stenosis. Motor disturbances were seen most often in central spinal stenosis, especially patellar reflex changes. Sensory disturbances were most common in patients with complete disc herniation.

Factors predicting healing complications in femoral neck fractures. 138 patients followed for 2 years

We have previously studied the radiographic outcome of femoral neck fracture osteosynthesis with either two hook-pins or a four-flanged nail performed by a small group of surgeons with special interest in the methods. In 138 femoral neck fractures a backwards stepwise logistic regression analysis was used to study the significance of preoperative fracture-related factors, intraoperative factors and the osteosynthesis. The development of non-union/redisplacement and segmental collapse of the femoral head was influenced by fracture displacement (P 0.001) and method of osteosynthesis (P 0.007). The postoperative scintimetric ratio was influenced by the method of osteosynthesis (P 0.0003), fracture displacement (P 0.004) and by the presence of a posterior fragment (P 0.03). Reduction of the fracture and positioning of the osteosynthesis were to a large extent within the accepted limits. This may explain why the previously well documented negative effects of malpositioning of the osteosynthesis and inferior reduction were not demonstrated to influence the rate of healing-complications. We conclude that neither patient age, sex nor preoperative fracture variables, with the exception of the extent of fracture displacement, can be used to predict radiographic healing-complications in femoral neck fractures.

Postlaminectomy problems with reference to spinal fusion

Absence of relief of sciatica after laminectomy is not an indication for fusion. Significant remaining low back pain with a distinct morphologic explanation sometimes may be considered an indication for fusion. Recurrent sciatica due to fibrosis is not relieved by fusion. Induced instability because of facetectomy responds well to fusion. Fusion for unspecific remaining complaints after decompressive surgery, not explained by distinct morphologic findings, should be avoided.

Femoral neck fracture fixation with hook-pins. 2-year results and learning curve in 626 prospective cases

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

Effect of lumbar orthosis on intervertebral mobility. A roentgen stereophotogrammetric analysis

To determine the stabilizing effect of external lumbar supports on the intervertebral mobility in the lower lumbar spine, seven patients with a posterolateral lumbosacral fusion without internal fixation were examined by roentgen stereophotogrammetric analysis in supine and erect positions 1 month after surgery, that is, after soft tissue healing but before fusion consolidation. Each patient was examined without lumbar support, with a molded, rigid orthosis and with a canvas corset with molded, plastic posterior support. Neither of the two types of lumbar support had any stabilizing effect on the sagittal, vertical, or transverse intervertebral translations. This study using roentgen stereophotogrammetric analysis confirms that lumbosacral orthosis has effect by restricting gross motions of the trunk rather than intervertebral mobility in the lumbar spine.

Early intensive treatment of clubfoot. 75 feet followed for 6-11 years

47 consecutive children with 28 bilateral and 19 unilateral clubfeet were treated during the neonatal period according to a strict protocol including physiotherapy and bracing from the first 2 weeks of life; further, in most of the children, an operation was performed at 3 (2-5) months of age. Physiotherapy was continued during the first year of life and bracing for 3 years. 27 feet had repeat operations. No peroperative or postoperative complications were seen. At follow-up at aged 8 (6-11) years, the cosmetic result was good in 62 feet, acceptable in 12 feet, and poor in 1 foot, whereas the functional result was excellent in 51 feet, good in 21 feet, and fair in 3 feet. The radiographs showed a higher lateral talocalcaneal angle in the control feet than in the treated feet; but in other radiographic aspects, no differences were seen. The need of a secondary or even tertiary operation did not indicate a poor result.

Influence of spinal immobilization on consolidation of posterolateral lumbosacral fusion. A roentgen stereophotogrammetric and radiographic analysis

To determine the influence of the duration of postoperative lumbar immobilization with the aid of a rigid lumbar orthosis on the consolidation of posterolateral lumbosacral fusions, 22 patients with no previous osseous spinal surgery and with fusion without osteosynthesis due to spondylolysis-olisthesis Grade 1 to 2 or intervertebral disc or facet joint disorder were examined by roentgen stereophotogrammetric analysis in supine and erect positions and by conventional radiography for 1 year after surgery. In Series 1, patients (n = 11) were instructed to keep the trunk straight with the aid of a molded, rigid lumbar orthosis for 5 months after surgery; and in Series 2 (n = 11), the same instructions were given, but for 3 months. In Series 1, osseous fusion was seen on radiographs in eight patients. In these patients, the intervertebral translations between the fused vertebrae began to decrease 3-6 months after surgery, and within 1 year, the fusions became rigid, as defined by roentgen stereophotogrammetric analysis, or intervertebral translations of mostly less than 1 mm persisted. In three patients with poor fusion still seen on radiographs 1 year after surgery, no rigid fusion was obtained and intervertebral translations of up to 10 mm persisted. In Series 2, a similar roentgen stereophotogrammetric analysis pattern was noted in two patients with osseous fusion and in seven with poor fusion seen on radiographs. The fusion was radiographically doubtful in two patients. In these patients, the intervertebral translations decreased, but translations of 1.5 mm persisted 1 year after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Function of the hip after femoral neck fractures treated by fixation or secondary total hip replacement

Two matched groups of 28 patients each, with femoral neck fractures treated by primary internal fixation or by secondary total hip replacement after a complication of primary treatment, were evaluated and compared five years or more after primary pin fixation or secondary total hip replacement. The Nottingham Health Profile questionnaire was sent and returned by mail and the patient groups were matched with regard to age, sex, health, and social situation. Patients with healed fractures had less problems with sleep, housework and hobbies, and thus functioned better than patients who had required a secondary total hip replacement.