LSTVs are common within the spine, and their association with low back pain has been debated in the literature for nearly a century. LSTVs include sacralization of the lowest lumbar vertebral body and lumbarization of the uppermost sacral segment. These vertebral bodies demonstrate varying morphology, ranging from broadened transverse processes to complete fusion. Low back pain associated with an LSTV may arise from the level above the transition, the contralateral facet when unilateral, and/or the anomalous articulation when present. Although this association is still somewhat controversial, beyond dispute is the importance of identifying an LSTV in patients in whom a surgical or interventional procedure is planned. This is essential to avoid an intervention or surgery at an incorrect level. In this article, each of these issues will be addressed with attention to identifying and correctly numbering LSTVs as well as detecting imaging findings related to the genesis of low back pain.

http://www.ajnr.org/content/ajnr/31/10/1778.full.pdf

Lumbosacral Transitional Vertebrae: Classification, Imaging Findings, and Clinical Relevance

Ten patients who had been managed with posterior spinal arthrodesis and Texas Scottish Rite Hospital instrumentation because of idiopathic scoliosis had a delayed deep wound infection at an average of twenty-five months after the operation. The signs of infection included spontaneous drainage in eight patients and fluctuance in two patients. In addition, six patients--including five of the eight who had drainage--had mild pain in the back. The average erythrocyte sedimentation rate was thirty-nine millimeters per hour (range, nineteen to eighty-one millimeters per hour). The instrumentation was removed from all of the patients. In two patients, a pseudarthrosis that had not been noted on preoperative radiographs was noted intraoperatively; in both patients, the pseudarthrosis occurred at a level at which two hooks had been placed in one intervertebral space. Primary closure was performed in seven patients, and delayed primary closure was performed on the third postoperative day in three patients. All wounds healed uneventfully. Cultures of specimens taken from deep within the wound were positive for Propionibacterium acnes (five patients), Staphylococcus epidermidis (two patients), a rare coagulase-negative Staphylococcus species (one patient), or Micrococcus varians (one patient). No organisms grew on culture of the specimen obtained from the remaining patient. Propionibacterium acnes required an extended period of incubation before identification. Antibiotics were administered parenterally to all of the patients after the removal of the hardware, and this treatment was followed by oral administration of antibiotics for nine of the patients. We suspect--but can not prove--that several of the delayed infections resulted from intraoperative seeding and remained subclinical for an extended period of time.

Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis.

This article reviews the extent of blood loss in spine surgery for scoliosis corrections in the pediatric age group An extensive literature review presents blood loss values in surgery for adolescent idiopathic scoliosis, cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy, and myelomeningocoele The underlying disorder plays a major role in determining the extent of blood loss Blood loss is considerably higher in those patients with a neuromuscular scoliosis compared with adolescent idiopathic scoliosis Within the neuromuscular group those with Duchenne muscular dystrophy demonstrate the highest mean levels of blood loss Blood loss is also shown to be progressively greater with increasing numbers of vertebral levels incorporated into the fusion, with posterior fusions compared to anterior fusions, and in those patients having both anterior and posterior fusions

/pdf/blood-loss-in-pediatric-spine-surgery-12fl6d4voj.pdf

Blood Loss in pediatric spine surgery

Study design Cross-sectional magnetic-resonance imaging (MRI) study. OBJECTIVE To investigate the relation of the lumbosacral transitional vertebra to signs of disc degeneration in MRI and to low back pain (LBP). Summary of background data An association between the transitional vertebra and herniation in the disc above has been found in patients with LBP, but knowledge of the relation to other degenerative disc changes detected in MRI and to LBP is lacking. Methods MR images of the lumbar spine of 138 middle-aged working men and 25 healthy young men were evaluated. The presence and type of lumbosacral transitional vertebra and of degenerative changes in intervertebral discs were evaluated. The history of low back symptoms was obtained with a questionnaire from the middle-aged men. Results The prevalence of transitional vertebra was 30%. Transitional vertebra was associated with an increased risk of degenerative changes in the disc above among the young men and with a decreased risk in the disc below among the middle-aged men. Transitional vertebra, symmetric or asymmetric, was not associated with any type of LBP in the middle-aged men. Conclusions Lumbosacral transitional vertebra increases the risk of early degeneration in the upper disc. This effect seems to be obscured by age-related changes in the middle age. The degenerative process is slowed down in the lower disc. For these effects, the presence of a transitional vertebra should be noticed when morphologic methods are used in research on lumbosacral spine. Transitional vertebra is not associated with any type of LBP.

Lumbosacral transitional vertebra: relation to disc degeneration and low back pain.

Farooq Qureshi, FRCS Anderson Walk Smithfield. SA 5114 so that the full thickness of the vas is not destroyed. The distal end is fulgurated at the cut surface and the sheath of the vas closed over it with a single suture. This creation of a fascial barrier between the ends prevents spontaneous rejoining, and also facilitates reversal later on if required. Ligatures or metal clips should not be used on the vas, whether absorbable or unabsorbable. These cause necrosis and sloughing of the vessel, and it becomes permanently fibrosed.

Smoking and health.

The relationship between herniated lumbar disc and abnormalities of the transverse process of the lumbosacral junction was investigated. Two hundred consecutive patients with positive myelographic findings of herniated lumbar disc were reviewed. Sixty patients presented abnormalities of the transverse process to satisfy the criteria for lumbosacral transitional vertebra. A new classification of lumbosacral transitional vertebra is presented based upon the morphologic and clinical characteristics with respect to herniated nucleus pulposus. Type I represents a "forme fruste" of lumbosacral transitional vertebra and shows no difference in the incidence of the location of herniations. In types III and IV, there are no herniations at the level of the lumbosacral transitional vertebra and no increase in the incidence of herniations just proximal to the lumbosacral transitional vertebra. The Type II lumbosacral transitional vertebra presents herniated lumbar disc at the level of transition. It also presents a greater than normal incidence of herniations at the level just above the lumbosacral transitional vertebra.

Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects.

Fifty-two posterior spinal fusions were performed for pediatric idiopathic, congenital, and neuromuscular scoliotic curves. Cotrel-Dubousset instrumentation was used in all patients. Nine had prior anterior spinal releases and fusions. The patterns were mixed, with a predominance of right thoracic curvatures. The average preoperative curve measured 60.6 degrees, with correction to 29. Seven patients required revision surgery, and 17 wore orthoses after operation. There were 17 complications in this group, including hook pullout, prominent hardware, infection, pseudarthrosis, and two cases of broken Cotrel-Dubousset instrumentation rods. Fatigue failure of this instrumentation, secondary to pseudarthrosis, has not been reported previously, and these two cases are presented in detail. The operative morbidity and difficulty were increased in the larger idiopathic curves and in neuromuscular and congenital scoliosis. Cotrel-Dubousset instrumentation is an overall excellent tool for the multiplanar correction of scoliosis and is amenable to revision surgery.

Cotrel-Dubousset instrumentation. Results in 52 patients

Study Design. A prospective evaluation of the smoking habits of new spine patients was performed during a 4-year interval. Objective. To assess what effect the spine health care provider has on a patient's ongoing nicotine addiction. Summary of Background Data. The negative effects of smoking and nicotine for the spine patient are well defined. Methods. Spine patients (N = 10,901) were queried as to their smoking habits during their new patient consultation; 3041 current smokers were identified. Data were obtained during 20,835 follow-up visits. Some of the smokers (n = 1632) were seen in follow-up visits and evaluated for their cigarette usage. Two different approaches were applied to assist the patient to stop smoking: 1) chart identification, reinforcement at each visit, continued education, written handout, practitioner assigning high priority, and 2) occasional mentioning, lower priority. Results. The number of smokers who quit smoking was 35.6% in the high priority group versus 19.5% in the lower priority group. There was also a difference in the number of patients who decreased their smoking (67% vs. 38%). The fear that confronting a patient who smoked would cause the patient to leave the practice was not realized. Other factors that predicted successful cessation were fewer packs per day, fewer years smoking, and older age. The effect of the practitioner was independent of these other variables as determined by a logistic regression analysis. Conclusion. Patients will respond better if the practitioner assigns a priority and works with the patient to educate them about ways to address this particular substance abuse. Just asking about the patient's smoking status had a dramatic effect on smoking status. All spine practitioners should do all in their power to help their patients overcome their nicotine addiction.

Antonio Castellvi

Papers

Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects.

Cotrel-Dubousset instrumentation. Results in 52 patients

Effect of the spine practitioner on patient smoking status.