Showing papers in "Spine in 1980"
TL;DR: Nonorganic physical signs in low-back pain are described and standardized in 350 North American and British patients and can be used as a simple clinical screen to help identify patients who require more detailed psychological assessment.
Abstract: Nonorganic physical signs in low-back pain are described and standardized in 350 North American and British patients. These nonorganic signs are distinguishable from the standard clinical signs of physical pathology and correlate with other psychological data. By helping to separate the physical from the nonorganic they clarify the assessment of purely physical pathologic conditions. It is suggested also that the nonorganic signs can be used as a simple clinical screen to help identify patients who require more detailed psychological assessment.
734 citations
TL;DR: The records of 3920 patients entering a model family practice unit between 1975 and 1978 have been analyzed and the complaint of medically reported low-back pain was significantly related to occupational factors such as truck driving, lifting, carrying, pulling, pushing, and twisting.
Abstract: The records of 3920 patients (2068 females, 1852 males) entering a model family practice unit between 1975 and 1978 have been analyzed. Eleven percent of males and 9.5% of females reported an episode of low-back pain during that 3-year interval. The complaint of medically reported low-back pain was significantly related to occupational factors such as truck driving (p < 0.001), lifting, carrying, pulling, pushing, and twisting (P < 0.001 for all variables) as well as nondriving vibrational exposure (P < 0.001). Patients reporting low-back pain also reported more episodes of anxiety (P < 0.001) and depression (P < 0.001) and had more emotionally stressful occupations (P < 0.001). The mean number of pregnancies was greater in women with low-back pain (2.6) than in those without (1.6) (P < 0.001). The low-back pain sufferers were more likely to be cigarette smokers (P < 0.001), particularly when smoking was accompanied by a chronic cough (P < 0.001). This population is currently under prospective study to define the relevance of each of these risk factors to the complaint of low-back pain.
496 citations
TL;DR: There is a considerable need for a greater allocation of resources for improvement in methods of prevention, diagnosis, and treatment of disorders of the lumbar spine.
Abstract: Disorders of the lumbar spine are among the most common medical problems in western countries, affecting up to 80% of people at some time during their lives. The epidemiology and impact of six specific disorders of the lumbar spine are reviewed. These include prolapsed discs, disc degeneration, osteoarthrosis of the apophyseal joints, fractures and dislocations of vertebrae, osteoporosis, and spondylolisthesis. Various mechanical factors contribute to the causation of most of these disorders, but other underlying pathologic mechanisms are important as well. In light of the great impact of these conditions on society and on individuals, it is concluded that there is a considerable need for a greater allocation of resources for improvement in methods of prevention, diagnosis, and treatment.
487 citations
TL;DR: Cadaveric lumbar intervertebral joints were subjected to physiologic loads to simulate flexion and the results show that at the limit of flexion the supraspinous and interspinous ligaments sprain first and that the capsular ligaments and the interverTEbral disc offer considerably more resistance than the ligamentum flavum and the suPRaspinous/interspinous ligaments.
Abstract: Cadaveric lumbar intervertebral joints were subjected to physiologic loads to simulate flexion. The resistance to bending was measured first with the joint intact and again after cutting in turn through the supraspinous/interspinous ligaments, the ligamentum flavum, and the capsular ligaments of the apophyseal joints. In this way the part played by each of these structures, and the intervertebral disc, in resisting and limiting flexion was determined. The results show that at the limit of flexion the supraspinous and interspinous ligaments sprain first and that the capsular ligaments and the intervertebral disc offer considerably more resistance than the ligamentum flavum and the supraspinous/interspinous ligaments. The intervertebral joint was found, on average, to be sufficiently stiff to balance about half the bending moment exerted by the trunk in full flexion.
385 citations
TL;DR: Three hundred four consecutive patients with low-back pain were given epidural anesthetic and steroid injections and selected patients had 87% short-term success and 34% relief of pain for as long as 6 months.
Abstract: Three hundred four consecutive patients with low-back pain were given epidural anesthetic and steroid injections. A prospective study demonstrated that selected patients had 87% short-term success and 34% relief of pain for as long as 6 months. No patient was cured by these injections. Needle placement during epidural injections was incorrect 25% of the time in experienced hands.
363 citations
TL;DR: The results make it possible to estimate the strength of a vertebral body from the knowledge of its bone Mineral content as determined by dual photon absorptiometry and provide a basis for estimations of normal and abnormal amounts of bone mineral content in the vertebrae of the lumbar spine.
Abstract: The bone mineral content of 109 lumbar vertebrae from 36 different subjects was determined by dual photon absorptiometry. The mean age of the subjects was 58.5 years (range, 31 to 79 years). The ultimate strength of the vertebral bodies was determined during axial compression. Bone mineral content and ultimate compressive strength were correlated (r = 0.86) and the strength was found to increase linearly with increasing amounts of bone mineral content. No differences in this correlation were found in the four vertebral levels (L1–4) included in the study, but a difference in this correlation was found between specimens taken from male and female subjects. The results make it possible to estimate the strength of a vertebral body from the knowledge of its bone mineral content as determined by dual photon absorptiometry and provide a basis for estimations of normal and abnormal amounts of bone mineral content in the vertebrae of the lumbar spine.
288 citations
TL;DR: The ratios showed that the patients had attempted extension strengths that were significantly less than their strengths in the other types of movements tested, and the strength ratios for attempted extension were particularly low for patients with sciatica.
Abstract: Trunk strengths were measured in 27 health males and 30 health females, and in 25 male and 15 female patients with low-back pain and/or sciatica Maximum voluntary isometric strengths were measured during attempted flexion, extension, and lateral bending from an upright standing position Both male and female patients had approximately 60% of the absolute trunk strengths of the corresponding healthy subjects Intra-individual trunk strength ratios were used to interpret the results Use of these ratios tends to avoid interpretational problems created by the general weakness of the patients and any lack of motivation of either patients or healthy subjects The ratios showed that the patients had attempted extension strengths that were significantly less than their strengths in the other types of movements tested The strength ratios for attempted extension were particularly low for patients with sciatica
224 citations
203 citations
TL;DR: Internal fixation of fractures of the thoracolumbar spine with early ambulation is evaluated in this study of 100 patients with 106 fractures, 34 of which were treated by recumbency, 13 with Meurig-Williams plates, and 59 with Harrington rods.
Abstract: Internal fixation of fractures of the thoracolumbar spine with early ambulation is evaluated in this study of 100 patients with 106 fractures, 34 of which were treated by recumbency, 13 with Meurig-Williams plates, and 59 with Harrington rods. Fracture reduction in the recumbent group was 14% unsatisfactory and 82% satisfactory; only one fracture was anatomically reduced. After plating, 38% of fracture reductions were unsatisfactory and 61 % were satisfactory. Harrington rod reduction and internal fixation resulted in 67% anatomic, 31 % satisfactory, and 2% unsatisfactory reductions. Neurologic improvement in partial lesions was 53% with Harrington rods and 44% with recumbent treatment. For paraplegic patients the time between treatment and wheelchair mobilization was reduced from 10.5 weeks with recumbent treatment to 5.3 weeks with Harrington instrumentation. Rehabilitation time for ambulatory candidates was decreased from 7.1 weeks to 2.5 weeks. Complications were reduced from 18% in the recumbent group to 7% in the Harrington rod group. By using the three above-three below, rod long/fuse short approach rather than the two above-two below with fusion over the length of the rods technique, the number of anatomic reductions was increased from 70% to 82% and the length of the fusion decreased from 4.8 levels to 1.4 levels.
188 citations
TL;DR: A simple model is presented that explains the observed function and failure of the intervertebral disc in compression, torsion, and bending; this model is based upon the observed arrangement of collagenous fibers in the annulus fibrosus.
Abstract: A simple model is presented that explains the observed function and failure of the intervertebral disc in compression, torsion, and bending; this model is based upon the observed arrangement of collagenous fibers in the annulus fibrosus. The fibers are considered to have the same mechanical properties as tendon; thus the stresses required to produce a given deformation and which irreversibly damage the fibers can be predicted. Predictions of the mechanical behavior of the disc are in good agreement with published results for compression and torsion; no comparable experiments have been performed for bending. It is further predicted that torsion and bending are likely to cause annular failure and protrusion. Failure is likely to occur posteriorly because of the effect of forward bending and because in the flattened and reentrant discs of the lumbar spine, torsional stress is concentrated at the points of maximum curvature. The structure of the disc tends to protect the collagenous fibers in forward bending and torsion. Compression is predicted to cause end-plate fracture rather than annular failure.
182 citations
TL;DR: The results showed that bedrest, as compared with ambulation, will decrease the amount of time lost from work by 50% and analgesic medication, when added to bedrest in the treatment of lumbago, does not provide an advantage over bedrest alone.
Abstract: The roles of bedrest, antiinflammatory medication, and analgesic medication in the treatment of acute back strain were objectively analyzed to determine whether they have a measurable effect on the return of patients to full daily activities as well as on the relief of pain. Two hundred patients were studied prospectively. Each patient had the diagnosis of acute back strain, which was defined as nonradiating low-back pain. The results of the patient's neurologic examination, straight leg raising test, and lumbosacral spine roentgenograms had to be within normal limits for the patient to be included in the study. The results showed that bedrest, as compared with ambulation, will decrease the amount of time lost from work by 50%. Bedrest will also decrease the amount of discomfort by 60%. Analgesic medication, when combined with bedrest, will further decrease the amount of pain incurred, particularly when used in the first three days of the healing process. However, analgesic medication will not allow a more prompt return to work. Antiinflammatory medication, when added to bedrest in the treatment of lumbago, does not provide an advantage over bedrest alone.
TL;DR: Scar formation after laminectomy was evaluated in dogs treated with hemostatic agents, antiinflammatory drugs, or mechanical barriers, and microfibrillar collagen was found to be superior to gelatin foam.
Abstract: Scar formation after laminectomy was evaluated in dogs treated with hemostatic agents, antiinflammatory drugs, or mechanical barriers. Microfibrillar collagen was found to be superior to gelatin foam. The antiinflammatory drugs delayed healing and frequently resulted in abscess formation, and eventually scar filled the defect. The fat grafts formed a viable mechanical barrier. Gelatin foam sponge was compared with microfibrillar collagen for hemostasis with free fat grafts in a clinical series of 50 patients. The latter technique was clearly superior.
TL;DR: It is suggested that the greater accuracy of medial branch neurotomy will permit a more adequate trial of the rationale and efficacy of facet denervation.
Abstract: Percutaneous lumbar medial branch neurotomy is a technique for facet denervation in which the target is specifically the medial branch of the dorsal ramus The radiology of the technique is illustrated, and the technical aspects of the procedure are described The accuracy of previous techniques for facet denervation as compared with medial branch neurotomy is reviewed in a comparative analysis of radiographs illustrating the various techniques It is suggested that the greater accuracy of medial branch neurotomy will permit a more adequate trial of the rationale and efficacy of facet denervation
TL;DR: The mechanics relating the orientation of the articular facets with joint forces and stability of the lumbar spine are discussed.
Abstract: Lumbar intervertebral joints were subjected to compressive and shear forces calculated to simulate walking with a heavy pack on the back. The joints with articular tropism were found to rotate toward the side of the more oblique facet. The mechanics relating the orientation of the articular facets with joint forces and stability of the lumbar spine are discussed.
TL;DR: Eight of the nine patients who underwent anterior cervical fusions for cervical spondylosis were found to have radiographic evidence of increased degenerative diseases located primarily below the level of fusion but occasionally occurring both above and below the fusion.
Abstract: In nine patients who underwent anterior cervical fusions for cervical spondylosis, preoperative cervical spine films were compared with radiographs taken seven to 15 years after fusion. Eight of the nine patients were found to have radiographic evidence of increased degenerative diseases located primarily below the level of fusion but occasionally occurring both above and below the fusion. Whether these degenerative changes are the body's response to altered mechanical forces on joints next to a now immobile spinal segment or whether these changes merely represent the natural progression of the degenerative disease process could not be ascertained from this study. Perhaps both factors contributed.
TL;DR: Fiveyear follow-up studies suggest that interlaminal laminectomy without fusion is the best procedure when surgical treatment of herniated lumbar disc is necessary in children and adolescents.
Abstract: Seventy cases of surgically documented herniated lumbar disc in children and adolescents were analyzed Twenty-six of the 70 cases were followed at least five years postoperatively The incidence of juvenile disc herniation in Japanese patients appear to be much higher than in Caucasians Repeated trauma may be an important etiological factor of herniated lumbar disc in this age group The history and physical findings in children and adolescents are not fundamentally different from those in the adult, although abnormal neurological findings are not common Five-year follow-up studies suggest that interlaminal laminectomy without fusion is the best procedure when surgical treatment of herniated lumbar disc is necessary in children and adolescents
TL;DR: It is thought that selective lumbosacral radiculography and block is an especially excellent diagnostic technique for disorders featuring nerve root entrapment in the lateral foraminal recess, in which accurate localization cannot be determined by the other auxiliary diagnostic measures.
Abstract: Selective lumbosacral radiculography and block was performed on 106 patients, using 60% Conray or Dimer-X and 1% lidocaine mixed with corticosteroid. The technique of this method is reported, and the radiculographic findings and diagnostic value of this method are discussed. According to our experience, this method is technically simple and very useful in determining the limit of the lumbosacral nerve root lesion, and occasionally can be used to relieve radicular symptoms. We think it is an especially excellent diagnostic technique for disorders featuring nerve root entrapment in the lateral foraminal recess, in which accurate localization cannot be determined by the other auxiliary diagnostic measures.
TL;DR: Poor results were recorded in patients who had significant nerve root or cauda equina injury from surgery, associated “arachnoiditis“ which is thought to result from surgical trauma in many instances, or multiple operations leading to a hopelessly disabled state.
Abstract: The failures and poor results of lumbar spine surgery are analyzed in a retrospective study of 105 consecutive patients referred to the authors for evaluation during 1976. Those who had a history of industrial or vehicular accident outnumbered others by about two to one. Review of histories, physical findings, and myelograms in most of the patients failed to substantiate the diagnosis of ruptured disc or nerve root compression. Many of the failures occurred in those patients in whom little if any evidence of nerve root compression was found. The indications for surgery were poor in this group. Other failures occurred in patients who had improper, incomplete, or inadequate operations, especially those with lumbar spondylosis, a retained fragment of disc, or surgery at the wrong level. In addition to failures, poor results were recorded in patients who had significant nerve root or cauda equina injury from surgery, associated “arachnoiditis“ which is thought to result from surgical trauma in many instances, or multiple operations leading to a hopelessly disabled state.
TL;DR: It is suggested that the myelographic defect and symptomatology arise from traction applied to the nerve root by the medially displaced pedicle and not a simple forward displacement.
Abstract: A variety of techniques were used to study the morbid anatomy of 19 spines demonstrating degenerative spondylolisthesis in order to define the precise changes which produce this lesion and its radiographic appearance. An association between this affliction and vascular disease is suggested. The studies indicate that the listhesis is basically a persistent rotary deformity and not a simple forward displacement. Furthermore, there is no construction of the neural canal at the site of the listhesis. These findings suggest that the myelographic defect and symptomatology arise from traction applied to the nerve root by the medially displaced pedicle.
TL;DR: Thirty-eight patients with the diagnosis of postoperative epiduro-arachnoiditis are reported upon, all of which had had previous surgery for disc herniation, and the diagnosis was confirmed at repeat surgery.
Abstract: Thirty-eight patients with the diagnosis of postoperative epiduro-arachnoiditis are reported upon. All had had previous surgery for disc herniation, and the diagnosis of epiduro-arachnoiditis was confirmed at repeat surgery. Massive epidural scarring with no coexistent pathologic condition was found in every patient, and adhesive arachnoiditis was noted in three. The common clinical presentation consisted of low-back pain and sciatica, and radicular pain was usually a continuation or a recurrence of the preoperative sciatic pain. Neurologic deficits were mild, and no patients with the classic picture of adhesive arachnoiditis were found. Myelographic patterns did not disclose any correlation with the clinical symptoms. Five myelograms were normal, while six others simulated a recurrent disc herniation. The results of scar excision were good in 13 patients, fair in eight, and a failure in 17.
TL;DR: Forty-three cases of neurologic complications of untreated spinal deformities are reviewed, and a plea for prevention is made, as it is far preferable to avoid this dreaded complication by early fusion of kyphotic problems.
Abstract: Forty-three cases of neurologic complications of untreated spinal deformities are reviewed. Kyphosis, averaging 95 degrees, was present in all but one patient. The most common deformity was a congenital kyphosis, present in 17 patients. The complication was more common in males, in the presence of thoracic deformities, and in the second decade. Treatment consisted of anterior spinal cord decompression in 25 patients, laminectomy in ten, Capener decompression in six, correction and fusion in five, and Hyndman-Schneider decompression in three. Laminectomy gave the worst results; six of ten patients who received this treatment showed deterioration. Anterior cord decompression gave the best results, with 16 of 25 showing improvement. A treatment plan for this complication is proposed. A plea for prevention is made, as it is far preferable to avoid this dreaded complication by early fusion of kyphotic problems.
TL;DR: This article critically analyzes the neurologic patterns of injury, radiologic features, management, outcome, and pathomechanics in 97 children whose acute spinal cord injury was managed and followed at The Institute for Rehabilitation and Research.
Abstract: There is considerable confusion and controversy regarding the incidence of radiologic abnormalities, prognosis, and pathomechanics of spinal cord injuries in children The comparison of mechanisms of injury, severity of trauma, methods of management, and outcome has been very difficult because some authors have used 12 years as the upper age limit, while others have included patients as old as 18 years This article critically analyzes the neurologic patterns of injury, radiologic features, management, outcome, and pathomechanics in 97 children whose acute spinal cord injury was managed and followed at The Institute for Rehabilitation and Research Pertinent literature on the subject is also extensively reviewed
TL;DR: Ligamentum nuchae, which is similar to ligamentum flavum in its high elastic content, was also effective in preventing scar formation and free fat grafts prevented fibrosis whether the graft was placed at the laminectomy site or around the nerve roots.
Abstract: In repeat lumbar surgery for failure of the original operation to provide lasting relief, well-organized fibrous tissue is often noted binding together the dura, nerve roots, and erector spinae muscles. Lumbar laminectomy was carried out in 46 dogs and seven groups of animals studied. Gelfoam failed to prevent fibrosis. Free fat grafts prevented fibrosis whether the graft was placed at the laminectomy site or around the nerve roots. Vascularization of the grafts was demonstrated by injection of India ink before sacrifice. Ligamentum nuchae, which is similar to ligamentum flavum in its high elastic content, was also effective in preventing scar formation. The operative biopsy findings at reexploration in four patients who had free fat grafts following laminectomy are presented.
TL;DR: In normal controls, maximal muscle torque is greater in back muscles than in abdominal muscles, and the definite influence of aging is found in both muscles.
Abstract: A new method of quantitative measurement with a cybex machine is applied to the trunk muscles. The curves of muscle torque and muscle fatigue are easily obtained in clinical medicine. In normal controls, maximal muscle torque is greater in back muscles than in abdominal muscles, and the definite influence of aging is found in both muscles. Furthermore, the trunk muscles are more easily fatigued by a sustained contraction than by repeated contractions, and abdominal muscles are more easily fatigued than back muscles. The role of the trunk muscles in the mechanism of pain production and prevention is still to be determined.
TL;DR: The author's 35 years' experience using cadaver bone for interbody spinal fusion operations has led to the development of a simplified bone bank method, which was compared with fusions using autografts or banked bone from proven methods with no untoward complications.
Abstract: Cadaver bone for spinal fusion operations is as safe as autografts The author's 35 years' experience using cadaver bone for interbody spinal fusion operations has led to the development of a simplified bone bank method Unsterile bone removed from young, fresh cadavers is cut into appropriate sizes and shapes, washed clean, packaged and sterilized with ethylene oxide gas, then aerated and stored at room temperature The results of spinal fusion, both cervical and lumbar, using 187 gas-sterilized bone grafts in 58 patients operated on over the past year and half, were reviewed and compared with fusions using autografts or banked bone from proven methods The rate and percentage of fusion of gas-sterilized bone was comparable to other bone grafts with no untoward complications
TL;DR: In this paper, a retrospective review was made of 30 patients who had failed multiple traditional surgical procedures for low-back pain, sciatic pain, or both, and the most common cause of the poor results appeared to be failure of initial selection, even though all patients appeared to meet traditional indications for operative intervention.
Abstract: A retrospective review was made of 30 patients who had failed multiple traditional surgical procedures for low-back pain, sciatic pain, or both. The most common cause of the poor results appeared to be failure of initial selection, even though all patients appeared to meet traditional indications for operative intervention. Psychosocial problems (eg, drug abuse, alcoholism, marital discord, personality disturbances) were prevalent, but were not initially recognized. Thoughtful assessment of patients being considered for initial lumbar spine surgery, which includes objective psychological testing, may reduce the incidence of unsuccessful lumbar spine surgery.
TL;DR: Patients who underwent anterior interbody fusion for lumbar disc derangement were examined two to 15 years after the operation, finding complete relief of back pain and marked improvement of sciatica.
Abstract: Ninety-seven patients who underwent anterior interbody fusion for lumbar disc derangement were examined two to 15 years after the operation. Complete relief of back pain was obtained in 60% and of sciatica in 85%; marked improvement of back pain was obtained in 29% and of sciatica in 10%. The fusion rate was 63% and was only slightly correlated with symptomatic improvement. Many complications were encountered, most of which were transient.
TL;DR: When compared with healthy subjects, the patients seeking hospitalization had significantly smaller strengths during attempted extension relative to their strengths during tried flexion or lateral bending, and their trunk-strength ratios did not differ significantly from those of the outpatient group.
Abstract: Trunk strengths of 16 male and 17 female patients with chronic low-back disorders were measured. The patients sought hospitalization for four weeks in a pain clinic. Maximum voluntary trunk strengths in the standing position were measured during attempted flexion, extension, and lateral bending. The trunk strengths of these patients were then compared with those of health subjects and with those of patients with low-back disorders who sought treatment as outpatients of a general orthopaedic office practice. In making the comparisons, intra-individual trunk-strength ratios were used to overcome problems due to the effects of patients' general weakness and any psychologic factors. When compared with healthy subjects, the patients seeking hospitalization had significantly smaller strengths during attempted extension relative to their strengths during attempted flexion or lateral bending. Their trunk-strength ratios did not differ significantly from those of the outpatient group.
TL;DR: It is concluded that attention should be given to this effect of the hamstrings on the lumbar spine when workplaces are designed.
Abstract: The hamstring muscles can restrict hip flexion, especially when the knees are extended. It was hypothesized that individuals with short or tight hamstrings would have abnormal tilting of the pelvis in some seated postures, with greater flattening or reversal of the lumbar lordosis. Healthy adults were studied. A toe-touch test was used to measure range of hip flexion. Lumbar spine curvature was measured in standing, in sitting with the knees flexed, and in sitting with knees partially extended. Large individual variations in range of hip flexion were found. Persons with a small range had the most pronounced change in spine curvature in the second seated posture. It is concluded that attention should be given to this effect of the hamstrings on the lumbar spine when workplaces are designed.
TL;DR: Twenty-four cases of lumbosacral hemivertebrae are reviewed and clinical and radiographic spine decompensation was found to be an important parameter in following these patients.
Abstract: Twenty-four cases of lumbosacral hemivertebrae are reviewed. The treatment groups consisted of observation, bracing, posterior spinal fusion with and without Harrington instrumentation, and two-stage hemivertebral excision. Clinical and radiographic spine decompensation was found to be an important parameter in following these patients. Results with observation and bracing were variable and unpredictable. The best surgical correction was obtained with lumbosacral hemivertebral excision.