Pyrophosphate arthropathy.

A scanning electron microscopic study of six cases of pyrophosphate arthropathy has been conducted. In the majority of cases the crystals were rectangular. In some cases giant crystals were present. In one case, the crystals were pyramidal. It is concluded that many geometrically different forms of calcium pyrophosphate crystal exist and that the scanning electron microscope is a useful tool in the differentiation of pyrophosphate arthropathy from other forms of crystal synovitis.

Selective ascending lumbosacral venography in the assessment of lumbar-disc herniation. An anatomical study and clinical experience.

Epidural venography was performed in 110 patients with suspected lumbar-disc herniation by catheterization of the ascending lumbar and ascending sacral veins. The findings by venography and by myelography were compared with those revealed by operative exploration. Only sixty-one patients had venography, myelography, and operative exploration. In fifty of these patients with no previous disc surgery, the diagnostic accuracy of venography was 98 per cent and of myelography, 90 per cent. Venography had limited value in the other eleven patients who had had one or more prior disc operations because it did not distinguish between scarring and recurrent disc herniation at the levels previously explored. Selctive ascending lumbosacral venography is indicated both in patients who have not had a prior disc operation, as a guide to whether myelography should be performed when the clinical picture is ambiguous, and in patients whose myelogram is normal or equivocal but whose signs and symptoms are strongly suggestive of disc herniation.

Use of polymethylmethacrylate to enhance screw fixation in bone.

Pull-out testing of screws inserted into cement and bone under various conditions showed that the cement-screw complex was significantly stronger when the screw was placed in soft cement and the cement was allowed to polymerize without further manipulation. When screw fixation in osteoporotic bone was reinforced with cement, the bone was the weakest component in the system. Fixation under these conditions should be enhanced by increasing the area of contact between the cement and bone. By cooling the cement to prolong its working time, it could be injected with a syringe in such a way that maximum endosteal and periosteal contact was provided.

Anomalies of the lumbosacral nerve roots. Review of 16 cases and classification.

Sixteen cases of lumbar nerve root anomalies found at surgery are reviewed and a classification system presented. All but two patients had an associated disc herniation which initiated the symptomalogy and was the indication for surgery. Fifty percent were found at repeat exploration. Eleven patients had conjoined nerve roots, five had two roots in one foramen, and three had connecting roots. Nerve root anomalies should be suspected in cases of failed disc surgery. Adequate decompression by foraminotomy or excision of pedicles is required as well as discectomy to alleviate the symptomatology.

Hip-spine syndrome.

Thirty-five patients were reviewed with what is called hip-spine syndrome. Concurrent disease at both the hip and spine is not infrequent in the older population. In most cases, the finding and diagnosis were straight forward, and were classified as a simple hip-spine syndrome. Cases in which the spine symptoms are aggravated by deformity of the hip were called a secondary hip-spine syndrome. Symptomatic disease at both the hip and spine can present as a complex hip-spine syndrome. Symptoms from both sites gives a confusing clinical picture and may require ancillary investigations to diagnose the major source of disability. Failure to recognize concurrent disease at both the hip and spine may lead to misdiagnosis and possibly erroneous treatment.

Spinal metastases: the obvious, the occult, and the impostors.

Spines from 832 deceased patients with a terminal diagnosis of malignant neoplasm were examined grossly, microscopically and radiographically for evidence of tumor. Gross tumor and bone destruction or sclerosis were reliable signs of obvious metastases. Occult lesions visualized on gross sagittal sections but not detectable radiographically occurred in 26% of spines with confirmed metastatic deposits. Vertebral collapse was not a reliable indicator of metastases. Collapse was not caused by neoplasm in 22% of cases. Overall, metastases were found in 36% of patients dying from neoplastic disease. Although most metastases are obvious, occult lesions not visible radiographically occur. Collapsed vertebra may be impostors simulating metastatic disease.

Nerve root infiltration in the diagnosis of radicular pain.

Clinical and standard radiographic evaluation of patients with lumbosacral radicular symptoms may, on occasion, fail to delineate a cause. This study retrospectively reviews 62 patients who had undergone nerve root infiltration (NRI) and assesses the accuracy and indications for this diagnostic study. Surgical exploration of patients with a Group 1 response (typical pain reproduced by needle placement and then relieved by NRI) confirmed local root pathology in all. Exclusive of patients with arachnoiditis, a Group 1 response showed 85% accuracy in identifying a single symptomatic root. A Group 2 response (typical pain reproduced by needle placement but not relieved by local anesthesia) indicated multiple root involvement. Patients with a Group 3 or Group 4 response (typical pain not reproduced by needle insertion, with or without relief of pain by local anesthesia) were seldom relieved of radicular pain. NRI was most useful in investigation of patients with radicular symptoms in whom other investigations were 1) normal, 2) showed multiple level involvement, or 3) were difficult to interpret because of previous surgery.

Localisation of the level of symptomatic cervical disc degeneration.

There are many difficulties associated with the localisation of the symptomatic segment in patients presenting with cervicobrachial pain with no evidence of impaired conduction in the nerve root. Ancillary radiological investigations such as myelography, epidural phlebography, and epidural myelograms are of unreliable diagnostic value. However, discography can be of value if the technique described here is used. Infiltration of the cervical nerve root with local anaesthetic has also proved useful in the localisation of the symptomatic segment. The techniques used in cervical discography and infiltration of the nerve root are described and their reliability is assessed.

Chymopapain versus conventional surgery for lumbar disc herniation. 10-year results of treatment.

We reviewed two comparable groups of patients who had been treated for lumbar disc herniation by chymopapain chemonucleolysis (145) or conventional surgical discectomy (91). They were reviewed 10 years after treatment by questionnaire, followed by a personal interview by an independent observer. The results of the surgically treated groups were slightly better than those treated with chymopapain. In particular, there was significantly better early relief of leg and low back pain, and fewer patients needed a second procedure. Complications were few in both groups.

A porous metal system for joint replacement surgery.

A porous coated chrome cobalt system has been developed to provide long term stabilization in joint replacement surgery. The pore sizes are 50 to 100 microns, thus ensuring sufficient fatigue strength for use in high load bearing situations. Extensive in vitro and in vivo studies have been performed, and a five year follow-up of porous coated total shoulder prostheses has failed to reveal any evidence of loosening. The early results of porous coated hip implants is encouraging.