Differential diagnosis of recurrent lumbar disc herniation and postoperative deformation by myelography. An impossible task.

A series of 44 patients with persistent or recurring sciatic pain after myelography and operation for disc herniation were remyelographed and reoperated. Patients with lesions at a new level or at the same level but on the opposite side presented no diagnostic problems. However, in patients with myelographic changes at the same level and on the same side as at the first operation, it was impossible to distinguish disc herniation from postoperative extradural scarring. This was true whatever myelographic sign or combination of signs was chosen.

Lumbar myelography with amipaque.

In lumbar myelography, early side effects occur in about half the patients examined with modern water-soluble contrast media. At myelography with Amipaque (metrizamide) these reactions are usually minor, and serious adverse reactions are rare. In our own series of 650 consecutive lumbar myelographies with Amipaque there were no serious adverse effects. Minor adverse reactions occurred in 56% of the patients. Transient electroencephalogram (eeg) changes were seen in 14% of the patients, with only 5 patients showing paroxysmal spike activity. Adhesive arachnoiditis following lumbar myelography occurs significantly less often with Amipaque than with any other contrast medium. The properties of Amipaque provide excellent possibilities for detailed studies of all parts of the spinal subarachnoid space, and the medium constitutes a new and interesting aid for these investigations.

Computed tomography of bone fragments in the spinal canal. An experimental study.

The detectability of bone fragments of differing size and structure, placed epidurally in the spinal canal at different levels from T XI to L II, was studied in three vertebral preparations using three different CT scanners, Philips Tomoscan 310, General Electric 8800 and Siemens Somatom 2. The thickness of the bone fragment was the most decisive factor. Cortical bone fragments could be detected down to a thickness of 0.6 mm and spongy bone fragments down to 1.2 mm. No difference in detectability between the different CT scanners was found.

Reduction of radiation dose in radiologic examination of patients with scoliosis.

In an attempt to reduce the radiation dose during the examination of scoliotic patients, several screen-film combinations have been compared with a conventional system used at present. Kodak's Lanex Regular screen with Kodak Ortho H film enables the dose to be reduced eight times without significant deterioration of the image quality. The dose to the mammary glands can be reduced further by a factor of five if posterior--anterior instead of anterior--posterior projection is used.

Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion.

One hundred patients from the Gothenburg Scoliosis Data Base were studied. They met the following criteria: (1) adolescent idiopathic scoliosis (2) completion of treatment before age 20, (3) a minimum follow-up of five years thereafter, (4) a minimum age of 22 years at final follow-up, and (5) operation performed by the senior author. Of these, 95 were personally examined. The surgical technique from 1968 to 1973 included a two-stage Harrington distraction, with fusion added at the second operation (52 patients). From 1973 to 1975, 48 patients were treated with a one-stage distraction and fusion after a week of preoperative Cotrel traction. Postoperatively, all patients were treated with a Milwaukee brace. A spinal examination and functional assessment, including a questionnaire and pain drawing, full standing anterior-posterior (AP), and lateral roentgenograms of the spine, was performed by independent observers. Eighty-five subjects without scoliosis served as a control group. The radiographic evaluation showed the usual nearly 50% permanent correction at the follow-up examination averaging nine years postoperatively. Lateral roentgenograms, however, demonstrated in 52% flattened or kyphotic cervical spines producing no significant complaints, non-significant flattening of the thoracic kyphosis, but significant lowering of the lumbar lordosis. Fifteen of the 24 patients with distal hook insertion and fusion including L4 or L5 demonstrated retrolisthesis. All had significant low-back pain. Degenerative facet joint changes and disc space narrowing was noted in 11 patients, again with a distal hook purchase in L4 or L5. Compared to the controls, the operated patients, as a group, revealed no lessened activity or back pain at any location.(ABSTRACT TRUNCATED AT 250 WORDS)

Unstable thoracolumbar fractures. A study by CT and conventional roentgenology of the reduction effect of Harrington instrumentation.

Fourteen patients with unstable thoracolumbar fractures were examined with conventional roentgenologic technique and CT before and after operation with Harrington instrumentation. CT was superior in evaluating posterior elements, bone fragments in the spinal canal, and degree of narrowing of the spinal canal. Harrington rods restored the general spinal alignment. However, even after surgery, the midsagittal diameter, as well as the cross-sectional area of the spinal canal were still diminished by 26%. The reduction of the spinal canal improved significantly by early surgical intervention. Open reduction and stabilization with Harrington rods and fusion within three days after injury is recommended.

The crush-cleavage fracture. A "new" thoracolumbar unstable fracture.

Among 14 patients with unstable thoracolumbar fractures examined by both conventional radiography and CT, we found seven patients with a "new" common fracture pattern. This fracture pattern consisted of (1) superior disc injury, (2) crush fracture of the upper half of the vertebral body, (3) sagittal fracture (cleavage fracture) of the lower half of the vertebral body, (4) bone fragments in the spinal canal, and (5) laminar fracture. Five of the seven patients had sustained their injuries in vertical falls; all five had primary neurological deficit symptoms. We consider this fracture to be unstable.

The thoracolumbar crush fracture. An experimental study on instant axial dynamic loading: the resulting fracture type and its stability.

Seven vertebral preparations of L1, with surrounding discs, facet joints, and ligaments were exposed to an instant axial dynamic force in order to produce a burst or crush fracture. The resulting fractures were similar to fractures observed clinically and showed a comminuted vertebral body with fractured vertebral end-plates, dislocated disc nucleus, bone fragments severely encroaching upon the spinal canal, and facet joint laxity. The flexion-extension range was increased considerably. This implies that this fracture type should be regarded as unstable with a risk of progressive flexion deformity, neurologic deterioration and pain. The fracture could be reduced by an axial distraction force of 400 N simulating the effect of Harrington distraction rods. However, the distraction resulted in an "empty" vertebral body with small areas of spongious bone mixed with fragments of the disc nucleus and fragments of the vertebral end-plate.

Radiologic progression of isthmic lumbar spondylolisthesis in young patients.

In 311 patients (160 girls and women and 151 boys and men) with lumbar spondylolysis/spondylolisthesis 30 years of age or younger at diagnosis and with at least two separate examinations available, radiographs were evaluated retrospectively to estimate the magnitude of slip progression in relation to age and to search for possible prognostic factors of progression. The mean age at diagnosis was 16.2 years, and the mean observation time was 3.8 years. Nine patients (3%) had a slip progression (defined as an increase greater than or equal to 20%). The magnitude of progression per year was low (0.6%). No prognostic factors for progression were found.

Intrinsic disc pressure as a measure of integrity of the lumbar spine.

Intradiscal pressure and volume measurements were made in 84 fresh cadaveric lumbar spine disc spaces. The nucleus was injected with a roentgenographic contrast agent under fluoroscopic examination. The intrinsic pressure, the pressure at which the agent entered the disc, and the maximum pressure that the disc could hold were measured. The discs were graded for degeneration. The intrinsic and maximum pressures were found to be inversely related to disc degeneration grade, and directly related to each other. Relatively greater degeneration was found at lower levels of the lumbar spine as compared to the upper levels. The intrinsic disc pressure may prove to be a useful clinical tool in the evaluation of spinal integrity.

Roentgenographic measurement of lumbar intervertebral disc height.

The influences of differences in both intervertebral motion segment orientations and in reader judgments on measurements of the apparent intervertebral disc heights in lateral roentgenographs of the lumbar spine were examined. Forty-nine roentgenographs were obtained of nine discs that were titled laterally up to +/- 10 degrees, and rotated longitudinally up to +/- 20 degrees. Three orthopaedic surgeons and three radiologists measured disc heights from five of these roentgenographs, all using the same measurement method. The differences in apparent height that resulted from the orientation changes and differences in judgments among the six readers were considerable, usually of the order of one half of the nominal disc height. The results show that, while roentgenographic measurements can be used to estimate disc height, accurate measurements cannot readily be made from routine roentgenographs, and the interpretation should always be cautious.

Intertrochanteric osteotomy for osteoarthritis of the hip. A radiological assessment of non-compressive and compressive methods.

A radiological review of two groups of intertrochanteric osteotomies of the femur for primary osteoarthritis of the hip has been made. Each group oroginally consisted of forty-one hips. In one group a Wainwright straight V-spline without compression had been used for fixation, and in the other group an AO angled plate with compression. The time for bony union was equal in the two groups but the incidence of non-union was lower in the AO group. Regression of cysts and of bone sclerosis was more frequent in the Wainwright group, possible as a consequence of the greater medial displacement and varus angulation.

Fixation of ankle fractures: power-driven staples compared with a routine method, a 3-year follow-up study.

A new method of internal fixation of ankle fractures with power-driven staples is presented. The results in 25 ankle fractures treated with this method were compared with those of 25 matched ankle fractures treated with Wiberg staples, cerclage, and Palmer pins. Reduction was exact in 22 fractures in the stapled group and in 23 in the routine group; all the fractures healed within 6 weeks. The only difference between the two groups was a gain of 20 min in operating time when using the power-driven staples (p less than 0.01). At follow-up observation 3 years later, no additional significant subjective, objective, or radiological differences appeared.

Side effects after lumbar myelography with dimeglumine iocarmate (Dimer-X). Further experiences.

Lumbar myelography with dimeglumine iocarmate was performed in 90 cases premedicated with diazepam (Valium). EEG was performed before, as well as 3 and 24 hours after myelography. The use of diazepam interfered to some extent with the interpretation of the EEG. In 3 cases EEG abnormalities occurred 3 hours after myelography, most probably ascribable to Dimer-X. No further changes were found in the 24-hour recording. Immediate side effects were few and mild and seizures did not appear. The EEG abnormalities were equally distributed among patients with and without side effects.

Adverse effects of lumbar myelography with amipaque and dimer-X.

The adverse effects in a series of 50 lumbar myelographies with Amipaque were compared with those in a corresponding series, examined with Dimer-X. Side effects occurred in 58% of the cases examined with Amipaque and in 68% of the Dimer-X series. No seizures occurred in 58% of the cases examined with Amipaque and in 68% of the Dimer-X series. No seizures occurred in either series but slight fibrillations of fasciculations appeared in 2 Dimer-X patients. Hyperreflexia of the legs was recorded in 22% of the Amipaque and in 36% of the Dimer-X cases. Other adverse reactions to the media were mild to moderate. Some burst activity, but no definite paroxysmal abnormality was noted in EEG recordings in 2 Amipaque cases. The low epileptogenicity of Amipaque has ensured a wider safety margin of lumbar myelography.

Elongation in profundus tendon repair. A clinical and radiological study.

A radiographical study of 63 digits with tendon lacerations within the digital sheath is presented. 60 of these digits were evaluated clinically 6-36 months (mean 15 months) after surgery. At primary tendon repair one wire marker was placed on each side of the repair site in the profundus tendon. The distance between the markers was measured at operation and postoperatively on 3 different occasions on radiograms. The results showed that increase of the distance between the markers by more than 5 mm, considered to indicate elongation in the suture, occurred in 25 out of 59 repaired profundus tendons (42%) and in most instances this happened during the period of immobilization. The cause of elongation could be identified in 9 digits. In 5 it was due to rupture of the suture material, the tendons being repaired with 5-0 Flexon steel wire. In the other 4 digits, sutured with 4-0 Silky Polydec, slipping of the knot was revealed at reoperation. There was a strong correlation between increased distance between the markers and a poor outcome, elongation being the most frequent cause.

Unstable thoracolumbar fractures. A comparative radiologic study of conservative treatment and Harrington instrumentation.

Two comparable groups with unstable thoracolumbar fractures have been studied: one consisting of 23 patients treated conservatively and one consisting of 20 patients treated surgically with Harrington instrumentation. The vertebral injuries have been analysed radiologically at the time of injury as well as after completion of conservative and surgical treatment and at follow-up on average 6 years and 3 months after injury in the conservatively treated group and 2 years and 2 months after injury in the operated group. The vertebral fractures were often solitary at the L1 level with a characteristic radiologic appearance and mainly caused by flexion-rotation injuries. There were indirect signs of associated ligament injuries in most cases. Indirect signs of associated disc injury were found in 77 per cent of the cases, most of them related to the superior disc. The signs of disc injury were accentuated at the two follow-up examinations. In the operated group, the radiologic appearance of the vertebral body normalised after Harrington instrumentation. A preoperative gibbus angle of 19.4 degrees was reduced to 6.8 degrees on average postoperatively. In 13 of the operated cases the rods were removed. Among these patients the gibbus angle increased to 17.6 degrees at the final follow-up examination, compared with 11.9 degrees in the patients who had their rods retained. This difference in gibbus angle was significant. In the conservatively treated group, the initial gibbus angle of 19.5 degrees continuously increased to 27.6 degrees at the follow-up examination. All vertebral fractures had healed at the follow-up examination.