Energy supply and demand in the intervertebral disc / Fornecimento e demanda de energia no disco intervertebral / Suministro de energía y demanda en el disco intervertebral

ABSTRACT The intervertebral disc (IVD) is one of the parts of the body most commonly affected by disease, and it is only recently that we have come closer to understanding the reasons for its degeneration, in which nutrient supply plays a crucial role. In this literature review, we discuss the basic principles and characteristics of energy supply and demand to the IVD. Specifically, we review how different metabolites influence IVD cell activity, the effects of mechanical loading on IVD cell metabolism, and differences in energy metabolism of the annulus fibrous and nucleus pulposus cell phenotypes. Determining the factors that influence nutrient supply and demand in the IVD will enhance our understanding of the IVD pathology, and help to elucidate new therapeutic targets for IVD degeneration treatment.

RESUMO O disco intervertebral (IVD) é uma das partes mais comuns do corpo e apenas recentemente nos aproximamos de compreender as razões da sua degeneração, em que o suprimento de nutrientes desempenha um papel crucial. Nesta revisão da literatura, discutimos os princípios básicos e as nuances do fornecimento e da demanda de energia para o IVD. Específicamente, analisamos como os diferentes metabólitos influenciam na atividade das células IVD, os efeitos da carga mecânica no metabolismo das células IVD, a diferença no metabolismo energético dos fenótipos das células fibrosas e do núcleo do pulposus anelar. A determinação de fatores que influenciam o suprimento e a demanda de nutrientes no IVD aumentará nossa compreensão da patologia IVD e ajudará a elucidar novos alvos terapêuticos para o tratamento da degeneração IVD.

RESUMEN El disco intervertebral (IVD, por sus siglas en inglés) es una de las partes más comúnmente enfermas del cuerpo y solo recientemente nos acercamos a la comprensión de los motivos de su degeneración, de los cuales el suministro de nutrientes juega un papel crucial. En esta revisión de la literatura discutimos los principios básicos y los matices de la oferta y demanda de energía para el IVD. Específicamente, revisamos cómo los diferentes metabolitos influyen en la actividad de las células IVD, los efectos de la carga mecánica sobre el metabolismo de las células IVD y las diferencias en el metabolismo energético de los fenotipos de las células del anillo fibroso y el núcleo pulposo. La determinación de los factores que influyen en la oferta y demanda de nutrientes en el IVD mejorará nuestra comprensión de la patología IVD y ayudará a dilucidar nuevos objetivos terapéuticos para el tratamiento de la degeneración IVD.

Corpectomia lateral parcial para o tratamento de compressão ventral extradural crônica entre T9-T10 em um cão / Partial lateral corpectomy for treatment of chronic ventral extradural compression between T9-T10 in a dog

Objetivou-se relatar um caso de protrusão do disco intervertebral com localização atípica e descrever a técnica cirúrgica de corpectomia lateral parcial no tratamento da afecção em um cão. Um cão de sete anos de idade, macho, raça Pug, foi atendido com ataxia proprioceptiva dos membros pélvicos havia três meses, associada à doença do disco intervertebral entre a nona e 10ª vértebras torácicas. Após um mês de tratamento conservativo sem melhora, o paciente foi encaminhado para o tratamento cirúrgico, quando foi realizada corpectomia lateral parcial esquerda para descompressão da medula espinhal. Após a cirurgia, o paciente apresentou melhora considerável do quadro, sendo a técnica eficaz na remoção da compressão extradural, sem manipulação da medula espinhal ou outras complicações.(AU)

The aim of this study is to report a case of intervertebral disc protrusion with atypical location and describe the surgical technique of partial lateral corpectomy in the treatment of this disease in a dog. A dog, seven -years-old, male, Pug breed was attended with proprioceptive ataxia of the hind limbs for three months correlated with intervertebral disc disease between the 9th and 10th thoracic vertebrae. After a month of conservative treatment without improvements, the patient was referred for surgical treatment, which was performed as a partial left lateral corpectomy for decompression of the spinal cord. After surgery, the patient showed considerable improvement, this technique being shown to be effective in the removal of extradural compression, without manipulation of the spinal cord or other complications.(AU)

BIOMECHANICS OF THERAPEUTIC RIDING DURING THE DISEASES OF I-II DEGREE DYSPLASTIC LUMBAR AND STATIC (SHORT LEG) SCOLIOSIS.

The goal of the paper is to substantiate the essence of ridetherapy biomechanics as the pathogenetic therapeutic and prophylactic method at lumbar dysplastic (the I and II degrees) and static (short-legged induced) scoliosis. Uneven lower extremities caused by any reason and asymmetric support induce the change in the arrangement of trochantin to the vertebra and correspondingly the uneven loading of lumbar muscles. The asymmetric strength of lumbar muscles evoked by the change in rotator condition becomes the cause of the formation of scoliosis primary arc which, in its turn, causes a compensatory spinal curvature. In case of dysplastic scoliosis a leading role belongs to the beginning of dystrophic changes in intervertebral discs and its further decentration. At riding position the lower extremities are completely disengaged from the antigravity redistribution, the child is in direct contact with vibrations and jolts coming from the horseback; the antigravity loading is distributed on the muscles of the torso and thus, it creates an opportunity to purposefully affect the correction of the spine. During scoliosis the pathogenic essence of ridetherapy is due to the comprehensiveness of its procedures, expressed in the fact that during one procedure several factors are influenced simultaneously: nucleus pulpous, the torso and iliopsoas muscles, the antigravity system, etc. According to the clinical-functional and radiographic studies carried out in the dynamics on 11-16 years old adolescents it has been established that in those groups where the rehabilitation was conducted in a complex with ridetherapy the authentically higher results were obtained as compared to the groups where the rehabilitation was held using therapeutic exercises and massage.

Long-term outcomes of lumbar posterior apophyseal end-plate lesions in children and adolescents.

BACKGROUND: A lesion of the lumbar posterior apophyseal end plate in children and adolescents causes symptoms similar to those associated with a herniated disc. However, the end-plate lesion and the herniated disc differ in terms of pathology. The purpose of this study was to clarify the long-term clinical and radiographic outcomes in children and adolescents who were treated either surgically or conservatively for a lumbar posterior apophyseal end-plate lesion. METHODS: We identified twenty-four consecutive patients who had been treated in the sports clinic of our hospital. The mean age at the first medical examination was 14.5 years. The mean follow-up time was 13.8 years. The mean age at the time of final follow-up was 28.4 years. All twenty-four patients had symptomatic low back pain with sciatica. All but two were active in sports. Sixteen patients were treated conservatively, and eight patients underwent surgical intervention. Skeletal maturity was evaluated on the basis of the appearance of the secondary ossification center of L3. RESULTS: The apophyseal stage ("A" stage), which was assigned when the secondary ossification center of the vertebral body was visible on radiographs, was seen most frequently. Both the surgically treated group and the conservatively treated group demonstrated progressive disc degeneration at the involved level. The average Roland-Morris Disability Questionnaire (RDQ) score was 1.3 for the patients treated conservatively and 1.8 for those treated surgically, a nonsignificant difference. One patient developed spinal stenosis after twelve years of conservative treatment. One patient treated surgically demonstrated severe lumbar instability. There were no significant associations between the magnetic resonance imaging (MRI) findings and RDQ scores. Histological examination of surgical specimens showed irregular alignment of the anulus fibrosus, with degenerative matrix and chondrocytes without a nucleus. CONCLUSIONS: The long-term outcome for patients with a posterior end-plate lesion is favorable, regardless of whether it is treated surgically or nonsurgically.

Magnetic resonance imaging findings in the painful adult coccyx.

OBJECTIVE: Imaging of the painful coccyx currently relies on standard and dynamic radiography. There are no literature data on MRI of the coccyx. This examination could provide information on the cause of pain. METHODS: 172 patients with severe chronic coccydynia underwent MRI and dynamic radiography of the coccyx. RESULTS: Disc abnormalities (seen in 70 patients) were related to either the presence of intradiscal liquid effusion (17/70), or abnormality of the endplates similar to Modic 1 changes (38/70), or uncertain abnormalities (15/70). Abnormalities of the tip of the coccyx (seen in 41 patients) were located in the surrounding soft tissues: venous dilatations (18/41), soft tissue inflammation (13/41) and ambiguous images (9/41). Vertebral bone oedema was observed in five cases and a benign tumour was observed once. The type of imaging feature depend broadly on the mobility of the coccyx: the 105 cases with a mobile coccyx mainly presented abnormal features mainly in a disc (63 cases vs. 4 cases for the tip), whereas the 67 patients with a rigid coccyx mainly showed abnormal features at the tip (37 cases vs. 7 for the joints, p < 0.001). CONCLUSIONS: We recommend MRI of the painful coccyx when dynamic radiography fails to reveal clearly a pathological lesion (i.e., normal or slightly increased mobility of the coccyx or a rigid coccyx lacking a spicule).

Progressive anterior vertebral bars: a study of 16 cases.

STUDY DESIGN: In a retrospective study, we report on 16 patients with congenital kyphosis due to progressively ossifying anterior unsegmented bars. OBJECTIVE: To specify the therapeutic strategy in such malformation. SUMMARY OF BACKGROUND DATA: Congenital kyphosis due to progressively ossifying anterior unsegmented bars is a particular and uncommon entity of congenital kyphosis. Progressive anterior vertebral bars result in slowly progressive kyphosis, which rarely lead to neurological compromise. Sagittal equilibrium of the spine is maintained by compensatory curves adjacent to the primary curve. METHODS: All patients had clinical assessment and successive measurements of segmental angle made on a standing lateral radiograph of the spine. Magnetic resonance imaging was obtained in four patients. Six patients were just observed. A brace was used in three. And seven were treated surgically. RESULTS: The compensatory capacity of the spine is reduced in lumbar area where there are few discs spaces below the bar. Presentation therefore tends to be at an earlier age and pain is more common.Magnetic resonance imaging enables definition of the structures immediately posterior to the bar and provides information regarding the integrity of the intervertebral disc. CONCLUSION: There is usually no need for surgery in thoracic and thoracolumbar localization. In lumbar localization, if the diagnosis is done early in childhood and if magnetic resonance imaging shows beyond the anterior ossification a normal T2-weighted magnetic resonance imaging disc space signal, desepiphysiodesis bar resection and cement interposition is mandatory. If the disc magnetic resonance imaging signal is abnormal or if the disc space is totally ossified, we propose a surgical correction of the kyphosis. For such cases a posterior wedge osteotomy seems to be the more suitable procedure.

Central precocious puberty associated with pituitary duplication and midline defects.

Central precocious puberty (CPP) is due to premature activation of the hypothalamic-pituitary-gonadal axis. It may be idiopathic or result from congenital or acquired CNS lesions. We describe a 7.4 year-old Brazilian girl with CPP who also presented hypertelorism, limitation of lateral neck rotation and synkinesis of the hands. Sellar and cervical column MRIs revealed pituitary duplication and rudimentary intervertebral disks. We present the clinical and imaging observations of this case, and a thorough literature review of this rare developmental abnormality.

Cervicobraquialgia / Neck pain

A dor em região cervical e braços é uma queixa comum. A dor pode ser fruto de alteração em diversas estruturas, por isso, seu diagnóstico diferencial é extenso. Os autores apresentam uma revisão sobre cervicobraquialgia, seu impacto socioeconômico, fatores etiológicos e aspectos importantes a serem observados durante anamnese e exame fisico. O diagnóstico, exames complementares e modalidades terapêuticas também são analisados. Por fim, apresentamos os recentes progressos na área terapêutica e profilática

Impaired intervertebral disc formation in the absence of Jun.

Jun is a major component of the heterodimeric transcription factor AP-1 and is essential for embryonic development, as foetuses that lack Jun die at mid-gestation. Ubiquitous mosaic inactivation of a conditional Jun allele by cre/LoxP-mediated recombination was used to screen for novel functions of Jun and revealed that its absence results in severe malformations of the axial skeleton. More-specific Jun deletion by collagen2a1-cre demonstrated the essential function of Jun in the notochord and sclerotome. Mutant notochordal cells showed increased apoptosis, resulting in hypocellularity of the intervertebral discs. Subsequently, fusion of vertebral bodies caused a scoliosis of the axial skeleton. Thus, Jun is required for axial skeletogenesis by regulating notochord survival and intervertebral disc formation.

Surgical treatment of congenital vertebral displacement Type A in the sagittal plane only: a retrospective study involving eleven cases.

STUDY DESIGN: The essence of congenital vertebral displacement Type A pathology is a congenital structure defect including a vertebral or intervertebral disc with instant curvature of the spinal canal in the sagittal plane. Clinically this defect assumes the shape of kyphosis or kyphoscoliosis. A retrospective review of 11 patients with this congenital deformity was conducted. OBJECTIVES: To evaluate the effectiveness of surgical treatment for congenital vertebral displacement, and to establish the optimal operative management. METHODS: Nine patients with a mean age of 3.3 years (range, 1.8-5.5 years) underwent surgery. Two patients were treated conservatively. All the patients underwent radiologic investigation, which included radiographs, three-dimensional computed tomography scans, and magnetic resonance imaging scans. The neurologic condition was assessed by clinical neurologic examination and somatosensory-evoked potentials. The following surgical techniques were performed: 13 posterior fusions in situ in eight patients; 4 anterior fusions in situ in four patients, 8 total or partial vertebrectomies with anterior fusion and stabilization using cylindric cage in 6 patients, 3 total or partial vertebrectomies with anterior fusion and stabilization using fibula graft in 3 patients, and 5 posterior fusions with instrumentation in 2 patients. The total mean follow-up period was 5.7 years (range, 2.1-9.9 years). RESULTS: The mean follow-up period after the last operation was 22 months (range, 2-48 months). The general results observed during the follow-up period were as follows. Deformity stabilization was obtained in six patients, whereas it was still progressive in three patients. In five patients, regression of neurologic deficits was obtained, whereas in patients, it was stable. Progression of neurologic deficits was observed in one patient (paraplegia). Retrospectively, the best clinical results were achieved after extensive decompression of the spinal cord with anterior stabilization of the spine using a cylindric cage or fibula autograft. These procedures were preceded or followed by posterior fusion. CONCLUSIONS: The findings showed that only extensive vertebrectomy and anterior stabilization using a cylindric cage or fibula graft combined in one operative procedure, preceded or followed by posterior fusion, ensures patients against progression of neurologic deficits and deformity of spine.

Congenital maldevelopment of intervertebral disc simulating a neurofibroma.

Intervertebral disc herniation is a common cause of radiculopathy and myelopathy in adulthood. It is an uncommon tumor mimic. We report on an extradural disc associated with an osseous defect ostensibly caused by pressure erosion and appearing as a neural tumor. It showed homogeneous enhancement on a contrast-enhanced MR examination, leading to an erroneous diagnosis of nerve sheath tumor. An attempt has been made to explain the likely mechanism of formation accounting for the imaging appearances, along with a review of the literature.

Compressao intradiscal em L5/S1 no exercicio de agachamento / Intradisk compression in L5/S1 in squatt exercise

A mensuracao da compressao do disco invertebral e uma das tecnicas aplicadas na analise da sobrecarga na coluna lombra.O objetivo deste trabalho foi estimar a compressao intradiscal(CI)em L5?S1 no momento final do exercicio de agachamento(AG)com peso.A amostra foi composta de 25 individuos com idade 25,8 +ou-5,3anos,estatura media 171,3+ ou- 9,9cm e peso medio 69,5+ou-13,9Kg fotografados com sobrecarga:de pe,AG com flexao minima e AG com flexao de tronco.As cargas utilizadas representaram um percentual medio do peso corporal de 25,0+ ou-7,7 por cento.Foram medidos,nas fotos,os angulos de flexao de tronco,joelho e tornozelo,utilizados como dados no aplicativo 2D STATIC STRENGTH PREDICTION PROGRAMVersion 4.2(Michigam University USA),alem de outras medidas antropometricas para estimativa da CI.Os valores estimados de CI foram comparados atravez do teste estatico Wilcoxon,o os resultados considerados significativos com p menor 5.Os resultados medios de CI na posicao em pe foi de 124,6 + ou-39,8lbs.A CI no exercicio com minima flexao de tronco foi 508,1 + ou-127,0lbs,significativamente menor que a no exercicio com flexao livre de tronco que foi de 670,3 + ou -128,7lbs.Os resultados masculinos apresentam valores medios maiores que os femininos.Mesmo exercutado corretamente, o AG aumenta significativamnete a CI,sendo fundamental a orientacao profissional na realizacao e indicacao do exercicio de AG

MR abnormalities of the intervertebral disks and adjacent bone marrow as predictors of segmental instability of the lumbar spine.

PURPOSE: To assess whether MR abnormalities of the intervertebral disks and adjacent bone marrow can predict segmental instability of the lumbar spine as diagnosed on functional radiographs. MATERIAL AND METHODS: A consecutive review was made of 60 patients examined with MR imaging and with lateral flexion and extension views of the lumbar spine. Sagittal T1- and T2-weighted images were evaluated blindly with regard to abnormalities of the intervertebral disk and the adjacent bone marrow. Segmental instability was diagnosed when a.p. translation of 3 mm or more was present on the functional radiographs. Moreover, the presence of osteophytes was evaluated on lateral standard radiographs. RESULTS: Of a total of 300 segments, 32 (10.7%) were unstable. Anular tears were the most relevant MR finding. Their sensitivity, specificity, and positive and negative predictive values for segmental instability were 18.8%, 97.0%, 42.9% and 90.9%. The corresponding values for traction osteophytes were 12.5%, 98.1%, 44.4% and 90.4%. Abnormalities of bone marrow were not significantly related to segmental instability (p=0.35). CONCLUSION: Functional radiographs should be considered in patients with anular tears or traction osteophytes. No correlation was found between segmental instability and abnormalities of bone marrow adjacent to the endplates.

[Combination of rare anomalies of the cervical spine and peripheral skeleton]. / Kombination seltener Anomalien der Halswirbelsäule und des peripheren Skeletts.

This paper presents a case report on a 59-year old patient of small stature with moderate mental retardation, strabismus and several rare skeletal anomalies. We found an os odontoideum, a dysontogenetic 3fold fusion of cervical vertebrae, multiple double-sided wrist bone dysplasias and brachytelephalangical digiti pedis I, but no anomalies of the heart or genitals. Clinical signs, biochemical parameters and results of x-ray and ultrasonic examination are demonstrated in this complex malformation syndrome that combines different anomalies known from other syndromes.

Resultados del tratamiento quirúrgico de la lumbociática de origen discal / Results of surgical treatment of lumbociatic pain from intervetebral disc origin

Se revisaron los expedientes de 84 pacientes operados por síndrome radicular con lumbociatalgia considerada de origen discal entre 1970 y 1987 en los hospitales Guadalupe e ISSSTEP de puebla, mediante laminectomía y en caso necesario foraminotomía, con observación postoperatoria de 12 meses a 15 años. En la cirugía se encontró que la lesión causal fue artrosis interfacetaria en nueve casos que se corrigió con foraminotomía; tres pacientes tuvieron patología diferente que consistió en cada caso en : ependimoma, plasmocitoma y cisticercosis. Los demás presentaron diversos niveles de severidad de herniación discal. Los resultados postoperatorios de acuerdo con la sintomatología fueron: en la lumbociática hiperálgica hubo 37 excelentes (69.8%), 11 buenos (20.7%) y cinco malos (9.4%). En la lumbociática paralizante hubo seis excelentes (50%), cuatro buenos (33.3%) y dos malos (16.6%). En los pacientes con lumbociática recidivante hubo nueve excelentes (47.3%), cinco buenos (26.3%) y cinco malos (26.5%).

Spinal neurological complications of achondroplasia. Results of surgical treatment.

Spinal neurological complications caused the admission of 17 patients with achondroplasia to the UCLA affiliated hospitals between 1955 and 1979. These patients constituted 41% of all achondroplastic patients admitted during that period. The spinal stenotic syndromes could be divided into three groups: Group I: thoracolumbar stenosis (10 patients); Group II: foramen magnum and upper cervical stenosis (five patients); and Group III: generalized spinal stenosis (two patients). Eleven patients underwent a total of 18 decompressive operative procedures for treatment of paraparesis, quadriparesis, sensory deficits, and sphincter dysfunction. Excellent results were obtained with patients in Group I and II, 77% of whom were ambulatory and continent postoperatively. Two patients in Group III fared less well, showing steady neurological deterioration despite multiple operative procedures. The spectrum of spinal neurological manifestations secondary to achondroplasia is reviewed. Problems with conventional radiological studies and the potential role of computerized tomographic analysis of such patients are discussed. Recommendations for surgical technique are made. Early recognition, prompt clinical evaluation, and safe and accurate radiological analysis of spinal neurological complications of achondroplasia will allow appropriate decompressive surgical procedures to be performed. Excellent results may be anticipated in the reversal and prevention of neurological deficit secondary to achondroplasia with such an approach.