[Therapeutic algorithm for low back pain]. / Algorithme thérapeutique de la lombalgie.

Low back pain (LBP) has become one of the greatest public health problems. The differentiation between specific and non-specific low back pain is mandatory. In the specific low back pain are classified all diseases whose etiology is well defined, quick and accurate diagnosis is required for specific treatment. Other types of low back pain can be considered non-specific. The management of acute low back pain is mainly based on analgesic treatment and early mobilization. Maintaining activity can prevent chronicity of LBP. Chronicity factors are multiple, mainly psycho-social and professional. The chronic low back pain treatment goals are the reduction of pain and better activity/participation to achieve the prevention of disability and maintaining work ability. Multidisciplinary treatment programs including personalized and guided physical therapy, cognitive behavioral therapy and short-term training programs will help to improve, restore and maintain the function in chronic low back pain.

Prevalence of degenerative joint complaints of the lower extremity: a representative study.

As part of the international campaign of the bone and joint decade, we aimed to present epidemiological data on the prevalence of major joint complaints in a Central European region. Ten thousand subjects aged between 14 and 65, selected randomly by the Hungarian central office of statistics from three counties in southern Hungary, were surveyed using our own questionnaire based on widely accepted scoring systems in the literature, focusing on major degenerative joint complaints, and using the short form 36 (SF-36) questionnaire. We found that the prevalence of hip pain in the observed group was 22.2%, the prevalence of knee pain 30.3%, and frequent ankle pain occurred in 9.7%. The results of the SF-36 questionnaire showed that with the exception of social function, neither of the values of the examined health dimensions reached levels of other international surveys. Details of the survey and the possible causes of the higher prevalence are discussed, along with the results of the SF-36 questionnaire.

Survey of Raynaud's phenomenon and systemic sclerosis based on a representative study of 10,000 south-Transdanubian Hungarian inhabitants.

OBJECTIVES: To assess the prevalence of Raynaud's phenomenon (RP) and of RP associated systemic sclerosis (SSc) in a large regional representative study. METHODS: Ten thousand individuals aged between 14-65 years participated in face-to-face interviews. The stratified sample of the South-West Hungarian population was representative for age, sex and urban or rural residence. Individuals reporting complaints suggesting the presence of "clinically significant" RP were asked to undergo a clinical investigation. Patients showing complaints provoked by taking something out of the freezer (-20 degrees C) compartment of the refrigerator and/or whether they had experienced digital ulcers were sorted into this category. RESULTS: The overall prevalence of RP was at least 578.9/10,000, and the prevalence of "clinically significant" RP could be calculated as at least 87.7/10,000 inhabitants. In this latter group 17.2% of the cases had either established SSc or anticentromere antibody or scleroderma capillary pattern on nailfold capillaroscopy. SSc with "clinically significant" RP and/or ulcers was identified in a prevalence of 9.1/10.000 individuals, whilst there was a prevalence of 14.7/10,000 of RP with either anticentromere antibody or scleroderma capillary pattern. CONCLUSIONS: "Clinically significant" RP affects almost 1% of the population. We identified cases with early stages of scleroderma spectrum disorder showing either anticentromere autoantibody or scleroderma capillary pattern. The prevalence of SSc was found to be higher than expected. It is reasonable to screen "clinically significant" RP cases for scleroderma-related symptoms because this approach makes it possible to identify patients with both SSc and early scleroderma related symptoms.

The importance of spinopelvic parameters in patients with lumbar disc lesions.

Using a special software program we measured spinopelvic parameters on digitised radiographs of the entire spine and the pelvis of 50 patients with lumbar disc herniation and compared these with the same measurements on 30 healthy subjects. In the disc hernia group the patients had a relatively straight spine in the sagittal plane. The sacrum was more vertical, and the value of the lumbar lordosis was lower, as was the amplitude of the spinal curvatures, when compared with those of the healthy group. This results in a higher gravitational compressive force which may, in turn, lead to progressive degeneration of the discs. The anterior shift of the line of gravity may cause spinopelvic instability, and contraction of the posterior spinal muscles in trying to balance this disturbed spatial relationship may produce back pain.

Tissue specific mosaicism of trisomy 9 in a patient with severe torsion scoliosis.

We report on a female patient who had mosaic trisomy 9, presenting with severe scoliosis and mental retardation. Scoliosis is seldom reported in patients with mosaic trisomy 9 syndrome. FISH studies in our proband detected no trisomic cell line in the paravertebral muscle.

Decreased bone mineral density in neurofibromatosis-1 patients with spinal deformities.

A cross-sectional study was carried out to obtain data on the bone mineral density status of a group of neurofibromatosis-1 patients with spinal deformities, and to search for possible accompanying changes in the bone mineral turnover. Neurofibromatosis-1 is a heredofamiliar disorder that is associated with a variety of skeletal anomalies (mostly spinal deformities) in 10-50% of patients. Intraoperatively, a poor vertebral bone quality has been observed. Efforts have been made to identify factors preventing curve progression, to optimize operational planning and to explain the pathomechanism. As part of the preoperative evaluation, dual-energy X-ray absorptiometry was used to assess the bone mineral density of the lumbar spine in 12 patients with neurofibromatosis-1, supplemented by laboratory blood/urine investigations. A significant decrease in bone mineral density of the lumbar spine was measured. An inverse relation was suggested between the severity of scoliosis and the lumbar spine Z-scores. No pivotal alterations were identified in the laboratory measurements. The bony tissue abnormality observed intraoperatively in neurofibromatosis-1 patients may be described as a diminution of the axial bone mineral density. The biochemical parameters do not support the presence of hyperparathyroidism, renal disorders or other associated diseases influencing the bone mineral turnover. The evaluation of bone mineral density in the course of the preoperative planning is proposed in neurofibromatosis-1; the exact background and the role of a possible osteoporosis in the prognosis remain to be elucidated.

Surgical correction of Scheuermann's kyphosis.

This is a retrospective study of eight consecutive patients of mean age 19 (13-27) years with severe Scheuermann's kyphosis who underwent anterior and/or posterior fusion using the Cotrel-Dubousset (CD) instrumentation. In two an anterior release and fusion with rib grafts had been previously performed. The mean follow-up was 5 years. The preoperative hyperkyphosis averaged 86 degrees (71 degrees - 99 degrees), which was postoperatively 44 degrees (32 degrees - 58 degrees). The average loss of correction was 4.6 degrees (1 degrees - 12 degrees). The lumbar hyperlordosis spontaneously improved from -67 degrees to -48 degrees. Two patients, who had chronic back pain refractory to conservative treatment, improved considerably after surgery.

Computer-assisted assessment of spinal sagittal plane radiographs.

The sagittal shape of the spine, particularly its sagittal balance, currently is being extensively investigated. The major purpose of this study is to examine the measurement repeatability of SpineView software, which calculates 13 independent variables, to shorten and facilitate the measurement of lateral spinal radiographs; another purpose is to collect physiological data for nonpathologic spines, which can be used as a reference in future research. This article also presents two new parameters and discusses their possible role in forthcoming investigations. The interobserver repeatability study shows that most of the variables are more repeatable (less than +/-1.5 degrees ) when the operator is experienced. A less (+/-6.5 degrees ) repeatable measurement is T4-T12 kyphosis, which may be because of the poor contrast generally observed on radiographs of the upper thoracic vertebrae. The intraobserver repeatability study also demonstrates that subjective failures do not influence the results significantly, but the quality of the radiographs may have significant effect on long-term repeatability. The mean values were generally different between male and female subjects, and significant differences between the two sexes were only noticed for pelvic thickness and global spinal inclination. Normal range values and correlations between some pelvic and spinal parameters were similar to data found in the literature. The results of the current study provide evidence that the SpineView software is useful for experimental investigation of sagittal spinal alignment.

Subluxation of a lumbar vertebra in a patient with Marfan syndrome. Case report.

Marfan syndrome is a hereditary disorder of the connective tissue that, in its most classic form, includes cardiovascular, ocular, and skeletal features. The neurological problems associated with the disease are mainly caused by intracranial vascular abnormalities and spinal meningeal defects, but other neurological manifestations are rarely present. Scoliosis, a skeletal manifestation of the syndrome, occurs frequently, but its onset, natural history, and radiological characteristics differ from those of the idiopathic form. Scoliosis in a patient with Marfan syndrome seldom accompanies other spinal deformities. In this article the authors describe the case of a patient with Marfan syndrome and scoliosis in whom lumbar subluxation occurred. This rare deformity, diagnosed on three-dimensional computerized tomography scanning, has not been reported previously in association with Marfan syndrome. Its development can be explained in terms of the theory of progressive rotatory dislocation. The morphological characteristics, clinical features, and surgical treatment of the deformity are presented.

[Decreased bone mineral density as a risk factor in the development of spinal deformities in neurofibromatosis]. / Csökkent csontdenzitás, mint lehetséges tényezó a neurofibromatosist kíséró gerincdeformitások kialakulásában.

Neurofibromatosis-1 is a here-do-familiar disorder that is associated with a variety of skeletal anomalies, mostly with spinal deformities in 10-50% of the patients. Intraoperatively, a poor vertebral bone quality has been observed. Efforts have been made to identify factors preventing curve progression, to optimize operational planning and to explain the pathomechanism. As part of the preoperative evaluation, the authors used a dual X-ray absorptiometry to assess the bone mineral density of the lumbar spine in 12 non operated patients with neurofibromatosis-1, supplemented by laboratory blood/urine investigations. A significant decrease in bone mineral density of lumbar spine was measured. An inverse relation was suggested between the severity of scoliosis and the lumbar spine Z-scores. No pivotal alterations were identified in the laboratory measurements. The bony tissue abnormality observed intraoperatively in neurofibromatosis-1 patients may be described as a diminution of the axial bone mineral density. The evaluation of bone mineral density in the course of the preoperative planning is proposed in neurofibromatosis-1.

Limb-saving surgery, survival, and prognostic factors for osteosarcoma: the Hungarian experience.

BACKGROUND AND OBJECTIVES: There are many factors thought to have an influence on the prognosis of osteosarcoma that have been reported in the literature. Their significance, however, still remains controversial in most cases. Experience with osteogenic sarcoma (OS) was reviewed in order to evaluate surgical results and survival and to determine the prognostic factors. METHODS: Ninety-six patients with high-grade osteosarcoma of the extremities were treated between 1986 and 1997 in the authors' institution. They were divided into 3 groups: In group I, all 75 patients with nonmetastatic OS received intensive chemotherapy (high-dose methotrexate, doxorubicin, ifosfamide, and cisplatin) and underwent surgery. In group II, 9 patients already had metastases at the time of referral. In group III, 12 patients received chemotherapy in delayed or suboptimal form. Results and Conclusions In group I, there were local recurrences in 3 patients (7%) and metastases in 8 patients (20%) with limb-saving, whereas these numbers were 1 (3%) and 14 (38%) in those who had amputation. The 5-year disease-free survival (DFS) was 72% and 69% in the limb-saving and amputation groups, respectively. In groups II and III, 5-year DFS was extremely poor, 10% and 20% only, underlining the importance of stage and intensity of chemotherapy, respectively. With univariate analysis, sex, duration of symptoms, and radiographic appearance of OS had no prognostic value, whereas tumor volume <60 cm(3), wide or radical surgical margin, distal location of OS, cartilagineous ground substance <20%, and response to chemotherapy were positive prognostic factors. The last 4 variables maintained their significance in the multivariate Cox model as well. Age >30 years showed indirect negative influence on the final outcome through enhanced intolerability to the drugs and less cooperability of the patients. The results on survival with limb-saving surgery were well comparable with those of amputation.

The surgical treatment of spinal deformities in the Department of Orthopaedic Surgery, University Medical School of Pécs, Hungary: history and development.

Since its foundation in 1966, a great deal of attention has been paid to the treatment of spinal deformities, especially idiopathic scoliosis, in the Department of Orthopaedic Surgery, Medical School of University, Pécs. The authors compared the results of three different surgical methods (modified Hibbs, Harrington, Cotrel-Dubousset) on 171 patients between 1966 and 1992. The average follow-up period was between 2 and 13.2 years. In cases in which the modified Hibbs procedure was used we achieved a 26% correction, in the Harrington cases we achieved a 43.9% correction, and the loss of correction was 100% after the Hibbs operation and 18% after the Harrington operation in the follow-up period. In cases of Cotrel-Dubousset Instrumentation we achieved about 70% correction, but the follow-up period was too short (2 years) to evaluate the loss of correction in these cases.

Lectin histochemistry of pathological bones.

Our present knowledge of the structure and function of glycoproteins in bone tissue is very limited. The introduction of lectins into histology offered principally a new approach for studying the presence and chemical structure of glycoproteins in tissue sections. In this paper these highly specific carbohydrate binding molecules have been used to characterize glycoproteins in the cellular elements of normal bone and benign bone lesions. We retrospectively examined 35 benign bone lesions (7 fibrous dysplasias, 5 foreign body granulomas, 5 epulis, 8 osteoid osteomas, 10 giant cell tumors) together with 25 normal bone samples. In normal bone samples and all cases of benign bone lesions, two characteristic types of PNA binding were found after neuraminidase digestion in osteoclasts. In osteoclasts which did not adhere to bone surface, diffuse intracytoplasmic PNA binding was seen, and following the adherence to the bone surface, it disappeared, and the resorption zone became stainable. We assume that this PNA binding glycoprotein is formed in the cytoplasm of osteoclasts, then, after the activation of osteoclasts, the glycoprotein gets accumulated at the resorption zone of the cytomembrane where it plays a significant role in the bone resorption.

[Fatal acute liver damage caused by a therapeutic dose of paracetamol]. / Terápiás dózisban alkalmazott paracetamol okozta heveny fatális májkárosodás.

A 16-year-old boy undergone on an "anterior release" surgery for severe scoliosis, since fever developed in the postoperative phase, a total dose of 3500 mg paracetamol was given during a 3-day period. Four days after the end of antipyretic medication, the patient became confused and icteric, later unconscious, and within 24 hours died from fulminant hepatic failure. Autopsy revealed a confluent centrolobular (zonal 3) liver cell necrosis definitely characteristic for paracetamol hepatotoxicity. The case history may illustrate that paracetamol may cause liver injury even in therapeutic doses, if certain risk factors are present. Such factors are malnutrition and starvation, that causing depletion of hepatic glutathione, can result in enhanced susceptibility to toxicity of the drug. Authors emphasize, that in the case they presented, the young patient was malnourished and in the postoperative period fasting, and only a moderate calorie intake was given via parenteral nutrition. All these circumstances may well explain the unexpected fatal complication.

[Study of the reactivity of giant cell tumors of bones to different lectins]. / Etude de la reactivite des tumeurs a cellules geantes des os a differentes lectines.

The authors have examined 18 cases of giant cell bone tumours using various lectins. Type I stromal cells resembling fibroblasts and participating in the construction of matrix were Con A positive. The intensity of Con A binding and the number of positive cells increased with increasing stage. The nature and intensity of PNA-lectin binding in giant cells, after digestion with neuraminidase, varied according to the stage. While in Group I giant cells, 30 % of cells were negative and, in the great majority of cells, the reaction was limited to a clearly defined segment of the membrane, in Group III tumours, the proportion of negative cells was approximately 1 % and a diffuse and very intense intracytoplasmic reaction was observed in 60 % of the positive cells. According to the authors, the histochemical study of lectins could help classify giant cell tumours.

[Lectin-histochemical characteristics of bone tumors. I. Stage-related changes in lectin-binding of giant cells in osteoclastoma]. / A csonttumorok lektin-hisztokémiai jellemzése. I. Az óriássejtek stádiumfüggö lektin-kötés változása osteoclastomákban.

Authors examined 18 cases of osteoclastoma chosen at random with different lectins. The fibroblast-like type I stromal cells taking part in the formation of the ground substance were Con A positive. The strength of the Con A bond and the number of positive cells increased with the progress of the stage. The PNA lectin bond following the digestion with neuraminidase was in the single stages of different character and intensity. Whereas in the Gr I osteeoclastomas 30 per cent of the reacting osteoclast was localized to a well defined segment of the membrane in the Gr III tumors the ratio of the negative cells moved around 1 per cent, and in 60 per cent of the positive cells strong diffuse intracytoplasmatic reaction could be observed. Authors think that the lectin histochemical examinations give help to the definition of the activity of the tumor forming cells.

[Use of Cefuroxime as antibiotic prophylaxis in the surgical management of scoliosis]. / Cefuroximmal végzett antibiotikus profilaxis a scoliosis mütéti kezelésében.

Cefuroxim treatment as antibiotic prophylaxis was used in the operative treatment of the scoliosis. It was found that this antibiotic was an effective drug. There was't any postoperative suppuration and no side effect of the Cefuroxim was registered.