Ischias. Von der Säftelehre zur Pathomorphologie.

Today, lumbar disc disease is a very common disease, which will be often seen in both the family practice as well as in the consultations of orthopedics, neurology, rheumatology or neurosurgery. Furthermore, lumbar disc surgery is one of the most common spinal surgical procedures worldwide. But, for many centuries, physician had no clear understanding of the anatomical condition and the pathomechanism of this disease. Therefore, no rational treatment was available. The Hippocratic physicians knew the signs and symptoms of lumbar disc disease, which they then called "sciatica". But, they subsumed different disorders, like hip diseases under this term. In the mid-18th century, it was the Italian physician Domenico Felice Antonio Cotugno (1736-1822), who first brought clarity in the concept of radicular syndromes; he recognized, that the so-called "sciatica" could be of neurogenic origin. In 1742, a contemporary of Cotugno, the German Josias Weitbrecht (1702-1747) has to be credited for the first precise description of the intervertebral disc. Nearby a hundred years later, the German Hubert von Luschka (1820-1875) described for the first time a herniated disc in a pathologic specimen. With the landmark report of the New England Journal of Medicine in 1934, the two American surgeons, William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963), finally cleared the pathomechanism of lumbar disc disease.

[Sciatica. From stretch rack to microdiscectomy]. / Ischias. Von der Streckbank zur Mikrodiskektomie.

In ancient times as well as in the Middle Ages treatment options for discogenic nerve compression syndrome were limited and usually not very specific because of low anatomical and pathophysiological knowledge. The stretch rack (scamnum Hippocratis) was particularly prominent but was widely used as a therapeutic device for very different spinal disorders. Since the beginning of the nineteenth century anatomical knowledge increased and the advances in the fields of asepsis, anesthesia and surgery resulted in an increase in surgical interventions on the spine. In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich O. Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in the New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined. In the late 1960s the surgical microscope was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil and his colleague Wolfhard Caspar and so-called microdiscectomy was introduced. Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures. In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material. In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation.

The Prolo Scale: history, evolution and psychometric properties.

BACKGROUND: The Prolo Scale (PS) is a widely accepted assessment tool for lumbar spinal surgery results. Nevertheless, in the literature there is a dearth of consensus about its application, interpretation and accuracy. The purpose of this review is to investigate the evolution of the PS from its introduction in 1986 to the present, including an analysis of different versions of the scale and research on the existing studies investigating its psychometric properties. MATERIALS AND METHODS: PubMed, Cochrane Library and PEDro databases were searched. Studies in English, Italian, French, Spanish and German published from 1986 to December 2012 were analyzed. RESULTS: The original lumbar surgery outcome scale consisted of two Likert-type scales (economic and functional). There are three more versions of the scale: Schnee proposed one consisting of 10 items, Brantigan made one with 20 items and introduced 2 more subscales (pain and medication), and Davis adapted the scale for the cervical spine. PS is often mentioned without any specific reference to the version used; therefore, a homogeneous comparison of studies is difficult to achieve. Several authors agree on the need to embrace a multidimensional measuring system to evaluate low back pain (LBP), but there is still no consensus regarding the most reliable tool. To date, PS has been mostly used as secondary outcome measure in association with validated primary measures for LBP. CONCLUSIONS: The Prolo Scale has been adopted for clinical examination for 20 years because it is easy to administer and useful to compare significant amounts of data from surgical studies carried out at different times. Although several authors demonstrated the scale sensitivity among a battery of tests, no thorough validation study was found in the current literature.

[The influence of Donguibogam during the middle Joseon era based on clinical records on low back pain in Seungjeongwon ilgi].

The recently increasing interest in historical records has led to more research on historical records in various fields of study. This trend has also affected medical research, with the medical climate and popular treatment modalities of the past now being revealed based on historical records. However, most research on medical history during the Joseon era has been based on the most well-known record, Joseon wangjo sillok or Annals of the Joseon Dynasty. Joseon wangjo sillok is a comprehensive and organized record of society during the Joseon era and contains key knowledge about medical history during the period, but it lacks details on the treatment of common disorders at the time. Seungjeongwon ilgi or Diary of the Royal Secretariat has detailed records of daily events and is a valuable resource for the daily activities of the era. And in the middle Josoen era, a variety of medical books - especially Donguibogam - was published. Therefore, the authors focused on the under-researched Seungjeongwon ilgi, Donguibogam and attempted to assess and evaluate low back pain treatment performed on Joseon royalty. The most notable characteristic of low back treatment records within the Seungjeongwon ilgi is that diagnosis and treatment was made based on an independent Korean medicine, rather than conventional Chinese medicine. This paradigm shift is represented in Dongeuibogam, and can be seen in the close relationship between Dongeuibogam and national medical exams of the day. Along with the pragmatism of the middle Joseon era, medical treatment also put more focus on pragmatic treatment methods, and records show emphasis on acupuncture and moxibustion and other points in accord with this. The authors also observed meaning and limitations of low back pain treatment during that era through comparison with current diagnosis and treatment.

Sources and patterns of pain in lumbar disc disease: revisiting Francis Murphey's theory.

OBJECT: Francis Murphey's theory was analyzed to determine whether or not his opinion is evidence-based medicine and whether or not it can be applied clinically. METHODS: The English literature was reviewed using Medline in reference to Dr. Murphey's theory of discogenic chronic LBP, which was first postulated in 1967. Deductive and inductive logic was utilized for the evaluation of his theory. We reviewed and analyzed his unprecedented study of the annulus fibrosus (AF) and posterior longitudinal ligament (PLL) under local anesthesia that was presented to the Congress of Neurological Surgeons in 1967 and 1972. RESULTS: He reported that: "It is found that the posterior longitudinal ligament and the remaining annulus fibrosus over the herniated discs are also exquisitely tender; even the slightest pressure on them produces pain." We noticed that in Dr. Murphey's presentation, he did not disclose any hard data, yet he concluded: "when an incomplete tear in the annulus occurs and if the tear is in the midline posterior, a fragment of nucleus will protrude in this tear, stretching the annulus and posterior longitudinal ligament, causing midline back pain. If the tear in the annulus is lateral, the pain is over the sacroiliac joint in the buttock and hip, and 20% of the patients in the lower abdomen, groin or testicle on that side." CONCLUSIONS: Because of a flaw in his understanding, in our opinion the unproven mechanical theory of discogenic LBP is weak inductive logic and does not justify discography and intra-discal procedures.

The degenerative lumbar disc: not a disease, but still an important consideration for OMPT practice: a review of the history and science of discogenic instability.

BACKGROUND: A recent AAOMPT position paper was published that opposed the use of the term 'degenerative disc disease' (DDD), in large part because it appears to be a common age-related finding. While common, there are significant physiologic and biomechanical changes that occur as a result of discogenic degeneration, which are relevant to consider during the practice of manual therapy. METHODS: A narrative review provides an overview of these considerations, including a historical perspective of discogenic instability, the role of the disc as a pain generator, the basic science of a combined biomechanical and physiologic cycle of degeneration and subsequent discogenic instability, the influence of rotation on the degenerative segment, the implications of these factors for manual therapy practice, and a perspective on an evidence-based treatment approach to patients with concurrent low back pain and discogenic degeneration. CONCLUSIONS: As we consider the role of imaging findings such as DDD, we pose the following question: Do our manual interventions reflect the scientifically proven biomechanical aspects of DDD, or have we chosen to ignore the helpful science as we discard the harmful diagnostic label?

John F. Kennedy's back: chronic pain, failed surgeries, and the story of its effects on his life and death.

The 35th president of the United States, John F. Kennedy (JFK), experienced chronic back pain beginning in his early 20s. He underwent a total of 4 back operations, including a discectomy, an instrumentation and fusion, and 2 relatively minor surgeries that failed to significantly improve his pain. The authors examined the nature and etiology of JFK's back pain and performed a detailed investigation into the former president's numerous medical evaluations and treatment modalities. This information may lead to a better understanding of the profound effects that JFK's chronic back pain and its treatment had on his life and presidency, and even his death.

Walter Mercer's (1891-1971) contribution to the surgical treatment of low back pain.

In 1936, Walter Mercer described a new method for the operative treatment of patients with spondylolisthesis. Using a transabdominal approach in two patients he inserted iliac crest bone graft into the intervertebral disc. His publication in the Edinburgh Medical Journal caused a furore as the levels operated on did not reflect the description and one of the two patients died post-operatively. However, Mercer continued to promote the operation in his textbooks. The anterior approach to the lumbar spine is now performed routinely. This paper explores Mercer's contribution to anterior spinal surgery.

[Acupuncture and tuina clinical thoughts of "treating the back from abdomen" for low back pain].

In clinical treatment, it is found that certain patients always have some positive reaction points those are relevant with low back pain in the abdomen area. When the simple treatment on the low back is ineffective, the efficacy could be significantly improved if acupuncture or tuina is performed at the abdomen areas, which is called "regulating yin to treat yang", or "treating the back from abdomen". In this paper, with the diagnosis and treatment method of "treating the back from abdomen" for low back pain as principal line, the detailed manipulation is explained for low back pain that is induced by TCM meridian diseases or modern anatomy, which could open the methods for clinical treatment of low back pain and enrich the therapeutic options.

Medical knowledge and the intractable patient: the case of chronic low back pain.

Chronic low back pain (CLBP) is endemic in Western societies, and while a good deal of attention has been paid to the lay experience of such pain, much less sociological attention has been paid to the way in which medical ideas about it have been formulated. This paper takes the latter course, tracing the development of clinical notions about the relationship between pathological signs and expressed symptoms from the 1820's to the 1930's, and then placing these developments in the context of postwar notions of 'somatization'. We point to the extent to which the disparity between expressed symptoms, pathological signs and perceived disability in CLBP has led to the moral character of the sufferer forming a constant subtext to medical discourse about the condition. We also note the extent to which medical ideas themselves have been constructed in intimate linkage with socio-legal questions of compensation and worker's insurance.

Intraspinal therapy using methylprednisolone acetate. Twenty-three years of clinical controversy.

The intraspinal use of methylprednisolone acetate (Depo-Medrol, Upjohn Company, Kalamazoo MI) began in 1960, followed 10 years later by reports of complications. In 1960, methylprednisolone acetate was first injected by the epidural route to treat low-back syndromes. Then in 1961, the intrathecal route was more widely used to treat arachnoiditis and multiple sclerosis. Epidural therapy again came into general use in 1980 for the treatment of the failed-back syndrome because intrathecal therapy was virtually abandoned after 10 years of spirited scientific controversy. Epidural steroid therapy is now employed extensively, and there are many sanguine reports of its efficacy in treating chronic pain secondary to the failed-back syndrome, but there have also been reports of complications. This review was prompted by recent manufacturer warnings, as well as by an ongoing heated controversy in Australia regarding its use epidurally. During the last 30 years, one can define 5 instructive historical parallels between intrathecal and epidural steroid therapy, and this historicity points up several principles that should govern any further epidural therapy with methylprednisolone acetate. This critical chronologic review surveys neurosurgical use from 1960 to 1970, neurologic use from 1970 to 1980, and anesthesiology use from 1980 to present.

Acupuncture for low back pain in huang di nei jing su wen. (Yellow Emperor's Classic of Internal Medicine Book of Common Questions).

In Huang Di Nei Jing Su Wen, among the materials which heretofore have no English translation, there are three Chapters on pain. One of them was devoted entirely to the low back pain. This is certainly an indication of its importance even more than 2,300 years ago. Since it still plagues us nowadays, we have translated that Chapter of this medical classic to see what we can learn from the ancients. We attempted to second guess the ancients in the diagnosis of the various sets of symptoms, in the light of western medicine. We discussed the difficulties in interpreting the archaic text. We pointed out that there were associations of the Mais (i.e., the Meridians) with various sets of symptoms but the loci of puncture were rather vaguely described and had no names. We inserted our selections of currently used acupoints to match the described loci. We would like to solicit our readers' comments.

Basic and update knowledge of intervertebral disc herniation: review.

Lumbar disc herniation is one of the most common causes of low back pain and/or sciatica. However, the pathogenesis of lumbar disc herniation, low back pain, and sciatica has not been fully understood. Inflammation in nerve root and dorsal root ganglia induced by nucleus pulposus may play an important role in the pathogenesis of spinal pain. I reviewed the basic and update papers regarding lumbar disc herniation. Herniated nucleus pulposus had been considered an enchondroma occurred from intervertebral disc, historically. At present, however, it is emphasized that nucleus pulposus has an inflammatogenic properties to affect the nerve root function, structure, vascular permeability, and pain.

Reconceptualizing John F. Kennedy's chronic low back pain.

When the medical records for John Fitzgerald Kennedy were made public, it became clear that the 35th President of the United States suffered greatly from a series of medical illnesses from the time he was a toddler until his assassination in November of 1963. Aside from having Addison disease, no condition seemed to cause him more distress than did his chronic low back pain. A number of surgical procedures to address the presumed structural cause of the pain resulted in little relief and increased disability. Later, a conservative program, including trigger point injections and exercises, provided modest benefit. Herein, the mechanisms underlying his pain are evaluated based on more contemporary pain research. This reconceptualizing of John Fitzgerald Kennedy's pain could serve as a model for other cases where the main cause of the pain is presumed to be located in the periphery.