Nonorganic pain drawings are associated with low psychological scores on the preoperative SF-36 questionnaire in patients with chronic low back pain.

The Short Form 36 questionnaire (SF-36) measures general health and well-being. Within the last 5 years it has been used increasingly to characterise patients in the medical literature. Relatively few studies have used the SF-36 on patients with chronic low back pain undergoing preoperative evaluation, but results suggest that it may be predictive of surgical outcome. Pain drawings are a routine part of evaluation prior to spinal surgery in several centres, since their classification of organic or nonorganic has been shown in some studies to correlate well with psychological characteristics predicting poor outcome. The purpose of the present study was to assess possible correlations between nonorganic pain drawings and the psychological scales in the SF-36. We included 128 patients in the study, all of them referred from other hospitals. Previous spinal surgery had been undergone by 25%, and 59% required daily medication because of low back pain. All patients completed pain drawings using predefined symbols These pain drawings were scored dichotomously as organic or nonorganic based on a brief description of a typical nonorganic characteristics. Patients also completed the Danish version of the SF-36 questionnaire. Statistical analysis was performed using logistic regression analysis. The pain drawing classification was used as the dependent variable and scores on the eight scales of the SF-36 as independent variables. P values of <0.05 were considered significant. The mean scores of the patient population on all eight scales were significantly lower than Danish norms. The only scales that correlated with the presence of nonorganic pain drawings were emotional role (RE) and mental health (MH), both measuring psychological health. The odds ratio (OR) of receiving a nonorganic pain drawing was 22 (95% confidence interval, or CI, 7-65) if the scores on RE and MH were more than 2 standard deviations (SD) below the Danish norm. This is the first study providing evidence that pain drawing ratings are influenced by the psychological scales of the SF-36. The clinical relevance of this observation regarding prediction of outcome after spinal surgery should be assessed in future studies.

[Percutaneous fixation of sacral fractures. Primary experiences with a new technique]. / Perkutan fiksering af sacrumfrakturer. Primaere erfaringer med en ny teknik.

A number of techniques have been introduced to obtain reduction and fixation of rotational and vertical unstable sacral fractures and sacro-iliac (SI) joint disruptions. The purpose of this study is to report our primary experience with percutaneous cannulated screw fixation across the joint or fracture line. Fifteen consecutive patients, seven males and eight females, were operated. Six patients had isolated sacral fractures or SI joint disruption. All patients had a type C pelvic fracture according to Tile's classification. Percutaneous fixation of sacral fractures and sacro-iliac joint disruptions allows a short operating time, minimal bleeding and soft tissue damage, and immediate non-weight bearing mobilisation. No non-unions were seen and there were no cases of infection. In two patients the material had to be removed. The method gives adequate fixation of unstable posterior pelvic-ring fractures, but is technically difficult as malposition of the screws might cause serious perioperative complications.

Clinical outcome after spinal fusion with a rigid versus a semi-rigid pedicle screw system.

Several biomechanical studies have evaluated the quality of fusion obtained with a rigid versus a semi-rigid pedicle screw implant. Some studies indicate that increased rigidity of the implant system results in an increased strength of the fusion mass. Other reports have underlined the risk of stress shielding due to rigid implant systems. Based on these findings some authors have recommended the use of a semi-rigid system. There are, however, few studies focusing on any possible difference in clinical outcome between the two different types of implant systems. Questionnaires were sent to 89 patients who had undergone primary spinal fusion with either a rigid or a semi-rigid pedicle-screw-based implant system. In every case the diagnosis was spondylolisthesis or degenerative lumbar disease. The questionnaires were analysed using forward stepwise logistic regression analysis. Eighty (90%) of the questionnaires were returned. There was a mean follow-up of 4 years (range 2-8 years). It was not possible to demonstrate any difference in clinical outcome between patients undergoing lumbar fusion with a rigid implant system and those given a semi-rigid system. The overall patient satisfaction rate was 69%, with no difference between the two types of implant. No difference in clinical outcome between the two types of implant was found. Considering the fact that the primary goal of spinal fusion procedure is to obtain a solid fusion mass, biomechanical tests favour the used of a rigid pedicle screw system. This fact combined with the fact that early mobilisation is possible with rigid implants justifies the use of rigid implant systems, although no difference in clinical outcome could be demonstrated in this study.

The Cotrel-Dubousset instrumentation for unstable sacral fractures. Report of 3 patients.

We present a new operative procedure using the Cotrel-Dubousset (C-D) instrumentation in unstable sacral fractures, where the vertebral column is dissociated from the pelvis. This technique is based on screw fixation in the ileum and in the first sacral and the fifth lumbar vertebrae or the fifth and fourth lumbar vertebrae, with help of interconnecting rods. 3 patients were successfully treated.

Indomethacin and disodium etidronate for the prevention of recurrence of heterotopic ossification after surgical resection. Two case reports.

Two spinal cord injured patients had extensive heterotopic ossifications around their hips surgically removed. The use of disodium etidronate from 2 weeks presurgery to 2-5 months postsurgery and in particular indomethacin 25 mg twice daily, from 2 weeks prior to surgery to 6 weeks postsurgery may have helped to prevent recurrence of the ossifications in the follow up periods of 4 and 5 years respectively.

[Lumbosacral spondylolisthesis. Occurrence and therapeutic possibilities]. / Lumbosakral spondylolistese. Forekomst og behandlingsmuligheder.

The incidence of lumbosacral spondylolisthesis is 5%, and 25% of the patients will develop symptoms. The debut of the symptoms typically occurs during the teenage years, and is not always related to the degree of spondylolisthesis. The principles of conservative treatment include symptomatic relief and reduction of the lumbar lordosis using a brace. Conservative treatment often results in temporary improvement, but symptoms often come back. In case of ineffective conservative treatment, progressive neurologic symptoms and disability surgery is indicated. New techniques make it possible to reduce the spondylolisthesis and the lumbosacral kyphosis using metal implants and spondylodesis involving the transverse processes, facet joints and pedicles.

[Acute surgical treatment of spinal fracture with medullary involvement]. / Akut operativ behandling af columnafrakturer med medullaer påvirkning.

Two case histories are presented to illustrate the possibility of decisive improvement in the neurological sequelae after spinal fractures with spinal stenosis by means of rapid operative decompression and stabilisation. The importance of rapid transfer of patients of this type to centres where therapeutic decisions can be taken on the basis of several possible therapeutic methods, including the above-mentioned, is emphasized.

Decreased blood perfusion in canine tibial diaphysis after filling with acrylic bone cement compared with inert bone wax.

Sixteen dogs had one tibia filled with acrylic PMMA bone cement and the opposite, control tibia filled with inert bone wax. After 1, 4, and 12 weeks, the blood perfusion in diaphyses was measured with Sc-46 labeled microspheres. The blood flow rates increased from 1 to 4 weeks and dropped to about the 1-week level after 12 weeks on both sides, with the acrylic side lower than the control side. On both sides, Disulphine Blue staining of the bones showed severe endosteal avascularity after 1 and 4 weeks and massive periosteal apposition after 4 and 12 weeks. The initial increase in blood flow is considered due to periosteal apposition, and the differences in blood flow rates are attributed to avascularity caused by the polymerization heat and toxicity of the acrylic cement.

[Fractures of the thoracolumbar spine. Surgical treatment using the Harrington-Luque method]. / Fractura columnae thoracalis et lumbalis. Operative behandling a.m. Harrington-Luque.

In the period of 1984-87 five women and 20 men aged 15 to 67, underwent open reduction and stabilization of thoraco-lumbar spine fractures with Harrington or Luque rods, segmental wires and interlaminar bone-chips. Half the patients had complete spinal cord lesions and these remained so. Criteria for instability were based on the three-column concept, the demand for early mobilization (10 days), or progression in neurological deficits. No operative complications nor deterioration in neurological findings occurred. Fusion and stability was obtained in all cases. Incomplete cord lesions and, particularly, cauda equina lesions improved substantially. Open reduction and stabilization in the early postinjury period performed by cooperation between a neurosurgeon and an orthopedic surgeon in centres experienced in the treatment of paraplegia is recommended.

Microcirculation of the juvenile knee in chronic arthritis.

In order to investigate pathogenetic factors in growth abnormalities of the knee in hemophilic arthropathy and juvenile rheumatoid arthritis, the hemodynamic changes of the knee following chronic synovial inflammation and elevated joint pressure were studied in puppies. Unilateral arthritis was induced by intraarticular injections of carrageenan solution. Regional blood flow (RBF) was measured by tracer microsphere technique. Microvascular volume (VV) was estimated from the distribution volumes of Cr51-labelled erythrocytes and I125 fibrinogen. Mean transit times (TT) of blood components were calculated from volume/flow ratios. The arthritic joint capsules were characterized by high RBF rates, increased VV, low tissue hematocrit (HCT) and short TT of blood. In the juxtaarticular epiphyses and the patella, RBF was largely unchanged, whereas VV was significantly elevated and TT of blood prolonged. The growth plates formed borders for the extension of these changes. The increased permeability and surface area between blood and bone in arthritis may accelerate the resorption and subsequent destruction of subchondral bone in chronic arthropathies of the juvenile knee.

Physical exercise as prophylaxis against involutional vertebral bone loss: a controlled trial.

1. The skeletal effects of physical training were studied in a controlled trial involving 31 healthy women (aged 50-73 years) with previous Colles' fracture of the forearm. The bone mineral content of the lumbar spine and both distal forearms was measured by dual-photon (153Gd) absorptiometry. 2. The participants were allocated to either a physical exercise group or a control group. The former group followed a standardized exercise programme, exercising for 1 h twice weekly during 8 months. 3. Twenty-seven women completed the study. Lumbar spine bone mineral content of the exercise group increased by 3.5%, whereas that of the control group decreased by 2.7%. The rate of bone loss in the control group equalled that of age-matched normal women. 4. The changes in forearm bone mineral content appeared to be independent of the exercise. The bone mineral content of the previously fractured forearm remained nearly unchanged. The bone mineral content of the uninjured forearm decreased on average by 3.5%. 5. The data suggest that physical exercise can inhibit or reverse the involutional bone loss from the lumbar vertebrae in normal women. Physical exercise may prevent spinal osteoporosis.

Bone blood flow in conscious dogs at rest and during exercise.

Using the microsphere technique bone blood flow was measured in different anatomical and functional regions in long bones in conscious dogs. The measurements were performed during physical exercise upon a treadmill, and the bone blood flow values were obtained as prework resting values after 1 and 2 hours of exercise and after 1 hour of rest. The perfusion rates increased 50 per cent from 1.6 to 2.5 ml X 100 g tissue-1 X min-1 in the femoral and tibial cortical bones during work. In the cancellous bone of the femoral head an increase from 12.6 to 20.6 ml X 100 g tissue-1 X min-1 was found. Equal flow responses were determined in the fat-filled tibia-condylar and femoral supracondylar bone. The increase took place after 2 hours' exercise, but nonstatistically verified increased perfusion was found after 1 hour's work. The alternation in bone blood flow suggests that bone has a capability of physical vasodilation during muscular work but the flow response is slow and therefore the vasodilatation seems mediated by a metabolically induced stimulus.

Regional blood flow, microvascular blood content and tissue haematocrit in canine myocardium.

Regional myocardial blood flow, myocardial microvascular blood content and tissue haematocrit were determined in mongrel dogs. In nine dogs the intramyocardial distribution volumes of 99Tcm-albumin and 125I-fibrinogen were examined. Tracer equilibration times of 5, 10 and 30 min were used. The 125I-fibrinogen distribution volume was significantly lower than the distribution volume of 99Tcm-albumin. The 125I-fibrinogen distribution volume was not found to change with time and was thus taken to be a measure of the plasma volume. In 10 dogs intramyocardial distribution of 51Cr-labelled red cells and 125I-fibrinogen was estimated and regional myocardial blood flow was measured by 15 microns 99Tcm-albumin spheres. Plasma and red cell volumes, interpreted as myocardial microvascular blood content, ranged from 3.66 to 4.93 cm3-100 g-1. The distribution volumes indicated gradients with higher endocardial and longitudinal microvascular blood content in the left ventricular free wall and the septum. The intramyocardial haematocrits calculated from the plasma and red cell volumes were uniformly 0.3 all over the heart and amounted to 0.75 of arterial haematocrit. The mean right ventricular blood flow of 46.80 cm3 . min-1 . 100 g-1 amounted to 0.6 of a mean left ventricular blood flow of 86.65 cm3 . min-1 . 100 g-1. Transmural and longitudinal gradients of regional myocardial blood flow within the ventricular wall were observed. The patterns of transmural and longitudinal gradients of regional blood flow and microvascular blood content implies higher flow rates through more or larger vessels indicating a greater endocardial and apical vascular conductance in the vicinity of the left ventricular cavity.

Bone mass of the axial and the appendicular skeleton in women with Colles' fracture: its relation to physical activity.

The aim of this investigation was to elucidate whether Colles' fractures in middle-aged women were indicative of generalized bone loss (osteopenia) and whether bone mass of the axial and the appendicular skeleton was related to the extent of daily physical activity. Thirty-six patients (aged 50-73 years) with previous Colles' fracture were studied. The median time elapse after the injury was 18 months (range 9-20.5 months). Bone mineral content of the 2nd, 3rd, and 4th lumbar vertebrae (lumbar BMC) and both distal forearms (forearm BMC) were determined to dual-photon (153Gd) absorptiometry. The physical activity level was graded according to a standard interview and a bicycle ergometer test. Mean lumbar BMC was reduced by 9% compared to age-matched normal women (p less than 0.05), mean forearm BMC was reduced by 5% (NS). Twenty patients showed spinal osteopenia by either conventional radiography or absorptiometry (95% confidence limits 38-72%). The fracture-related bone loss from the forearms was most prominent when the fracture had occurred in the dominant forearm, suggesting that the loss of 'dominant' forearm activity per se results in bone loss. No relation between working capacity and forearm BMC was found. However, the working capacity was positively related to lumbar BMC (P less than 0.01), even if the common relationship to age was eliminated (P less than 0.05). The data suggest that the bone mass of the axial skeleton reflects the extent of daily physical activity. Patients with Colles' fractures represent an easily definable population which might benefit from prophylactic measures against vertebral bone loss and compression fractures. One of these could be physical exercise.

Regional vascular volumes and dynamic haematocrit compared to regional perfusion in canine cancellous and cortical bone.

Regional vascular volumes in different areas of long bones in dogs were measured with 125I-fibrinogen and 51C-r erythrocytes. According to the volumes determined, the dynamic small vessel haematrocrit was calculated to be 50 per cent of the arterial cortical bone. The perfusion rate in the same regions was determined with 99Tcm-labelled microspheres (size 15 mu +/- 5 mu). A linear relation between perfusion rate and blood volume was demonstrated. The data obtained showed that the perfusion rate and blood volume in the red marrow in the femoral neck are 25 times greater than values obtained from tibial and femoral cortical bone. A thorough testing of the plasma indicators showed that the distribution volume in the tissue for albumin and transferrin is twice the value determined with fibrinogen. The degrees of the indicators seems to be correlated with molecular weight.

Blood flow rates in canine cortical and cancellous bone measured with 99Tcm-labelled human albumin microspheres.

Regional differences in bone blood flow rates in the femur and the tibia of dogs were measured with 99Tcm-labelled microspheres. The measurements show an average flow rate of 3.7 ml (100 g)-1 x min-1 in cortical bone. A more rapid pace was found in red marrow containing areas, with an average flow rate in the femoral head of 19.7 ml blood (100g)-1 x min-1, and in the femoral neck of 50.3 ml blood (100 g)-1 x min-1. In the calcar femorale the average flow rate was 9.0 ml (100 g)-1 x min-1, and compared to cortical flow a positive correlation between strain and perfusion seems obvious. No difference between cortical bone in tibia and femur was found. The flow rates in the red marrow of the femoral neck are remarkably high, but the flow in the cortical bone is relatively low. It is concluded that handling of fragments of cortical bone and the associated soft tissue is presumably critical, and that the surgical technique has to be quite gentle to obtain optimal conditions for fracture healing.

Blood flow in different adipose tissue depots during prolonged exercise in dogs.

Adipose tissue blood flow was measured by the microsphere technique in all major adipose tissue depots in dogs during exercise. The measurements were done during rest, after 1 and 2 h of exercise and after a postexercise rest period. It was found that the blood flow to the inguinal, subcutaneous adipose tissue increased from about 6 ml/(100 g . min) during rest to about 10 ml/(100 g.min) during exercise. This increase in flow was significantly smaller than the increase found in the perirenal, the mesenteric and the pericardial depots. In these depots the resting blood flow was about 10 ml/(100 g . min) increasing to about 30 ml/(100 g . min) during exercise. It is concluded that the increase in adipose tissue blood flow during exercise is a general phenomenon for all major adipose tissue depots. The increase in flow in the inguinal, subcutaneous fat pad was comparable to the previously described increase in flow in abdominal, subcutaneous tissue in man. Blood flow to abdominal skin was constant during exercise, while the flow in tissues from the gastrointestinal canal and in the kidneys decreased. The flow in the tongue and in the Achilles tendon significantly increased during exercise.