Significance of patient-controlled analgesia in combination with continuous epidural block for patients who underwent posterior lumbar surgery.

The purpose of the study was to evaluate the efficiency of patient-controlled analgesia (PCA) combined with continuous epidural block in patients who underwent lumbar spine surgery. In group 1 (postoperative PCA group), 23 patients were administered postoperative continuous epidural block in combination with analgesics, which was self-regulated by the patient using a device. In contrast, the 22 patients in group 2 (control group) received suppositories or intramuscular injections of analgesics on request. The following factors were compared between the two groups: pain relief according to the visual analog scale for pain assessment, the frequency of administration of analgesics, and side effects of the postoperative analgesia. The patients in group 1 had more satisfactory relief of pain according to the visual analog scale for pain assessment and needed suppositories and intramuscular injection of analgesics less frequently on the 1st, 2nd, and 3rd postoperative day. The time spent by nurses on pain management in group 1 was less than that in group 2. No patient had any serious complications in either group. In conclusion, the present patient-controlled method combined with postoperative continuous epidural block could decrease the intensity of postoperative pain and the amount of time spent by nurses on the administration of postoperative analgesics after lumbar spine surgery.

Hypertrophic spinal pachymeningitis. A case report.

STUDY DESIGN: This is a case report and review of the literature. OBJECTIVE: To describe the clinical findings and the surgical treatment of a 28-year-old man with hypertrophic spinal pachymeningitis in the thoracic and lumbar region managed by expansive laminoplasty. SUMMARY OF BACKGROUND DATA: Hypertrophic spinal pachymeningitis is extremely rare. No description of findings present after expansive laminoplasty for hypertrophic spinal pachymeningitis has been reported. METHODS: The clinical findings, course, and surgical treatment of a 28-year-old man with a hypertrophic spinal pachymeningitis are presented. The patient required expansive laminoplasty. The follow-up period after the surgical procedure was 4.2 years. RESULTS: An unusual etiology of spinal cord compression by thickened dura mater was found with a contrast ring- or crescent-shaped enhancement on gadopentetate magnetic resonance imaging. Spasticity disappeared after the patient underwent expansive laminoplasty. CONCLUSION: This is the first report of a patient with hypertrophic spinal pachymeningitis treated with expansive laminoplasty. Spinal canal decompression and autogenous bone grafting are accepted treatments in the young patient. Careful observation of the patient to watch for local progression is necessary.

Significance of patient-controlled analgesia combined with continuous epidural block for patients with limb trauma.

Patients who were treated for fractures of the limbs were assigned to 1 of 2 groups for the management of postoperative pain. In Group 1 (postoperative patient-controlled analgesia group), 46 patients were given postoperative continuous epidural anaesthesia in combination with narcotic analgesics and this was regulated by the patient using a device. The 46 patients in Group 2 (control group) received suppositories or intramuscular injections of narcotic analgesics on their request. Patients in Group 1 needed suppositories and intramuscular injection of narcotic analgesics less often than those in Group 2, and had more satisfactory pain relief according to the visual analogue scale for pain assessment made on the first, second and third postoperative day. The time spent by nurses for pain management in Group 1 was less than that in Group 2. It appears that this patient-controlled method, combined with postoperative continuous epidural anaesthesia, is a safe, effective and efficient method for the management of postoperative pain.

Bilateral anterior dislocation of the hips. A case report.

A case of traumatic bilateral anterior dislocation of the hips complicated by a femoral head fracture is described. The mechanism is discussed and the literature reviewed.

Diffuse spinal leptomeningeal metastases from prostatic cancer. A case report.

A patient with a spinal form of diffuse metastatic leptomeningeal carcinoma from prostatic cancer is reported. The clinical manifestations and diagnosis are discussed, and the literature reviewed.

Effects of axial traction stress on solute transport and proteoglycan synthesis in the porcine intervertebral disc in vitro.

The effects of axial traction stress on intradiscal hydration, solute transport and proteoglycan synthesis were examined in 658 porcine coccygeal intervertebral discs in vitro. Measurements were performed in three tissue fractions: nucleus pulposus, inner and outer annulus fibrosus. At 0.80 MPa traction stress, the equilibrium hydration did not change in the nucleus pulposus. However, in the inner and outer annulus, the equilibrium hydration was reduced, and the change led to an increase of the effective fixed charge density. Diffusion of solute to the nucleus pulposus was significantly suppressed at 0.80 MPa traction stress. The fluid flow of the intervertebral disc tended to be suppressed during the creep recovery process after compression. The proteoglycan synthesis rate in the outer annulus was markedly suppressed by traction stress of 0.80 MPa for 4 h, but not that in the nucleus pulposus. These results suggest that a prolonged excessive axial traction stress induces a decrease in tissue hydration in the annulus fibrosus, and this may lead to an increase in the fractional volume of solid in the matrix and tissue osmotic pressure, resulting in diffusion inhibition of solute and suppression of proteoglycan synthesis. Thus, prolonged and excessive spinal traction may accelerate disc degeneration.

Structural variation of the anterior and posterior anulus fibrosus in the development of human lumbar intervertebral disc. A risk factor for intervertebral disc rupture.

A morphologic comparison of the laminated structure of the anterior and posterior anulus fibrosus of lumbar intervertebral disc was made on 24 L3-4 and L4-5 discs obtained from 10 fetus, one child, and one young adult cadavers. Low power microscopic and polarized microscopic observations and measurements on the transverse sections were performed to assess 1) lamellar bundle arrangement, 2) number of distinct lamellar bundles, 3) percentage of incomplete lamellar bundles, and 4) fiber-interlacing angles. The number of lamellar bundles was greater in the anterior anulus than in the posterior anulus. A very complex structure was observed in the posterior middle anulus in all the specimens, with a high percentage of incomplete/discontinuous lamellar bundles and greater fiber-interlacing angles. Loose connection of the lamellar bundles of posterior outer anulus was observed in fetal discs. The annular strength was not measured in the present study, however, the risk of posterior disc rupture in the young may be influenced by an inherent structural variation with a weak posterior anulus fibrosus.

Biorheological responses of the intact and nucleotomized intervertebral discs to compressive, tensile, and vibratory stresses.

Using intact and nucleotomized discs obtained from porcine coccyges, the biorheological responses to compressive, tensile, and vibratory stresses were investigated; in particular the creep characteristic change in compressive and tensile stresses, and the dynamic elastic modulus and dissipated energy under vibratory stress were analysed. In the nucleotomized disc the viscosity coefficient and the dissipated energy were decreased. However, the elastic modulus and the dynamic elastic modulus were increased compared to the intact disc under compressive and vibratory stresses, but there was no difference between intact and nucleotomized discs in the creep response to tensile stress. After nucleotomy the disc and surrounding structures of the disc are likely to be exposed to severe mechanical stresses. These mechanical stresses on the nucleotomized disc might accelerate degeneration of the disc due to the biorheological, nutritional, and biological alterations.

Familial predisposition and clustering for juvenile lumbar disc herniation.

The siblings and parents of 40 patients (cases) with lumbar disc herniation (aged 18 years or younger) who underwent surgery at the Department of Orthopaedics at Toyama Medical and Pharmaceutical University Hospital between 1976 and 1990 were examined for incidence of lumbar disc herniation. A total of 120 randomly sampled, age- and sex-matched patients (controls) who were hospitalized during the same period due to extraspinal diseases also were studied in the same manner. A survey of the occurrence of definite lumbar disc herniation was carried out that included 75,237 students in elementary, junior high, and senior high schools in Toyama Prefecture, Japan, covering a mean period of 3 years and 4 months. The incidence of surgically treated lumbar disc herniation among people aged 18 years or younger was calculated, and the expected value of disc herniation was obtained in an age-specific manner, on the basis of the age distribution of encumbrances in the above case-control study. The encumbrances of 18-year-old or younger patients with lumbar disc herniation showed familial predisposition, with an odds ratio of 5.61 in comparison to the controls. It was suggested that there is familial clustering of lumbar disc herniation among the encumbrances of 18-year-old or younger patients with lumbar disc herniation.

Effects of continuous quantitative vibration on rheologic and biological behaviors of the intervertebral disc.

The authors attempted to investigate the effect of vibration on the physiologic behavior of the intervertebral disc from rheologic and biological responses. Using fresh disc-cartilaginous end plate complexes of porcine coccygeal vertebrae, the frequency characteristics of dynamic compressive elastic modulus and dissipated energy were monitored by means of a biomechanical spectrometer. The effect of vibration on proteoglycan synthetic rates and solute transport in the intervertebral disc were analyzed using a radioisotope. When the disc-cartilaginous plate complexes were subjected to sinusoidal vibration with a static load of 5 N and a vibratory load of 3 N, the elastic modulus decreased at 11 Hz compared with 3.5 Hz. After this, it increased again at 35 Hz. The dissipated energy increased rapidly with an increase in frequency. Proteoglycan synthetic rates did not change appreciably down to the inner and outer layers of the anulus fibrosus, but the rate in the nucleus pulposus alone decreased remarkably at 10 Hz and 35 Hz. Solute transport increased as a response to vibration, particularly in the nucleus pulposus. When the intervertebral disc is exposed to vibration for a long period of time, therefore, the proteoglycan content in the nucleus pulposus may be decreased, eventually resulting in disruption of matrix integrity.

Histochemical and ultrastructural observations on brown degeneration of human intervertebral disc.

Thirty-eight fresh human intervertebral discs collected during anterior interbody fusion surgery were histochemically and ultrastructurally analyzed for pigments. Macroscopically, five stages of degeneration were classified according to the color, fibrosis, and fragility of the nucleus pulposus of the discs. In order to demonstrate lipofuscin granules, specimens were subjected to special staining procedures, including carbol fuchsin lipofuscin stain, the Schmorl's reaction, and autofluorescence. Lipofuscin granules were distributed from the inner layer of the annulus fibrosus to the nucleus pulposus. Such granules were numerous in cases of slight or severe degeneration, whereas fewer granules were found in cases of moderate degeneration. However, the stage of macroscopic degeneration of the intervertebral disc did not necessarily correlate with the incidence of lipofuscin granules. By ultrastructural observation, the morphological features of the components of the intervertebral disc and the ultrastructure of the lipofuscin granule were clarified. The ultrastructure of the "brown degeneration" disc exhibited markedly increased amorphous electron-dense bodies located among collagen fibrils in the matrix.

Water, fixed charge density, protein contents, and lysine incorporation into protein in chymopapain-digested intervertebral disc of rabbit.

Chymopapain (Discase) was injected at a dose of 0.125 nanokatal unit into the intervertebral discs of rabbits, and sequential changes in the metabolism of water, proteoglycan, collagen, and noncollagenous protein were investigated separately in the nucleus pulposus, anterior, and posterior anulus fibrosus. One week after chymopapain injection, the water and proteoglycan content was lower in all of the fractionated tissues of the anterior and posterior anulus and nucleus pulposus of the discs than in the control discs. In the anterior and posterior anulus, the proteoglycan content recovered after 12 weeks, but there was no recovery in the nucleus pulposus. The collagen content continued to increase up to the 12th week in the nucleus pulposus, while the noncollagenous protein content decreased in all tissue fractions after 1 week. In the anterior and posterior anulus, the content of noncollagenous protein recovered after 3 to 6 weeks, but there was no recovery in the nucleus pulposus. The lysine incorporation in collagen and noncollagenous protein was inhibited in all tissue fractions after 12 weeks, suggesting a decrease in synthetic activity. The intradiscal pressure calculated from proteoglycan hydration at 1 to 6 weeks after chymopapain injection showed a marked decrease to 0.8 to 0.9 atm, but it recovered to 1.6 atm after 12 weeks.