Early mobilisation of thoracolumbar burst fractures without neurology: a natural history observation.

AIMS: The authors present the results of a cohort study of 60 adult patients presenting sequentially over a period of 15 years from 1997 to 2012 to our hospital for treatment of thoracic and/or lumbar vertebral burst fractures, but without neurological deficit. METHOD: All patients were treated by early mobilisation within the limits of pain, early bracing for patient confidence and all progress in mobilisation was recorded on video. Initial hospital stay was one week. Subsequent reviews were made on an outpatient basis. RESULTS: The mean duration from admission to final follow-up was three months, and longer follow-up was undertaken telephonically. The mean kyphosis deformity on arrival was 17.4° (5° to 29°); mean kyphosis at final discharge three months later was 19.5° (1° to 28°). Spinal canal encroachment had no influence on successful functional recovery. DISCUSSION: Pain has not been a significant problem for any patient, irrespective of the degree of kyphosis and no patient has a self-perception of clinical deformity. In all, 11 patients took occasional analgesia. All patients returned to their original work level or better. Two patients died 2.5 years after treatment, from unrelated causes. TAKE HOME MESSAGE: The natural history of thoracolumbar burst fractures without neurology would appear to be benign.

The Oswestry Risk Index: an aid in the treatment of metastatic disease of the spine.

The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make difficult decisions in the management of patients presenting with spinal metastases. A prospective cohort study of 199 consecutive patients presenting with spinal metastases, treated with either surgery and/or radiotherapy, was used to compare the three systems. Cox regression, Nagelkerke's R(2) and Harrell's concordance were used to compare the systems and find their best predictive items. The three systems were equally good in terms of overall prognostic performance. Their most predictive items were used to develop the Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient of determination than any of these three scores. A bootstrap procedure was used to internally validate this score and determine its prediction optimism. The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and general condition (GC): OSRI = PTP + (2 - GC). This simple score can predict life expectancy accurately in patients presenting with spinal metastases. It will be helpful in making difficult clinical decisions without the delay of extensive investigations.

Observations on the natural history of massive lumbar disc herniation.

We have treated 15 patients with massive lumbar disc herniations non-operatively. Repeat MR scanning after a mean 24 months (5 to 56) showed a dramatic resolution of the herniation in 14 patients. No patient developed a cauda equina syndrome. We suggest that this condition may be more benign than previously thought.

Senescence in human intervertebral discs.

Intervertebral discs demonstrate degenerative changes relatively early in life. Disc degeneration, in turn, is associated with back pain and disc herniation, both of which cause considerable clinical problems in the western world. Cell senescence has been linked to degenerative diseases of other connective tissues such as osteoarthritis. Thus we investigated the degree of cell senescence in different regions of discs from patients with different disc disorders. Discs were obtained from 25 patients with disc herniations; from 27 patients undergoing anterior surgery for either back pain due to degenerative disc disease (n = 25) or spondylolisthesis (n = 2) and from six patients with scoliosis. In addition, four discs were obtained post-mortem. Samples were classified as annulus fibrosus or nucleus pulposus and tissue sections were assessed for the degree of cell senescence (using the marker senescence-associated-beta-galactosidase (SA-beta-Gal)) and the number of cells present in clusters. There were significantly more SA-beta-Gal positive cells in herniated discs (8.5% of cells) than those with degenerative disc disease, spondylolisthesis, scoliosis, or cadaveric discs (0.5% of cells; P < 0.001). There was more senescence of cells of the nucleus pulposus compared to those of the annulus fibrosus and in herniated discs a higher proportion of cells in cell clusters (defined as groups of three or more cells) were SA-beta-Gal positive (25.5%) compared to cells not in clusters (4.2%, P < 0.0001). This study demonstrates an increased degree of cell senescence in herniated discs, particularly in the nucleus where cell clusters occur. These clusters have been shown previously to form via cell proliferation, which is likely to explain the increased senescence. These findings could have two important clinical implications: firstly, that since senescent cells are known to behave abnormally in other locations, they may lead to deleterious effects on the disc matrix and so contribute to the pathogenesis and secondly, cells from such tissue may not be ideal for cell therapy and repair via tissue engineering.

Coccygectomy for coccydynia: case series and review of literature.

STUDY DESIGN: This is a case series in which case notes review and telephone interview update were used to assess the outcome following coccygectomy. OBJECTIVE: To correlate the clinical results of coccygectomy with histology and discography of the sacrococcygeal and intercoccygeal segments. SUMMARY OF BACKGROUND DATA: Clinicians regard chronic disabling pain in the sacrococcygeal region with much dismay because of the reputed unpredictability of the treatment outcome. METHODS: A total of 38 patients had coccygectomy for intractable coccydynia, and 31 were available for follow-up. The excised specimen with intact sacrococcygeal joint was sent for histologic examination in 22 patients. There were 6 patients investigated using sacrococcygeal and intercoccygeal discography. RESULTS: Mean postoperative follow-up was 6.75 years (range 2-16). There were 16 patients who benefited highly from the surgery, and 6 benefited to some extent, giving an overall beneficial result of 71%. Of all specimens, 86.3% had histologic changes of degeneration. Moderate-to-severe degenerate changes in sacrococcygeal and intercoccygeal joints on histology were found in 54.5% of patients. Of these patients, 83.3% did well with surgery. Only 57.1% of those patients with mild changes did well. There were 2 patients who had positive discography, and both did well with surgery. Three patients had negative diskographies, and 2 of them had a poor result, and 1 had only some relief. CONCLUSIONS: It is possible that degenerate changes in sacrococcygeal discs and/or intercoccygeal discs are associated with pain. Surgical results are better in those with a severe degree of degenerative change. Coccygectomy remains a successful treatment for a majority of severely disabled patients with coccydynia.

En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases.

En bloc removal of the lower lumbar vertebral bodies (VBs) is a major surgical challenge. The authors describe the surgical technique used in two patients who presented with chordoma confined to the L-5 and L-4 VB, respectively. These tumors were diagnosed using magnetic resonance (MR) imaging during investigation for back pain. Both patients underwent a combined (two-stage) anterior-posterior approach. In the first case the posterior stage of the procedure was followed by an anterior retroperitoneal approach, and in the second case a lateral retroperitoneal approach was used. Complete en bloc excision of the tumor was achieved in each case, even though in the second case the VB fractured when it was mobilized. The correlation between the MR imaging findings and surgical specimens was remarkable. The authors conclude that en bloc resection is feasible in these cases. Because mobilization of the VB is more difficult in the lateral approach, the authors favor the anterior retroperitoneal approach. The authors anticipate the need for such procedures to increase with the widespread use of MR imaging, which demonstrates the extent of these tumors with remarkable accuracy.

Matrix metalloproteinases and aggrecanase: their role in disorders of the human intervertebral disc.

STUDY DESIGN: A comprehensive immunohistochemical study of matrix metalloproteinase activity in discs from patients with different disc diseases. OBJECTIVES: To identify individual matrix metalloproteinase enzymes that could contribute to the degeneration of the matrix of the intervertebral disc, to identify the cells that produce matrix metalloproteinases (for example, the endogenous disc cells or invading cells associated with vascularisation), and to determine if "aggrecanase" contributes to degradation of proteoglycans in disc disorders. SUMMARY OF BACKGROUND DATA: Matrix disorganization and loss of substance are the most common findings in degenerate discs, and proteinase enzyme activity is one means of causing these changes. METHODS: Forty-nine discs from 46 patients with degenerative disc disease, posterior anular tears, spondylolisthesis, or disc herniation were studied immunohistochemically to determine the presence of matrix metalloproteinases 1, 2, 3, 7, 8, 9 and 13, tissue metalloproteinases 1 and 2, and proteoglycan degradation products generated by either matrix metalloproteinases or aggrecanase activity. In addition, in situ zymography was used to confirm matrix metalloproteinase activity. RESULTS: The most extensive staining was seen for matrix metalloproteinases 1, 2, 3, and 9, with 91%, 71%, 65%, and 72% of samples having some immunopositivity for the respective antibodies. In contrast, staining for matrix metalloproteinases 7 and 8 was much less (38% for both). Tissue inhibitor of metalloproteinases 1 and 2 were expressed in 34% and 79% of specimens, respectively. Matrix metalloproteinases were found particularly in cell clusters and blood vessels of degenerate discs, with staining correlating positively with macroscopic degenerative grade. For all of the enzymes, there was most staining in the herniation specimens and least in the autopsy samples. The opposite was true of staining for the matrix metalloproteinases inhibitor, tissue inhibitor of metalloproteinases 2, with most found in the autopsy specimens. Enzyme activity was confirmed by in situ zymography and staining for matrix metalloproteinase degradation products of proteoglycans. In addition, there was staining with antibodies demonstrating aggrecanase degradation products. CONCLUSIONS: Matrix metalloproteinase activity is more prevalent in herniated discs than in other disc disorders studied, although matrix metalloproteinases may have been more common earlier in the disease progression. Matrix metalloproteinases can be produced by invading blood vessels and associated cells, as well as by indigenous disc cells. Aggrecanase activity, although present in some samples, was not as obvious as that of matrix metalloproteinases. In addition to altered matrix metalloproteinase production, there appears to be a change in the balance between enzymes and endogenous inhibitors, tissue inhibitors of metalloproteinases. This study highlights specific matrix metalloproteinases that might be most efficient to target in developing therapeutics for minimizing degradation of the extracellular matrix of the disc.

Vertebral intra-osseous chordoma or giant notochordal rest?

Chordomas of the lumbar vertebral bodies are rare. We report an unusual case of an entirely intraosseous chordoma of the fifth lumbar vertebra treated by vertebrectomy. Conventional radiographs and scintigraphy were normal. The lesion was well visualised by MR imaging, but showed only slight sclerosis on CT. We give our reasons for making a diagnosis of chordoma rather than giant notochordal rest and discuss the problems of management resulting from this diagnostic dilemma.

Matrix metalloproteinases in the human intervertebral disc: role in disc degeneration and scoliosis.

STUDY DESIGN: Biochemical study of human intervertebral discs collected at surgery from patients with low back pain associated with disc degeneration or scoliosis. Matrix metalloproteinases were studied by quantitative zymography. OBJECTIVE: To determine whether changes in the expression of matrix metalloproteinases will bring about tissue remodelling that contributes to the progressive nature and pathology of these diseases of the intervertebral disc. SUMMARY OF BACKGROUND DATA: The diseases of the intervertebral disc, degenerative disc disease and scoliosis, are both characterized by changes in the extracellular matrix components that will affect the mechanical function of the tissue. Matrix metalloproteinases are known to have the capability of degrading all the known extracellular matrix components of the disc. METHODS: Matrix metalloproteinases 2 and 9 were detected by gelatin-gel zymography and quantified by laser scanning densitometry. Both pro and active forms of the enzymes were measured. Thirty-four discs from patients with low back pain and 29 from patients with scoliosis were investigated. RESULTS: A correlation was found between the increasing levels of matrix metalloproteinases 2 and 9 and the grade of degenerative disc disease. In addition, the levels of these enzymes show a differential expression across the scoliotic disc with the highest levels in samples taken from the convexity of the curve. CONCLUSIONS: The difference between the concave and convex side of the scoliotic curve indicates that mechanical loads might influence the expression of these enzymes. The increased expression of these enzymes in both degenerative disc disease and scoliosis strongly suggests that they may affect the progressive nature of these diseases.

Neuropeptides in the human intervertebral disc.

The innervation of the human intervertebral disc was investigated by immunochemical methods. Immunoreactivity to the general nerve marker protein gene product (PGP 9.5) was found in the outer annulus fibrosus of 11 of 12 discs removed during anterior arthrodesis for back pain. PGP 9.5-immunoreactive fibres ran between and across the collagenous lamellae, both in association with blood vessels and distant from them, and extended at least 3 mm into the disc. No innervation was observed in the nucleus pulposus. Fine fibres (< 1 micron in diameter) immunoreactive to calcitonin gene-related peptide and substance P (neuropeptides located in sensory and possibly nociceptive nerves) were identified in eight and four of the annuli fibrosi, respectively. Nerve fibres immunoreactive to vasoactive intestinal peptide and to the c-flanking peptide of neuropeptide Y were found in the majority of specimens of annulus fibrosus that were examined.

Morphological basis for back pain: the demonstration of nerve fibers and neuropeptides in the lumbar facet joint capsule but not in ligamentum flavum.

The innervation of lumbar facet capsule and ligamentum flavum was investigated using antisera to a general neuronal marker protein gene product (PGP) 9.5 and to peptide markers of sensory nerves (calcitonin gene-related peptide [CGRP] and substance P) and autonomic nerves (vasoactive intestinal polypeptide [VIP] and C-flanking peptide of neuropeptide Y [CPON]). In the facet capsule (n = 14), PGP 9.5 and CGRP-immunoreactive nerves occurred in 12 and five specimens, respectively, both around blood vessels and as free fibers in the stroma. Free fibers immunoreactive for substance P or VIP were noted in three and five specimens, whereas in nine specimens there were CPON-immunoreactive nerves located perivascularly. There was no immunoreactivity in the ligamentum flavum. This study provides further evidence that the facet capsule but not the ligamentum flavum has substantial innervation by sensory and autonomic nerve fibers and has a structural basis for pain perception.

Dynamic assessment of anterior cruciate ligament using an electronic force plate.

The active force exerted by the movement of arms and trunk with the knee in extension was measured in 25 patients with anterior cruciate ligament deficient knee. The electronic force sensitive foot plate was used to measure the force. Two sets of measurements were carried out. The antero-posterior stress test for measurement of Fy and the rotational stress test for measurement of Mz. Peak values obtained in anterior cruciate deficient knee were compared with the normal knee on the other side. The measurement of the difference in Fy was found to be a reliable indicator of instability of the knee, but no significant difference was found in the peak torque values (Mz) between the two knees. This study suggests that this test may be useful in the objective measurement of knee instability. Details of the method used and its possible indications are discussed.

Renal pelvi-ureteric injury in traumatic paraplegia.

Three cases of pelvi-ureteric injury associated with traumatic paraplegia are described. The diagnosis of such injuries is usually late and the consequences can seriously affect the outlook of the patient. The problems of late diagnosis are discussed and recommendations made concerning earlier diagnosis.