Sciatic spinal deformity-lumbosacral list: an "unusual" presentation with review of the literature.

Sciatic spinal deformity or lumbosacral list has received little attention in the literature. The phenomenon was first described in 1881 by Remak, but it was not until 1942 that Duncan and Hoen made the association between disk herniation and lumbosacral list. Since that time, the literature concerning this topic has been sparse and the terminology inconsistent. A case of lumbosacral list associated with disk herniation is presented with documented resolution after surgery. The pathogenesis of the list is described with a comprehensive review of the literature.

The results of surgical treatment for adult scoliosis.

This study was done to define and characterize those adult patients with scoliosis who will have problems of pain and/or progression leading to a surgical procedure and to review the results of these surgical procedures. The authors reviewed the cases of 49 adult patients who had undergone surgical treatment for scoliosis (average follow-up, 34 months; range, 24-140 months). The patients were categorized according to age, which allowed analysis of the data comparing age and the incidence and level of pain, age versus the degree of curvature, and age versus the incidence of progression. The relative incidence of pain and progression as indications for surgery were found to vary with respect to age. In the younger groups, progression was more often the indication for surgery than in the older groups. The younger groups also had larger curves than did the older groups, on average. The degree of pain was not found to correlate with the magnitude of the deformity. Surgical complications occurred in 20 patients; however, 14 of these were minor complications during the perioperative period, which did not result in any sequelae. Surgical treatment can be done with a relatively low serious complication rate and good results in terms of pain relief and reasonable correction of the deformity.

Spinal stenosis with scoliosis.

A retrospective review was carried out on 40 patients who met the criteria of 1) having a significant lumbar scoliosis associated with spinal stenosis, with symptoms of neurogenic claudication; and 2) having been treated with posterior decompression and pedicular screw fixation techniques. The average age of the patients was 61.5 years (range, 38-77 years), and 25 of the 40 patients were female. Eighty-eight percent of the patients had significant back pain in addition to lower extremity pain. All patients had pedicular screw fixation at all levels. Zielke instrumentation was used in 24 patients, Cotrel-Dubousset instrumentation in 8 patients, and Texas Scottish Rite Hospital instrumentation in the remaining 8 patients. After surgery, there was marked improvement in regard to pain status: 34 patients (83%) had severe pain before surgery, with 38 patients (93%) reporting mild or no pain at follow-up. Average length of follow-up was 44 months (range, 24-61 months). There were no deaths and no instrument-related failures or pseudarthroses noted in this series. A mean correction of the deformity of 19 degrees was obtained. Average scoliosis was 37 degrees before surgery and 18 degrees at follow-up.

Muscle disease as a cause of kyphotic deformity in ankylosing spondylitis.

The effects of ankylosing spondylitis on skeletal muscle were investigated in nine consecutive patients referred for correction of severe spinal deformity. Enzymatic studies (creatinine phosphokinase, aldolose), electromyography, and paraspinal muscle biopsy were performed. The enzyme studies and electromyography yielded only variable results, but muscle biopsy uniformly demonstrated evidence of severe skeletal muscle disease. Small, scattered, sharp angular fibers were present in all specimens along with atrophy of Type I and Type II muscle fibers. Core or targetoid fibers were present in all but one patient. These findings suggest that muscle disease may be present in all ankylosing spondylitis patients with spinal flexion deformity.

Evidence from cadavers suggestive of entrapment of fifth lumbar spinal nerves by lumbosacral ligaments.

Lumbosacral spines from 51 geriatric-age cadavers (25 men and 26 women) were examined both grossly and under the dissecting microscope for evidence of compression of fifth lumbar spinal nerves by their respective lumbosacral ligaments. These ligaments were found to extend from the transverse process and body of L5 to the ala of the sacrum in 97% of the specimens, and from the transverse process and body of L5 to the promontory of the sacrum in 3% of the specimens. Anterior primary rami of the fifth lumbar spinal nerve were observed to be compressed in 11% (11 of 102) of the specimens examined grossly and under the dissecting microscope. Histologic evidence of chronic compression, as suggested by perineurial and endoneurial fibrosis, peripheral thinning of myelin sheaths, or subjective evidence of a shift in fiber diameter to a population of smaller size fibers was found, deep to the lumbosacral ligament, in three of the 11 nerves judged to be compressed. The information derived is of interest to the clinician whose patient presents with L5 root signs and a myelogram, discogram, and computed tomographic scan which do not show any abnormality. The possibility of extraforaminal compression must be considered as a possible source of the clinical signs.

Neck injuries to high school football players in western New York State.

The goals of this study were to document the incidence of all injuries to the cervical spine at four Western New York high schools over two consecutive football seasons, and to compare the regional incidence to other reports. We also sought to identify the athletes at greatest risk of injury as determined by preseason questionnaire, medical history, and physical examination. Seventy-four high school football players entered the study prior to their junior season of play, and were followed prospectively for any reportable injury to the cervical spine. An overall 10.8% rate of injury occurred over the two-year study period; the highest rate was for defensive backs and linebackers making a tackle. Thirty-two percent of players had an abnormal history, examination, or both prior to the first season of play. The medical community has a responsibility to educate the public concerning cervical spine injuries in high school football players.

Morphometry of the lumbar spine: anatomical perspectives related to transpedicular fixation.

The pedicles of lumbar vertebrae were measured both directly and radiographically to determine the differences between the sexes and the accuracy of radiographic measurement. The lumbar pedicles of cadavera of forty-nine patients--twenty-four men and twenty-five women--who died between the ages of sixty and ninety-eight years were measured directly and on radiographs. The pedicles of lumbar vertebrae from fifty-one patients--twenty-three men and twenty-eight women--between the ages of twenty and fifty years who had low-back problems were measured on radiographs and computerized tomographic scans. Comparison revealed that the average transverse and sagittal diameters of the pedicles and the distance from the posterior aspect of the laminar cortex to the anterior aspect of the cortex of the vertebral body along the central axis of the pedicles were 5 to 20 per cent greater in men, but the transverse and sagittal angles of the pedicle did not differ significantly between the sexes. Measurements on radiographs and computerized tomographic scans of the transverse angles of the pedicles and of the distances from the posterior aspect of the laminar cortex to the anterior aspect of the cortex of the vertebral body from the second to the fifth lumbar vertebra were greater than direct measurements, even without magnification. Direct measurements of the diameters of the transverse and sagittal diameters of the pedicle of the fifth lumbar vertebra, however, were greater than the radiographic measurements.

Coronal and sagittal plane spinal deformities correlating with back pain and pulmonary function in adult idiopathic scoliosis.

One hundred one referred adult patients (ages 20-63; mean, 36 years) with painful idiopathic scoliosis were evaluated. None had prior surgical treatment. Severity of pain was graded and localized over radiographic deformities in the coronal and sagittal planes. Radiographic changes in primary as well as full and fractional compensatory curves were studied. Degrees of scoliosis, percent correction on side bending, vertebral body rotation at curve apex, spinal balance, and lateral olisthesis in the coronal plane, degenerative disc disease, and other degenerative changes in all curves were measured and graded in both the coronal and sagittal planes. Lordosis and kyphosis were measured on all standing sagittal radiographs. Forty-one patients had pulmonary function studies. Multiple variable statistical analysis (Spearman correlation coefficients) of the data found fractional lumbosacral curves most painful and disabling. Scoliosis greater than 40 degrees and kyphosis greater than 50 degrees correlated with increasing pain and decreasing forced vital capacity. Reduction in forced vital capacity also correlated with curve rigidity. Rotation correlated closely with degrees of scoliosis (r = 0.70; P less than 0.0001) and had the highest correlation with pain (r = 0.59; P less than 0.0001) of all radiographic findings and deformities studied.

Posterior transpedicular Zielke instrumentation of the lumbar spine.

Thirty-three patients treated by posterior transpedicular Zielke instrumentation of the lumbar spine were followed 1.1-2.7 years postoperatively. The average age of the patients was 64 years. The transpedicular technique allowed excellent fixation in patients with poor bone stock secondary to osteoporosis and extensive laminectomy defects. In particular, it allowed distraction and realignment of asymmetrically collapsed foramina with relief of pedicular kinking, correction of lateral deformity, and correction of reduced and fixed listhetic segments. Complications included one broken rod in the immediate postoperative interval while in the hospital. There was no late breakage of rods. The technique of transpedicular fixation with the ability to selectively distract or compress individual segments prevented any further collapse or displacement and allowed correction of areas of scoliotic collapse with relief of root entrapment. A normal lordosis was maintained as indicated by preoperative and postoperative measurements.

Neuro-myopathic flexion deformities of the cervical spine.

A study is presented of six patients who suffered flexion (chin-on-chest) deformity of the cervical spine on a neuropathic or myopathic basis. An awareness of this possibility is recommended, differentiating these patients from those with similar deformities due to ankylosing spondylitis, trauma, or primary degenerative change. Recognition is based on a detailed history, weakness of neck extension, electrodiagnostic studies, and muscle biopsy. A mildly elevated creatine phosphokinase (CPK) was the only consistent laboratory finding. Appropriate surgical correction of severe deformity involves anterior surgical release of contracted sternomastoid muscles, halo-dependent traction, posterior vertebral inferior facet resection, and spinal fusion over an adequate length, supplemented with internal fixation. Where extension correction involves extensive vertebral body separation anteriorly, additional anterior keystone strut grafting is indicated.

Intradural connections between adjacent cervical spinal roots.

It is not always possible to localize the level of cervical pathology accurately on the basis of clinical signs and symptoms. Intradural intersegmental connections between sensory rootlets occur frequently in the cervical region and have been shown to be clinically and surgically significant. Similar connections between motor rootlets also have been noticed, but their incidence was not reported. Fifty-four human cervical spines were dissected to investigate the incidence of both types of connections. Fifty-three of the 54 specimens had posterior rootlet connections, and nine of the 54 had anterior connections. The preponderant pattern (85%) was for a peripheral dorsal or ventral rootlet to join the central portion of the next rostral or caudal root, and for the two to pass together into the spinal cord. Six distinct patterns were recognized, and a classification system is proposed. These connections may provide a pathway for overlap of sensory dermatomes and motor innervation of the neck and upper extremity. Our observations imply that when a cervical nerve root is injured, small segments of an adjacent root may be equally affected, and the process may be clinically localized one segment higher or lower than it actually is.

Ender nailing in fractures of the proximal femur.

Seven hundred twenty-three consecutive patients with intertrochanteric fractures of the femur have been treated by intramedullary nailing with Ender's nails. Six hundred forty-four patients have survived for 6 months or longer, with one patient requiring secondary surgery for delayed union and six patients requiring revision of the fixation device. The morbidity has been low, the complication rate acceptable, and the complications readily corrected. The overall result in terms of fracture healing, maintenance reduction, and functional activity has been very satisfactory.

Delayed union and nonunion of the tibia: experience in a community teaching hospital.

Delayed union and nonunion are frequent sequelae of high-energy tibial fractures, particularly compound ones. The authors studied 45 such cases; of these, 20 fractures were compound. The authors analysed the initial management but found no apparent correlation between the initial management of these fractures and subsequent delayed union or nonunion. The Phemister bone-grafting technique was used to achieve union and was considered a safe, efficacious method. Aggressive initial management of the soft-tissue component of tibial fractures is recommended to minimize the possible development of chronic osteomyelitis, a serious complication that occurred in eight patients and necessitated below-knee amputation in three.

Anomalies of the lumbosacral nerve roots. An anatomical investigation and myelographic study.

Lumbosacral nerve root anomalies have been documented in the literature for over 30 years; however, no significant quantitative studies have been undertaken so far. We describe parallel studies of 100 cadaveric specimens and an equal number of metrizamide myelograms. The anatomical specimens were prepared by wide deroofing of the lumbar canal to permit precise examination of individual nerve roots and their intradural and extradural connections. The incidence of nerve root anomalies was 14%, the L5-S1 level being most commonly involved. In sharp contrast the incidence of nerve root anomalies determined by myelography was only 4%. The anomalies were classified into four groups and the diagnostic and practical implications of our findings are discussed.

Incidence and severity of back pain in adult idiopathic scoliosis.

Incidence of back pain in a referred and followed group of 197 adults with idiopathic scoliosis and in a comparable control group of 180 adults without known spinal deformity was the same. Severity of pain, however, was greater in scoliotic patients. The clinical course of back pain in adults without spinal deformity and in scoliotics was different: 64% improvement in adults without scoliosis versus 83% persistence and progression in adults with scoliosis. Fifty-one percent of adult scoliotics (101 patients) had significant pain. Pain increased with age and degree of scoliotic curvature (P less than 0.0005). Patients with major lumbar curves had more pain. Major complaint was frequently below major deformity. Compensatory lumbosacral fractional curves were most painful and disabling. Pain comes mainly from concavity of curves and includes discogenic, facet joint, and radicular origins. Surgery significantly reduced pain (P less than 0.0001); conservative therapy did not. Eighty-three percent of surgical patients had sufficient pain relief to make surgery worthwhile at five years average follow-up.