Cartilage endplate stem cells inhibit intervertebral disc degeneration by releasing exosomes to nucleus pulposus cells to activate Akt/autophagy.

Degeneration of the cartilage endplate (CEP) induces intervertebral disc degeneration (IVDD). Nucleus pulposus cell (NPC) apoptosis is also an important exacerbating factor in IVDD, but the cascade mechanism in IVDD is not clear. We investigated the apoptosis of NPCs and IVDD when stimulated by normal cartilage endplate stem cell (CESC)-derived exosomes (N-Exos) and degenerated CESC-derived exosomes (D-Exos) in vitro and in vivo. Tert-butyl hydroperoxide (TBHP) was used to induce inflammation of CESCs. The bioinformatics differences between N-Exos and D-Exos were analyzed using mass spectrometry, heat map, and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. NPC apoptosis was examined using TUNEL staining. The involvement of the AKT and autophagy signaling pathways was investigated using the signaling inhibitor LY294002. Magnetic resonance imaging, Western blotting, and immunofluorescence staining were used to evaluate the therapeutic effects of N-Exos in rats with IVDD. TBHP effectively induced inflammation and the degeneration of CEP in rat. N-Exos were more conducive to autophagy activation than D-Exos. The apoptotic rate of NPCs decreased obviously after treatment with N-Exos compared to D-Exos. N-Exos inhibited NPCs apoptosis and attenuated IVDD in rat via activation of the AKT and autophagy pathways. These results are the first findings to confirm that CEP delayed the progression of IVDD via exosomes. The therapeutic effects of N-Exos on NPC apoptosis inhibition and the slowing of IVDD progression were more effective than D-Exos due to activation of the PI3K/AKT/autophagy pathway, which explained the increase in the incidence of IVDD after inflammation of the CEP.

Ergonomics and musculoskeletal disorders in neurosurgery: a systematic review.

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) are a growing and probably undervalued concern for neurosurgeons and spine surgeons, as they can impact their quality of life and career length. This systematic review aims to ascertain this association and to search for preventive measures. METHODS: We conducted a PRISMA-P-based review on ergonomics and WMSDs in neurosurgery over the last 15 years. Twelve original articles were included, of which 6 focused on spine surgery ergonomics, 5 cranio-facial surgery (mainly endoscopic), and one on both domains. RESULTS: We found a huge methodological and content diversity among studies with 5 surveys, 3 cross-sectional studies, 2 retrospective cohorts, and 2 technical notes. Spine surgeons have sustained neck flexion and neglect their posture during surgery. In a survey, low back pain was found in 62% of surgeons, 31% of them with a diagnosed lumbar disc herniation, and 23% of surgery rate. Pain in the neck (59%), shoulder (49%), finger (31%), and wrist (25%) are more frequent than in the general population. Carpal tunnel syndrome showed a linear relationship with increasing cumulative hours of spine surgery practice. Among cranial procedures, endoscopy was also significantly related to shoulder pain while pineal region surgery received some attempts to optimize ergonomics. CONCLUSIONS: Ergonomics in neurosurgery remains underreported and lack attention from surgeons and authorities. Improvements shall target postural ergonomics, equipment design, weekly schedule adaptation, and exercise.

[Release of moveable segments after dorsal stabilization : Impact on affected discs]. / Freigabe von Bewegungssegmenten nach dorsaler Stabilisierung : Auswirkung auf die betroffenen Bandscheiben.

BACKGROUND: Bisegmental dorsal stabilization is a common treatment option for instable compression fractures of the thoracolumbar spine; however, it remains unknown to what extent bridging compromises intervertebral discs. OBJECTIVES: The purpose of this study was to determine the disc height and functional features in comparison to healthy intervertebral discs after removal of the dorsal fixator and particularly under consideration of the time span between dorsal stabilization and implant removal (IR). MATERIAL AND METHODS: The IR was performed in 19 patients after an average of 13 months (range 8-24 months) after dorsal stabilization of instable vertebral compression fractures of the thoracolumbar junction and lumbar spine. An additional ventral monosegmental spondylodesis was performed in 10 patients with incomplete burst fractures. Thus, a total of 28 intervertebral discs were temporarily bridged (bridged discs), with an adjacent endplate fracture in 10 (injured discs) and no adjacent bony lesion in 18 discs (healthy discs). The intervertebral discs superior and inferior to the instrumentation were selected as controls (control discs). Standardized conventional lateral radiographs were taken prior to and after IR as well as after 6 months. Additionally, standardized lateral radiographs in flexion and extension were taken. The intervertebral disc height (disc height) was determined by two independent board approved orthopedic observers by measuring the anterior, central and dorsal intervertebral disc spaces on all lateral radiographs as well as the intervertebral disc angles (disc angle) defined by the intervertebral upper and lower endplates in the flexion and extension views. Intradisc function (disc function) was defined as the difference between the disc angle in extension and flexion. The measurements were repeated after 12 months. Univariate analysis was performed using ANOVA and significance was set at p < 0.05. Interobserver and intraobserver comparisons of the disc heights and the disc angles were determined with intraclass correlation coefficients. RESULTS: No significant differences were seen in disc function and disc height between the controls and the bridged discs at all times of measurement; however, injured discs showed a significantly reduced disc height and disc angle in extension compared to healthy discs (p = 0.028 and p = 0.027, respectively). Additionally, patients with IR during the first 12 months had significantly reduced disc heights compared to those patients with delayed IR within the second postoperative year (p = 0.018). Interobserver and intraobserver agreement for disc function was 0.80 (95 % confidence interval CI: 0.68-0.88) and 0.85 (95 % CI 0.76-0.90), respectively. The interobserver and intraobserver correlations for disc height were 0.85 (95 % CI: 0.76-0.90) and 0.93 (95 % CI 0.88-0.95), respectively. CONCLUSION: Bridging of an intervertebral disc with IR within 24 months does not cause immediate loss of disc function or reduction of disc height; however, temporary bridging in combination with an adjacent endplate fracture causes significant reduction of disc height and loss of extension. Additionally, no beneficial effects could be seen by reducing the time span between stabilization and IR to below 12 months.

Gender specific analysis of occupational diseases of the low back caused by carrying, lifting or extreme trunk flexion--use of a prevention index to identify occupations with high prevention needs.

BACKGROUND: Gender specific analysis of the occupational disease of the lumbar spine caused by carrying, lifting, or extreme trunk flexion in Germany (OD No.2108) with the aim to identify areas of focus for prevention and research with a prevention index (PI). METHODS: Data from the German Statutory Accident Insurance stratified by gender are shown. RESULTS: From 2002 until 2009 there were 2,877 confirmed cases of an OD No. 2108 (40.1% male and 59.1% female). The PI indicated the highest prevention need for female nursing/midwifery associate professionals and male building frame and related trades workers. Patient transfer and working in extremely bent posture were the most frequent exposures. CONCLUSIONS: The identified occupations with high need for prevention among men come from nearly all major occupational groups whereas women cluster in occupational groups from the health and care sectors.

The safety and efficacy of minimally invasive discectomy: a meta-analysis of prospective randomised controlled trials.

PURPOSE: The objective of this study was to compare the safety and efficacy of minimally invasive discectomy (MID) with standard discectomy (SD) and determine whether the use of the MID technique could decrease the recurrence of lumbar disc herniation (LDH) after the surgery. METHODS: In February 2014, a comprehensive search was performed in PubMed, EMBASE, Web of Science, Cochrane Library and the Chinese Biological Medicine Database. Only randomised controlled trials (RCT) that compared MID with SD for the surgical management of LDH were included. These trials were carefully picked out following the inclusion and exclusion criteria. Using the Cochrane Collaboration guidelines, two authors independently extracted data and assessed these trials' quality. The age of the patients, size of incision, surgical time, blood loss, visual analogue scale (VAS) score after the surgery, hospital stay, disc herniation recurrence, X-ray exposure and surgical costs in these studies were abstracted and synthesised by a meta-analysis with RevMan 5.2.0 software, and the main results (VAS score after the surgery and disc herniation recurrence) of publication bias were examined by Stata 12.0. RESULTS: Overall, 16 trials involving 2,139 patients meeting our criteria were included and analysed. Comparing MID and SD, the former was more likely to increase disc herniation recurrence [relative risk (RR) = 1.95, 95 % confidence interval (CI) 1.19-3.19, p = 0.008], and it involved a smaller size of incision [mean difference (MD) = -1.91, 95 % CI -3.33 to -0.50, p = 0.008], shorter hospital stay, longer operating time (MD = 11.03, 95 %C I 6.62-15.44, p < 0.00001) and less blood loss (MD = -13.56, 95 % CI -22.26 to -4.87, p = 0.002), while no statistical difference appeared with regard to the age of the patients, VAS score after the surgery, X-ray exposure, hospital stay and surgical costs. CONCLUSIONS: Based on available evidence, MID results in less suffering for patients during the hospital course with a similar clinical efficacy compared to SD. This makes MID a promising procedure for patients with LDH; however, to popularise it greater effort is required to reduce disc herniation recurrence.

Prosthesis in Anterior Cervical Herniated Disc Approach Does Not Prevent Radiologic Adjacent Segment Degeneration.

STUDY DESIGN: Retrospective analysis using data from RCTs. OBJECTIVE: This study aimed to report on the incidence of radiological adjacent segment degeneration (ASD) in patients with cervical radiculopathy due to a herniated disc that were randomized to receive cervical arthroplasty or arthrodesis. SUMMARY OF BACKGROUND DATA: Cervical disc prostheses were introduced to prevent ASD in the postsurgical follow-up. However, it is still a controversial issue. METHODS: Two hundred fifty-three patients were included in two randomized, double-blinded trials comparing anterior cervical discectomy with arthroplasty (ACDA), with intervertebral cage (ACDF), or without intervertebral cage (ACD) for one-level disc herniation. Neutral lateral radiographs were obtained preoperatively, at 1- and 2-year follow-up after surgery. Radiological ASD was evaluated on X-ray and defined by a decrease in disc height and the presence of anterior osteophyte formation on both the superior and the inferior level in relation to the target level. RESULTS: Radiological ASD was present in 34% of patients at baseline and increased to 59% at 2-year follow-up in the arthrodesis groups (ACD and ACDF combined), and to 56% in the arthroplasty group. Progression of radiological ASD was present in 29% of patients in the arthrodesis group and in 31% of patients in the arthroplasty group for 2-year follow-up. CONCLUSIONS: Radiological ASD occurs in a similar manner in patients who were subjected to arthrodesis in cervical radiculopathy and in patients who received arthroplasty to maintain motion. Current data tend to indicate that the advantage of cervical prosthesis in preventing radiological ASD is absent. LEVEL OF EVIDENCE: 2.

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

Delayed complications following lumbar spine fusion may occur amongst which is adjacent segment degeneration (ASD). Although interspinous implants have been successfully used in spinal stenosis to authors' knowledge such implants have not been previously used to reduce ASD in instrumented lumbar fusion. This prospective controlled study was designed to investigate if the implantation of an interspinous implant cephalad to short lumbar and lumbosacral instrumented fusion could eliminate the incidence of ASD and subsequently the related re-operation rate. Groups W and C enrolled initially each 25 consecutive selected patients. Group W included patients, who received the Wallis interspinous implant in the unfused vertebral segment cephalad to instrumentation and the group C selected age-, diagnosis-, level-, and instrumentation-matched to W group patients without interspinous implant (controls). The inclusion criterion for Wallis implantation was UCLA arthritic grade UCLA grade II in the adjacent two segments cephalad to instrumentation. All patients suffered from symptomatic spinal stenosis and underwent decompression and 2-4 levels stabilization with rigid pedicle screw fixation and posterolateral fusion by a single surgeon. Lumbar lordosis, disc height (DH), segmental range of motion (ROM), and percent olisthesis in the adjacent two cephalad to instrumentation segments were measured preoperatively, and postoperatively until the final evaluation. VAS, SF-36, and Oswestry Disability Index (ODI) were used. One patient of group W developed pseudarthrosis: two patients of group C deep infection and one patient of group C ASD in the segment below instrumentation and were excluded from the final evaluation. Thus, 24 patients of group W and 21 in group C aged 65+ 13 and 64+ 11 years, respectively were included in the final analysis. The follow-up averaged 60 +/- 6 months. The instrumented levels averaged 2.5 + 1 vertebra for both groups. All 45 spines showed radiological fusion 8-12 months postoperatively. Lumbar lordosis did not change postoperatively. Postoperatively at the first cephalad adjacent segment: DH increased in the group W (P = 0.042); ROM significantly increased only in group C (ANOVA, P < 0.02); olisthesis decreased both in flexion (P = 0.0024) and extension (P = 0.012) in group W. The degeneration or deterioration of already existed ASD in the two cephalad segments was shown in 1 (4.1%) and 6 (28.6%) spines in W and C groups, respectively. Physical function (SF-36) and ODI improved postoperatively (P < 0.001), but in favour of the patients of group W (P < 0.05) at the final evaluation. Symptomatic ASD required surgical intervention was in 3 (14%) patients of group C and none in group W. ASD remains a significant problem and accounts for a big portion of revision surgery following instrumented lumbar fusion. In this series, the Wallis interspinous implant changed the natural history of ASD and saved the two cephalad adjacent unfused vertebra from fusion, while it lowered the radiographic ASD incidence until to 5 years postoperatively. Longer prospective randomized studies are necessary to prove the beneficial effect of the interspinous implant cephalad and caudal to instrumented fusion. We recommend Wallis device for UCLA degeneration I and II.

Injectable cellulose-based hydrogels as nucleus pulposus replacements: Assessment of in vitro structural stability, ex vivo herniation risk, and in vivo biocompatibility.

Current treatments for intervertebral disc degeneration and herniation are palliative only and cannot restore disc structure and function. Nucleus pulposus (NP) replacements are a promising strategy for restoring disc biomechanics and height loss. Cellulose-based hydrogel systems offer potential for NP replacement since they are stable, non-toxic, may be tuned to match NP material properties, and are conducive to cell or drug delivery. A crosslinked, carboxymethylcellulose-methylcellulose dual-polymer hydrogel was recently formulated as an injectable NP replacement that gelled in situ and restored disc height and compressive biomechanical properties. The objective of this study was to investigate the translational potential of this hydrogel system by examining the long-term structural stability in vitro, the herniation risk and fatigue bending endurance in a bovine motion segment model, and the in vivo biocompatibility in a rat subcutaneous pouch model. Results showed that the hydrogels maintained their structural integrity over a 12-week period. AF injury significantly increased herniation risk and reduced fatigue bending endurance in bovine motion segments. Samples repaired with cellulosic hydrogels demonstrated restored height and exhibited herniation risk and fatigue endurance comparable to samples that underwent the current standard treatment of nucleotomy. Lastly, injected hydrogels elicited a minimal foreign body response as determined by analysis of fibrous capsule development and macrophage presence over 12 weeks. Overall, this injectable cellulosic hydrogel system is a promising candidate as an NP substitute. Further assessment and optimization of this cellulosic hydrogel system in an in vivo intradiscal injury model may lead to an improved clinical solution for disc degeneration and herniation.

Multi-laminate annulus fibrosus repair scaffold with an interlamellar matrix enhances impact resistance, prevents herniation and assists in restoring spinal kinematics.

Focal defects in the annulus fibrosus (AF) of the intervertebral disc (IVD) arising from herniation have detrimental impacts on the IVD's mechanical function. Thus, biomimetic-based repair strategies must restore the mechanical integrity of the AF to help support and restore native spinal loading and motion. Accordingly, an annulus fibrosus repair patch (AFRP); a collagen-based multi-laminate scaffold with an angle-ply architecture has been previously developed, which demonstrates similar mechanical properties to native outer AF (oAF). To further enhance the mimetic nature of the AFRP, interlamellar (ILM) glycosaminoglycan (GAG) was incorporated into the scaffolds. The ability of the scaffolds to withstand simulated impact loading and resist herniation of native IVD tissue while contributing to the restoration of spinal kinematics were assessed separately. The results demonstrate that incorporation of a GAG-based ILM significantly increased (p < 0.001) the impact strength of the AFRP (2.57 ±â€¯0.04 MPa) compared to scaffolds without (1.51 ±â€¯0.13 MPa). Additionally, repair of injured functional spinal units (FSUs) with an AFRP in combination with sequestering native NP tissue and a full-thickness AF tissue plug enabled the restoration of creep displacement (p = 0.134), short-term viscous damping coefficient (p = 0.538), the long-term viscous (p = 0.058) and elastic (p = 0.751) damping coefficients, axial neutral zone (p = 0.908), and axial range of motion (p = 0.476) to an intact state. Lastly, the AFRP scaffolds were able to prevent native IVD tissue herniation upon application of supraphysiologic loads (5.28 ±â€¯1.24 MPa). Together, these results suggest that the AFRP has the strength to sequester native NP and AF tissue and/or implants, and thus, can be used in a composite repair strategy for IVDs with focal annular defects thereby assisting in the restoration of spinal kinematics.

Surgical Experience and Complications in 50 Patients Treated with an Anular Closure Device Following Lumbar Discectomy.

OBJECTIVE: To examine the results of an anular closure device for prevention of lumbar disc reherniation in daily routine practice. METHODS: Fifty patients with large anular defects were treated with limited discectomy and a bone-anchored anular closure device. The device physically occludes the defect in the anulus fibrosus and is intended for prevention of lumbar disc reherniation. Pain scores on a visual analogue scale, back function on the Oswestry Disability Index, and neurological status were noted. Symptomatic reherniation and reoperation rates were assessed at each follow-up. Surgical findings and complications, device-related and/or procedure-related, were recorded. Follow-up was 6, 12, 26, and 52 weeks. RESULTS: Mean anular defect height/width was 4.6 mm/10.1 mm. The overall symptomatic reherniation and reoperation rate was 2%. During the 1-year follow-up period, mean back pain decreased from 43 to 8 (P < 0.001), leg pain decreased from 71 to 4 (P < 0.001), and the Oswestry Disability Index decreased from 46 to 5 (P < 0.001). Among 15 patients with preoperative neurological deficits, improvements in neurological function were noted in 14 (93%). There were no serious device-related complications. CONCLUSIONS: The presented study shows promising early results in using the anular closure device. The procedure is safe with significantly fewer reherniations than for patients with large anular defects without anular closure. Further studies with longer follow-up periods are warranted to prove these findings for long-term outcomes.

Moderate alcohol consumption may decrease risk of intervertebral disc degeneration.

Intervertebral disc degeneration (IDD) is a serious health problem worldwide. Unfortunately, efforts to control IDD are largely unsuccessful. It is therefore important to get better understanding of risks. Various evidences indicate that moderate alcohol consumption has protective effect on IDD. Here, we review the clinical evidence on alcohol consumption and IDD, and propose a possible mechanism. There is increasing evidence indicating that moderate alcohol consumption keeps the feeding arteries smooth. Furthermore, strong evidence indicates that some inflammatory factors are very important in the pathophysiology of IDD, while moderate alcohol consumption can decrease the expression of these inflammatory factors. Moreover, experimental studies show that alcohol exposure could increase the type II collagen and aggrecan, the major constituents of nucleus pulposus matrix. Given the above background, we hypothesize that moderate alcohol consumption may reduce the risk of IDD.

Pathophysiology of low back pain during exposure to microgravity.

Astronauts exposed to microgravity frequently report low back pain. This pain is described as moderate to severe in intensity. This condition warrants investigation as low back pain may hinder an astronaut's ability to perform challenging tasks by virtue of disruption of sleep and, subsequently, mental concentration. It is reported by astronauts that a "fetal tuck position" described as knees to chest position relieves back pain. It is possible that the pathogenesis of back pain in microgravity is discogenic (or mechanical) and somatic, referred from the sinuvertebral nerves due to excessive expansion of the lumbar intervertebral discs associated with reduction of gravitational compressive loads in space. The fetal tuck position may increase lumbar intervertebral disc hydrostatic pressure by flexion and transfer of spinal compressive forces toward the anterior region of the lumbar discs, subsequently reducing disc volume. Moreover, this position may reduce Type IV mechanoreceptor facilitation and nerve impulse propagation from the sinuvertebral nerves of the annulus fibrosus, and thus diminish low back pain perception. Elongated posterior soft tissues (apophyseal joint capsules and ligaments) with spinal flexion may potentially stimulate Type I and II mechanoreceptors. This neutralizes substance P in the spinal cord dorsal horn by increasing naturally occurring opioids such as enkephalins. Separately, other investigators have reported a higher incidence of herniated discs (HNP) in astronauts postflight. Further studies of countermeasures are recommended to prevent excessive spinal elongation and disc expansion, reduce low back pain in microgravity, and simulate 1-G disc homeostasis, which may also help prevent HNPs postflight.

Annular closure in lumbar microdiscectomy for prevention of reherniation: a randomized clinical trial.

BACKGROUND CONTEXT: Patients with large annular defects after lumbar discectomy for disc herniation are at high risk of symptomatic recurrence and reoperation. PURPOSE: The present study aimed to determine whether a bone-anchored annular closure device, in addition to lumbar microdiscectomy, resulted in lower reherniation and reoperation rates plus increased overall success compared with lumbar microdiscectomy alone. DESIGN: This is a multicenter, randomized superiority study. PATIENT SAMPLE: Patients with symptoms of lumbar disc herniation for at least 6 weeks with a large annular defect (6-10 mm width) after lumbar microdiscectomy were included in the study. OUTCOME MEASURES: The co-primary end points determined a priori were recurrent herniation and a composite end point consisting of patient-reported, radiographic, and clinical outcomes. Study success required superiority of annular closure on both end points at 2-year follow-up. METHODS: Patients received lumbar microdiscectomy with additional bone-anchored annular closure device (n=276 participants) or lumbar microdiscectomy only (control; n=278 participants). This research was supported by Intrinsic Therapeutics. Two authors received study-specific support morethan $10,000 per year, 8 authors received study-specific support less than $10,000 per year, and 11 authors received no study-specific support. RESULTS: Among 554 randomized participants, 550 (annular closure device: n=272; control: n=278) were included in the modified intent-to-treat efficacy analysis and 550 (annular closure device: n=267; control: n=283) were included in the as-treated safety analysis. Both co-primary end points of the study were met, with recurrent herniation (50% vs. 70%, P<.001) and composite end point success (27% vs. 18%, P=.02) favoring annular closure device. The frequency of symptomatic reherniation was lower with annular closure device (12% vs. 25%, P<.001). There were 29 reoperations in 24 patients in the annular closure device group and 61 reoperations in 45 control patients. The frequency of reoperations to address recurrent herniation was 5% with annular closure device and 13% in controls (P=.001). End plate changes were more prevalent in the annular closure device group (84% vs. 30%, P<.001). Scores for back pain, leg pain, Oswestry Disability Index, and health-related quality of life at regular visits were comparable between groups over 2-year follow-up. CONCLUSIONS: In patients at high risk of herniation recurrence after lumbar microdiscectomy, annular closure with a bone-anchored implant lowers the risk of symptomatic recurrence and reoperation. Additional study to determine outcomes beyond 2 years with a bone-anchored annular closure device is warranted.

Effect of a posterior dynamic implant adjacent to a rigid spinal fixator.

BACKGROUND: A slightly degenerated disc adjacent to a segment that has to be fused is sometimes instrumented with a dynamic fixator. The dynamic implant is assumed to reduce disc loads at that level and to preserve disc function, thus inhibiting the progression of degeneration. METHODS: A three-dimensional finite element model of the lumbar spine was used to study the effect of a dynamic implant on the mechanical behavior at the corresponding level. After studying a healthy lumbar spine for comparison, a rigid fixator and a bone graft were inserted at L2/L3. Healthy and degenerated discs were assumed at the adjacent level, i.e. L3/L4. An additional paired dynamic posterior fixator was then implemented at level L3/L4. Finally, the segment with the dynamic fixator was distracted to the height of a healthy disc. The loading cases of walking, extension, flexion and axial rotation were simulated. FINDINGS: A dynamic implant reduces intersegmental rotation for walking, extension and flexion as well as facet joint forces for axial rotation at its insertion level. Intradiscal pressure is not markedly reduced by a dynamic implant. Moreover, there are no substantial differences between the mechanical behavior of rigid and dynamic fixators. INTERPRETATION: Our model does not predict major differences in the mechanical effects between rigid and dynamic fixators despite the extreme assumption that a dynamic implant does not transfer moments. The results do not support the assumption that disc loads are significantly reduced by a dynamic implant. For axial rotation, however, dynamic fixation devices do reduce the force in the facet joint.

Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects.

The lumbar spine was assessed by magnetic resonance imaging (MRI) in 14 children (mean age 12.4 years) with unspecific activity-related low back pain for more than 3 weeks presenting with normal plain radiographs. Impending spondylolysis was diagnosed when typical signal abnormalities were confined to the pars interarticularis without signs of thinning or fragmentation. After brace treatment for 3 months, follow-up MRI was performed 3 and 6 months after treatment. MRI signals returned to normal after 3 months in six patients and after 6 months in one patient. MRI showed promising results in detecting and monitoring the early onset of spondylolysis. Bracing and avoiding strenuous activities prevented the formation of pars defects in all our patients.

[Criteria to notify to the authorities the occupational lumbar trait diseases]. / Criteri per la denuncia ex D.M. 27/4/04 delle spondilodiscopatie del tratto lombare e dell'ernia discale lombare.

To carry out the requirement of notification according to the Italian law D.M. 27/4/04 in relation to the item "Manual handling of loads made continuously during working shift" it is necessary to clarify some quantitative and chronological aspects regarding the exposure and to precise the nature of the diseases to be notified. To fulfil their choices doctors at the moment can not rely on quantitative referrings based on the evidence and wide spread accepted, but they basically have operative indications partly taken from literature and stil under validation. However, to carry out the requirement of the law and to avoid choices not based on considered criteria, we propose some operative criteria deriving from the knowledge that at the moment seems more consolidated and accepted in the occupational and previdential medicine.

Evidence-based development of a post-surgical lumbar discectomy leaflet intervention: a Delphi consensus study.

OBJECTIVE: To produce free, expert-informed postoperative information for lumbar discectomy patients, satisfying UK National Health Service Information Standards. DESIGN: A mixed methods approach utilising the Delphi technique and focus groups. SETTING: Five spinal centres across the UK. PARTICIPANTS: Panel members included 23 physiotherapists, 11 patients and 17 spinal surgeons. INTERVENTION: Three rounds of questionnaires including open and closed questions and attendance at a clinician/patient focus group. RESULTS: Response rates of 85%, 26% and 35% were achieved for the Delphi rounds. Ten clinicians and six patients participated in the focus groups. Consensus for leaflet sections was achieved in round 1 and content in round 3. The focus groups informed further revisions. CONCLUSIONS: A consensually agreed, Information Standard compliant, patient lumbar discectomy leaflet was produced containing: (1) normal spine anatomy; (2) anatomy disc herniation and surgery; (3) back protection strategies and (4) frequently asked questions. Illustrations of exercises enable tailoring to the individual patient.

Low back pain/prolapsed lumbar intervertebral disc.

Low back pain is common throughout the adult years in both men and women; first episodes most frequently occur among people in their 20s and 30s. Prolapsed lumbar disc most often affects individuals in the age range 25-45 years; prolapses occur infrequently in persons below 20 years or over 65 years. Major risk factors for low back pain in general and for prolapsed disc specifically include frequent lifting of objects weighing 25 pounds or more, especially if the objects are lifted with the arms extended and with the knees straight and if the lifting is done while the body is twisted; exposure to whole-body vibration, including driving motor vehicles; cigarette smoking; and, for prolapsed lumbar disc, narrow lumbar vertebral canals. Possible risk factors for which the evidence is weak or inconsistent include frequent stretching, reaching, pulling, and pushing on the job; sedentary occupations; jobs in which workers stay in one position for long periods of time; recent employment in a physically demanding job; jobs requiring frequent twisting without lifting; tallness; heredity; extent of forward flexibility in the lumbar area; lack of physical fitness; pregnancies; psychological symptoms; and frequent participation in bowling. The methods suggested to date with the greatest potential for prevention include modification of jobs so as to reduce exposure to known occupational risk factors, and careful selection of workers by such means as strength testing for the particular job for which they are to be employed.