Analysis of injury and pain scores during fusion surgery for multisegmental lumbar spinal stenosis in elderly patients.

INTRODUCTION: Lumbar stenosis has become a common disease. Controversies exist regarding fusion surgery. MATERIAL AND METHODS: The patients were divided into groups per the method of fusion received: the posterolateral fusion group (group P) and the intervertebral fusion group (group I). The patients were further divided into groups based on the number of fusion segments: the 2-segment group (P2 and I2), the 3-segment group (P3 and I3), and the 4-segment group (P4 and I4). The operative time, intraoperative blood loss, blood transfusion volume, and postoperative drainage volume were summarized. In particular, wound healing appearance and management were observed. RESULTS: The operation time and blood transfusion volume of the P2 and P3 groups were significantly less than those of the I2 and I3 groups (p < 0.05). The postoperative drainage volume of group I4 was less than that of group P4 (p < 0.05). Postoperative numeric rating scale (NRS) scores of P2 and P3 groups were lower than those of I2 and I3 groups (p < 0.05), while the NRS scores of P4 group were higher than those of I4 group (p < 0.05). CONCLUSIONS: Posterolateral and intervertebral fusion techniques can be used in the surgical treatment of elderly patients with lumbar spinal stenosis. The posterolateral fusion method should be used when three or fewer segments require surgery. The intervertebral fusion method should be used when four segments require surgery.

[A special type of discogenic low back pain: normal signal intensity of magnetic resonance imaging with abnormal discography].

OBJECTIVE: To report a group of special patients showing a normal signal intensity of MRI with a positive discography and discuss its pathogenesis and clinical significance. METHODS: From August 2003 to November 2008, 288 patients with chronic low back pain were treated. Of these patients, 12 showed a normal intensity signal of MRI in lumbar intervertebral discs with a positive discography. There were 7 males and 5 females aged 20 - 44 years with an average of 29.6 years. The duration of disease was 8 months to 3 years with an average of 1.8 years. Dallas CT grading method was used for assessing the degree of annular disruption. RESULTS: Of these 12 patients, 33 lumbar discs underwent discography. Twelve discs in 12 patients showed annular disruption and low back pain reproduction. Among 12 painful discs, 3 showed grade 2 annular disruption and 9 showed grade 3 annular disruption. CONCLUSION: Patients who are refractory to conservative care and have normal signal intensity in lumbar disc MRI and who are suggested as discogenic origin and might need further treatment such as minimal invasive surgery or lumbar interbody fusion should still be examined by discography.

[Natural history and prognosis of discogenic low back pain].

OBJECTIVE: To understand the natural history and prognosis of patients with discogenic low back pain so as to offer a better guide on its clinical treatment. METHODS: From December 2003 to November 2004, we consecutively hospitalized 72 patients with discogenic low back pain diagnosed by lumbar discography. These patients were randomized into two groups. One group (n = 36) received an intradiscal methylene blue (MB) injection immediately after discography while another group (n = 36) received a placebo. Both Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used to assess the back pain symptoms and the lumbar function respectively during a 4-year follow-up period. RESULTS: In total, 32 of 36 patients who received a placebo injection underwent a 4-year follow-up. Of these patients, 4 cases (12.5%) had their low back pain symptoms alleviated, 1 case (3.1%) slightly improved, 3 cases (9.4%) aggravated and 22 cases (68.8%) had no change in symptoms. According to VAS and ODI scores taken at different time points, these two scores gradually decreased over time; however, no statistical significances were found (VAS: F = 3.049, P > 0.05; ODI: F = 2. 272, P > 0.05). CONCLUSION: The disease course of discogenic low back pain is chronic and persistent so that its symptoms show no improvement over time.

[Diagnosis and surgical treatment of back pain originating from endplate].

OBJECTIVE: To explore the methods of diagnosis and surgical treatment for patients with back pain originating from endplate. METHODS: All patients received examinations of radiography, CT, and MR imaging. Pain level of disc was decided by discography in each patient. The principal outcome judgment were pain and disability, and the efficacy of surgical treatment was assessed by visual analog scale (VAS) for pain, and the Oswestry disability index (ODI) for functional recovery. RESULTS: All patients with a diagnosis of back pain originating from endplate according to discography were treated with anterior or posterior fusion surgery. The mean follow-up period was three years and five months (from 2 to 6 years). Among of the 21 patients, 20 (95%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement on the ODI and the VAS scores were obtained in the patients with chronic low back pain originating from endplate (P = 0.0001) after treatment. CONCLUSIONS: The study suggests that the discography and fusion surgery may be very effective methods for the diagnosis and treatment of chronic back pain originating from endplate respectively.

Crossing anastomosis of nerve bundles near innervated organs to treat irreparable nerve injuries.

OBJECTIVE: To study the therapeutical effects of crossing anastomosis of nerve on the peripheral and central nerve injuries. METHODS: Twelve kinds of central and peripheral nerve disorders and their complications were treated with 11 kinds of crossing anastomosis of nerve bundles near the innervated organs. After nerve injury and repair, somatosensory evoked potentials (SEPs) and horseradish peroxidase (HRP) retrograde tracing studies were used to investigate the rabbit's nerve function and morphology. RESULTS: The ulcers of all patients healed. Sensation, voluntary movement, and joint function recovered. Four weeks after the anastomosis of distal stump of radialis superficialis nerve and median nerve, pain sensation regained and SEPs appeared. HRP retrograde tracing studies demonstrated sensory nerve ending of medial nerve formed new connection with the body of neuron. CONCLUSION: Crossing anastomosis of nerve is an effective method to treat peripheral and central nerve injuries.

Brown-Sequard syndrome produced by calcified herniated cervical disc and posterior vertebral osteophyte: Case report.

Brown-Sequard syndrome (BSS) produced by cervical disc disorders has rarely been seen clinically and only 50 cases have been reported in English literatures. However, most of which have resulted from acute disc herniation. Here, we report a case of BSS produced by calcified herniated C4-C5 disc and posterior vertebral osteophyte, in which decompression through anterior approach was performed. This case revealed the potential of cervical spondylopathy leading to BSS in a chronic manner. Once the diagnosis is established, it is advisable to perform decompression as early as possible.

[Experimental study on promotion of neurotropic reinnervation with chemically extracted acellular nerve allograft].

OBJECTIVE: To investigate the promotion effect of neurotropic reinnervation with chemically extracted acellular nerve allograft. METHODS: The sciatic nerves of 5 healthy adult SD rats, regardless of gender and weighing 270-300 g, were collected to prepare chemically extracted acellular nerve allograft. Eighteen healthy adult Wistar rats, regardless of gender and weighing 300-320 g, were made the model of left sciatic nerve defect (10 mm) and randomly divided into 2 groups: autograft (control group, n = 9) and allograft group (experimental group, n = 9). The defects were bridged by acellular nerve allograft in experimental group and by autograft by turning over the proximal and distal ends of the nerve in control group. At 3 months after transplantation, dorsal root ganglion (DRG) resection operation was performed in 6 rats of 2 groups. At 3 weeks after operation, the sural nerves were harvested to calculate the misdirection rate of nerve fibers with pathological staining and compute-assisted image analysis. Cholinesterase staining and carbonic anhydrase staining were performed in the sural nerve of 3 rats that did not undergo DRG resection at 3 months. RESULTS: The results of cholinesterase staining and carbonic anhydrase staining showed that experimental group had less brown granules and more black granules than control group. After DRG resection, count of myelinated nerve fiber were 4 257 +/- 285 in the experimental group and 4 494 +/- 310 in the control group significant (P < 0.05). The misdirection rate was 2.27% +/- 0.28% and 7.65% +/- 0.68% in the experimental group and in the control group respectively, showing significant difference (P < 0.05). CONCLUSION: Chemically extracted acellular nerve allograft can not only act as a scaffold in the period of nerve defects repair, but markedly enhance the effects of neurotropic reinnervation.

[Observation on maintenance of scoliosis curve correction and preservation of spinal mobility after removing plate-rod system for scoliosis].

OBJECTIVE: To investigate the effect of removing the implanted plate-rod system for scoliosis (PRSS) on maintaining scoliosis curve correction and preserving spinal mobility in patients with scoliosis. METHODS: From June 1998 to February 2002, 119 cases of scoliosis were treated with the implant of PRSS, which was removed 26-68 months later (average 46.8 months). Complete follow-up data were obtained in 21 patients, including 6 males and 15 females aged 11-17 years old (average 13.8 years old). The disease course was 9-16 years (average 12.1 years). There were 2 cases of congenital scoliosis and 19 cases ofidiopathic scoliosis, which included 5 cases of IA, 2 of IB, 1 of IIA, 2 of IIB, 2 of IIC, 2 of IIIA, 3 of IIIB, and 2 of IVA according to Lenke classification. There were 13 cases of thoracic scoliosis and 8 of thoracolumbar scoliosis. AP view and the lateral and anterior bending view of X-ray films before and at 3 to 6 months after removing PRSS were comparatively analyzed, the coronal and the sagittal Cobb angle were measured, and the height of vertebral body on the concave side and the convex side were measured, so as to know the effect of PRSS on the growth of the vertebral endplates. RESULTS: All the implants were removed successfully with an average operation time of 2.5 hours (range 2-4 hours) and a small amount of intraoperative blood loss. Twenty-one cases were followed up for 6-72 months (average 34.4 months). The coronal Cobb angle before and after the removal of PRSS was (20.25 +/- 8.25) degrees and (23.63 +/- 8.41) degrees, respectively, indicating there was no significant difference (P > 0.05); while the sagittal Cobb angle was (39.44 +/- 12.38) degrees and (49.94 +/- 10.42) degrees, respectively, indicating there was a significant difference (P < 0.05). The height of the top vertebral body on the concave side before and after the removal of PRSS was (1.78 +/- 0.40) cm and (2.08 +/- 0.35) cm, respectively, and there was a significant difference (P < 0.01); while the height on the convex side was (2.16 +/- 0.47) cm and (2.18 +/- 0.35) cm, respectively, indicating no significant difference was evident (P > 0.05). All the 21 patients had good prognosis and no major operative complication occurred. CONCLUSION: PRSS is an effective instrumentation for the management of scoliosis. After the removal of the PRSS, the correction of scoliosis can be maintained, and the spinal mobility can be protected and restored.

Expression and role of connective tissue growth factor in painful disc fibrosis and degeneration.

STUDY DESIGN: We collected the specimens of lumbar intervertebral discs from patients with discogenic low back pain, to study the histopathological features and connective tissue growth factor (CTGF) expressions. OBJECTIVE: To study the expression and role of CTGF in fibrosis and degeneration of painful disc tissue. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated that degenerative disc commonly showed fibrosis in histology. CTGF, a downstream effector mediated by transforming growth factor-beta1 (TGF-beta1), is commonly related to tissue fibrosis. We do not know whether CTGF is expressed in painful disc, and related to painful disc degeneration and fibrosis. METHODS: This study included 43 lumbar intervertebral disc specimens from 28 patients with discogenic low back pain obtained during posterior lumbar interbody fusion and 16 asymptomatic degenerative discs from patients without low back pain. Further, 8 normal discs were included as controls. Their histopathological features were studied, and the expression of CTGF was assessed using immunohistochemistry. RESULTS: Histologic examination revealed that the painful discs showed chronic inflammatory reaction with blood vessel infiltration in varying degrees. The anulus fibrosus had lost its normal lamellar architecture, and instead, disorganization, disruption, and crossed fusion were observed. Normal fibroblasts were replaced by chondrocytes in the anulus fibrosus. The nucleus pulposus showed marked fibrosis, blood vessel infiltration, and inflammatory granulation tissue formation. Immunohistochemical staining demonstrated strong CTGF expression in the painful discs, weak expression in the asymptomatic degenerative disc, and no expression in the control discs. CONCLUSION: The painful degenerative disc is significantly different from the asymptomatic degenerative disc with regard to histopathological findings. The strong CTGF expression in the painful disc may be related to disc fibrosis and degeneration.