The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation.

Biopsy specimens of the lumbar multifidus were obtained from 18 patients with lumbar disc herniation at operation and after a postoperative follow-up period of 5 years. The structure and morphometry of the muscle fibers were analyzed and these data were compared with intraoperative biopsy results and the clinical outcome of the operation. The main findings were: 1) on the basis of occupational handicap score 10 patients belonged in the "positive" and 8 in the "negative" outcome group; 2) the intraoperatively recorded selective type 2 muscle fiber atrophy and the extent of pathologic inner structure changes both decreased in the "positive" outcome group, whereas they persisted in the "negative" group; 3) grouping as a definite sign of reinnervation was seen in only two versus four patients of the "positive" versus "negative" outcome group; 4) the relative amount of adipose tissue within the muscle decreased more markedly in the "positive" outcome group. The authors propose that both inactivity and axonal injury (mainly of neurapraxia type) contribute to the selective type 2 atrophy and inner structure changes in disc patients' multifidus muscle. These pathologic structural changes correlated well with the clinical outcome, and most importantly they are reversible and can be diminished by adequate therapy.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part I: Patient characteristics and differences between groups.

Based on a prospective study on 342 sciatica patients examined with rhizography, the aim was to determine which factors others than the rhizography finding and the grade and duration of symptoms were related to the selection of patients to undergo operation. Compared with surgically treated patients, conservatively treated patients who did not undergo operation and who had pathologic rhizography findings had pessimistic attitudes to possible surgery, often expressed a desire to retire, and considered their work as physically stressful. The women in this group were older and had lower pain indices than women who underwent operation. Conservatively treated patients with negative rhizography had more severe occupational handicaps, minor expectations of possible surgery, physically more strenuous jobs requiring difficult physical positions, and lower indices for pain and ADL than did the operated patients. The social and ergonomic background problems are emphasized in sciatica patients conservatively treated after rhizography.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part II: Results after one year follow-up.

The prospective study included 122 sciatica patients who had not undergone operation (NOPs) and 220 sciatica patients who had undergone operation (OPs); all had been examined by rhizography. The follow-up study was done on 110 (90%) of the NOPs and 212 (96%) of the OPs. The NOPs were divided into two groups: 30 patients with pathologic rhizography (PR) and 80 patients with negative rhizography (NR). Pain-, ADL-, and occupation-handicap indices showed that after the 1 year follow-up the OP group had the best result and the NR group the lowest result. The PR group had nearly as good a result as the OP group. Thus, sciatica patients are candidates for conservative therapy, even though they have pathologic findings in rhizography, if the symptoms are mild. To improve therapeutic outcome, more accurate diagnostic tools are needed to develop specific therapy especially for those sciatica patients with negative rhizography.

The multifidus muscle in patients with lumbar disc herniation. A histochemical and morphometric analysis of intraoperative biopsies.

Structural changes in the multifidus muscle were analyzed in 41 patients operated on for herniated intervertebral disc. Twelve cadavers served as controls. The two main findings follow: Both in the patients and in the controls the Type 2 muscle fibers were markedly and selectively smaller than the Type 1 fibers, which were of normal size for striated muscles, and the internal structure of Type 1 fibers showed so-called core-targetoid and/or moth-eaten change. Group atrophy or fiber-type grouping (indicators of denervation and reinnervation) were observed only in a few patients. The selective small size of the Type 2 fibers may indicate atrophy due to relative inactivity of the multifidus muscle both in the patients and in the controls, ie, it does not need to be related to the herniated disc. Definite proof for denervation of the multifidus muscle was not observed, but neither the possibility be excluded. The cause of the core-targetoid and/or moth-eaten changes cannot yet be determined with certainty, because these changes are not specific for any single entity but may be due, for example, to denervation, ischemia, or altered use of the muscles because of pain. In any case, because the changes were significantly more common in the patients than in the controls, they signal for a pathologic condition, the character of which remains to be elucidated.

Connective tissue changes of the multifidus muscle in patients with lumbar disc herniation. An immunohistologic study of collagen types I and III and fibronectin.

The connective tissue components, Types I and III collagen fibronectin, were immunohistologically analyzed using their specific antibodies for localization and semiquantitative estimation in 24 patients (11 women and 13 men, all under 55 years of age) operated on for herniated lumbar intervertebral disc. Nine cadavers without known back problems (2 women, 7 men) served as controls. In controls, Type I collagen was present in the endo- and perimysial structures of the muscle, more conspiciously in the former. Type III collagen, together with fibronectin, were more abundant in the perimysium than in the endomysium. Thickening of these structures was not evident in the controls. In most patients Types I and III collagen and fibronectin distribution was similar to that of the controls. However, fibrotic changes of both and endo- and perimysial structures involved all Types I and III collagen and fibronectin in ten cases. In two patients an increase in Type I collagen staining intensity in the endomysium was recorded and thickening of the endomysial structures was observed in six patients. There were correlations with the severity of the connective tissue structural changes to atrophy of the muscle and furthermore to disability of the patient in the 1-year postoperative check-up. These findings suggest that if marked fibrosis of the muscle occurs, it can be a factor impairing recovery from the disease during the long-term postoperative course.

Histological and enzyme histochemical study on the injured knee meniscus in human.

The activity and distribution of 10 enzymes was determined in the ruptured knee meniscus of 23 patients, when meniscus was operatively removed. The activities of NADH and SDH indicating oxydative energy metabolism were low in the ruptured meniscus as well as in the synovium close to it. On the contrary, NADPH and LDH, indicating anaerobic energy metabolism and G-6-PDH as an indicator of pentose-phosphate shunt, showed moderate or high activity. The activities of GLDH, ATPase, AcPase, AlPase, and LAPase were low in the meniscus tissue, but moderate and sometimes high in synovial tissue and fibroblasts close to the meniscus. In the vascular walls these enzyme activities all were moderate or high indicating reparative capacity in the peripheral, vascularized part of meniscus. The age of the patients as well as the time interval between the trauma and the operation was not in relationship with enzyme activities studied.

Rehabilitation after surgery for lumbar disc herniation: results of a randomized clinical trial.

The aim of this prospective study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation randomized in two groups: one with comprehensive rehabilitation and the other taken care of by normal care facilities. A total of 212 patients without any previous spinal operations comprised the final study group. The physiatrist, the surgeon, the social worker, and the psychologist performed the handicap evaluation according to the occupation handicap scales of the WHO. The handicap was evaluated for two phases: before the onset of acute sciatica leading to operation and one year after operation. No significant differences in handicap distribution between the intervention and normal care groups were seen. The postoperative handicap correlated highly significantly with preoperative handicap for both groups. More than half (57%) of all the patients returned to work within two months of the operation. The amount of sick leaves did not differ significantly between the intervention and normal care groups. A total of 15 persons (7%) retired during the postoperative year.

Girdlestone operation. An acceptable alternative in the case of unreconstructable hip arthroplasty.

Between 1970 and 1984, 1250 total hip arthroplasties using methylmethacrylate bone cement were performed at the Department of Surgery, University of Turku, Finland. Girdlestone arthroplasty was performed in nine women and one man in ten cases of failed arthroplasty. In general, the results were evaluated as good. The patients were satisfied, and they had no pain or only slight or occasional pain on weight bearing. Nine of ten patients could walk, two of them without any walking aids. In conclusion, the Girdlestone operation can offer an acceptable functional result when reconstruction of the hip joint is not possible.

Postoperative synovial fluid. Metabolic response to meniscectomy or synovectomy.

The metabolic response of synovial tissue to surgery was investigated by synovial fluid analysis after two types of operations, medial meniscectomy and synovectomy. Analyses of intra-articular fluid were also performed in non-operated patients with traumatic effusion or chronic synovitis in the knee. It was found that the knee joint metabolism in chronic synovitis is shifted towards anaerobic glycolysis in both operated and non-operated patients whereas meniscectomized and traumatized knees are more capable of maintaining oxidative metabolism. The data also demonstrate that one of the main reasons for decreased oxygen supply on the articular surface after meniscectomies or synovectomies is excessive intra-articular effusion which, according to earlier investigations, produces pressure in the joint cavity and inhibits local capillary circulation.

A prospective 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation.

The study consists of 276 patients who were hospitalized between 1980 and 1982 because of suspected lumbar disc herniation. Treatment choice was based on clinical indications only; no randomization was used. A total of 179 patients were treated surgically and 97 had continued conservative treatment. Both groups were followed-up 1 and 5 years later. Five-year follow-up results showed that 68% of operated patients still had pain in sciatic distribution and 21% were retired. Re-operation frequency was 13.8%. Of non-operated patients, 82% still had sciatica and 26% were retired. Reasons for outcome differences between the study groups are discussed.

Lumbar muscles: structure and function.

We review new data derived from careful dissection studies on the macroscopic anatomy, innervation and function of the lumbar muscles, as well as information on the fibres in these muscles. The new findings correct previous misconceptions of the functional anatomy of the lumbar muscles. The innervation and function of the erector spinae and multifidus muscles are so different that they cannot be classified as a single unit. The new interpretation of the innervation of multifidus muscle is of importance, for example, for the neurophysiological examination of the lumbar muscles. The relative number of the slow and fast type of muscle fibres in lumbar muscles varies considerably, and selective atrophy of the fast fibres seems to ensue from inactivity, not only in patients with back pain but also in sedentary controls. The atrophy may be corrected by adequate exercise. Both the fibre type composition and degree of atrophy may well influence a person's susceptibility to low back pain arising from the muscles.

Extra-abdominal desmoid tumour. Report of three cases.

Three cases of desmoid tumour in a lower extremity are described. Primary radical excision is necessary for this type of tumour, because of its clear tendency to recur. In the described cases surgery was complicated by the proximity of neural structures and blood vessels. Preoperative angiography was useful for determining the size of the tumour and its position in relation to large blood vessels. Pathologic vascularity was found in the tumours, but histologic examination revealed no sign of malignancy. The histologic structure of the tumours corresponded in all respects to benign fibromatosis, apart from a clear increase in the number of mast cells. The tumours showed a tendency to grow between the muscle fibres, though a pseudocapsule was observed at operation in two cases. None of the specimens from the extirpation line displayed any signs of tumour tissue, but this did not preclude recurrence.

Effect of the position of immobilization upon the tensile properties of the rat gastrocnemius muscle.

This study compared the tensile properties of the atrophied gastrocnemius unit after immobilization in a shortened position (SP) and lengthened position (LP). The left hind legs of 52 male Wistar rats were fixed with plaster casts either with the knee in flexion and the ankle in extension, or vice versa. After seven to 21 days of immobilization the load-deformation curves and the weights of both gastrocnemius muscle-tendon units from each rat were evaluated. The initial length increased about 4% in the LP immobilized muscles and decreased about 5% in the SP immobilized muscles when compared to the contralateral controls. The decrease in force to failure averaged 21% in the LP and 31% in the SP immobilized muscles after one week and continued to about 26% and 48%, respectively, in three weeks. The corresponding elongation decreased 13% and 21% in one week and 17% and 36% at the end of the third week when immobilized in the LP and SP, respectively. The decrease in elastic stiffness was similar in both groups, but the loss of energy absorption capacity before failure was more prominent in SP fixed muscles (64%) than in LP fixed muscles (49%). The loss of weight of the muscle-tendon units due to the immobilization was greater in the SP (36%) than in the LP (12%). We conclude that immobilization of the rat gastrocnemius muscle-tendon unit in an SP is followed by a more marked muscle atrophy and a greater decrease in tensile properties than immobilization in an LP.

Effects of sodium aurothiomalate on hyaluronic acid synthesis in normal and rheumatoid synovial fibroblast cultures.

In studies with normal and rheumatoid synovial fibroblast cultures the effects of sodium aurothiomalate on the quantity and quality of hyaluronic acid were tested. This gold compound produced one clear effect: the molecular weight of hyaluronate produced by rheumatoid fibroblasts was increased (shifted towards normal) whereas the effects on the amounts of hyaluronic acid synthesized were small in both rheumatoid and control cultures. The importance of this finding in relation to the known beneficial effects of gold preparations in clinical medicine is discussed.

Synthesis of underpolymerized hyaluronic acid by fibroblasts cultured from rheumatoid and non-rheumatoid synovitis.

Fibroblast cultures were started from synovial tissue of normal controls and patients with seronegative and seropositive rheumatoid arthritis, juvenile rheumatoid arthritis and chronic non-rheumatoid synovitis. Glycosaminoglycan synthesis of the cultures was studied by metabolic labeling with 3H-glucosamine. Molecular weight of hyaluronic acid produced and secreted into culture medium by these fibroblast strains was studied by gel filtration in a Sepharose 2 B column. All fibroblast strains from joints with active inflammation produced hyaluronate with decreased molecular weight. The synthesis of underpolymerized hyaluronate thus appears to be a property of activated synovial fibroblasts common to rheumatoid and non-rheumatoid inflammation.

Operated lumbar disc herniation: epidemiological aspects.

A total of 1011 operations for lumbar disc herniation were carried out in South-West Finland during the period 1975-1979. Of these operations 907 were first and 104 reoperations. Eleven patients had cauda equina symptoms. There were 856 operations performed on patients living in the area served by Turku University Central Hospital, an area with 455 000 inhabitants. Operations on 778 patients (342 women and 436 men, mean age 41.6 years) were first and operations on 78 patients (36 women and 42 men, mean age 42.7 years) were reoperations (9.1%). Nearly 90% of the patients were between 25 and 54 years of age. Neither heavy nor light work was more common among the first operated or reoperated patients than in the population at large. The monthly variation in the number of operations had no statistical significance. The incidence of operation for first lumbar disc herniation varied yearly from 31 to 36 per 10(5) persons living in the Turku University Central Hospital area.