We measured the intraarticular pressure in 10 knees during knee arthroscopic surgery. The average intraarticular pressure found in cases with bleeding was 53.7mmHg. When we studied the relationship between the Knee flexion angle and intraarticular pressure, we found that the minimum intrrarticular pressure occurred at 30° of knee flexion in all cases.
161 patients, 169 knees were evaluated with magnetic resonance imaging (MRI) and arthroscopy. MR findings and arthroscopic findings agreed in 74.6% of medial menisci, 74.6% of lateral menisci, 92.3% of anterior cruciate ligaments (ACL), 95.3% of posterior cruciate ligaments (PCL). The results between JOA (the Japanese Orthopaedic Association) -authorized orthopedists and junior residents were almost similar. On the basis of arthroscopic findings, false-positive and false-nagative cases of MRI were studied. Intrameniscal signal communicating with a meniscal articular surface was an important MRI finding for meniscal tear at arthroscopy. False-positive findings at MRI of the anterior and posterior horn regions of menisci may reflect the inability to completely and accurately visualize the meniscus with arthroscopy. False-negative findings at MRI of menisci often occurred in small tears. It may be difficult to accurately evaluate the region around the popliteus tendon with MRI. False-positive findings at MRI of the ACL may result from the partial volume effect because of proliferating synovium. False-positive findings of the PCL occurred, because ACL deficiency brings the sigmoid deformity at MRI of the PCL. False-negative findings of cruciate ligaments resulted from small tears.
We report a simple method for repairing damage to the meniscus by utilizing eye-holed Kirschner wire and a single suture strand. The repair involves the following: Step 1, the peripheral meniscal tear suitable for repair is identified arthroscopically. Step 2, a 1.8mm diameter eye-holed Kirschner wire is inserted into the joint and passed through the meniscus across the tear and then panetrates through to the skin. Step 3, an open incision is made around the wire and the neurovascular structurues are retracted. A free nylon suture is then passed through the eye-hole of the wire. Step 4, The wire is pulled back into the joint and repushed out through the meniscus about 5mm from the original stitch. Step 5: The nyron suture is removed from the wire and tied over the retinaculum. The same procedure may be need to repeated according to the width of the meniscal tear.
We measured the incidence of osteoarthritis of outpatients in six university and thirty-six general hospitals. In addition we performed a case study on osteoarthritis of the knee to investigate physical and other factors associated with severity of symptoms, uning a selfadministered questionnaire. Investigation of the hospital statistics revealed that 7.6% of all orthopeadic patients had osteoarthritis of the knee, and 70% of these cases were females. Regarding age 97% of patients were over forty years of age, and 900, 000 men and women were newly diagnosed with this disease every year. Symptoms of this disease were more severe with increasing body weight and BMI (Body Mass Index) at the time of both initial examination and at forty years of age. Bluecollar workers presented with more severe symptoms than did other workers.
Twenty-Three knees with early stages of osteoarthritis of the knee were assessed by fat suppressed magnetic resonance imaging (MRI). Abnormalities shown by fat suppressed MR included synovitis (39%), joint effusions (39%), degenerative changes of the meniscus (87%), soft tissue cysts (9%), hyaline cartilage thinning (70%) and subchondral signal changes (52%). Signal changes of the bone marrow were separated into three groups (localized type; 21%, diffuse type; 30%, mixed type; 4%). The results indicate that fat suppressed MR is capable of providing information about not only soft tissue, but also hyaline cartilage and bone marrow.
We report four cases of osteonecrosis of the medial femoral condyle treated conservatively. All of the four cases were classified as Stage 2 with less than 180° in FTA. The area of necrosis in the four cases was 1.5 1.8, 2.0 and 4.5cm2 respectively. Two cases were treated by complete entrussing for about 7 months and the other two cases were treated by lateral wedge supports. At greater than five years all cases were found to be well. If it is posebble to protect lesion, conservative treatment appears to be a good method for the patients refuse surgery treatment.
We report on 28 patients (47 knees) who were treated using the Lord's procedure. Overall results were evaluated by Hukubayashi's classification, X-ray evaluation and Q angle. All cases were clinically evaluated as almost excellent or good. We then compared excellent cases with good ones in regard to degree of medialization and ventralization. Results showed that the degree of medialization correlated with an improvement in X-ray evaluation and Q angle, but the degree of ventralization did not correlate. Therefore, when performing the Lord's procedure, corrct medialization is more important than ventralization.
Methicillin resistant Staphylococcus aureus (MRSA) infections are extremely important nosocomial infections due to the difficulty in eradication them. We reviewed six patients who had had nosocomial infections caused by MRSA in our clinic. Four patients had wound infections and two had MRSA enterocolitis. The cases wound infections were treated success-fully but the MRSA enterocolitis became seriously ill, with one dying due to respiratory and circulatory failure. It is more important to prevent nosocomial infections rather than to treat them. So strict basic infection control measeres should be kept, to interrupt the transmission of MRSA within the hospital.
Twelve patients with infected decubitus ulcers were treated surgically. Four of twelve patients infected with MRSA were treated with continuous wound irrigation using diluted povidone-iodine. Three of twelve patients received continuous wound irrigation with a diluted antibiotic solution. Two patients irrigated with this diluted antibiotic solution died from the MRSA infection. The four patients irrigated with diluted povidone-iodine were cured, however high iodine levels were found in these patients although they had no complications.
A 58-year-old woman was admitted to our hospital for treatment of a tibial shaft fracture. Open reduction and internal fixation with plate and screws were performed 5 days after injury. Six weeks after surgery, swelling appeared around the operation scar. Aspirated fluid from the swollen area revealed an infection with Gram-positeve cocci. Continuous irrigation and drainage were immediately performed. Three days later, MRSA was detected in the culture supernatant of the aspirated fluid. The plate and screws were then removed, and continuous irrigation with minocycline started. Simultaneously, VCM was administered intravenously for 11 days, with ABK following for 5 day. Three days after the start of treatment, MRSA vanished from the drainage fluid. Irrigation was continued for 25 days. In this case, clinical symptoms were moderate and laboratory data showed almost normal values which are characteristic features of MRSA infecion.
We report a case of a 69-year-old man with a late infection in his total hip arthroplasty due to methicillin-resistant Staphylococcus aureus (MRSA). Debridement and removal of the implants were performed with continuous closed irrigation and intravenous antibiotic therapy. However, MRSA infection recurred after the first debridement. IN total, five operations were performed to reduce the infection. Objective signs of the infection had disappeared in a section of the proximal femur after treatment with VCM and FMOX. At follow-up 2.9 years after the last operation there were no signs of infection.
The incidence of Methicillin-resistant Staphylococcus aureus (MRSA) infections of the joints or bones has increased in recent years. MRSA is less sensitibe to many types of antibiotics, making it a very difficult infection to treat. We treated two patients who had arthritis caused by MRSA, one in the shoulder joint and the other in the hip joint. The patient with arthritis of the shoulder joint had curettage five times followed by surgical treatment with a musculocutaneous flap of Latissimus dorsi. Another patient with paralysis from the spinal level Th7, developed a decubitus MRSA infection of the sacral region and left sided coxarthritis caused by MRSA. In this patient, the decubitus ulcer was treated using a rotation flap, and the coxarthritis was treated with a muscle flap of Rectus Femoris and Vastus Lateralis after three courses of curettage. Recurrence of MRSA infection has not been noted in these two patients for at least one year since their last operation. Musculocutaneous flaps are a good method for treating large dead spaces caused by MRSA infections around joints or over bones.
We reviewed 23 patients with MRSA infections in the Department of Orthopaedic Surgery. Decubitus infections should be treated with MC flap even if MRSA is positive. We did not find on effective treatment for osteomyelitis. For patients who have renal dysfunction, ABK should be used carefully.
We report on hospital-Acquired infections, focusing principally on methicillin-resistant staphylococcus aureus (MRSA), and its therapy. MRSA infections are very important hospital-acquired infections and have recently become prevalent enough to present a serious clinical problem in Japan. Between May 1991 and December 1993, in our hospital, Staphylococcus aureus infection was found in 321 patients giving an MRSA infection rete of 65.4%. In the Department of Orthopaedic Surgery, MRSA infection was observed in 15 patients, with 13 of these patients requering surgical treatment. Two patient in particular required multiple operations 5 and 10 temes and were finally cured by using a Musculocutaneous flap. Moreover 7 other patients were successfully treated using a Musculocutaneous flap. In our experience, We found that surgical therapy is necessary to cure orthopaedic MRSA infections.
MRSA infections have become one of the major therapeutic problems in the orthopedic field. The rates of MRSA-positive inpatients were 1.6% in the orthopedic ward and 25% in the tuberculous ward. We reviewed these 22 MRSA-positive inpatients. Six cases of deep infections, including postmetal-replacement-operations, pyogenic spondylodiscitis and post-traumatic leg necrosis, were treated operatively and/or conservatively by antibiotics. MRSA disappeared in 5 cases and one case died from the MRSA infection which caused heart failure. In regard to retes of nasal carriage among the medical staff, the nasal MRSA-positive rate was 2.6% in 1992, and this increased to 16% by 1994. There was no difference in carriage rate between doctors and nurses. It is very important to carry out measures which will prevent further MRSA infections.
We investigated the effectiveness of measures taken to prevent MRSA infections by examining MRSA outbreaks, contamination of hospital wards by MRSA and by assessing, health profession for carriage of MRSA. We also determened the percentage of S. aureus accounted for by MRSA in the hospital as a whole, and in our Department of Orthopedic Surgery in particular. Our results showed that cases of MRSA infection in our Orthopedic surgical ward (nosocomial infection) had decreased to approximately a quarter of previous levels, demonstration that measures taken to prevent MRSA infection have been successful in improving the overall level of cleanliness in our department. Similar results, however, were not seen in the hospital as a whole. Older patients with other diseases are especially prone to MRSA self infection, and also may easily become a source of cross infection, therefore caution is requered when dealing with such patients. In comparison with other departments, our immunocompromised patients had less MRSA infections, showing that the measures taken at our hospital to prevent infection were particularly effective.
Seven orthopedic patients with MRSA osteomyelitis were assessed as to the effectiveness of hyperbaric oxygen therapy (HBO). All patients were admitted between May 1992 and October 1993. The average age of the patients was 57, 6 years. Four patients had open fracture, two cases were infection after operation, and one patient was hematogenous infection. There were two patients with closed irrigation. Five patients healed without drainage. One patient required amputation. Drainage is still cotinuing in one patient. Vancomycin was administered in two patients.
The clinical results of arthroscopic anterior cruciate ligament reconstruction using the bone-patellar tendon-bone technique in a series of twenty-four patients over six months after surgery were reviewed. Eleven patients were treated using only bone-patellar tendon-bone (BTB group) and thirteen patients were treated with augmented Kennedy LAD (BTB+L group). Statiatical analysis of the objective findings showed no significant differrences between the groups. However vague pain was reported in the BTB+L group significanthy more. We concluded that augmentation with Kennedy LAD is indicated for a limited number of specical cases.
55 reconstructed anterior cruciate ligaments made of a patellar tendon were evaluated using angled sagittal magnetic resonance (MR) scans. Normal grafts showed low signal intensity as early as 6 months postoperatively. Anterior tunnel placement resulting in impingement might cause diffuse or focal areas of high signal intensity and this may lead to edema in the graft.
Most criticisms concering ACL reconstruction using the patellar tendon are related to the extensor mechanism, including muscle weakness of the quadriceps, patello-femoral disorders, and limitation of extension. The purpose of this study was to investigate complications involing the extensor mechanism after this methhod was used. Thirty-one patients, who underwent ACL reconstruction using bone-patellar tendon-bone, were followed up for a period of 2 years and 10 months and their mean age at surgery was 24 years. Twenty patients were male and eleven patients were female. Quadriceps strength was 81% and hamstring strength was 92% at follow-up 2 years postoperativerly. Four patients had limitation of extension ranging from 5 to 25 degrees. Two of then underwent arthroscopic debridement of fibrous tissue around the reconstructed ACL and eventually obtained full estension. Only one of 18 patients, who had a second look arthroscopy, showed advancement of degeneration of the patello-femoral joint.
We reviewed complications after anterior cruciate ligament (ACL) reconstruction of the knee. From 1977 to 1994, 226 patients, (237 joints) were operated on with ACL reconstruction, in which 177 joints were treated with artificial ligaments. Subjects comprised 122 men and 104 women ranging in age from 13 to 64 years with an average of 26.7 years. Of these 135 patients were followed from 12 to 93 months. The average duration of follow-up was 2 years and 8 months. There were 3 major complications associated with ACL reconstruction surgery, of which flexion contracture (more than 5 degrees) occurred in 15%, muscle weakness (less than 80% compared to the opposite side on a Cybex machine) was found in 51% and 9% had graft failure including reoperation. We have treated patients with ACL insufficiency using bone-tendon-bone since 1992 because of the problem with graft failure and the poor appearance at the 2nd look at the artificial ligament. In conclusion we think that it is important to prevent flexion contracture after ACL reconstruction because it causes several disabilities, such as patello-femoral problems and muscle weakness.
We evaluated seventy-three cases of arthroscopic anterior cruciate ligament reconstruction. These cases were divided into three groups. The L-K group (37 cases) were reconstructed using the Leeds-Keio artificial ligament. The combined group (20 cases) were reconstructed using a bone-patella ligament-bone autograft augmented by Kennedy LAD. The PT group (16 cases) were reconstructed with a bone-patella tendon-bone autograft only. Mean duration of follow-up was three years in the L-K group and two years in both the combined group and PT group. A positive Lackmann test and joint effusion were seen in 25% of the L-K group and combined group. Flexion contractuctures were seen in 19% of the L-K group. Wide notch plasty and accurate isometric points of the tibial drill hole were important for preventing the development of any complications.
A total of 132 (average age, 23 years) patients who underwent ACL reconstruction by Lindemann's procedure were evaluated for their complications. Specific operative complications were as followed; limitation of motion, 7 cases; compartment syndrome of the lower leg, 3 cases; and hyesthesia on the anteromedial aspect of the knee, about 50% of cases. The mean side-to-side difference in terminal extension and flexion at the final examination were 8 and 12 degrees respectively. The mean deficit torque value compared to the opposite side was 17% (30°/s) and 24% (180°/s) for the quadriceps, and 16% (30°/s) and 16% (180°/s) and for hamstrings one year after the reconstruction. There were no differences in response time of hamstring muscles between reconstructed and non-reconstructed groups nor between injured and uninjured sides.
Since 1986, we have been performing arthroscopically aided double stay reconstruction using the iliotibial tract for repair of the anterior cruciate ligament deficient knee. Eighty-five patients with a minimum follow-up of 2 years were reviewed. Nearly a full range of motion had been achieved in all patients. The pivot shift test was negative in 75 patients (88%), and the average knee rating score according to the Cincinnati Knee Score was 94.3 points. The average side-to-side difference in tibial displacement was 2.3mm in KT-1000 arthrometric measurments, and 18 patients (21%) showed a difference of more than 3.0 millmeters. Recurrent patholaxity was frequently observed in early cases where the tibial bone tunnel was located anterioly and where notch plasty had not been perfomed.
Follow-up studies of 90 cases of ACL reconstruction were reviewed. The surgical technique used was arthroscopic ACL reconstruction using bone-patella tendon-bone through the over-the-top route. The mean duration of follow-up after surgery was 44 months (24-71). Fifty-seven cases returned to sport at the same lower level they had prior to their injury or higher. Twenty-two returned to sporthing achvites at a lower level and twenty-one stopped participating in sport. The reasons for stopping included going to college, getting a job and fear of reinjury. Severe complications of ACL reconstruction were not found except for pain during sitting Japanese-shyle and weighting on the anterior scar of the patella tendon. The gross ligament mass should be used as soon as possible resulting in the second looks of arthroscoic exsamination. We use the patella tendon of 10mm width and transplant iliotibial band to the resected patella tendon and bone chips to the patella.
A relatively rare case of a lumber intradural epidermoid cyst is presented. Gd-DTPA enhancement MRI, which was characterized by rim enhancement, was useful in the diagnosis of this lesion. Lumber puncture may have been a precipitating cause in this case.
Spinal subarachnoid hematoma is a very rare disorder with few cases reported in Japan. This disorder may be due to tumor, disorders of vessels, coagulation dysfunctions, trauma or of unknown etiology. We report a case of subarachnoid hematoma with hypertension, in which the cause of the bleeding was not found. A 68-year-old male presented with sudden onset of pain in the bilateral femoral area, and gluteal area. He had a decrease of leg muscularity, and developed urinary retention on November 9, 1993. On admission, spinal MRI showed a space occupying lesion in his spinal canal at L1-L3 and lumbar puncture showed bloody CSF, and developed protein. He was suspected of having a spinal tumor and was transferred to our hospital on November 29. We suspected subarachnoid hematoma, so laminectomy was performed and the hematoma was removed on the same. Post-operatively, he had no pain and urinary retention improved. Two months after surgery, he had made a complete recovery.
We experienced three cases of spinal vascular disorders showing negative angiographic findings. Case 1: A 15-year-old female had two paraplegic attacks with spontaneous remission after the first attack. Intraspinal hemorrhage was speculated because of a chronological change in her MR imaging. Two selective angiographies did not reveal any pathological findings. Surgery was done after the second attack which had resulted in severe paraplegia. Intraspinal hemorrhage without any abnormal vessels was found and was evacuated. Paraplegia improved markedly. Case 2: A 28-year-old female showed staggering gait due to a deep sensation disturbance. Case 3: A 34-year-old female developed numbness in her left lower extremity. In both cases, a spinal vascular disorder was strongly suspected by MR imaging, but selective angiography did not reveal any positive findings. Possible reasons why selective angiography failed to show any pathological findings include the failure to hit feeder arteries, no arterial component in the vascular disorder and a vascular disorder that was too small to detect. Spinal vascular disorders may show a similar clinical course to multiple sclerosis. Using sequential MR imaging and MR imaging enhanced with Gd-DTPA, intraspinal hemorrhage can be distinguished from multiple sclerosis.
We report four cases of spinal arteriovenous malformations. While MRI was useful for making an early diagnosis, selective angiography was necessary for the final diagnosis. Embolization was performed in 2 cases, feeder ligation in one case, and another case underwent extraction. Excellent results were achieved in all cases.
This report investigated the influence of age on F-waves in median and ulnar nerves and the possibility of using the F-wave as an objective index for electrodiagnosis in cervical spondylotic myelopathy (C. S. M.). The shortest latency and the F-wave conduction velocity (FWCV) with the shortest latency were significantly slower in the normal group over 50 years than in any other groups. There were no significant differences in the incidence of F-wave and FWCV between the control and C. S. M. groups. But the usefulness of the amplitude of the F-wave was recognized. The incidence of big F-waves tended to increase in the C. S. M. group. In addition, along with a postoperative improvement in clinical symptoms, the incidence of big F-waves decreased slowly. Therefore, F-waves reflected the clinical abnormal state and the amplitude of the F-wave was found to be useful as an objective index of electrodiagnosis on C. S. M..
Dermatomal Somatosensory Evoked Potentials (DSEP) have been described as a technique for stimulating individual dermatomes and recording from the scalp. However diagnosis using these may not be clear because of their vague basis or artifacts. In the present study, DSEPs were recorded from 31 cases with lumbar spinal problems and were accurately evaluated, using our simple criteria for visual impression. We used strict criteria of DSEP detected sensory deficit or pain using specific questions. Our criteria which might make visual assessment possible, failed to detect sensory deficit or pain, but successfully diagnosed motor deficit. Based on the abovementioned results, DSEPs would reflect motor function and be useful for electrophysiological assessment of lumbar spinal disorders.
We evaluated the change of cervical alignment after laminoplasty using a biomechanical method. Thirty-one patients with cervical spondylotic myelopathy were analyzed. Alignment value (“A” value) is the index of the degree of malalignment. Preoperative “A” values of patients who had malalignment after surgery were significantly higher than for patients who had no malalignment after surgery. Preoperative “A” values are useful for estimating postoperative malalignment. 22.6% of patients had normal “A” values after surgery. In regard to spinal alignment, the biomechanical effect of laminoplasty was not found to be significant.
It is difficult to make a diagnosis between space occupying lesions and inflammatory lesions in the thoracic spine. Twelve needle biopsies of the thoracic vertebral bodies from Th3 to Th12 were performed under CT guidance without complications. Of these twelve cases, nine provided true-positive results with a pathologic diagnosis. CT guided needle biopsy of the thoracic spine is a safe, rapid, and reliable procedure.
Helical volume computed tomography (CT) involves continuous patient translation during x-ray source rotation and scan data acquisition. As a result, high-quality three-dimensional images can be produced from the continuous volume data sets in a relatively short period of time. Helical CT scanning and three-dimensional surface reconstruction of the spinal lesions were performed. In fracture and dislocation of the spine, three-dimensional CT provides excellent images of posterior aspects of the lesion and demonstrates sharp sagittal images of vertebral fractures compared with magnetic resonance imaging. In degenerative spinal disorders, three-dimensional CT is helpful in evaluating patients with ossification or calcification of ligaments. Three-dimensional images with helical volume scanning may be useful for the diagnosis of spinal disorders.
We report our follow-up studies over the past ten years investigating the efficacy of the underarm brace used in 41 patients with idiopathic scoliosis (2 males and 39 females). The average are at the time of bracing was 13.7 years, and the average duration of bracing was 1 year and 4 months. The average Cobb angle was 32.0 degrees before bracing, and 29.8 degrees at follow-up. Progressive vertebral curvature, of 5 degrees or more, was seen in only 6 patients (15%) at follow-up. Progression of scoliosis was not seen in those who at the time of beginning bracing were over 15 years old, or were one year or more after menarche. There was no significant difference in progression of curvature between those wearing the brace full-time and those wearing it only part-time. When the best correction rate was satisfactory, the final correction rate was also inclined to be satisfactory in those wearing the brace full-time, but there were poor results for those wearing it only part-time. We conclude that treatment using the under-arm brace was effective for idiopathic scoliosis.
We report a case of congenital scoliosis with L4 hemivertebra. A 12-year-old boy who complained of spinal deformity had neither low back pain nor neurological complications. His scoliotic curve was 37 degrees and this was reduced to 5 degrees by a single stage excision of the hemivertebra and fusion using a pedicle screw system. The only complication was a short period of femoral nerve palsy, but this fully recovered in about one month. We consider that shortening correction by using a one stage excision of hemivertebra and fusion with a pedicle screw system is useful as it offers the advantages of being less invasive, a safer procedure and has a short fusion area.
Postoperative results were evaluated in 3 patients with thoracic disc herniation combined with ossification of the ligamentum flavum. The surgical method used was posterior decompression with posterolateral fusion using a pedicle screw system. Mean recovery rate using Hirabayashi's method was 61% and no complications were noted. We concluded that the posterior approach was an acceptable method for treating these lesions.
Usefulness of Autologous Blood Thransfusions in Spinal Surgery. The purpose of this study was to elucidate whether autologous blood transfusion is useful in spinal surgery. We divided 78 patients who underwent spinal surgery into an autologous blood transfusion group (A group; 39 patients) and allogenic blood transfusion group (B group; 39 paticnts). There were no significant differences in the total amount of blood transfused and operation time between the two groups. We compared the postoperative complications between two proups. Only one patient developed a urinary tract infection in the A group, whereas 5 patients with urinary tract infection, 3 with liver dysfunctions, 2 with decubitus infections and one with ulcer were found in the B group. In conclusion, autologous bloodtransfusion is useful in spinal sugery because it reduces the amount of postoperative complications.
We investigated 47 patients treated with posterolateral fusion (PLF) and conpared then with 50 non-fusion cases. Crinical results, according to improvement in their score was 82.8% in the PLF group and 82.9% in the non-fusion group. The PLF. group particularly improved in their pain score. Segmental instability was more effectively restricted in the PLF group than the non-fusion group. Also in the PLF group, some new olisthesis developed in the upper adjacent segment. Rigid bony fusion masses were seen in 80%, and non-union occurred frequently in cases of multi-segmental fusion and L5/S1 fusion. We belive that PLF is useful for cases with segmental instability and low back pain.
To evaluate the usefulness of Luqueinstrumentation for posterior surgery, we compared 83 Luque cases (LR) with 50 cases who were Neated with posterior decompression (PD) only. Clinical results as judged by the JOA improvement rate were smilar for/both groups, however the LR group achieved better pain relief the LR group had reduction in new movements or olistheses not only in the decompressed segments but also in adjacent segments. We believe Luque instrumemtation is useful for: 1) patients aged qreater than 65yrs. 2) unstable segments with low back pain 3) multiple degenerative segments or deformity.
To assess the indications for using pedicular screwing (PS) for lumbar arthrodesis, we compared 25 cases treated with PS with 47 cases posterolateral fusion (PLF) cases. The PS gained significantly better clindcal results than the PLF Group, due to relief of low back pain (LBP). The group also achieved good bone union and reduction of movement or olisthesis of the unstable segment. However developed some new olistheses lower adjacent segment. We concluded that the use of PS should be limited to: 1) middlu aged patients 2) unstable segments with LBP 3) For patients without multiple degenerative segments.
Lumbar disc herniation following spondylolisthesis migrates in a cephalic or caudal direction, with anteriohr or posterior slipping, respectively. Some cases of disc herniation have shown migration of disc material without malalignment of the lumbar spine. In the present study, we report on 90 cases withoht malalignment operated on in our hospital during the last two years. These results demonstrated that the slip ratio of vertebral body correlated with the direction of the migrated disc material.
Seventy-three discs in 44 patients were examined for disc degeneration by magnetic resonance imaging (MRI), discograpy, and by computered tomography after discography (CTD). We classified discs into three types, white, speckled or black by sagittal T2 magnetic resonance imaging. MRI (T2-weighted), discography and CTD of discs showed a high correlation with each other. However about 50% of the white type had mild to severe degeneration on MRI (T2). Therefore, precise diagnosis of disc degeneration cannot be obtained solely by MRI.
MR images provide valuable information on herniated lumbar intervertebral disc. In this report, we discuss the natural history of intervertebral discs based on signal intensity data for herniated discs obtained from T2-weighted MR images. Forty-seven patients with lumbar disc herniation were examined by MRI. On the T2-weighted sagittal MRI image, we measured the signal intensity of herniated material and the orignating nucleus pulposus. The ratio of signal intensity in the herniated material to that in the nucleus was determined and designated as the signal intensity ratio (SIR). We divided patients into three groups according to SIR data, high SIR with a ratio of 1.2 or more, iso SIR with a ratio of 0.8 to 1.2, and low SIR 0.8 or less. The relationship between SIR and duration of illness was evaluated. In seven patients, who were re-examined by MIR at six months, changes in the herniated material size were valuated. The duration of illness was 22.2±16.0, 44.4±53.3 and 123.9±54.5, in the high, iso and low SIR groups, respectively. The value in the low SIR group was significantly longer than the value in the other two groups. A significant relationship was observed between SIR and duration of illness on the negative exponential curve. These results suggested that SIR would become high immediately following herniation and thereafter decrease with increasing duration of illness. In the patientes who were re-examined by MRI, two were in the high SIR group and four in the low SIR group. Although herniated material in all two patients in the high SIR group was noted to be smaller at the time of follow-up, no such change was noted in the other patients. This result suggested that high SIR may indicate that the reaction of water imbibition and inflammation in the herniated material would occur, and in low SIR, the reaction would be finished.
It has been hypothesized that “chemical radiculitis” occurs on the root damage due to lumbar disc herniation. In this report, we studied inflammatory cytokines in the removed disc by staining with the “ABC-AP method”. We studied 5 cases whose discs were removed. We stained for Interleukin-1β(IL-1β), IL-6, IL-8 and tumor necrosis factor-α(TNF-α) in both the prolapsed disc as well as the intervertebral disc. We found that inflammatory cytokings stained in the granulation area and inflammatory cells were present around the prolapsed disc. We also found it in the chondrocytes of the intervertebral disc. In this experiment, we can conclude that inflammatory cytokines have a relationship with root inflammation and also with degeneration of the disc.
This study investigated the correlation between regression of the herniated intervertebral disk and cellular proliferation in the surgical specimens. Tissues of herniated discs were obtained from 24 patients. For immunohistochemical studies, we used antibodies against CD68, UCHL-1, Vimentin, and Tenascin. Strong immunostaining for CD68 or Vimentin was observed in proliferating cells of herniated discs. Moderate immunostaining for Tanascin was detected in the extracellular matrix of the cellular proliferation area. The results presented here suggest that phagocytosis by macrophages and fibrosis by fibroblasts produce regression of herniated discs.
We have experienced 2201 cases surgically treated for lumbar disc herniation from 1976 to 1993. Treatments included 22cases of anterior nucleotomy (AN), 29 with anterior discectomy (AD) and 38 cases of percutaneous nucleotomy (PN) from 1986. Of these 18 cases of AN, 25 of AD and 36 of PN were clinically evaluated using the JOA score. The post-operative results were as follows: Average improvement rate was 77.8%, 72.7% and 55.6% in AN, AD and PN respectively. Excellent and good rates were 89%, 88% and 69%. A satisfactory rate was achieved in 83%, 76% and 72% of patients respectively. Postoperative merits were in order of AN, AD and PN. As a rule AN and AD are considered extensive major surgery due to the abdominal incision and general anesthesia, but the average operation time is 20 minutes and duration of return to former professional activities (sport and job) is with in 3 to 6 weeks. Therefore AN and AD are better procedures for lumbar disc herniation than PN. On the other hand there are many reports that the results of PN are not so satisfactory, therefore the indication must be discreet and not extensive. We have indicated cases with higher intradiscal pressure and less disc degeneration because of the need for intradiscal decompression. The best indication is intradiscal herniation. Furthermore many authors report that the technique is an intermediate procedure between surgery and conservative treatment, but PN is almost the same as surgical treatmert due to its disc damage and accidental complications.
In recent years, MRI has been increasingly performed and shown to be useful in patients with lumbar spinal disease. We report a patient with dorsal migration type lumabar disc herniation in whom preoperative MRI suggested an extradural mass. A 42-year-old male developed lumbar pain in his left lower limb in January, 1993. In june, he was admitted to hospital due to increased lumbar pain. On admission, his lift SLR test was positive at 60°. Dorsiflexion strength was decreased in the left hallus, and hypesthesia was observed in the S1 region. Lumbar spinal MRI showed extradural low signals at L5-S2, with T1 and isointensity signals with T2 and a mass enfanced in a ring pattern with Gd-DTPA. After laminectomy at L5-S2, a mass the size of the thumb tip was observed immediately below. This mass posteriorly compressed the dura, reaching in a stalk pattern to the L5/S1 space. Histopathological examination showed this mass to be conposed of degenerative exogenous tissue with inflammatory cell infiltration.
From 1987 to 1993 we operated on eleven cases who had had extreme lateral lumbar disc herniations (ELLDH). All cases had severe leg pain and nine had low back pain. The severe leg pain was thought to be due to compression of the dorsal root ganglion and the spinal nerve. All cases had resisted conservative therapy. Regarding surgical method, lateral facetectomy was performed in seven cases, medial and lateral facetectomy in two cases, and osteoplastic laminectomy, unilateral facetectomy plus posterolateral fusion combined with instrumentation in one case each. All cases required microscopic surgical techniques. The results, using the Japan Orthopedic Association score (JOA score), shawed that the preoperative mean score of 5.1 improved to 12.1 postoperatively. We then compared two groups, group A were operated on within 30 days of developing symptoms, and Group B in which surgery was performed more than 31 days after developing symptoms. In regard to improvement in leg pain and percentage improvement. Group B was worse than Group A. We concluded that if the patients who had suffered ELLDH had severe leg pain, conservative therapy for relief of pain should be used first and if it fails, surgery should then be performed. We recommend the lateral procedure.
We perfomed surgical treatment in 284 cases with lumber disc herniation. Of these, 21 cases were over 60 years of age. We compared their preoperative clinical, myelographic and MRI findings with that of cases under 60 years of age. 1) Clinical Findings All the cases over 60 years had severe leg pain, and 11 cases (52.4%) were within the normal range in the straight leg Raising (SLR) test. 2) Myelographic Findings In 11 cases (52.4%), defects over 2/3 of the dural tube diameter were observed. The older the case was, the larger the defect of the dural tube. 3) MRI findings 8 cases (57.1%) had Grade III degeneration of the herniated disc and 4 cases (28.6%) had GradeVI. Degeneration of herniated discs was more pronounced in cases over 60 years than in the younger group.