Main theme of this issue is which situation is suitable to fusion for lumbar disc hernia in the elderly patients. In the elderly patients mechanical stress to lumbar may be smaller, the mobility of intervertebral disc is decreased, decompression from dorsal and ventral areas may be sufficient for disc hernia in combined stenotic spinal canal, therefore decompressive surgery will be mainly indicated. Fusion surgery in the elderly patients as the 1st surgery for disc hernia may be, hernia mass in less-degenerated discs, social demand for lumbar discs, and disc hernia in upper lumbar discs, which will be treated ventrally or dorsally with wide fenestration. Fusion surgery as the 2nd surgery may be, failed back cases without re-extrusion of disc hernia after herniotomy.
Neurogenic intermittent claudication due to lumbar spinal canal stenosis (LSCS) was classified into three types: radicular, cauda equina and mixed. Patients with radicular type stenosis were treated with nerve root block (RB). Patients with cauda equina type stenosis and patients presenting with mixed type stenosis were treated with sympathetic ganglion block (SB). The results of our conservative treatment for patients with LSCS were analyzed, retrospectively. 47% of radicular type stenosis patients showed a therapeutic effect of RB. Patients with degenerative spondylolisthesis showed less effectiveness compared to the patients with spondylosis. 25% of cauda equina and mixed type stenosis patients showed therapeutic effects attributable to SB. The patients with shorter duration of symptoms showed more effectiveness. In conclusion, when we consider the type of nerve involvement, the causative disease of lumbar canal stenosis, and the duration of symptoms, RB and/or SB may be an effective conservative treatment modalities to pursue before contemplating more aggressive treatment approaches
We performed a retrospective study of conservative treatment alternatives for patients diagnosed with lumbar canal stenosis in our hospital. We divided the subjects into two groups. Group One had conservative treatment only. Group Two had conservative treatment followed by operative therapy. We analyzed the outcomes for both groups based upon symptom reduction using the Japanese Orthopaedic Association Score (JOA score). Sixty persent of patients with radiculopathy without numbness had recovered with conservative treatment only. On the other hand, patients with numbness tend to be resistant to conservative treatment.
We studied 81 patients (38 males and 43 females whose age at the time of surgery raneged 52-89years) who presented with radicular symptoms who received nerve root block. We sought to clarify the relationship between the therapeutic effect of nerve root block and age at surgery, duration of symptoms, pre-operative JOA score, the findings of myelogram, the location of the dorsal root ganglion (DRG), the diameter of the lateral recess and the diameter of the spinal canal. A significant relationship was demonstratd between the therapeutic effect of nerve root block and pre-operative JOA score, the findings of myelogram and the diameter of the lateral recess. In the cases of aged patients over 65 with proximally located DRG, nerve root block was more effective, because the diameter of the lateral recess of them was more wide than that of younger patients.
We studied 117 patients with a chief complaint of intermittent claudication to define the frequency and the differential diagnosis of lumbar spinal canal stenosis (LSCS) and peripheral arterial occlusive disease (PAOD). The patients were classified into three groups: Group 1: LSCS, Group 2: PAOD and Group 3: patients with LSCS and PAOD after lumbar MRI (or myelography) and MRA of the lower limbs was performed in all patients. Thirty patients (25.6%) had vascular disease (PAOD=13, coexistence=17). Effective physiological findings for differential diagnosis were a standing endurance test, postural factors, the pulse of dorsalis pedis artery, and calf pain. The ABPI was highly useful for detecting PAOD patients. Given that approximately a quarter of patients presenting intermittent claudication had PAOD, orthopedists need to diagnose PAOD patients as a primary doctor of intermittent claudication.
There is no clear scientific evidence on the efficacy of any physical therapy or exercise therapy for lumbar spinal stenosis. Traction therapy may be effective for back pain, but mis-directed traction may induce symptom deterioration. Transcutaneous electrical nerve stimulation has been shown to have an effect on the transient recovery of intermittent claudication. Muscle strengthening exercises may induce dural pressure increases at the stenotic level, so that exercises can not be recommended for spinal stenosis. An urgent need exists for scientific clinical trials regarding the effectiveness of physical therapy for lumbar spinal stenosis. The Japanese Society of Lumbar Spinal Disorders should take an important position with regard to these research projects.
306 patients (227 male and 79 female) with an average age of 44.2 years, diagnosed with lumbar disc herniation were treated by nerve root block, and followed for more than 6 months. Clinical determinations were JOA scores, effect of nerve root block. The level, localization, size, migration and T2 weighted intensity of the disc herniations were determined by MRI. 105 of 189 cases were deemed unsuitable for surgical intervention. They presented with an average JOA score of 12.5 points. Nerve root block outcomes were “excellent” in 71 cases, “good” in 73 cases and “poor” in 162 cases. Our study concluded that in cases of paracentral type herniation with mild migration, lateral hernations, and sized more than 1/3 the volume of the spinal canal, spinal nerve root block proved to be ineffective while, spinal nerve root block was more effective in addressing central lumbar disc herniation, paracentral type herniation with severe migration and disc herniation with T2 weighted high intensity. As a result of our research we were able to create a map of lumbar disc herniation indicating appropriate treatment approaches.
Based on about twenty thousand cases of epidural blook to lumbar herniation, I present techniques for a safer and more useful and rapid method for epidural block . The difficulty of epidural blook is dependent on the thickness of the ligamentum flavum or the shape of posterior wall of the vertebral foramen. For 101 examples of lateral x-ray of bleached spinal bones, ①I classified the shape of posterior wall of the vertebral foramen into four types. ②and I represented the thickness of the lamina by means of the interval between the anterior surface of the lamina and the posterior surface of the pars interarticularis. I named this interval the S-zone (stenosis zone). There are three types of S-zone, +, 0 and - . This analysis of S-zone is useful in predicting the thickness of the ligamentum flavum and the a-p diameter of the foramen by the lateral radiograph of the lumbar spine.
The first aim of this study was to clarify the significance of “block therapies” in patients with lumbar disc herniation. The second aim was to assess the clinical effectiveness of nerve root infiltration with steroids for lumbar monoradiculopathy in patients with lumbar disc herniation. The data demonstrated that “block therapies” were significantly more effective than non-block therapy at six months follow-up. However, the difference in the outcome between two groups was not significant at 2 years follow-up. There was no difference in pain intensity and functional status between patients in either the steroid or the non-steroid group. These data suggest that steroids might be less important for nerve root infiltrations in patients presenting with lumbar disc herniations.
We evaluated the results of steroid intradiscal injection therapy (SIDT) in patients presenting with lumbar disc herniation. The short term (6 months post injection ) efficacy rate (excellent+good results) was 60.1%, and the long term (more than 5 years post injection) efficacy rate was 64.4%. Sorted by age, efficacy rate was worse at 31.4% for patients in their teens, with better results achieved for patients in their fiftties and sixties. We were able to determine that for release of low back pain and leg pain, SIDT was more effective than the nerve root block. After SIDT, the incidence and degree of calcification in our patients were significantly lower than those reported in previous studies. Intradiscal injection of betamethasone did not appear to confer any incremental relative risk for lumbar spinal canal calcification based on review of follow-up X-ray.
For lumbar disk herniation, conservative treatments such as medication, physical therapy and neural injection have achieved successful outcomes, with while the time required for the improvement of to improve the clinical symptoms and neural deficit variesd. For the competitive athlete, the optimal management should be designed to completely relieve the lumbago and sciatica, enabling a return to a pre-injury level of sports activity as rapidly as possible. From 1997 to 2002, 55 athletes (43 men, 12 women) were conservatively treated for the lumbar disk herniation at our institute. The teratment included a combination of caudal injection, nerve root injection and stretching exercises for the initial 3 weeks, followed by strengthening exercise of the trunk muscles. Pain relief was achieved within 3 weeks in 29 patients (52.7%), and 45 patients (81.8%) returned to previous levels of their sports activity on an average of 15.6 months. Only 4 patients, who had no improvement of the initial symptoms at 3 weeks or complained of pain during the sports activity at 6 weeks, underwent surgery.
Restorative laminotomy was reinforced using the Polly L-lactic acidpin to adress lumbar canal stenosis. On-the-strength change of the Polly L-lactic acid pin which removed about two cases in which the re-operation was done in postoperative one year, and postoperative four months was considered. Under observation, the two cases did not demonstrate remarkable change. Decomposition was not progressing in comparison with in vitro experimental change in average molecular weight measurement. It is thought that a Polly L-lactic acid pin could expect sufficient initial fixation to facilitate the restoration of the lamina.
A questionnaire concerning lower back symptoms was administered to 282 female dancers of classical ballet, over 18 years old. Average hours for training was longer in professionals (11hrs), than in amateurs (6hrs). Number of stage performances was 12 times greater in professional dancers, in comparison with amateur dancers who averaged only 2 performances. Low back pain was found in 92% of professionals versus in 84% of amateurs. Out of this 43% of professionals who reported experiencing that impaired their training exercises, 10% of professional dancers were unable to dance, on occasion. Both professional and amateur dancers reported that low back pain was most prevalent on the left side of low back. Only 10% of the dancers visited hospitals for low back pain. The study concluded that the main cause of the low back pain in professional and amateur dancers was due to overuse and overwork. Regular medical examinations and dance education are necessary in order for ballet dancers to minimize the occurrence of chronic low back pain.
The author reports on his use of Selective Serotonin Reuptake Inhibitor (SSRI) to treat chronic low back pain in 26 subjects, 10 males, 16 females ranging in ages from 42 years old to 83 years old with an average age of 68 years. Subjects were given paroxetine hydrochloride hydate 20 mg/day. The evaluation went with SDS (Self-rating Depression Scale) and PRS (Pain Release Score). [results] The points of SDS was 24 ∼ 68 (an average of 48.9) before SSRI started. PRS was 3 ∼ 10 points (an average of 6.96) three months after start of SSRI. The correlation between SDS before SSRI started and PRS after three months were analysed. The single recurrence coefficient recognized significant correlation on SDS before the dosage of SSRI and PRS three months later (R=-0.519, p<0.001). In the case where SDS was more than 50 points, average of PRS was 7.7+1.9. In cases where the SDS was less than 50 points, PRS was 6.2+2.2. There is a statistically significant difference between SDS between patients in these two groups. (P<0.01). SSRI can be an effective adjunct when treating patients with chronic low back pain.
40 patients with lumbar pain and lower limb pain who visited the Watanabe Hospital, were randomly divided into 2 groups and nerve-root blocks were performed: Group (+) : Received concomitant administration of steroid with local anesthetic at the time of nerve-root block ; Group (-) : Received administration of local anesthetic alone at the time of nerve-root block. The Visual Analog Scale (VAS) and Present Pain Intensity (PPI) scales were used when compairing outcomes between the groups : (1) before nerve-root block, (2) 1 hour post nerve-root block, and (3) 1 week after the nerve-root block. There was no statistically significant difference in VAS and PPI between the Group (+) and Group (-) at any of the studied intervals. The efficacy of nerve-root block is assumed to be attributable to the pharmacological action of local anesthetic that interrups the pain cycle, induces remission from pain and recovers the spontaneous healing power, thereby achieving persistent therapeutic effect.
We treated three cases of lumbar disc herniation using percutaneous disc decompression. Our clinical results are as follows: Patient One: Poor result, required further operation. Patient Two: Excellent result. Herniation type was considered “extrusion” type. Patient Three: Outcome Good. A clearer understanding of the selection criteria for this procedure is indicated, as most intradiscal thermal technologies utilize a heat driven process to ablate tissue, with no adverse effects reported in a review of the literature. This method may be an efficacious minimally invasive procedure for the treatment of lumbar disc herniation.
The efficacy of therapeutic ultrasound (US) was assessed for residual symptoms in patients operated on with lumber herniated nucleus pulposus (HNP). Subjects were 20 patients with residual symptoms such as pain or numbness in their lower extremities postoperatively. US with the intensity of 1.5W/cm2 was perfprmed for 10 minutes once a day during hospitalization. The frequency of US-application was 4 to 23 times, and the average was 10.7 times. The resolution of residual symptoms was assessed at discharge. Outcome measurements were evaluated based on the type of HNP, the duration of symptoms, muscle weakness, and the degree of straight-leg-raising (SLR). US was effective in 90.0%of the patients. In outcome, it was less effective for the patients with transligamentous extrusion type. The duration of symptoms did not seem to adversely effect positive US treatment outcome. Patients with weak muscles were less responsive to US. A few patients with SLR of less than 30 degrees at the time of hospital admission demonstrated poor resolution of symptoms. We conclude that US is a very useful conservative therapy for the patients with postoperative residual symptoms due to HNP.
For evaluating the lumbar stabilizing function, we reviewed the reproducibility of the test-retest examinations using a mercury sphygmomanometer, because of the non-invasive nature of this testing instrument. Fifty subjects (40 females, 10 males) who had no history of low back pain and leg pain were evaluated. The results of test-retest examinations, revealed a high correlation in both male and female subjects with regard to the difference of maximum and minimum pressure showed by mercury sphygmomanometer. This suggests that the assessment of the lumbar stabilizing function using a mercury sphygmomanometer is reproducible, and its practicality may be high even for evaluating in low back pain patients.
Macnab proposes the so-called Hip-Spine Syndrome when discussing lumbar spinal deformities that sometimes affects the progression of osteoarthritis of hip joint. This study examines the relationship between lumbar kyphotic deformity and the progression of osteoarthritis of the hip joint. <Method and result> Total hip arthroplasty was performed on 51 patients for a year in our department. Patients were divided into two categories: Category 1: Patients with secondary osteoarthritis of hip joint (SOA: 37 joints) based on acetabular dysplasia, and Category 2: Patients with primary osteoarthritis (POA: 14 joints). Both sacral tilting angle and lumbar lordosis angle decreased in POA group in comparison with SOA group. <Discussion/ Conclusion> Lumbar degenerative kyphosis could cause posterior pelvic tilting, resulting in promotion of osteoarthritis of hip joint. Such a mechanism is probably due to: 1) the decrease of the front covering of the femoral head and/or, 2) increase in the stress applied to hip joint.
This study reports the outcome of the orthosis therapy for the lumbar spinal stenosis. Patients were provided with a semi-rigid Williams-type flexion orthosis and asked to return for the follow-up evaluation at least one year after the initiation of therapy. Forty-eight patients (30 men and 18 women with an average age of 65.5 years) reported no improvement. These patients reported other complications; they tended to be those with other complications, such as spasticity and had a backgrounds suggesting mental instability. There was no clear significant difference regarding a patient's background and the results of their radiographs. The author found that patients required detailed instruction and follow up in order for the prescribed course of orthosis treatment to be successful. In addition, in order to achieve a higher degree of patient satisfaction, the author recommends the development of the orthosis devices that can be more readily used, flexible and easier to maintain in order to retain their shape. Materials that allow maintenance of the shape is also important.
Thirty-six cases of lumbar spinal canal stenosis with thoracic outlet syndrome, treated by satellite ganglion block, were investigated retrospectively. The average number of satellite ganglion blocks per patient was 13 (range one to 58), and the average follow-up period was five months (range one to 15). The average duration of intermittent claudication improved from 10 minutes at the first examination to 48 minutes at final follow-up, and JOA score improved from 17 points to 26. Worsened symptoms were not indicated in any cases. The average Hirabayashi’ improvement ratio was 76%, and there was no significant difference in improvement between the root type and the cauda type. How satellite ganglion block performs in lumbar spinal canal stenosis is unclear, however, the authors believe that satellite ganglion block could be a useful conservative treatment for patients with lumbar spinal canal stenosis.
Ninety-one patients with lumbar spinal stenosis (LSS) were evaluated for clinical signs and conservative treatment results. Conservative treatment program is as follows: orally active prostaglandin E1 derivative (Limaprost Alfadex) is administered first. When symptoms do not improve at all, other conservative treatments such as an intravenous drip of prostaglandin E1, nerve root block, epidural steroid and steroid injection into facets are added. Seventy-three patients were treated by only Limaprost Alfadex and 18 patients needed additional conservative treatment. Fifty-four patients who were treated by only Limaprost Alfadex and 10 patients treated by Limaprost Alfadex with additional conservative treatment showed significant improvement in their symptoms. After all, 64 out of 91 patients (70%) who were treated by this conservative treatment program showed significant improvement in capacity to walk and their symptoms. The author conculude Limaprost Alfadex is the first choice in the treatment of LSS.
To clarify the “natural” course of spinal stenosis, the following retrospective study of non-operative patients was done in our clinic. The average patient’s age was 65.2 years old, with an average follow-up term was 100 months. 16 patients already died, 13 patients were being treated for other diseases. 22 patents reported improvement, 23 patients have had ongoing symptoms of spinal stenosis and, 8 of this latter group have had self-described conservative treatments, while 19 patients got worse and had surgery at another hospital. We had evaluated instances of intermittent claudication using treadmill test. Patients able to walk more than 500m on the treadmill obtained a better prognosis. We concluded that patients with radicular symptoms had better prognosis than patients with cauda equina symptoms.
The aim of this study is to determine the optimal periods for conservative therapy of lumbar disc herniation and when it is appropriate to implement surgical intervention. From 1991 through 1996, after a diagnosis of lumbar disc herniation was made, we recommended surgical treatment at an early stage for the patient who did not obtain good results via conservative treatment (group 1), from January 1997 forward, prolonged conservative treatment was extended from two to four weeks (group 2). By comparison the number of patients in group 2 who were operated decreased significantly when compared with patients in group 1 who underwent surgery. We concluded that extended conservative treatment significanly reduced the incidents of surgical intervention in group 2. Although, the exact mechanism is unknown, it is thought that resolution of herniated nuclear material occurs upon contact with the epidural space in the extrusion type. Because the number of operation performed within one month was remarkably decreased in the group 2, we concluded that optimal period of the conservative therapy is one month.
Seven patients diagnosed with thoracic-lumbar compression fracture were treated using the Jewett type elasticity corset. In clinical evaluation, JOA-scores for low back pain were measured. In roentgenographical evaluation, the wedge condition ratio of the damaged vertebral body was measured. All patients’ lumbagos were decreased, and all returned to original walking state. JOA-score returned to an average of 20.3 points from an average of 10.1 points. The wedge condition ratio of vertebral body returned to an average of 62.0 % from an average of 78.5 %. The Jewett type hard vertebral equipment supports the body in the waist back section and the sternum and the pelvis based upon a three point fixed theory. The hard vertebral corset was heavy and was difficult for patients to wear. The newly produced Jewett type elasticity corset was easy to fit, wear and remove, and because it did not press an abdomen, it was appropriate for overweight patients
In order to treat the elderly patients with vertebral fractures as outpatients we developed an easily wearable plastic body cast that would make patients feel better and stabilize their ADLthereby treating them as outpatients. In the present study, 40 patients (average age,74 years old) with vertebral fractures were treated by this method. No patients needed to be admitted because of good clinical result obtained by the application of this method. Elderly patients often have cardiovascular and pulmonary complications from the beginning of the treatment. The very tight conventional body casts will often worsen their symptoms. Our easily wearable light weight plastic cast can be well fitted to patients who subsequently report no complaints of tightness or discomfort, allowing us to treat all those patients on an outpatient basis.