We report a case of paraplegic rheumatoid patient with spinal compression caused by granulation tissue from thoracic intervertebral joint. Sixty-four year old woman with a 3 weeks' history of leg weakness was admitted to our hospital. She also complained of dysuria. There was a 17 years' history of RA. Neurological examination revealed paresis of the iliopsoas and the quadriceps, and she was not able to move her ankles and toes actively. Her sensation was disturbed below the umbilical line. Plane roentgenogram showed multiple compression fractures of thoracolumbar spine, which were often seen in osteoporotic patients. But MRI and CT-myelogram showed bilateral compressive lesion against the spinal cord between the 9th and the 10th thoracic vertebra. A posterior decompression was carried out. A granulation tissue from intervertebral joint was observed to compress the spinal cord, and which was removed. Her neurological symptoms were immediately improved after the above surgery.

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We had developed an alternative surgical procedure in the treatment of spondylolysis since June 1994. Exellent results were obtained in all cases. We introduce our surgical technique and clinical results. In our procedure, we use cortical screw with washer as pedicle screw and DANEK cable system for wiring.

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We have investigated the results from the operative treatment performed for an unstable lumbar spine in 48 cases. During the past six years-from 1992-1997-we performed wire fixation for 24patients (11 male and 13 female, with a mean age at operation 53.4 years) and pedicle screw fixation for 24 patients (9 male and 15 female, with a mean age at operation 57.1 years) alternately. Between these two groups, there was no difference in the resulting%slip, slip-angle, rate of bone fusion or in rate of instrument failure. In those with lumbar spondylolisthesis, the operative results were good or excellent in 8 (64.3%) of the 14 patients who received wire fixation, and in 13 (76.5%) of 17 patients who received pedicle screw fixation. In those with lumbar canal stenosis, there was no difference in the result. In conclusion, between wire fixation and pedicle screw fixation, there was no difference the resulting for an unstable lumbar spine.

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It is speculated that some kinds of biochemical mediators, such as proinflammatory cytokines and prostaglandin E₂ (PGE₂), may play an important role in the pathogenesis of lumbar disc herniation. Though PGE₂ seems to be one of the key factors of the pain induction in terms of radiculopathy, it is still elusive that the regulation of this synthesis at the site of lumbar disc herniation. Since cyclooxygenase-2 (COX-2), which is one of the isoforms of the prostaglandin synthase, is expressed in the many kinds of cells such as macrophage or synovial cell in the presence of proinflammatory cytokines, it seems to regulate this PGE2 synthesis in lumbar disc herniation as well as other inflammatory conditions. The purpose of this study is to clarify the role of COX-2 and proinflammatory cytokines in the pathomechanism of radiculopathy induced by lumbar disc herniation. Three herniated lumbar disc specimens were obtained from the patients who underwent surgery for certain radicular symptoms. They were examined immunohistologically using monorlonal or polyclonal antibodies against either human COX-2, interleukin-1 β (IL-1β) or tumor necrosis factor- α (TNF-α). The monolayer culture of the disc cells were prepared from the herniated lumbar disc of the same patients by collagenase digestion. In the 6-multiwell plates, 1.0 × 10⁵ attached cells/cm² were cultured in DMEM supplemented with 10% fetal calf serum in the presence of either 100 U/ml of IL-1β or TNF-α. After 6 hours, total cellular RNA was directly isolated from the cell monolayers using AGPC method for RT-PCR in order to detect the COX-2 and IL-1β mRNA expression. Both of COX-2 and proinflammatory cytokines, IL-1β and TNF-α, were detected in the cytosol of the disc chondrocytes as well as the inflammatory cells infiltrating around the herniated disc tissues histologically. By the RT-PCR, COX-2 mRNA was strongly expressed in the herniated lumbar disc-derived cells stimulated with both IL-1 β and TNF-α, while little COX-2 mRNA expression was detected in unstimulated cells. Furthermore, IL-1 β mRNA expression was also induced by 100 U/ml of IL-1β stimulation autocrinely. These results reveal that the cells in the lumbar disc express COX-2 paracrinely and release IL-1β autocrinely by the stimulation of proinflammatory cytokines. It is, therefore, suggested that proinflammatory cytokines play an important role in causing radiculopathy of lumbar disc herniation due to produce PGE₂ by COX-2 induction and enhance IL-1β release autocrinely or paracrinely.

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The frequent occurrence of low back pain among nurses is well known and have been reported. This study is to evaluate low back pain in 346 manufacturers, 233 nurses and 40 office workers by means of questionnaire. Low back pain was frequently observed on nurses as comparison with other occupation, and it grew worse by work. In all occupations, working postures caused low back pain were lifting and a half-sitting postures. Three postures have been attributed on the performance of nurses handling patients. The risk factors of low back pain were standing posture in manufacturers, and a half- sitting posture in nurses.

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It has been shown by several surveys that degenerative lumbar spondylolisthesis has a high prevalence in females over 40 years of age. In order to assess the ralationship between the general factors peculiar to elderly females and the incidence of lumbar spondylolisthesis we made an epidemiologic study of 1, 245 female inhabitans living in two rural towns by means of a questionnaire and X-ray examinations. The questionnaire was concerned with the experience of low back pain, the number of children borne, and past history of ovariectomy. In lateral view of a lumbar X-ray, the percentage slip, the direction of slip, and the level of slip were investigated. Two hundred and ten females (16.9%) had lumbar spondylolisthesis. One hundred and fifty five females had anterior slip and 50 females had posterior slip. In order of frequency the anterior slip occured at the L4-L5, L3-L4, L5-S1 level and posterior slip occuerd at the L3-L4, L2-L3 level. The incidence of lumbar spondylolisthesis did not increase linearly with the age. Among women in the 50's it increased remarkably after the age of 55. Females with anterior slip had experienced low back pain more frequently than those without it. It was not proved statistically that the occurrence of lumbar spondylolisthesis was associated with the number of children borne and the history of ovariectomy.

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Radiographs revealed lateral tilting into intervertebral space of the lumbar spine in 117 of 163 cases of acute locked back. The affected level was L3/4 in 3.1%, L4/5 in 25.8%, and L5/S in 42.9%, The mean lateral tilting angle was 2.6° K. Of these cases scoliosis associated with vertebral body rotation thought to be related to proble s of facet joint motion was noted in 36%, Therapy consisted of 90-90 traction aimed at reducing the facet joint subluxation. Making use of the weight of the trunk and pelvis, the 90-90 traction was imposed to allow assumption of a position to reduce the lordosis and gently open the posterior facet joint, thereby acting to reduce the facet joint subluxation. After the 90-90 traction, the lateral tilting deformity was improved in all cases, and at the same times symptoms were alleviated. The above finding suggest that subluxation of the facet joint is a major factor in the development of acute locked back.

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A new method of traction for immediate cure of acute low back pain (LBP) was devised. With this new method, the patient initially lay supine with both legs suspended from the bed while maintaining the lumber lordosis. After 7 minites of this traction, the patient was helped to sit up gradually while holding on the surgeon. L P was reproduced soon after starting thetraction in almost all cases and ceased thereafter. One hundred and eleven patients were treated using this method. Their average age was 43 years, none of them had scitica and 85% had experienced acute LBP before. This treatment was done once in 35% of patients, twice in 22%, 3 times in 9 %, and 4 times in 34%, and the mean frequency was 4.4 times. Medications were not used. The outcome was evaluated using a pain score. The outcome was excellent in 42%, good in 50%, fair in 7 %, unchanged in 1 %.A poor outcome was not seen. This method was apparently effective for LBP arising from the facet joints and traction force may have improved the adaptability of the facet joints. In addition, this method seems to be favorable for the patient because immediate cure of acute LBP is achieved without using medications.

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Patients occur severe low back pain suddenly when they raise the trunk from a forward bent and rotatory position. They keep the lumbar spine in this position and can not move the lumbar spine for severe pain. It is not clear that Why this pain occurs and how to treat this kind of low back pain. In general, local anesthesia with or without steroid has been used but it isnot always effective. we considered it might be caused by impingement of loose connective tissue at facet joint. For the treatment, manipulation has been tried and good results were obtained. Manipulation is performed to patients with just low back pain with lumbar spine in forward and side flextion. An affected thigh is extended with hip in flextion and also lumbar spine is flexed and rotate to open the facet to release soft tissue out. Forced flexion should not be done by manipulation. Severe low back pain will be improved immediately after manipulation and lumbar spine become straight in most cases.

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The effectiveness of continuous spinal epidural block for lumbar disc herniation was investigated in 49 patients, retrospectively. Every patient had intracanal disc herniation in the L4/5 or L5/S disc level. Twenty patients showed central, 21 centrolateral and 8 subradicural type of disc herniation in CT scans or MR images. The outcome was analyzed by the scoring system of the Japanese Orthopedic Association, its ratio of improvement (JOA-ratio), a ratio of improvement in straight leg raising test (SLRT-ratio). The block was considered to be effective in patients whose final JOA-ratio was over 60%. Effective block was obtained in 38 cases (73%) but not in 13 (27%). The duration of treatment averaged 28 days (6-70 days) when the block was effective and 46 days (25-92 days) when it was not effective. The effective cases were higher in the patients having the central or centrolateral type of disc herniation than in those having the subradicular type. The serial SLRT-ratio rose rapidly or gradually in the effective cases, although it continued to be low in the ineffective cases. Especially, the SLRT-ratio of the ineffective cases did not rise in the third and fourth week compared to the gradually improved patients. The block is useful for the central or centrolateral type of lumbar disc herniation. Whether the block is to be considered effective should be determined at 4 weeks.

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This study reviwed the results of conservative treatment of lumbar disc herniation.Ninety patients with lumbar disc herniation were included in this study.The avarage age at admission was 41 yeras old and avarage follow up period was 2 years and 7 months. We evaluated JOA score and the findings of MRI at the time of admission.All cases had only radicular symptoms and operations were performed in all patients with cauda equina syndrome. The location of the herniation that evaluated by MRI correlated with JOA score and prognosis, the cases that had the herniation nearby the nerve root had severer symptoms than the cases of central type.There was a correlation between JOA score and prognosis.We thought that the findings of MRI and JOA score at the time of admission were useful to predict the prognosis.

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Spinal block was performed in 269 cases of lumbar disc herniation or spinal canal stenosis who responded poorly to the usual treatment including epidural or nerve block, and in 6 cases with postoperative complaints.The mean age of the cases was 54 years, and the mean duration between onset and treatment was 775 days.Spinal block was performed using 3 ml of 1% mepivacaine hydrochloride or 1% lidocaine, and the combination with dexamethazone sodium 1.9-3.8 mg was performed in 150 cases. The over-all improvement rate evaluated by subjective findings including low back pain, gait pain and intermittent claudication was 66%, and a remarkable response was obtained in all 6 cases with postoperative complaints.Seventy-three (27%) of the patients who were ineffectively treated, had surgical treatment. However their clinical assesments before spinal block showed an indication for surgery. No severe complications were observed except for mild headache noted in 2% of the patients. These results suggested that spinal block served as both therapeutic and diagnostic tools.

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Magnetic resonance imaging (MRI) was performed in 298 patients who were diagnosed clinically.MRI findings were evaluated by occupational ratio, location and signal intensity of herniated nucleus pulposus (NPS) in spinal canal.Clincal findings included low back pain, lower extremity pain, sensory diturbance, loss of muscle strength and straight leg raising test (SLR).Occupatinal ratio of NHP in spinal canal was a mean of 35.0±15.3 (12-100)% in saggital plane and a mean of 33.1±11.7 (11-100)% in transverse plane. Isosignal intensity was showed in 102 patients and low signal intensity in 196 patients. 82 patients was classified as mid type, 136 patients as paramid type and 80 patients as lateral type. Compared MRI findings with clincal findings, patients with occupatinal ratio of NHP in spinal canal of 40% or more have a tendency to show positive SLR, and those with 50% or more tend to show loss of muscle strength.

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Clinical analysis of low back pain due to degenerative spine disease was carried out using lumbosacral nerve root block at a single level and lumbar sympathetic nerve block. The clinical feature of low back pain relieved by nerve root block was unilateral pain restricted in the area cranial to the medial iliac crest and frequently accompanied with sciatica due to lumbosacral nerve root impairment. Nerve root block can assess to determine whether it is low back pain due to segmental lesion of the spinal column. On the other hand, the clinical feature of low back pain relieved by sympathetic nerve block was pain in paravertebral area on unilateral or bilateral side, but it was nonspecific. Sympathetic nerve block may have the therapeutic effects for pain due to nonsegmental lesion of the spinal column considering anatomic distribution of afferent nerve in the sympathetic trunk.

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A possibility of the diagnosis of low back pain based on the location of pain was discussed. In our laboratory, following facts were demonstrated inrats. The ventral portion of the lumbar disc was innervated by sympathetic sensory fibers non-segmentally, while the posterior portion and the facet joint were innervated by both non-segmental sympathetic fibers and segmental somatic fibers. Electrical stimulations of the ventral portion of the lumbar disc elicited a spinal reflex in the genitofemoral nerve innervating the groin area. Recently it was reported that nerve bundles in the lumbar spinal nerves show an anteroposterior stratification in humans. Given that the sympathetic sensory fibers projecting the lumbar spine line insuch a layer structure, the ventral and dorsal portions of the lumbar spine would correspond to the groin and low back pain, allowing the diagnose of the anteroposterior location of a low back pain disease.

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