ஜர்னல் ஆஃப் ஸ்பைன்

Gomez Orthotic Spine Systems is a clinical method of measurement and, conservative treatment used in the management of spinal deformities including idiopathic scoliosis. This method uses easily accessible and economic measurement tools and permits a quantitative postural evaluation by using photometry for 3D analysis based on the center line in each corporal plane, line which is established as the line of greatest stability. In this article the method will be discussed in detail from its theoretical basis through implementation using a single clinical case.

Background content: Tuberculous spondylitis (Pott’s disease) is known for nonspecific findings which can mimic metastatic disease. Spinal pain, local tenderness and night sweats may be presenting symptoms. There is no pathognomic radiographic appearance of tuberculous spondylitis.

Back pain may also be the first sign of multiple myeloma (MM) and is usually caused by bone destruction or vertebral collapse. The tumour itself can also cause pain by nerve or spinal cord damage resulting from direct pressure or secondary peripheral neuropathies. MM is often complicated by infectious diseases caused by the mainly cell mediated and humoral immune deficiency.

Purpose: To report a case of a patient who presented with Pott’s disease and multiple myeloma in the same vertebra.

Study Design: Case Report Patient Sample: Description of one case Outcome measures: Multiple myeloma and Pott’s disease can coincide. If one of these diseases is overlooked, it may have serious consequences for the patient.

Methods: We present a case of a patient with Pott’s disease and multiple myeloma in the same vertebra. This is shown on radiographic findings, laboratory results and pathologic findings.

Results: Radiographic findings, laboratory results and pathologic findings showed a Pott’s disease and multiple myeloma in the same vertebra.

Conclusion: We present a patient with persisting back pain, who was initially diagnosed with spinal tuberculosis. Despite antituberculous medication he developed signs of spinal cord compression and was operated on. Retrieved tissue samples revealed multiple myeloma.

This case highlights that, as MM may predispose for active TB, the two diagnoses may coincide. Because of similarity of clinical appearance one of them may be overlooked, which may have serious consequences for the patient.

Background: Low back pain is one of the most prevalent problems in industrialized countries and often results in decline in the quality of life of the affected individuals. There are a number of contributors to low back pain, one of which is Degenerative Disc Disease (DDD) of the spine. Although fusion has been well accepted for the treatment of DDD, high rates of complications and stress to adjacent segments remain a concern. Iumbar Total Disc Replacement (lTDR) is one technology that has become popular as an alternative to fusion. Artificial disc replacements were developed with a goal of preserving motion and avoiding various fusion-related complications.

Methods: This is a multi-center, single arm, prospective post-market registry of the M6®-L, a compressible core TDR, consisting of consecutive patients presenting with lumbar DDD who agreed to participate. Clinical outcome measures include the Oswestry Disability Index (ODI) and back and leg Visual Analogue Scales (VAS). Data was collected pre-operatively, peri-operatively and post-operatively at 6 weeks, 3, 6 and 12 months and yearly thereafter. AP, Lateral and flexion/extension x-rays were performed for radiographic analysis. Patients are monitored continuously to track complications.

Results: Results for 45 patients, (20 males, 25 females, mean age 44.6 years) are reported. Thirty-one patients were treated at 1 level, and 14 at multiple levels, between L3 and S1. Mean ODI has decreased significantly (p<0.001) from 45.9 ± 16.5% at baseline to 19.7 ± 19.3 at 2 years post-implant. Low back pain has also decreased significantly (p<0.001) from baseline with a preoperative back pain VAS of 7.0 and a 2 year value of 2.5. Physiologic range of motion was maintained from baseline through 2 years.

Conclusions: Two year results from the post-market registry suggest initial device safety and effectiveness when used for the treatment of lumbar degenerative disc disease.

In the literature, there is no longer agreement neither on the real existence neither on the pathogenicmechanism that causes ligamentous lumbar stenosis or “soft stenosis”. In particular, the main questions are: 1 – is it caused by the hypertrophy of the ligamentum flavum or by its withdrawal into the spinal canal due to the loss of elasticity and the disc collapse? 2 - is there a molecular substrate that can explain the hypertrophy of the ligamentum flavum? Lately, the identification of the fractalkine’s overexpression demonstrated a fundamental role of the metameric instability and of the joint inflammation in the pathogenesis of hypertrophy of the ligamentum flavum, thus making clear the association between joint hypermobility and soft spinal stenosis.

The study of this association is worthy of more clinical and instrumental findings, even if recent studies have shown growing evidence that the soft stenosis is a clinic-pathological well-defined entity. Its primum movens seems to be the vertebral instability and its molecular substrate seem to be the overexpression of fractalkine, going to place in the unstable phase of the degenerative cascade of the lumbar spine.

Abstract Study design: Qualitative study design, using semi-structured interviews. Objective: To characterize the shared decision-making (SDM) process from the perspective of orthopedic and neurosurgical physicians treating patients with low back pain (LBP). Summary of background data: Unwarranted variations in quality and cost of healthcare for LBP persist. SDM is a process of informed consent that could improve patient education and outcomes. Its success depends on the quality of patient-physician communication. Lack of monolithic, cross-specialty, clinical guidelines for physicians treating LBP makes SDM especially important for this preference-sensitive condition. Therefore, further study of physician perceptions of the SDM process is warranted. Methods: We conducted semi-structured, in-depth interviews in a sample of thirteen orthopedic and neurosurgeons that treated patients with LBP. Interviews were then transcribed, coded and qualitatively analyzed using a grounded theory approach. Results: Detailed narratives of surgeons’ experiences and perspectives revealed varying interpretations of SDM. Some limited it to the patient-physician dyad, describing it as a process of educating patients about their illness, treatment options and optimum treatment goals. Others included inter-practitioner and systemic dimensions, hospital environment, physician-patient characteristics, physician-patient relationships and financial considerations as influential in SDM. Although physicians indicated SDM as beneficial in theory, patient expectations, the experience and attitude of the physician, and time pressure influenced the actual practice of it. Conclusions: Patient-related barriers to SDM were unrealistic expectations, hidden motives, multiple morbid conditions and older age, while facilitators were fewer illnesses and younger age. Physician-level facilitators included younger age and SDM-related training or experience, while time constraints and specialty biases toward treatment options were barriers. The physician-patient relationship was deemed critical to SDM, but insurance coverage and treatment affordability limited the available choices.

We report a case of a 81-year-old woman with a subacute bilateral legs palsy due to venous congestion of the spinal cord caused by an arteriovenous fistula in the first lumbar vertebra which fractured previously.

We diagnosed her spinal infarction only by MRI. She recovered from leg palsy at first. So we waited and saw her symptom. But after that leg palsy repeated with short interval and gradually her palsy was getting worse and became completed palsy. We performed selective spinal angiography and found out arteriovenous fistula in first lumbar vertebra fractured previously.

We estimated that vertebral fracture might make arteriovenous fistula in vertebral body and this fistula caused venous congestion spinal cord.

Spinal cord venous infarctions due to venous congestion with lumbar vertebral body malformation is a very rare. Therefore we delayed to diagnose and this delay caused to permanent neurological deficits.

Introduction: The incidence of symptomatic thoracic disc herniation (TDH) is quite low, and most patients present with either radiculopathy as pain in the chest wall or thoracic myelopathy involving the lower extremities. However, not only these typical symptoms, but also various other symptoms pointing to other general diseases can be the sole presenting complaints. We describe a rare case in which a patient presented with predominant abdominal pain caused by thoracic disc herniation.

Materials andMethods: Retrospective data analysis and review of the literature.

Results: A 45-year-old man experienced sudden onset of abdominal pain and presented to our internal medicine outpatient clinic. Due to obvious concomitant paraplegia, he was referred to our department. Physical examination revealed spastic paraplegia below the T10 dermatome level. Thoracic magnetic resonance imaging showed disc herniation at the T9-10 level. Herniotomy was performed, and abdominal pain completely disappeared immediately postoperatively.

Conclusions: Although the anatomical location within a given axial cross-section of the spinal cord where visceral pain is processed is still controversial, some reports have defined the visceral nociceptive pathway as ascending in the midline of the dorsal columns, particularly in the nucleus gracilis. Damage to this pathway seems to represent a cause of abdominal pain with TDH. Further investigations in this area are required to elucidate the exact mechanisms involved. Surgeons should be aware of atypical presentations of TDH, to prevent misdiagnosis and progression to irreversible myelopathy.

Design: Retrospective study.

Objective: To examine and compare pre/postoperative sagittal alignment of the lumbar spine following AxiaLIF® and to identify patient category with respect to preservation/restoration of lumbar lordosis.

Background: Interbody arthrodesisis an effective treatment for lower back pain and provides immediate structural support with high fusion rates. AxiaLIF® is an interbody device to be implanted through a paracoccygeal approach. Sagittal alignment change after AxiaLIF® has not been studied in past literature.

Methods: Retrospective study of all patients who underwent a 360° lumbar interbody fusion at L5-S1 and L4-S1 with AxiaLIF® between Nov. 2008 and Sept. 2009. Surgeries were performed with patients prone on a Jackson table. Lumbar Cobb angles were measured at L1-S1, L4-S1 and individual lumbar levels. The sacral slope and percentage of total lordosis coming from the L4-S1 levels were also recorded.

Results: 60 patients identified for inclusion (mean age: 44 years). No difference in total average lordosis was observed preoperatively (47.9º) versus postoperatively (47.7º). The difference between pre and postoperative Cobb angles at the L4-S1 and L4-L5 levels was statistically significant (p=0.022 and 0.029, respectively). The change in percentage of total lordosis coming from L4-S1 segments (68.9% preoperatively vs. 56.5% postoperatively) was also significantly different (p=0.0004). A >10º postoperative change in total lordosis, L4-S1, and SS occurred in 18%, 20%, and 11% respectively. 50% and 43% of patients had a >5º change at the individual segments of L4-L5 and L5-S1.

Conclusions: A significant portion single and multilevel fusions with AxiaLIF® had a statistically significant change at the L4-5 and L4-S1 levels. The percentage of total lordosis from the L4-S1 level decreased significantly in the multilevel group. Further observation will determine if change in alignment will impact outcomes or accelerate adjacent level disease.

Summary of background datas: The management for thoracolumbar fractures remains challenging. It is still controversial which surgical option and approach can correct the deformity, induce neurological recovery, allow patients early mobilization and return to work with minimal risk of complication. The load sharing classification was proposed to describe the thoracolumbar fracture and guide the surgical approach and widely used.

Objectives: To review the related studies reporting the load sharing classification for the management of thoracolumbar fractures, discusses the generation, biomechanics, clinical application and advancement of load sharing classification.

Material and Methods: PubMed was used to search for articles published from January 1992 to January 2013 using keywords (thoracolumbar fracture and load sharing). References were checked to identify additional studies.

Results: There were 19 original articles that ultimately constituted the basis for the review. 16 prospective or retrospective studies reporting clinical results using load sharing classification to treat the thoracolumbar fracture were listed. The sample size was relatively small and it was difficult to compare the results among different studies without the same outcome measures or length of follow-up periods.

Conclusion: The optimal surgical method to reduce the postoperative complications and maintain the favorable long-term result for thoracolumbar fractures, all of these are still the challenges of the spine surgery. The load-sharing theory and the load-sharing classification have made contribution to solve the above problems and laid the theoretical basis and provided the clinical guideline meanwhile.

Introduction: Spinal cord injury due to traumatic accidents is a major cause of disability throughout the world. Among the spinal injury patients more than 30% suffered from Thoracolumbar Spine (TLS) injury with great preponderance to Thoracolumbar Junction (T10-L2) injury. Delay or inappropriate management of these patients leads to a great socio-economical impact on the society.

Methods and materials: This was a prospective study on 38 patients who were admitted in the Neurosurgery Department at Dhaka Medical College and Hospital (DMCH) in the period of January 2010 to December 2011 with thoracolumbar junction injuries and were analyzed regarding demographic patterns after getting approval of the Ethical Committee of Bangladesh College of Physician and Surgeons (BCPS) and DMCH. Patients with single level Thoracolumbar Junction Injury (D10-L2) and who had TLICS score ≥ 4 were included in this study. Patients with TLICS score ≤ 3, multiple level thoracolumbar junction injury, associated other injuries like head injury, abdominal injury, long bone fractures and any pathological thoracolumbar fractures were excluded.

Result: There were 36 males and 2 females with average age of 29.42 ± 8.11 years (range 17-50 years). Fall from height was the commonest (79%) cause of injury. Most of the patients were farmers and came from lower income class. Most of the patients 29(76.3%) were illiterate. The mean time interval from injury to admission was found to be 8.97 ± 10.11 days (2 to 60 days).

Conclusion: In this study large number of patients was in their active period of life. Due to lack of awareness in their working place, proper counseling and appropriate management of these patients eventually become burden to their family and society. This burden can be minimized with good governance regarding safety measurement in working place and raising awareness among people in their active lives.