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Functional and morphological disturbances of health at the vertebral column lead to instability, dislocation and reduction of intervertebral distance in the mobile segment. A safe therapy to remove these changes must aim at achieving three goals: 1. Re-establishment of stability 2. Repositioning of slipped disks and 3. Re-establishment of intervertebral distance. Especially in spondylolisthesis, results are often unsatisfactory. Even if dorsal traction rods are used, the intervertebral bodies will often slip due to uncoupling in the vertebral joints. This situation can be avoided by effecting together with the introduction of bone blocks. This procedure enables satisfactory repositioning, full restoration of intervertebral distance and permanent restoration of stability.

Lumbar epidural varicosis presenting with radiculopathy is a seldom anticipated condition. An uncommon case of symptomatic enlargement of epidural veins mimicking lumbar disc herniation led us to perform a literature review to elucidate aetiopathological and diagnostic considerations as well as treatment options of this intraspinal pathology.The case of a 40-year-old woman with acute sciatia accompanied by a complete paresis of foot elevation and extension caused by enlarged epidural veins is described. A literature survey (Medline 1960-2005) was conducted to uncover further cases of symptomatic epidural varicosis.The literature review revealed only 75 published cases of symptomatic epidural varices which is generally judged as a rare cause of radiculopathy. Different models for the origin of enlarged epidural veins have been proposed. Enlargement may occur primary or secondary to a herniated disc or compressive lesions in the spinal cord. In some cases obstruction or occlusion of the inferior vena cava due to pregnancy or deep vein thrombosis are suspected to increase the pressure of the epidural venous plexi via collateral pathways. MRI has been reported to be of high value in demonstrating the dilated epidural vein, but the findings might be misinterpreted as herniated nucleus pulposus material. Coagulative ablation and/or excision of enlarged epidural veins is recommended and produces good long-term results in cases without extraspinal vessel pathology.Enlargement of epidural veins with compression of lumbar nerve roots can mimic the clinical signs of disc herniation or spinal stenosis, even when accompanied by neurological disorders. Although rare, lumbar epidural varicosis should be appreciated as a possible cause of radiculopathy and diagnosed before surgery. Apart from intraspinal abnormalities causing dilatation of epidural veins, stenosis or occlusion of the extraspinal venous drainage system should be considered.

We present the clinical case of a fifty-year-old man who presented two times with a foot elevator paresis and an erysipel first on the right and after two months on the left side. Afterwards, we carried out a thorough case history with the help of clinical, radiological and magnetic resonance imaging. Even so the clinical pathology of the foot elevator paresis could not be manifested. A compartment syndrome could be discounted. In the context of the second stay during a neurology examination on both legs electromyography was performed and the nerve speed was tested. A peripheral peroneus paresis of unknown level and of unknown aetiology was demonstrated. The erysipel regressed rapidly under intravenous ampicillin antibiotics while the peroneus paresis was unchanged. The patent was released with a peroneus splint on both sides. With this case report we would like to point out the causes of peripheral peroneus paresis with regard to an additional erysipel. This case report is discussed regarding the possible aetiopathology and the current literature.

The aim of this study was to find out the reliability of several dermatomic maps (description of pain pattern within a nerve root lesion) according to the respective segmental area.Different studies which deal with pain pattern caused by disc lesions were searched for with MedLine support and then reviewed.A clear correlation between the pain projections of the lumbar spine does not seem to exist. A contradiction of the most common pain projection (S1) and operated disc (L4/5) is described.Even though there are studies of high scientific design and value (Nitta H, Wolff A) the pain pattern of dermatomic maps is only of limited value for the definition of the affected segment.

The aim of this study was to investigate the effects of temporary distraction on a degenerated intervertebral disc to characterize regenerative changes associated with disc distraction.New Zealand white rabbits (n = 32) were used for this experimental animal study. The rabbits were randomly assigned to one of five groups. 6 animals were loaded for 28 days using a custom-made external loading device to stimulate disc degeneration (G2). In 6 animals the discs were first loaded for 28 days and after 28 days loading time the discs in six animals were treated as dynamic distraction with an external distraction device (G1). In six animals the discs were distracted for 28 days without previous loading (G5) and in six animals the discs were loaded for 28 days and afterwards the loading device was removed for 28 days for recovery without distraction (G3). Six animals were sham operated (G4) without application of axial load. After 28 to 56 days loading and distraction time, the animals were sacrificed and the lumbar spine was harvested for histological and radiographic analysis. Histology was performed according to a degeneration score and disc height was calculated radiographically. For the cell viability examination, the number of apoptotic cells was determined.After 28 days of loading (G2), the discs showed a significant decrease in disc space of the treated segment. Histologically, a disorganization of the architecture of the annulus occurred. The number of dead cells increased significantly in the annulus and cartilage endplate. These changes were reversible after 28 days of distraction (G1). The disc thickness increased significantly to physiological levels as compared to the specimens from the 28 days loading group without distraction. Histologically, the discs showed signs of tissue regeneration after 28 days of distraction (G1). The number of apoptotic cells decreased significantly in comparison to the loaded discs without distraction (G2).The results of this study suggest that disc regeneration can be induced by axial dynamic distraction in the moderately degenerated rabbit intervertebral disc. The decompressed rabbit intervertebral discs showed signs of tissue recovery at the cellular and histological levels after temporary disc distraction.

Surgery in cervical spine disease using titanium cages is a common procedure to reduce the pain and neurological deficits. This study was aimed to evaluate the results in pain reduction using the wing cage intraoperatively.In this prospective study demographic data were noted, whereas special emphasis was placed on pain, which was noted using a visual pain scale and the prolo score, neurological deficits and the causing pathology. Furthermore, questions about the use of analgesics and the duration of pain were asked. After operation with insertion of a wing cage instead of the disk, a neurological investigation 6, 12 and 24 months later was done to evaluate the postoperative status.54 patients underwent a cervical discectomy in 64 segments as therapy for neck pain or a radiculopathy caused by osteochondrosis or disc disorder. Patients with brachialgia profited most from the operation. Less improvement was seen in cases of osteochondrosis or combined pathology.Patients with pain caused by discs in the cervical spine, have better improvement than patients with other pathologies. This should be taken into account when choosing the mode of therapy.

A 65-year-old patient was referred to our clinic with persisting, severe tinnitus aurium. Due to the facts that prior otolaryngological as well as neurological assessment had been unremarkable and that the patient showed marked degenerative changes in the cervical spine the referring orthopaedic surgeon suggested the cause to be of vertebral origin. Case history showed that the tinnitus had spontaneously occurred and was pulse synchronous. Overall clinical evaluation of the cervical spine was inconspicuous. A brachialgia or other symptoms typically associated with a degenerative cervical syndrome could not be provoked. On the basis of this atypical clinical picture we performed a digital subtraction angiography (DSA) to exclude pathology in the vicinity of the cerebral vessels. This revealed an arteriovenous fistula of the sigmoid sinus which was then, under the auspices of our neurosurgeons, successfully closed by Gugliemo coil embolism. The patient reported that the tinnitus subsided almost immediately. This case demonstrates that despite the manifold pathology that is associated with degenerative cervical syndrome, pulse synchronous tinnitus aurium needs further clarification. Had the case history been taken more accurately and the quality of the tinnitus assessed earlier, the period between onset of symptoms and correct treatment could have been decreased significantly.

The type and frequency of side effects due to treatment of vertebral pain syndromes with local injections were examined. Risks and complications were evaluated and precautions are presented in order to avoid these problems.The medical records of 453 patients who had undergone injection therapy in hospital for spinal pain syndromes were investigated retrospectively.Paravertebral injections with cervical and lumbar spinal nerve analgesia, facet joint injections, lumbar epidural-perineural injections, epidural-dorsal and epidural-sacral injections, and injections next to the ileosacral joint were administered, amounting to a total of 7 963 injections. In 25 cases (0.3 %) unfavourable side effects were observed. Epidural-perineural injections led to headache in 10 cases and paravertebral lumbar nerve analgesia in 3 cases. Five times after epidural-perineural injections circulatory dysregulation with vertigo, nausea and decreased blood pressure was observed. One patient fell after an epidural-perineural injection, and one patient developed a sensory block up to the thoracic segment 6. Five patients showed local allergic reactions at the injection site after Mepivacain. All complications could be treated with simple symptomatic measures and had no severe effects.Compared to other studies, only few side effects were observed. The injections described above may thus be regarded as low-risk therapy.

The clinical indication for graf's ligamentoplasty and dorsoventral fusion may be described as the "lumbar instability syndrome". A follow-up comparison between Graf's ligamentoplasty and instrumental dorsoventral fusion in a consecutive series of 52 patients was performed.52 patients operated on for low back pain were recalled for a clinical and radiological review (at mean 79 months postoperatively). 26 patients underwent Graf' ligamentoplasty and 26 patients underwent dorsoventral fusion. We evaluated the surgical results and measured an objective outcome using the Oswestry Score, Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS). For radiological evaluation the Mimura and the Pathria Scores were used.There was no statistically significant difference between the two groups, when measured by the Oswestry Score, LBOS and VAS at the latest follow-up. The difference between the preoperative and actual VAS in each group was statistically significant (p0.001). Furthermore, there was no provable preoperative parameter in favour of either one of these therapies.Both methods for stabilisation methods of the lumbar spine had a comparable clinical outcome.

Lumbar discogenic pain in the sense of an internal disc disruption (IDD) represents a nociceptive pain syndrome with the source of pain in the innervated outer third of the annulus. Such discs anatomically appear with almost normal contours. Neither clinical nor technical assessments have any diagnostic value, with the exception of MRI which has been shown, if present in symptomatic patients, to have a positive predictive value of up to 89 % to indicate a strong correlation to a painful grade 3 or 4 fissure. However, only the stimulation of a disc (controlled provocation discography) with a subsequent CT scan is of exclusive diagnostic value. As an underlying pathomechanism, a compression fracture of the superior subchondral endplate like a fatigue fracture is discussed. In this way, a deterioration of the homogeneous intradiscal stress distribution could occur with consecutive damage to the internal disc environment and the expression of a radial fissure. The clinical picture of discogenic pain is non-specific. It does not correlate with degenerative changes. It does not differ from any other back pain. Thus, it has to be differentiated from zygapophysial joint pain as well as from sacroiliac joint pain and muscular-ligamentous pain sources. In a single study of American workers, the prevalence of IDD was 39 %, rendering it one of the most important causes for patients with a specified source of back pain.

The aim of this study is to give a short overview about the innervation of the intervertebral disc and the nerve connections between the somatosensible and autonomous nervous systems in the paravertebral region.A short review of the clinical and experimental literature including gross-anatomical, histochemical and immunohistochemical studies as well as functional studies after application of tracer substances has been made. We also present our own experimental immunohistochemical and molecular biological investigations on paravertebral muscle biopsies of a patient with post-discotomy syndrome.The annulus fibrosus of the intervertebral disc is innervated by myelinated nerve fibres. Neuronal markers for pain-leading fibres were found to be positive in the dorsal region of the annulus, and especially in the posterior longitudinal ligament. Nerve ingrowth into the diseased intervertebral disc was found in chronic back pain. The main innervation of the intervertebral disc is formed by the sinuvertebral nerves. The sinuvertebral nerves are recurrent branches of the ventral rami that re-enter the intervertebral foramina to be distributed within the vertebral canal. They are mixed polysegmental nerves and nerve plexuses, each being formed by a somatic root from a ventral ramus and an autonomic root from a grey ramus communicans. The number of nerve bundles was reduced by resection of sympathetic trunks. The expression of neuronal markers in the sarcolemma of the paravertebral muscles is reduced after discotomy.The neuroanatomical basis of discogenic pain can be summarised as follows: 1. The intervertebral disc receives an extensive innervation, especially the annulus fibrosus. 2. Nerve extension was found into the nucleus pulposus of the degenerated disc. 3. The sinuvertebral nerve plexuses facilitate a polysegmental signal and pain spreading. 4. The innervation of the intervertebral disc is very high connected with the paravertebral muscles. 5. A local denervation of the paravertebral muscles was found in post-discotomy syndrome.

The aim of vertebral body replacement is the stabilisation and restoration of the anterior column of the spine with removal of the diseased region. We present our results of stabilisation, pain reduction and neurological improvement using vertebral-body replacement systemsBetween April 1997 and December 2002, 53 patients with malignant vertebral destruction or instability due to traumatic and osteoporotic fracture were treated. We evaluated the results after vertebrectomy and vertebral body replacement by using expandable titanium cages in a retrospective study.The average follow-up time was 18.9 +/- 19.9 months. The mean operation time was 173.2 +/- 77.4 minutes. Intraoperatively, we saw no implant-related complications. Perioperatively, complications appeared in 18 patients (34.0 %). 4 of them were severe, with 2 patients dying. In the total follow-up, 16 patients died, 10 of them (62.5 %) due to tumour progression. Pain reduction was reported in 52.7 %, neurological improvement in 48.0 %. One patient had a loosening of his posterior instrumentation in the further follow-up due to tumour growth with dislocation of the cage and a deterioration of his neurological deficit.By using vertebral body replacement systems, sufficient stabilisation of the vertebral column, pain reduction and neurological improvement can be achieved with an acceptable perioperative risk.

The aim of this study was to evaluate the mid-term results of an in-patient conservative therapy regimen for discogenic cervicobrachialgia.A retrospective follow-up of 100 patients after an average of 4.01 years with clinical examination and a questionnaire was performed.The subjective outcome rating for pain on a scale from 0 (pain-free) to 10 (maximum imaginable pain) was reduced from 7.91 at beginning of the therapy to 3.19 at the end of the therapy and to 1.5 at follow-up (p0.005). Duration of pain, reductions of motion and palsy improved significantly. The patients' appraisal of required surgical therapy could be reduced from 26 % at beginning to 2 % at the end of the therapy.The intensive conservative in-patient treatment for discogenic cervicobrachialgia shows a high satisfaction of the treated patients even after a follow-up of four years. The natural course of the disease shows a rapid and stable remission after wearing off the acute or subacute complaints.

The authors present the therapeutic management of a 12-year-old boy with known hereditary multiple exostosis syndrome (HME), who developed spinal cord compression symptoms caused by an exostosis of the C2 lamina. A perinatal brain lesion with tetraparesis delayed the recognition of the spinal cord compression substantially, which resulted in an extensive spur-like growth of the exostosis.In comparison with already published cases, this growth pattern was rather unique and required consideration on the best surgical management. We decided to monitor the spinal cord function from positioning of the patient to skin closure and to modify the surgical steps of the laminectomy with initial lateral cutting of both hemilaminae.Electrophysiological monitoring helped to avoid spinal cord compression by inadequate head anteflexion during positioning. Lateral cutting of the hemilaminae C2 resulted in spontaneous extrusion of the exostosis with immediate improvement of the electrophysiological findings. The boy experienced a prompt improvement of his neurological deficits.The good surgical and clinical result confirm the value of the applied management concept.

Evaluation of the efficacy of a dynamic stabilizing system for different indications using medium-term clinical and radiological parameters.Out of a total of 70 evaluated patients, 35 showed initial disc degeneration and disc herniation (group 1). In this group, additional nucleotomy was performed. Group 2 included 22 patients with initial osteochondrosis and facet joint osteoarthritis. 13 patients suffered from progressive segment degeneration or degenerative spondylolisthesis (group 3). Clinical evaluation was performed preoperatively, three months postoperatively and at follow-up (33 months). Examinations included subjective and objective measures using the Oswestry Index and VAS as well as radiographs and MRI.Oswestry Index and VAS improved significantly in groups 1 and 2 and remained improved until follow-up. Group 3 showed no significant changes. The evaluation of radiographs and MRI of groups 1 and 2 revealed no progression of the degeneration either at the operated segments or at the adjacent segments. In group 3, 9 cases of progressive degeneration of the operated segments and 3 cases of adjacent segment degeneration were found. Out of 5 implant-associated complications 4 were observed in group 3.Dynesys is able to compensate initial morphological changes and to prevent progression of segment degeneration. The system seems not to be indicated for treating marked deformities or if osseous decompression needs to be performed.

To evaluate changes in static and dynamic values, X-rays of patients who underwent total disc replacement for degenerative disc disease were analyzed.An analysis of pre- and postoperative lateral X-rays in 22 patients with 24 total disc replacements (Prodics, Spine Solutions) was performed. The total lumbar lordosis, the segmental lordosis angle, the disc height and the range of motion in the operated level were measured.Postoperatively a significant increase was observed for the following parameters: the anterior (pre: 9.0 +/- 3.4 mm; post: 16.7 +/- 2.4 mm; p0.001) and posterior (pre: 4.4 +/- 1.3 mm; post: 8.8 +/- 1.3 mm; p0.001) disc height and the segmental lordosis angle (pre: 20 degrees +/- 7.2 degrees; post: 27.7 degrees +/- 7.4 degrees; p0.001). Statistically no significant changes could be observed postoperatively for the total lumbar lordosis (pre: 56.2 degrees +/- 10.7 degrees; post: 58.6 degrees +/- 9.3 degrees; p = 0.196) and the range of motion (pre: 5.0 degrees +/- 4.0 degrees; post: 5.9 degrees +/- 3.5 degrees; p = 0.293).Total disc replacement for degenerative disc disease of the lumbar spine with the current concept does not alter the range of motion but significantly increases the disc height. The significant increase in segmental lordosis without a change in the total lumbar lordosis accounts for a change in lordosis in adjacent segments.

Judgment of factors concerning the indication for the implantation of an artificial disc endoprosthesis, the rating of this operation and biomechanical considerations.Presentation of the indication and the value of a new operative concept in comparison to a so-called dynamic stabilization procedure (Dynesys' method). Indications for the operation are: unsuccessful, orthopedic conservative treatment for6 months, segmental pain, age45 years, evidence of an MRI demonstrable mono- or bisegmental disc degeneration with or without disc prolabation, exclusion of psychogenic disease and positive preoperative, diagnostic measures such as facet joint infiltration and discography.In an earlier investigation the efficacy of the Link method was demonstrated as shown by the reduction of the analgesic use, the angle of the lumbar lordosis (L1-S1) increased from 35.6 degrees to 42.6 degrees (20.2 %), the segmental angle from 19 degrees to 30 degrees (57.5 %). The new investigation using the Aesculap endoprosthesis resulted in a change of the angle of lumbar lordosis from 35.4 degrees to 45.4 degrees (25.4 %) and a change of the segmental angle from 17.3 degrees to 29.1 degrees (57.6 %). This method is a real endoprosthetic instrumentation in the field of spinal surgery.In younger patients with mono- or bisegmental disc degeneration there is an indication for the implantation of a disc endoprosthesis. A facet joint arthrosis and an age over 45 years are contraindications for the operation. The indication in patients with a classic failed back surgery syndrome is still unclear, the improvement of the instrumentation and a further adaptation of the systems to the known biomechanics of the lumbar spine are mandatory as is an intensive discussion of the operative procedure in the case of revision operations. The Dynesys method, with the inherent danger of segmental kyphozitation, a published, significant revision quota combined with a reduction of motility, does not fulfill this criterion.

This article describes the prevalence of degenerative changes of the upper cervical spine (C1-C2) and cervical facet joints found during investigations of spinal column remains.This study was conducted on a sample of 196 cervical spines from southwestern Germany which derive from the 6th to 8th centuries AD. The degenerative lesions were classified into grades 1 (marginal osteophytes), 2 (uneven joint surfaces), or 3 (osseous ankylosis).Of the skeletons examined, 19.4 % (n = 38) showed degenerative changes of the cervical facet joints and/or upper cervical spine (mean age at death was 44 years). The medial (6.1 %) and lateral (0.6 %) atlanto-axial joints were rarely involved in degenerative changes. The facet joints from C3-C4 to C6-C7 showed degenerative changes in 8.0-11.7 % of cases (usually grade 1 and 2). The C2-C3 facet joints were significantly involved in degenerative changes in 19.7 % of cases, one fourth of which were osseous ankylosis (grade 3).The C2-C3 facet joints showed a high rate of degenerative changes.

Degenerative changes of the motion segments are accompanied by an increased vascularization of the endplates. Nerve elements have been demonstrated in the environment of the endplate vessels, which might play a role in pressure related pain sensation. In order to investigate this theory we compared and correlated the extent of memory pain as determined by discography with the amount of vascularization in the endplates on histological examination.Discography was performed in 32 Patients (21 female, 11 male), who underwent spinal fusion. The extent of pain sensation was determined on a self reported visual analogue scale ranging from 0-10 Points. Bone chips from the anterior vertebral endplates were obtained during surgery. Decalcified paraffin-embedded samples were then immunostained with the vascular endothelial marker CD 34. The quantification of endothelium as part of the whole cross section area was performed by means of a computerized optical method.The extent of the pain sensation during discography ranged from 0-9 points on the VAS (average: 5.3 points, SD 3.1). On the histological quantification the total endothelial area per observed field varied from 0.04 to 7.39 % (average: 2.19 %, SD 1.62). The comparison of the pain extent on discography and the vascularization of the endplate resulted in a correlation coefficient after Spearman of rho = + 0.64 (p=0.0006).The extent of vascularization in the degenerated endplates of a motion segment shows a moderate correlation with the self reported VAS scores after discography. Further investigations will have to clarify, whether neurogenic structures originating from vascular endothelium yield a better correlation to discogenic pain.

Our retrospective study analyzed the outcome of patients with degenerative lumbar instability with spinal stenosis, who underwent decompression surgery with dorsoventral fusion (Group I) and decompression surgery with posterior dynamic stabilization (Group II).For 10 patients in each group intra- and postoperative data were obtained and the functional outcome was evaluated with the "Oswestry Low Back Pain Disability Questionnaire" (OQ) and the "Short Form 36 Health Survey Questionnaire" (SF-36). The average follow up was 14.4 months in Group I, 15.2 months in Group II.In Group I the OQ averaged postoperatively 32 points (preoperatively 46 points), the "Physical Component Summary" (PCS) of SF-36 averaged 34 points (preoperatively 24 points), the "Mental Component Summary" (MCS) averaged 43 points (preoperatively 36). In Group II the values at follow up were as follows: OQ 33 points (preoperatively 54), PCS 34 points (preoperatively 28) and MCS 46 points (preoperatively 36). The average hospitalization was 28.4 days in Group I, 19.3 days in Group II and the average operation time was 218 minutes in Group I, 163 minutes in Group II.When compared the functional outcome, the dynamic stabilization seems to be a promising alternative to fusion in patients with degenerative lumbar instability with spinal stenosis.

To determine the effect of different cage geometries and posterior instrumentation on the sagittal spinal profile after monosegmental lumbar interbody fusion.The study is based on a retrospective analysis of 119 patients with segmental instability, who were surgically managed by monosegmental PLIF with PEEK-Cages and dorsal instrumentation.At radiographic follow-up after surgery we found a significant improvement of the lumbar sagittal spinal profile, independent of the cage geometry utilised. A marked discrepancy between 0 degrees -standard and 4 degrees -trapezoid implants concerning the radiographic parameters lumbar lordosis, disc height, correction of spondylolisthesis and sacral inclination was not found. With the use of 4 degrees optimised cages in segment L4/5 slightly better results for segmental lordosis were obtained. Reliability of the radiographic evaluation, expressed as intra-observer error, was satisfactory. Cage geometry did not have an effect on the clinical result. By combining interbody fusion with pedicular instrumentation the reposition of slipped vertebra and distraction of the interbody space could more effectively be achieved. Patients without dorsal instrumentation had a higher rate of pseudarthrosis as well as a less satisfactory clinical outcome.These results show that normal sagittal alignment after single-level lumbar fusion can be achieved with rectangular and 4 degrees -wedged cages. Although results after utilization of 4 degrees -wedged cages do not significantly differ, these implants offer the surgeon one more sizing variation with which physiological lumbar lordosis may be attained. The combination of intersomatic implants with dorsal instrumentation achieves a more precise realignment and has a lower rate of cage-associated complications. It therefore seems prudent that an interbody fusion for the surgical management of lumbar segmental instability should be combined with pedicular instrumentation.

Degeneration of the intervertebral disc is a common disease in the adults, especially at advanced age. A causal therapy is not known, but the progress in new therapeutic strategies, for example in tissue engineering, shows new possibilities. The goal of our study was to develop a new animal model that stimulates a load induced degeneration of the disc. We used the New Zealand rabbit, because morphology is similar to the human intervertebral disc. The degeneration was induced by axial compression of the disc L4 - L5 with an external fixateur. After different loading intervals, the animals were sacrified and the discs examined by radiology, histology, apoptosis and biomechanical testing. Radiography showed a significant decrease of the disc thickness in all loaded groups. Morphologically the intervertebral discs of loaded rabbits showed degenerative changes which were comparable to those in humans. A significantly increased number of dead cells in the annulus occurred after 14 and 28 days loading compared to the controls. The bending stress measured as the load to failure was not significantly different between the unloaded discs and the 28 days loaded discs. The results show that our animal modell can create degeneration. Four weeks compression leads to significant degeneration. Degeneration of the discs persisted in animals that were allowed a recovery time of 28 days after 28 days of loading.

The aim of the study was to evaluate the outcome of outpatient rehabilitation in patients with low back pain and lumbar disk disease with a specific stabilizing exercise of the M. multifidus and M. transversus abdominis.99 outpatients admitted to a rehabilitation unit were included in a prospective randomized controlled interventional trial. The interventional group consisted of 50 patients (34 male, 16 female; mean age 41.1 +/- 9.1, range; 21 - 54 years), 49 patients (31 male, 18 female; mean age 37.9 +/- 9.5, range; 19 - 55 years) were in the control group. Outcomes were assessed at the beginning and the end of the treatment and at a three month follow-up with the Oswestry Low Back Pain Disability Questionnaire, the Hannover Functional Ability Questionnaire FFbH-R, the pain scale SES and a numeric rating scale.In both groups there was a significant functional improvement as measured with the Oswestry Score and the FFbH-R. The interventional group showed better values at the end of the treatment. Pain as well could be reduced significantly by the treatment, but no differences were noted between the two groups.Outpatient rehabilitation improved functional capacity and pain in both groups. Advantages could be seen in the interventional group concerning functional status. The specific stabilizing exercise approach appears to be effective in conservative treatment programs of low back pain and lumbar disk disease.

Lumbar disc herniation is rare in adolescents and often misread. The difference of etiology, symptoms and therapy in comparison to adults were investigated and the long-term outcome of conservative and surgically treatment evaluated.We analysed informations obtained from the medical records of 51 patients younger than 20 years with 79 lumbar disc herniations. For the long-term follow-up we prepared a questionnaire composed of general questions about the patient's lifestyle, pain level and remaining symptoms.The average period from the beginning of the symptoms to the finding of the right diagnosis took about 14,3 months. We compared disc herniations in adolescents with the current literature of disc herniations in adults and found differences in etiology and symptoms. In 16 % of our patients the beginning of the pain was associated with a trauma, in 12 % the pain began during sports activity (microtrauma). In 49 % we found radiological signs of spinal aberrations. Low back pain and monoradicular sciatica were the main complaints, but findings of neurological deficits were rare. 27 patients were managed conservatively and 24 surgically. On the day of discharge 94 % of patients reported excellent or good results. The outcomes of the follow-up period were similar in both treatment groups. Almost all patients were able to attain a normal activity level and few reported restrictions of their daily life. The success rate of the pain frequency was 85 % and pain intensity was 81 %.The etiology of lumbal disc herniations in adolescents has a multifactoral basis. Conservative treatment should be pursued as a mainstay of treatment. Only if conservative treatment fails, surgical treatment should be considered.

Aim of this prospective study was an investigation concerning the indication for the implantation of an artificial disc endoprosthesis and the rating of this operation.35 patients with 11 bi- and 24 monosegmental implanted disc endoprosthesis were observed over an average follow-up of 14.7 months. Indications for the operation were: unsuccessful, orthopedic conservative treatment6 months, segmental pain, age45 years, evidence of a radiologic (MRI) demonstrable mono- or bisegmental disc degeneration with or without disc prolabation, exclusion of psychogenic disease and positive preoperative, diagnostic measures.The average stay in the hospital was 16.8 days (preoperative: 4.3 days), the average operation time 85.5 minutes, the average blood loss was 125 ccm. 23 patients were operated in L 5 / S 1, 20 in L 4 / 5 and 2 in L 3 / 4. NSAR was given in 33 patients preoperatively, opiates in 2 further patients, postoperatively NSAR was necessary in 5 patients, opiates in 2 patients. The preoperative angle of lordosis (L 1 - S 1, n = 25) was changed from 35.6 degrees to 42.6 degrees (20,2 %), the segmental angle from 19 degrees to 30 degrees (57.5 %).The implantation of the artificial disc was followed by a good pain relief in patients suffering from a mono- or bisegmental disc degeneration. In patients with a facett joint arthrosis and elderly patients45 years this method cannot be used, the indication in patients with failed back surgery syndrome cannot be estimated yet. Improvements of the instrumentation and the discussion in the case of revisional operations are mandatory.

We report on a case of spontaneous intramedullary hemorrhage initially misdiagnosed as a lumbar nucleus pulposus prolapse due to the clinical appearance and findings on CT-scan.

Since 1993 occupational influences of the spine are included into the German workman's compensation law (Berufskrankheitenverordnung). Because it is difficult to differentiate degenerative from occupational disc diseases only 3 % of the proposals have been accepted in the last years. Unfortunately most of the epidemiologic studies only consider morphologic changes of the spine but not discogenic diseases. More efforts have to be made to prevent spine diseases in the working place by exercises and back training. Our results of medical opinions in 256 cases of occupational spine diseases are presented and analysed.

It should be cleared whether or not the interpretation of lumbar disk disease as an occupational disease is justifiable. Which disc changes follow whole-body vibration and can they be distinguished from those which occur constitutionally while aging?Orthopedic meta-analysis of epidemiological and occupational studies concerning the influence of whole- body vibration.Reliable studies are rare. Severe methodological problems limit the interpretation of difficult relationships. The role of age when working influences begin as well as the stress and behaviour of exposed persons away from the work-place before and while working with whole-body vibration is not known. There is no study which could be called exact according orthopedic criteria. It is therefore not evident that whole-body vibration causes lumbar disc disease.After whole-body vibration similar to long term heavy lifting an earlier beginning of disk degeneration in X-ray-studies can be observed. This leads to prevalence differences, which diminish with increasing age. Deviation to the left of the prevalence curve lasts for five to ten years. Whole-body vibration leads to a topographic modification of disk degeneration of the lumbar spine. After long duration exposition an increased amount of spondylotic changes at the thoracolumbar junction and the middle half of lumbar spine can be observed (up to the upper plate of the fourth vertebral body). This can be explained by biomechanic means: whole-body vibration caused by tractor driving and similar long-term exposures leads to traction of the disks of the lower thoracic spine and the upper and middle parts of lumbar spine.

To examine the quality and usefulness of time-of-flight MR-angiography and duplex-doppler sonography, respectively, in assessment of the extracranial arteries before cervical spine operations.Patients scheduled for operations of the cervical spine had an MRI plus TOF as well as a duplex and Doppler scan. At the time of the examination the radiologist and the neurologist in charge were blinded for the study. Endpoints were not only the accuracy of the procedures but more so which method improved the preoperative process most.Twenty patients were examined so far. Only in one case did the result differ when a complete occlusion diagnosed sonographically was judged as a severe stenosis on MRA. One patient did not tolerate the MRA for the extra 5 minutes necessary, therefore a contrast-enhanced MRA was performed. MRA eased the preoperative process as imaging of the pathology and the carotids were realised in one step. The costs were slightly higher for MRA than for duplex-doppler sonography.TOF-MRA can replace the duplex-doppler examination in the preoperative assessment of the carotids and has the potential to streamline the preoperative time schedule. Similar to duplex and doppler, in order to be accurate enough the method requires a high degree of expertise from the radiologist.

The difference in consistence of the nucleus pulposus and the annulus fibrosus allows the water jet to selectively remove the nucleus in a closed vertebral disc at a certain pressure range. The aim of the study was to investigate the use of water jet cutting in microinvasive spinal surgery.A comparison in terms of efficiency between the water jet and those of the laser and APLD (automatic percutaneous lumbar discotomy) was achieved by plastic reconstruction of the resected spaces using the in-vitro-model of the spinal column of young pigs. The in-vitro-study was followed by a prospective clinical study with 21 patients.The in-vitro-employment of the three different methods showed that there were no significant differences in volume of the removed nucleus material. During the use of the hydro jet at 50 bar and simultaneous suction the intradiscal pressure measured in vitro remained below 1 bar. Clinical tests on the 21 patients showed good to very good results in 71% of the patients tested (mean follow-up 5.8 months). No complications were found. As working mechanism the pure mechanical effect and the influence on chemical processes within the nucleus remain points for discussion.The current studies results demonstrate that hydrojet spinal surgery might be a safe new method for surgery of disc protrusion and contained prolapse.

Chirotherapy is a popular and successful management option for reversible functional disorders of the cervical spine. Though rarely observed, complications do occur, mainly involving the cerebrovascular system. By means of the here described case and a literature survey, we aim to highlight non-cerebrovascular complications of chirotherapeutic cervical spine manipulation.A 43-year-old male initially consulted an ENT specialist, suffering from tinnitus aurium and loss of hearing ability. His hearing significantly increased after intravenous drug therapy, but the tinnitus remained. During chiropractic manipulation of the cervical spine by an orthopaedic surgeon for the tinnitus, the patient described severe neck pain following a clearly audible clicking sound. Scans of the cervical spine prior to and after manipulation showed an intracapsular/intraosseus oedema of the facet joints C2/C3 with lesion of the nerve root C3, most probably induced by chirotherapy.Although complications after chiropractic manipulation are extremely rare, treatment of the spine, especially the cervical spine, is not wholly harmless. An adequate history taking followed by clinical and radiographic patient evaluation is necessary to keep the risk of iatrogenic trauma at a minimum. Above all, the chiropractic manipulation of the cervical spine belongs in the hands of a qualified and experienced medical practitioner.

The aim of this study was to determine the influence of two different artificial nucleus implants for lumbar discs on the biomechanical properties of the spinal motion segment.From 7 calf spines, the lumbar segments L2/3 and L4/5 were harvested, the lamina and the muscles were removed with care to preserve the anterior and posterior longitudinal ligament. The segments were fixed on a special testing device mounted in an universal testing machine (Zwick, Ulm, Germany). Physiological load with a maximum of 7 Nm was applied in flexion/extension, right and left side bending, and right torsion. Three cycles of measurement were performed in all specimen: a) the intact segment, b) segment after nucleotomy, c) 6 segment with 2 PDN devices (Ray Medica) and 8 segments with an autopolymerized polymer.There was a statistically significant (p = 0.0078/p = 0.0313) increase in segmental mobility in all directions after nucleotomy. After introduction of two PDN implants as well as the polymer implant, there was a restoration of segmental mobility for all movement directions with no statistically significant difference (p0.05) compared to the intact situation before nucleotomy.

The aim of this study is to demonstrate the importance of the differential diagnosis of sciatica. Radiculopathy in the lower extremity of an adult usually originates from a herniated nucleus pulposus. In this paper an extraspinal cause of sciatica due to a pelvic tumor is reported, which is initially often not recognized.A 67-year old woman suffered from sciatica. After one year of unsuccessful conservative treatment and beginning weakness of hip flexion a computed tomography of the pelvis revealed a giant lipoma with compression of the lumbosacral plexus.The results of this case illustrate the problem of over-rating CT-findings of the lumbar intervertebral disks in patients with sciatica. Extraspinal tumorous causes of radiculopathy are rare, but should be considered if the therapeutical measures are resistant to treatment. Computed tomography and magnetic resonance imaging are most useful in confirming a retroperitoneal tumor causing lumbosacral radiculopathy.

Diagnosis of Guillian-Barré Syndrome usually is not difficult, but diagnostic failure occurs for the variable initial presentation. Diagnosis is based on physical examination showing loss of motor strength in more than one limb and loss of deep tendon reflexes. Ventilatory assistance, pharmacologic maintenance of cardiovascular homeostasis, corticosteroids, IgG and plasma exchange are the dominant therapeutic measures.This article reports on a case of a 59-year old surgeon suffering from degenerative disc disease in the lumbar spine. The patient developed a severe course of the Guillian-Barré Syndrome with persisting motor weakness of the legs.If the primary problem at presentation is limb and back pain the pathology appears to be in the musculoskeletal rather than in neurological system. The awareness of this presentation of Guillian-Barré-Syndrome will eliminate delay in diagnosis.

The hyaluronic acid concentration of the nucleus pulposus is in direct connection with osmotic printing. This examination shoes the free and bound hyaluronic acid content of the nucleus pulposus during acut and chronically degenerative disc modifications.20 humane disc parts of the rungs L4/5 and L5/S1 were examined. The intervertebral disc material were deep-frozen to -80 degrees C directly after discectomy. The determination of the hyaluronic acid was carried out with the HA-test of the company Pharmacia. The examined disc material was treated with isotonic common salt solution (0.9%) and triton X-100 (2%). The investigation material was examined with the RIA-test. The patients were subdivided in 3 groups reference to there different anamnese. The first group included 5 patients with an acut disc herniation and an anamnese time under 1 week. The second group consisted of 8 patients with an disc herniation and an anamnese time of more than 4 weeks with extensive conservative therapy. In the third group, the control group including 7 patients, a spondylodese was performed due to other degenerative disc modifications.The results of the investigation showed significantly more (p0.05) free and bound hyaluronic acid in the group with an acut disc herniation. On the other hand, no significant difference appeared between the control group and the patients with an disc herniation of older anamnese (p0.05).We could show that the nucleus pulposus contains more hyaluronic acid in the case of an acut disc herniation than in case of older degenerative disc modifications. The results shoes important new views for the discussion of the genesis of acut and chronic nucleus pulposus prolapses.

To evaluate the perioperative risks for lumbar disc surgery.Over a 10-year period 558 patients (mean age 45, range from 18 to 83 years; 62.7% male, 37.2% female) underwent conventional lumbar disc nucleotomy (69.4% mono-, 27.3 bi-, and 3.3% tri-segmental) for the first (84.4%), second (12.3%), third (2.3%) or more (1.0%) time. Main levels operated were L4/L5 in 56.3% and L5/S1 in 35.3%. In 63.9% there was a preoperative motor deficit. Before the operation and until 3 months after the operation all complications were recorded.In 115 (20.6%) of our patients intra- and/or postoperative complications were observed. Of these 115 patients 33 (5.9%) had slight complications (i.e. urinary tract infection, GI tract disturbance, local irritation of the wound), 57 (10.2%) had moderate complications (i.e. respiratory tract infection, superficial wound infection, dural tear), and 25 (4.4%) suffered from severe complications (i.e. deep vein thrombosis, pulmonary embolism, increase of the neurological dysfunction, additional operation because of a complication). Only in severe complications the hospital stay was prolonged (from a mean of 21 days to a mean of 33 days, p0.05). Our analysis showed a doubling of the complication risk in patients older than 75 compared to patients younger than 40 years. Multiple regression analysis revealed significant influence of concomitant diseases like diabetes mellitus and hepatitis (p0.01).25 or 4.4% of all our patients were confronted with severe complications. The indication for nucleotomy should be weighed especially careful in old patients with diabetes mellitus or hepatitis.

Herniation of the calcified nucleus pulposus is a complication of intervertebral disc calcification. The herniated nucleus pulposus may assume an intraspinal location which may lead to cord compression and produce alarming neurological symptoms and radiographic images. Surgical intervention is, however, rarely necessary as complete resorption of the calcified disc material will generally occur. We report the case of a five years old boy with the symptoms of an acute tortcollis, radiographs of the cervical spine revealed calcification of C5/C6 intervertebral disc and MRI narrowing of the spinal canal. With conservative treatment his symptoms resolved within three weeks, three months later X-rays and MRI showed complete resolution of the calcification and herniation.

Are there any radiological criterions which are able to indicate the profession related disease No. 2108?The medical documents and x-rays of the whole spine of 390 back pain patients who applied for a profession related disease of the spine were evaluated. Those patients who fulfilled the professional claims for acknowledgement of the profession related disease were compared to those who didn't fulfill these conditions.Concerning the segmental alterations of the cervical and the lumbal spine specific allocation frequencies were found. The dominance of L3/4 in the comparison group was conspicuous. Looking at the allocation frequencies of the cervical and lumbal disc alterations in view of affection heaviness it was obvious, that the predominating slight alterations mainly were located in the central parts of the cervical and the lumbal spine whereas bad alterations mainly were found in the lower parts. Regarding this matter test and comparison groups behaved the same way. Looking at the allocation frequencies concerning single respectively multiple alterations it was found that in the comparison group single respectively bisegmentale alterations could be recognized even in duplicate than in the test group in which the multiple alterations were dominant. The comparison of the cervical and the lumbal spine regarding chondrotic? spondylotic, slight and bad alterations in all mentioned features the next deeper located segment was affected particularly in the test group. Therefore a distal shift of the chondrotic alterations could be recognized. In case of the spondylotic affections it was the other way round: a cranial shift was conspicuous.After doing heavy labour for years only a few isolated multiple affections of the lumbal spine are found. On the strength of this fact the proof of exclusively in the lumbal spine located alterations doesn't allow the acknowledgement of a profession related disease. However, a distal shift of osteochondrotic alterations respectively a cranial shift of spondylotic affections in the lumbal spine is suspicous for being job-related. L3/4 takes a very special place in the differential diagnosis of profession related disease of the spine. In the test group this part of the lumbal spine showed bad alterations much more frequent. The affection of L3/4 pleads against a considerable participation of mechanical influences and therefore against a profession related disease. Singular or bisegmental disc affections are out of question for being a profession related disease because these alterations are seen much more frequent in the comparison than in the test group.

The influence of non somatic factors, especially the social status of the patients' profession on postoperative reintegration following lumbar discectomy is investigated.In 511 patients postoperative loss of working time and time till return-to-work after lumbar discectomy were investigated. Patients were interviewed by questionnaire at an average of 7.6 years postoperatively.Patients returned to work at an average of 10.5 weeks after operation. Looking at the social status of the patients we found an average time of 5.4 weeks until return to full work for self employed people. Civil servants took on average 10.2 weeks and regular employees returned to work after 14.0 weeks. The longest time to return to work was seen in workers with 17.2 weeks. Somatic risk factor profile for nucleus pulposus prolaps was identical in the group of self employed and employees. There was a different risk profile in the other two groups.We could show a correlation between the length of the return-to-work period and long-term clinical outcome with the social status of the patient. This correlation was most clearly shown in the group of self employed and employees.For judgement of the postoperative rehabilitation period, the social status may indicate the pain level and duration of pain that has to be expected.

It is well known that cytokines are involved in the induction of intervertebral disc and articular cartilage destruction. Therapeutic proteins are of great potential as locally produced drugs after transfer of their cognate genes to the sites of interest.Chondrocytic cells from bovine os coccygis and discal chondrocytes from 6 wistar rats were isolated and cultured in vitro. The bacterial beta-galactosidase (LacZ) gene and the cDNA of the human interleukin-1 receptor antagonist (IL-1ra) were introduced into the cells by retrovirus mediated gene transfer. LacZ activity was determined by Xgal staining, IL-1ra protein was determined by ELISA.Our study confirms that isolation and cultivation of bovine chondrocytic end plate cells and of rat discal cells in possible. Transfer of both LacZ and of the IL-1ra cDNA to cultured cells was successfull.The introduction of exogenous therapeutical genes into cells from the intervertebral disc and the end plate opens the possibility for a local gene therapy of IVD degeneration. This therapy has the potential to be specific, effective and appropriate to the chronicity of the disease.

Published methods to quantify height of lumbar discs from lateral radiographic views of the lumbar spine yield inaccurate results due to distortion in central projection. Normal values of disc height have not been compiled.Starting from an analysis of the imaging properties of vertebral bodies in a lateral view and following a logical evolution of Farfan's proposal, a new protocol for the measurement of disc height is given which is independent of distortion. A database of normal values of the height of lumbar discs from T12/L1 to L5/S1 was compiled from 892 lateral views of healthy male and female subjects in the age range between 16 and 57 years.Employing the new protocol, height of all discs on a lateral view can be measured. Variations in position (standing, side-lying) do not influence the result. Retrospective investigations are feasible. The precision of the disc height measurement amounts to 4.15%. Normal, age-appropriate values for the height of lumbar discs are given for the first time. In the individual case, disc height can be quantitatively evaluated by comparison with the normative database.The new protocol can be employed to quantitatively identify processes which effect a decrease of disc height. In the individual case, the new protocol and the comparison with the normal database can be employed to quantitatively assess overload injury to lumbar discs in compensation cases.

One important step in lumbar discotomy is the safe penetration and exact partial removal of the Lig. flavum. This is a crucial prerequisite for the selective and gentle removal of prolapsed and sequestrated intervertebral disc tissue. Extensive lancing of the Lig. flavum should be avoided, to minimize intraoperative and postoperative complications, such as injuries to the nerves and the Dura mater, instabilities, bleeding and scarring. As there has up to now been insufficient information on the anatomy of the Lig. flavum especially regarding microdiscotomy, an analysis of the Ligg. flava L2/L3 to L5/S1, guided by this aim, was carried out on 36 corpses kept in formaline (16 f, 20 m; 52-78 y). Preparations showed the lumbar Ligg. flava to be embodied in the Foramina interarcualia in a characteristic configuration. There also proved to be defined insertion areas on the laminae of the vertebral arches, which must be taken into consideration during the operative exposure. The Lig. flavum rises from the cranial vertebral arch from the ventral surface of the lamina (6.8 mm) whilst the insertion area on the caudal lamina covers the dorsal and the ventral surface. The extent at the ventral surface is 2.2 mm in average. Taking the insertion proportions into account we would suggest the Lig. flavum to be divided as follows: Pars interspinalis, which clearly differs from the Lig. interspinale (and from the M. interspinalis), and which houses venous anastomoses in its dorsal, ridge-shaped extension. Pars interlaminaris, which starts at the laminae and constitutes the target area for flavotomy in its lateral section, and Pars capsularis, which merges into the capsular structures of the facets. In all levels examined, there proved to be dorso-ventrally a typical change in the direction of the course of the fibres in the Pars interlaminaris. Whilst the direction of the fibres dorsally is oriented cranio-medially to caudo-laterally at an angle between 15 degrees and 30 degrees to the median line, the ventral fibres of the Lig. flavum are strictly aligned cranio-caudally. The changes in the directions of the fibres are continuous with the fibres being very closely intertwined, without there being any spatium at all. The texture of the Lig. flavum is, therefore, a mirror image of that of the autochthonuous muscular system of the back, even if the overlapping angle area is considerably smaller. The different segment levels show a segment-specific thickness profile. The analysis has provided anatomic information about the Ligg. flava L2/L3 to L5/S1. These data represent important prerequisites for a selective, gentle and safe intraoperative procedure for discotomy.

In 6.26% of 846 patients with lumbar disc surgery a reoperation was necessary. A total of 93 patient had undergone a revision surgery inclusive a patient group with primary surgery performed elsewhere. 68 patient had 1 reoperation, 22 patients 2, 2 patients 3, and one patient had even 4 revisions. Follow-up ranged between 19 and 42 years with an average of 31 years. 53 patients were clinically examined at a time of follow up and another 15 patients answered a questionnaire. An excellent result with no complaints and patients able to work could be achieved in only 16%. A good result with no radicular pain, but some minor back pain and some loss of sensibility and ability to work was found in 24%. In 40% of the patients the result was only fair with some radicular pain and limited capability for work. 20% of the patients had only a poor result with unchanged symptoms and continued therapy. Those patients were not able to work. Young and female patients had a better prognosis. Another positive predictor was a short period of preoperative pain. Negative predictors were multiple prior operation as well as scar tissue at time of revision. Also spondylodesis according to Cloward correlated also with a negative clinical outcome.

As a seeming law of nature the possibility of making use of various multiplanar sectional imaging techniques is accompanied by diagnostic exaggeration. Simple and cost effective procedures with low radiation dosage such as plain x-rays of the spine are being thrust into the background. Not seldom are patients referred to the spine surgeon with MRI or Cat scan at hand but lacking standard radiographs. As far as the assessment of intervertebral disc disease is concerned the combination of plain X-rays of the spine and computed tomography of the level in question turned out to be sufficient for indication of the operation in more than 90% of 450 patients after nucleotomie at the Orthopedic University Clinic Mainz. To our mind MRI should be restricted to cases in whom disc surgery had failed to relieve sciatica. Here it allows to distinguish between a recurrent HNP and postoperative scar tissue. In our patients myelography, an invasive procedure, has its role only in emergency diagnostics, and in the dynamic-functional examination.