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Background: The variables pain intensity (SI), disability (DS) and quality of life (QoL) belong to a set of primary patient-based outcomes in chronic low back pain (CLBP). The avoidance-endurance model (AEM) assumes three maladaptive and one adaptive pain response pattern. The purpose of this study was to study the level and course of the outcomes with regard to the four AEM patterns., Patients and Methods: A total of 52 CLBP inpatients were investigated at 2 points in time: during the first days after admission and 6 months after the acute exacerbation of pain. Differences between AEM patterns were analyzed with repeated measurement analyses of variance., Results: Groups differences were found for SI (F((3, 48))=2.82, p<0.05), general (F((3, 48))=6.78, p<0.05) and health-related QoL (F((3, 48))=5.99, p <0.05). In contrast, for the variable disability only a significant time effect was found., Conclusion: The results show differences in the level and process of SI, DS and QoL between the subgroups. An AEM-based classification of subgroups is also reasonable for CLPB patients., (© Deutsche Gesellschaft zum Studium des Schmerzes)

Background: To compare the in vitro effects of selective COX-2 inhibitors (L-745,337, NS-398 and DFU) and of COX-unspecific diclofenac on release of PGE(2 )and 6-keto-PGF(1alpha) from inflamed bursa subacromialis tissue (IBST) obtained from a total of 35 patients with shoulder impingement syndrome (SIS)., Patients and Methods: Bursal specimens were incubated in the presence of drugs (0.01-1000 microM) for 20 min and 16 h., Results: After 20 min 10 microM diclofenac significantly inhibited formation of PGE(2) and 6-keto-PGF(1alpha), whereas L-745,337 and NS-398 (10-1000 microM) induced significant inhibition only at concentrations > or =100 microM. In contrast to equimolar diclofenac, DFU (0.01-10 microM) induced no inhibition of bursal PGE(2) release but a dose-dependent, although statistically not significant inhibition after 16 h. The inhibitory potency of diclofenac (0.01-10 microM) was even more increased during long-term incubation showing greater inhibition than DFU at all concentrations studied., Conclusion: The data suggest that in IBST in SIS in vitro the majority of PG is generated via the COX-1 pathway.

Surgical treatment of lumbar spinal stenosis is aimed at decompressing the structures of the spinal canal. Several surgical techniques have been described over the last few years. This article gives a survey of the surgical procedures used for the treatment of spinal stenosis. When comparing and discussing indications and current surgical techniques used for spinal stenosis, one can describe some general tendencies: if the symptoms are severe or disabling and do not respond to appropriate conservative treatment, or if the patient is not able to cope with the pain any longer and views his or her quality of life as unacceptable, surgery is indicated. If the symptoms are mainly radicular, (microsurgical) decompression should be performed. If back pain is the main problem combined with preoperative evidence of segmental instability, spondylolisthesis, or scoliosis, one should consider spinal fusion in addition to an appropriate decompression. Further investigations are necessary to exactly find out the appropriate indications for a fusion and to answer the question of whether spinal instrumentation should be used.

Identification and treatment of spinal disorders have been described for thousands of years. Nevertheless, systematic operative treatment was more or less impossible until about 200 years ago. During the second half of the last century, spinal surgery developed rapidly due to several technical improvements. This article summarizes the main aspects of the historical development of spinal surgery.

Purpose of the Study: Aim of this investigation was the examination of the therapeutic effect of cervical nerve infiltration with mepivacaine in comparison to local applications of isotonic sodium chlorid solution in a prospective randomised double blind study., Methods: 57 patients with cervicocephalgia or cervicobrachialgia were injected daily with mepivacaine ( n=28) or physiological sodium chlorid solution ( n=29). The success was judged through the blinded patients and blinded therapists first after three days of treatment. If no improvement occurred a single injection of mepivacaine and triamcinolonacetonid was given. This injection could be repeated if required. At the end of the inpatient treatment, after a mean of 14 days, the patients assessed the treatment according to a scale of 1-4 (painfree - no improvement)., Results: The average therapeutic effect, in the subjective appraisal of 1-4 by the patients, was 2.15 in the mepivacaine-group and 2.54 in the sodium chlorid - group. In the mepivacaine-group no pain (note 1) was achieved two times and 21 times a clear improvement (note 2), while in the sodium chlorid - group 18 times a clear improvement was achieved and never freedom of pain ( p<0,038). In the mepivacaine-group twice a steroidinjection was required, while in the sodium chlorid - group this was necessary in 16 cases ( p<0,01)., Conclusion: Cervical injections with mepivacaine improve the subjective pain perception in cervicocephalgia and cervicobrachialgia significantly better than isotonic sodium chlorid - solution in short term results and can therefore be prefered. After an inpatient treatment good and excellent subjective results could be achieved in a high percentage.

Purpose: The aim of this study is to analyse the mid-term clinical and sonographical results of non-operative therapy of calcifying tendinitis., Methods: Retrospectively the anamnestical, clinical and sonographical results after various non-operative treatment of patients with calcifying tendinitis were reviewed. For this purpose 159 patients with 178 calcifying deposits in the rotator cuff were evaluated on an average of 60 months after their first examination in our clinic (mean age: 49.2 years; sex ratio: 58% women)., Results: During a mean symptomatic period of 49 months, an average of 4.2 different therapeutic modalities were applied. After this time 70% of all patients showed an excellent or good result. With regard to the age-correlated Constant-Score 85% of all patients had more than 81 points, i.e. a good result. The mid-term results on a visual analogous scale from 10 (pain) to 0 (no pain) showed a decrease from 7.7 to 2.2 and this correlated with the shoulder function scores (Constant-/Patte-Score, r -0.8). After an average of 104 months 82% of the hydroxyapatite deposits could not be diagnosed by sonography (7.5 MHz.) anymore., Conclusion: In the treatment of calcifying tendinitis the conservative methods achieve good and excellent results in 70%. Patients should be treated with analgetics, subacromial injections, physiotherapy and ice therapy up to a period of twelve months, above all with small deposits and radiologic resorptive stadiums. The results of this study should be compared with any invasive regimen.

Purpose: Investigation of clinical und ultrasonographical results after operatively treated calcifying tendinitis., Methods: 131 patients with calcifying tendinitis were treated by surgical decompression and, if necessary and possible, calcific deposit removal. 93% of these patients were clinically and ultrasonographically examined after an average time of 4 years and 5 months., Results: Pain rating on a visual analogue scale 0-no pain to 10-maximum pain was 8.7 before surgery and 1.4 at follow-up. 88% of the patients rated the operation excellent or good. The Constant Score results corresponded to the average results of a normal population (100.3). At the time of examination in 16.4% of the cases new calcific deposits could be discovered., Conclusion: According to the clinical results operative treatment shows good and excellent results in a high degree even after unsuccessful non-operative therapy.

Low back pain is the most expensive condition in industrialized countries. Approximately 65-80% of the population will be afflicted with low back pain at some point during their life. Low back pain has many causes and can originate from any of several pain-sensitive foci, among which are facet joints, sacroiliac joint, muscle and ligaments. Primary care in the acute phase consists of nonsteroidal anti-inflammatory drugs to address the biochemical and inflammatory mediators of pain or skeletal muscle spasmolytics to reduce low back pain symptoms. Injection procedures should be reserved for the patients with low back pain who fail to respond to a directed, conservative treatment trial and have had pain for at least 2 weeks duration. Eliminating sensation from a certain pain source has been proposed as a way to allow an examiner to determine if that joint is responsible for the patient's pain. Injections of local anesthetic into the facet joint or around its nerve supply are clinical methods of eliminating pain from focal areas such as facet joints or myofascial trigger points. When a particular joint is determined to be the source of pain, long-term relief can be sought by directing therapeutic interventions at that joint. The anatomic accessibility of the most common pain sources of low back pain make diagnostic blocks and therapeutic instillation of corticosteroids particularly appealing. If used, their potential benefit for the individual case needs to be carefully weighed. They should be used to facilitate more aggressive conservative care and not as an isolated treatment. Certainly, if response to corticosteroids does not occur after the first injection, no further administration of corticosteroids is indicated.

The question is, if a possible concentration of stress in the segment adjacent to the fusion level might result in disc degeneration. Two series of patients have been evaluated: One group of 70 patients underwent a posterolateral fusion without instruments and the other group of 69 patients underwent a posterolateral instrumented fusion. The follow-up was in average 5.7 years resp. 4.6 years. The operations were divided in monosegmental, floating and polysegmental fusions. In the total group, 10% of the non-instrumented and 28% of the instrumented patients had an osteoarthritis of the facet joints, 10% resp. 23% were unstable and in 9% resp. 1% a disc resorption occurred. There have been no statistical differences in the both polysegemental groups, but this was the case for all osteoarthritis and instabilities in the monosegmental fusions. It is supposed that the changes in kinematics together with material related alterations of elasticity led to higher stress concentration in case of instrumentation.

Video-laparoscopic transperitoneal ventral fusion of the lumbar spine using the Bagby-and-Kuslich (BAK) interbody fusion system combines the advantages of the conventional transperitoneal approach with the well-known advantages of minimally invasive surgery. According to our experience it is a safe procedure with an acceptable operating time, little postoperative pain, fast recovery and a short postoperative stay in hospital. Long term results need to be observed and further studies made.

The implantation of fixation devices increases the primary stability after surgery significantly. Little is known about the comparison of flexibility of instrumented and posterolateral fusions or the lumbosacral distractions spondylodesis (LSDS). The purpose of the study was to compare the flexibility of instrumented and posterolateral fusions or LSDS after simulation with polymethylmethacrylate (PMMA). Dynamic testing from 0-16 Nm in flexion/compression and 0-900 N in compression was performed on 14 lumbosacral spines. The spines were tested intact, after laminectomy, instrumentation with an internal fixateur L5-S1, and simulation of posterolateral fusion L4-S1 or LSDS and thereafter a pseudoarthrosis was simulated. The laminectomy resulted in a significant increase of flexibility and posterior distraction in flexion and compression. The stabilization with an internal fixateur or PMMA simulation for posterolateral fusion or LSDS resulted in a significant decrease of the flexibility. Creation of a unilateral pseudoarthrosis did not effect the flexibility. The instrumented fusion as well as the PMMA simulated bony posterolateral fusion and LSDS resulted in this model in a significant stabilization of the laminectomy. After unilateral fusion the flexibility was not significantly increased.

Synovial tissue from 37 patients suffering from osteoarthritis, chondrocalcinosis, active and inactive rheumatoid arthritis was investigated. The tissue was obtained during knee surgery and immediately incubated in tyrode solution. PGE2, 6-keto-PGF1 alpha, LTB4 and LTC4 were measured by radioimmunoassay. Calcium ionophore A 23187 stimulated the eicosanoid release significantly. This effect was more pronounced with LT than with PG. In the four different joint diseases there was no significant difference in the PG release. The LTC4 release was significantly lower in inactive rheumatoid arthritis as compared to the other joint diseases. For LTB4 this effect was significant only when compared to osteoarthritis. Indomethacin 10(-5) and 10(-7)mol/l inhibited the PG release from synovial tissue in all joint diseases significantly (p less than 0.05), there was no significant effect on the LT release. LT as well as PG are pro-inflammatory mediators. Non-steroidal anti-inflammatory drugs inhibit only the PG release. The remaining LT synthesis might thus be partially responsible for the lack of efficacy of these drugs in some patients.

The in vitro effect of nucleus pulposus removal from human lumbar FSU's was investigated in a special test apparatus. Instability was determined by ROM, loss of disc height and displacement of the center of rotation. Disc height showed a decrease of 3.2 mm under axial load (700N). ROM increased up to 70%. The center of rotation demonstrated a distinct displacement in extension and lateral bending.

The effect of sodium chloride solution on disc tissue was investigated in vitro. Tissue material was obtained from 19 discectomies. The specimens were incubated in aqua ad injectionem and in different sodium chloride solutions and weighted regularly during a maximum of 24 hours. Following the incubation periods the specimens were examined histologically. After one hour the surgical specimens showed a weight increase of 290% for aqua bidest., 170% for 0.9% NaCl and 100% for 5.85% NaCl and 10% NaCl. Disc tissue obtained from six autopsies was also examined under the same conditions. The weight increase in nucleus pulposus and anulus fibrosus tissue was less than in the disc tissue obtained from surgery. The weight increase in anulus fibrosus tissue was less than in nucleus pulposus tissue. In vitro incubation of disc tissue in a hypermolar sodium chloride solution always resulted in a weight increase. Successful therapy could not be explained by shrinkage of disc tissue treated with hypermolar sodium chloride.

Lumbosacral fusions of the L4/5 and L5/S1 segment were performed in 168 patients with a tricortical iliac crest bone graft between the spinal processes L4 and S1 and two posterolateral fusions (LSDS). At follow-up five or more years after surgery, 46 of 55 patients with prior back surgery had a solid bony fusion. Pain was reduced in 94% of the failed back patients; 61.8% were satisfied with the result. On a ten-point scale from no (0) up to unacceptable (10) pain, the degree of back-pain decreased five years after fusion from 9.1 to 4.9 points, while the leg pain was reduced from 8.5 to 4.3. During surgery and the early postoperative period four major complications occurred in 168 patients. Twice the dura was perforated and two graft luxations were seen. No deep wound infections and no nerve root lesions were seen after surgery. The average blood loss was substituted by 2.4 erythrocyte concentrates. The lumbosacral distraction spondylodesis is a fusion of the two lower lumbar segments with satisfactory clinical and radiological results and a low complication rate. In patients with a failed back syndrome the pain in most cases decreased. The fact that 38.2% of the patients are unsatisfied with the result is most likely due to the severe scar tissue following prior surgery.