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Summary: Background. Spondylodiscopathies are usually counted among the "work-related diseases" that are those chronic-degenerative diseases with multifactorial etiology where the work environment can sometimes assume the role of direct and efficient contributing cause. Low back pain is the main cause of functional limitation and absence from work in the western world, resulting in a huge individually and socially economic burden. Objective. This work was designed to provide an overview of the impact that lumbar rachipathies have on health surveillance, highlighting the correlations between the pathology severity, characterization of professional risk and issue of elegibility for the specific task. Methods. Was analyzed a case studies of lumbar rachipathies reports received by INAIL in the entire Abruzzo region in 2017, the last year available in the INAIL database at the time of data extrapolation dating back to May 2019. For each dossier were collected data extrapolated from: DVR, medical record and risk, instrumental examinations and specialist visits. The software "Epi Info" version 7 was used for the statistical analysis of the sample, provided by the CDC (Centers for Disease Control and Prevention) in Atlanta. Results. The expression of work elegibility with limitations and/or prescriptions by the phisicians is related only to clinical symptoms and not to the presence of a herniated disc on CT or MRI tests. The exposure to risk from MMH and WBV, documented in the DVR, was not found to be related to the presence of a herniated disc on instrumental examinations. There was no significant difference in the average age between workers recognized as technopathic from non-technopathic. Conclusions. Although biomechanical overload has always been considered as an important wear element of the intervertebral disc, genetic influences and constitutional factors seem to be elements more implicated in the development of hernial disc disease., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by GIMLE.)

Objectives: According to the 2010 Annual Report from INAIL (National Institute for Insurance against Accidents at Work), intervertebral disc conditions are the most commonly reported pathologies in Italy, with 9,000 cases/year. The last report published by INAIL in 2016, which covers musculoskeletal and connective tissue disorders in general, indicates 38.414 (63,75% of the total) cases reported throughout 2016 and 12.578 (63.47% of the total) confirmed cases. These numbers highlight the extent of the problem and calls attention to the importance of characterizing and classifying these cases., Methods: The spinal column itself, because it is a complex and articulated structure, can face pathologies of various origins that may lead to structural and functional deficiencies, event significant ones. This paper sought to extract data for the correct classification and management of these pathologies from greatly varied sources (scientific literature, legislative regulations, INAIL guidelines)., Results: It was revealed that, in regard to lumbar hernial conditions,it must be considered that even simple disc protrusions can lead to significant clinical events by compressing nerve structures. Other than hernial conditions, intervertebral disc pathologies are also included in what is to be considered as the target of manual lifting movements., Conclusions: As such, without evident signs of disc disease, it would seem problematic to classify the condition as having wok-related origins., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Mesotherapy is an intradermal treatment for patients with local pain. The literature describes the efficacy of mesotherapy in the treatment of musculoskeletal disorders measuring a reduction of analgesic drug intake and of healthcare spending. The aim of this study was to measure the effects of mesotherapy on pain and disability in patients with low back pain due to spondyloarthrosis.

The primary obstruction of the bladder neck is a condition which is diagnosed in many young people with symptoms of lower urinary tract, such as obstructive symptoms (difficulty in the initial phase of urination and urinary retention) and irritative symptoms (pollakiuria, dysuria and nocturia). These tests are needed for the diagnosis: uroflowmetry, urodynamics, rx urethrocystography. For the treatment are used alpha-blockers or surgery. The main diagnostic test is the urodynamic study. Even though the alpha-blockers are effective and safe drugs, sometimes the treatment is surgical. The gold standard is the transurethral incision of the prostate or bladder neck (TUIP), a technique with good results, but with some complications, including retrograde ejaculation, that is the most dangerous, and erectile dysfunction, that occurs in a lower percentage of patients. In this work was studied, in terms of forensic medicine, the case of a patient who is 35 years old and reported erectile dysfunction after an intervention of transurethral incision of the prostate or bladder neck. Although there is a limited possibility, documented in the literature, of erectile dysfunction as a result of TUIP, there is no sufficient evidence to confer the responsibility of patient's organic nature impotence to the health professional civil conduct which is directly related to the transurethral incision of the bladder neck, considering the presence of a lumbo-sacral disc disease in the patient, documented by CT two years before the surgery.

Background: In the past ten years European and Italian statistics reported a significant increase in work-related musculoskeletal disorders, which also covered the construction industry., Objectives: To verify this issue, the EPM Research Unit, in collaboration with the Small Craft Industries Territorial Joint Committee in Bergamo (CPTA), undertook a research project on muscular-skeletal disorders with special reference to the lumbar spine and upper limbs., Methods: The health survey was carried out by an ad hoc trained staff, Results: Between November 2009 and July 2010, data on 2247 subjects doing a variety of jobs were obtained, more than 50% of whom were masons. The entire sample and the group of masons were investigated and both exhibited a prevalence of upper limb disorders that was definitely higher than in the reference group of non-exposed subjects. Regarding the lumbar spine, the most significant evidence was the high prevalence of degenerative diseases (herniated disc), while subjective disorders appeared to be lower than in the reference groups. These data are influenced by the healthy worker effect, which is extremely marked in this industrial sector, as well as by the economic crisis that led to many workers having to leave., Conclusions: Active research needs to be included in the protocol of health surveillance (with appropriate clinical protocol), of upper limb and spinal MSDs. The data also highlight the need for biomechanical overload exposure data aimed at reconstructing risk profiles (from biomechanical overload)for each job and at simplifying risk assessment requirements according to present legislation but above all at identifying the technological and organizational solutions to eliminate this particular risk.

Transfusion program and chelating therapy treatment has extended the life expectancy of thalassaemic patient; osteoporosis is considered an important cause of morbidity in adult patients who display increased fracture risk. This is a case report is about a thalassaemic young female with multiple spine fractures (D11, D12 e L2) and lumbar spine DEXA - T score = -3,1 and femoral = -3,4. This was in spite of therapy with alendronate 70 mg/week from January 2006 to September 2007. The patient was subsequentently treated for 18 months with 1-34 recombinant human parathyroid hormone and colecalciferol (100.000 U/monthly). After 4 months of therapy, the patient showed a decrease in spinal pain (Roland and Morris Disability Questionnaire) and an improvement of quality of life (Qualeffo) with normalization of osteocalcin and 25-OHcolecalciferol haematic levels after 6 months. Lumbar spine and femoral DEXA - Tscore, at 18 months, rose respectively to -2,5 and -2,4. Thalassaemia-induced osteoporosis is multifactorial and its management is very difficult. Bone marrow expansion, endocrine dysfunction, iron overload and genetic factors all seem to play important roles in the development of low bone mass in these patients. Bisphosfonates have been used in the management of thalassemia induced osteoporosis but there is no data about fracture risk. Anabolic therapy for thalassemic patients requests additional study on a large scale.

Purpose: Psoas abscesses are the most frequent complication of tuberculosis with skeletal involvement. The aim of this paper is to report our experience with the systematic application of percutaneous drainage to tuberculous psoas abscesses., Materials and Methods: Between January 1997 and December 2005, 23 patients (14 men and nine women; age range 21-48 years), after a previous study with computed tomography (CT) and/or magnetic resonance (MR) imaging, underwent percutaneous drainage of a tuberculous fluid collection in the psoas muscles. Follow-up consisted of monthly clinical and laboratory assessment, and plain chest radiography and spinal CT every 6-12 months., Results: Spondylodiscitis involved the thoracolumbar spine. Fluid collections were bilateral in 14 cases and communicating in ten of these. Maximum transverse diameter was 7 cm, whereas longitudinal diameter was 14 cm. Placement of the drainage catheter was successful in all cases, and the catheter was left in place for 5-36 (mean 18.4) days. Symptom regression occurred immediately after drainage of the fluid collection. The drainage procedure was curative in 100% of cases. Dislodgement of the drainage catheter occurred in two cases as a result of excessive traction during dressing removal., Conclusions: A serious complication of bone tuberculosis, psoas abscesses, can be effectively treated by percutaneous drainage, leading to immediate pain resolution. The drainage catheter requires daily monitoring to identify when it can be safely removed without risk of recurrence.

Purpose: This study was done to assess the presence of both asymptomatic and symptomatic intervertebral disc calcifications in a large paediatric population., Materials and Methods: We retrospectively reviewed the radiographs taken during the past 26 years in children (age 0-18 years) undergoing imaging of the spine or of other body segments in which the spine was adequately depicted, to determine possible intervertebral disc calcifications. The following clinical evaluation was extrapolated from the patients' charts: presence of spinal symptoms, history of trauma, suspected or clinically evident scoliosis, suspected or clinically evident syndromes, bone dysplasias, and pre- or postoperative chest or abdominal X-rays., Results: We detected intervertebral disc calcifications in six patients only. Five calcifications were asymptomatic (one newborn baby with Patau syndrome; three patients studied to rule out scoliosis, hypochondroplasia and syndromic traits; one for dyspnoea due to sunflower seeds inhalation). Only one was symptomatic, with acute neck pain. Calcifications varied in number from one in one patient to two to five in the others., Conclusions: Apart from the calcification in the patient with cervical pain, all calcifications were asymptomatic and constituted an incidental finding (particularly those detected at the thoracic level in the patient studied for sunflower-seed inhalation). Calcification shapes were either linear or round. Our series confirms that intervertebral disc calcifications are a rare finding in childhood and should not be a source of concern: symptomatic calcifications tend to regress spontaneously within a short time with or without therapy and immobilisation, whereas asymptomatic calcifications may last for years but disappear before the age of 20 years. Only very few cases, such as those of medullary compression or severe dysphagia due to anterior herniation of cervical discs, may require surgical procedures.

Aims: Mud-bath treatment has a relevant therapeutic activity in reducing symptoms and disabilities in rheumatic diseases, as studies on inflammation process and clinical symptomatology have shown. Objective of this study is to evaluate the efficacy of mud therapy by natural limans of Cervia on clinical parameters in patients with lumbar spine osteoarthrosis (OA)., Materials and Methods: 30 patients (20 females and 10 males) suffering from lumbar OA, diagnosed by clinical symptoms and X-Ray findings (osteophytosis, morphological changes of vertrebral somes, tightness of intervertebral spaces, alterated lumbar physiologic lordosis) were studied. All patients were examined first when recruited (T0) and after two weeks of therapy (T1). Interviews were submitted in order to estimate functional restrictions and pain. Statistical analysis was performed via t test for paired data., Results: On the basis of the statistical analysis a very significant difference was demonstrated between the average values of the tests before and after the treatment. These results confirm the improvement of the symptoms concerning the pain, the articular functionality and the quality of life., Conclusions: The results of the study demonstrate the efficacy of the mud-bath treatment with natural limans of Cervia on the patients affected by lumbar spine osteoarthrosis (OA).

Batson's epidural venous plexus plays a crucial role for the generation of vascular back pain, in particular in those conditions characterized by venous congestion, such as heart failure or pregnancy. Except some rudimentary cuspids, the vertebral venous system is considered to be a valveless anastomotic system; as a result the blood is supposed to flow in either direction depending on changes of cardiovascular conditions during the day. Within the narrow boundaries of the neural canal, the epidural veins can therefore get congested, inducing low back pain. The aim of this case report was to highlight a correlation between lumbar superficial veins in patients with chronic low back pain and epidural deep venous plexus congestion. The patients selected underwent a morphologic examination of venous epidural plexus (included its connections with lumbar superficial blood vessels) through a 3D dynamic contrast-enhanced Magnetic Resonance Angiography. The Authors found two different radiological behaviours: total and partial congestion of the vertebral deep venous system. Clinical consequences were discussed and therapeutic strategies were suggested.

Purpose: This paper describes discolysis by intradiscal, periganglionic and periradicular oxygen-ozone (O(2)-O(3)) injection, a minimally invasive percutaneous technique for the treatment of lumbar disk herniation., Materials and Methods: From June 2000 to December 2006, we performed O(2)-O(3) chemonucleolysis procedures in 2,900 patients affected by lumbar disk herniation. Patients were selected on the basis of clinical, psychological, neurological and neuroradiological criteria. Exclusion criteria were extruded hernia and/or free disc fragments, hyperalgesic-paralysing sciatica and progressive neurological impairment of the affected limb. All percutaneous treatments were performed under computed tomography (CT) guidance. All patients were evaluated after 1 month, and those showing only partial success were scheduled for a second treatment session., Results: Results were evaluated with the modified MacNab classification, the visual analogue scale and the Oswestry Disability Index at 6 and 12 months. Success rates were 75%-80% for soft disc herniation, 70% for multiple-disc herniations and 55% for failed back surgery syndrome. None of the patients suffered early or late neurological or infectious complications., Conclusions: According to our data, minimally invasive percutaneous treatment by intradiscal, periradicular or periganglionic O(2)-O(3) infiltration is a valuable and competitive technique that provides excellent results at low cost and without complications.

Spondylodiscitis is an infection of the intervertebral disk and the adjacent vertebrae, with or without associated epidural or psoas abscesses. It is a serious disease both due to its long-term course and the possible outcomes. It is frequently caused by S. aureus and, in endemic areas, by Mycobacterium tuberculosis and Brucella spp. We describe 9 cases, from October 2004 to August 2005, all spontaneous diseases occurring in adults (mean age 64 years). The site of infection was lumbar in 7, lumbar-sacral in 1 and dorsal in 1. None were associated to sepsis. The causative bacteria were known in 6 cases (1 BK, 1 S. aureus, 4 Brucella) and unknown in 3 cases. In all cases therapy was only medical. Significant circulation in Sicily of both Mycobacterium tuberculosis and Brucella spp. make those microorganisms the most frequent agents of spondylodiscitis.

Background: Occupational health professionals must rely on the best available evidence in support of the appropriateness of diagnostic tests and preventive or clinical interventions. This study aims at comparing the decisions made in respect of health care personnel with the decisions made on the basis of the evidence and evaluating the effectiveness of these decisions., Materials and Methods: Five female nurses with back problems exposed to health risk mostly associated with patient handling and movement were considered. The diagnostic results and the interventions following the decisions made in 2002 were evaluated and compared with the medical data during the years 2004-2005. To assess health changes occurring after the intervention, an indicator of impact was used. During 2006 the health problems were reviewed by means of the multi-step evidence-based occupational health paradigm: starting from identification of the problem and search for evidence (with a new and validated search string and the database Medline) followed by evaluation of performance. Professional performance was assessed by comparing the medical decisions made in 2002 with the decision supported by the evidence., Results: All the medical decisions were in agreement with the decisions inferred from scientific evidence. Furthermore, all subjects showed an improvement in both perceived and objective health conditions after the intervention, together with increased acceptability of working conditions., Conclusion: Given that no gold standard exists and that guidelines for the management of back pain need to be assessed for their effectiveness, this study shows that the occupational health professional should be aware of the availability of up-to-date scientific evidence which can provide appropriate solutions to the commonly encountered problems. This perspective will be a challenge for professionals aware of the need to adopt practices related to the concept of quality in occupational health care.

Introduction: Vascular injuries during lumbar disc surgery vary between 1 and 5 per 10,000 disc operations and usually represent life-threatening events., Material and Methods: The authors present a case of aorto-iliac and ICY laceration during lumbar disc hernia repair, successfully treated with immediate damage control and direct suture, followed by endovascular procedure., Case Report: A 34-year-old lady was operated on for a symptomatic disc herniation at L4-L5. Shortly after this procedure, an ipovolemic shock (IV degree) suddenly occurred with an evident abdominal distension. An emergent laparotomy in the same neurosurgery OR was then performed and revealed an active haemorrhage arising fJom an expansive retroperitoneal bleeding at the level of aorto-iliac bifurcation. After a proximal and distal damage control (manual compression plus aortic clamping) aortic and caval lacerations were repaired. An abdominal packing completed the procedure, due to the concomitant coagulopathy applied. At the second surgical look, carried out 24 hours after the first procedure, no active bleeding or vascular impairment were detected but an intraoperative US examination revealed a 3.5 cm wide right iliac pseudoaneurism confirmed by angioCT scan. This pseudoaneurism was later successfully treated with a double endovascular stenting. Postoperative outcome was uneventful and the patient was then discharged 11 days after the discectomy. Follow up study at 2 years did not demonstrate significant sequels., Conclusion: Although rare, vascular injuries during lumbar disc hernia surgery, are extremely severe complications, leading to high morbidity and mortality rates. In case of massive bleeding the presence of an "intrahospital" trauma team is a crucial factor for life-saving.

To carry out the requirement of notification according to the Italian law D.M. 27/4/04 in relation to the item "Manual handling of loads made continuously during working shift" it is necessary to clarify some quantitative and chronological aspects regarding the exposure and to precise the nature of the diseases to be notified. To fulfil their choices doctors at the moment can not rely on quantitative referrings based on the evidence and wide spread accepted, but they basically have operative indications partly taken from literature and stil under validation. However, to carry out the requirement of the law and to avoid choices not based on considered criteria, we propose some operative criteria deriving from the knowledge that at the moment seems more consolidated and accepted in the occupational and previdential medicine.

Hepatocarcinoma occurs frequently throughout the world. Bone metastases are rare although incidence has increased because of progress in diagnosis and treatment. The authors report 5 cases of bone metastases and review the literature. The spine is the most frequent localization of bone metastases. Radiotherapy is the treatment of choice for this lesion. Surgery should be used to prevent and treat complications such as nerve compression and pathologic fracture, only if the coagulative pattern and the conditions of the patient allow it. The authors recommend the use of long intramedullary nailing when localization of the disease is in the femur, with prophylactic stabilization of the neck in diaphyseal metastasis.

Herniated disc patients represent a limited subset of patients with low back pain. Incidence of surgical intervention for lumbar disc pathology is 3% to 4%. The goal of surgery is to achieve neural decompression and relief neurological symptoms. Discectomy through laminotomy is the most common approach. More recently percutaneous approaches to lumbar discectomy, include the use of suction, laser and spinal endoscopy have evolved with mixed results. Microendoscopic discectomy (MED) combines endoscopic technology with the principles of microdiscectomy: open surgical principles are used through a tubular retractor using endoscopic visualization. We present our experience with MED in 149 patients who underwent this procedure. The patient population consisted of 83 men and 66 women aged 18 to 88 years. All patients had substantial relief of their radiculopathy.

It is the purpose of this study to demonstrate how in the surgical treatment of vertebral osteoid osteoma a video-aided mini-invasive method may be used as an alternative to modern percutaneous X-ray-CT-guided mini-invasive methods such as radiocoagulation, interstitial photocoagulation with laser injection. Reported here is the case of a female aged 13 years where instrumental testing showed the presence of an osteoid osteoma involving the internal surface of the lamina of L3 and spreading in the lumen of the vertebral canal. Once we established that it was impossible to carry out the aforementioned mini-invasive percutaneous treatment because of the closeness of the osteoid osteoma to the nervous structures, thus risking complications, the only procedure that could guarantee complete removal of the tumor was open aminarthrectomy. But to reduce surgical aggressiveness to a minimum, we decided to proceed by means of a video-aided mini-invasive method with the purpose of limiting hospitalization and recovery time in order to obtain economically favorable results.

General surgeons are more and more frequently requested to prepare an operative exposure of the spine, in order to perform anterior maneuvers of removal and stabilization of the vertebral bodies. Since 1989 to date, in collaboration with the neurosurgical équipe of Prof. G. Cantore, Neurological Sciences Department, La Sapienza University of Rome, the Authors have collected 116 cases of vertebral diseases: among them, 48 involved the thoraco-lumbar junction of the spine (D12-L2). In this paper, Authors' aim is to state precisely the surgical technique of the anterior access to the thoraco-lumbar junction: attention has been focused on this tract of the column stating its anatomical complexity and the high invasivity of the procedures requested for its exposure. Therefore, such notes of technique have been elaborated to make safer the neurosurgical demolitive and reconstructive procedures and, most of all, to reduce the surgical trauma whenever it is possible.

The authors describe six cases of cauda equina syndrome (CES) with different clinical manifestations, etiopathogenetic causes, and degrees of disc prolapse. In three of the cases, the clinical onset was dramatic and acute, in the others it was a hemisyndrome (with acute onset in only 1 case). The site of the disc prolapse was L4-L5 in 3 patients, L3-L4 in 2 patients, and L5-S1 in 1 patient. The authors emphasize the need for the early recognition of the syndrome with a careful clinical examination and history of the patient, as well as timely treatment within 24 hours. For the sake of prevention, and particularly when the hernia is large, the authors suggest monitoring of the stability of the residual disc during surgery and postoperatively the use of a brace for at least one month.

The authors report the case of a patient aged 10 years with late diagnosis of osteoid osteoma localized in the right pedicle of L1 due to a paucisymptomatic and aspecific clinical onset, characterized only by the occurrence of left-convex wide-range scoliosis that was completely solved after surgical excision of the neoformation.

We describe a case of TBC spinal column infection complicated by vertebral abscesses in an immigrant teenager. We underline the importance of always suspecting a tubercular illness when fever has unknown origins, and when patients come from countries where TBC is still endemic. We reaffirm, for early and accurate diagnosis, the importance of abdominal echography and spinal tomography.

Synovial cysts may occasionally be localized in the facet joints of the lumbar spine. These lesions are usually secondary to interapophyseal arthritis or trauma, that may cause hypermobility of the facet joints. Given the frequent association with arthrosis, synovial cysts are more often observed at L4-L5, which represents the level of greater mobility in the lumbar spine, in subjects aged over 50 years. A rare case of synovial cyst of the posterior joint of L5-S1 associated with sacralization of L5, a congenital anomaly that determines considerable segmental mechanical stability, is described.

A retrospective clinical-pathological review of 192 lumbar intervertebral discs removed via an interlaminar approach or percutaneous nucleotomy from patients suffering from sciatic pain was carried out in order to assess if routine examination is useful. Only for a case of our series, which showed ill defined features at preoperative neuroradiologic imaging, an intraoperative pathologic examination was necessary. Immunohistochemical study was never required. A routine examination with a hematoxilin-eosin stain was sufficient also to recognize postoperative scar in patients reoperated. In conclusion we think that routine examination of the intervertebral disc is a procedure which is not expensive and useful to assess the nature of the lesion in reoperated patients and in rare cases showing unclear radiologic pattern.

The authors report their experience with short- and medium-term microdiskectomy for the treatment of lumbar disc herniation. It is based on 760 operations performed between 1985 and July 1999: expulsed hernias and those of large size with intense pain symptoms and/or neurologic deficit were treated. During the same period of time, the authors used enzymatic and percutaneous nucleolysis according to Onik for smaller hernias. The incidence of satisfactory results was high (90.1%), in agreement with the results published in the literature. There was a low incidence of complications (4.6%), and of these 2.8% had a benign spontaneous evolution; 1% was prevented during surgery, 0.5% was prevented with subsequent surgery, while only 0.2% was the cause of definitive failure. Unsatisfactory results were constituted by the sequelae of complications (1 discitis, 4 liquoral cysts, 1 error in level not diagnosed intraoperatively), stenosis of the lateral recess not diagnosed pre- or intraoperatively, and thus not treated; in 6.1% of cases there was no plausible justification. The microsurgical technique above all reduces the duration of hospitalization (5 days on the average, but with 91% of cases dismissed on day 3), and allows for a rapid return to work activity (after 63 days for patients who are not employees, but with a return after 20 days in 95% of cases).

It is the purpose of this study to evaluate the clinical and radiographic medium-term results of a series of 60 patients submitted to intersomatic lumbar fusion by posterior approach, using a system constituted by carbon wedges to be associated with bone grafts for intersomatic fusion, and by steel or titanium plates or bars used for posterior pedicle osteosynthesis. Satisfactory clinical results were obtained in 88.2% of cases and complete radiographic fusion in 91.4% of cases. Complications were generally observed in 8.3% of cases. In light of these results, we may consider intersomatic lumbar fusion by posterior approach a method that is perhaps aggressive, but effective in the treatment of severe lumbar spondylolysis. The use of carbon wedges brings several advantages that favor intersomatic fusion, its progressive control, and the restoration of normal lordosis of the lumbar spine.

The authors report a rare case of recurrence of lumbar nerve root compression caused by herniated intradiscal gas treated surgically with resolution of pain symptoms. They describe the possible causes of the formation of gaseous material reported in the literature. They believe that to avoid recurrence it is important to associated removal of the hernia with complete emptying of the disc and resection of the posterior longitudinal ligament.

Seronegative inflammatory spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, juvenile chronic arthritis and colitic arthritis. These diseases share some characteristics among which the most important is the presence of the histocompatibility antigen HLA B27; moreover the frequent overlapping of the various inflammation patterns have accounted for their classification in a single group. Diagnostic imaging can differentiate among the different forms only if the diagnostic algorithm, based on clinical history and laboratory findings is followed, considering the advantages and limitations of each method. In this respect, it should be kept in mind that the findings relative to the spine and sacroiliac joints allow to establish a definitive diagnosis.

With the advances in diagnostic and surgical procedures, for degenerative disease of the lumbar spine an aggressive therapeutic approach is more frequently indicated. The available surgical procedures are numerous and in continuing evolution. Most common surgical procedures used in major degenerative disease of the lumbar spine as disk herniation and stenosis are described. Indications, results and complications associated to these procedures are also illustrated.

The case of presented of an obese 42 year-old female patient, undergoing a second spinal cord decompression for a large dorsolumbar fibrous-scar mass, having a small-bore Montgomery tracheal stent (T-tube) on site. Stent replacement with a tracheotomy tube was impossible because of strong accretions hindering stent removal, as well as insertion of a suitable tracheal tube through the external stent branch, because of its very small lumen. So, general anaesthesia was not administered and surgery was performed under continuous epidural block, with light sedation, using two catheters introduced up and down the compression. Surgical and anaesthetic outcomes were optimal and confirm the effectiveness and safety of epidural anaesthesia for dorsolumbar spinal surgery, even in the obese patient. Moreover, with the continuous double-catheter technique it was possible to achieve a good and homogeneous spread of the analgesic solution, with low volume, despite the hard compression and deformation of the epidural space due to the fibrous-scar mass.

The authors report a case of an 81-year-old woman affected by a synovial cyst arising from the left facet joint of L3. The patient presented with severe pain and claudicatio spinalis. Diagnosis was based upon standard x-rays and MRI; the patient was operated on and the histology of the lesion confirmed the pre-operative diagnosis. On MRI images the lesion appeared as a roundish extradural mass arising from the left facet joint of L3, compressing the cauda equina posteriorly, and it appeared with an increased heterogeneous signal, consistent with a high quantity of fluid and hemosiderin within the cyst. A communication between the lesion and the joint space was evident on the MRI sagittal reconstruction. Grossly the cut surface of the mass had a cystic aspect, with some hemorrhagic areas between whitish myxoid tissue. Histologically the lesion was formed by fibrous connective tissue covered by synovium; focal inflammation and hemosiderin-laden macrophages were also present in some areas. At one year follow-up the patient is symptom-free.

Although the clinical picture of discogenic sciatica is well known already in the ancient world, it is not until 1933 that WJ Mixter and JS Barr provide the correct pathogenetic interpretation and suggest surgery as the treatment of choice. The work of the American Authors was however based on the knowledge acquired during the previous centuries starting with Domenico Cotugno, who first suggested the neurogenic nature of sciatica (1764) and later with the neurologists of the french school Valleix, Lasègue, Dejerine, Sicard who elucidated the semeiology and debated in detail the etiopathogenesis of the condition. The german pathologists Schmorl and Andrae (1927-29) are to be credited for their contribution to the pathology of intervertebral disc, recognizing the frequency and degenerative (not neoplastic) nature of nucleus pulposus herniation. Surgery of disc herniation starts with Oppenheim and Krause (1909). Mixter and Barr used laminectomy and a transdural route although a more limited approach to the spinal canal had already been proposed by the italian Bonomo (1902), unknown to many. Love, of the Mayo Clinic (1937-39) introduced the extradural/interlaminar approach while Caspar and Yasargil (1977) applied the concepts of microsurgery to the procedure. The latest advances are represented by percutaneous and endoscopic techniques.

Instability of the spine consequent to the diffusion of a primary tumor is a serious complication in cancer patients. The experience of our Service in the surgical treatment of vertebral metastases is reported. Since 1990, 21 patients have undergone surgery. The vertebral metastases were localized at the cervical level in 4 cases, thoracic in 13, and lumbar in 4. Pain was the first symptom in 18 patients. The necessary criterion for intervention was intractable severe pain and/or neurologic deficit. At the thoracic and lumbar levels (17 cases) a posterior approach was always used to perform wide decompressive laminectomy and to stabilize the spine. An anterior approach is unadvisable in light of the risk related to the operation and the long recovery time. In 13 cases Cotrel-Dubousset bars were utilized, in 3 cases Roy-Camille, and in 1 case Louis plates. After surgery, significant pain relief was noted in 85% of patients. Of those with neurologic deficit, improvement in neurologic status was seen in 50%; in 28% neurologic deficit was completely resolved. We conclude that, although palliative, wide laminectomy accompanied by stabilization is a satisfactory treatment of vertebral metastases. Given the appropriate indications, surgical treatment improves the patient's quality of life.

After brief notes on techniques used to radiate the spine, its indications and the limits of doses required by its adjacency to the spinal cord, our experience in the treatment of 28 patients with a diagnosis of Ewing's sarcoma localized in the spine, not metastatic at onset, that came to our observation between 1980 and 1994 is reported. All of the patients were treated by chemotherapy. As for local treatment radiotherapy was performed in all of the cases, in 50% of cases it was associated with surgery (6 laminectomies, 6 excisions, and 2 vertebrectomies). Five-year survival rate was 43.5%. The prognosis of this group of patients was intermediate among forms localized in the limbs and those localized in the pelvis. There is a greater frequency of cerebral (20%) and skeletal metastases (55%) as compared to the disease that occurred in other sites where secondary pulmonary localizations generally prevailed. Local control was similar for disease occurring in other sites despite the need to deliver doses that were lower than those typically used for this pathology in regions above the cauda.

It is the purpose of this study to report our new surgical technique and the outcome of total en bloc spondylectomy (TES) to resect the primary spinal tumor as a whole in order to ensure oncological curability. TES consisting of en bloc laminectomy and en bloc corporectomy was performed on 7 patients with primary vertebral tumors between 1989 and 1993. There were 2 osteosarcomas, 1 malignant fibrous histiocytoma, 1 chondrosarcoma, 1 undifferentiated sarcoma, 1 solitary plasmocytoma, and 1 giant cell tumor. All of the patients had partial or complete pain relief after TES. None of the patients worsened neurologically after surgery and there was no local recurrence following TES, except for 1 patient who died 3 months postsurgery as a result of a tumor developing in the mediastinum. The advantage of TES is en bloc resection of the affected vertebrae by marginal or wide margin, not piecemeal pattern. This new surgical technique offers the most radical therapy of primary malignant tumors.

In metastatic breast cancer the goal to reach must be the best possible palliation with minimum discomfort for the patient. We reviewed our experience with radiotherapy (20 or 30 Gy), systemic therapy and brace. Among 2200 breast cancer patients, we extracted 28 potential candidates for resection. All of them developed new metastases outside the treated field within one year. Local control was achieved in 68%, and 80% of them had stable or better performance status at 3 months. From our analysis, even patients with a so called "solitary lesion" do not seem to have a better prognosis than others. We conclude that radiotherapy (with systemic therapy and a brace) is still first-choice treatment for vertebral metastases; CT-guided percutaneous biopsy can avoid worthless major operations. The role of surgery should be limited to neurological compression, severe mechanical instability and to salvage the failures of conservative treatment.

Brucellosis may show itself only through its bone and muscle complications, especially in the lumbar region, such as vertebral colliquation or psoas abscess. The authors describe a case of brucellosis (56 year old male, butcher) with lumbar bone and muscle involvement. The first symptom was a persistent pain of the right lumbar region, with irradiation to the homolateral leg. At admission the patient showed a lumbar cutaneous fistula with pus-like secretion. Quick diagnosis and therapy can prevent irreparable damage, even when the symptoms are silent.

The application of CT and MR techniques for the evaluation of degenerative disease of lumbar disk is illustrated in this work. A critical review of the literature was done.