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Forward displacement of the ossified portion of the vertebral rim has been observed from the lower margin of C-2 and/or C-3 vertebrae in 4 adolescents, a finding which heralds prolapse of the contiguous intervertebral disc. Healing occurs with osteophyte formation at the site of injury. No late clinical or neurologic sequelae have been observed. Posterior displacement of the ossified posterior vertebral rim occurred from the inferior margin of L-4 in 2 adolescents. Prolapse of the subjacent disc with the vertebral rim was demonstrated by myelography in these cases and confirmed at surgery in one.

Five years or more after automobile accidents which caused soft-tissue injuries of the neck in 146 patients who had no pre-existing cervical degenerative changes, evaluation revealed statistically significant positive correlations between poor results and the following findings shortly after injury: numbness or pain, or both, in an upper extremity; shape reversal of the cervical lordosis visible on roentgenograms; restricted motion at one interspace as shown by flexion-extension roentgenograms; need for a cervical collar for more than twelve weeks, or for home traction; and need to resume physical therapy more than once because of recurrence of symptoms. Symptomatic recovery occurred in 57 per cent of the 146 patients, while degenerative changes developed after the injury in 39 per cent. Clinical studies of patients with soft-tissue injuries of the neck have been of little help to clinicians who must make a prognosis. This study was undertaken in an effort to identify the initial or early symptoms and the physical and roentgenographic findings that are important in predicting the results in patients whose initial roentgenograms after injury show no evidence of arthritic changes, narrowing of an intervertebral disc, or spur formation.

Clinical application has proved radio-isotope myelography with gas (133Xe) a highly valuable diagnostic method. It is indicated when clinical details about the continuity of the subarachnoid space and the level of a block require greater precision. — The basic principles of employing radioactive 133Xe for radioisotope myelography are given. The method is based on determining the location of a subarachnoidally introduced bubble of radioactive gas by means of external gamma radiation registered by counters, scanning device, or gamma-camera. If the cerebrospinal canal is obstructed (tumor, arachnoidal adhesions, median intervertebral hernias, etc.) the radioactive gas is retained at the block. — We have investigated 1500 patients and have found that the method of radioisotope myelography with 133Xe will corroborate and, in a series of cases, improve the topical diagnosis. — It will also establish the presence of a block and its level along the spinal cord but will not, however, reveal the nature of the lesion. — Radioisotope myelography with radiactive gas 133Xe is simple, safe and may be recommended as a routine technique for neurological and neurosurgical clinics.

1. Passive straight-leg raising may induce pain in the back or leg or a combination of both in patients with acute lower lumbar disc lesions. Clinical, myelographic and operative observations were carried out prospectively in fifty such cases to investigate the relation of the pattern of pain on straight-leg raising to the site of the protrusion. 2. In patients with central protrusion straight-leg raising induced mainly back pain. In patients with intermediate protrusion, lying in contact with both dura and nerve root, a combination of back and leg pain predominated. Patients with lateral protrusion usually experienced only pain in the leg. This correlation was found in 80 per cent of cases. 3. Production of pain in the leg by straight-leg raising is of practical significance in lateral protrusions where myelography may be normal. 4. Pain in the back and pain in the leg on straight-leg raising may be related respectively to dural and nerve root sensitivity.

Hitchcock's original method of hypothermic subarachnoid irrigation employed both temperature and osmolarity. Spinal cooling was then abandoned in favour of intrathecal injection of normothermic hypertonic salilne. Modifications of the procedure that followed have continued to accept hyperosmolarity as the factor causing pain relief. Fifty patients were treated by a technique evolved to enhance the effect of hypothermia while avoiding the complications associated with hyperosmolar solutions. For the cases of terminal carcinoma and others considered to be poor surgical risks, the results have been quite satisfactory. For non-neoplastic painful syndromes, rapid perfusion cooling of the subarachnoid space offers an alternative therapeutic approach.

✓ Five patients with intermittent claudication due to compression of the cauda equina in the presence of lumbar spinal canal stenosis or midline intervertebral disc protrusion are described. The characteristic myelographic evidence was complete obstruction during extension of the spine and release of the block with flexion. The cause of this syndrome is considered to be intermittent bulging of the ligamentum flavum into a narrow spinal canal so as to compress the cauda equina during extension of the back.

A case of spinal compression by herniation of the thoracic disc Th7–8 is described and the differential diagnosis discussed. The importance of air myelography in the diagnosis of these lesions is stressed. In the surgical treatment a comparatively less radical proceeding is considered advisable.

After a short outline of the clinical and diagnostic features and the indications for operation of those cervical syndromes which are due to disc pathology the authors describe the operative procedure and the operation results in 212 personal cases.

1. A conservative regimen which includes manipulative treatment of lower lumbar intervertebral disc syndrome under anaesthesia eventuates in a sufficiently high percentage of satisfactory results to warrant its use as an essential part of conservative therapy. 2. Treatment by manipulation should be given precedence over surgical intervention, except in those cases in which there is a definite contra-indication. 3. Satisfactory results, if obtainable, are to be expected after one or, at the most, two manipulations; repeated manipulation is not justified. Successful treatment is predicated upon a prompt loss of sciatic pain. 4. Failure to respond to an organized regimen of conservative treatment, including manipulation under anaesthesia, warrants the recommendation for prompt surgical intervention, provided the incapacity is sufficiently pronounced. 5. A certain percentage of cases are not amenable to manipulation, but premanipulation differentiation is impossible in the light of our present knowledge. 6. This series reveals a higher percentage of complete symptomatic relief following manipulation and its accompanying regimen than that following surgery, with a lesser amount of permanent disability in those cases in which residual disability persists. 7. Substantiating the premise that disc herniation is on the basis of disc disease, 23 per cent. of the patients in this series showed demonstrable roentgenographic disc changes prior to the beginning of treatment. 8. The apparent discrepancies in end results between the private and the industrial patient can be explained by the monetary factor and the larger percentage of the latter patients engaged in heavy labor.

In terms of man-hours of lost productivity, the lumbar disk syndrome remains as one of man's more disabling disorders. Improved diagnostic and surgical technics permit a more optimistic attitude toward treatment. The basic decision in treatment is whether to operate. At the Mayo Clinic the percentage of patients in whom grafting is combined with disk excision has risen gradually and is now almost 50 percent.

We have reported three cases of iatrogenic lumbar meningocoeles after surgery for herniated lumbar intervertebral discs. We reject the term spurious, pseudo, or false as given by earlier writers. We feel that, in reality, these sacs are true meningocoeles, with complete arachnoidal lining and freely communicating with the intraspinal subarachnoid space. We have also given a brief outline of the clinical features, elucidated the mechanisms operative in the production of symptoms, and suggested the cardinal features of radiographic diagnosis. Prevention is, of course, the best way to avoid this complication. If a dural tear does occur, every effort should be made to suture it in a watertight manner.

Summary An instance of a protruded disc in a child 3 years of age is reported. Recovery following surgical removal was complete, after conservative measures had failed. The literature on disc disorders in children is briefly reviewed.

Background: Lumbar disc surgery has come a long way since its first description by Dandy in 1929. Evolving through the transdural approach and a laminectomy for the removal of a disc, it now surpasses the primal technique with essentially a minimally invasive procedure, an extradural approach without laminectomy. Objective: The objective of this study is to ascertain the effectiveness of Minimally Invasive Open Lumbar Discectomy in the treatment of lumbar disc prolapse. Materials and methods: It is a descriptive study entailing the patients with paramedian or central disc prolapse at single or two consecutive lumbosacral levels undergoing surgery at the National Institute of Neurological and Allied Sciences, Bansbari, Nepal, over a period of one and a half years. Patients who underwent either laminectomy or bilateral fenestration were excluded. Results of surgery were measured prospectively in terms of primary outcome measure (outcome at six months follow up as measured with Prolo Functional and Economic Scale) and secondary outcome measures (radicular pain relief, mobilisation, complication, and residual disc). Results: In the series of 137 consecutive patients, 120 fulfilled the criteria. 98.33 % of patients had an improvement in the radicular pain and ambulation was commenced from the first post-operative day. There were three instances of inadvertent dural tear without fascicle injury, and one instance of residual disc requiring reoperation. At 6 months, 97.5 % had good to excellent (grade 4, or 5) results reaching the premorbid states in the Prolo Functional and Economic Scale. Conclusion: The results of Minimally Invasive Open Lumbar Discectomy compare favourably with those of a microlumbar discectomy, and could therefore be an alternative to the latter in resource deprived circumstances. Key words: Disc prolapse; Minimally Invasive Open Lumbar Discectomy; Microlumbar Discectomy DOI: 10.3126/kumj.v7i3.2724 Kathmandu University Medical Journal (2009) Vol.7, No.3 Issue 27, 204-208

A fatal case of fibrocartilaginous embolization with massive infarction of the upper spinal cord and lower medulla oblongata is reported. Cartilage from intervertebral discs is believed to cause such emboli, probably first by intrusion into vertebral bodies (Schmorl's nodes) followed by retrograde venous transport from the bone marrow to the spinal veins. This route can be outlined by injecting India ink in the cancellous bone of vertebral bodies. Access of the emboli to arteries can be explained by postulating the existence of arteriovenous shunts in the normal spinal vasculature or by trauma-induced communications between the vascular beds. In our case, the 7th reported in the literature, the majority of occluding cartilaginous emboli were in small arteries and arterioles and the resulting infarcts were of the ischemic rather than the hemorrhagic type.

T HE diagnosis and treatment of lumbar disc protrusions are usually straightforward and effective. In some patients, however, an accurate diagnosis cannot be made. Exploratory surgery may be performed in an effort to find and to remove the offending disc. If this fails, the patient becomes even more uncomfortable. Surgery should aim to preserve the integrity of normal tissue whenever possible and, therefore, should be therapeutic rather than diagnostic. We have tried discography as an adjunct to myelography in order to clarify the diagnosis in those patients suspected of harboring disc protrusions but whose myelograms were normal or equivocal. We also wished, in a specific series, to compare the accuracy of discography with that of myelography.

(1956). Asymptomatic intervertebral disc protrusions. Acta Radiologica: Vol. 46, No. 1-2, pp. 9-27.

No abstract available.

Es wird ein eigenes Zustandsbild, klinisch-rontgenologisch herausgehoben: „Vorderes Klaffen der IVS“. Auf den vermutlichen Entstehungsmechanismus wird kurz verwiesen.

THOUGH the intervertebral disc was described by Vesalius over 400 years ago, its impor tan t role as a cause of various clinical symptoms has been recognized for only 3 decades. In 19s Stookey 17 reported a number of clinical syndromes resulting from protrusion of the cervical discs, but he and other investigators incorrectly identified these protrusions as chondromas, or neoplasms of notochordal origin. During the period from 19~7 to 193~, the investigations of Schmorl and his students in Europe, TM and those of Keyes and Compete in this country TM provided a more precise understanding of the pathophysiology of the intervertebral disc. Finally, the classic paper of Mixter and Barr in 1934,11 clearly correlated protrusion of the lumbar intervertebral disc with symptoms and signs of nerve root compression. Short ly thereafter, damage to the discs of the cervical spine was recognized as an impor tant cause of radicular symptoms in the upper extremities and operative decompression of a cervical nerve root by laminotomy became an established form of therapy for the various syndromes caused by cervical disc protrusion. However, not all neurological surgeons were satisfied with the results of this type of operative t reatment . Consequently, an anterior approach accomplishing total excision of the disc in conjunction with an interbody fusion was independently developed by several workers. 1'14 This approach immediately aroused violent controversy. In this study we review a series of 63 patients who have undergone operation utilizing this anterior approach. We will a t tempt to appraise the results objectively and critically and to determine the proper applica