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Purpose of Review: To discuss the challenges to early diagnosis of axial spondyloarthritis (axSpA) and present the impact an early inflammatory back pain service (EIBPS) had on diagnostic delay in the UK., Recent Findings: Diagnostic delay in axSpA varies greatly worldwide, and has continued in the UK at an average of 8.5 years. Education, public awareness, and accessibility to inflammatory back pain (IBP) pathways are some of the key barriers to achieving a prompt diagnosis. A recent national inquiry has highlighted insufficiencies in the availability of specialist axSpA services and limited provision of education and training to first contact practitioners and allied healthcare providers. We demonstrate diagnostic delay in axSpA can be successfully reduced to 3 years when an early inflammatory back pain service is embedded within a rheumatology department alongside a local educational and awareness campaign. Sharing these experiences and outcomes will enable other departments to engage in best practice and achieve similar results, facilitating a timely and accurate diagnosis.

Background/aim: Stem cells are widely used in regenerative medicine and in clinical practice for the treatment of damaged nerve tissue, myocytes, tendons, and ligaments. The aim of the study was to monitor VEGF levels after the administration of allogenic cellular material (SVF) in the course of treatment of dogs suffering from degenerative joint disease in the spinal region., Materials and Methods: The study was conducted on 10 dogs of both genders, aged between 6 and 13 years in which allogenic stromal vascular fraction of stem cells (SVF) was administered intravenously. The control group was composed of 10 clinically healthy dogs. Before treatment and after 2- and 8-week intervals blood samples were obtained from the study group dogs in order to determine VEGF levels via immunoenzymatic test., Results: in a few days after the therapy, alleviation of pain symptoms and reduction of lameness were noticed. The VEGF level in 2 weeks after the therapy was significantly elevated (median: 38.77 pg/ml), while in 8 weeks a decrease was observed (median: 18.37 pg/ml). Conlusion: Administration of allogenic stem cells has a positive influence on elevation of the VEGF levels in the blood serum of affected animals as well as their regeneration capacity., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Chronic low back pain (cLBP) affects millions of Americans and costs billions. Studies suggest a link between cLBP and joint hypermobility., Methods: We conducted cross-sectional primary analyses of joint hypermobility and cLBP, lumbar spine osteoarthritis (OA), and lumbar facet joint OA (FOA) in 3 large studies-the Generalized Osteoarthritis Study, Genetics of Generalized Osteoarthritis Study, and Johnston County Osteoarthritis Project (total n = 5072). Associations of joint hypermobility and Beighton trunk flexion with cLBP and lumbar OA were estimated using separate adjusted logistic regression models. Adjusted pooled odds ratios (pORs) and 95% confidence intervals (CIs) were then summarized-using random effect univariate, multivariate crude, and adjusted models-and heterogeneity was determined (I 2 statistic)., Results: In univariate models, hypermobility was associated with symptomatic FOA (pOR = 0.64 [95% CI 0.44, 0.93]) but this result was not found in the multivariate models. In multivariate adjusted models, hypermobility was not significantly associated with cLBP and lumbar OA, but trunk flexion was inversely associated with cLBP (pOR = 0.40 [95% 0.26, 0.62]), spine OA (pOR = 0.66 [95% CI 0.50, 0.87]), symptomatic spine OA (pOR = 0.39 [95% CI 0.28, 0.53]), and symptomatic FOA (pOR = 0.53 [95% CI 0.37, 0.77]). Generally, between-study heterogeneity was moderate-high., Conclusions: Hypermobility was not associated with cLBP or lumbar OA. The inverse association of trunk flexion with cLBP and lumbar OA may indicate a role for a flexible spine in avoiding or managing these conditions.

Purpose: The aim of this study was to evaluate the effectiveness of PNF and manual therapy methods in the treatment of patients with cervical spine osteoarthritis, especially their efficacy in reducing pain and improving functionality in everyday life. Long-term results were also compared in order to determine which method of treatment is more effective., Subjects and Methods: Eighty randomly selected females aged 45-65 were included in the study. They were randomly divided into two groups of 40 persons. One group received PNF treatment and the other received manual therapy (MAN.T). To evaluate functional capabilities, the Functional Rating Index was used. To evaluate changes in pain, a shortened version of the McGill Questionnaire was used., Result: The PNF group achieved a greater reduction in pain than the MAN.T group. The PNF group showed a greater improvement in performing daily activities such as sleeping, personal care, travelling, work, recreation, lifting, walking and standing as well as decreased intensity and frequency of pain compared to the MAN.T group., Conclusion: The PNF method proved to be more effective in both short (after two weeks) and long (after three months) term.

We report a case of Bartonella henselae, an agent of cat scratch disease, C1-C2 osteoarthritis with osteolysis of the lateral mass of C2 in a 14-year-old boy. Oral antibiotics did not successfully treat the infection and surgery was necessary to treat the septic arthritis. The case opens discussion about bacterial osteoarthritis of the cervical spine and bone involvement in disseminated bartonellosis., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: We aimed to evaluate interobserver agreement in the definition of spine instability among spine neuroradiologists with or without experience in dynamic magnetic resonance imaging (MRI)., Material and Methods: Two expert neuroradiologists and two residents retrospectively evaluated the pre-operative dynamic MRI examinations of patients with vertebral instability. Segmental motion, defined as excessive (more than 3 mm) translational motion from supine to upright, was investigated in 103 subjects (309 segments) using kinetic MRI. Radiographic parameters which can help indicate segmental instability include disc degeneration, facet joint osteoarthritis, and ligament flavum hypertrophy. These three radiographic parameters were simultaneously evaluated, and the combinations corresponding to significant segmental instability at each level were determined. The agreement among the neuroradiologists was calculated using the kappa coefficient. All patients had neurosurgical intervention to stabilize the spine., Results: Agreement was high among experienced and non-experienced neuroradiologists. Agreement was nearly perfect for spinal location of spinal instability., Conclusions: This study demonstrates that the experience of the evaluator has a low impact on the assessment of spinal instability if correct classification is used. The interobserver agreement confirms the usefulness and safety of kinetic MRI in the correct diagnosis of spinal instability even by less experienced evaluators., (© The Author(s) 2015.)

The anatomy of the facet joint subchondral mineralized zone (SMZ) is the main parameter used in diagnosing osteoarthritis. Usually, a single CT scan slice is used to measure the thickness, but the measurement is highly location-dependent. Bone mineral density (BMD) and porosity could be more reliable than thickness for detecting SMZ sclerosis, and linking them to stiffness can provide insights into the mechanism of osteoarthritis progression. The goal of this study was two-fold: (1) to assess spatial heterogeneity in thickness, BMD, and porosity within the non-pathological human facet joint SMZ; (2) to correlate these measurements with the static modulus of elasticity (MOEsta ). Four non-pathological facet joints were excised and imaged using micro-computed tomography (µCT) to measure SMZ thickness, BMD, and porosity. A total of eight parallelepiped SMZ samples were similarly analyzed and then mechanically tested. The mean SMZ BMD, porosity, and thickness (± Standard Deviation) of the whole facet joints were 611 ± 35 mgHA/cc, 9.8 ± 1.3%, and 1.39 ± 0.41 mm, respectively. The mean BMD, porosity, and MOEsta of the eight SMZ samples were 479 ± 23 mgHA/cc, 12 ± 0.01%, and 387 ± 138 MPa, respectively, with a positive rank correlation between BMD and porosity. BMD and porosity were more homogeneous within the facet joint than thickness and they could be more reliable parameters than thickness for detecting SMZ sclerosis. The values for the physiological SMZ and MOEsta of human facets joints obtained here were independent of BMD. SMZ BMD and porosity were related to each other., (© 2015 Wiley Periodicals, Inc.)

Purpose: The present clinical-radiological study examines retrospectively the relation between lumbar disc prolapse and degenerations like chondrosis and spondylosis., Method: Firstly the relation between disc prolapse and chondrosis was examined. 44 patients with disc prolapse and chondrosis in actual MRI scans in the same segment were recruited in our clinic. By regarding older MRI scans, we could find out which finding was first to occur. Concerning the second question, we followed patients with spondylosis to see if they could progress to a disc prolapse., Results: In 67% of our cases with disc prolapse and chondrosis, a chondrosis was seen before the disc prolapse. More than a half had had a spondylosis and a chondrosis in the same segment before the herniation. Only 33% of our cases showed a prolapse before chondrosis., Conclusion: Concerning patients with disc prolapse and chondrosis in the same segment, chondrosis was seen before the herniation in most cases. Also patients with spondylosis progress to a herniation. A causal relation between both radiological findings is not possible. In a future study it must be analysed with statistical tests whether these results are generally valid., (Georg Thieme Verlag KG Stuttgart · New York.)

We report 2 cases of acute, progressive myelopathy after a fall in elderly patients who had a retroodontoid pseudotumour and extensive ossification of the anterior longitudinal ligament.

Objectives: To examine the relationship between serum biomarkers and self-reported pain intensity and pain-related function, in addition to the contribution of magnetic resonance imaging (MRI) findings of lumbar spine degenerative changes, in older adults with chronic low back pain., Design: Single-center cross-sectional cohort study., Setting: Academic medical center., Participants: Individuals aged 60 and older with axial low back pain without radiculopathy or previously diagnosed osteoarthritis of the knee or hip or pain outside the low back that is more severe than the back pain (n = 43)., Measurements: To examine pain-related impairment, pain was measured on a pain thermometer and the McGill Pain Questionnaire Short Form was administered. To examine pain-related function or activity limitation, the Roland Morris Disability Questionnaire, Short Physical Performance Battery (SPPB), and repetitive trunk rotation were used. Single plasma samples were obtained before and after physical performance tests and analyzed for inflammatory markers (E-selectin and regulated on activation, normal T cell expressed and secreted (RANTES)), inhibitors of catabolic enzymes (tissue inhibitor of metalloproteinases-1 (TIMP-1)), markers of matrix turnover (C- telopeptide of type II collagen (CTX-II) and aggrecan chondroitin sulfate 846 (CS846)), and stress biomarkers (neuropeptide Y (NPY)). Conventional nongadolinium lumbar MRI was performed and analyzed quantitatively and clinically., Results: Composite MRI measurements did not show significant correlation with pain or pain-related function. Basal levels and changes in serum biomarkers in response to activity, particularly NPY and RANTES, demonstrated associations with pain and pain-related function in addition to the explanatory power of MRI-based results., Conclusion: Serum biomarkers may be a metric for assessment of active disease in older adults, in whom imaging changes are ubiquitous. In addition, changing levels of biomarkers in response to activity suggests that they may be useful as metrics to measure treatment responses in future studies and may reflect potential targets for use in designing personalized treatment for older adults with low back pain., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objective: To investigate a cohort of professional ballet dancers for evidence of early signs of osteoarthritis (OA)., Design: One radiologist and 1 orthopedic surgeon specialized in musculoskeletal disorders analyzed magnetic resonance imaging scans independently., Setting: University Teaching Hospital., Participants: Fifteen professional ballet dancers (4 males and 11 females; age range, 19-36 years) experiencing chronic pain in the hip, knee, spine, ankle, or foot joints., Main Outcome Measures: Presence of osteophytes, subchondral sclerosis, joint space narrowing, cysts, and bone marrow changes; the Kellgren and Lawrence scale was used to quantify the knee OA., Results: In the knee, there was thinning and irregularity of the articular cartilage over the medial femoral condyle and bone marrow changes within the lateral femoral condyle. In the hip, there was a loss of joint space and a frayed labrum with deep recess. The first metatarsophalangeal joint showed evidence of osteophytic development., Conclusions: Early signs of OA, in different joints, were present in a small but highly selected cohort of professional ballet dancers. In future, prospective studies among a number of ballet companies should control for medical and natural history alongside the visual analysis of images and plain radiographs to confirm these preliminary results.

Study Design: A population-based study., Objective: To study the prevalence and features of symptomatic degenerative lumbar osteoarthritis in adults., Summary of Background Data: Lumbar osteoarthritis adversely affects individuals and is a heavy burden. There are limited data on the prevalence of lumbar osteoarthritis., Methods: A representative, multistage sample of adults was collected. Symptomatic degenerative lumbar osteoarthritis was diagnosed by clinical symptoms, physical examinations, and imaging examinations. Personal information was obtained by face-to-face interview. Information included the place of residence, age, sex, income, type of medical insurance, education level, body mass index, habits of smoking and drinking, type of work, working posture, duration of the same working posture during the day, mode of transportation, exposure to vibration, and daily amount of sleep. Crude and adjusted prevalence was calculated. The features of populations were analyzed by multivariable logistic regression in total and subgroup populations., Results: The study included 3859 adults. The crude and adjusted prevalence of lumbar osteoarthritis was 9.02% and 8.90%, respectively. There was no significant difference in the prevalence of lumbar osteoarthritis between urban, suburban, and rural populations (7.66%, 9.97%, and 9.44%) (P = 0.100). The prevalence of lumbar osteoarthritis was higher in females (10.05%) than in males (9.1%, P = 0.021). The prevalence of lumbar osteoarthritis increased with increasing age. Obese people (body mass index >28 kg/m), those engaged in physical work, those who maintained the same work posture for 1 to 1.9 hours per day, those who were exposed to vibration during daily work, and those who got less than 7 hours of sleep per day had a higher prevalence. These features differed by subgroup., Conclusion: This study established epidemiological baseline data for degenerative lumbar osteoarthritis in adults, especially for people younger than 45 years. Lumbar osteoarthritis is epidemic in Beijing and will become a more severe problem in aging society. Different populations have different features that require targeted interventions.

Background: osteoarthrosis is a common cause of low back pain. The diagnosis is clinical and can be confirmed by imaging studies. Pain treatment and confirmation of diagnosis are made by intra-articular injection of corticosteroid and by local anesthetic use, due to clinical improvement. A direct monitoring of the procedure can be done under fluoroscopy, a classic technique, or else by an ultrasound-guided procedure., Case Report: female patient, 88 years old, 1.68 m and 72 kg, with facet osteoarthrosis at L2-L3, L3-L4 and L4-L5 for two years. On physical examination, she exhibited pain on lateralization and spinal extension. We opted in favor of an ultrasound-guided facet joint block. A midline spinal longitudinal scan was obtained, with identification of the desired joint space at L3-L4. A 25G needle was inserted into the skin by the echographic off-plane ultrasound technique. 1 mL of contrast was administered, with confirmation by fluoroscopy. After aspiration of the contrast, 1 mL of solution containing 0.25% bupivacaine hydrochloride and 10mg of methylprednisolone acetate was injected. Injections into L3-L4, L2-L3 and L1-L2 to the right were applied., Conclusions: the visualization of the facet joint by ultrasound involves minimal risk, besides reduction of radiation. This option is suitable for a large part of the population. However, fluoroscopy and computed tomography remain as monitoring techniques indicated for patients with specific characteristics, such as obesity, severe degenerative diseases and anatomical malformations, in which the ultrasound technique is still in need of further study., (Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

This article reflects the radiologist's perspective on the imaging and interpretation of axial spondylarthritis (SpA). The arthritis subcommittee of the European Society of Skeletal Radiology provides a consensus for the following questions: When and how should we image? How should we analyze the images? How should we interpret the imaging findings? To answer these questions, we address the indications in imaging axial SpA and the different imaging techniques, with a special focus on magnetic resonance imaging protocols. The value of different imaging modalities is discussed. For adequate image analysis, knowledge of the anatomy and the pathologic changes in chronic and acute inflammation of the sacroiliac joints and the spine is mandatory. Differential diagnoses of inflammatory lesions of the sacroiliac joints and the spine are addressed due to their importance in image interpretation., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The symptoms of osteoarthritis vary widely from patient to patient, depending especially on the localization on the disease. There is a poor correlation between radiological involvement and pain. In general, symptom onset is gradual and symptoms increase slowly but progressively. The most commonly affected joints are the knees, hips, hands, and spine. The main signs and symptoms are pain, stiffness, joint deformity, and crepitus. Pain is mechanical and its causes are multifactorial; in the initial phases, pain usually manifests in self-limiting episodes but may subsequently be almost constant. The criteria of the American college of Rheumatology for the classification of osteoarthritis of the knee, hip and hands are an aid to classification and standardization but are not useful for diagnosis. Hip osteoarthritis usually produces inguinal pain in the internal and anterior sections of the muscle extending to the knee and, with progression, tends to limit mobility. Knee osteoarthritis is more frequent in women and is usually associated with hand osteoarthritis and obesity. In hand osteoarthritis, the most commonly affected joints are the distal interphalangeal joints, followed by the proximal interphalangeal joints and the trapeziometacarpal joints; the development of Heberden and Bouchard nodes is common; involvement of the trapeziometacarpal joint is called rhizarthrosis and is one of the forms of osteoarthritis that produces the greatest limitation on hand function. Osteoarthritis of the spine affects the facet joints and the vertebral bodies. Other, less frequent, localizations are the foot, elbow and shoulder, which are generally secondary forms of osteoarthritis., (Copyright © 2014 Elsevier España, S.L. All rights reserved.)

Imaging of the spine is increasingly available, whether as dedicated spine examinations or as studies that include the spine in the images obtained (e.g. CT abdomen). This pictorial review discusses imaging of the spine with CT and MRI and how prior review of this imaging can be helpful with potentially difficult spinal procedures. Pathologies illustrated include osteoarthritis, scoliosis, inflammatory spondyloarthropathies and post-operative spines.

Study Design: A cohort study with 1-year follow-up., Objective: To identify prognostic factors in patients with chronic nonspecific low back pain (LBP)., Summary of Background Data: The factors (e.g., sociodemographical, low back-related, radiological, and biological) associated with persistent pain and disability for patients with chronic nonspecific LBP are uncertain. Furthermore, sparse information exists about the relationship between biological factors like impaired fasting glucose tolerance and chronic nonspecific LBP., Methods: The participants consisted of 250 patients with nonspecific LBP of more than 6 months duration and degenerative lumbar osteoarthritis. The patients were originally recruited for a randomized controlled trial from the clinics of general practitioners, physiotherapists, and chiropractors. Potential predictors were evaluated at baseline. The outcome was absolute level of pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at 1 year. The association between potential prognostic factors and the outcome was analyzed with multivariate linear backward regression., Results: At baseline and 1 year, the RMDQ scores were 9.5 and 5.1 points, respectively. Mean (SD) baseline values for body mass index (BMI), EuroQol (EQ)-index, EQ-visual analogue scale were 25.4 (4.3), 0.60 (0.3), and 61.2 (20.8), respectively. Higher pain-related disability levels (1-year RMDQ score) were associated with 6.1 mmol/L or more fasting glucose level at baseline (β, 3.7; 95% confidence interval [CI], 1.2-6.1; P = 0.00), baseline pain-related disability (β 0.2; 95% CI, 0.1-0.4; P = 0.00), BMI (β, 0.2; 95% CI, 0.1-0.3; P < 0.03), EQ-index (β, -4.5; 95% CI, 6.9 to 2.1; P = 0.00), and EQ-visual analogue scale (β, 0.3; 95% CI, -0.6 to -0.0; P = 0.03). However, a limited number of patients had 6.1 mmol/L or more of fasting glucose level at baseline (13/250 patients). The imaging findings, modic changes, and high intensity zones had no predictive ability., Conclusion: Increased pain-related disability at 1 year was seen in patients with impaired fasting glucose tolerance, greater pain-related disability, higher BMI, and lower quality of life at baseline.

Objective and Importance: Traditionally, magnetic resonance imaging (MRI) was contraindicated for patients with cochlear implants (CIs), due to concern about device displacement, overheating of the device or tissues, or direct damage to the device electrode. In addition, image artifact from the device magnet gave poor imaging information in the cranial and upper cervical spine region. Today, MRI is increasingly required in patients who have undergone cochlear implantation, and CI design and MRI protocols have therefore changed to allow implanted patients to safely enter the MRI field, in some cases without removal of the CI internal magnet., Clinical Presentation: We present a patient with bilateral CIs who required MRI to investigate new neurological symptoms. Despite tight head bandaging applied according to our protocol, MRI at 1.5 T led to bilateral skin reactions and displacement of the magnet on the left. Both magnets were subsequently removed to allow the skin reactions to settle and for further imaging without artifact. The functioning of the patient's implants was not affected., Conclusion: The final decision to recommend that a patient with a CI undergoes MRI, with or without removal of the internal magnet, requires close cooperation between the CI team, the physician requiring the scan, and the radiology team involved in the patient's care. The case study we present highlights the need for patients to be fully informed of the risks involved.

The uncommon variant of degenerative hip joint disease, termed rapidly progressive osteoarthritis, and highlighted by severe joint space loss and osteochondral disintegration, is well established. We present a similar unusual subset in the lumbar spine termed destructive discovertebral degenerative disease (DDDD) with radiological features of vertebral malalignment, severe disc resorption, and "bone sand" formation secondary to vertebral fragmentation. Co-existing metabolic bone disease is likely to promote the development of DDDD of the lumbar spine, which presents with back pain and sciatica due to nerve root compression by the "bone sand" in the epidural space. MRI and CT play a complimentary role in making the diagnosis.

Study Design: In vivo 3-dimensional facet joint space width measurement., Objective: To determine lumbar facet joint space width within clinically relevant topographical zones in vivo and its correlations with age, level, and presence of lower back pain symptoms., Summary of Background Data: Facet joint gap narrowing, articular cartilage thinning, and subarticular cortical bone hypertrophy are frequently observed age-related changes. Facet joint space width is a well-defined parameter to evaluate osteoarthritis. To the best of our knowledge, there is no other study that quantifies 3-dimensional facet joint space width distribution in vivo., Methods: Three-dimensional measurement to quantify facet joint space width distribution based on 5 clinically relevant topographic zones in a cohort of healthy and symptomatic volunteers with low back pain, using subject-based 3-dimensional computed tomographic models with respect to spinal level, subject age, sex, and presence/absence of lower back pain., Results: Facet joint space width (mean ± SD) was 1.93 ± 0.51 mm for the central zone, 1.75 ± 0.48 mm for the superior zone, 1.63 ± 0.49 mm for the inferior zone, 1.48 ± 0.44 mm for the medial zone, and 1.65 ± 0.48 mm for the lateral zone, respectively. There were no significant differences between right and left facet joints. Male patients showed larger space width than female patients. Overall, space width of symptomatic subjects was significantly narrower than that of the asymptomatic group. Facet joints in the peripheral zones were narrower than in the central zone. Age-group comparisons showed that local narrowing occurring as early as in the third decade at the inferior zone of L5-S1, with all the remaining zones implicated after the fourth decade., Conclusion: This in vivo study shows variations in facet joint space width narrowing with spinal level and region within the facet joint and in vivo evidence of localized, age-influenced facet cartilage thinning. Techniques developed in this study may be applied in the detection of early osteoarthritis-related changes in the facet joints.

Osteoarthritis of the spine develops as a consequence of the natural aging process and is associated with significant morbidity and health care expenditures. Effective diagnosis and treatment of the resultant pathologic conditions can be clinically challenging. Recent evidence has emerged to aid the investigating clinician in formulating an accurate diagnosis and in implementing a successful treatment algorithm. This article details the degenerative cascade that results in the osteoarthritic spine, reviews prevalence data for common painful spinal disorders, and discusses evidence-based treatment options for management of zygapophysial and sacroiliac joint arthrosis., (Copyright © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Purpose of the Study: Atlantoaxial osteoarthritis (AAOA) is a clinical syndrome with signs distinctly different from those of degenerative sub - axial spine disease. Its diagnosis may long be delayed, partly because of insufficient knowledge and partly due to difficulties in interpreting both anteroposterior and lateral radiographs. The aim of this prospective study was to evaluate the first 27 AAOA patients treated at our department., Material: From 2001 we performed atlantoaxial fixation with fusion in a total of 29 patients with painful arthritis of the atlanto axial complex. The 27 patients treated before the end of 2010 were enrolled in the study and analysed in detail. This group included 13 women and 14 men aged between 35 and 72 years, with an average age of 53.5 years. In all patients atlanto - axial fixation was performed using the polyaxial screw-rod system according to Harms., Methods: The patients were followed up at 6 and 12 weeks, 6 and 12 months and then once a year after surgery. X-ray examinations were done at the same intervals as clinical examinations; functional radiographs were made at 12 to 14 weeks after surgery. The definitive analysis of the group was made in the range of 4 to 59 months (average, 25.7 months) after the primary operation. Patients' subjective evaluation was based on NPDI and VAS scores and a question of whether the patient would undergo the surgery again. Objective evaluation included clinical outcomes - pain and neurological findings; radiographic results - stability and healing of C1-C2 fusion; and complications during surgery and in early and late postoperative periods. As intra-operative complications were regarded those associated with the surgical approach, nerve injury and vertebral artery injury. Early post-operative complications included poor wound healing and changes in the patient's neurological status, late complications included instrumentation failure and infection. Patients' clinical status (NPDI, VAS) was statistically evaluated using the one-way ANOVA., Results: The mean VAS score was pre-operatively 7.0 and post-operatively 5.6 at 3 months, 5.0 at 6 months, 5.1 at 1 year; 3.9 at 2 years and 4.0 at 3 years. The mean NPDI value was pre-operatively 39.6 and post-operatively 38.7 at 3 months, 36.0 at 6 months, 34.5 at 1 year, 34.3 at 2 years and 33.1 at 3 years. The question of willingness to undergo the same operation again was answered in the affirmative by 21 patients (77.8%), in the negative by five (18.5%) and one patient did not know (3.7%). Complete bone fusion, as assessed by radiography or CT scanning, was achieved in 26 out of 27 patients (96.3%). In one patient the result was ambiguous but, at 3 months as well as the next follow-ups, C1-C2 complex stability was found., Discussion: All patients in our group underwent a unified system of clinical, radiological, CT and MRI examination. In the decision-making process, emphasis was placed on a correlation of clinical findings with CT scanning results. All patients were operated on from the posterior approach using the Harms method, and radiological outcomes were similar to those of Grob et al. who used the Magerl's technique of C1-C2 fixation. The VAS and NPDI scores demonstrated significant improvement as early as 3 post-operative months, with still further improvement in the following period. The stable clinical status of the patients was achieved at 2 years after surgery. From the practical standpoint we were interested in an answer to the question of whether the patients would be willing to undergo the procedure again. Almost 80% of affirmative answers testified to the correct choice of treatment. The values found corresponded to those reported by Grob at al., Conclusions: Patients with painful osteoarthritis refractory to conservative treatment will benefit from atlantoaxial fixation and fusion. For the patient, restricted cervical rotation is acceptable in return for pain relief. From the surgical point of view, the risk of complications associated with the operative technique did not exceed a tolerable rate.

Two patients with occipital neuralgia due to severe arthropathy of the C1-2 facet joint were treated using atlantoaxial fusion with transarticular screws without decompression of the C-2 nerve root. Both patients experienced immediate postoperative relief of occipital neuralgia. The resultant motion elimination at C1-2 eradicated not only the movement-evoked pain, but also the paroxysms of true occipital neuralgia occurring at rest. A possible pathophysiological explanation for this improvement is presented in the context of the ignition theory of neuralgic pain. This represents the first report of C1-2 transarticular screw fixation for the treatment of arthropathy-associated occipital neuralgia.

Background: Many patients with degenerative joint disease of the hip have substantial degeneration of the lumbar spine. These patients may have back and lower extremity pain develop after THA and it may be difficult to determine whether the source of the pain is the hip or spine., Questions/purposes: We therefore: (1) identified the incidence/prevalence of pain in the lower back in a group of patients with end-stage arthritis of the hip undergoing THA; (2) described the natural history of low back pain in this cohort undergoing THA; and (3) determined factors that were predictive of persistent low back pain after THA., Methods: We administered a detailed questionnaire and a diagram of the human body on which the patients could draw the site of their pain, to 344 patients preoperatively, at 6 weeks, 6 months, and 1-year after THA. Before the THA, 170 patients (49.4%) reported pain localized to the lower lumbar region, whereas 174 patients did not have low back pain., Results: Low back pain was variable in location. Postoperatively, the low back pain resolved in 113 (66.4%) of the 170 patients. Thirty-seven of the remaining 57 patients had known spine disorders. Thirty-five of the 174 patients (20%) without prior low back pain had low back pain develop within 1 year postoperatively. The low back pain improved in 17 of these 35 patients; 12 of the remaining 18 patients had preexistent spine disorders. Pain radiating below the knee was associated most closely with preexisting spine disorders., Conclusions: Hip and spine arthritis often coexist. Most patients who presented with hip arthritis and lower lumbar pain experienced resolution or improvement of their pain after THA., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Aim: Lumbar spinal canal stenosis is a common disease of the elderly patient, with a high prevalence and clinical importance. MRI is the established method of choice for the imaging of spinal canal stenosis. However, there is often a discrepancy between the clinical symptoms and the spinal canal stenosis as shown using MRI in a supine position. In such cases preoperative functional imaging is often warranted., Methods: In an image gallery three cases of a functional spinal canal stenosis of the lumbar spine are shown. In all three patients a dynamic, positional MRI (upright MRI) was performed., Results: The pathomechanisms of the spinal canal stenosis could be shown in all three cases., Conclusion: Using upright MRI a functional spinal canal stenosis can be shown. The pathomechanisms of the spinal canal stenosis are discussed. The possibilities and limitations of this new imaging modality are presented and analysed.

Purpose: To characterize the inter- and intraobserver variability of qualitative, non-disk contour degenerative findings of the lumbar spine at magnetic resonance (MR) imaging., Materials and Methods: The case accrual method used to perform this institutional review board-approved, HIPAA-compliant retrospective study was the random selection of 111 interpretable MR examination cases of subjects from the Spine Patient Outcomes Research Trial. The subjects were aged 18-87 years (mean, 53 years +/- 16 [standard deviation]). Four independent readers rated the cases according to defined criteria. A subsample of 40 MR examination cases was selected for reevaluation at least 1 month later. The following findings were assessed: spondylolisthesis, disk degeneration, marrow endplate abnormality (Modic changes), posterior anular hyperintense zone (HIZ), and facet arthropathy. Inter- and intraobserver agreement in rating the data was summarized by using weighted kappa statistics., Results: Interobserver agreement was good (kappa = 0.66) in rating disk degeneration and moderate in rating spondylolisthesis (kappa = 0.55), Modic changes (kappa = 0.59), facet arthropathy (kappa = 0.54), and posterior HIZ (kappa = 0.44). Interobserver agreement in rating the extent of Modic changes was moderate: kappa Values were 0.43 for determining superior anteroposterior extent, 0.47 for determining superior craniocaudal extent, 0.57 for determining inferior anteroposterior extent, and 0.48 for determining inferior craniocaudal extent. Intraobserver agreement was good in rating spondylolisthesis (kappa = 0.66), disk degeneration (kappa = 0.74), Modic changes (kappa = 0.64), facet arthropathy (kappa = 0.69), and posterior HIZ (kappa = 0.67). Intraobserver agreement in rating the extent of Modic changes was moderate, with kappa values of 0.54 for superior anteroposterior, 0.60 for inferior anteroposterior, 0.50 for superior craniocaudal, and 0.60 for inferior craniocaudal extent determinations., Conclusion: The interpretation of general lumbar spine MR characteristics has sufficient reliability to warrant the further evaluation of these features as potential prognostic indicators., ((c) RSNA, 2008.)

Degeneration of the spine is a common reason for pain in the musculoskeletal system. Radiography is an important tool for diagnosis and differential diagnosis. Cost efficacy and economy of time are advantages in using conventional x-rays. Although narrowing of intervertebral disc spaces, irregular ossification of the vertebral end-plate as well as osteophytes, facet joint osteoarthritis and spondylolisthesis can be observed, early changes in the discs or the subdiscal bone can not be detected by x-rays. Moreover, 3-dimensional imaging is not possible. Computer tomography (CT) and magnetic resonance imaging (MRI) are reliable for identifying disorders of the spine and soft-tissue. Differentiation between inflammation, trauma and tumor is possible. There is still a problem with the relationship between the information obtained by x-rays or MRI and clinical symptoms. Therefore, interpretation of radiological examinations assumes a knowledge of clinical symptoms and the different kinds of diseases which are possible.