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Minimally invasive amnioscopic surgery has several potential advantages over traditional open hysterotomy, including the reduction of the risk of preterm labor and spontaneous abortion. Adequate visibility of the fetal target organ is obligate to the success of in utero procedures. This is a preliminary report on the use of an end-emitting infrared fiber (750 microns; 810-nm wavelength) that allows image fusion with Infravision videocamera systems (Gabriel Medical, Lafayette, LA). Once placed, this fiber can serve as a homing beacon to identify the fetal bladder in the surgical creation of an amnioscopic vesicostomy for the relief of obstructive uropathies. Under general endotracheal halothane anesthesia, amnioscopic access was established in time-dated pregnant ewes using one 3.7-mm and two radially dilating 2-mm to 5-mm trocars. This access allowed the investigation of several methods of intravesicular infrared fiber placement. Ultrasound-guided direct needle puncture is the quickest method of accessing the fetal bladder but is unreliable when the bladder is empty. Accurate placement of the access needle directly over the suprapubic region was accomplished with amnioscopic assistance. The fiber was also placed transurethrally in one female and one male fetus, with subsequent perforation of the female's bladder. Successful infrared bladder illumination was accomplished in all animals. The fusion integration of this camera system allows simultaneous viewing by visible spectrum and near-infrared wavelengths. We believe that this system provides a further degree of safety for amnioscopic procedures.

Study Design: Frameless stereotaxy with doppler ultrasound and three dimensional computer model registration is assessed in vitro for pedicle screw placement., Objective: To identify feasibility of pedicle screw navigation and placement using this technology., Summary of Background Data: Inaccurate pedicle screw placement can lead to neurovascular injury or suboptimal fixation. Present techniques in pedicle screw placement involve only confirmation of hole orientation., Method: Forty-four pedicle screws were placed in lumbosacral models and cadaver specimens. Accuracy was assessed with a computed tomography scan and vertebral cross sectioning., Results: All screws were intrapedicular. Accuracy of anterior cortical fixation was 1.5 mm, with a range of 2.5 mm., Conclusion: In vitro frameless stereotaxy is accurate for pedicle screw placement. This technology adds a component of navigation to pedicle screw placement.

Study Design: A retrospective chart review of 36 patients treated with dynamized anterolateral instrumentation and fusion after decompression for thoracolumbar and lumbar burst fractures is presented., Objectives: To evaluate a device that allows continual bone graft vertebral endplate compression and determine its potential for healing in patients with thoracolumbar and lumbar burst fractures., Summary of Background Data: Anterior spinal surgery has led to implant adaptations. Such implants have undergone an evolution in hopes of improving the rate of healing and avoiding neurovascular catastrophes., Methods: Thirty-six patients underwent anterior decompression dynamized instrumentation and fusion for thoracolumbar and lumbar burst fractures. This involved a dual-rod, quadrilateral, cross-linked frame that allows for continual compression but deters rotation and shear stresses., Results: All patients healed solidly without instrumentation failure. An average recovery of 1.3 Frankel grades was recorded. Subsidence of bone graft vertebral endplate was less than in those placed in a trough., Conclusions: Dynamized load-sharing anterolateral Cotrel-Dubousset instrumentation led to solid bone graft healing without implant failure by allowing continual compression while deterring shear and rotational stresses.

Attempted endoscopic fetal interventions have been increasingly reported, given the knowledge that minimizing the trauma to the uterus by a small access portal can allow prolonged amnioscopic-guided surgery. Numerous fetal anomalies have been targeted for these interventions, including congential obstructive uropathies. This preliminary investigation explored innovative access strategies utilizing time-dated pregnant ewes, 95 to 100 days' gestation (term 145 days). Two strategies were specifically investigated: percutaneous, ultrasonographically guided microamnisocopy and ultrasonographically aided, laparoscopically guided amnioscopy. Both strategies provided excellent fetal visibility and were facilitated by the use of small trocars and microlaparoscopic instrumentation, which promoted prolonged amnioscopy with minimal access trauma.

A consecutive series of thirty-nine patients who had had a reoperation of the lumbar spine was followed up for an average of forty-eight months (range, twenty-four to eighty-six months). The patients were evaluated with regard to pain, functional status, and work status. Twenty-eight patients (72 percent) had a successful outcome, as determined by their ability to return to work, their lack of a need for narcotic analgesics, and their satisfaction with the operative results. Factors that were significantly associated with a successful outcome included a younger age (p < 0.02), working outside the home (p < 0.05), an initial period of improvement after the previous (index) operation (p < 0.01), fewer spinal levels operated on previously (p < 0.05), and a revision procedure incorporating anterior interbody arthrodesis (p < 0.02).

A limited survey analysis of 617 surgical cases in which pedicle screw implants were used was undertaken to ascertain the incidence and variety of associated complications. The different implant systems used included variable spinal plating (n = 249), Edwards (n = 143), and AO fixateur interne (n = 101). The most common intraoperative problem was unrecognized screw misplacement (5.2%). Fracturing of the pedicle during screw insertion and iatrogenic cerebrospinal fluid leak occurred in 4.2% of cases. The postoperative deep infection rate was 4.2%. Transient neuropraxia occurred in 2.4% of cases, and permanent nerve root injury occurred in 2.3% of cases. Previously unreported injury to nerve roots occurred late in the postoperative course in three cases. Screw breakage occurred in 2.9% of cases. All other complications had an incidence of less than 2%. The authors conclude that pedicle screw placement may be associated with significant intraoperative and postoperative complications. This information is of value to surgeons using pedicle implant systems as well as to their patients. Repeat surgery is associated with greater numbers of complications.

A work tolerance program was used for rehabilitation treatment of 45 patients with spinal dysfunction. Patients entering the treatment group were prospectively evaluated by objective physical capacity assessment (PCA). Treatment patients averaged 4 weeks of three, one half day sessions per week. These patients were compared with a control group of 33 patients who did not participate in the rehabilitation program but were evaluated by PCA. A telephone review of all patients in each group was carried out at 6- and 12-month follow-up. Results demonstrated that 78% of the rehabilitation treatment group were discharged with an improved functional work capacity. Most importantly, at 6-month follow-up, 73.0% of patients in the treatment group were productively working while only 38% of control group patients were actively employed. In addition, 84.4% showed an improvement in spinal range of motion. The subjective pain scale ratings of these treatment patients demonstrated only 44.4% decreased pain, while 51.1% stayed the same, and two patients increased discomfort. Further medical diagnostics or intervention was required in 24.4% of treatment patients. These findings definitely show that a spinal rehabilitation work-tolerance program based on objective measurement will enhance an increased rate of return to productive employment activity. There is poor correlation of subjective pain assessment when compared to objective PCAs. Therefore, recommendations of patients for return-to-productive work should be based pain ratings. When adjusted for nonselection patients, the authors community-based hospital program showed similar results to other programs. The work tolerance and rehabilitation program in Concord, New Hampshire, demonstrated a significant cost-effective approach; being less expensive, less time-consuming, and less psychologically oriented.

The technique for lumbar discography is not well standardized. To better understand lumbar pathology, we have developed a consistent, reproducible, and relatively simple procedure for lumbar discography. We describe our technique and discuss variables that may differ among individual lumbar discography procedures.

Primary osseous neoplasms of the thoracic and lumbar spine are uncommon lesions. Between 1965 and 1982, of 1971 patients with musculoskeletal neoplasms, only 29 (1.5%) had primary osseous tumors in these locations. There were eight children and 21 adults. Back pain was the most common complaint in 25 patients (86%), and neurologic symptoms or deficits were present in 16 patients (55%). All lesions were visible on routine spine roentgenograms, while computed tomography and myelography demonstrated spinal canal encroachment and extradural spinal cord compression in 19 patients (66%). The histologic diagnoses included 11 benign and 18 malignant lesions. Benign lesions occurred predominantly in children and malignant tumors in adults. Treatment was individualized, based on the histologic diagnoses. Twenty-two patients had surgical resection of their lesions. Laminectomy without stabilization and arthrodesis resulted in late instability and neurologic deterioration in three of seven patients (43%) with malignant lesions. Resection and decompression combined with arthrodesis did not predispose to late instability. Twenty-one patients were followed for a mean of 4.1 years (range, two to 14 years). Eight patients died from malignant disease between one month and seven years after diagnosis.

A histopathologic system of classifying minced human hip and knee osteoarthritic cartilage often used in organ cultures was developed. The tissue types characterizing the cartilage fragments were correlated with characteristics noted in full thickness cartilage specimens from young normal, aged and osteoarthritic cartilage. In the minced tissue specimens 3 distinct tissue types (A, B, and C) were discerned. Tissue types A and B were seen in nonfibrillated discolored as well as fibrillated osteoarthritic cartilage. Type C tissue was derived principally from chondroosteophytic spurs. Each tissue type differed in the number and organization of chondrocytes and orthochromatic and metachromatic staining of the perilacunar region and interterritorial matrix. No A, B or C tissue types were seen in normal cartilage samples derived from patients below the age of 50. Cartilage from patients above this age contained elements of all 3 tissue types.

A three-stage Papineau protocol for the management of chronic pyogenic osteomyelitis was critically investigated in 13 prospectively treated patients with draining osteomyelitis. Stage I involved removal of nonviable tissue and retained metal. Stage II involved grafting of cancellous iliac bone. In Stage III skin coverage was accomplished. Infection was eradicated in all but one patient, and the osseous defect filled in all patients. Five patients attained skin coverage after split-thickness grafting. In seven patients epithelialization occurred, while one patient underwent a soleus muscle transposition with skin grafting. The prospective protocol could have been improved by prolonged hospitalization with repeated surgical debridements. Rather than demonstrating absolute cure of all kinds of osteomyelitis, the present results reveal factors that help to ensure successful treatment.

The computed tomography (CT)/discograms and discographic pain provocation reports of 291 clinical patients, 790 discs (mean age, 38; range, 17-79) were collected. The CT/discograms were classified separating anular disruption and degeneration and recording the pain provoked during discography as no pain, dissimilar, similar, or exact reproduction of the patient's clinical pain. Nondegenerated discs usually were found to be painless, and deteriorated discs painful. The proportion of severely degenerated but painless discs increased with age, as did the discs producing dissimilar pain. This may help explain the poor correlation of low-back pain with radiographic degenerative changes reported in previous epidemiologic studies.

Patient and graft survival in 655 consecutive renal transplants performed at the University of California, San Francisco, was analyzed in two separate groups to assess the results of the low-dose immunosuppressive regimen established in September, 1972. These results show that graft survival is not jeopardized by adopting a policy of low-dose immunosuppressive therapy, but, in fact, that patient survival is improved significantly. This study also shows that cadaver renal transplantation can be performed with a mortality rate comparable to or better than that in patients on chronic hemodialysis.

Rabbit chondrocytes from pooled articular joints have been delineated by their time of attachment to culture flasks after initiation of primary monolayer culture, either attached (48-AT) or floating (48-F) after 48 hours. A general population of chondrocytes (attached after 72 hours, 72-AT) was also studied. The growth-promoting activity of pituitary fibroblast growth factor (FGF) and its effect on sulfated-proteoglycan synthesis was studied on each chondrocyte population in secondary monolayer culture. 3H-thymidine incorporation during a 1-hour pulse was stimulated by FGF (100 ng/ml) in each chondrocyte population. The response of AT-72 chondrocytes to FGF required an additional fetal bovine serum supplement, while 48-F cells responded independent of serum. The response of 48-AT chondrocytes to FGF (100 ng/ml) during a 1-hour pulse with 3H-thymidine was increased in low serum (0.5-2.0%) rather than when high serum (8-10%) was present in the culture medium. FGF reduced 35SO4 incorporation into sulfated-proteoglycans in the 48-AT and 48-F chondrocyte populations, but not in the 72-AT population. The reduction in 35SO4 incorporation in the 48-AT and 48-F chondrocytes was not characterized by alterations in the hydrodynamic size of the sulfated-proteoglycans as measured by Sepharose CL-2B chromatography nor by changes in the types of sulfated-glycosaminoglycans produced. These results indicated that FGF produced quantitative rather than qualitative alterations in chondrocyte sulfated-proteoglycan synthesis. The latter appears uncoupled from the growth-promoting activity of FGF on chondrocytes.

Disc deterioration and pain provocation in different low-back pain syndromes was studied using computed tomography (CT) discography. Data were prospectively collected for 300 patients (816 discs). Patients were classified by their pre-discography diagnosis of disc herniation (DH), degenerated disc (DD), lumbar syndrome (LS), lumbar radicular syndrome (LRS), or other. The CT/discograms were classified by discographic pain response, the amount of degeneration and annular disruption. Eighty-two percent of DH patients, 80% of DD, 56% of LS, and 59% of LRS patients had both positive discographic pain provocation and moderate or severe disc deterioration. The study indicates that intradiscal pathology plays a major role in nonspecific low-back pain syndromes.

It has been observed that discontinuity in the outline of the spinous process on standard anteroposterior radiographs is a characteristic finding in some unstable spine fractures. Since the spinous processes are often not depicted clearly on lateral views of the trauma victim's spine, these are less reliable; however, if a transverse fracture through the spinous process at the level of, or adjacent to, an anterior compression fracture is demonstrable, this confirms the unstable nature of the injury. Recognition of this sign, when present, may eliminate excessive pretreatment manipulations in some patients who have sustained major trauma and are suspected of having unstable spine fractures.

The histopathologic characteristics, in vitro proteoglycan and glycosaminoglycan biosynthesis, and proteoglycan content of osteoarthritic (OA) cartilage tissue types from human femoral heads obtained at the time of total joint replacement were compared. Articular cartilage from fibrillated or discolored cartilage surfaces demonstrated overlapping histopathologic patterns, while cartilage from osteophytic areas was distinct. 35SO4 from each of these three tissue types was found in two peaks of radioactivity on a Sepharose CL-2B column. The average partition coefficient (Kav) of the first peak (peak I) was 0.07, while that of the second (peak II) was 0.63. Proteoglycan monomer predominated in discolored, fibrillated, and osteophytic OA cartilage in peak I. The hydrodynamic size on Sepharose CL-2B of the synthetic proteoglycan monomer was the same for discolored, fibrillated, and osteophytic samples (Kav, 0.25-0.28). Discolored and fibrillated tissues showed a similar percentage of proteoglycan monomer in peak II, whereas osteophyte was reduced in proteoglycan monomer content in peak II. In addition, the endogenous proteoglycans extracted from each cartilage area were generally of a smaller hydrodynamic size than the newly synthesized peak I or proteoglycan monomer. Glycosaminoglycans were predominantly chondroitin 6-sulfate. These results indicated that OA discolored and fibrillated cartilage tissue types from defined topographical areas of human femoral heads possessed neither unique histopathologic nor synthetic or endogenous proteoglycan characteristics. Osteophytic cartilage appeared more histopathologically distinct than either discolored or fibrillated OA cartilage, but synthesized proteoglycan monomer with similar hydrodynamic size to the other cartilage tissue types.