Frequency and clinical meaning of long-term degenerative changes after lumbar discectomy visualized on imaging tests.

The aim of this retrospective controlled study was to evaluate radiographic degeneration in the lumbar spine of patients who had undergone lumbar discectomy minimum 21 years earlier and its clinical meaning. Indeed, no previous investigation on degenerative changes occurring after lumbar discectomy with a comparable long follow-up has been published. The study participants consisted of 50 patients who had undergone discectomy for lumbar disc herniation. The mean length of follow-up was 25.3 +/- 3.0 years. Patients were assessed by Short Form-36 Health Survey (SF-36), Oswestry Disability Index, and a study-specific questionnaire. Radiographic views of the lumbar spine were obtained from all patients and compared to those of 50 asymptomatic controls. A five-step published classification was used to assess the increasing severity of radiographic changes. CT or MRI scans were also available for 27 patients who had undergone discectomy. Moderate to severe radiographic changes were present in 45 patients (90%) and 34 controls (68%), respectively (P = 0.013). The most prevalent MRI/CT changes were loss of disc height (89%), facet joint arthritis (89%), and endplate changes (57%). Thirty-two of 33 subjects (97%) reporting pain during the last 12 months had significant degeneration on their radiographs, and the frequency of changes was higher with respect to subjects without pain (P = 0.040). In conclusion, standard lumbar discectomy frequently leads to long-term degenerative changes on imaging tests. The presence of moderate to severe degeneration is associated with self-reported pain.

Osteoarticular tuberculosis in a developed country.

OBJECTIVES: To evaluate the clinical and diagnostic features of osteoarticular tuberculosis (OT) from a series of cases seen over 30 years in a large university hospital in Naples, Italy. METHODS: We reviewed the files of all patients admitted to our department from 1975 to 2004 with a diagnosis of osteoarticular tuberculosis. RESULTS: We identified 136 patients with 140 osteoarticular tuberculosis lesions. Fifty-three cases were diagnosed from 1975 to 1984, 36 cases from 1985 to 1994, and 47 cases from 1995 to 2004. Eleven patients (8%) were from high-incidence areas outside of Italy. The mean delay until diagnosis was 216.6 days. Pain, low-grade fever, and loss of weight were the most common presenting symptoms. Neurological involvement was present in 11 cases out of 79 spinal lesions (13.9%). Serological methods were used to study antimycobacterial antibodies using enzyme-linked immunosorbent assays (ELISA-TB test) in 59 patients (42.1%). Positive results on this test were obtained in 43 patients (72.9%). ELISA-TB test was the only diagnostic test associated with a shorter diagnostic delay in a model of multivariate regression analysis (p=0.001). Tc-99m MDP bone scans were obtained from 83 patients with 84 lesions and increased uptake in the affected area was noted in 72 lesions (85.7%). Histological and microbiological examinations were positive in 97 (69.3%) and 57 (40.7%) lesions, respectively. In 43 (30.7%) lesions, we could not definitively confirm the diagnosis. In these cases chemotherapy was nevertheless initiated. CONCLUSIONS: Thorough and even invasive diagnostic work-up is mandatory for the proper and timely management of patients with OT. Tc-99m MDP bone scanning and ELISA-TB test are useful diagnostic tools. We always used microbiological testing and histological examination to confirm the diagnosis of OT, but empirical antituberculosis treatment was nevertheless initiated in the patients with high clinical suspicion in order to limit the potentially permanent destruction of affected skeletal segments.