Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease.

We obtained intervertebral discs with cartilage endplates and underlying cancellous bone at operation from patients with degenerative disc disease and then used immunohistochemical techniques to localise the nerves and nerve endings in the specimens. We used antibodies for the ubiquitous neuronal protein gene product 9.5 (PGP 9.5). Immunoreactivity to neuropeptide Y was used to identify autonomic nerves and calcitonin gene-related peptide (CGRP) and substance P to identify sensory nerves. Blood vessels were identified by immunoreactivity with platelet-endothelial cell-adhesion molecule (CD31; PECAM). In a control group with no known history of chronic back pain, nerve fibres immunoreactive to PGP 9.5 and neuropeptide Y were most closely related to blood vessels, with occasional substance P and CGRP immunoreactivity. In patients with severe back pain and markedly reduced disc height, proliferation of blood vessels and accompanying nerve fibres was observed in the endplate region and underlying vertebral bodies. Many of these nerves were immunoreactive to substance P or CGRP, and in addition, substance P- and CGRP-immunoreactive nociceptors were seen unrelated to blood vessels. Quantification by image analysis showed a marked increase in CGRP-containing sensory nerve fibres compared with normal control subjects. We speculate that a chemotactic response to products of disc breakdown is responsible for the proliferation of vascularity and CGRP-containing sensory nerves found in the endplate region and vertebral body adjacent to degenerate discs. The neuropeptides substance P and CGRP have potent vasodilatory as well as pain-transmitting effects. The increase in sensory nerve endings suggests increase in blood flow, perhaps as an attempt to augment the nutrition of the degenerate disc. The increase in the density of sensory nerves, and the presence of endplate cartilage defects, strongly suggest that the endplates and vertebral bodies are sources of pain; this may explain the severe pain on movement experienced by some patients with degenerative disc disease.

Thoracic myelopathy due to isolated ossification of the ligamentum flavum.

We report a 72-year-old patient with thoracic myelopathy due to isolated ossification of the ligamentum flavum at T9-T10. Severe paraparesis had developed before the lesion was identified when thinning of a segment of the lower thoracic spinal cord was suspected on a second MRI examination. The diagnosis was then established by CT.

Excision of laminal pseudoarthroses in spondylolytic spondylolisthesis. A review of 13 cases.

A conservative operation involving the excision of laminal pseudoarthroses in patients with spondylolytic spondylolisthesis who complained of referred leg pain is described. The spinous process and related ligaments of the affected lamina are preserved, allowing reattachment of the lumbodorsal fascia to the supraspinous ligaments after completion of the decompression procedures. The results obtained with the use of this method in 13 patients are described. The outcome in only one patient was unsatisfactory due to recurring bouts of back pain and lumbar spasm. No significant complications occurred in the series.

Spinal arachnoiditis ossificans. Observations on its investigation and treatment.

The histories of two patients with arachnoiditis ossificans leading to severe neurological impairment are presented. Analysis of these cases highlights the importance of three-dimensional (3 D) computed tomography (CT) scanning for the establishment of the diagnosis and in postoperative assessment of this rare disease, whereas magnetic resonance imaging (MRI) is less useful. The neurological function in both cases improved following re-exploration operations in which the whole length of the dural sac covering the intradural ossific lesions was freed totally from external obstructions imposed by the covering laminae.

Re-exploration of the lumbar spine following simple discectomy: a review of 23 cases.

A retrospective study of 23 patients is presented, all of whom complained of recurrent symptoms of back and leg pain following simple discectomy. Five patients (22%) had been refused further surgery by the original surgeon on the grounds that they were psychologically disturbed. On examining the clinical records, 18 patients were reported to have had frank disc prolapses found at operation. In 5 cases, disc tissues were removed even though disc prolapses had not been demonstrated. Among the 18 patients in whom disc prolapses had been removed at their first operations, we found recurrent prolapses at reoperation in only 2 of them (11%). We treated 19 of these patients by nerve root canal and foraminal decompressions and 4 by anterior lumbar interbody fusion operations. The mean follow-up period was 34 months. Satisfactory relief of symptoms was achieved in 21 cases. In the published literature, even after the advent of CT and MRI, the incidence of recurrent disc prolapse at reoperation varies markedly from author to author. The reasons for these differences are discussed. They appear to relate to three factors: 1. failure to differentiate acute disc prolapse from annular bulging which develops and is inevitably associated with disc space narrowing; 2. difficulty in distinguishing between MRI findings of scar tissue enhancement and local perineural oedema due to persisting foraminal and nerve root canal stenosis; 3. failure to identify the existence of foraminal stenosis, which is sometimes demonstrated only in oblique plain X-rays showing facet hypertrophy and subluxations of zygapophyseal joints.(ABSTRACT TRUNCATED AT 250 WORDS)

Ossification of the posterior longitudinal ligament in the thoracic spine causing intermittent paraplegia in an Englishman: case report.

Compression of the spinal cord due to ossification of the posterior longitudinal ligament (OPLL) often leads to quadriplegia or paraplegia in Japanese patients. This disease is uncommon in other races. We report the case of a middle-aged Englishman who presented with complaints of intermittent paraparesis due to OPLL at the T5-T6 level in his thoracic spine.

Anatomic studies of the circulation in the region of the vertebral end-plate in adult Greyhound dogs.

In order to study the detailed arrangements of vascular terminations in the region of the vertebral end-plate in adult dogs, infusions of Japanese ink mixed with a suspension of barium sulfate were used to produce filling of the vascular terminations at the vertebral end-plates. Radiographs were made of the decalcified specimens. Photomicrographs were prepared from transparent sections embedded in celloidin. The distribution of the large veins within the vertebral bodies was found to be more complex than described earlier. Over the entire bone-disc interface there is a continuous capillary bed that is most dense in the area related to the nucleus pulposus. These vessels drain either into the subchondral postcapillary venous network or directly into the veins of the marrow spaces in the vertebral bodies.

The results of 150 anterior lumbar interbody fusion operations performed by two surgeons in Australia.

The work of two Australian surgeons using the same techniques for anterior lumbar interbody fusion operations in 150 patients has been analyzed by an independent observer (A.F.). Used as a primary procedure in 84 cases, only four patients failed to return to work. Time off work varied between 3.3 to 11.8 months, depending on the patients' occupations. Used as a salvage procedure in 38 cases, only five patients failed to return to work. Time off work varied between 24 and 5.6 months depending on the patients' occupations. In 28 cases, supplementary operations were performed following interbody fusions. Even in this difficult group only nine patients failed to return to work.

Anterior lumbar interbody fusion: indications for its use and notes on surgical technique.

A technique using dowel cutting instruments for anterior lumbar interbody fusion operations is recommended for the treatment of other failed spinal operations; certain disc lesions; in the management of selected cases of spondylolisthesis; certain spinal infections; following some vertebral fractures; correction of selected spinal deformities and in the treatment of rare miscellaneous cases, e.g., vertebral body tumors and nucleus pulposus calcification. Extra peritoneal approaches to the lumbar vertebral column are recommended. Dowel cavities are cut to predetermined depths with specially designed cutters of appropriate size. The greater bulk of disc tissues and vertebral end plate cartilages are then removed using ring curettes and pituitary rongeurs. Autogenous grafts are cut from the iliac crest using a cutter one size larger than that used to prepare the intervertebral dowel cavities. With the depths of the dowel cavities having been checked with a depth gauge, the grafts are duly impacted after careful retraction of all adjacent structures away from the cavities.

[The surgical treatment of calcification of thoracic or lumbar discs in adults (author's transl)]. / Traitement chirurgical de la calcification du nucleus pulposus du disque intervertébral dorsal et lombaire, chez l'adulte.

The author have reviewed 10 cases of calcification of the nucleus pulposus treated operatively. The lesions were situated in the thoracic or lumbar spine and were the cause of severe pain. Operation was done after failure of conservative treatment. The results have been considered to be satisfactory.

Clinical studies of isolated disc resorption in the lumbar spine.

Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption.