Chymopapain versus conventional surgery for lumbar disc herniation. 10-year results of treatment.

We reviewed two comparable groups of patients who had been treated for lumbar disc herniation by chymopapain chemonucleolysis (145) or conventional surgical discectomy (91). They were reviewed 10 years after treatment by questionnaire, followed by a personal interview by an independent observer. The results of the surgically treated groups were slightly better than those treated with chymopapain. In particular, there was significantly better early relief of leg and low back pain, and fewer patients needed a second procedure. Complications were few in both groups.

Spinal metastases: the obvious, the occult, and the impostors.

Spines from 832 deceased patients with a terminal diagnosis of malignant neoplasm were examined grossly, microscopically and radiographically for evidence of tumor. Gross tumor and bone destruction or sclerosis were reliable signs of obvious metastases. Occult lesions visualized on gross sagittal sections but not detectable radiographically occurred in 26% of spines with confirmed metastatic deposits. Vertebral collapse was not a reliable indicator of metastases. Collapse was not caused by neoplasm in 22% of cases. Overall, metastases were found in 36% of patients dying from neoplastic disease. Although most metastases are obvious, occult lesions not visible radiographically occur. Collapsed vertebra may be impostors simulating metastatic disease.

Nerve root infiltration in the diagnosis of radicular pain.

Clinical and standard radiographic evaluation of patients with lumbosacral radicular symptoms may, on occasion, fail to delineate a cause. This study retrospectively reviews 62 patients who had undergone nerve root infiltration (NRI) and assesses the accuracy and indications for this diagnostic study. Surgical exploration of patients with a Group 1 response (typical pain reproduced by needle placement and then relieved by NRI) confirmed local root pathology in all. Exclusive of patients with arachnoiditis, a Group 1 response showed 85% accuracy in identifying a single symptomatic root. A Group 2 response (typical pain reproduced by needle placement but not relieved by local anesthesia) indicated multiple root involvement. Patients with a Group 3 or Group 4 response (typical pain not reproduced by needle insertion, with or without relief of pain by local anesthesia) were seldom relieved of radicular pain. NRI was most useful in investigation of patients with radicular symptoms in whom other investigations were 1) normal, 2) showed multiple level involvement, or 3) were difficult to interpret because of previous surgery.

Localization of symptomatic lumbar pseudarthroses by use of discography.

Twenty-four patients with lumbar pseudarthroses following attempted fusion were investigated by preoperative discography. The pseudarthroses were confirmed at surgical exploration. In 19 patients, discography at the level of a pseudarthrosis reproduced typical back pain, and in two patients the level above the fusion reproduced typical pain. Discography is not indicated when the major symptoms are leg or buttock pain. Technical errors included injection into the annulus fibrosis and impingement of the needle into the vertebral endplate. The latter may produce a false-positive result. Previous posterior fusions and very narrow disc spaces prevented insertion of the needle in some patients. Not all lumbar pseudarthroses were symptomatic, and two frequently occurred in the same patient. Discography is a useful adjunct to the traditional investigation of lumbar pseudarthroses.

Anomalies of the lumbosacral nerve roots. Review of 16 cases and classification.

Sixteen cases of lumbar nerve root anomalies found at surgery are reviewed and a classification system presented. All but two patients had an associated disc herniation which initiated the symptomalogy and was the indication for surgery. Fifty percent were found at repeat exploration. Eleven patients had conjoined nerve roots, five had two roots in one foramen, and three had connecting roots. Nerve root anomalies should be suspected in cases of failed disc surgery. Adequate decompression by foraminotomy or excision of pedicles is required as well as discectomy to alleviate the symptomatology.

Hip-spine syndrome.

Thirty-five patients were reviewed with what is called hip-spine syndrome. Concurrent disease at both the hip and spine is not infrequent in the older population. In most cases, the finding and diagnosis were straight forward, and were classified as a simple hip-spine syndrome. Cases in which the spine symptoms are aggravated by deformity of the hip were called a secondary hip-spine syndrome. Symptomatic disease at both the hip and spine can present as a complex hip-spine syndrome. Symptoms from both sites gives a confusing clinical picture and may require ancillary investigations to diagnose the major source of disability. Failure to recognize concurrent disease at both the hip and spine may lead to misdiagnosis and possibly erroneous treatment.

The "fabella syndrome": an update.

Sixteen adolescents presented with symptoms referable to the posterior lateral compartment of the knee, specifically the region of the fabella. The salient features of the syndrome include intermittent pain in the posterolateral region, accentuated by knee extension and localized tenderness when the fabella is compressed against the femoral condyle. The condition appears to be unique to late adolescence (15-17 years of age). Five patients responded to conservative measures. Eleven patients required surgery, all of whom obtained immediate relief of symptoms with removal of the ossified fabella, cartilaginous fabella, or thickened gastrocnemius fibers.

Localisation of the level of symptomatic cervical disc degeneration.

There are many difficulties associated with the localisation of the symptomatic segment in patients presenting with cervicobrachial pain with no evidence of impaired conduction in the nerve root. Ancillary radiological investigations such as myelography, epidural phlebography, and epidural myelograms are of unreliable diagnostic value. However, discography can be of value if the technique described here is used. Infiltration of the cervical nerve root with local anaesthetic has also proved useful in the localisation of the symptomatic segment. The techniques used in cervical discography and infiltration of the nerve root are described and their reliability is assessed.

Bone ingrowth and stress shielding with a porous surface coated fracture fixation plate.

The extent of bone remodelling under metal fixation plates attached to bone by (i) normal screw fixation and (ii) bone ingrowth into a porous metallic surface underlayer sintered to the metal plate was investigated. Extensive bone remodelling was observed under the integrally bonded porous surface layered plate. This remodelling could be attributed to the more extensive stress transfer from bone to metal plate because of the good bone-to-implant bonding. The importance of stress shielding with high stiffness implants is demonstrated.

Pitfalls in the diagnosis of leg pain.

Problems may confront the practitioner in the diagnosis of leg pain related to exercise. The diagnostic features of the history and the physical examination that will help to elucidate the various causes of leg pain are outlined in this article, and the necessity for re-examination of the patient after a period of exercise is stressed. In most patients the diagnosis can most easily be made by means of clinical methods, without recourse to special investigations.

Ligamentous laxity and scar formation.

The character of scar tissue is relative to or influenced by ligamentous laxity. Patients who are able to passively hyperextend the terminal interphalangeal joint of the index finger to 45 degrees and beyond have a tendency to leave broad scars. This proved to be statistically significance (p less than .001). It is suggested that in female patients in particular, assessment of the passive hyperextensibility of the terminal interphalangeal joint of the index finger can be used preoperatively to determine whether the patient will be left with a cosmetically displeasing scar following any operative procedure.

A porous metal system for joint replacement surgery.

A porous coated chrome cobalt system has been developed to provide long term stabilization in joint replacement surgery. The pore sizes are 50 to 100 microns, thus ensuring sufficient fatigue strength for use in high load bearing situations. Extensive in vitro and in vivo studies have been performed, and a five year follow-up of porous coated total shoulder prostheses has failed to reveal any evidence of loosening. The early results of porous coated hip implants is encouraging.

The Fabella Syndrome.

The Fabella Syndrome is recognized by a sharp pain, local tenderness, and intensification of pain in the area of the fabella by full extension of the knee. After diagnostic tests with local anesthesia and ineffective conservative treatment, surgical extirpation may produce lasting relief of symptoms.

Evaluation of biodegradable ceramic.

An evaluation of a porous biodegradable ceramic, tricalcium phosphate, has been carried out. When implanted in cancellous bone, it is rapidly infiltrated with bone and slowly resorbed. When held rigidly against raw, bleeding, cortical bone, again rapid bone ingrowth occurs. The material does not give rise to any untoward tissue reaction, nor does it cause any systemic reaction. It can therefore be concluded that the material is safe for use in clinical practice, and can be used in specific instances either to replace or to supplement bone grafting.

Etiological factors in the pathogenesis of femoral trabecular fatigue fractures.

Detailed histological evaluation of 72 femoral heads in terms of bone density, cartilagenous integrity and number of stress fractures in 3 different clinical groups of patients suggest that femoral trabecular fatigue fractures are largely determined by the degree of osteoporosis in all clinical states. The state of the hyaline cartilage also contibutes to the development of these fractures but only when the cartilage is degenerated to a severe degree as seen in rheumatoid arthritis. Both bone density and cartilage viability may be determining factors in the pathogenesis of trabecular stress fractures in rheumatoid hips.