Altered loading patterns and femoral bone mineral density in children with unilateral Legg-Calvé-Perthes disease.

Maximization of bone accrual during the growing years is thought to be an important factor in minimizing fracture risk in old age. Mechanical loading through physical activity has been recommended as a modality for the conservation of bone mineral in adults; however, few studies have evaluated the impact of different loading regimes in growing children. The purpose of this study was to compare bone mineral density (BMD) in weight-bearing and non-weight-bearing limbs in 17 children with unilateral Legg Calvé Perthes Disease (LCPD). Children with this condition have an altered weight-bearing pattern whereby there is increased mechanical loading on the noninvolved normal hip and reduced loading on the involved painful hip. Thus, these children provide a unique opportunity to study the impact of differential mechanical loading on BMD during the growing years while controlling for genetic disposition. BMD at four regions of the proximal femur (trochanter, intertrochanter, femoral neck, total of the regions) was measured using dual energy x-ray absorptiometry (DXA), and the values were compared between the involved and noninvolved sides of the children with LCPD. The BMD of the both sides also were compared with normative values based on both chronological and skeletal age data. A significantly higher BMD was found on the noninvolved side over the involved side for all regions (P < 0.01 and percentage differences of 12-15%) except at the femoral neck (percentage difference of 3.9%). The BMD (at all regions) of the noninvolved side also was significantly greater (P < 0.01) than either the chronological or skeletal age based norms for all sites except the trochanter. The results support the concept that mechanical loading of the skeleton during the growing years is an important factor in BMD accrual.

Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine. Can they be measured reliably on radiographs?

STUDY DESIGN: Interexaminer reliability study. OBJECTIVES: To determine the reliability of grading apophysial joint and disc degenerative changes and the reliability of measuring sagittal curves on lateral cervical spine radiographs. SUMMARY OF BACKGROUND DATA: Several authors have proposed that the presented of degenerative changes and the absence of lordosis in the cervical spine are indicators of poor recovery from neck injuries caused by motor vehicle collisions. The validity of those conclusions is questionable because the reliability of the methods used in their studies to measure the presence of degenerative changes and the absence of lordosis has not been determined. METHODS: Kellgren's classification system for apophysial joint and disc degeneration, as well as the pattern and magnitude of the sagittal curve on 30 lateral cervical spine radiographs were assessed independently by three examiners. RESULTS: Moderate reliability was demonstrated for classifying apophysial joint degeneration with an intraclass correlation coefficient of 0.45 (95% confidence interval, 0.09-0.71). Classifying degenerative disc disease had substantial reliability, with an intraclass correlation coefficient of 0.71 (95% confidence interval, 0.23-0.88). Measuring the magnitude of the sagittal curve from C2 to C7 had excellent interexaminer agreement, with an intraclass correlation coefficient of 0.96 (95% confidence interval, 0.88-0.98) and an interexaminer error of 8.3 degrees. CONCLUSIONS: The classification system for degenerative disc disease proposed by Kellgren et al and the method of measurement of sagittal curves from C2 to C7 demonstrated an acceptable level of reliability and can be used in outcomes research.

Biomechanical modelling of the human sacroiliac joint.

From a mechanical point of view, the human pelvis can be considered as a stable, complex three link structure. This three-link closed-chain system explains why there is so little motion in the sacroiliac joint. Based on the minimum total potential energy principle, a quasi-static model of the human pelvis with its three joints is developed. In the model, the articular cartilage linings of the joint surfaces are considered as thin layers with a geometric non-linear behaviour. They lie between two rigid curved surfaces that are represented by small three-node elements. Accessory ligaments and capsules are represented by a number of non-linear springs. A primary model is developed based on a female cadaver. According to the primary model, the translation of the sacroiliac joint in the direction of force is about 0.5 mm in the lateral direction, about 1.8 mm in the antero-posterior direction, and about 1.5 mm in the superior or inferior direction, when a load of 1000 N is applied to the sacrum. When a load of 50 N m-1 is applied to the sacrum, the rotation in the load direction is about 1.6 degrees in axial rotation, about 1.0 degree in flexion or extension and about 1.1 degrees in lateral bending.

Crossed femoral stretching test. A case report.

STUDY DESIGN: A case is reported of L3-L4 far lateral disc herniation, in which the femoral stretching and crossed femoral stretching tests were positive. OBJECTIVES: To discuss the clinical usefulness and pathophysiologic mechanics of the femoral and crossed femoral nerve stretching tests. SUMMARY OF BACKGROUND DATA: The femoral and crossed femoral stretching tests have received little clinical and research attention. The validity of these two nerve root tension signs to evaluate upper disc herniations remains unknown. METHODS: A 73-year-old woman presented with progressive low back pain and left anterolateral thigh pain of 2 months duration. The diagnosis of far lateral disc herniation at L3-L4 was initially suspected from a positive crossed femoral nerve stretch. An open discectomy was performed without complications. RESULTS: Eight months after surgery, the patient had recovered and the femoral and crossed femoral stretching tests were negative. CONCLUSIONS: It is hypothesized that the crossed femoral stretching test may be a valid maneuver to help in the diagnosis of symptomatic disc herniation above L4.

Ganglioneuroma of the thoracic spine presenting as adolescent idiopathic scoliosis: a case report.

Ganglioneuromas are rare soft-tissue tumors that can present as painless spinal deformities. The surgical outcome is usually satisfactory when complete excision is achieved. A case of spinal ganglioneuroma presenting as adolescent idiopathic scoliosis is presented to illustrate the illusive nature of this condition.

The failed back syndrome: personal opinions and experiences.

The author presents his personal opinion on failed back syndrome. The most frequent causes were a not indicated or contraindicated operation; a wrong site of surgery; an incomplete decompression; an omitted fusion; a pseudoarthrosis of a fusion; a recurrent disc herniation. Epidural scar is considered an enhancing factor for symptoms. Psychosocial factors are very important prognostic elements.

Pathophysiology and rationale for treatment in lumbar spondylosis and instability.

The author discuss the pathophysiology and the rationale for treatment of low back pain in spondylosis and instability. The concept of the three phases of degeneration is useful in understanding [correction of the comprensione] the clinic-pathological correlations. Surgical indications for low back pain and sciatic are rare, because of the natural history of degenerative instability and spinal stenosis is usually benign. Surgical treatment, decompression and/or fusion, is indicated when conservative treatment fails. Decompression is indicated, in addition to disc herniation, for central and lateral stenosis. Fusion is indicated for lytic and degenerative spondylolisthesis, after facetectomy, in some cases of scoliosis. Simple degenerative disc disease, in the absence of herniation, nerve compression or instability, is not an indication for surgery. There is no proof yet that fusion for back pain alone, due to degenerative disc disease, is better than the natural history of the disease.

Sacro-iliac joint pain: etiology and conservative treatment.

Orthopedic surgeons use many modalities in conservative treatment of low back pain (LBP) and sacroiliac pain (SIP) but few have been studied with randomized controlled trials. We have been studying the physiological effects of manipulation on joints and the clinical effect on patients. Manipulation is different from other forms of manual therapy. Quantitative sacroiliac scintigraphy and three clinical tests in patients with unilateral pain and tenderness over the SI joint suggest sacroiliac joint syndrome is a clinical entity. The iliac and sacral surfaces of the sacroiliac joint develop differently. Although this statement need further study it seems that manipulations may play a role in the treatment of LBP and SIP.

Effect of various head and neck positions on vertebral artery blood flow.

The purpose of this study was to assess blood flow velocity in the vertebral arteries with duplex Doppler ultrasound during various positions of the head and neck. Vertebral artery morphology and blood flow velocity were assessed in a control group and in a group of subjects who displayed clinical signs and symptoms of vertebrobasilar insufficiency. The two groups did not differ in vertebral artery gross morphology as assessed by ultrasound. The arteries were examined for vascular impedance by calculating the ratio of peak systolic velocity to end diastolic velocity (systolic/diastolic ratio). In the context of this study, a lower velocity ratio implied less resistance to vascular flow. These velocity ratios were established during several positions of the head and neck, including a widely used provocational test manoeuvre for vertebrobasilar insufficiency. No meaningful significant differences in mean velocity ratios were found between the two groups. None of the subjects had abnormal spectral flow patterns during the different testing positions.

The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: a randomized controlled trial.

OBJECTIVE: The main objective of this study is to compare the immediate results of manipulation to mobilization in neck pain patients. DESIGN: The patients were compared in a randomized controlled trial without long-term follow-up. SETTING: The study was conducted at an outpatient teaching clinic on primary and referred patients. PATIENTS: One hundred consecutive outpatients suffering from unilateral neck pain with referral into the trapezius muscle were studied. Fifty-two subjects were manipulated and 48 subjects were mobilized. The mean (SD) age was 34.5 (13.0) yr for the manipulated group and 37.7 (12.5) yr for the mobilized group. Sixteen subjects had neck pain for less than 1 wk, 34 subjects had pain for between 1 wk and 6 mo and 50 subjects had pain for more than 6 mo. Seventy-eight subjects had a past history of neck pain. Thirty-one subjects had been involved in an injurious motor vehicle accident and 28 subjects had other types of minor trauma to the neck. There were no significant differences between the two treatment groups with respect to history of neck pain or level of disability as measured by the Pain Disability Index. INTERVENTION: The patients received either a single rotational manipulation (high-velocity, low-amplitude thrust) or mobilization in the form of muscle energy technique. MAIN OUTCOME MEASURES: Prior to and immediately after the treatments, cervical spine range of motion was recorded in three planes, and pain intensity was rated on the 101-point numerical rating scale (NRS-101). Both pre- and post-test measurements were conducted in a blinded fashion. RESULTS: The results show that both treatments increase range of motion, but manipulation has a significantly greater effect on pain intensity. Eighty-five percent of the manipulated patients and 69% of the mobilized patients reported pain improvement immediately after treatment. However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (p = .05). CONCLUSION: This study demonstrates that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree. Further studies are required to determine any long-term benefits of manipulation for mechanical neck pain.

The effect of manipulation on pain and range of motion in the cervical spine: a pilot study.

OBJECTIVE: The objective of this pilot study was to determine the number of patients required for a randomized controlled trial of spinal manipulation for neck pain and to determine if there is a relationship between pain and range of motion (ROM) in the cervical spine. DESIGN: Fifty consecutive outpatients were studied in a pretest-posttest design without long-term follow-up. SETTING: The patients were taken from a primary cae outpatient teaching clinic specializing in back pain. PATIENTS: All patients had unilateral neck pain without neurological deficit. The patients were selected as a consecutive sample. INTERVENTION: All the patients received a single cervical manipulation. MAIN OUTCOME MEASURES: Prior to and immediately after the treatment, cervical ROM was recorded on a goniometer, and pain intensity was rated on the 101-point numerical rating scale. RESULTS: The results show an increase in all planes of post-treatment ROM and a decrease in post-treatment pain scores. Partial correlations between post-treatment ROM and 101-point numerical rating scale scores reveal a significant relationship between a decrease in pain and an increase in cervical rotation (p < .005). CONCLUSIONS: Since the results of this pilot study are not controlled, they cannot be seen as proof supporting the clinical efficacy of manipulation for neck pain. However, the correlation between an increase in cervical rotation and a decrease in pain is clinically instructive. In addition, the outcome measures used in this study could prove to be useful in the design of future randomized controlled trials of cervical manipulation.

Lumbar facet joint asymmetry. Intervertebral disc herniation.

A study of 136 patients with lumbar intervertebral disc herniation was undertaken to test the hypothesis that asymmetry of the facet joints is associated with the level, type, and side of herniation. Fifty cases of central herniation and 86 cases of lateral herniation, all at the L4-5 or L5-S1 levels, were studied by computed tomographic scans. Adjacent (nonherniated) levels were used as controls. The facet joint angles were measured at the L4-5 and L5-S1 levels of the control, central, and lateral herniated levels. The results showed a similar degree of facet joint asymmetry at all levels. In cases of lateral herniation, there was a significant difference in the facet angle between the herniated and nonherniated side at the L5-S1 level, but not the L4-5 level. The mean difference, however, was less than 3 degrees and not considered to be clinically relevant. There was no difference in the distribution of the more coronally or sagittally facing facet joints with respect to the side of lateral herniation. These results do not support the hypothesis that facet asymmetry is associated with lumbar intervertebral disc herniation.

The use of coronal computed tomography in the evaluation of Kienbock's disease.

In a prospective study of 12 consecutive patients with Kienbock's disease, direct coronal CT of the wrist was more sensitive than plain films and plain film tomography in demonstrating structural change including sclerosis, compression and fractures of the lunate. Fractures are more common in Kienbock's disease than previously reported. Earlier detection of fractures by CT, before collapse of the lunate occurs, may allow treatment to prevent the collapse.

Causes and clinical management of vertebral osteomyelitis in Saskatchewan.

A retrospective review of all patients with vertebral osteomyelitis admitted to all Saskatchewan referral hospitals from 1973 to 1986 was undertaken to determine the incidence and clinical characteristics of the disease. There were 73 patients, an incidence of 5.3 cases/million per year. Erroneous initial diagnoses were common (41%). There was a significantly increased risk in patients older than 60 years. Staphylococcus aureus was the most frequent organism. Mycobacterium tuberculosis was present in 29.5% and was more common in native Indian patients. Surgery was performed in 31% of all patients, and in 50% of those with tuberculous infections. The outcome was excellent in 92% of patients. Diabetes and transurethral resection of the prostate were risk factors for vertebral osteomyelitis.

Computed tomography of wrist trauma.

We devised a rapid and sensitive computed tomography (CT) method to assess the acutely injured wrist, healing carpal fractures and post-traumatic osteonecrosis, when the plain films offer insufficient information. The wrist is positioned in a simple reverse-L-shaped Perspex immobilizer. With the scaphoid as the center of the arc and the long axis of the distal radius as the reference 0 degrees line, sequential coronal scans of the wrist were done in 10 degrees increments in an arc of 40 degrees to give 0 degrees, 10 degrees, 20 degrees, 30 degrees and 40 degrees scans. The 0 degrees and 10 degrees arc scans were best for evaluating the distal radius and ulna and soft tissues, the 10 degrees and 20 degrees scans for the carpal bones other than the scaphoid, and their relation to each other, the 30 degrees and 40 degrees scans, parallel to the long axis of the scaphoid, for fractures of the scaphoid and the hook of the hamate. In addition the 40 degrees scan offered an excellent carpal tunnel view. In 22 patients examined for wrist trauma CT was found to be more accurate than plain films and plain-film tomography in determining the presence of a fracture (4 scaphoid and 1 distal radius), in assessing the degree of osseous union (12) and in evaluating intercarpal fusion (2). In addition CT detected avascular necrosis of the lunate in two patients and erosions of the scaphoid and distal radius attributed to rheumatoid arthritis in one.

Forty degree angled coronal CT scanning of scaphoid fractures through plaster and fiberglass casts.

A method for obtaining coronal CT scans angled 40 degrees to the longitudinal axis of the wrist, parallel to the long axis of the scaphoid, is described. Its potential for evaluating scaphoid fractures is assessed in 10 patients with healing or clinically suspected fractures. Overlapping 3 mm thick angled coronal CT scans were obtained for each patient both in and out of cast. The CT images were compared to plain films and tomography. Comparisons were also made of CT images obtained through fiberglass and plaster casts. All fractures apparent by plain films and tomography were apparent by CT; one case suspected of fracture on initial plain films showed no evidence of fracture on CT and subsequent clinical course and plain films. Osseous union of healing fractures was more reliably assessed on CT than on plain films and plain film tomography. There was no degradation of CT images by either fiberglass or plaster casts; fiberglass casts allowed easy planning of tomographic slices from scout films. We conclude that direct 40 degree angled coronal CT examination of the scaphoid is a quick reliable method to detect scaphoid fractures and to assess their healing without the need of cast removal.

Low-back pain and straight leg raising in children and adolescents.

The relation between a history of low-back pain (LBP) and straight leg raising (SLR) was investigated in 267 children (6-13 years) and 135 adolescents (14-18 years). The prevalences of a history of LBP and low mean SLR values were significantly greater in the older age group. In each age group, boys had significantly lower SLR values than girls. No significant difference in straight leg raising was found between those subjects with and those subjects without a history of low-back pain except for male adolescents, for whom there was a significant direct relation between a history of LBP and decreased SLR.

A study of the effects of bipedism and upright posture on the lumbosacral spine and paravertebral muscles of the Wistar rat.

Twenty-one bipedal rats were prepared by forelimb amputation and reared with 19 control rats. All of the bipedal rats became proficient upright walkers. There was significant anterior wedging of the lower lumbar vertebral bodies in all of the bipedal rats and four had radiographic evidence of degenerative disc disease. Five bipedal rats developed lumbosacral disc herniations, and the lumbar neural canal was significantly smaller in the bipedal population. There was no difference in radionuclide uptake between the two groups. Histochemical analysis of the psoas and multifidus muscles showed a significant shift from type I to type II fibers in the psoas and from type II to type I fibers in the multifidus in the bipedal population. These results indicate that upright posture places considerable stress on the lumbosacral spine and paravertebral muscles of the rat.