The ligamentum flavum at L4-5: relationship with anthropomorphic factors and clinical findings in older persons with and without spinal disorders.

OBJECTIVE: To examine the relationship between ligamentum flavum thickness and clinical spinal stenosis. DESIGN: A validation study. SETTING: Clinical research laboratory. PATIENTS: A total of 119 subjects from the Michigan Spinal Stenosis Study (MSSS). METHODS: Two new measurement techniques were compared by use of magnetic resonance images of 4 asymptomatic subjects by 2 examiners. The technique with the best interrater reliability was then used to measure the ligamentum flavum at L4-L5 in 119 subjects in the MSSS who, on the basis of clinical examination without imaging, were thought to have lumbar stenosis, mechanical back pain, or no pain. These findings were related to other radiologic findings, demographics, clinical severity, and electrodiagnostic findings. MAIN OUTCOME MEASUREMENTS: Perpendicular on the inside of the spinal canal from the deepest point of concavity of the lamina to the edge of the ligament. RESULTS: The ligamentum flavum width measurement had high interrater (r = 0.774) and intrarater (r = 0.768) reliability. In 28 asymptomatic volunteers, ligamentum flavum width averaged 5.72 ± 0.95 mm, with the left side significantly thinner than the right (t = 2.117, P = .044), and thicker ligaments with age (r = 0.653, P < .001). Asymptomatic persons whom radiologists thought had stenosis had thicker ligaments (t = 2.273, P = .032). Persons with clinical stenosis (n = 48) and mechanical pain (n = 43) had ligament thickness similar to that of asymptomatic volunteers. Among patients with clinical stenosis, ligamentum flavum thickness did not relate to symptom severity (pedometer and laboratory ambulation tests, Pain Disability Index, and visual analog scale for pain). Most neurophysiological findings had no relationship with ligamentum flavum width, except the presence of limb fibrillation potentials related to a thinner ligament (t = 2.915, P = .004). CONCLUSIONS: The measurement technique is standardized for the ligamentum flavum for future use. Although the ligamentum flavum appears to get thicker with age, other factors, including clinical diagnosis, pain, and function, do not appear to relate to the ligamentum flavum width.

The practice of physical medicine and rehabilitation in sub-Saharan Africa and Antarctica: a white paper or a black mark?

INTRODUCTION: The medical specialty of Physical Medicine and Rehabilitation (PM&R) has had a proven impact on persons with disability and on healthcare systems. Documents such as The White Book on Physical and Rehabilitation Medicine in Europe have been important in defining the scope of practice within various regions. However in some continents the practice has not been well defined. OBJECTIVE: To explore the practice of PM&R in sub-Saharan Africa and Antarctica. METHODS: Medline searches, membership data searches, fax survey of medical schools, Internet searches and interviews with experts. RESULTS: The continents are dissimilar in terms of climate and government. However both Antarctica and sub-Saharan Africa have no PM&R training programs, no professional organisations, no specialty board requirements and no practicing physicians in the field. Since there are no known disabled children in Antarctica and adults are airlifted to world-class health care, the consequences of this deficit are minimal there. However, the 788,000,000 permanent residents of sub-Saharan Africa including approximately 78 million persons with disability are left unserved. CONCLUSIONS: Antarctica is doing fine. Africa is in a crisis. Local medical schools, hospitals doctors, and persons with disability; along with foreign volunteers, aid groups and policymakers can impact the crisis. However government--specifically national ministries of health--is ultimately responsible for the health and well-being of citizens.