"The tempest in my mind": cultural interfaces between psychiatry and literature, 1844-1900.

The professional literature of the first generation of American psychiatrists is replete with poetical passages drawn from the imaginative works of such English authors as Shakespeare, Byron, and Scott as well as the writings of residents of the asylums they tended. A close reading of such passages in the American Journal of Insanity (AJI), the central medium through which members of this nascent profession attempted to "popularize the study of insanity," suggests they were not simply textual ornaments or signs of the underdeveloped state of American psychiatry in the mid-nineteenth century. Indeed, literary manifestations of the imaginative minds of patients and renowned writers were scrutinized by psychiatrists seeking to advance their understanding of mental disease. Moreover, the English authors were often elevated to the status of medical experts and their poetry and prose were commended to fellow medical practitioners as sources of psychological insight. Toward the turn of the century psychiatrists' engagement with these literary forms was less pronounced in the AJI, due in large part to the impact of rising asylum populations and the coming of a culture of positivist medicine. Yet literary influences on psychiatric writing are still evident in this period, indicating the complexity of the cultural interfaces between psychiatry and literature and the importance of examining the historical processes that have served to define and distinguish the enterprise of the psychiatrist from that of the poet.

Can lumbar spine radiographs accurately determine fusion in postoperative patients? Correlation of routine radiographs with a second surgical look at lumbar fusions.

Controversy centers on the determination of surgical fusion in lumbar spinal patients. What method best determines the nature of surgical arthrodesis remains unanswered. Numerous studies have investigated the accuracy of different radiologic tests. Although the best method has not been determined, plain radiography is certainly the most widely used in many centers and reported in scientific articles. In most of the literature a poor agreement between radiographic interpretation and surgical findings was observed. The main reasons seemed to be the lack of an accurate method to assess the radiographs. The authors rely on a radiologist or spinal surgeon to estimate the success of bony fusion by reviewing a two-dimensional radiograph. The purpose of this study was to determine the accuracy of plain radiographs to predict the presence of a surgical fusion. Forty-nine patients underwent fusion site exploration in the course of hardware removal. All patients had a one- or two-level posterolateral fusion and posterior lumbar interbody fusion with pedicle screw/link rod instrumentation. Immediate preoperative anteroposterior and lateral radiographs were taken before hardware removal that included both visual assessment and a Kocher mechanical test. Two spinal surgeons and two musculoskeletal radiologists blindly judged the preoperative radiographs as to the absolute presence or absence of successful arthrodesis. A second review was repeated at 3 months. The overall agreement between radiographic assessment and actual surgical findings was 69%. The range among observers was 57-77%. The overall false positive rate was 42% (0-75%), while the false-negative rate was 29% (20-51%). Success of observed surgical arthrodesis at the time of the second look was 90% and this number was used as the standard in the agreement process. In comparing the radiographic observations with the surgical findings it is suggested that in one of five cases the plain radiographs underestimate the degree of fusion. This finding agrees with the authors' knowledge of osteoid and mineralized bone. The premineralized osteoid may be functionally fused, but appear radiolucent on radiographic film. Once solid trabecular bony bridging occurs radiographic identification of fusion is easier to determine.

Functional results after anterior lumbar fusion at L5-S1 in patients with normal and abnormal MRI scans.

The debate continues as to which patient responds best to surgical versus nonsurgical intervention for painful degenerative disc syndrome. Discography is often used as the basis for that decision. In a review of 53 cases followed for an average of 20 months after surgery, only 50% of patients with type I (contained) discography and normal magnetic resonance imaging findings were found to be improved. In those patients with types II and III (noncontained) discography and abnormal magnetic resonance imaging scans, a 75% success rate was seen. There was an overall 80% fusion rate for all patients who underwent anterior lumbar fusion at L5-S1. Average age was 34 years, with average length of disability from low-back pain of 11 months. All patients were placed in a similar presurgery and postsurgery rehabilitation protocol and had failed nonsurgical treatment options. In this matched group of patients, those with abnormal magnetic resonance imaging scans and abnormal discography, clearly fared better, with a 75% percent success rate versus 50% success rate in those with normal magnetic resonance imaging findings. This series raises the question as to whether those patients with normal magnetic resonance imaging findings are surgical candidates.

Clinical experience with automated percutaneous discectomy: the Nucleotome system.

The Nucleotome system was used to treat contained herniated nucleus pulposus of the lumbar spine over a 2-year period. The results were categorized as successful or unsuccessful according to patient perception and anticipated result. The overall success rate was 79%; 93% in private pay and 65% in workers' compensation. The causes of failure were three free fragments not identified in the preoperative scanning technique and 10 cases with significant back pain failing to respond to percutaneous techniques. Overall, percutaneous lumbar discectomy is believed to be an acceptable treatment technique for those patients with contained herniated nucleus pulposus.

The role of anterior lumbar fusion for internal disc disruption.

Internal disc disruption is a syndrome of traumatically induced low-back pain arising from the intervertebral disc. The diagnosis is confirmed by abnormal discography with concordant pain reproduction at the affected level or levels. Thirty-four patients with internal disc disruption at one level were followed for an average of 29 months. Eighteen (53%) underwent anterior lumbar fusion at the L4-5 disc, 11 (32%) at the L5-S1 disc and the remainder at the L3-4 or L2-3 disc. Bank bone was used in all but seven patients for interbody fusion. Treatment was judged a success by the patient returning to work or normal activities and requiring either no medications or an antiinflammatory drug only. By the above criteria 25 patients (74%) had successful outcome of treatment. The average time to return to work or normal activities was 6.1 months. The overall union rate was 73% with an average time to union of approximately 12 months. Complications consisted of graft extrusion requiring revision and retrograde ejaculation. These occurred in one patient and were the only complications in the series. We concluded that disc excision and anterior interbody fusion is an effective treatment for internal disc disruption.

Lumbar Scheuermann's. A clinical series and classification.

Scheuermann's disease of the thoracic spine is a well-defined entity, although its exact etiology is unknown. In the thoracolumbar or lumbar spine however, the criteria are much less strict for the application of this eponym. A retrospective review of all the cases of lumbar Scheuermann's disease seen at the Texas Scottish Rite Hospital revealed two distinct radiographic pictures. These consisted of a "classic" Scheuermann's and an "atypical" type characterized by vertebral end plate changes, disc space narrowing, and anterior Schmorl's nodes, but not otherwise fulfilling Sorenson's criteria. This group tended to occur in more athletic adolescents or those with a history of increased axial stress to the spine. A subgrouping of atypical Scheuermann's disease is proposed and includes acute traumatic intraosseous disc herniation. Based on these findings, a classification of lumbar Scheuermann's disease is proposed.