Inter- and intraobserver variability in the interpretation of computed tomography of the lumbar spine.

In order to assess the variability in interpreting lumbar CT-scans, two radiologists and two rheumatologists examined the same set of 40 CT-scans and evaluated the presence of primary abnormalities using pre-established criteria. Inter- and intraobserver concordance was assessed using kappa statistics. Interpretation of herniated nucleus pulposus appeared reliable in this study (interobserver and intraobserver kappa statistics approximately 0.7 and 0.9, respectively). Conversely, significant variability of interpretation was seen in many findings often considered important in benign low-back pain or sciatica. Particularly low levels of agreement (interobserver kappa statistics lower to 0.20) were found for facet joint osteoarthritis and spinal stenosis. Since herniated nucleus pulposus appeared as the only reliable CT finding, lumbar CT ordering should therefore be currently restricted to confirmation and localization of herniated nucleus pulposus, especially when surgery or any other invasive intervention is planned to treat prolonged sciatica.

[Enthesopathy in inflammatory spondyloarthropathy. Incidence, clinical, radiological and anatomical descriptions. Current status of the question. Apropos of 37 cases]. / Les enthésopathies des spondyloarthropathies inflammatoires. Fréquence, description clinique, radiologique et anatomique. Etat actuel de la question. A propos de 37 observations.

Based on a series of 37 personal patients and data from the literature, a number of characteristics of enthesopathies can be observed in the course of inflammatory spondyloarthropathies. Our series is based on 20 cases of ankylosing spondylitis (ASP), 8 cases of Fiessinger-Leroy-Reiter syndrome, 8 cases of psoriatic rheumatism (Pso Rh) and one combined form (psoriasis + Reiter + ASP). As well as the frequent involvement of the calcaneus (29 patients), we found more unusual extra-calcaneal localisations in 23 patients. The clinical symptomatology consisted of pain on activity and on weight-bearing at the sites of insertion of the tendons, which were sometimes swollen. The disease was occasionally very incapacitating. The radiological signs consist of lesions of erosion (initially) and reconstruction (subsequently). The histological signs consist of zones of osseous reorganisation and osteo-tendinous inflammatory infiltration. The mechanism of these enthesopathic lesions is still unclear. Our observations are similar to those reported in the literature, which are essentially paediatric studies. Enthesopathy appears to be a diagnostic and lesional element in common with inflammatory spondyloarthropathies (which include ASP, Reiter's Pso Rh, enteropathic rheumatisms and Behçet's disease) and, at least partially, with juvenile rheumatisms. In the latter case, the precocity of the tendinoperiosteal signs seems to be a very important element in the orientation of the diagnosis at the pre-spondylitic stage.

[Systematic research on enthesopathies in chronic rheumatism. Results and pathological significance. Relation to erosive spondylitis and other tendinous or synovial lesions]. / Recherche systématique des enthésopathies au cours des rhumatismes chroniques. Résultats et signification pathologique. Rapport avec la spondylite érosive et les autres lésions tendineuses ou synoviales.

A routine investigation for rheumatic tendon lesions was conducted in 47 patients with an inflammatory spondylo-arthropathy and in 30 patients with rheumatoid arthritis. The incidence of tendon lesions (calcaneal and extra-calcaneal) differed very significantly (p less than 0.001) between the two groups (58.3% of patients with inflammatory spondylo-arthropathy had at least one tendon lesion, 6.6% of patients with rheumatoid arthritis). These results and data from the literature suggest that rheumatic tendon lesions are a characteristic feature of spondylo-arthropathy in the same way as sacro-iliitis, the absence of subcutaneous nodules, the absence of rheumatoid factor and the high incidence of histocompatibility antigen HLA B27. Together with this diagnostic value, there is also a histopathological value: inflammatory and ossifying tendinitis contrasts with the destructive synovitis of rheumatoid arthritis and can be considered to be a "sign" of inflammatory spondylo-arthropathy. Tendinitis and juxta-articular bone lesions in the limbs, so-called "peripheral" lesions, are similar to the vertebral lesions around the intervertebral disk and the posterior interapophyseal joints found in inflammatory spondylo-arthropathy. These lesions seem to be a common pathological feature, at least in part, with the polyarthropathies of childhood.

[Enthesopathies in ankylosing spondylitis and seronegative inflammatory rheumatism. 28 cases]. / Les enthésopathies dans la spondylarthrite ankylosante et les rhumatismes inflammatoires séronégatifs. 28 observations.

A few demonstrative cases of severe and disabling enthesopathy in patients with ankylosing spondylitis (AS) and related syndromes, psoriatic arthritis (PA) or Reiter's disease (RD) have prompted the authors to investigate the incidence of enthesopathy in such patients. A retrospective clinical and radiological study was conducted in 48 patients (mean age: 34.8 years) 27 of whom had AS, 9 RD and 12 PA. The overall incidence of enthesopathy was 58.3%. Beside the classical calcaneal lesions (50%), extracalcaneal manifestations of the disease involving the knees and shoulders were found in 39% of the patients. The HLA B27 antigen was detected in 87% of patients with enthesopathy, while 82% had clinical inflammation of the spine. The mean duration of clinical symptoms due to enthesopathy was 2-6 weeks in 36% and 6 months to 1 year in 45%. One striking feature of enthesopathy in this series was the lack of response to steroidal and non-steroidal anti-inflammatory drugs contrasting with the response of the associated arthritis. Since enthesopathies appear to be of diagnostic significance in the group of arthropathies of the spine, their incidence in other articular diseases should be the object of systematic comparative evaluations. A diffuse exacerbation of enthesopathy may constitute the initial manifestation of seronegative HLA B27 positive arthropathy, which is not without therapeutic implications.

[Results of a new controlled survey of the spine of tractor operators]. / Résultats d'une nouvelle enquête contrôlée sur le rachis des tractoristes.

In order to appreciate the consequence of tractor driving on the incidence of low back pain 72 tractorists (mean age: 35,1 +/- 6,3; mean first year driving (18,6 +/- 4,8), mean duration of driving (15,2 +/- 4,7) were compared to 62 non tractor driving farm workers (mean age: 36,5 +/- 6,5). Subjects were studied during a systematic yearly examination at the regional office for medical prevention. They were not informed of the purpose of the study. All subjects were submitted to a 45 items questionnaire made by one rheumatologist and to a standard physical examination of the dorsal and lumbar spine by another rheumatologist. No X-rays examination were performed during this enquiry. Results were as follows: non specific lowback pain was a frequent complaint in both groups, but was found significantly more frequent in non tractorists (p less than 0,01). Discrimination of non specific low back pain by duration of pain episodes (greater than or equal to 3 months) gave of lower frequency of the symptom which was found similar in both groups. Non tractorists complained more frequently of lumbago and sciatica (p less than 0,05). Identical abnormal physical examination were found in tractorists and non tractorists. Professional consequence were infrequent and not different between tractorists and non tractorists. No correlation were found between results of questionnaire, physical examination and mean duration of tractor driving.

[Disk curettage in inveterate lumbago. Recent results in 45 cases]. / Le curetage discal dans la lombalgie invétérée. Nouveaux résultats portant sur 45 cas.

Forty-five cases of intractable discogenic low back pain without sciatica were treated by curettage of the disc without grafting. One disc was curetted in 23 cases, two disc in 22 cases. The results are very good in 23 cases, good in 19 cases, and poor in 3 cases. The post-operative follow-up is between 1 and 2 years in 19 cases, 2 and 5 years in 13 cases, and more than 5 years in 13 cases. The length of follow-up and the number of discs curetted bear no relation to the quality of the result. In 8 cases a typical disc protrusion was found. In all other cases the appearance was different from that seen in the surgery of sciatica. Degeneration of the disc was a constant finding and presented various manifestations: simple protrusion, thickening of the posterior vertebral ligament, abnormal compressibility, and even an apparently normal disc, in which degeneration was only demonstrable after incision of the disc. Surgical exploration confirmed in early every case the data from discography. Radiodynamic examination after the operation showed a diminution in the mobility of the curetted disc, but perfect anatomical fusion is not necessary in order to obtain good results. The authors stress the necessity for great care in the selection of patients and in the operative technique.