David F. Fardon

Nomenclature and Classification of Lumbar Disc Pathology

Standardization of language is difficult, especially among those who have expert knowledge of the subject and clear understanding of what their own words mean. The difficulties must be overcome because deleterious effects ensue when we do not understand what one another’s words mean. Existing dictio

Spine rehabilitation: secondary and tertiary nonoperative care

North American Spine Society Committee: Contemporary Concepts Review Committee Departments of a Orthopedic Surgery and b Psychiatry, University of Texas Southwestern Medical Center, 5701 Maple Avenue, 100, Dallas, TX 75235, USA c Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, 411 N. Washington Avenue, 4000, Dallas, TX 75246-1713, USA d Knoxville Orthopedic Clinic, 1128 Weisgarber Road, Knoxville, TN 37909, USA e Puget Sound Sports and Spine Physicians, 1600 E. Jefferson, 401, Seattle, WA 98122-5698, USA f PO Box 685226, Austin, TX 78768-5226, USA g Department of Orthopedic Surgery, 13 Gibson Road, Hanover, NH 03755-3202, USA h Institute for Spinal Microsurgery, Denver Orthopedic Clinic, 1601 E. 19th Avenue, 5000, Denver, CO 80218-1216, USA

Lumbar disc nomenclature: version 2.0: recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology.

Study Design. This article comprises a review of the literature pertaining to the normal and pathological lumbar disc and the compilation of a standardized nomenclature. Objective. To provide a resource that promotes a clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers. Summary of Background Data. The article “Nomenclature and Classification of Lumbar Disc Pathology. Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology and American Society of Neuroradiology” was published in 2001 in Spine

Odontoid fracture complicating ankylosing hyperostosis of the spine.

Ankylosing hyperostosis of the spine (Forestiers disease) is a distinct clinical entity which must be differentiated from ankylosing spondylitis (Marie-Strumpells disease) and hypertrophic spondylosis. In the case presented, the distinction was made by clinical, roentgenographic, and postmortem pathologic findings. This case had the unique and previously unreported feature of complication by a fracture of the odontoid. The patients particular circumstances led to the decision to treat the fracture by posterior arthrodesis, though this is not necessarily recommended for all spinal fractures occuring in this disease.

Open discectomy as treatment for herniated nucleus pulposus of the lumbar spine

Open discectomy is the “gold standard” for operative intervention in patients with herniated lumbar discs whose conservative treatment has failed. Over 60 years the indications for surgery and the expected success rates have been clearly elucidated. The specific patient selection and determination of surgical procedures continues to evolve. Recurrent herniations occur at a low rate, and serious complications are rare.

What To Do for a Pain in the Neck

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Emerging technologies in spine surgery.

This course will explore the new advances in the field of emerging technologies in spine surgery. We are hoping the course would provide the participants with the current state of the art in the use of technology for treating spinal pathology. Topics include and are not limited to intraoperative imaging, navigation, robotics, next generation microscopes and surgical instruments, combinatorial technologies, augmented reality and surgical simulators.

From the Clinic

The concomitant presentation of tubulointerstitial nephritis and uveitis is known as tubulointerstitial nephritis and uveitis (TINU) syndrome, also known as the Dobrin syndrome. Since first described in 1975, <300 cases have been reported in the medical literature, most of them in children. Establishing the diagnosis of TINU syndrome may be challenging because concurrent acute interstitial nephritis (AIN) and uveitis manifestations may not occur. This might have led to the under-diagnosis of this syndrome. A 60-year-old was referred to the nephrology clinic because of abnormal kidney functions. During her routine follow-up, she was found to have elevated serum creatinine (Scr) and blood urea nitrogen (BUN). One month prior, she presented to the ophthalmologist with bilateral eye pain and redness and was diagnosed with anterior uveitis. At that time she was started on oral prednisone 60 mg daily. The patient did not have any complaints of fever, weight loss, headache, fatigue, malaise, arthralgia, myalgia, flank pain or rash. She denied using any antibiotics or nephrotoxic drugs such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, direct renin inhibitors or nonsteroidal anti-inflammatory drugs. Vital signs were within normal. Laboratory investigations showed a Scr of 2.32 mg/dL (205 μmol/L). Urinalysis showed proteinuria 100+ and hematuria with a moderate number of intact red blood cells. Urine protein to creatinine ratio was 127.5 mg/ g. Renal ultrasound showed normal sized kidneys without gross abnormalities. Renal biopsy revealed diffuse inflammatory infiltrates with lymphocytic predominance affecting the cortex of the renal tubules and the interstitium with associated tubulitis (Figures 1 and 2). The glomeruli appeared nonproliferative and did not show areas of immune complex deposition by immunofluorescence. These pathological features were consistent with active tubulointerstitial nephritis. Given her recent history of uveitis, TINU syndrome was suspected. Antinuclear antibodies (ANA), anti-neutrophil cytoplasmic antibody (ANCA), anti Ro/SSA and La/SSB, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), anti-Smith antibody, angiotensin-converting enzyme (ACE) level, liver function tests, glomerular basement membrane antibodies and thyroid function tests were either normal or negative. The patient was diagnosed clinically with TINU syndrome and treated with prednisone 1 mg/kg/day for 3 months. After 2 months, the eye pain and redness resolved with marked improvement of the kidney function tests [Scr was1.1 mg/dL (97 μmol/L) and estimated GFR 51 mL/min/1.73 m]. Six months after treatment, she continued to be asymptomatic with normal blood pressure and improved kidney function tests. TINU syndrome is defined as tubulointerstitial nephritis associated with uveitis that can occur concurrently, precede or follow the onset of renal dysfunction. Most of the patients with TINU syndrome are children and young adolescents with a median age of 15 years [1] but it has also been reported in adults and in old age. Some of the risk factors for developing TINU syndrome are infection and drug usage such as antibiotics and nonsteroidal anti-inflammatory drugs [1]. The underlying mechanism for TINU syndrome is not clearly known. Genetically predisposed individuals with HLA-DRB1*14 (DR6 subtype), DQA1*01, DQB1*06(DQ1) may be prone to producing the lesions observed in the TINU syndrome upon activation of their immune system [2]. Early diagnosis of TINU syndrome is challenging because patients with this syndrome present with nonspecific systemic manifestations including fever, weight loss, headache, fatigue, malaise, arthralgia and myalgia. Bilateral, or less commonly unilateral, uveitis usually occurs after the onset of AIN but it has been observed to occur 2 months before, concurrently, and up to 14 months after the AIN [1]. Renal manifestations with TINU syndrome may include flank pain, sterile pyuria, hematuria, proteinuria (usually subnephrotic range), renal insufficiency, and/or acute kidney injury (AKI). Renal biopsy is the definitive method of establishing the diagnosis of AIN [3]. TINU syndrome is a diagnosis of exclusion. Other systemic diseases that can cause both uveitis and AIN should be ruled out first. Laboratory findings may include anemia, eosinophilia and elevation of the liver function tests, ESR and urinary beta-2-microglobulin. Krebs von den Lunge-6 (KL-6) glycoprotein, in addition to the mCRP antibodies, might serve as potential laboratory parameters for the diagnosis of TINU syndrome [3]. There is no established standard treatment for TINU syndrome. Early steroid administration (usually prednisone 1 mg/kg/day for 2–3 weeks, followed by gradually tapering dose over 3–4 weeks) is likely to reduce the number and extent of inflammatory infiltrates and subsequent fibrosis [4]. Immunotherapy with methotrexate, cyclosporine A and azathioprine was suggested for the frequent recurrence of ocular involvement [5]. Most reports suggested a good prognosis for TINU syndrome. In contrast, Li et al. [3] reported that 92% of patients with TINU had incomplete renal recovery. In this study the authors found that baseline characteristics such as older age, concurrent thyroid diseases, higher levels of

The Lady Tasting Tea: How Statistics Revolutionized Science in the Twentieth Century,

The review of Salburg’s The Lady tasting Tea by David MacIntosh that follows this introduction was taken from the website http://www.leader-values.com. This wonderful book covers the history of statistics and its impact on science since the early days of the 20 century. It tells the story as a series of anecdotes about the lives, contributions and interactions, sometimes controversial, of the major protagonists. It is a truly delightful account and for the nonstatisticians amongst you who have sometimes haboured negative thoughts towards statistics and your colleagues, think again!