Hannu Alaranta

Lumbar spinal stenosis : assessment of long-term outcome 12 years after operative and conservative treatment

The present study focuses on the long-term prognosis of radiographically verified stenosis of the lower lumbar spine. The purpose here was to describe the outcome 12 years after radiographic diagnosis of spinal stenosis and to identify factors predicting disability after operative or conservative treatment. Data were compiled on 75 patients (43 men and 32 women) with changes in functional myelography diagnostic for spinal stenosis. Their mean age at the interview 12 years later was 61 years. The sagittal diameter of the dural sac was measured from baseline myelographs at all intervertebral levels and was corrected for magnification. In the interview, subjective outcome assessment was obtained with a structured questionnaire, and the low-back disorder was scored using the Oswestry disability index. The sagittal diameter of the dural sac was severely stenotic (<7.0 mm) in 32 patients (26 operated), and moderately stenotic (7.0-10.5 mm) in 43 patients (31 operated). The severity of the stenosis significantly predicted disability, even when the effects of age, sex, therapy regimen, and body mass index were adjusted for. For moderate and severe stenosis, the adjusted mean Oswestry indices were 28.4 and 39.1, respectively (p = 0.01). Therapy as such (operative versus nonoperative) did not significantly correlate with later disability. The radiographic severity of lumbar spinal stenosis predicts disability independently of therapy regimen. Randomized clinical trials are needed to establish the indications for surgical and conservative treatment. Radiographic severity of the stenosis should be considered as an effect-modifying or confounding factor in clinical trials and other studies focusing on the outcome of lumbar spinal stenosis.

Fat content of lumbar extensor muscles and low back disability: a radiographic and clinical comparison.

The fat content of the lumbar back extensor muscles was assessed from computed tomograms and correlated to self-reported disability in 39 consecutive chronic low back pain patients. The assessment for the quality of fat was done separately for the three lowest lumbar intervertebral levels. The Oswestry index was used to evaluate the low back disability. Analysis showed positive relationship between the fat content of the lumbar paraspinal muscles at lumbosacral level and self-reported disability in men. The relationship was weaker in women, and at higher lumbar levels it was not found in either sex.

Calcitonin treatment in lumbar spinal stenosis: A randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up

SummaryA randomized, placebo-controlled, double-blind, crossover study in 40 lumbar spinal stenosis patients with a 1-year follow-up showed that calcitonin had beneficial effects on the patients symptoms without producing any notable side effects. Calcitonin had a clear analgesic effect. The mean of walking distance increased, but the crossover trend was not as good as the analgesic effect. Side effects such as erythema and nausea were usually mild and transient. Calcitonin therapy can be used as a conservative treatment in selected cases of lumbar spinal stenosis. When rest pain was mild or the walking distance was under 200–300 m because of neurogenic claudication, the effect of calcitonin seemed to be poor.

Spondylodesis augmented by transpedicular fixation in the treatment of olisthetic and degenerative conditions of the lumbar spine.

Fifty-one patients having lumbar or lumbosacral posterolateral fusion with pedicle screw internal fixation were reviewed retrospectively two years after the fusion by an independent observer. In 44 patients, the underlying condition was lytic or degenerative spondylolisthesis. The internal device was removed one year after the fusion. The fusion rate was 94%. The subjective disability was assessed using the Oswestry disability index. The mean Oswestry score was 38% preoperatively, and 24% two years after the fusion. Preoperatively, only every fifth patient was able to work; two years postoperatively, almost 60% held jobs. Complications due to internal fixation were recorded in 57% of the cases. Most of these, such as screw breakage and screw loosening in the sacrum, were of no clinical importance. The use of internal fixation seems to enhance the fusion rate but is associated with more complications than posterolateral fusion without implants.

Lumbar mobility in asymptomatic individuals

A radiological study of angulatory and translational lumbar mobility and of lumbar scoliosis was performed on 56 persons aged 35-54 years who had no history of back pain. The measurements of mobility were based on extension-flexion views; the assessment of scoliosis was done using radiographs taken in the standing position. The results indicated that the largest range of angulatory motion occurred in the L5-S1 segment (mean, 17.3 degrees for women and 16.4 degrees for men). Five-millimeter translational motion was so common in the L3-L4 and L4-L5 segments, as was 4-mm in the L5-S1 segments, that these values cannot be considered with certainty as pathological. Ten subjects (18%) showed scoliosis of > or = 10 degrees. Although based on a small series, these results are a step toward a more objective and careful interpretation of extension-flexion and functional radiographs of low-back pain patients.

Calcitonin treatment in lumbar spinal stenosis: Clinical observations

SummaryThe prognosis of patients with lumbar spinal stenosis is usually considered poor, and they often need decompression surgery. This study investigates the clinical efficacy and safety of intramuscular calcitonin therapy in 15 lumbar spinal stenosis patients with a neurogenic claudication syndrome. The study is based on several tests used to measure the patients physical performance capacity. Calcitonin had some beneficial effects on the patients without appreciable side-effects. Because of possible placebo effect, a double-blind crossover study has been started.

External fixation test in low back pain : function analyzed in 25 patients

We recorded the musculoskeletal performance capacity of 25 patients suffering from chronic severe low back pain before and during the external fixation test of the lumbar spine. The capacity was measured by isometric and isokinetic lifting, repetitive upper extremity lifting with a load, repetitive squatting, and the walking distance. Only walking distance was increased by fixation of the spine.

Fibrinolytic defect in chronic back pain. A controlled study of plasminogen activator activity in 20 patients.

We analyzed the fibrinolytic system in patients with chronic low back pain using a venous occlusion test to stimulate fibrinolysis, and we subsequently determined the levels of tissue plasminogen activator (TPA) and fast-acting inhibitor of TPA (PAI). There were 20 patients with a mean age of 50 years. Two thirds had radiographically spinal stenosis. Scar tissue around the spinal nerves was seen in 11 cases. Thirteen patients had undergone back surgery, whereas 21 healthy subjects served as controls. In the basal samples, TPA activity was decreased in the patients while TPA antigen level was increased compared with the controls. No clear explanation for this defective function of TPA in the patients was obtained, because no difference was seen in PAI level in basal samples. After the venous occlusion, no difference was observed in TPA activity between the two groups excluding the constitutionally defective fibrinolytic system in the patients. However, our results confirm low basal fibrinolytic activity in patients with chronic low back pain with manifest spinal pathology.

Letter to the Editor Severe Frostbite of the Upper Extremities — a Psychosocial Problem Mostly Associated with Alcohol Abuse

In the catchment area of Helsinki University Central Hospital (in total 16 surgical hospitals) amputation was performed on 9 patients with frostbite in the upper extremities during 1984-1985. The population during the study period in this area was 1.165,000 inhabitants, corresponding to 24% of the whole population in Finland. All 9 patients were male and the mean age was 49 years (range 31-75). All amputations performed were of the fingers, the third, fourth and fifth fingers most frequently affected. Alcohol was a marked etiologic or contributing factor in most of the frostbites. Two patients were chronic schizophrenics showing no signs of alcohol abuse, but the remaining 7 were either acutely or chronically alcohol intoxicated: 5 patients were chronic alcoholics, one was an alcohol abuser without a definite diagnosis of alcoholism, and one patient with no previous history of alcohol abuse was alcohol intoxicated. Based on the present study it is clear that, in addition to the cold winters in Finland, other factors contribute to severe frostbite. These include many psychosocial factors such as alcoholism or mental disease, unbalanced marital status, occupation handicap and lack of regular residence.In the catchment area of Helsinki University Central Hospital (in total 16 surgical hospitals) amputation was performed on 9 patients with frostbite in the upper extremities during 1984-1985. The population during the study period in this area was 1.165,000 inhabitants, corresponding to 24% of the whole population in Finland. All 9 patients were male and the mean age was 49 years (range 31-75). All amputations performed were of the fingers, the third, fourth and fifth fingers most frequently affected. Alcohol was a marked etiologic or contributing factor in most of the frostbites. Two patients were chronic schizophrenics showing no signs of alcohol abuse, but the remaining 7 were either acutely or chronically alcohol intoxicated: 5 patients were chronic alcoholics, one was an alcohol abuser without a definite diagnosis of alcoholism, and one patient with no previous history of alcohol abuse was alcohol intoxicated. Based on the present study it is clear that, in addition to the cold winters in Finland, other factors contribute to severe frostbite. These include many psychosocial factors such as alcoholism or mental disease, unbalanced marital status, occupation handicap and lack of regular residence.