John P. O'Brien

Induced pain referral from posterior lumbar elements in normal subjects.

Patterns of pain referral, induced from the posterior elements, have been studied in normal volunteer subjects. A series of intracapsular and pericapsular injections were performed at the L1 - 2 and L4-5 levels. The areas of pain referral indicate overlap between the upper and lower lumbar spine. It is also shown that the pericapsular and intrafacetal pain referral areas are similar and that the upper lumbar spine is more sensitive than the lower.

Simultaneous Combined Anterior and Posterior Fusion, An Independent Analysis of A Treatment for the Disabled Low-back Pain Patient

Sixty-nine patients were treated by a simultaneous combined anterior and posterior fusion for disabling low-back pain as directed by discographic pain provocation. They were evaluated independently, with an average follow-up of 2 1/2 years (range, 1.6 to 4.1 years). Fusion rates in excess of 90% were noted in patients who had undergone one- and two-level fusions, whereas the fusion rate for three-level procedures dropped to 77.8%. Acceptable clinical results were seen in approximately 80% of the primary low-back pain and the postlaminectomy patients. Results within the group of patients who had undergone previous fusion procedures were less favorable: two thirds good or fair. The available evidence suggests that this procedure is a valid surgical technique, especially applicable to multilevel lumbar fusions and the postlaminectomy patient. Despite its seemingly radical nature, it can be performed quickly and safely with adequate surgical training.

Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes.

Twenty-five out of 41 adult patients suffering from their first attack of acute low-back pain were subjected to local anesthetic injection into the maximally tender lumbar apophyseal joints under controlled conditions. Two clinical syndromes can be identified according to whether the patients responded to the facet injection or not. Various clinical differences were statistically significant and included a wider than normal spinal canal in the responding group. The clinical significance of these two distinct groups is discussed in detail.

Acute traumatic intraosseous disc herniation.

The clinical, radiologic, and discographic findings are reviewed in eight patients with acute traumatic intraosseous disc herniation. The syndrome should be considered in adolescent patients having severe back pain with limited radiation to the upper thigh, following significant compression/flexion stress to the spine. The intraosseous disc herniation can be confirmed by discography and reproduction of symptoms during the procedure is a helpful confirmatory feature. The radiologic natural history of the lesion is presented, and the role of bone scintigraphy is discussed. This type of injury may be responsible for considerable pain and disability in the adolescent age group and has proved extremely difficult to manage except by conservative treatment and analgesics.

Isolated intervertebral disc resorption. A source of mechanical and inflammatory back pain

Seven patients underwent anterior interbody spinal fusions to alleviate pain due to resorption of an intervertebral disc. The anterior annulus of the discs at operation was inflamed. The specimens were studied histologically, and the findings are discussed. The demonstration of inflammation in the anterior annulus together with the recent identification of nerve fibres in the anterior annulus now allows a better understanding of discogenic pain and its management.

Fissuring of the posterior annulus fibrosus in the lumbar spine

Severe back-ache in young adults may present a difficult clinical problem when the absence of neurological signs results in delayed diagnosis. Fourteen patients, with discographic evidence of posterior annular fissuring are reported. The discrepancy between painful disability and negative radiographic examination including radiculography is stressed. Discography has proved to be the investigation of choice in these patients. This will demonstrate the morphology of the lesion and reproduce the symptomatology in the majority of cases. The clinical implications are discussed.

Comparisons of Preoperative and Postoperative Mmpi Data in Chronic Back Patients

The purpose of this study was to analyze 42 patients disabled with low-back pain in order to assess (1) Minnesota Multiphasic Personality Index (MMPI) changes before and after surgery, (2) the predictive value of MMPI, (3) the results of anterior lumbar fusion in one group of severely disabled lumbar low-back pain patients. Statistical analyses were performed to compare and contrast MMPI, pain assessment, functional and occupational levels, and disability index before and after surgery. The degree of morbidity of the patients preoperatively was severe. After surgery, the majority of the patients showed improvement in their overall status. The available evidence suggests the following: (1) Improvement in physical condition can produce improvement in psychological test scores; (2) The preoperative MMPI is not a reliable indicator of surgical success.

ALTERATIONS IN VERTEBRAL GROWTH FOLLOWING PROLONGED PLASTER IMMOBILISATION

Long-term immobilisation in serial plasters for scoliosis, including the period of the adolescent growth spurt, leads to an increase in height of the vertebral bodies and a decrease of their height to width ratio. These changes are at the expense of the disc which is reduced in thickness. This stimulating effect on the vertebral body growth is probably due to the changes in mechanical factors.

Disc damage above a spondylolisthesis

Fifty-two patients with low back pain and spondylolisthesis at L5/S1 had discograms performed at the L4/L5 level. Retrolisthesis at L4/L5 occurred in 44%, but no direct relationship was demonstrated between the extent of retrolisthesis and either the grade of spondylolisthesis or the presence of disc damage. There was an inverse relationship between the degree of spondylolisthesis and L4/L5 disc damage. Thirty-six patients were assessed for symptomatic pain reproduction during discography. Fourteen (39%) had normal nuclear morphology and no pain induction on injection. Twenty-two patients had disc damage and 11 (50%) had symptomatic pain induced by injection. These results were correlated with the discographic appearances.

Spondylarthrography: The demonstration of spondylolysis by apophyseal joint arthrography

Twenty selected patients with spondylolysis have been studied following apophyseal joint arthrography. In each instance a communication with the defect of the pars interarticularis was demonstrated by the extension of contrast medium from injection into the adjacent facet joint. The clinical and radiological features are described. The anatomical basis of the abnormality is presented using macroscopic and radiographic correlation from a dissected cadaveric specimen of spondylolysis. Sixty-five per cent of the patients experienced significant relief of pain symptoms when long-acting local anaesthetic was introduced into the facet joint.