Matti Hurme

The multifidus muscle in patients with lumbar disc herniation. A histochemical and morphometric analysis of intraoperative biopsies.

Structural changes in the multifidus muscle were analyzed in 41 patients operated on for herniated intervertebral disc. Twelve cadavers served as controls. The two main findings follow: 1) Both in the patients and in the controls the Type 2 muscle fibers were markedly and selectively smaller than the Type 1 fibers, which were of normal size for striated muscles, and 2) the internal structure of Type 1 fibers showed so-called core-targetoid and/or moth-eaten change. Group atrophy or fiber-type grouping (indicators of denervation and reinnervation) were observed only in a few patients. The selective small size of the Type 2 fibers may indicate atrophy due to relative inactivity of the multifidus muscle both in the patients and in the controls, ie, it does not need to be related to the herniated disc. Definite proof for denervation of the multifidus muscle was not observed, but neither the possibility be excluded. The cause of the core-targetoid and/or moth-eaten changes cannot yet be determined with certainty, because these changes are not specific for any single entity but may be due, for example, to denervation, ischemia, or altered use of the muscles because of pain. In any case, because the changes were significantly more common in the patients than in the controls, they signal for a pathologic condition, the character of which remains to be elucidated.

Rehabilitation after surgery for lumbar disc herniation: results of a randomized clinical trial.

The aim of this prospective study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation randomized in two groups: one with comprehensive rehabilitation and the other taken care of by normal care facilities. A total of 212 patients without any previous spinal operations comprised the final study group. The physiatrist, the surgeon, the social worker, and the psychologist performed the handicap evaluation according to the occupation handicap scales of the WHO. The handicap was evaluated for two phases: before the onset of acute sciatica leading to operation and one year after operation. No significant differences in handicap distribution between the intervention and normal care groups were seen. The postoperative handicap correlated highly significantly with preoperative handicap for both groups. More than half (57%) of all the patients returned to work within two months of the operation. The amount of sick leaves did not differ significantly between the intervention and normal care groups. A total of 15 persons (7%) retired during the postoperative year.

Connective tissue changes of the multifidus muscle in patients with lumbar disc herniation. An immunohistologic study of collagen types I and III and fibronectin.

The connective tissue components, Types I and III collagen and fibronectin, were Immunohistologically analyzed using their specific antibodies for localization and semiquantitative estimation In 24 patients (11 women and 13 men, all under 55 years of age) operated on for hemlated lumbar Intervertebral disc. Nine cadavers without known back problems (2 women, 7 men) served as controls. In controls, Type I collagen was present In the endo- and perlmysial structures of the muscle, more conspiciously In the former. Type III collagen, together with fibronectin, were more abundant In the perimysium than in the endomysium. Thickening of these structures was not evident In the controls. In most patients Types I and III collagen and fibronectin distribution was similar to that of the controls. However, fibrotic changes of both and endo- and perimysial structures Involved all Types I and III collagen and fibronectin In ten cases. In two patients an Increase In Type I collagen staining Intensity in the endomysium was recorded and thickening of the endomysial structures was observed In six patients. There were correlations with the severity of the connective tissue structural changes to atrophy of the muscle and furthermore to disability of the patient In the 1-year postoperative check-up. These findings suggest that If marked fibrosis of the muscle occurs, It can be a factor Impairing recovery from the disease during the long-term postoperative course.

A prospective 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation.

The study consists of 276 patients who were hospitalized between 1980 and 1982 because of suspected lumbar disc herniation. Treatment choice was based on clinical indications only; no randomization was used. A total of 179 patients were treated surgically and 97 had continued conservative treatment. Both groups were followed-up 1 and 5 years later. Five-year follow-up results showed that 68% of operated patients still had pain in sciatic distribution and 21% were retired. Re-operation frequency was 13.8%. Of non-operated patients, 82% still had sciatica and 26% were retired. Reasons for outcome differences between the study groups are discussed.

A Prospective Study of Patients with Sciatica: A Comparison Between Conservatively Treated Patients and Patients Who Have Undergone Operation, Part II: Results After One Year Follow-Up

The prospective study included 122 sciatica patients who had not undergone operation (NOPs) and 220 sciatica patients who had undergone operation (OPs); all had been examined by rhizography. The follow-up study was done on 110 (90%) of the NOPs and 212 (96%) of the OPs. The NOPs were divided into two groups: 30 patients with pathologic rhizography (PR) and 80 patients with negative rhizography (NR). Pain-, ADL-, and occupation-handicap indices showed that after the 1 year follow-up the OP group had the best result and the NR group the lowest result. The PR group had nearly as good a result as the OP group. Thus, sciatica patients are candidates for conservative therapy, even though they have pathologic findings in rhizography, if the symptoms are mild. To improve therapeutic outcome, more accurate diagnostic tools are needed to develop specific therapy especially for those sciatica patients with negative rhizography.

Neurotransmission and the experience of low back pain; no association between csf monoamine metabolites and pain

&NA; We have investigated the possible associations between the demographic, clinical and psychological characteristics of 80 patients with low back pain and the CSF levels of 5‐hydroxyindoleacetic acid (5‐HIAA), homovanillic acid (HVA) and 3methoxy‐4‐hydroxyphenylglycol (MHPG), the principal central nervous system metabolites of serotonin, dopamine and noradrenaline, and of tryptophan, the amino acid precursor of serotonin. Neither the clinical measures nor the psychological characteristics were significantly correlated with the CSF neurochemistry. Therefore the hypothesis about an intimate relationship between monoaminergic neurotransmission and the experience of chronic low back pain was not confirmed. Among the other factors studied, body height contributed most to the variance in both 5‐HIAA and HVA concentrations; the levels of MHPG increased with age.

Neuropeptide converting enzyme activities in CSF of low back pain patients

&NA; The activity levels of a dynorphin converting enzyme (DCE), a substance P endopeptidase (SPE) and a substance P alpha‐amidating enzyme (SP‐GLYE) were measured in the cerebrospinal fluid (CSF) of 90 patients with chronic low back pain, sciatica and neurological signs of rhizopathy. The DCE activity was significantly higher in men than in women. Age was related to the DCE activity independent of sex i.e., older patients had higher enzyme activity. The activities of two substance P converting enzymes were not related to sex or age. Self‐reported pain experience and affective covariates (anxiety, depression, hostility, somatization) of pain, and myelography data were not found to be related to the enzyme activity levels once adjustment had been made for sex and age. The activity levels of the enzymes measured here had no predictive value for the long‐term outcome of rehabilitation and therapy at the 5‐year follow‐up of the patients. The sex difference in DCE activity provides further evidence in favor of the role of gender in the psychoendocrine coping with pain distress.

Clinical, social, and psychological factors and outcome in a 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation

The study consisted of 276 patients who were hospitalized between 1980 and 1982 because of suspected lumbar disc herniation. No randomization of treatment was used. On the basis of clinical indications 179 patients were operated on and 97 had further conservative treatment. Results of physical, social, and psychological examinations performed after 1 year were related to the 5-year outcome defined by occupation handicap of the WHO system. For operated patients, subjective working incapacity, sensory deficit of leg, tightness of hamstrings, age, and pain in lumbar extension predicted a poor outcome. Predictive factors for non-operated patients were increased occurrence of occupational hazards and co-morbidity.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part I: Patient characteristics and differences between groups.

Based on a prospective study on 342 sciatica patients examined with rhizography, the aim was to determine which factors other than the rhizography finding and the grade and duration of symptoms were related to the selection of patients to undergo operation. Compared with surgically treated patients, conservatively treated patients who did not undergo operation and who had pathologic rhizography findings had pessimistic attitudes to possible surgery, often expressed a desire to retire, and considered their work as physically stressful. The women in this group were older and had lower pain indices than women who underwent operation. Conservatively treated patients with negative rhizography had more severe occupational handicaps, minor expectations of possible surgery, physically more strenuous jobs requiring difficult physical positions, and lower indices for pain and ADL than did the operated patients. The social and ergonomie background problems are emphasized in sciatica patients conservatively treated after rhizography.

Clinical findings as outcome predictors in rehabilitation of patients with sciatica.

In rehabilitation of patients with sciatica, factors prognostic of long-term outcome could prove beneficial in interventions and in evaluating progress toward fitness or capacity for work. In this study results of physical examinations, carried out one year after hospital treatment for suspected lumbar intervertebral disc herniation, were related to outcome after five-years, as assessed by the categorization of occupational handicap of the International Classification of Impairments, Disabilities and Handicaps (ICIDH). The sample consisted of 276 patients admitted to hospital in the years 1980-1982. Based on established clinical indications 179 patients underwent lumbar disc surgery and the remaining 97 received further conservative treatment. One year after hospitalization a physician and physiotherapist examined the patients at the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Finland. In 1986 the patients returned to the RRC for further evaluation of their occupational handicap at that time. Stepwise logistic regression analysis showed that sensory deficits of legs, tenderness in lumbar extension, decreased repetitive trunk flexion performance (sit-up test), decreased lumbar lordosis and tightness of hamstrings were indicative of a poor outcome in the operated group. For the non-operated patients no statistically acceptable regression analysis model could be established.