Robert Gunzburg

Low back pain in a population of school children

Abstract A study was undertaken to analyse the prevalence of low back pain (LBP) and confounding factors in primary school children in the city of Antwerp. A total of 392 children aged 9 were included in the study. All children completed a validated three-page questionnaire and they all underwent a specific lumbar spine oriented medical examination during their annual routine medical school control. This examination was performed by the city school doctors. The questionnaire was composed of easy “yes/no” questions and visual analogue scales. Statistical analysis was performed using Student’s t-test and chi-squared test at the significance level P < 0.05. The prevalence of LBP was high. No gender difference was found. A total of 142 children (36%) reported having suffered at least one episode of LBP in their lives. Of these, 33 (23%) had sought medical help for LBP from a doctor or physiotherapist. Sixty-four percent of children reporting LBP said that at least one of their parents suffered from or complained of LBP. This was significantly higher than for the children who did not report having suffered LBP. The way in which the school satchel was carried (in the hand, on the back) had no bearing on the incidence of LBP. There was significantly more LBP in children who reported playing video games for more than 2 h per day, but this was not so for television watchers. The visual analogue scales concerning general well-being were all very significantly correlated with self-reported LBP, with children who reported LBP being more tired, less happy, and worse sleepers. Of the 19 clinical parameters taken down during the medical examination, only one was significantly more prevalent in the group of children reporting LBP: pain on palpation at the insertion site on the iliac crest of the ilio-lumbar ligament. From this study we can establish that there are few clinical signs that can help to single out school children with LBP.

Spine arthroplasty: a historical review

Abstract. Degenerative disc disease is one of the most frequently encountered spinal disorders. The intervertebral disc is a complex anatomic and functional structure, which makes the development of an efficient and reliable artificial disc a complex challenge. Not only is the disc function arduous to reproduce, but there are important consequences associated with the conception and the choice of materials that will have to bear the loads. Biochemical problems have complicated things even more. Two different principles have been applied in the realisation of a discal replacement: a metallic and/or polyethylene prosthesis allowing mainly mobility or a prosthesis enabling the reproduction of viscoelastic properties. Of course some devices attempt to combine both principles. In this paper we will try to present, in chronological order, an overview of the designs published in the literature as well as in the patents granted in this field. The very fact that such a long list of implants, based on highly varied principles, has been proposed, and that only very few have reached the level of animal models, let alone human implantation, clearly demonstrates how challenging the task of designing an intervertebral disc replacement is. Proper randomized controlled trials are now on the way, and should help in assessing the efficacy and real place of spine arthroplasty in the treatment of spinal disorders. Only then will spinal surgery join the list of successful joint replacements.

A cadaveric study comparing discography, magnetic resonance imaging, histology, and mechanical behavior of the human lumbar disc.

The aims of this study were 1) to compare discography and magnetic resonance imaging scanning on cadaver specimens and to correlate these imaging procedures by examining all the discs histologically; and 2) to study the extent to which the amplitude of rotational movement in the neutral and flexed position at a certain level correlates with the morphologic appearance of that disc. Twenty-four human lumbar spines were harvested from cadavers between the ages of 19 and 75 years. Each specimen underwent standard radiography, magnetic resonance imaging scanning, discography, histologic examination, and measurement of axial rotation in a torsion apparatus. For practical reasons, all specimens did not undergo all of the examinations. Not all peripheral anular lesions were detected by discography. Histology showed rim lesions of the anterior anulus in 18% of discs with normal discography. The overall incidence of anterior and posterior anular tears was greater in discs where larger amplitudes of rotation were observed. To which extent the one is a consequence of the other or vice versa is not clear. Magnetic resonance imaging was found to be less specific than discography. However, it must be emphasized that no axial magnetic resonance imaging scans were taken in this study. Discs with significantly decreased amounts of nuclear material (observed at histology) can still produce normal magnetic resonance imaging images. Infolding of the inner layers of the anulus fibrosus (33% anterior, 4% posterior) was a frequently observed feature.

Lumbar spinal stenosis in the elderly: an overview

Lumbar spinal stenosis is a common condition in elderly patients and also one of the most common reasons to perform spinal surgery at an advanced age. Disc degeneration, facet degeneration and hypertrophy, and ligamentum flavum hypertrophy and calcification usually participate in the genesis of a stenotic condition in the elderly. These changes can lead to symptoms by themselves or decompensate a preexisting narrow canal. Although some lesions are more central or more lateral, this classic dichotomy is less present in the elderly patient, in whom the degenerative process usually encroaches both central and lateral pathways. Some less common causes of lumbar spinal stenosis are found in the aging subject, such as Pagets disease. However, it must be stressed that so-called stenotic images (sometimes severe) are present on imaging studies in a great number of symptom-free individuals, and that the relationship between degenerative lesions, importance of abnormal images, and complaints is still unclear. Lumbar stenosis is a very common reason for decompressive surgery and/or fusion. Various conditions can lead to a narrowing of the neural pathways and differential diagnosis with vascular troubles, also common in the elderly, can be challenging. The investigation of stenotic symptoms should be extremely careful and thorough and include a choice of technical examinations including vascular investigations. This is of utmost importance, especially if a surgical sanction is considered to avoid disappointing results.

The conservative surgical treatment of lumbar spinal stenosis in the elderly.

Canal stenosis is now the most common indication for lumbar spine surgery in elderly subjects. Degenerative disc disease is by far the most common cause of lumbar spinal stenosis. It is generally accepted that surgery is indicated if a well-conducted conservative management fails. A meta-analysis of the literature showed on average that 64% of surgically treated patients for lumbar spinal stenosis were reported to have good-to-excellent outcomes. In recent years, however, a growing tendency towards less invasive decompressive surgery has emerged. One such procedure, laminarthrectomy, refers to a surgical decompression involving a partial laminectomy of the vertebra above and below the stenotic level combined with a partial arthrectomy at that level. It can be performed through an approach which preserves a maximum of bony and ligamentous structures. Another principle of surgical treatment is interspinous process distraction This device is implanted between the spinous processes, thus reducing extension at the symptomatic level(s), yet allowing flexion and unrestricted axial rotation and lateral flexion. It limits the further narrowing of the canal in upright and extended position. In accordance with the current general tendency towards minimally invasive surgery, such techniques, which preserve much of the anatomy, and the biomechanical function of the lumbar spine may prove highly indicated in the surgical treatment of lumbar stenosis, especially in the elderly.

Clinical and psychofunctional measures of conservative decompression surgery for lumbar spinal stenosis: a prospective cohort study

Abstract. Less invasive decompressive surgery has emerged as a logical surgical treatment alternative to wide decompression of spinal stenosis. The clinical outcomes of such conservative surgical treatment, however, are not well known. The aim of the study was to evaluate short-term psychometric and functional outcomes after conservative decompressive surgery for lumbar canal stenosis. Forty patients had a lumbar laminectomy procedure, which preserved the integrity of the neural arches, facet joints and most muscle attachments. Pre-operative clinical evaluation of the patients included: Waddells non-organic signs (NOS) performed by an independent surgeon observer; three self-report questionnaires – the Waddell Disability Index (WDI), the Oswestry Low Back Pain Disability Questionnaire (ODI), and the Low Back Outcome Score (LBOS); and a general questionnaire that included a visual analog pain intensity scale (VAS). Post-operative clinical evaluations and questionnaires were obtained in 36 subjects (mean age 59.8 years) after a 1.7-year follow-up (range 1–2.6 years). Pre-operative versus post-operative statistical comparisons of the data were performed using adjusted error rates within families of predictors. Successful surgical outcome was defined as an improvement in at least three of the following four criteria: self-reported pain on a VAS, self-reported functional status measured by LBOS, reduction of pain during walking and reduction of leg pain. At follow-up, there was a statistically significant improvement in VAS pain intensity, ODI, WDI, and LBOS. Patients classified as having mixed stenosis had a higher incidence of continuous pain symptoms in comparison with acquired stenosis, but there was no differential improvement with treatment depending upon stenosis classification and/or number of operative levels. Overall, 58% (21/36) of patients met the successful surgical outcome criteria, including 14 subjects who met all four success criteria. Based upon a stringent definition of successful surgical outcome, the results of a conservative laminectomy were as good as those of more aggressive decompressive procedures presented in the literature. Our findings indicate that, even in a highly organic disorder such as spinal stenosis, illness behavior plays an important role in predicting surgical outcome.

Prevention of hip lag screw cut-out by cement augmentation: description of a new technique and preliminary clinical results.

Cement augmentation of hip lag screws to avoid cut-out displacement is classically described, along with a number of technical drawbacks. In a series of six elderly patients with hip fractures in osteoporotic bone, we illustrate catheter-assisted delivery of limited amounts of a new bisphenol-a-glycidyl dimethacrylate (bis-GMA)–based composite into hip compression screw threads, enabling significant increase in insertional torque compared with unaugmented screws. In two patients, unaugmented screws that did not initially purchase were tightened with a minimum torque of 1 N-m after augmenting with bis-GMA–based composite. No screw or femoral head displacement relative to baseline (2 days postoperative) was seen in any patient on serial x-rays taken up to 6 months after surgery. This technique adds approximately 10 minutes to surgery time. Advantages of bis-GMA–based composite over traditional PMMA augmentation include mixing on-demand, the ability to make repeated injections over extended periods in the event of femoral head perforations (in one patient in this series), precise placement of adequately small volumes of material, and a lower exotherm. Potentially, this bis-GMA–based composite may reduce the frequency of cut-out complications by enhancing bone–implant interface.

A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis.

This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddell’s nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery

Applications of Calcium Phosphate-Based Cancellous Bone Void Fillers in Trauma Surgery

For more than a century, fracture repair has been augmented with autogenous cancellous bone grafting, which supplies 3 requisite properties: growth factors for osteoinduction, progenitor stem cells for osteogenesis, and scaffolding for osteoconduction. However, disadvantages to using autogenous bone include procurement morbidity, longer operative time, and limited availability. Allograft is more readily available but does not supply osteoinductive or osteogenic properties. Better alternatives for bone grafting currently include autologous bone marrow, ceramics, allograft demineralized bone matrix, and regulatory growth factors; however, none of these fulfills all 3 requisite properties. Replacement or augmentation of autograft with a calcium phosphate-based composite graft, which combines the best elements of each component into a single engineered graft, is discussed.

Axial rotation of the lumbar spine and the effect of flexion: An in vitro and in vivo biomechanical study

A series of experiments were performed on eight whole, cadaveric lumbar spines and on eight male volunteers to determine whether axial rotation changed with subjects bending forward compared with being in a neutral posture and whether rotation was affected by articular tropism. Kirschner wires were inserted into the spinous processes of the eight cadaveric lumbar spines, and the axial rotation of the wires was measured while the spine was rotated in a torsion apparatus. Similarly, Steinmann pins were inserted into the spinous processes of L3, L4, and L5 of the eight volunteers, and the axial rotation of the pins was measured while the subjects rotated in a torsion apparatus. Axial rotation was found to be less when combined with forward flexion, and articular tropism did not influence the amplitude of rotation.