Sakari Einola

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.

Lumbar Muscles: Structure and Function

We review new data derived from careful dissection studies on the macroscopic anatomy, innervation and function of the lumbar muscles, as well as information on the fibres in these muscles. The new findings correct previous misconceptions of the functional anatomy of the lumbar muscles. The innervation and function of the erector spinae and multifidus muscles are so different that they cannot be classified as a single unit. The new interpretation of the innervation of multifidus muscle is of importance, for example, for the neurophysiological examination of the lumbar muscles. The relative number of the slow and fast type of muscle fibres in lumbar muscles varies considerably, and selective atrophy of the fast fibres seems to ensue from inactivity, not only in patients with back pain but also in sedentary controls. The atrophy may be corrected by adequate exercise. Both the fibre type composition and degree of atrophy may well influence a persons susceptibility to low back pain arising from the muscles.

Patellectomy after fracture. Long-term follow-up results with special reference to functional disability.

Twenty-eight out of a group of 38 patients, who had undergone a patellectomy during the period 1950-70, were investigated clinically and radiologically. The results were compared with the subjective symptoms of the patients to see if there was a correlation. The follow-up period was 7.4 years on average. A good subjective result was reported by only six patients. The predominant subjective symptoms were weakness of the limb and pain on movement and/or exertion. The most usual findings were atrophy of the quadriceps muscle, crepitation, and palpation tenderness. The muscular power of the quadriceps was found to be greater than or equal to 75 per cent of the power of the intact knee in only seven cases (25 per cent).

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.

CT Five Years after Myelographic Diagnosis of Lumbar Disk Herniation

Fifty-seven patients were examined with CT 5 years after primary myelography for disabling sciatica and suspected herniated lumbar disk. Forty were in an operated group, 22 with good and 18 with poor results evaluated by occupational handicap (21) 5 years after surgery. Seventeen patients had myelography indicating disk herniation, but were treated conservatively, 9 with good and 8 with poor result. Various spinal dimensions measured at CT did not correlate with outcome. Operated patients had narrower canals than others, and male canals were broader than those in females. Increased amount of scar tissue at L4 level correlated with poor result (p = 0.008). Operated patients with poor result had more advanced lateral stenosis than those treated conservatively (p < 0.001). Patients with good result after operation had more degeneration observed on CT of erector spinae muscle than those treated conservatively with good outcome. Only 9% of operated patients did not have muscle degeneration. A tendency for more frequent recurrent disk herniations could be seen for conservatively treated patients. The narrowing of the spinal canal 5 years after operation did not correlate with the 5-year outcome.

Effects Of Sodium Aurothiomalate On Hyaluronic Acid Synthesis In Normal And Rheumatoid Synovial Fibroblast Cultures

In studies with normal and rheumatoid synovial fibroblast cultures the effects of sodium aurothiomalate on the quantity and quality of hyaluronic acid were tested. This gold compound produced one clear effect: the molecular weight of hyaluronate produced by rheumatoid fibroblasts was increased (shifted towards normal) whereas the effects on the amounts of hyaluronic acid synthesized were small in both rheumatoid and control cultures. The importance of this finding in relation to the known beneficial effects of gold preparations in clinical medicine is discussed.

Postoperative synovial fluid metabolic response to meniscectomy or synovectomy

The metabolic response of synovial tissue to surgery was investigated by synovial fluid analysis after two types of operations, medial meniscectomy and synovectomy. Analyses of intra-articular fluid were also performed in non-operated patients with traumatic effusion or chronic synovitis in the knee. It was found that the knee joint metabolism in chronic synovitis is shifted towards anaerobic glycolysis in both operated and non-operated patients whereas meniscectomized and traumatized knees are more capable of maintaining oxidative metabolism. The data also demonstrate that one of the main reasons for decreased oxygen supply on the articular surface after meniscectomies or synovectomies is excessive intra-articular effusion which, according to earlier investigations, produces pressure in the joint cavity and inhibits local capillary circulation.