The natural history of herniated nucleus pulposus with radiculopathy

STUDY DESIGN

The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis.

OBJECTIVES

The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur.

SUMMARY OF BACKGROUND DATA

The study population consisted of 77 patients with radiculopathy.

METHODS

All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times.

RESULTS

Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence.

CONCLUSION

Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.

Spinal cord monitoring of the ventral funiculus function. Analysis of spinal field potentials after galvanic vestibular stimulation

STUDY DESIGN

This study was designed to examine the possibility of a new spinal cord monitoring method using galvanic vestibular stimulation to monitor the function of the ventral funiculus of the spinal cord.

OBJECTIVES

To settle the problems of previous monitoring methods by using galvanic vestibular nerve stimulation, which is highly selective for monitoring the function of the ventral funiculus of the spinal cord.

SUMMARY OF BACKGROUND DATA

Although various spinal cord monitoring methods have been used, there are still problems because potentials recorded by these methods do not reflect selectively the function of the ventral funiculus of the spinal cord, which is vulnerable during anterior spinal surgeries.

METHODS

In anesthetized cats, field potentials evoked by galvanic stimulation of the labyrinth were recorded from the epidural space of the spinal cord. The origin of these potentials was determined by mapping field potentials from within the upper cervical spinal cord using a micropipette and by examining the effect of sectioning the brainstem on the evoked potentials.

RESULTS

The spinal cord potentials evoked by galvanic stimulation between the bilateral labyrinths could be recorded from the epidural space, and these potentials mainly originated from the ventral and ventromedial funiculus of the spinal cord. The latency and intraspinal distribution of the evoked potentials and the effect of sectioning the medial longitudinal fascicle on the evoked potentials indicated that the earliest component of the evoked potentials reflects mainly the activity of the vestibulospinal tract.

CONCLUSIONS

Recording spinal cord potentials evoked by galvanic vestibular stimulation from the epidural space appears to be a potential technique to monitor the functional state of the ventral funiculus during anterior spinal surgeries.

A new method of multisegment motor pathway monitoring using muscle potentials after train spinal stimulation

STUDY DESIGN

Evoked muscle and nerve action potentials after spinal stimulation for intraoperative monitoring were investigated using a modified stimulation technique. Animal experiments and clinical application were performed.

OBJECTIVES

To contrive a useful method of intraoperative motor pathway monitoring under inhalation anesthesia.

SUMMARY OF BACKGROUND DATA

Many different kinds of procedures have been reported. No reliable method that reflects pure motor tract function has been established.

METHODS

Characteristic of our stimulating technique was the use of numbered consecutive pulses ("train stimulation"). In 16 cats, optimum condition of train stimulation, effects of anesthetic agents, and conductive pathway were examined. In 35 patients, muscle potentials evoked by train stimulation were recorded, and clinical usefulness was evaluated.

RESULTS

In the experimental study, the optimum stimulus condition was determined 1 ms interstimulous interval train of five pulses. Conductive pathway of this method was identified as a lateral column by selective spinal cord transection. In the clinical application, by using train stimulation, multisegmental muscle potentials were obtainable even using inhalation anesthetics.

CONCLUSIONS

The facilitative effects of train stimulation, attributed to temporal summation, are considered to overcome the suppression of inhalation anesthesia. The evoked muscle potentials by train spinal stimulation reflect the functions of pure motor tract and is the only, extremely efficient method for intraoperative motor pathway monitoring.

Reduced neck movement after operations for cervical spondylotic myelopathy

Complaints resulting from reduced neck movements were investigated in 50 patients who had operations for cervical spondylotic myelopathy. Seventy per cent had difficulty in performing 11 basic movements of daily living. Lateral bending or rotation were more difficult than flexion and extension. To look backwards was the most difficult movement. Complaints were highest among those in whom more than three levels of fusion had been carried out.

In utero and lactational exposure of the male rat to 2,3,7,8-tetrachlorodibenzo-p-dioxin: impaired prostate growth and development without inhibited androgen production

To determine whether in utero and lactational 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure decreases male rat accessory sex organ weights during postnatal development secondary to decreases in testicular androgen production or changes in peripheral androgen metabolism, pregnant Holtzman rats were administered a single dose of TCDD (1.0 microgram/kg, po) or vehicle on Gestation Day 15 and offspring were exposed via placental and subsequent lactational transfer until weaning on Postnatal Day (PND) 21. Between PNDs 21 and 63, circulating androgen concentrations and intratesticular androgen content tended to be decreased by in utero and lactational TCDD exposure, but in most cases decreases were not statistically significant. In vitro human chorionic gonadotropin-stimulated testosterone production by decapsulated testes from TCDD-exposed animals was not different from control, although 5 alpha-androstane-3 alpha,17 beta-diol production was decreased on PNDs 32 and 49 and increased on PND 63. Taken together, these results imply that in utero and lactational TCDD exposure can cause subtle decreases in testicular androgen production. However, the biological relevance of these reductions is equivocal because they do not correlate temporally with one another or with decreases in androgen-dependent male accessory sex organ weights. Of the male accessory sex organs, ventral prostate (VP) and dorsolateral prostate (DLP) were the most severely affected. Between PNDs 21 and 63, relative VP and DLP weights were decreased to 65-84% and 57-80% of control, respectively, and the magnitude of observed decreases was greatest at early times. In contrast, relative weights of the seminal vesicle and coagulating gland ranged from 80 to 104% of control, and the magnitude of observed decreases was greatest at later times. The sensitivity of the prostate to TCDD could not be explained by tissue-specific decreases in dihydrotestosterone (DHT) concentrations. Although VP DHT concentration was decreased to 63% of control on PND 21, DHT concentration was not decreased in the VP between PNDs 32 and 63 or in the DLP at any time. We conclude that in utero and lactational TCDD exposure selectively impairs rat prostate growth and development without inhibiting testicular androgen production or consistently decreasing prostate DHT concentration.

Isolated muscle atrophy of the distal upper extremity in cervical spinal cord compressive disorders

The purpose of this article is to clarify one mechanism of muscular atrophy of the distal upper extremity that we attribute to cervical compression (Hirayama-type amyotrophy) by medical imaging and anatomical studies of the cervical spine. Five young male patients (mean age: 22.6 years) with this disorder showed characteristic findings to include an abnormal anterior displacement of the posterior dura wall in flexion that resulted in an anteroposterior compression of the spinal cord segment from C7 to C8. To identify an anatomical relationship to this disorder, the lower cervical spine was studied using 11 embalmed adult human cadavers. Abundant posterior epidural ligaments were observed between the posterior dura mater and the ligamentum flavum. Posterior epidural ligaments in the cervical spine have not been reported previously. The anterior displacement of the dura mater may be attributed to a lack of and/or insufficiency of the posterior epidural ligaments.

Dissociated motor loss in forearm and hand muscles: case report

A 27-year-old man was diagnosed with the unilateral dissociated motor loss of the forearm and hand muscles. His medical image findings were completely different from those of other reports such as so called flexion myelopathy (abnormal anterior displacement of the dura mater and the spinal cord against the posterior wall of the vertebral body in neck flexion). Our patient demonstrated lateral shift of the spinal cord to the right attributed to high thoracic scoliosis and disk herniation at the level of C6-7. The right side of the spinal cord was compressed between the disk herniation and the right lamina. In this condition, circulatory insufficiency probably occurred and resulted in damage of the anterior horn, which was selectively vulnerable for ischemia in the spinal cord.

Morphology of C5 ventral nerve rootlets as part of dissociated motor loss of deltoid muscle

STUDY DESIGN

This study analyzed anatomic characteristics of cervical ventral rootlets. After total vertebrectomy, detailed morphology of the ventral rootlets was studied from the anterior.

SUMMARY OF BACKGROUND DATA

The clinical study showed the predominance of ventral root lesion. There are few studies concerning the morphologic pathogenesis of cervical amyotrophy and detailed cervical ventral rootlet anatomy.

METHODS

Thirty-six embalmed adult human cadavers were studied. The measurements for the ventral rootlets of C5 to C8 were made as follows: 1) angle between the rootlet and spinal cord, 2) longitudinal width of the ventral rootlet origin, and 3) length of the ventral rootlets.

RESULTS

The C5 ventral rootlets were shorter and issued more obtusely from the cervical spinal cord than lower rootlets. The spinal cord segment of the deltoid muscle, indicated by the longitudinal widths of the C5 and C6 ventral rootlet exits from the spinal cord, were wider than the C7 and C8 segments. Preforaminal anterior compression at the C4-C5 disc level might affect the lower part of the C5 ventral rootlets and upper part of the C6 ventral rootlets.

CONCLUSION

Short C5 ventral rootlets appeared to become taut and easily injured by hemilateral anterior compression. Spinal cord lesion resulting from localized anterior compression at the single disc level might not play as important a role in the pathogenesis of dissociated motor loss of the deltoid muscle because of the wider spinal segments of C5 and C6.

Giant sacral cysts with neurogenic bladder

Most sacral cysts are accidentally found on lumbar myelograms and are usually asymptomatic. We operated on two patients with giant sacral cysts from S3 nerve roots who complained of neurogenic bladder and perianal sensory disturbance as well as buttock pain. Morphology of these cysts and intraoperative electrophysiological findings of nerve conduction block showed two kinds of pathogenesis causing these neurological symptoms. One was attributed to conduction block of more caudal sacral nerves squeezed between these giant sacral cysts and the other was due to degeneration of nerve root fibers involved in the sacral cyst walls. Postoperatively, buttock pain and perianal hypesthesia were resolved, but the neurogenic bladder showed only partial recovery.

Structural characterization of porcine enteropeptidase

Enteropeptidase (EC 3.4.21.9) is a key enzyme in the intestinal digestion cascade responsible for the conversion of trypsinogen to trypsin, which then activates various pancreatic zymogens. In order to structurally characterize the enzyme, we purified the enzyme from porcine duodenal mucosa and showed that it consists of three polypeptide chains, which we named "mini" chain (M chain), light chain (L chain), and heavy chain (H chain) in order of increasing molecular size. Based on their NH2-terminal sequences, a cDNA clone for porcine enteropeptidase was isolated and analyzed. The clone was 3597 base pairs long, which encoded 1034 amino acid residues of a single-chain precursor form of enteropeptidase. The precursor contained an additional NH2-terminal 51-residue sequence including a putative internal signal sequence, followed by the M chain (66 residues), the H chain (682 residues), and the L chain (235 residues) in that order. The H chain had regions partially homologous in sequence with low density lipoprotein receptor and complement components. On the other hand, the L chain was highly homologous with the catalytic domains of trypsin-like serine proteinases. The structural model of the L chain suggests that the sequence, Arg885-Arg-Arg-Lys888, is probably involved in the unique substrate specificity of the enzyme, preferring acidic amino acid residues at the P2-P5 sites.

[Experimental exposure to carbon monoxide in rats (II)--blood volume of organs obtained by calculations from amounts of carbon monoxide in organ tissues and in blood]

We have found a correlation between the degree of carboxyhemoglobin saturation and the amount of carbon monoxide (CO) in the organ tissues of rats. This essay is titled "Experimental exposure to carbon monoxide in rats (I)". In this report, the blood volumes in organs were calculated from the amount of CO in the blood and in the organ tissues of the same rat. The obtained blood volume (microliter/g of organ tissues) were as follows: spleen 0.196 +/- 0.0222 liver 0.186 +/- 0.0576, lung 0.166 +/- 0.0156, myocardium 0.095 +/- 0.0319, kidney 0.094 +/- 0.0267 and encephalon 0.033 +/- 0.0183. Except for the 10% COHb experimental group, it has become clear that the blood volume in the spleen and in the kidney did not change much despite the variation of degree of carboxyhemoglobin saturation. In order to diagnose the cause of death of a burned cadaver in which the heart did not contain the liquid blood, values of CO amounts should be determined from those in the spleen or the kidney.

The excitability of blink reflexes in patients with neurologic and psychiatric disorders

The blink reflex and its recovery curve were studied in 12 patients with neurologic and psychiatric disorders, i.e., juvenile Parkinson's disease (case 1), Gilles de la Tourette's syndrome (case 2), anorexia nervosa (case 3), mild developmental delay (cases 4 and 5), a meningomyelocele with winking spasms (case 6), Parkinson's disease (cases 7-10) and OPCA (cases 11 and 12). The cases were divided into 4 groups on the basis of the results, (1) hyperexcitability of facial motoneurons only (case 6), (2) hyperexcitability of facial motoneurons and brainstem interneurons (case 1 and 2), (3) hyperexcitability of brainstem interneurons only (cases 4, 5 and 7-12) and (4) hypoexcitability of both sides (case 3). Therefore, as to the excitability an abnormal pattern of blink reflexes could be a neurophysiologic marker of some neurologic and psychiatric disorders.

[Experimental exposure to carbon monoxide in rats (I)--Relation between the degree of carboxyhemoglobin saturation and the amount of carbon monoxide in the organ tissues of rats]

This paper presents the correlation between the degree of carboxyhemoglobin saturation and the amount of carbon monoxide (CO) in the organ tissues of rats. The experiment was performed to make male rats of the Sprague Dawley strain inhalate air containing 0.195% carbon monoxide in the exposure apparatus. Five experimental groups of various degrees of carboxyhemoglobin saturation were made by controlling the length of exposure time to CO gas (0.195% CO in air). After exposure to CO gas, the rats were killed by nitrogen gas. The carboxyhemoglobin saturation levels (COHb%) of each of the experimental group were 12.2 +/- 1.16, 31.6 +/- 2.38, 42.4 +/- 2.11, 52.3 +/- 1.81 and 73.6 +/- 3.01. Immediately following the death of the rats, blood from the right ventricle and several organ tissues were collected and analysed for CO by means of an Ecolyzer Model 2600 (CO analyzer). The order of CO amount in their organ tissues in decreasing order was blood > spleen divided by liver > lung > kidney divided by myocardium > encephalon divided by pectoral muscles. There was a good positive correlation between the degree of carboxy hemoglobin saturation (y%) and the CO content (x microliter/g) in the organ tissues examined. The results obtained were as follows: [table: see text] This report might be useful for deciding the cause of death for a burned cadaver who was discovered in a fire.

Neuroradiologic and electrophysiologic assessment of cervical spondylotic amyotrophy

Dissociated motor loss due to cervical spondylosis and disc herniation was evaluated in 10 patients who presented with left deltoid paresis in the absence of sensory deficits or myelopathy. All of these cases underwent cervical anterior decompression. Based on magnetic resonance imaging, computed tomography myelography, and computed tomography discography, patients were divided into two pathologic types: The first showed focal bony spur and disc herniation with axial cord rotation and nerve root compression, and the second demonstrated ventral cord flattening. Electrophysiologic studies included evoked spinal potentials, motor evoked potentials, and evoked muscle action potentials. Motor evoked potentials, recorded epidurally from the ventral aspect of the thecal sac and the nerve root within the anterior discectomy or vertebrectomy sites, proved clinically most useful. Combining the latest available neuroradiologic and electrophysiologic information, 4 types of neural injury associated with deltoid pareses were identified in the 10 patients. The first included isolated C5 nerve root lesions; the second, C6 nerve root lesions; the third, both C5 and C6 nerve root lesions, and finally, intrinsic cord pathology.

Pseudarthrosis and delayed union after anterior cervical fusion

Anterior cervical spine fusion was carried out on 443 cases between 1965 and 1988 with pseudarthrosis or delayed union in 15 (3.4%). The causes of these complications were malalignment and faulty postoperative care. Symptoms resulted from abnormal mobility, cord compression due to posterior slip or rotation of the upper vertebral body, kyphotic deformity or a problem at the adjacent level. Four out 5 cases with symptoms recovered successfully after a second operation.

Evaluation of cervical diskography in pain origin and provocation

The purpose of this article is to analyze the role of cervical diskography as a diagnostic method via reproduced pain. A nonionic contrast medium (Iohexol) that does not harm normal tissue was used in this series to prevent false-positive provocative pain. One hundred forty-four patients (128 with cervical spondylotic myelopathy, eight with cervical spondylotic radiculopathy, and eight with cervical spondylotic amyotrophy) were studied. Among 72 patients in the symptomatic neck pain group who complained of neck pain before diskography, 65% showed reproduced pain. However, in the control group (neurologic symptoms only) 50% of the patients complained of provocative neck pain during dye injection. These results demonstrated that this provocation technique appeared unreliable for diagnosing symptomatic disk levels.

Studies on new cross-axis coil planet centrifuge for performing counter-current chromatography. III. Speculations on the hydrodynamic mechanism in stationary phase retention

Retention of the stationary phases of one organic-aqueous solvent system and three aqueous-aqueous polymer solvent systems was investigated on a cross-axis coil planet centrifuge. A graphic statistical treatment of all the data highlighted the prevailing effect of the inward-outward elution mode. A simplified model was proposed and studies on the paths and accelerations of cross-axis devices described in the previous paper provided explanations about the observed hydrodynamic behaviors.

Studies on a new cross-axis coil planet centrifuge for performing counter-current chromatography. I. Design of the apparatus, retention of the stationary phase, and efficiency in the separation of proteins with polymer phase systems

An improved model of the cross-axis synchronous flow-through coil planet centrifuge has been designed in light of previous studies. The apparatus has a versatile feature in that both analytical and preparative columns can be accommodated in both off-center and central positions. Each has merit in separations. Retention of stationary phase was examined with various two-phase solvent systems used for the separation of biopolymers. Both analytical and preparative columns showed satisfactory retention of the stationary phase under optimum conditions. The apparatus was evaluated in separation of a set of protein samples using a polyethylene glycol-potassium phosphate biphasic system. In both types of columns all proteins were resolved with partition efficiencies of 260 to 670 theoretical plates. Further studies indicated that the relatively low partition efficiency of proteins is mainly attributed to their high molecular mass or molecular heterogeneity within each species rather than due to the high viscosity of the polymer phase system.

An analysis of failures in primary cervical anterior spinal cord decompression and fusion

Recently, postoperative results of cervical spondylosis, disc herniation, and ossification of the posterior longitudinal ligament (OPLL) after anterior cervical surgeries have improved. However, occasional unsatisfactory cases needing a second operation remain. We analyzed and developed strategies for multioperated neck (MON) cases; all patients had two operations. From 1965 to 1988, 443 cervical anterior surgeries were performed in our hospitals; 53 (12.0%) of these patients needed second operations. These MON cases were classified by the following causes: pseudarthrosis, graft fracture, insufficient decompression, misdiagnosis, and adjacent disc problems. These groups were analyzed, and the resulting surgical strategies, including indications and techniques of anterior surgery, are described.

The blink reflex in neonates with a subsequent poor outcome

We examined maturational changes in the electrical blink reflex in 11 handicapped children, i.e., 4 cases of developmental delay, 4 of cerebral palsy, 2 of congenital hydrocephalus, and 1 of congenital cytomegalovirus infection. The developmental delay and cerebral palsy cases were all born at 25-36 weeks' gestation. In all cases, prolonged latency, low amplitude, or the absence of the late component of the blink reflex was observed in the follow-up study. These results indicate that prematurity and some congenital impairment mainly influence the maturation of the long-loop reflex arc in the blink reflex.

Spontaneous histogenic tumors of epididymis observed in B6C3F1 mice

Four primary histiogenic tumors of the epididymis were discovered in 110 male B6C3F1 mice used in a carcinogenicity study in our laboratory. From the results, all these tumors were considered to be spontaneous. Histologically, the tumors were characterized by compact growth of spindle to oval shape histiocytic cells with or without a cleaved nucleus. Focal hemorrhage was present in three cases, and erythrophagocytosis occurred in such lesions. The tumors had some similar histological features of histiocytic sarcomas, which had been observed with high malignancy in other male and female animals. However, systemic growth and atypsim of neoplastic cells found in the histiocytic sarcomas were not observed in these epididymal tumors. On the other hand, four histiogenic tumors of the uterus, with features characteristic of epididymal tumors, were observed in 106 female mice. The uterine histiogenic tumors were regarded as benign or precursor lesions of histiocytic sarcoma. Furthermore, it is suspected that histiocytic sarcoma arises from the epididymis.

Electrophysiologic studies in an infant with Möbius syndrome

The electrophysiologic findings in an infant with congenital facial diplegia (Möbius syndrome) are presented. As to serial electrically elicited blink reflexes, the R1 amplitude was significantly reduced and the R2 latency was significantly prolonged. The M response of the orbicularis oculi muscle showed slightly reduced amplitude. Auditory brainstem responses exhibited a prolonged time between waves I and V and reduced amplitude of wave V on the right side. Somatosensory evoked potentials and visual evoked potentials were normal. These findings suggest some degree of impairment of the peripheral facial nerve, and brainstem dysfunction including the pons and lateral medulla.

[A case of severe milk allergy. Relationship with type I and Type III allergic reactions]

A case of cow's milk allergy related to type I and type III allergic reactions is reported. The patient is a one-month-old girl. She had watery diarrhea and abdominal distention soon after commencement of milk feeding two weeks after birth. She was cyanotic and floppy on admission. Intravenous complete hyperalimentation was tried to combat her diarrhea with good clinical effect. Then feeding with 605Z milk (enzyme digested cow's milk antigen, Meiji Milk Products Co., Ltd.) was started, and the diarrhea improved. Laboratory findings showed positive milk PK test, elevated IgE score, and positive milk specific RAST score, decreased serum complement, elevated levels of each immunoglobulin class of milk specific antibodies, especially milk specific IgG1 antibody and increased complement absorption test. She was diagnosed as having milk allergy related to both type I and type III allergies from the above-mentioned results. Specific antibodies were diminished after feeding with 605Z. Although her mother had not taken cow's milk over the past 10 years, she took a lot of milk during her pregnancy. But her serum milk specific antibodies were not elevated. It was suggested that the baby's antibodies were not derived from her mother but that the baby produced them by herself.

Effect of OP-41483.alpha-CD, a prostacyclin analog, on a clamp-induced endothelial injury in rats

We studied the effect of OP-41483.alpha-CD, a stable prostacyclin analog, on clamp-induced endothelial injury in rats. The injury was assessed by vascular Evans blue leakage and using a scanning electron microscope. OP-41483.alpha-CD significantly reduced the Evans blue leakage at doses of 30 and 100 ng/kg/min. PGE1.CD was also found to show an equipotent inhibitory action on the dye leakage. From scanning electron microscopic observations, a moderate degree of intimal defects, microvillous projections and platelet adhesions at the luminal surface were seen in the specimens from OP-41483.alpha-CD (30 and 100 ng/kg/min) treated rats. Furthermore, OP-41483.alpha-CD, PGE1.CD and Dibutyryl cyclic AMP (DbcAMP) were found to accelerate a proliferation of cultured bovine endothelial cells in a dose-dependent manner in vitro. Taken together, these data indicate that the endothelial regenerative effect of OP-41483.alpha-CD could contribute to healing of clamp-induced endothelial injury and it may be an important therapeutic drug to protect vascular intimal injury.