Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12-48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.

Titanium cages in the surgical treatment of severe vertebral osteomyelitis

The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12-56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2 degrees (range -20 degrees to 64 degrees ) by 9.4 degrees to -0.2 degrees (range -32 degrees to 40 degrees ) postoperatively and lost 0.9 degrees during follow-up. All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0-22) in the Roland-Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.

A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

A newly designed technique for a minimally invasive approach to the laterally herniated disc is presented. Fifteen patients suffering from far lateral disc herniation (extraforaminal) were operated according to this technique. Through a small skin incision (1.5 cm), the paraspinal muscles are spread by dilators, until a working channel of 9 mm inner diameter and 11 mm outer diameter can be placed. The next steps are done through this channel using the surgical microscope. No bone resections are necessary and the facet joints are left untouched. However, partial resection of the intertransverse ligament may be necessary. The mean follow-up period for these 15 patients was 11.5 months, and they were evaluated by using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The average surgical time was 43 min. The ODI improved from 30.6 (preoperative) to 14.3 (postoperative). The VAS of leg pain improved from 7 (preoperative) to 3.6 (postoperative), which represented a statistically significant improvement at the significance level of (P<0.01). No intra-operative or early postoperative complications occurred. However, one recurrence did occur, which was treated by the same technique. This technique combines the advantages of three-dimensional visual control (operating microscope) with the minimal surgical trauma of endoscopic techniques, while avoiding some of the shortcomings of both the microsurgical and endoscopic techniques.

Coccygodynia: a proposal for an algorithm for treatment

Coccygodynia (coccydynia, coccygalgia) or coccygeal pain is a well-known but rarely studied painful syndrome affecting the coccyx region. Its etiology is not well understood. Symptoms include development of pericoccygeal soft tissues, pelvic floor muscle spasms, referred pain from lumbar pathology, arachnoiditis of the lower sacral nerve roots, local post-traumatic lesions, and somatization. In spite of advances in the treatment of other pain conditions, coccygodynia remains in a position for which therapeutic options are not clearly designed. On the basis of an anatomic review, proposed pathogenesis of coccygodynia, and the number of treatment approaches that have been proposed, we propose an algorithm for therapeutic decision making in the treatment of this syndrome.

Results of hemivertebrectomy and fusion for symptomatic thoracic disc herniation

We retrospectively analysed ten consecutive patients (age range 32-77 years) treated surgically from 1994 to 1999 for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. Clinically, eight patients had varying grades of back pain and eight patients had paraparesis. Radiography showed calcification in 50% of the herniated discs. Two patients had two-level thoracic disc herniation. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and bone grafting alone in two patients. The average follow-up was 24 months (range 13-36 months). Six patients had an excellent or good outcome, three had a fair outcome and one had a poor outcome. One patient had atelectasis, which recovered within 2 days of surgery. Another patient had developed complete paraplegia, detected at surgery by SSEPs, and underwent resurgery following magnetic resonance (MR) scan with complete corpectomy and instrumented fusion. At 2 years, she had a functional recovery. The patient with poor outcome had undergone a previous discectomy at T9/10. He developed severe back pain and generalised hyper-reflexia following corpectomy and fusion for disc herniation at T10/11. We advocate anterior transthoracic discectomy following partial corpectomy for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. This procedure offers improved access to the thoracic disc for an instrumented fusion, which is likely to decrease the risk of iatrogenic injury to the spinal cord.

Intraspinous postlaminectomy pseudomeningocele

Pseudomeningoceles are uncommon complications of lumbar surgery. They are encapsulated cerebrospinal fluid collections developing extradurally as a consequence of incidental dural tears. They are typically located in the paraspinal compartment and occasionally reach the subcutaneous space. We describe the case of a patient in whom a postlaminectomy pseudomeningocele developed over a 10-year period within the L5 spinous process and remained completely encircled within its bony boundaries. The surgical implications of this finding are discussed.

Potential sources of neck and back pain in clinical conditions of dogs and cats: a review

Pathological neck and back pain occurs in many medical conditions of dogs and cats. Pain may arise from a variety of structures including the intervertebral discs, facet joint capsules, dorsal root ganglia, vertebral ligaments, the vertebral periosteum, and the meninges. The source of this pain is dependent upon the type of disease process and its location within or surrounding the spinal column. Diseases can directly or indirectly stimulate pain sensors (nociceptors). Inflammatory diseases may hypersensitize these receptors or nociceptive pathways with inflammatory mediating substances such as serotonin, histamine and potassium. Diseases resulting in mechanical compression of nociceptors or nociceptive pathways may also result in neck or back pain. A thorough understanding of spinal pain occurring in dogs and cats will lead to more accurate diagnoses and treatments and may provide information regarding prognoses for various diseases. Evidence pointing to sources of spinal pain taken from scientific and clinical studies of a variety of species including humans is provided. Suspected or known sources of neck and back pain occurring in several clinical conditions of dogs and cats are discussed.

Lack of association between lumbar disc degeneration and osteophyte formation in elderly japanese women with back pain

Our study was designed to assess the contributions of the physical and constitutional factors to osteophyte formation, disc degeneration, and bone mineral density (BMD) in lumbar vertebrae of elderly postmenopausal women. A total of 126 Japanese women with back pain, aged over 60 years, were invited to participate in the study. Then 80 subjects with a full set of data for physical examinations, radiographs, MRI, and DXA were examined. TaqI polymorphism of vitamin D receptor (VDR) gene was examined in 60 subjects. Prevalence rates of osteophytes (on radiographs) and disc degeneration (on MRI) were 61 and 68%, respectively. Body weight and BMI correlated significantly with anteroposterior (AP) and lateral (LAT) BMD (r = 0.354 for weight, r = 0.347 for BMI) and mean osteophyte area (r = 0.557 for weight, r = 0.486 for BMI), and body weight also correlated with number of discs with osteophytes. However, these did not correlate with the disc area or the number of degenerated discs. Stepwise regression analysis revealed that body weight and LAT-BMD values independently related to the osteophyte area. Disc area (r = 0.386 for AP view) and osteophyte area (r = 0.384 for AP view) significantly correlated with BMD. However, disc area and osteophyte area did not correlate with each other (r = 0.056). The proportion of degenerated discs was higher in the lower lumbar discs, but not the proportion of discs with osteophytes. Frequencies of T and t alleles of VDR did not correlate with disc degeneration, osteophyte formation, or osteoporosis. Our data showed that increases in osteophyte formation and BMD in the lumbar vertebrae are influenced by body weight and BMI, but did not correlate with disc area, which correlated inversely with BMD. Disc degeneration and osteophyte formation seem to represent two different factors that affect lumbar spine in elderly women.

Nail patella syndrome: a review of the phenotype aided by developmental biology

Nail patella syndrome (NPS) is an autosomal dominant condition affecting the nails, skeletal system, kidneys, and eyes. Skeletal features include absent or hypoplastic patellae, patella dislocations, elbow abnormalities, talipes, and iliac horns on x ray. Kidney involvement may lead to renal failure and there is also a risk of glaucoma. There is marked inter- and intrafamilial variability. The results of a British study involving 123 NPS patients are compared with previously published studies and it is suggested that neurological and vasomotor symptoms are also part of the NPS phenotype. In addition, the first data on the incidence of glaucoma and gastrointestinal (GI) symptoms in NPS are presented. NPS is caused by loss of function mutations in the transcription factor LMX1B at 9q34. The expansion of the clinical phenotype is supported by the role of LMX1B during development.

MR imaging of the lumbar spine: relation of posterior soft-tissue edema-like signal and body weight

OBJECTIVE

Our purpose was to determine the association between posterior lumbar spine subcutaneous edema, fluid collections, and body weight on lumbar spine MR imaging.

MATERIALS AND METHODS

MR images of the lumbar spine obtained at 1.5 T of 307 consecutive outpatients (191 female, 116 male) were reviewed on the basis of MR imaging signal characteristics for the presence, degree, size, and location of presumed subcutaneous posterior soft-tissue edema and fluid collections. The patients were divided into three weight groups (<70, 70-85, or > 85 kg) and two age groups (<50 or >/=50 years old). Edema was graded on a scale of 0-5 according to its length relative to the vertebral bodies. When present, the fluid collection volumes were calculated. The vertical epicenter of the signal abnormality was noted by vertebral body level.

RESULTS

Lumbar soft-tissue edema was seen in 121 patients (39%), and discrete fluid collections were seen in 53 patients (17%). Both degree of edema and volume of fluid collection were associated with increasing weight (p < 0.001 and p = 0.002, respectively) and increasing age (p < 0.001 and p = 0.01, respectively). The degree of edema in females was significantly greater than in males (p = 0.003). However, the sex of the patient did not correlate with frequency of fluid collections (p = 0.12) or volume of collections (p = 0.08). The mean epicenters of edema in females and males were at similar levels (L3.4 and L3.9, respectively, p = 0.54).

CONCLUSION

The severity of posterior lumbar subcutaneous edema and the volume of fluid collections on MR imaging are associated with increased weight.

Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients

OBJECT

The current North American experience with minimally invasive vertebro- and kyphoplasty is largely limited to the treatment of benign osteoporotic compression fractures. The objective of this study was to assess the safety and efficacy of these procedures for painful vertebral body (VB) fractures in cancer patients.

METHODS

The authors reviewed a consecutive group of cancer patients (21 with myeloma and 35 with other primary malignancies) undergoing vertebro- and kyphoplasty at their institution. Ninety-seven (65 vertebro- and 32 kyphoplasty) procedures were performed in 56 patients during 58 treatment sessions. The mean patient age was 62 years (+/- 13 years [standard deviation]) and the median duration of symptoms was 3.2 months. All patients suffered intractable spinal pain secondary to VB fractures. Patients noted marked or complete pain relief after 49 procedures (84%), and no change after five procedures (9%); early postoperative Visual Analog Scale (VAS) pain scores were unavailable in four patients (7%). No patient was worse after treatment. Reductions in VAS pain scores remained significant up to 1 year (p = 0.02, Wilcoxon signed-rank test). Analgesic consumption was reduced at 1 month (p = 0.03, Wilcoxon signed-rank test). Median follow-up length was 4.5 months (range 1 day-19.7 months). Asymptomatic cement leakage occurred during vertebroplasty at six (9.2%) of 65 levels; no cement extravasation was seen during kyphoplasty. There were no deaths or complications related to the procedures. The mean percentage of restored VB height by kyphoplasty was 42 +/- 21%.

CONCLUSIONS

Percutaneous vertebro- and kyphoplasty provided significant pain relief in a high percentage of patients, and this appeared durable over time. The absence of cement leakage-related complications may reflect the use of 1) high-viscosity cement; 2) kyphoplasty in selected cases; and 3) relatively small volume injection. Precise indications for these techniques are evolving; however, they are safe and feasible in well-selected patients with refractory spinal pain due to myeloma bone disease or metastases.

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'

STUDY DESIGN

Case reports and survey of literature.

OBJECTIVE

Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse.

SETTING

Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted.

RESULTS

After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated.

CONCLUSIONS

Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.

Posterior reduction and anterior lumbar interbody fusion in symptomatic low-grade adult isthmic spondylolisthesis: short-term radiological and functional outcome

The aim of this study was to evaluate the short-term radiological and functional outcome of surgical treatment for symptomatic, low-grade, adult isthmic spondylolisthesis. Twelve patients underwent a monosegmental fusion for symptomatic spondylolisthesis. Posterior reduction with pedicle screw instrumentation was followed by second-stage anterior interbody fusion with a cage. All patients underwent a decompressive laminectomy. At an average of 2.1 (range 1.4-3.0) years following surgery, all patients completed the Oswestry questionnaire, VAS back pain score and a questionnaire detailing their work status. Radiographs were evaluated for maintenance of reduction and fusion. The patients (nine male, three female; mean age 42, range 22-54 years) had experienced preoperative symptoms for an average of 38 (range 6-96) months. An average preoperative slip of 21% (range 11-36%) was reduced to 7% (range 0-17%). Reduction of slip was maintained at latest follow-up, at which time the average VAS score was 2.8 (range 0-8) and the average Oswestry score was 13 (range 0-32). All patients achieved a successful fusion. There were no postoperative nerve root deficits. All patients stated that they would be prepared to undergo the same procedure again if required. Seventy-five percent returned to their pre-symptom work status. Our findings suggest that posterior reduction and anterior fusion for low-grade adult isthmic spondylolisthesis may yield good functional short-term results. A high fusion rate and maintenance of reduction with a low complication rate may be expected. Further follow-up is necessary to evaluate long-term outcome.

Burst fracture of the fifth lumbar vertebra: results of posterior internal fixation and transpedicular bone grafting

Burst fractures of the fifth lumbar vertebra are rare, and there are only a few reports on this subject, which is characterised by its unique anatomical and biomechanical features. This retrospective analysis reports on ten patients whose fractures of L5 were stabilised with a short internal fixator in combination with a posterior fusion as well as transpedicular bone grafting. The average follow-up period was 22 months. Radiometric data were surveyed and compared to the functional results. The height of the fractured vertebra remained nearly unchanged throughout the course. Loss of lordosis of 4 degrees in the upper disc space and 4 degrees in the lower disc space were observed postoperatively. At the time of follow-up, the values of segmental lumbar lordosis were significantly below the preoperative level. The narrowing of the neural canal was reduced from 57% to 28% with the surgical intervention. However, there was no correlation between the functional and the radiological outcome. Neurological deficits were documented in two patients, which declined during the course. There were no severe postoperative complications. The results of the present study demonstrate that the described surgical procedure in fractures of the fifth lumbar vertebra does not promote an anatomic restoration of the fractured vertebra, nor of the segmental lordosis. However, the clinical results do not correlate with the radiological outcome. Nonoperative treatment with early mobilisation without external support seems to be the treatment of choice.

Vertebral body compression fracture after removal of pedicle screws: a report of two cases

While the risks of pedicle screw insertion are well established, there is a paucity of reports on complications associated with implant removal. We report two cases of acute osteoporotic vertebral compression fractures of the instrumented vertebral body adjacent to the fractured vertebra due to removal of pedicle screws in two female patients previously treated for vertebral lumbar burst fractures. Both patients had experienced only mild occasional pain at the thoracolumbar junction prior to the removal of the implants. In the formerly almost asymptomatic individuals, the acute osteoporotic fractures led to persistent severe back pain despite prolonged intensive treatment. Patients must be thoroughly informed of the rare but potential risks of spinal implant removal, particularly in cases of osteoporosis. We therefore do not recommend removal of spinal implants unless there are clear clinical indications for implant removal.

Immunohistochemical findings in notalgia paresthetica

BACKGROUND

Notalgia paresthetica (NP) is a sensory neuropathy the pathogenesis of which is not yet completely elucidated.

OBJECTIVE

The aim of this study was to investigate the histopathological changes in NP with special emphasis on cutaneous innervation.

METHODS

Along with site-matched biopsies from 5 healthy individuals, lesional skin biopsies from 14 cases of NP and biopsies from contralateral nonlesional skin in 9 of these cases were stained with hematoxylin-eosin and Congo red. For immunohistochemical analysis, all samples were stained with two general neural markers (S-100 protein and protein gene product 9.5) and two neuropeptides (vasoactive intestinal polypeptide and substance P).

RESULTS

Light microscopy was compatible with postinflammatory hyperpigmentation. Immunohistochemistry did not reveal a significant difference in the staining pattern of lesional skin and control tissue (p > 0.05). Although not reaching statistical significance, the percentage of cases which showed no staining was higher in the group of patients with more chronic NP.

CONCLUSION

The finding of less immunohistochemical staining in cases with more chronicity could be of clinical importance and is worth investigating further.

[Continual epidural therapy in lumbosciatic syndrome. Personal experience]

BACKGROUND

The purpose of this retrospective study was to evaluate the effects of associating several currently used drugs: local anesthetics, corticosteroids, morphine hydrochloride and clonidine administered using continual epidural in lumbosciatic back pain. The association of an opiate and a solution of local anesthetic through infusion increases the analgesic effect and allows smaller quantities of both drugs to be used. The addition of another drug, like clonidine, may allow the dose of the single drugs to be reduced even further, thus resulting in fewer dose-dependent side effects. We know that at least two of the opiate receptor systems and at least three non-opiates modulate the painful sensory afferences. The cortisones can act as both antiphlogistics and antiedemigens, as well as inhibition prostaglandin.

METHODS

All the patients in this study were hospitalised after varying periods of home therapy or in other wards. The case histories of 462 patients were studied on admission using routine X-rays and laboratory tests, and also based on a chart divided into parts: the first showed the marks for EO of a patient with lumbosciatica, and the second contained pain-related data. This was measured both directly, using the Scott-Huskisson visual parallel and a language card, and indirectly (possible activities, drug intake, etc.). The scale of the analog used defines slight pain with values of less than 44 mm, moderate pain with values between 45-69 mm, strong pain with values between 70-88 mm, and very strong pain above 88 mm.

RESULTS

The following results were obtained from this study: successes 87.9%, partial successes 1.7%, failures 10.3%. Of the 48 failures, 31 were operated within a few days, whereas the remaining 17 cases were not operated because the patients declared that they were satisfied with the improvement obtained or gave other reasons. The analgesic effect was frequently observed. The improvement usually increased after the second block so that some patients did not require a third administration.

CONCLUSIONS

The results confirm that continual epidural therapy is the most successful and also the most rapid treatment available for pain of lumbar origin. At present we share Finneson's opinion that the same general indications are still valid: 1) discopathy with negative NMR; 2) discopathy with medical contraindications to surgery; 3) discopathy of lumbar and/or radicular origin with alterations to multiple NMR and no reliable signs of a specific root; 4) for symptomatic purposes while waiting for diagnosis and surgery.

Efficacy and tolerance of Harpagophytum extract LI 174 in patients with chronic non-radicular back pain

The aim of this open, multicentre study was to evaluate the clinical effectiveness and tolerance of the Devil's Claw extract LI 174 in patients suffering from non-radicular back pain over a period of at least 6 months. A total of 130 patients were treated twice a day with tablets containing 480 mg LI 174. The treatment lasted for 8 weeks. The effectiveness was judged according to the Multidimensional Pain Scale (MPS), Arhus back pain index and to parameters evaluating the mobility of the lumbar spine (finger-floor distance, Schober's sign). Data from 117 patients were evaluated for efficacy. The results showed a significant improvement of pain symptoms and mobility of the affected sections of the patient's spine in the course of treatment. No serious side effects were observed. In view of the excellent compliance and tolerability the investigated extract appears to be an effective plant alternative for the treatment of chronic back pain. However, further studies will be needed to clarify the therapeutic value of this plant remedy.

[The intervertebral disk in anatomy and pathology]

One of the most frequent and incapacitating medical and social problems of our times is back pain. In most patients the cause of the symptoms remains unknown, although some relevant clues have been discovered over the last few years: mechanical, nutritional, chemical, social, psychological and genetic factors. Pathoanatomic conditions that are generally accepted as related to the symptoms include disc herniation, fracture, infection, spinal stenosis, spondylarthropathy and spondylolisthesis. Diagnostic problems will only be solved by considering and synthesis of all findings.

Clinical aspects of nephropathia epidemica (Puumala virus infection) in Europe: a review

Nephropathia epidemica (NE) is a prevalent zoonosis throughout Europe and is caused by the Puumala type of hantavirus. The incidence of NE varies in a cyclic fashion, with peaks occurring every 3rd to 4th year, coinciding with peaks in vole populations. The clinical course of NE is generally milder than haemorrhagic fever with renal syndrome caused by hantaviruses in other parts of the world. Typically, NE has a sudden onset with fever, headache, backpain and gastrointestinal symptoms. However, severe complications, e.g. gastrointestinal haemorrhage, occur and fatal cases have been reported. Renal involvement is prominent and manifests as initial oliguria and later as marked polyuria. Tests of renal function show pronounced glomerular and tubular involvement. Vaccine against Puumala virus infection as well as specific treatment for NE are still lacking.

Innervation of the human costovertebral joint: implications for clinical back pain syndromes

BACKGROUND

The diagnosis of pain in the upper back, shoulder, chest, and arm is often made with considerable confusion and may be accompanied by needless expense and suffering by the patient. Despite the paucity of evidence concerning the tissues and mechanisms responsible for interscapular and atypical chest pain or "pseudo-angina," practitioners of manual therapy maintain that manipulation of the costovertebral elements and associated soft tissues may be helpful in the treatment of these painful conditions.

OBJECTIVE

We have examined the costovertebral complex in humans with respect to the presence of immune-like reactivity to neurofilament protein and the neuropeptide substance P and calcitonin gene-related peptide, markers that reveal the presence of axons in peripheral tissues.

DESIGN

Human costovertebral complexes obtained at autopsy were processed with standard histologic examination and immunocytochemical methods to detect the presence of neurofilaments, substance P, and calcitonin gene-related peptide.

MAIN OUTCOME MEASURES

Outcomes were descriptive and did not require statistical methods.

RESULTS

All costovertebral joints contained innervation within the anterior capsule and synovial tissues. In 4 separate cases, the costovertebral joints contained large intraarticular synovial inclusions or "meniscoids" found to contain small bundles of axons with immune-like reactivity to substance P. Axon bundles were identified in serial section with monoclonal antibodies to neurofilaments as well as with urea-silver nitrate staining.

CONCLUSIONS

The costovertebral joint has been considered a candidate for producing back pain and/or pseudo-angina that may be ameliorated by spinal manipulation. This study has demonstrated that the costovertebral joint has the requisite innervation for pain production in a similar manner to other joints of the spinal column.

Is there increased intervertebral mobility in isthmic adult spondylolisthesis? A matched comparative study using roentgen stereophotogrammetry

STUDY DESIGN

By roentgen stereophotogrammetric technique, the intervertebral mobility of the spondylolytic segment in eight patients was measured and compared with the mobility of eight nonspondylolytic patients matched according to sex, afflicted segment, and grade of disc degeneration.

OBJECTIVES

To compare the intervertebral mobility of a spondylolytic segment with the mobility of a segment without spondylolysis in adult patients with back pain.

SUMMARY OF BACKGROUND DATA

Evidenced by the resulting olisthetic deformity and supported by the outcome from prior investigations, spondylolysis is assumed to induce spinal segmental instability/hypermobility.

METHODS

After percutaneous application of tantalum indicators for roentgen stereophotogrammetric technique, the intervertebral translations of the spondylolytic fifth lumbar vertebra were measured in eight adult patients with low back pain and low-grade olisthesis. Eight other patients without spondylolysis but with low back pain presumably on degenerative basis were chosen for comparison and had an identical measuring procedure using roentgen stereophotogrammetric technique. The two groups were matched in pairs according to sex, afflicted segment, and grade of disc degeneration.

RESULTS

No significant difference was registered considering the intervertebral mobility for matched pairs in the two groups neither along the sagittal nor the vertical axis. The transverse translations were mostly negligible in both groups.

CONCLUSION

The spondylolytic defect in pars interarticularis does not cause permanent instability/hypermobility detectable in the adult patient with low back pain and low-grade olisthesis.