Comparative Study of Graf Stabilization and Posterior Fusion in the Treatment of Chronic Symptomatic Mechanically Unstable Low Back Syndrome

Spinal stabilization of unstable intervertebral segments is a well recognized technique in the management of patients with chronic pain with or without neural compression in an attempt to relieve the patient's symptoms. The introduction of internal fixation techniques using a variety of different materials began at the early part of this century and there has been a significant expansion of such techniques over the past 20 years.

There is significant controversy between treating spinal surgeons as to whether such stabilization techniques should involve semi-rigid or totally rigid systems.

Henry Graf in 1988 introduced a new concept in spinal stabilization utilizing dacron bands between pedicle implants as opposed to the previously available systems which used a solid plate or rod to interconnect the intervertebral fixation devices (pedicle screw, wires, sub laminar hooks).

This paper will report the results of a independently reviewed prospective study comparing patients who have undergone the Graf procedure and either a rigid plate fixation or spinal fusion without fixation.

The patients were equally matched for age, sex and psychological parameters (Zung and Somatic Indices).

The results demonstrated a much better functional outcome in those patients who underwent the Graf procedure. This was using rigid criteria introduced by Greenough and Fraser (Low Back Outcome Score). There was no significant difference with respect to patients' satisfaction in the case of Graf and patients undergoing spinal fusion without internal fixation. Those patients who underwent rigid spinal fixation did not report as good patient satisfaction as the other two groups. The psychological indices both pre- and postoperative for the three groups were similar.

The complications between all groups were also similar and not statistically significant.

This study would suggest that the Graf Soft Stabilization Technique does offer patients a potentially better functional outcome than the more rigid systems, though further prospective studies are necessary given the number of variables.

THE HARTSHILL HORSESHOE: THE TREATMENT OF CHRONIC PAIN PATIENTS WITH DISCOGENIC PAIN IN THE ABSENCE OF NEURAL COMPRESSION A PROSPECTIVE 2½- TO 3-YEAR REVIEW

Interbody fusion is a well-recognized technique to achieve spinal fusion. The advantage of using tricortical blocks as opposed to the dowel technique is that intervertebral disc height can be restored. Both techniques can be performed either by the anterior or posterior approach.

The traditional tricortical block technique has advantages over using dowels as it is a more stable construct and can restore intervertebral disc height. However, autologous bone graft has an unpredictable behavior causing potential problems of disc space collapse, forward displacement of the graft and donor bone graft site morbidity.

The Hartshill horseshoe was developed to overcome these autograft problems. It is an implant that is placed within the periphery of the intervertebral disc space where the vertebral end plate is strongest to resist compression forces. It has holes that allow screw fixation of the implant to bone to provide immediate stability and a central area for bone graft where the vertebral body is most vascular to allow incorporation of such a graft.

Previous reports on the Hartshill horseshoe have used autograft (single tricortical graft). This prospective study reports the clinical and radiological results of 19 patients who underwent this procedure using xenograft 2½ to 3 years postoperative. The radiological results do not show any evidence of loosening of the screws or implant nor evidence of intervertebral disc space subsidence. It was not possible to assess the exact incidence of spinal fusion.

SOFT STABILIZATION OF THE LUMBAR SPINE USING THE GRAF SYSTEM FOR SPINAL INSTABILITY SYNDROMES AND PSEUDOARTHROSIS — 5 YEARS' RESULTS

There is considerable controversy in the diagnosis and management of lumbar spinal instability. Most clinicians agree that patients suffering from the chronic low back syndrome who have suspected instability and have not responded to conservative measures, should be considered for operative treatment with stabilization using rigid or semi-rigid systems to reduce or eliminate movement at the painful segment.

The concept of soft stabilization was introduced by Henri Graf in 1988 and has become a routine procedure in various centres throughout the world for stabilization for clinical instability syndromes.

The Graf system was introduced into Western Australia in October, 1991. The aim of this paper is to report the independently reviewed retrospective results of the first 25 patients with respect to clinical outcome and radiological features.

The clinical outcomes were consistent with other reported treatment measures for the chronic low back pain syndrome. The radiological results do not show any evidence of implant loosening or breakage.

Anterior cervical fusion using the IntExt combined cage/plate

PURPOSE

To review our first 30 patients who underwent anterior cervical fusion using IntExt and xenograft.

METHODS

Records of 23 men and 7 women aged 18 to 83 (mean, 40) years were reviewed by a single researcher. 23 patients had traumatic fracture-dislocations and 7 had degenerative disease. Pain, range of movement, neurological status, return-to-work status, kyphosis, and lordosis were recorded. Radiography and computed tomography were used to assess integration of the xenograft with the host bone, intervertebral fusion around the cage, and any screw loosening.

RESULTS

The mean follow-up duration of the 30 patients was 14 (range, 1-47) months. There was no evidence of screw loosening or breakage. 20 of the 28 patients had no neck pain. Radiographs and/or computed tomographic scans of 23 patients showed bone union or clinical evidence of stability.

CONCLUSION

The IntExt is effective in stabilising traumatic fractures. Although the literature does not support single-level plating in degenerative fractures (because of high success rates with autologous bone grafting), the IntExt has advantages of avoiding grafting complications, donor-site morbidity, and resorting to a postoperative collar.

Social Security fixes--beware of conjurers!

Among the many proposals for reform, there is one that offers the best chance of truly solving Social Security's financial problems, these authors believe. That proposal would increase savings by requiring workers to invest an additional 2% of their covered wages in individual accounts. At retirement, 75% of the money would go toward buying the current level of Social Security benefits, and 25% would be given to the individual as an "extra" pension. Individuals, not the government, would control investment of these accounts.

Diaphyseal medullary stenosis with malignant fibrous histiocytoma: a hereditary bone dysplasia/cancer syndrome maps to 9p21-22

Diaphyseal medullary stenosis with malignant fibrous histiocytoma (DMS-MFH) is an autosomal dominant bone dysplasia/cancer syndrome of unknown etiology. This rare hereditary cancer syndrome is characterized by bone infarctions, cortical growth abnormalities, pathological fractures, and eventual painful debilitation. Notably, 35% of individuals with DMS develop MFH, a highly malignant bone sarcoma. A genome scan for the DMS-MFH gene locus in three unrelated families with DMS-MFH linked the syndrome to a region of approximately 3 cM on chromosome 9p21-22, with a maximal two-point LOD score of 5.49 (marker D9S171 at recombination fraction [theta].05). Interestingly, this region had previously been shown to be the site of chromosomal abnormalities in several other malignancies and contains a number of genes whose protein products are involved in growth regulation. Identification of this rare familial sarcoma-causing gene would be expected to simultaneously define the cause of the more common nonfamilial, or sporadic, form of MFH-a tumor that constitutes approximately 6% of all bone cancers and is the most frequently occurring adult soft-tissue sarcoma.

The effects of warming by active and passive means on the subsequent responses to cold water immersion

Two experiments were undertaken to investigate the effects of warming the body upon the responses during a subsequent cold water immersion (CWI). In both experiments the subjects, wearing swimming costumes, undertook two 45-min CWIs in water at 15 degrees C. In experiment 1, 12 subjects exercised on a cycle ergometer until their rectal temperatures (Tre) rose by an average of 0.73 degree C. They were then immediately immersed in the cold water. Before their other CWI they rested seated on a cycle ergometer (control condition). In experiment 2, 16 different subjects were immersed in a hot bath (40 degrees C) until their Tre rose by an average of 0.9 degrees; they were then immediately immersed in the cold water. Before their other CWI they were immersed in thermoneutral water (35 degrees C; control condition). Heart rate in both experiments and respiratory frequency in experiment 1 were significantly (P < 0.05) higher during the first 30 s of CWI following active warming. In experiment 1, the rate of fall of Tre during the final 15 min of CWI was significantly (P < 0.01) faster when CWI followed active warming (2.46 degrees C.h-1) compared with the control condition (1.68 degrees C.h-1). However, this rate was observed when absolute Tre was still above that seen in the control CWIs. It is possible, therefore, that if longer CWIs had been undertaken, the two temperature curves may have converged and thereafter fallen at similar rates; this was the case with the aural temperature (Tau) seen in experiment 1 and the Tau and Tre in experiment 2. It is concluded that pre-warming is neither beneficial nor detrimental to survival prospects during a subsequent CWI.

Comparison of magnetic resonance imaging and computed tomographic discography in the assessment of lumbar disc degeneration

Eighteen patients with chronic low back pain were studied with magnetic resonance imaging (MRI) and computed tomographic (CT) discography. Each study was classified as being normal, showing early disc degenerative changes including annular tear, showing established disc degeneration or disc herniation. There was comparable information in over 90% of the MRI studies when compared to CT discography, without reliance on pain provocation or carrying out an invasive procedure. The axial and sagittal T1 weighted images were used to exclude other causes of pain, such as foraminal stenosis and disc herniation. The mid-sagittal T2 weighted image used in this study was considered to be, in part, responsible for the underestimation of disc degeneration because it did not allow visualization of the lateral aspects of the discs.

Disc degeneration and the young fast bowler in cricket

Twenty-four male fast bowlers of mean age 13.7 years, who bowled competitively at a school and club level were selected from five Western Australian schools. At the time of the testing all bowlers, who were bowling completely freely, underwent magnetic resonance imaging to detect the presence of intervertebral disc abnormalities. While these radiological data were being analysed, the players were filmed both laterally (200 Hz) and from directly above (100 Hz) as their front foot impacted a force platform during the delivery stride of the fast bowling action. In addition these bowlers performed selected physical capacity tests. The occurrence of abnormal radiological data were then used to group the bowlers (group 1, no abnormal features; group 2, disc degeneration and/or bulging on scan). A Mann-Whitney U rank test was then used to identify any significant differences (P < 0.1) between the groups for all dependent variables. Five of the subjects recorded abnormal magnetic resonance imaging scans of the lumbar spine, while nineteen recorded normal intervertebral discs, normal alignment of the lumbar spine, and no sign of spondylolisthesis. Bowlers who rotated the trunk to realign the shoulders to a more side-on position between back foot impact and front foot impact in the delivery stride were more likely to record abnormal intervertebral disc features.

Lower spinal mobility and external immobilization in the normal and pathologic condition

The study presented here used lateral flexion and extension roentgenograms to determine lumbosacral motion in healthy persons and in patients with spondylolisthesis. The lumbosacral corset, Jewett extension brace, and plastic thoracolumbosacral orthosis (TLSO) were then placed and repeat roentgenograms were done to see if effective immobilization could be obtained. Although individual variation existed, there appeared to be no significant difference in lower lumbar motion between the two groups studied, and the orthotics acted in a similar fashion on both the volunteers and the patients. The lumbosacral corset was unable to immobilize the L3-S1 levels. There was a statistically significant decrease in the average lateral disk space motion at L3-4 and L4-5 with the use of the Jewett brace and the TLSO (P less than .01); however, the motion was never completely eliminated. No brace could adequately immobilize the L5-S1 level, and some people demonstrated increased motion at this level while wearing the orthotics.

Spinal abnormalities in young fast bowlers

The action of fast bowling in the game of cricket is known to cause injuries to the lumbar spine. We studied a group of 16- to 18-year-old fast bowlers, selected for special training in Western Australia. All 24 had MR scans of the spine, 22 had radiographs and CT scans; in 20 the bowling technique was analysed biomechanically. There was a high incidence of back pain and this was always associated with a radiological abnormality. Pars interarticularis defects were diagnosed in 54% and intervertebral disc degeneration in 63%. Bowling actions which involved counter-rotation were associated with a higher incidence of both injuries.

A physical approach to the rehabilitation of patients disabled by chronic low back pain

OBJECTIVE

To report the outcome of a multidisciplinary physically based program to treat sufferers of chronic low back pain who had not responded to previous treatment.

DESIGN

Prospective intervention study.

SETTING

The treatment program was conducted at the private practice of Brian C Edwards and Associates Rehabilitation Centre.

PATIENTS

A total of 54 patients participated in the treatment program. All patients were medically referred. No specific exclusion criteria were used; however, all were not working and had not responded to previous treatment.

INTERVENTION

The rehabilitation program consisted of mobilising physiotherapy, isokinetic testing, physical reconditioning, work hardening and psychological testing. This was carried out for seven hours a day, five days a week for four weeks.

RESULTS

Of the 54 patients taking part in this trial 30 (55%) were successfully rehabilitated (returned to work) and remained so at a follow-up session one year later.

CONCLUSION

While selection criteria for successful rehabilitation have not been established, the results do indicate that such physical rehabilitation programs have an important part to play in the rehabilitation of sufferers of chronic low back pain.

Lumbar pain in fast bowlers

Lumbar pain is common among cricket's fast bowlers, leading to premature retirement. The cause of a high incidence of back problems lies in the repetitive spinal movements necessary in the art of fast bowling. This combines repetitive lateral flexion, thoraco-dorsal rotation, spinal flexion and compression. The causes are basically too much bowling by young players with relatively immature pars interarticularis, poor physical fitness and a poor bowling action.

Long-term results of conservative and operative management in complete paraplegics with spinal cord injuries between T10 and L2 with respect to function

This study analyzed 87 athletes attending the Para Olympic Games at Stoke Mandeville in 1984. All athletes had had complete neurologic lesions between the levels of T10 adn L2. Clinical details were obtained from each athlete. Assessment then consisted of measurement of spinal movement in the sagittal plane using spondylometers and movement in the rotation plane using a rotameter. Body trunk strength was measured with the athletes in their own wheelchairs using a myometer. This gave a recording of kilograms of force. Trunk balance was assessed on both a static and a dynamic basis. The age, sex, follow-up period, and body weight for both spinal fusion and conservatively treated groups were similar. There was little difference in the incidence of pain between those treated by conservative and operative methods. There was statistically significant difference in the range of sagittal plane and rotation movement. There was no difference in flexor trunk power measured with the myometer between the two groups, but when extensor power was measured it was found to be 25% less in the spinal fusion group. There was no difference between the two groups when tested for static and dynamic trunk balance. Two other athletes who had had spinal fusions extending from the upper thoracic region to the sacrum showed unusually poor trunk stability. Overall, this study demonstrates that spinal fusion, particularly over multiple segments in complete paraplegics, has a deleterious effect not only on spinal movement but also on body trunk strength.

Hereditary bone dysplasia with malignant change. Report of three families

In this paper three families are reported with members who had hereditary bone dysplasia that was originally described by Arnold in one family. We provide further information about that family and suggest that the diagnosis of the malignant change should be changed from fibrosarcoma to malignant fibrous histiocytoma. A thorough search of the literature has failed to reveal any conditions, either hereditary or acquired, that are similar. The major feature of the dysplasia is diaphyseal medullary stenosis of bone with overlying cortical-bone thickening, and the propensity to malignant transformation and fractures with minimum trauma is emphasized. The tumors in seven, and possibly eight, of the nine patients in whom a malignant lesion developed were originally classified as fibrosarcoma and proved to be markedly aggressive. The hereditary pattern appears to be autosomal dominant. The clinical manifestations of a malignant lesion occur generally in the second to the fifth decades of life.

The significance of the Trendelenburg test

Trendelenburg's test of function of the hip joint was first reported before radiology was available. At least four methods of performing it have since been described in the literature. We examined 50 normal subjects and 103 people with disorders affecting either the spine or the hip, in order to determine the different responses that occurred when they were asked to stand on one leg. This has enabled us to define a standard method of performing the Trendelenburg test, and to interpret the test as a method of assessing hip abductor function. The major pitfalls that result in misinterpretation, or false-positive responses, are pain, lack of cooperation from the patient, and impingement between the rib cage and the iliac crest. False-negative responses result from the patient using muscles above and below the pelvis, and from leaning beyond the hip on the standing side.

Near-total laryngectomy with myo-mucosal valved neoglottis

The entire larynx is usually sacrificed in the process of surgical treatment of T3 glottic carcinoma, trans-glottic carcinoma and pyriform sinus carcinoma, with consequent loss of speech. Most of the uninvolved, cancer-free part of the larynx is discarded for no good reason. According to the surgical principles of oncology, a tumour should be removed with clear margins, but this does not necessarily mean that the whole organ has to be extirpated. In a recently applied surgical procedure, the small tumour-free part of the larynx is fashioned into an innervated myo-mucosal valved shunt joining trachea and pharynx. This neoglottis allows expiration into the pharynx in speech production but it also contracts during swallowing to avoid aspiration. The first four consecutive cases in which this procedure has been carried out with complete success are presented.

Acute rupture of the lateral ligament of the ankle. To suture or not to suture?

One hundred patients with acute ruptures of the lateral ligaments of the ankle were randomly allocated either to conservative treatment in a plaster cast or to operative repair. With the aid of stress tenography, the extent of the injury was established. There were 30 patients with isolated anterior talofibular ruptures and 20 with additional calcaneofibular ligament ruptures in each treatment group. Operative repair was associated with a higher incidence of complications in the first weeks, and slightly delayed the patients' return to work. At an independent two-year review there was no evidence that operative repair offered improved symptomatic or functional benefit.