Degenerative Findings Research Articles

THE PREVALENCE OF DISC AGING AND BACK PAIN AFTER FUSION EXTENDING INTO THE LOWER LUMBAR SPINE. A matched MR study twenty-five years after surgery for adolescent idiopathic scoliosis

Purpose: To determine the long-term outcome after fusion for adolescent idiopathic scoliosis in terms of degenerative disc findings diagnosed using MR imaging and to elucidate the clinical consequences. Material and Methods: Thirty-two patients with adolescent idiopathic scoliosis, who had undergone spinal fusion using Harrington rods to the lower lumbar spine with one or two unfused discs below the fusion, were re-examined 25 years after the fusion. The re-examinations included validated questionnaires, clinical examination, full standing frontal and lateral radiographs and MR examination of the lower lumbar region. Curve size and degenerative findings on MR images were evaluated by two unbiased radiologists, blinded to the clinical findings. A matched control group of 32 persons without scoliosis was subjected to the same examinations. Results and Conclusion: There were significantly more degenerative disc changes (p<0.0001), disc height reduction (p=0.0010) and end-plate changes (p<0.0001 for both upper and lower end-plates) in the lowest unfused disc in the patient group compared with the control group. The MR findings in the lowest unfused disc, but not the one above, in the patient group correlated to lumbar pain intensity as well as to the diminished lumbar lordosis.

An unusual presentation of dermatomyositis: The type Wong variant revisited

We describe a 53-year-old white woman with dermatomyositis (DM) who had additional clinical findings of pityriasis rubra pilaris (type Wong dermatomyositis) with histopathologic features of both pityriasis rubra pilaris (PRP) and porokeratosis. Type Wong dermatomyositis was originally described in 11 patients by Wong in 1969 and has been reported in 5 additional patients. This is a rarely described phenomenon in which patients with DM develop cutaneous hyperkeratotic lesions that resemble PRP and histologically show follicular hyperkeratosis and hair follicle destruction. Arrector pilorum muscles also show degenerative findings and myositis. We believe that this is the first reported case of a patient with type Wong DM who also has clinical and histologic features suggestive of porokeratosis. This is important because of the wassociation of adult-onset dermatomyositis with internal malignancy and the well-documented association of porokeratosis with immunosuppression. These clinical and histologic findings serve as markers for malignancy in patients with DM. These patients warrant a complete review of systems and investigation for age-appropriate neoplasms as well as close long-term follow-up by dermatologists to ensure that these cutaneous eruptions are not overlooked. (J Am Acad Dermatol 2000;43:908-12.)

The degenerative cervical spine: Pathogenesis and rehabilitation concepts

The degenerative process associated with spondylosis in the cervical spine has been reviewed. The two compressive syndromes commonly associated with spondylosis, radiculopathy and myelopathy, are briefly reviewed. Except for more severe, multilevel degenerative changes producing neurologic compromise, correlation between degenerative changes and patient symptoms or functional limitations is generally poor. A conceptual scheme for guiding rehabilitation of mechanical neck pain, based on irritability level and the effects of mechanical stress on symptoms, is proposed. Further research is required to test the reliability and validity of categorization schemes like the one proposed. Such schemes based on history and effects of mechanical stresses, rather than solely on degenerative radiographic findings, are necessary to classify patients in meaningful ways that help guide specific rehabilitation strategies and tactics. When meaningful classification schemes exist, treatments matched with specific categories of dysfunction can be tested for effectiveness.

The long-term effects of rally driving on spinal pathology

Objectives. To investigate the consequences of rally driving on lumbar degenerative changes. Background. Vehicular driving is suspected to accelerate disc degeneration through whole-body vibration, leading to back problems. However, in an earlier well-controlled study of lumbar MRI findings in monozygotic twins, significant effects of lifetime driving on disc degeneration were not demonstrated. Another study of machine operators found only long-term exposure to vibration on unsprung seats led to a reduction in disc height. Design. Case-control study comparing rally drivers with population sample. Methods. Eighteen top rally drivers and co-drivers, mean age 43 yrs (SD, 10), volunteered for the study. The subjects were interviewed and imaged with a MR scanning and lumbar images were analyzed for degenerative findings using a standard scoring protocol previously published. The reference group was composed of 14 men, mean age 55 yrs (SD, 10), selected from a population sample. Results. Overall results showed no significant differences in lumbar degenerative findings as assessed from MR images between the rally drivers and the reference group; age-adjusted differences were not statistically significant for disc heights, bulges, herniations, end-plate irregularities, or osteophytes. Conclusion. Even extreme vehicular vibration as experienced in rally driving does not appear to have significant effects on disc generation. Relevance The study results do not support driving, and its associated whole body vibration, as a significant cause of disc degeneration and question the theory that the higher incidence of back pain among drivers is due to accelerated disc degeneration. Other driving-related factors, such as postural stress, may deserve more attention.

Long-term clinical and magnetic resonance imaging follow-up assessment of patients with lumbar spinal stenosis after laminectomy.

A cross-sectional retrospective study to observe the correlation between postoperation findings shown on magnetic resonance imaging and clinical observations of 56 patients 10 years after laminectomy for lumbar spinal stenosis. To evaluate the relation between postoperation findings on magnetic resonance imaging and surgical outcome in patients surgically treated for lumbar spinal stenosis. Surgical management of lumbar spinal stenosis is based on the compression seen in radiologic imaging of neurovascular structures in the vertebral canal, but the success of surgical decompression and its correlation with clinical observations very seldom have been monitored by postoperation radiologic imaging. In this study, 56 patients surgically treated for lumbar spinal stenosis were re-examined clinically by use of the Oswestry disability questionnaire. Their walking capacity was evaluated by the treadmill test. Severity of pain before and after the treadmill test was investigated using a visual analog scale. Patients' perception of improvement measured as the change in their condition during the preceding 5 years was elicited by a questionnaire. On the basis of the stenotic findings on magnetic resonance imaging, the patients were classified into no stenosis (NoSten, n = 15) and stenosis (Sten, n = 41) groups, and a summative degenerative scale also was constructed with the findings categorized as follows: disc degeneration, disc herniation, facet joint arthrosis, and degenerative spondylolisthesis. Whereas the patients' perception of improvement correlated very strongly with the Oswestry score and walking capacity, there was no statistical difference between the NoSten and Sten groups in the Oswestry score, walking capacity, perception of improvement, or severity of pain. The effect of the summative degenerative scale on the patients' walking capacity was 13 times greater than the effect of the minimum area of the dural sac. Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on postoperation magnetic resonance imaging. Moreover, degenerative findings had a greater effect on patients' walking capacity than stenotic findings.

The influence of occupation on lumbar degeneration.

In many countries, back problems have been defined as occupational injuries. The belief underlying this injury model is that back symptoms are caused primarily by work-related mechanical factors that damage the structures of the spine, either through a single incident or repeated loading. Although the etiopathogenesis of degenerative findings in the disc and their relation to pain are poorly understood, changes in the disc are suspected of underlying many back symptoms. The focus of this article is on examining the relation between occupational factors and disc degeneration. Occupational factors suspected of accelerating spinal degeneration include accident-related trauma; heavy physical loading and materials handling, including lifting, bending, and twisting; prolonged sitting; and sustained nonneutral work postures and vehicular driving. There is evidence to suggest that occupational exposures have an effect on disc degeneration. However, these factors explain little of the variability in degeneration found in the adult population. Furthermore, the lack of a clear dose-response relation between time spent in various occupational loading conditions and degenerative findings adds to doubts about a strong causal link. The contribution of suspected occupational risk factors appears to be particularly modest when compared with familial influences, which reflect the combined effects of genes and early childhood environment. These findings challenge the dominant role assumed for occupational loading in disc degeneration and associated back problems, and suggest a more complex etiology.

Musculo-skeletal pathology in patients with angina pectoris and normal coronary angiograms.

To evaluate the role of the musculo-skeletal apparatus in patients with angina pectoris despite normal coronary angiograms. A survey of patients and controls investigated by blinded observers. A tertiary cardiologic referral centre. Thirty women and 18 men (mean age 52.9 years) with chest pain of an average duration of 3 years and 11 months were investigated. All had normal resting electrocardiograms. No patients showed evidence of left ventricular hypertrophy or valvular heart disease on echocardiography and all had a normal coronary angiogram. All had left ventricular ejection fraction > 50%, and none had signs of coronary vasospasm. Eighteen healthy persons (10 women and eight men, mean age 51.2 years) served as controls. The group frequency of chest wall complaints, spinal radiograph and physical examination findings; pressure pain thresholds. The patients had significantly more complaints of pain from the neck, chest, and thoracic spine, and sensations and pain radiating to the arms than the controls. The patients had more degenerative findings on radiograph than the controls, mainly at levels C4-C7. Physical examination showed that abnormal findings were significantly more frequent in patients than in the control group in the anterior and posterior chest wall, in the spine at levels Th1-Th6 and in the muscles of the neck and shoulder girdle. There were no statistically significant differences in pain thresholds or in neurological examination. The musculo-skeletal abnormalities observed in the patients could include reflex mechanisms. Whether the abnormal findings are mainly responsible for the angina pectoris symptoms or merely epiphenomena warrants further study.

Neurotoxicity of 1-bromopropane in rats

Neurotoxicity of 1-bromopropane (1-BP) used as an alternative solvent of fluorocarbons was experimentally studied. Eight rats in the experimental group were exposed to 1-BP at 1500 ppm for six hours a day, five days a week for four weeks in an exposure chamber. Another eight rats in the control group were exposed to room air in a similar exposure chamber as those in the experimental group. During the latter half of the fourth week of exposure, all the rats in the experimental group showed a loss of body weight and ataxic gait compared with control rats. At the end of the fourth week, the rats in both groups were perfused through the ascending aorta and fixed. The cerebellum, medulla oblongata, spinal cord and peripheral nerve were processed for histopathological studies. No statistically significant difference in the frequency of axonal degeneration in both peroneal and sural nerves was found between the experimental and control groups. In the cerebellum, the frequency of degeneration of Purkinje cells in both the vermis and hemisphere was higher in the experimental group than in the control group (P < 0.05). There was no significant difference in the frequency of myelin ovoids in the fifth thoracic and in the third cervical posterior columns of the spinal cord between control and experimental groups. There was also no significant difference in the frequency of axonal swelling in the nucleus gracilis of the medulla oblongata between control and experimental groups. Ataxic gait was considered to be induced by degeneration of Purkinje cells in the cerebellum due to 1-BP exposure. However, degenerative findings of nerve fibers in the peripheral nerve, spinal posterior column and nucleus gracilis of the medulla oblongata due to 1-BP exposure were not evident. At the end of the fourth week of exposure, rats in the experimental group showed loss of body weight and markedly decreased motor activities, and it was considered that they would die if we continued the exposure into the fifth week. Therefore, we feel that our experimental schedule should be reconsidered before undertaking any further studies on the peripheral nerve toxicity of 1-BP.

Familial predisposition for lumbar degenerative disc disease. A case-control study.

A case-control study using magnetic resonance imaging and plain radiography to evaluate whether a family history of lumbar disc herniation is a risk factor for disc degeneration. To evaluate the significance of a family history of operated lumbar disc herniation in the development of lumbar disc degeneration and lumbar disc herniation. There are only a few epidemiologic studies indicating that a family history of intervertebral disc herniation is a risk factor for juvenile disc herniation. Recently, similarities in degenerative findings of the lumbar spine between identical twins have been reported. In the case group, 24 patients who were the immediate relatives of patients who had undergone surgery for disc herniation and who presented or had a history of low back pain and/or unilateral leg pain were included. Control individuals included 72 age- and gender-matched outpatients who reported low back pain and/or leg pain without a family history of operated disc herniation. The incidence, level, and topographic location of disc herniation/diffuse bulge; the incidence and grade of disc degeneration observed on magnetic resonance images; and degenerative changes suggesting disc degeneration observed on plain radiographs were compared between the relatives of patients with disc herniation (cases) and the controls. The incidence of disc degeneration at L4-L5 and L5-S1 in cases (L4-L5, 18/24; L5-S1, 18/24) and controls (L4-L5, 45/72; L5-S1, 43/72) was similarly high. However, the grade of disc degeneration according to magnetic resonance imaging signal intensity on the T2-weighted sagittal image using Schneiderman's four-grade classification was significantly more severe in cases (L4-L5: Grade 1, 6/24; Grade 2, 4/24; Grade 3, 13/ 24; Grade 4, 1/24; L5-S1: Grade 1, 6/24; Grade 2: 3/24, Grade 3: 12/24, Grade 4: 3/24) than in controls (L4-L5: Grade 1, 27/72; Grade 2, 24/72; Grade 3, 20/72; Grade 4, 1/72; P = 0.034; L5-S1: Grade 1, 29/72; Grade 2, 23/72; Grade 3, 13/72; Grade 4, 7/72; P = 0.023; Mann-Whitney U test). The incidence of disc herniation/diffuse bulge at L4-L5 (16/24) and L5-S1 (11/24) in cases was higher than that in controls (L4-L5, 33/72; P = 0.07; L5-S1, 17/ 72; P = 0.04; chi-square test). The current study provided evidence that a family history of operated lumbar disc herniation has a significant implication in lumbar degenerative disc disease. There may be a genetic factor in the development of lumbar disc herniation as an expression of disc degeneration.

MRI of cervical intervertebral discs in asymptomatic subjects.

We studied degenerative changes in the cervical intervertebral discs of 497 asymptomatic subjects by MRI and evaluated disc degeneration by loss of signal intensity, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. In each subject, five disc levels from C2-C3 to C6-C7 were evaluated. The frequency of all degenerative findings increased linearly with age. Disc degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. We found significant differences in frequency between genders for posterior disc protrusion and foraminal stenosis. The former, with demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. Our results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine.

MRI of cervical intervertebral discs in asymptomatic subjects

We studied degenerative changes in the cervical intervertebral discs of 497 asymptomatic subjects by MRI and evaluated disc degeneration by loss of signal intensity, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. In each subject, five disc levels from C2–C3 to C6–C7 were evaluated. The frequency of all degenerative findings increased linearly with age. Disc degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. We found significant differences in frequency between genders for posterior disc protrusion and foraminal stenosis. The former, with demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. Our results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine.

Point of View: A Cross-Sectional Study Correlating Cervical Radiographic Degenerative Findings to Pain and Disability

Point of View: A Cross-Sectional Study Correlating Cervical Radiographic Degenerative Findings to Pain and Disability

A cross-sectional study correlating cervical radiographic degenerative findings to pain and disability.

A cross-sectional design was used to correlate cervical radiographic findings of spinal degeneration to neck pain and disability. The results were correlated to assess the clinical importance of radiographic spinal degeneration. Past investigations suggest little association between clinical findings and radiographic evidence of spinal degeneration. However, changes in activities of daily living and chronicity of complaint have not been investigated. Over a 5-month period, data were collected on 700 consecutive patients referred for cervical radiographic examination as part of their clinical evaluation. While in the radiology department, all subjects completed a visual analog pain scale, neck disability index, and short questionnaire, all of which quantified various aspects of any neck complaint. Relationships between indices of patient complaint and the number of cervical degenerative intervertebral discs were evluated using regression analysis. A significant relationship (P < 0.001) was noted between the number of levels of intervertebral disc degeneration and the chronicity of cervical complaint. No significant relationship was found between cervical degeneration and past trauma (P = 0.904) or gender (P = 0.213). Multiple-regression analysis of visual analog pain scale scores revealed a significant two-way interaction with chronicity and past trauma (P = 0.007) and a significant main effect with gender (P < 0.001). Cervical degeneration was not significant as a main effect or interaction with other factors. Multiple-regression analysis of neck disability index scores demonstrated a significant three-way interaction of chronicity, degeneration, and gender (P = 0.022) and a significant two-way interaction for chronicity and trauma (P = 0.025). No additional information was gathered by multivariate multiple-regression techniques. Increasing levels of spinal degeneration are related to increasing chronicity of patient complaints. Spinal degeneration is not related to past trauma or gender. Women, but not men, report higher disability with increasing levels of degeneration. Subjects with past trauma reported more intense pain and disability. Overall, men reported less neck pain and disability than women.

Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins.

Although the etiology of most degenerative changes in the lumbar spine is unclear, genetic factors may play an important role. To investigate this link, we reviewed magnetic resonance images of the lumbar spines of identical twins to assess the degree of similarities in degenerative findings in the discs. Observers who were blinded to twinship evaluated sagittal T1-weighted and T2-weighted magnetic resonance images of the lumbar spines of forty male identical twins (twenty pairs) with respect to changes in the end plates, desiccation of the discs, bulging or herniated discs, and decrease in the height of the disc space. Similarities between co-twins were significantly greater than would be expected by chance. Whereas smoking status and age explained 0 to 15 per cent of the variability in the various degenerative findings in the discs, 26 to 72 per cent of the variability was explained with the addition of a variable representing co-twin status. These findings are compatible with a marked genetic influence and warrant further investigation.

Observer variability in the assessment of disc degeneration on magnetic resonance images of the lumbar and thoracic spine.

Intraobserver and interobserver reproducibility study. This study investigates the variability in the interpretation of degenerative disc findings using magnetic resonance imaging. Magnetic resonance imaging has been used for years in clinical diagnostics, primarily to investigate disc herniation and spinal stenosis. Less attention has been paid to other disc findings and their assessment reliability. Three independent readers evaluated magnetic resonance images of the lumbar and the lower and middle thoracic spines of 122 subjects by grading 12 aspects of the intervertebral discs and adjacent endplates using written definitions and example images. Images of 20 subjects were reevaluated for the assessment of intraobserver agreement. Agreement was highest in the lower lumbar and poorest in the middle thoracic spine. Intraobserver agreement was generally fair to excellent for almost all variables in the lumbar and lower thoracic spine (most intraclass correlation and kappa coefficients for these regions were above 0.70). Interobserver agreement was notably lower than intraobserver agreement, except for osteophytes and endplate defects in some regions. Intraobserver agreement in the evaluation of disc degeneration was at an acceptable level, in general, in the lumbar and lower thoracic spine. However, assessments were substantially more variable between readers, which limits comparisons of evaluations between different readers.

Neurotoxicity of methyl bromide--neuropathologic evaluation--preliminary study

Methyl bromide exposure produces disorders of the central and peripheral nervous system. In the literature, there are many neuropathologic studies on the nervous system, especially on the central nervous system, of experimental animals intoxicated with methyl bromide presented. However, in our opinion, a variety of lesions of the nervous system described in the human methyl bromide intoxication have not been well reproduced in the experimental animals. In this study, male Wistar rats were subjected to a 6-hour exposure a day to methyl bromide at a concentration of 500 or 290 ppm 3 days a week for 3 to 8 weeks. The systematic neuropathologic studies of their central and peripheral nervous systems were carried out to reproduce the nervous system lesions in the human methyl bromide intoxication hitherto not produced in the experimental animals. Among the rats exposed to methyl bromide at a concentration of 500 ppm for 10 to 18 days, the axonal degeneration of myelinated fibers at the cervical level of the fasciculus gracilis, which probably corresponds to the degeneration of the spinal posterior column in humans, and the necrosis of the caudate-putamen and atrophy of neurons and pallor of the neuropile in caudate-putamen, thalamus and cingulate cortex, which probably correspond to the degenerative findings of the cerebrum in humans, were found. The rats exposed to methyl bromide at a concentration of 290 ppm for 8 weeks (24 days) did not show any noticeable abnormalities histologically.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracellular calcium levels in canine basilar artery smooth muscle following experimental subarachnoid hemorrhage: an electron microscopic cytochemical study

Changes in intracellular calcium levels in canine basilar arterial smooth muscle were semiquantitatively measured by an electron microscopic cytochemical technique using a combined oxalate-pyroantimonate method. Measurements made after subarachnoid hemorrhage were compared with those made after contraction induced by prostaglandin F2 alpha. Fifteen minutes after topical application of the drug, when the basilar artery was constricted by 20%, 15% of smooth muscle cells contained a large amount of intracellular calcium. One hour later, the diameter of the basilar artery and intracellular calcium precipitation returned almost to control levels. Fifteen minutes after the first intracisternal injection of autologous blood, when acute vasospasm was angiographically evident, 13% of smooth muscle cells contained a large amount of calcium. After 1 h, when acute vasospasm had already abated, the number of smooth muscle cells containing a large amount of calcium markedly increased to 37% and some smooth muscle cells showed early degenerative findings such as intracytoplasmic vacuoles including calcium accumulation. After 48 h, when delayed vasospasm had already started, the calcium deposits and early degenerative changes had decreased significantly. After 49 h and 4 days (1 h and 48 h after the second injection of blood), the change in the amount of calcium was the same as at 1 h and 48 h after the first injection, respectively, but degeneration of smooth muscle cells increased. Therefore, acute vasospasm after subarachnoid hemorrhage may be caused by an initial elevation of intracellular calcium levels, as is the case with drug-induced contraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Major depression in primary dementia. Clinical and neuropathologic correlates.

Cytopathologic features were quantified in seven brain regions in the brains of 37 demented patients, with or without major depression, and in those of seven controls with no history of dementia or depression. The middle frontal and superior temporal cortex, prosubiculum and entorhinal cortex of the hippocampus, nucleus basalis of Meynert, locus ceruleus, and substantia nigra were the areas evaluated. Patients with major depression had significantly more degenerative findings in the locus ceruleus and substantia nigra than demented patients who were not depressed. In contrast, these groups were similar with respect to other clinical features and indexes of global severity of dementia. A logistic regression model that included the degenerative features of both the locus ceruleus and the substantia nigra was significantly better at predicting the presence of major depression than those employing the characteristics of either pigmented nucleus alone. Our results indicate that the development of major depression in patients with primary dementia is associated with the degeneration of the locus ceruleus and substantia nigra.

Degenerative pathologic findings after long-term implantation of bovine pericardial bioprosthetic heart valves

Degeneration of bioprosthetic heart valves constitutes the most important limitation to their long-term durability and the factor that avoids a wider clinical use of these devices. We studied 26 degenerated bovine pericardial valves that belong to a series of 55 prostheses explanted for various reasons. Age of the patients at implantation of the valve and other factors predisposing to primary tissue failure did not seem to significantly influence the results obtained. Mean implantation time was longer for aortic than for mitral valves (p less than 0.05). Also, the mode of failure was different for mitral and aortic prostheses. Tearing of one or more leaflets without mineralization was more frequent (p less than 0.0025) among mitral than among aortic specimens. Coverage of the valve cusps by a macroscopically visible host sheath was more extensive on the outflow than on the inflow aspect (p less than 0.0015 aortic valves; p less than 0.015 mitral valves). On radiological examination the majority of valves had diffuse and severe mineralized lesions. Collagen degeneration was the most frequent histologic lesion to be found in both mineralized and calcium-free valves. Calcification was also frequent and appeared as mineral deposits that extended between different collagen planes. Scanning electron microscopy revealed the almost complete lack of "endothelium-like" cover on any of the valves and exposure of the underlying fibrous components of the pericardial tissue in areas subjected to abrasion. Transmission electron microscopy confirmed the collagen degeneration and disclosed electron-dense microparticles (probably mineralized) both in the extracellular space and within degenerated host connective tissue cells.

きょく上・きょく間靭帯の走査電子顕微鏡的観察

Supraspinous ligaments and interspinous ligaments, which were taken during surgery, were observed by SEM in order to clarity degenerative findings and ossification process of the ligaments.The observation of the ligaments in young persons showed that the fibers formed a dense and regular pattern.In older persons the fibers formed a large and wavy pattern and were separated into branches.Closer to the ossification, various degenerative changes were observed such as thickness of the fibers, disappearance of structure of the ligaments, invasion of blood vessels and Others.