Spinal Disc Disease Research Articles

Evaluating the use of robotically assisted percutaneous coronary intervention: a matter of being precise

Since the advent of catheter-based coronary intervention three decades ago, steady technological progress has led to the development and refinement of intracoronary devices [1]. Despite technological advances, the fundamental workflow of coronary procedures remains unchanged. Interventionalists still wear heavy protective lead aprons, stand at the bedside for long hours and manually manipulate catheters and intra vascular devices under direct fluoroscopic guidance. As the field has matured, greater attention has been paid to the long-term occupational hazards of this antiquated interventional approach [2]. A striking prevalence of orthopedic injuries and spinal disc disease has been reported following hours of standing under heavy lead aprons [3,4]. Although radiation badges worn by inter ventional personnel can help track and limit exposure, any radiation exposure may be harmful, and risks of solid or hematologic malignancy continue to be a significant concern [5,6]. A high prevalence of posterior lens radiation injuries leads to earlier cataracts among interventionalists and provides additional incentive to minimize ionizing radiation exposure [7]. Given the clear risks of modern practice, remotecontrol robotic catheter-based systems were first proposed to mitigate occupational hazards in percutaneous coronary interventions (PCIs). Beyar et al. developed the first-generation ‘Remote Navigation System’ for PCI (Remote Navigation System, NaviCath, Haifa, Israel), consisting of a joystick controlled operator module and motorized drive to advance and retrieve intravascular devices mounted on the procedure table. A small clinical pilot study demonstrated the feasibility and safety of this robotic system for single-vessel PCI [8,9]. Following this early study, the Robotic Navigation System was redesigned as the CorPath System (Corindus Vascular Robotics, MA, USA).

Radiation Exposure—Do Urologists Take it Seriously in Turkey?

A questionnaire was administered to urologists to evaluate attitudes and behaviors about protection from radiation exposure during fluoroscopy guided endourological procedures. The questionnaire was e-mailed to 1,482 urologists, including urology residents, specialists and urologists holding all levels of academic degrees, between May and June 2011. The questionnaire administered to study participants was composed of demographic questions, and questions on radiation exposure frequency, and the use of dosimeters and flexible protective clothes. If a respondent reported not using dosimeters or protective clothes, additional questions asked for the reason. Of the 1,482 questionnaires 394 (26.58%) were returned, of which 363 had completed answers. A total of 307 physicians (84.58%) were exposed to ionizing radiation, of whom 79.61% stated that they perform percutaneous nephrolithotomy at the clinic. Fluoroscopy guidance was the initial choice of 96.19% of urologists during percutaneous nephrolithotomy. Despite the common use of lead aprons (75.24%) most urologists did not use dosimeters (73.94%), eyeglasses (76.95%) or gloves (66.67%) while 46.44% always used thyroid shields during fluoroscopy. When asked why they did not use protective clothing, the most common answers were that protective clothes are not ergonomic and not practical. Results clearly highlight the lack of use of ionizing radiation protection devices and dosimeters during commonly performed fluoroscopy guided endourological procedures among urologists in Turkey.

Current Alternatives for Treatment of Degenerative Spinal Disc Disease

Current Alternatives for Treatment of Degenerative Spinal Disc Disease The improvements in non fusion techniques for the treatment of degenerative spinal discs disease and the other related conditions commenced a new era of spine surgery. This new techniques are different from conventional fusion methods. Fusion methods for treating degenerative segmental disc disease which knowingly impair normal motion by disrupting articular surfaces and locking two or more spinal vertebrae segments as a single unit. Non fusion methods aim to provide stabilization while maintaining the mobility and function of the spine. Many instruments were developed to provide stabilization without fusion. Among them, the application of pedicle screw-based systems is more familiar to spine surgeons.

Healthcare utilization of back pain patients: results of a claims data analysis

Objectives:The high life-time prevalence of chronic back pain (25–30% according to surveys in small samples) suggests that it may be a major source of healthcare cost and that prevention of chronic back pain may be both ethically and economically recommendable. To obtain valid economic data on the cost of back pain in Germany, a retrospective claims data analysis was performed.Methods:Using data from 2006 of 5.2 million beneficiaries of a German statutory health insurance fund (DAK Unternehmen Leben) covering ∼7% of the German population, mean value analyses report on key healthcare utilization figures from a sickness funds’ perspective. In contrast to other studies, cost data are primary data and not extrapolated, but clinical characteristics include surrogate markers as no clinical case descriptions were available.Results:Based on previously investigated diagnosis patterns three types of back pain could be identified: (other) specific back pain (n = 211,216), pain due to spinal disk disease (n = 195,712), and non-specific back pain (n = 534,272). Of all back pain patients, 25.8% were identified as at risk to develop chronic pain, where only 2.6% were detected as patients with chronic back pain. Mean resource utilization and related healthcare costs were significantly higher for beneficiaries with indicators for chronic back pain than for beneficiaries with only risk factors for developing chronic back pain. This especially holds for outpatient analgesic prescriptions (p < 0.05), for in-hospital multimodal pain therapy (p < 0.05), for in-hospital care in general (p < 0.05), as well as for direct cost of care (p < 0.05).Conclusion:The results show the potential that could be made accessible by an early detection of back pain patients who bear a risk of pain becoming chronic, both in terms of quality-of-life as well as in financial terms.

Neuraxial Blockade in Patients with Preexisting Spinal Stenosis, Lumbar Disk Disease, or Prior Spine Surgery

Patients with spinal canal pathology, including spinal stenosis and lumbar disk disease, are often not considered candidates for neuraxial blockade because of the risk of exacerbating preexisting neurologic deficits or developing new neurologic dysfunction. In contrast, a history of spine surgery is thought to increase the likelihood of difficult or unsuccessful block. In this retrospective study we investigated the risk of neurologic complications and block efficacy in patients with preexisting spinal canal pathology, with or without a history of spine surgery, after neuraxial anesthesia. During the 15-year study period, all patients with a history of spinal stenosis or lumbar radiculopathy undergoing a neuraxial technique were studied. Patient demographics, preoperative neurologic diagnoses and neurologic findings at the time of surgery/neuraxial block, details of the neuraxial block including technique (spinal vs. epidural, single injection vs. continuous), injectate, technical complications (paresthesia elicitation, bloody needle/catheter placement, inability to advance catheter, accidental dural puncture), and block success were noted. New or progressive neurologic deficits were identified. All patients were followed until resolution or last date of evaluation. There were 937 patients included, 207 (22%) of whom had undergone spinal surgery. A history of spinal stenosis was present in 187 (20%), lumbar radiculopathy in 570 (61%), and peripheral neuropathy in 210 (22%) patients; 180 patients (19%) had multiple neurologic diagnoses. A majority of patients had active but stable neurologic symptoms at the time of surgery. Overall block success was 97.2%. A history of spine surgery did not affect the success rate or frequency of technical complications. Ten (1.1%; 95% confidence interval [CI] 0.5%-2.0%) patients experienced new deficits or worsening of existing symptoms. Three (1.4%) complications occurred in patients with a history of spinal surgery, and the remaining 7 (1.0%) in patients without prior surgical decompression or stabilization (P = NS). Although an orthopedic procedure was not a risk factor, in 5 of the 6 patients in which the surgery was a unilateral lower extremity procedure, the postoperative deficit involved the operative side. Likewise, in both patients undergoing bilateral orthopedic procedures who developed bilateral deficits, the outcome was worse on the previously affected side. A surgical cause was presumed to be the primary etiology in 4 (40%) of 10 patients. The primary etiology of the remaining 6 (60%) complications was judged to be nonsurgical (including anesthetic-related factors). The presence of a preoperative diagnosis of compressive radiculopathy (P = 0.0495) or multiple neurologic diagnoses (P = 0.005) increased the risk of neurologic complications postoperatively. We conclude that patients with preexisting spinal canal pathology have a higher incidence of neurologic complications after neuraxial blockade (1.1%; 95% CI 0.5%-2.0%) than that previously reported for patients without such underlying pathology. However, in the absence of a control group of surgical patients with similar anatomic pathology undergoing general anesthesia, we cannot determine whether the higher incidence of neurologic injury is secondary to the surgical procedure, the anesthetic technique, the natural history of spinal pathology, or a combination of factors and the relative contributions of each.

Postural control in patients with lumbar disc herniation in the early postoperative period

Chronic spinal disc disease leads to disorders in postural movement coordination. An incorrect asymmetrical movement pattern for the lower limbs loading impairs proprioception and deteriorates postural stability, particularly when the vision is occluded. The standard surgical treatment improves biomechanical conditions in the lumbar spine, reduces pain, yet does it reduce the stability deficit in the upright position? An answer to the latter question would help work out targeted therapy to improve postural stability. We hypothesized that the standard surgical treatment would improve postural stability reflected by decreased sway variability accounting for better use of proprioceptive inputs postoperatively. Thirty-nine patients with lumbar disc herniation participated in the study. Their postural sway was recorded in anterior/posterior and medial/lateral planes with their eyes open or closed (EC) before and after surgery. The variability, range, mean velocity of the recorded time series and the area of the ellipse enclosed by the statokinesiogram were used as measures of postural stability. Preoperatively, EC condition resulted in an increased variability and mean velocity of postural sway, while postoperatively it caused an increase in sway mean velocity and sway area only with no effect on sway variability and range. The comparison of the balance before and after the surgery in the EC condition showed significant decrease in all parameters. In the early postoperative period, the patients recover the ability to control their postural sway in EC within normal limits, however, at the expense of significantly increased frequency of corrective torques. It is probably a transient short-term strategy needed to compensate for the recovery phase when the normal weighting factors for all afferents are being reestablished. We propose that this transient postoperative period may be the best timing of therapeutic intervention targeted at facilitating and reinforcing the acquisition of correct motor patterns.

The Current State of Cervical and Lumbar Spinal Disc Arthroplasty

Orr, R. Douglas MD; Postak, Paul D. BSc; Rosca, Mircea BSME; Greenwald, A. Seth DPhil(Oxon) Author Information

Occupational hazards for interventional cardiologists

Occupational hazards for interventional cardiologists

Degenerative Spine Disease : Pathologic Findings in 985 Surgical Specimens

A number of pathologic changes have been reported in spinal surgery specimens. The frequency of many of these is not well defined. We retrospectively reviewed the histologic features of 985 extradural spinal surgery specimens. Of the cases, 1.6% were identified clinically as synovial cysts. In addition, synovial tissue was seen in another 5.3% of cases, often embedded within disk material. Neovascularization of disk tissue was present in 8.1% of cases, chondrocyte clusters in 18.3%, and calcium pyrophosphate crystals in 2.8%, predominantly within disk material. With the exception of crystal deposits, all of these changes were significantly more common in the lumbar spine. A better understanding of cell-based degenerative changes will become essential with increasing research into cell-based therapies for spinal disk disease. We report data on the frequency of different pathologic changes and describe synovial metaplasia as a reactive change not previously reported.

Degenerative Spine Disease

A number of pathologic changes have been reported in spinal surgery specimens. The frequency of many of these is not well defined. We retrospectively reviewed the histologic features of 985 extradural spinal surgery specimens. Of the cases, 1.6% were identified clinically as synovial cysts. In addition, synovial tissue was seen in another 5.3% of cases, often embedded within disk material. Neovascularization of disk tissue was present in 8.1% of cases, chondrocyte clusters in 18.3%, and calcium pyrophosphate crystals in 2.8%, predominantly within disk material. With the exception of crystal deposits, all of these changes were significantly more common in the lumbar spine. A better understanding of cell-based degenerative changes will become essential with increasing research into cell-based therapies for spinal disk disease. We report data on the frequency of different pathologic changes and describe synovial metaplasia as a reactive change not previously reported.

Stem cell opportunities for neurosurgery

opment is so appealing to neurosurgeons can be found in the statement: “the adult human brain, in contrast to other organs such as skin and liver, lacked the capacity for selfrepair and regeneration.” This fundamental axiom of neuroscience has put severe limitations on treatment options for patients with neurological diseases. In fact, the progressive minimalism that has characterized the evolution of neurosurgery has largely been fueled by the desire to avoid damage to the nervous system during surgery. In addition, prevention of deficits has been the achievable alternative to the restoration of function after damage. However, in contrast to what has been believed for much of the last century, the adult nervous system may be capable of repairing itself. We now know that stem cells exist in the adult brain as well as in the embryo and that these cells can be isolated and transplanted, after which they survive, differentiate, migrate, and appear to integrate. Stem cells have been shown to produce positive therapeutic effects in animal models and in a few human trials. However, the exact mechanism of this positive effect is as yet unclear, and perhaps produced more by secretion of neurotrophic factors than by actual integration into the defective neural architecture. We know that stem cells in neurogenic areas of the brain can be induced to activate in response to an insult such as trauma or ischemia. There is now growing evidence that stem cells may play a role in neoplasia and cancer, where tumors are derived from the loss of control over tumor stem cells. We are currently moving toward the elucidation of the functional aspects of stem cells in addition to their histology. The true promise of stem cells is that, in contrast to what has been believed for most of the history of neurosurgery, stem cells may ultimately allow repair of neurological injury rather than merely its prevention. This dramatically broadens the spectrum of therapeutic possibilities. Indeed, the potential targets for restorative neurosurgery cover the entire spectrum of neurological disorders, including stroke (which is the second biggest killer of Americans after heart disease), neurodegenerative disorders (the number of afflicted patients overwhelm most other neurosurgical patients added together), traumatic injury, tumors, spinal cord injury, peripheral nerve injury, developmental disorders, and even spinal degenerative disorders. In this issue of Neurosurgical Focus, such topics with immediate relevance to neurosurgeons and the neurosurgical field are covered, including induction of endogeneous stem cell proliferation after nervous system injury, the stem cell microenvironment, spinal cord injury, stem cell therapy for degenerative spinal disc disease, and the treatment of malignant brain tumors. Neurosurg Focus 19 (3):Intro, 2005

Femoral neuropathy induced by a low–grade myofibroblastic sarcoma of the groin

Sirs: Femoral neuropathy is an uncommon disorder [4] and has sometimes been found to be associated with a pelvic hematoma due to anticoagulation therapy [10], the lithotomy position [1], pelvic surgery [7], renal transplantation [8] and radiation injury [6]. Here we report a case of femoral neuropathy induced by a low-grade myofibroblastic sarcoma (LGMS) of the groin, which is a recently established pathological entity [3], and which explains the characteristic radiological findings. A 64-year-old woman noticed numbness of the inner surface of the left leg, which was gradually spreading. An orthopedist made a diagnosis of lumbar spinal disk disease and prescribed a muscle relaxant. In spite of this, the patient’s left leg became gradually weaker and the sensory disturbance worsened. She then began to drag her left leg while walking and was referred to our department 2 months later. A neurological examination revealed weakness and muscle atrophy in her left quadriceps muscle. The left knee jerk reflex was decreased and numbness in the saphenous nerve distribution was found. There was no evidence of central nervous system involvement. On the basis of these clinical findings, the function of the left femoral nerve was considered to be impaired. The motor conduction velocity between above and below the inguinal ligament was estimated to be 64m/s for the right femoral nerve, and 33m/s for the left femoral nerve. Electric stimulation proximal to the inguinal ligament demonstrated that the amplitude of the motor action potential in the rectus femoris muscles was markedly reduced on the left side (8.9 mV on the right and 1.5 mV on the left). When the left saphenous nerve was stimulated antidromically, the sensory action potential decreased to 3.9 μV (7.3 μV in the right saphenous nerve), though nerve conduction was not impaired. This implied the presence of axonal damage in the distal part of the femoral nerve. Other nerve conduction studies showed no evidence of generalized peripheral neuropathy or lumbosacral plexopathy. Needle electromyographic (EMG) evaluation could only be performed for the left rectus femoris muscle, which indicated positive sharp waves and fibrillation potentials at rest. The patient declined further EMG investigation owing to the pain. CT revealed an ill-defined mass lesion in the left groin (Fig. 1a). This was a tumor that appeared to be infiltrating into the retroperitoneal area and surrounding muscles. It also showed heterogeneous enhancement and involved the left femoral nerve (Figs. 1a and b). Compared with the right femoral nerve, the left femoral nerve appeared to be enlarged and probable gadolinium enhancement was observed close to the tumor (Fig. 2). Short-tau inversion recovery (STIR) MRI of the lower leg revealed homogeneous high-intensity signal changes in the left denervated quadriceps muscle and sartorius muscle supplied by the femoral nerve (Fig. 3) [9]. In order to make a precise diagnosis, LETTER TO THE EDITORS

Digital technology-assisted minimally invasive spinal surgery (MISS) for spinal motion preservation

To identify and demonstrate how the digital technology-assisted minimally invasive spine surgery (MISS) for spinal disc disease redefines the algorithm for treatment of degenerative spine disease and preserves segmental spinal motion via a seamless computerized digital network. These technologies facilitate the precise diagnosis and MISS treatment.

Prevalence of Spinal Disc Disease Among Interventional Cardiologists

A suspected, but undocumented, excess of axial skeletal disease among interventional cardiologists (possibly a consequence of lead apron use) was investigated by comparing questionnaire responses from cardiologists, orthopedic surgeons, and rheumatologists (n = 714). Cardiologists reported more neck and back pain, more subsequent time lost from work, and a higher incidence of cervical disc herniations, as well as multiple level disc disease (all p <0.01): "interventionalist's disc disease" is a confirmed entity.

Cigarette smoking in the menopausal woman

Approximately 25% of postmenopausal women smoke cigarettes. Cigarette smoking has been linked to many diseases of the mature woman, both gynecologic and non-gynecologic. Cigarette smoking is associated highly with cardiovascular disease, and in women, it is estimated that 21% of all mortality from cardiovascular disease is related to cigarette smoking. Cigarette smokers demonstrate a markedly elevated prevalence for development of airway obstruction and clinical symptoms leading to chronic obstructive pulmonary diseases, as well as to recurrent respiratory tract infections. Many nongynecologic cancers are associated with cigarette smoking. Multiple other medical problems including peptic ulcer disease, psoriasis, thyroid disease, and spinal disc disease are also associated with cigarette smoking. An earlier onset of menopause in women who smoke cigarettes has been clearly demonstrated. Cigarette smoking is associated with a decreased risk of endometrial cancer. The opposite effect is noted in other cancers; specifically, an increased risk for vulvar and cervical cancers has been observed. The association between cigarette smoking and risk for breast cancer is not clearly established. No apparent increased risk is found for ovarian cancer. Cigarette smoking also is associated with a decreased risk of benign conditions of the female reproductive tract (eg, endometriosis, leiomyomas, benign breast disease). An increased prevalence of osteoporosis is found in postmenopausal smokers when compared with non-smokers.

901-15 Interventional Cardiologists Suffer an Excessive Incidence of Spinal Disc Disease

Back and neck pain are common complaints and frequent reasons for workdays lost amongst interventional cardiologists (Card) but neither an increased frequency of spinal skeletal problems within this specialty nor its presumed relationship to radiation shielding lead aprons has been previously verified. We mailed surveys to 875 interventional cardiologists (who performed an average of 12.1 ± 7.4 procedures per week) and for comparison, mailed 595 surveys to orthopods (who spend long hours standing, but without wearing lead) and 990 rheumatologists (with neither “risk factor”). Since the data on the latter 2 groups did not differ, they are combined as “controls.” The overall survey response was 30%. Card (N = 385) Controls (N = 329) Age 46.9 47.2 ns Spine painlmedical therapy 14.0% 6.4% p &lt; 00001 Spine surgery 5.2% 3.6% ns Lost work days 21.3% 12.5% p = 0002 Number days last/year 2.5 0.02 P = 004 Cervical disc disease 6.5% 0.03% P ≤ 0.0001 Lumbar disc disease 7.5% 6.0% ns Multiple disc disease levels 3.4% 0.0% p = 0007 Interestingly, we found a predominance of cervical and not low back complaints by interventionalists, although combined upper and lower spine complaints (multiple levels) were more common in the cardiology group. Long hours spent performing procedures while wearing radiationshielding lead aprons (which are purported to produce &gt;300 pounds per square inch of intervertebral disc pressure), induces a distinct occupational hazard, “interventional cardiologist's disc disease”.

The cerebrospinal fluid in patients with moyamoya disease (spontaneous occlusion of the circle of Willis) contains high level of basic fibroblast growth factor

The level of basic fibroblast growth factor (bFGF) in cerebrospinal fluid (CF) was measured by an EIA in 15 patients with moyamoya disease, in 11 patients with atherosclerotic occlusive disease, and in 8 patients with spinal disc disease. In the moyamoya patients, bFGF was found in 13 out of 15 CF samples with a mean value of 101 pg/ml. However, bFGF was detected in only 4 out of 11 patients with atherosclerotic disease with a mean of 8 pg/ml. In all the patients with disc disease, bFGF was not detected. The elevated level of bFGF may play a crucial role in the pathogenesis of moyamoya disease.

New aspects of lumbardisc disease

Magnetic resonance imaging (MRI) and plain X-ray and CT studies were performed in patients with a history of lumbar back pain due to spinal disc disease. Spin-echo pulse sequences (SE), phase-contrast techniques (partial saturation sequences with delayed readout, PS), and fat-suppressing inversion recovery sequences (STIR) were employed. In 74 of 325 patients, PS and STIR images displayed vertebral marrow changes adjacent to the end-plates of the affected segments. Bacterial infection, however, could be excluded. In six patients histological diagnosis showed substitution of hematopoietic marrow by fatty tissue, cartilaginous particles, degeneration of fat cells, and an increase in extracellular fluid with different components. The etiology is still unclear, but a correlation with lumbar disc disease is demonstrated. These vertebral marrow changes were best displayed with STIR and phase-contrast MR sequences, both providing contrast changes superior to T2-weighted SE techniques.

Transducer frequency considerations in intraoperative US of the spine.

To determine the effect of transducer frequency, we used intraoperative spinal ultrasound to study 15 patients. All patients but one had spinal stenosis and/or disk disease affecting the cervical cord (n = 5), the thoracic cord (n = 1), or the lumbosacral area (n = 8). One patient had an arteriovenous malformation of the cervical cord. Both 5-MHz and 10-MHz transducers were used in one patient; a transducer with the option of 3.5, 5, or 7.5 MHz was used in ten; and a 10-MHz transducer was used in four. We found that, intraoperatively, 10-MHz transducers currently produce the most detailed images of the spine.