Matrix metalloproteinases in the human intervertebral disc: role in disc degeneration and scoliosis

STUDY DESIGN: Biochemical study of human intervertebral discs collected at surgery from patients with low back pain associated with disc degeneration or scoliosis. Matrix metalloproteinases were studied by quantitative zymography. OBJECTIVE: To determine whether changes in the expression of matrix metalloproteinases will bring about tissue remodelling that contributes to the progressive nature and pathology of these diseases of the intervertebral disc. SUMMARY OF BACKGROUND DATA: The diseases of the intervertebral disc, degenerative disc disease and scoliosis, are both characterized by changes in the extracellular matrix components that will affect the mechanical function of the tissue. Matrix metalloproteinases are known to have the capability of degrading all the known extracellular matrix components of the disc. METHODS: Matrix metalloproteinases 2 and 9 were detected by gelatin-gel zymography and quantified by laser scanning densitometry. Both pro and active forms of the enzymes were measured. Thirty-four discs from patients with low back pain and 29 from patients with scoliosis were investigated. RESULTS: A correlation was found between the increasing levels of matrix metalloproteinases 2 and 9 and the grade of degenerative disc disease. In addition, the levels of these enzymes show a differential expression across the scoliotic disc with the highest levels in samples taken from the convexity of the curve. CONCLUSIONS: The difference between the concave and convex side of the scoliotic curve indicates that mechanical loads might influence the expression of these enzymes. The increased expression of these enzymes in both degenerative disc disease and scoliosis strongly suggests that they may affect the progressive nature of these diseases.     

The benefits of school screening for scoliosis in the central part of The Netherlands

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.     

Occurrence of hemophilia in the United States. The Hemophilia Surveillance System Project Investigators

OBJECTIVE: To discuss a case of sciatica associated with lower back pain that originates in a disc. We discuss the use of manipulative therapy as a conservative approach and compare it with other conservative methods and with surgery. CLINICAL FEATURES: The patient suffered from lower back and left leg pain that had increased in severity over a 6-day period. There was decreased sensation in the dorsum of the left foot and toes. Computed tomography demonstrated the presence of a small, contained disc herniation. INTERVENTION AND OUTCOME: The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care. CONCLUSION: We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.     

Delayed postoperative paraparesis in scoliosis surgery. A case report

STUDY DESIGN: A case report is presented of an unusual complication of scoliosis surgery that, to the authors' knowledge, has never been reported in the literature. OBJECTIVE: Neurologic complications can occur after an uneventful posterior spinal instrumentation and fusion for scoliosis. Careful observation during the post-operative period is crucial for early detection of impending neurologic deficit. SUMMARY OF BACKGROUND DATA: Nerve compression of the cauda equina has been reported as a complication of different types of surgery in the lumbar spine, but an ascending paraparesis has never been described as a complication of scoliosis surgery. METHODS: A 12-year-old boy with a right thoracic scoliosis measuring 68 degrees and a 72 degrees left lumbar curve underwent Cotrel-Dubousset instrumentation and fusion from T5 to L4. Spinal cord monitoring with somatosensory evoked potentials and motor action potential were recorded and stable through out the entire procedure. Thirty hours later, a rapidly progressive ascending para-paresis developed that required urgent decompression. RESULTS: This patient underwent urgent decompression and removal of the Cotrel-Dubousset instrumentation. After surgery, the clinical picture improved gradually, and at 2-month follow-up he had regained normal strength in his lower limbs except for a grade 4 left extensor hallucis longus. By 4 months postdecompression, he had made a total recovery. CONCLUSIONS: Although clinical examination may be difficult to perform in patients who are unconscious, on large doses of narcotic drugs, or mentally retarded, careful observation during the postoperative period and awareness of this complication can allow early detection of impending reversible neurologic deficit and provision of appropriate treatment.     

P450RAI (CYP26A1) maps to human chromosome 10q23-q24 and mouse chromosome 19C2-3

STUDY DESIGN: A case report. OBJECTIVES: To document a fracture of the 11th thoracic vertebra after spine fusion for adult idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Three cases of vertebral fractures associated with spine fusion for scoliosis were found in the literature. METHODS: Medical and radiologic records and related literature were reviewed. RESULTS: A 30-year-old woman had undergone anterior and posterior fusion with Cotrel-Dubousset instrumentation for progressive idiopathic scoliosis. Two years after surgery, she was in a car accident. A radiographic study and computer tomographic scanning depicted a fracture of T11 and bending of the rods. Observation was instituted and symptoms resolved. CONCLUSIONS: Fracture of a vertebra within an extensive spine fusion for scoliosis is rare. The 360 degrees solid fusion together with strong posterior instrumentation may have had some protective effect in this patient.     

Rapidly progredient scoliosis associated with multicore disease

Multicore disease is a rare congenital myopathy that normally stops or makes slow progress. It starts with delayed motor development and frequent falls. Especially the proximal muscles are involved. Other symptoms include contractures of joints, clubfoot, high arched palate, chest deformities, involvement of eye-muscle, cardiac abnormalities, hyperlordosis and scoliosis that normally does not require surgery. We report a rare case of advanced scoliosis in multicore disease requiring operative treatment in a 15-year-old girl. In this case the scoliosis took a rapidly progredient course in puberty close to the end of skeletal growth. A dorsal spondylodesis with USS instrumentation from T9 to L3 was performed. A significant reduction of the scoliosis was obtained. Scoliosis in multicore disease may take a rapidly progredient course. Frequent checks will lead to the initiation of surgical treatment in time.     

Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms

The mortality and causes of death in 115 patients (80 women), born 1902-1937, with untreated scoliosis were compared to the expected according to official Swedish statistics. Subgrouping for cause and onset of scoliosis was done. Fifty-five patients had died; 21 of respiratory failure and 17 of cardiovascular diseases. The mortality was significantly (P less than 0.001) increased. The increased risk was apparent at 40-50 years of age. The mortality was significantly increased in infantile (P less than 0.001) and juvenile (P less than 0.01) scoliosis but not in adolescent scoliosis. The mortality was also increased in post-polio scoliosis, scoliosis combined with rickets and scoliosis of unknown etiology indicating an increased mortality in idiopathic scoliosis. Among the surviving patients anti-hypertensive treatment was frequent (23 of 50).     

Review of 87 cases of scoliosis surgically treated

BACKGROUND: The authors compared the results and complications in surgical treatment of idiopathic scoliosis with Harrington's rod instrumentation with subtrasversal wires in dorsal treat. METHODS: A research on 87 cases operated on for idiopathic scoliosis from 1987 to 1995 is carried out. The 87 cases include 65 females and 25 males, 16 years old in average (range, 11 to 30). The curvature in Cobb's degrees and rotation of vertebrae with Raimondi's method on radiographs take just before, 15 days later and an year later on operation was measured. The patients have been divided into two groups: the first of 77 patients operated with Harrington's rod instrumentation; the second of 10 patients operated with Harrington's rod instrumentation and subtrasversal wires. RESULTS: In a general analysis without taking in to consideration the type and the seriousness of curvature it was obtained a better correction and derotation of vertebrae in patients of second group. The same group with wires had obtained a better correction and derotation of vertebrae in dorsal scoliosis from 40 degrees to 60 degrees and in the double scoliosis, while the first group obtained better results in dorsal scoliosis from 60 degrees to 80 degrees and in derotation of vertebrae on dorsal treat of double scoliosis. One case of pseudarthrosis in every group was observed. Any neurological complication were observed. CONCLUSIONS: The conclusions is drawn that the application of subtrasversal wire improves the Harrington's technique for the correction and derotation of dorsal and double scoliosis without neurological complications sometimes present with subliminar wires.     

The surgical treatment of low back pain

If nonoperative management fails to relieve a clearly identifiable and surgically treatable cause of lumbar pain, then surgery may be beneficial. Certain "red flags" indicate the need for urgent or emergent surgical intervention. Low back pain is associated with several degenerative conditions in the lumbar spine, including degenerative disc disease, spinal stenosis, spondylolisthesis, degenerative scoliosis, facet joint syndrome, and disc herniation.     

HTLV-I associated myelopathy with macular degeneration

The authors report a case of macular involvement in a patient with HTLV-I associated myelopathy (HAM). The patient was a 10-year-old girl who noticed sudden decreased vision in her right eye in November 1987. The corrected visual acuity was 0.01 in the right eye and 1.0 in the left eye. Fundus examination of the right eye disclosed mild optic disc pallor. The macula appeared to have pigmentary mottling with superficial irregular retinal reflex that was three disc diameters in size. Fluorescein angiography revealed a discoid hypofluorescent area in the macula, surrounded by mottled hyperfluorescent areas. She had no contributory family history of ocular disease, but had a history of blood transfusion during an operation for patent ductus arteriosus and ventricular septal defect at the age of 8 months. In November 1990, she developed gait disturbance due to spastic paraparesis and was admitted to our hospital. Antibodies to HTLV-I were markedly elevated in serum (titer, 1:8192) and in cerebrospinal fluid (titer, 1: 1024). She was diagnosed as HAM. Two months later, she developed encephalopathy and bilateral optic disc atrophy.     

Scoliosis and trunk asymmetry in upper limb transverse dysmelia

The incidence of scoliosis and trunk asymmetry were studied in 60 patients with upper limb dysmelia of the transverse type. The evaluations were based on radiographic measurements of the spine and scoliometer readings of the angle of trunk rotation (ATR), which were correlated with the side and level of the limb deficiency and also with leg length-inequality (LLI). Nineteen patients (31%) had a scoliosis between 10 and 19 degrees, whereas the curves were between 5 and 10 degrees in another 30 patients and the remainder had no measurable curve. The scoliosis seemed at least partly to be of postural origin as LLI significantly correlated with the direction of the curves, but there was no correlation between the Cobb angles and the magnitude of LLI. The scoliometer readings did not correlate with the scoliosis or LLI. Our findings indicate that most patients with upper limb transverse amputations do not develop a significant scoliosis. A scoliometer screen has a low positive predictive rate for scoliosis and the diagnosis of scoliosis requires a radiograph of the spine.     

Spontaneous epidural hematoma as a cause of sciatic pain in a schoolboy

A previously healthy 13-year-old boy began to manifest radiating pain in his left leg after heavy physical exertion during judo training. He also had a sensation of numbness in his left buttock and leg. Initially, the patient was treated conservatively with a clinical diagnosis of disc herniation. However, following 3 months of conservative treatment, there was no relief of pain. Magnetic resonance imaging of the lumbar spine demonstrated an epidural mass causing compression of the dural sac at the L4-L5 disc level. During surgery, the L5 nerve root was found to be severely compressed in the spinal canal because of a chronic epidural hematoma. Following microsurgical removal of this hematoid mass, the patient had a good recovery. Spontaneous epidural hematomas in the lumbar region are rare, and only a few cases presenting with features simulating those caused by a disc herniation have been reported. Our patient represents the first such case described in a child.     

Chronic dopamine D1, dopamine D2 and combined dopamine D1 and D2 antagonist treatment in Cebus apella monkeys: antiamphetamine effects and extrapyramidal side effects

STUDY DESIGN: This study involved weekly radiographic examination of pinealectomized rats, hamsters, and chickens to observe the development of scoliosis. OBJECTIVES: To determine whether pinealectomy produces scoliosis in animals more closely related phylogenetically to humans than to chickens, namely rats and hamsters, which are representative of mammals. SUMMARY OF BACKGROUND DATA: Pinealectomy in 3-day-old chickens has consistently resulted in the development of scoliosis with many characteristics similar to those seen in patients with adolescent idiopathic scoliosis. It has not been determined whether this phenomenon is restricted solely to chickens or is applicable to other animals, especially those more closely related to humans. METHODS: The pineal gland was removed from young rats, hamsters, and chickens. All animals underwent radiography weekly to detect the development of any scoliosis. Weight and length measurements were also taken weekly, and serum melatonin levels were determined at the time the animals were killed. RESULTS: Scoliosis was not observed in either the rats or the hamsters. In contrast, scoliosis developed in 10 of 21 chickens. Serum melatonin levels in all pinealectomized animals were zero. CONCLUSIONS: In contrast to the chickens, pinealectomy does not seem to cause scoliosis in either young rats or hamsters. The reasons for this discrepancy may include differences in the physiology and spinal morphology of the rat and hamster in comparison with the chicken. In the pinealectomized chickens, the results also suggest that future scoliosis development might be indicated by a significant increase in size when they are compared with pinealectomized chickens that do not develop scoliosis. Such differences in growth rates also distinguish patients with adolescent idiopathic scoliosis.     

Retinal ganglion cell layer and visual function in a patient with optic disc drusen

BACKGROUND: To correlate the retinal ganglion cell pattern to visual acuity and visual field data in a patient with bilateral optic disc drusen, a quantitative clinicopathological study was carried out. METHODS: Both retinae of a patient with optic drusen were whole-mounted. Retinal ganglion cell counts were made using a sampling scheme covering the whole retina and compared to the findings in 10 normal retinae. Relative ganglion cell reduction in the drusen retinae was correlated to clinical data. RESULTS: The total retinal ganglion cell count was reduced from 1244858+/-98736 in normal retinae to 305319 on the right and 527571 on the left eye with optic disc drusen. Large ganglion cells had a better chance of survival. Parafoveal ganglion cell loss was 57% for the right and 36% for the left eye, while visual acuity was 0.8 and 1.0 respectively. The mean light sensitivity loss increased from the centre (6.2 dB) to paracentral (9.9 dB), mid-peripheral (13.7 dB) and outer peripheral (15.0 dB) retina, while ganglion cell losses were smallest in outer peripheral retina (21.9%), followed by central (53.0%), mid-peripheral (70.9%) and paracentral retina (87.7%). CONCLUSION: These data validate Frisén's theory on central retinal resolution and provide the structural basis for the clinical rule that low visual acuity should not be attributed to disc drusen. Automated light sense perimetry gives an inadequate picture of retinal damage caused by optic disc drusen.     

Acquired dural arteriovenous malformations of the lumbar spine: case report

OBJECTIVE AND IMPORTANCE: Although dural arteriovenous malformations (AVMs) are considered to be acquired, no conclusive evidence has been obtained. The first case of dural AVMs of the lumbar spine that showed evidence supporting their being acquired lesions is described. CLINICAL PRESENTATION: A 27-year-old man was admitted to our hospital in November 1994, presenting with increasing pain and numbness in the left buttock to the left lower limb. Myelography and arteriography showed dural AVMs of the lumbar spine. However, the myelogram obtained before surgery for lumbar disc herniation in 1987 provided no findings suggestive of intradural vascular anomalies. INTERVENTION: Embolization procedures via the left iliolumbar arteries were performed. However, there was no improvement of the symptoms, and the patient underwent surgical treatment. CONCLUSION: The present report documents a case of dural AVMs of the lumbar spine that showed evidence supporting their being acquired lesions.     

Changes in the unfused lumbar spine in patients with idiopathic scoliosis. A 5- to 9-year assessment after cotrel-dubousset instrumentation

STUDY DESIGN: Postoperative changes in the lumbar spine were studied retrospectively in patients with adolescent idiopathic scoliosis who had been treated with Cotrel-Dubousset instrumentation. OBJECTIVE: To examine middle-term changes in the unfused lumbar segments below an instrumented scoliosis fusion. SUMMARY OF BACKGROUND DATA: Scoliosis fusion by the Harrington method is known to be associated with a flat back in the fused area and subsequent degenerative changes in the segments below the fusion. No data have yet been published concerning a segmental instrumentation system. PATIENTS AND METHODS: Thirty patients with idiopathic scoliosis, between the ages of 14 and 22 years at the time of surgery, were observed for 5-9 years after surgery. Activity, pain, complications, and 21 radiographic parameters were assessed. RESULTS: The prevalence of low back pain increased from 3% before surgery to 20% at the final follow-up visit, although in none of the patients was the pain so severe that specific treatment was required. Radiographically, uninstrumented lumbar segments generally were realigned successfully in the frontal plane. Analyses in the sagittal plane revealed tendencies to a gradual increase in lumbar lordosis, anterior-upward tilting of the lowest instrumented vertebra, and posterior shift of the sagittal spinal balance. During the follow-up period, seven patients (23%) developed degenerative changes, including mild junctional kyphosis, retrolisthesis, narrowing of disc spaces, or osteophytes. CONCLUSION: Whereas the overall clinical and radiographic results of surgery were satisfactory, the unfused lumbar segments required careful surveillance, especially in the sagittal plane.     

Neuroprotection after spinal cord injury: state of the science

There have been no reports indicating diurnal variations in MRI at different portions of each lumbar disc. Eight asymptomatic healthy volunteers between 22 and 29 years old had MRI of their lumbar spine, twice on the same day (in the morning and evening). Forty lumbar discs were studied and the signal intensity change was measured from three portions of each disc (a total of 120 portions). No visible changes could be detected between scans by blinded observers. However, the calculated signal intensity changes showed an average loss of -20.0% (ant., 5 cases), -19.0% (mid, 2 cases), and -17.5% (post., 1 case). Height loss of the disc showed an average loss of -9.9% (ant., 4 cases), -8.3% (mid., 2 cases), and -10.4% (post., 2 cases). An increase of disc bulge at L4-5 level (18.3%) was pronounced, but L5-S1 level was less than others. Loss of body height averaged a loss of 7 mm (0.39% of body height). There was no correlation between reduced signal intensity and height loss at the ant./post. portion (p = 0.42), but there was a close relation at the mid. portion (p = 0.008). Diurnal change of the disc bulge was not correlated with reduced signal intensity (p = 0.48) or height loss (p = 0.16). Intradiscal fluid change was not necessarily influenced by the disc height loss, and height loss did not necessarily have an effect on disc bulge. But diurnal change showed a trend that was reflected in reduced signal intensity, height loss, and an increase of disc bulge which was more apparent from the ant. portion to the post, portion on moving down to the lower levels. Loss of disc height was one factor in the reduction of body height. These changes occurred randomly throughout 5 lumbar disc levels in each case.     

Associations between spinal deformity and outcomes after decompression for spinal stenosis

STUDY DESIGN: Prospective observational study. OBJECTIVES: To examine associations between radiographic parameters (scoliosis and olisthesis) and outcomes of surgery for degenerative spinal stenosis. SUMMARY OF BACKGROUND DATA: Preoperative degenerative scoliosis generally is thought to be associated with an unfavorable outcome of surgery for spinal stenosis. Data on the relationship between an increase in olisthesis after laminectomy for spinal stenosis and outcomes of surgery are sparse and conflicting. METHODS: Radiographs were obtained before surgery and at least 6 months after surgery and coded for preoperative scoliosis and change in olisthesis after surgery. The reviewers of radiographs were blind to outcome information. Patients completed questionnaires on demographic and clinical data as well as on back pain, lower extremity pain, walking capacity, and satisfaction with surgery. Associations between radiographic data and patient reported outcomes were examined with the Spearman rank correlation and confirmed with multiple linear regression models that adjusted for potential confounders. RESULTS: Ninety patients met eligibility criteria. Preoperative scoliosis was associated with less improvement in back pain at 6 months and at 24 months after surgery. An increase in olisthesis after surgery was associated with greater improvement in lower extremity pain at 6 months and at 24 months after surgery. An increase in olisthesis also was associated with greater improvement in walking capacity at 6 months and at 24 months after surgery. In multivariable analyses that adjusted for potential confounders, a change in olisthesis was not associated significantly with greater improvement in any of the outcomes. CONCLUSION: The data support the widely held view that preoperative scoliosis is associated with an unfavorable outcome after decompression for degenerative lumbar spinal stenosis. Increase in olisthesis was not associated with unfavorable results. In fact, there was a weak trend toward better outcomes with greater slip. These data indicate that minor increases in olisthesis after surgery for spinal stenosis generally are tolerated well.     

Echocardiography after mitral valve replacement and criteria of paraprosthetic regurgitation

19 patients with Bj?rk-Shiley mitral tilting disc valve prostheses were studied by echocardiography before the valve replacement operation and postoperatively every three months up to one year. In 14 patients with normal prosthetic function the left atrial diameter decreased markedly after operation (p less than 0.001), but echocardiographic dimensional indices of left ventricular performance remained unchanged. Paradoxical or markedly hypokinetic motion of the interventricular septum was observed within 3 months of operation in 46% of the patients, but in only 28% in studies performed 9 - 12 months after the replacement. The ampliture of the disc was on average 11 +/- 2 mm. In 5 patients with paraprosthetic regurgitation the left atrial diameter increased with the development of regurgitation and decreased again after successful reoperation. In these patients the left ventricular end diastolic and stroke volumes were great (p less than o.01) than in patients with normal prostheses. The septal motion was in the normal direction in all these 5 patients and the septal amplitudes were greater (p less than 0.01) than in the patients with normal prostheses. The amplitudes of the disc were normal, but abnormal anterior movement of the disc at the beginning of the diastole was observed. These data demonstrate that echocardiography is useful in the diagnosis of paraprosthetic mitral valve regurgitation.     

Prevention of gastric ulcer recurrence with tetraprenylacetone

We have carried out an experimental investigation of lesions of the intervertebral disc produced by flexion, lateral bending and rotational forces in an attempt to produce disc herniations. Adult Wistar rats were divided into 4 groups: control and posterior, lateral and rotational herniation. There were 10 rats in each group. The tail between the 5th and 8th vertebral segments was used. A Kirschner wire was inserted into each of 2 adjacent vertebrae and the movement produced had an apex which was anterior or lateral depending on the group involved. Variables such as rupture of the annulus, the cellularity of the nucleus pulposus and the site of the lesion in the disc were studied histologically. The height of the disc, the protrusion, the thickness, and the surfaces of the annulus fibrosus and the nucleus pulposus were measured. In every case we found a nuclear displacement which did not become a protrusion. The surface parameters and the cellularity of the nucleus pulposus are most useful indicators and should be included in any study examining the disc after the injection of substances for treatment.