Application of a lumbar brace for thoracic and double thoracic lumbar scoliosis: a comparative study

A pilot study was performed to determine if thoracic and double thoracic lumbar scolioses can successfully be treated by applying a lumbar brace. In some of the patients application of a thoracic brace yielded insufficient correction of the lumbar curve. As the response of a curve to application of a brace is said to be the best guideline for prediction of the results of brace treatment, it was thought important to focus more attention on the behaviour of the lumbar curve. It was assumed that a lumbar brace would result in a better fit and might lead to better correction of the lumbar curve. In total 21 patients were treated according to the above-described method. Three patients were omitted from the study because of incomplete radiographic data. Thus, 18 patients treated with a thoracic brace, who showed insufficient correction of the lumbar curve, were subsequently treated with a lumbar brace. Radiographs taken in the thoracic brace patients showed a mean decrease of the thoracic curve of 9 degrees (27%) and a mean decrease of the lumbar curve of 5 degrees (16%). In the lumbar brace group the mean decrease of the thoracic curve was 7 degrees (21%) and the mean decrease of the lumbar curve was 12 degrees (38%). Brace treatment was successful (<6 degrees progression of the major curve) in 13 patients (70%). In this selection of patients with thoracic and double thoracic lumbar scoliosis a lumbar brace clearly led to a better initial correction of the lumbar curve; follow-up results seem to be comparable to those in literature.     

Hyperostotic lumbar spinal stenosis. A review of 12 surgically treated cases with roentgenographic survey of ossification of the yellow ligament at the lumbar spine

Although there is considerable literature concerning ossification of the posterior longitudinal ligament or the ligamentous flava (OPLL or OYL) in the cervical and thoracic spine, there are only a few references about OPLL or OYL in the lumbar spine. The authors have described lumbar spinal stenosis due to OPLL or OYL as hyperostotic lumbar spinal stenosis, and analyzed 12 surgically documented cases with this condition. The symptoms and signs of hyperostotic lumbar spinal stenosis are the same as those seen in degenerative lumbar spinal stenosis, but the degree of paraparesis is much more severe in hyperostotic lumbar spinal stenosis. Computed tomography scan imaging clearly demonstrates OPLL or OYL in the lumbar spine, although some lesions can be seen on the lateral view of a plain roentgenogram. The results of 12 surgical cases suggest that decompression laminectomy produces relief of symptoms. An analysis of 2,403 plain lumbar roentgenograms showed an incidence of 8.4% OYL in the lumbar spine, with frequent involvement of the upper and middle lumbar spine. A classification system of OYL in the lumbar spine has been developed. The entire spine should be examined before surgery on a patient with hyperostotic lumbar spinal stenosis because of a tendency to ossify spinal ligaments at other levels.     

Predictability of the spontaneous lumbar curve correction after selective thoracic fusion in idiopathic scoliosis

In this study we tried to achieve a better understanding of the biodynamic mechanism of balance in the scoliotic spine. Therefore we focused on the pre- and postoperative spine of patients with idiopathic scoliosis with a primary thoracic curve and a secondary lumbar curve. Several studies showed that the lumbar curve spontaneously corrects and improves after selective thoracic fusion. We try to understand and describe this spontaneous compensatory lumbar curve correction after selective thoracic correction and fusion. We performed a retrospective examination of pre- and postoperative radiographs of the spine of 38 patients with idiopathic scoliosis King type II and III. Frontal Cobb angles of the thoracic and lumbar curves were assessed on pre- and postoperative antero-posterior and side bending radiographs. We determined the postoperative corrections of the thoracic and lumbar curves. Relative (%) corrections and correlations of the postoperative corrections were calculated. The group was divided in three subgroups, depending on lumbar curve modifier, according to Lenkes classification system. The calculations were done for the whole group as for each subgroup. As expected, significant correlations were present between the relative correction of the main thoracic and the lumbar curve (mean R = 0.590; P = 0.001). The relation between relative thoracic and lumbar correction decreased with the lumbar modifier type. This study shows a highly significant correlation between the relative corrections of the main thoracic curve and the lumbar curve after selective thoracic fusion in idiopathic scoliosis. This correlation depends on lumbar curve modifier type. This new classification system seems to be of great predictable value for the spontaneous correction of the lumbar curve. Depending on the curve-type, a different technique for predicting the outcome should be used. The lumbar curve correction does not occur throughout the whole lumbar curve. Most correction is achieved in the upper part of the curve. The distal lumbar curve seems to be more rigid and less important in the spontaneous curve correction.     

The influence of diabetes mellitus on lumbar intervertebral disk herniation

BACKGROUND: It has recently been proven that smoking has a negative influence on lumbar disk herniation. This is probably due to microangiopathy. Our purpose was to find out if patients operated on for lumbar disk disease also have an increased incidence of diabetes mellitus. We have also examined if this increased incidence could be the result of diagnostic uncertainties (diabetic neuropathy operated as lumbar disk disease). METHODS: This is a prospective study. One hundred two patients operated on in our department for lumbar disk herniation were compared with 98 patients of the same age who were admitted for elective surgery and did not take cortisone. History for diabetes mellitus, blood glucose, and glycated hemoglobin were examined. chi(2) test was used for statistical analysis. We have also compared the results of the diabetics and nondiabetic patients operated on for lumbar disk disease. RESULTS: There was a statistically significant increased incidence of diabetes mellitus in patients operated on for lumbar disk disease. There was no difference in the results at 3 months of the 2 groups of patients operated on for lumbar disk disease. CONCLUSIONS: Patients operated on for lumbar disk disease have a statistically significant increased incidence of diabetes mellitus compared with similar patients operated on for other reasons. This difference cannot be explained by diagnostic uncertainties because if patients with diabetic polyneuropathy were wrongly operated on for lumbar disk disease, their results would not be as good as those of the other patients operated on for lumbar disk disease. Diabetes mellitus must be a predisposing factor in patients operated on for lumbar disk disease.     

Laparoscopic repair of a lumbar hernia: report of a case and extensive review of the literature

Lumbar hernias are a protrusion of intra-abdominal contents through a weakness or rupture in the posterior abdominal wall. They are considered to be a rare entity with approximately 300 cases reported in the literature since it was first described by Barbette in 1672. Petit described the inferior lumbar triangle in 1783 and Grynfeltt described the superior lumbar triangle in 1866; both are anatomical boundaries where 95 % of lumbar hernias occur, whereas the other 5 % are considered to be diffuse. Twenty percent of lumbar hernias are congenital and the other 80 % are acquired; the acquired lumbar hernias can be further classified into either primary (spontaneous) or secondary. The typical presentation of lumbar hernias is a patient with a protruding semispherical bulge in the back with a slow growth. However, they may present with an incarcerated or strangulated bowel, so it is recommended that all lumbar hernias must be repaired as soon as they are diagnosed. The “gold standard” for diagnosing a lumbar hernia is a CT scan, because it is able to delineate muscular and fascial layers, detect a defect in one or more of these layers, evaluate the presence of herniated contents, differentiate muscle atrophy from a real hernia, and serve as a useful tool in the differential diagnosis, such as tumors. Recent studies have demonstrated the advantages of a laparoscopic repair instead of the classic open approach as the ideal treatment option for lumbar hernias. We report a case of a spontaneous lumbar hernia initially diagnosed as a lipoma and corrected with the open approach, but after relapsing 2 years later it was corrected using a laparoscopic approach. It is followed by an extensive review of lumbar hernias literature regarding history, anatomy, and surgical techniques.     

腰椎间孔狭窄症的诊断与手术治疗

目的：讨论腰椎间孔狭窄症的病理解剖、临床特征、诊断和手术治疗。方法：对１９９１年至１９９８年间４２例腰椎间孔狭窄症病人的诊断与手术治疗进行了回顾性研究。结果：术后对其中的３８例病人进行了０．５～５．５年,平均３．５年的随访,手术优良率达９２．７％。结论：引起腰椎间孔狭窄并导致根本性卡压征的原因有腰椎间盘退变狭窄,小关节增生内聚,黄韧带肥厚内陷,椎间孔内间盘突出和腰椎滑脱等。诊断依赖于根性损害表现和可靠的腰椎ＣＴ扫描或ＭＲＩ检查。手术包括腰椎间孔的探查和减压,术中注意保护和重建脊柱稳定性,并防止神经结构误伤。     

Quantification of Lumbar Endurance on a Backup Lumbar Extension Dynamometer

We evaluated the reliability of static and dynamic lumbar muscle endurance measurements on a BackUP lumbar extension dynamometer. Sixteen healthy participants (8 male; 8 female) volunteered for this investigation. Fifty percent of each participant’s body weight was calculated to determine the weight load utilized for the static (holding time) and dynamic (repetitions) lumbar extension endurance tests. Four separate tests (2 static, 2 dynamic) were conducted with at least a 24-hour rest period between tests. Test-retest intraclass correlations were shown to be high (static lumbar endurance, ICC = 0.92 (p < 0.0005); dynamic lumbar endurance, ICC = 0.93 (p < 0.0005) for both of the performed tests. Our results demonstrated that static and dynamic lumbar endurance can be assessed reliably on a BackUP lumbar extension dynamometer.

Key Points

• Reliability studies that test lumbar endurance on machines that effectively stabilize the pelvis and isolate the lumbar extensors are limited.
• This is the first study to report reliability measures of static and dynamic lumbar endurance on a BackUP lumbar extension dynamometer.
• Static and dynamic lumbar endurance on a BackUP lumbar extension dynamometer, which uses a variety of pelvic stabilization mechanisms, can be reliably assessed in apparently healthy individuals.
• Future research is necessary to examine the reliability of lumbar extension endurance on the BackUP dynamometer in patient populations and validity in various settings.

Key words: Reliability, low back, static, dynamic     

腰丛的解剖及其在腰椎前外侧入路微创手术中的临床意义

目的 了解腰丛在腰椎前外侧入路微创手术中的应用解剖学特点.方法 通过15具成人腰椎标本、2具腰段的断层图片和3个数字人腰段数据集,观察腰丛的走行及其与腰大肌及腰椎横突的关系.结果 L2-5腰丛在腰椎侧方的组成具有一定的规律性,正面按从外到内的顺序排列,侧面按从腹侧到背侧的方向排列.腰神经出椎间孔的角度从L1到L5逐渐增加.横突与腰丛的关系紧密.断层解剖显示,腰丛在不同节段始终位于腰大肌的后1/3,因此在切开腰大肌暴露腰椎时,切开位置不宜超过腰大肌的后1/3,腰大肌的前2/3是切开安全区.结论 暴露腰椎侧前方切开腰大肌时,注意不要超过腰大肌的前2/3,以避免腰丛的损伤.横突可以作为手术中的解剖学标志,用以明确腰丛的解剖位置,避免术中腰丛损伤.     

腰椎滑脱症外科治疗策略选择

目的探讨不同类型腰椎滑脱症及合并症的手术治疗方式、疗效及优缺点。方法2000年2月～2004年4月应用后路椎弓根螺钉复位内固定后，分别采用后外侧植骨融合术、后路椎体间植骨融合术及前路椎体问植骨融合术治疗不同类型腰椎滑脱症及合并症的患者78例，比较术后及随访时疗效、滑脱椎体复位率、椎间隙高度恢复率、植骨融合率以及复位丢失率。结果术后28例Ⅰ度滑脱及37例Ⅱ度腰椎滑脱患者获得解剖复位．9例Ⅱ度滑脱及4例Ⅲ度腰椎滑脱患者矫正至Ⅰ度滑脱。随访时总体优良率为89．72％，42例椎体间植骨患者植骨融合良好，滑脱椎体复位无丢失，椎间隙高度维持良好；36例后外侧植骨者有12例复位丢失，2例椎弓根螺钉松动，2枚椎弓根螺钉断裂：结论对小于Ⅱ度退变性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉复位固定加后外侧植骨融合术；对峡部裂性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉固定加椎体间植骨融合术；对Ⅱ度以上峡部裂性单纯腰椎滑脱者以及腰椎滑脱翻修者宜选用后路椎弓根钉固定加前路椎体间植骨融合术。     

No relationship exists between the correction of the thoracic and the lumbar curves after selective thoracic fusion for adolescent idiopathic scoliosis King type II

In this study we focus on idiopathic scoliosis with a primary thoracic curve and a secondary lumbar curve. We were interested in how the lumbar curve corrects following selective thoracic fusion and whether one can explain or predict the behaviour of the lumbar curve. In the literature it is said that, if the lower level of fusion is properly selected, the lumbar curve spontaneously corrects to balance the thoracic curve after selective thoracic fusion. Most authors have assumed a mechanism whereby improvement of the lumbar curve occurs through counterbalancing the surgical correction of the thoracic curve. The correction of the lumbar curve is said to echo the correction obtained for the thoracic curve. Because of these hypotheses, we postulate there should be a correlation between the correction of the lumbar and the thoracic curves of a scoliosis. To validate this hypothesis, we performed a retrospective study on 27 patients with King type II adolescent idiopathic scoliosis treated by selective thoracic fusion. The mean preoperative Cobb angles were 54 degrees for the thoracic curve and 34 degrees for the lumbar curve. Postoperatively they were 31 degrees and 22 degrees respectively. Using Pearson correlation analysis, we found no significant correlation between the relative corrections of the individual thoracic and lumbar curves. Moreover, there was a decrease in the correlation between the thoracic and lumbar curve after operation (preoperative R=0.787, postoperative R=0.364). These results show that the correction of the lumbar curve is not a reflection of the thoracic correction. The exact mechanism by which the lumbar spine corrects remains to be elucidated.     

不同手术方式治疗腰椎滑脱症的比较

目的：比较采用不同内固定及植骨融合方式治疗腰椎滑脱症的手术疗效及适应证。方法：应用后路椎弓根螺钉复位内固定后．分别采用后外侧植骨融合术、后路椎体间植骨融合术及前路椎体间植骨融合术治疗不同类型及合并症的腰椎滑脱症患者67例，比较不同术式的手术时间与出血量、手术疗效与并发症、滑脱椎体复位率与复位丢失率以及椎间隙高度。结果：后路椎弓根钉固定加椎体间植骨融合术手术时间最长、出血量最多。手术总体优良率为88．71％，三种术式间无差异。所有椎体间植骨组植骨融合良好，椎间隙高度维持良好，滑脱椎体复位无丢失；12例后外侧植骨者平均复位丢失率为11．24％，2例椎弓根螺钉松动，2枚椎弓根螺钉断裂。结论：退变性腰椎滑脱者宜选用后路椎弓根钉固定加后外侧植骨融合术；峡部裂性腰椎滑脱者宜选用后路椎弓根钉固定加椎体间植骨融合术；腰椎滑脱翻修者宜选用后路椎弓根钉固定加前路椎体间植骨融合术     

Clinical anatomic study of the lower lumbar anterolateral vein: with respect to retroperitoneal endoscopic surgery

Objective： To study the anatomy of veins of the lower lumbar spine and provide the anatomic basement for laparoscopic lumbar surgery. Methods： A total of 15 formaldehyde-preserved cadav- ers were studied with special attention to the variety and surrounding structure of ascending lumbar vein （ALV） and iliolumbar veins （ILV）, and their relationship with lumbar plexus. Results： ALV and ILV can be found on every sides, which have four variants including separate entry and common entry. The ascending vein and iliolumbar vein separately enter common iliac vein in 18 cases, and as a common stem enter the common iliac vein in 12 cases. Retracting common iliac vein medially both the ascending lumbar and the iliolumbar veins are always at risk of avulsion on exposure of the disc space. The injury of obturator nerve and lumbosacral trunk of lumbar plexus should be avoided. Conclusion： Awareness of these anatomic variation can prevent the hemorrhage and be helpful for the surgeon in performing a careful ligation of these veins before medial retraction of the common iliac vein. Our findings emphasize the need for proper dissection of ALV and ILV before ligature during exposure of the lower lumbar spine.     

The lumbar shield: a progress report

The lumbar shield is a silicone implant designed to prevent postoperative perineural adhesions, indicate a recurrent intervertebral disc rupture, facilitate further surgery at that level, and aid in the postoperative management of the patient. Over three years it has been implanted in 123 experimental patients. There are 83 control patients. Statistical analysis of the results indicates that for the first three months, those patients with the lumbar shield had less postoperative pain. The diagnosis of a recurrent lumbar disc rupture on lateral lumbar spine radiographs is illustrated. The ease of secondary surgery for a recurrent lumbar disc rupture is emphasized. The value of the lumbar shield in postoperative management is discussed, especially in the workmen's compensation/medicolegal groups. One conclusion is that the frequency of multiple secondary surgical procedures on patients with unsatisfactory initial results could be reduced by the use of the lumbar shield.     

青少年腰椎间盘突出症的诊断与治疗

目的 探讨青少年腰椎间盘突出症的诊断依据与治疗方法。方法 对26例青少年腰椎间盘突出症患者的临床资料进行回顾性分析,根据其临床特征总结出诊断要点和有效的治疗方法。结果 青少年腰椎间盘突出症的诊断要点是：1．一般都有明显的外伤史或先天畸形。2．临床症状轻、体征重。3．临床检查和X线片检查不易确诊和定位。4．CT、MRI检查能明确诊断。非手术治疗效果差,胶原酶溶核和经皮穿刺抽吸疗效不理想,手术治疗优良率高。结论 青少年腰椎间盘突出症临床特征突,CT、MRI有助于明确诊断,手术是理想的治疗方法。     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy

There is no convincing medical evidence to support the routine use of lumbar fusion at the time of a primary lumbar disc excision. There is conflicting Class III medical evidence regarding the potential benefit of the addition of fusion in this circumstance. Therefore, the definite increase in cost and complications associated with the use of fusion are not justified. Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; however, the incidence of such instability appears to be very low (< 5%) in the general lumbar disc herniation population. Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. Patients with a recurrent disc herniation have been treated successfully with both reoperative discectomy and reoperative discectomy combined with fusion. In patients with a recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low-back pain, consideration of fusion in addition to reoperative discectomy is recommended.     

A critique of posterior lumbar interbody fusion: 12 years' experience with 250 patients

A comprehensive long-term follow-up analysis of the clinical and radiographic results of posterior lumbar interbody fusion for lumbar disk disease is presented. This 12-year experience with 250 patients is compared with a previous critique of our surgical management of lumbar disk disease by laminotomy and diskectomy alone. The clinical results and complications rates are comparable. However, posterior lumbar interbody fusion significantly reduces the rate of recurrent problems requiring subsequent surgery. Careful technique and judgment are mandatory for success with posterior lumbar interbody fusion. Homologous tissue bank bone grafts were found to be as successful as autogenous bone. Posterior lumbar interbody fusion represents an improvement in the surgical management of lumbar disk disease.     

Lumbar spinal loads and lumbar muscle forces evaluation with various lumbar supports and backrest inclination angles in driving posture

Purpose

The low back pain of professional drivers could be linked to excessive lumbar load. This study aims at developing a musculoskeletal model to study the lumbar spinal loads and lumbar muscle forces of the human body in driving posture, so as to contribute to a better understanding of low back pain and to improve the design of vehicle seats.

Methods

A standing musculoskeletal model, including limbs, head and neck, that can reflect several activities of daily living was established based on the Christophy spine model. The model was then validated by comparing the calculated lumbar loads and muscle forces to the experimental data in the previous studies. Referring to radiology studies, the musculoskeletal model was adjusted into different driving postures with several different lumbar supports (0, 2 and 4 cm) and inclinations of the backrest (from 23° to 33°, by 2° intervals). The lumbar biomechanical load with various lumbar supports and backrest inclination angles was calculated.

Results

The results showed that the overall lumbar spinal load and lumbar muscle force with 4 cm lumbar support were reduced by 11.30 and 26.24%. The lumbar spinal loads and lumbar muscle forces increased first and then decreased with the increase in backrest inclination angles from 23° to 33°. The lumbar biomechanical load varied slightly with the backrest inclination angles from 29° to 33°.

Conclusions

There are two findings: (i) the lumbar spinal loads at the L3–L4, L4–L5 and L5–S1, and lumbar muscle forces decreased obviously with the 4 cm lumbar support, while the seat cushion inclination angle was set to 10°. (ii) The recommended backrest inclination angles are 29° to 33° with a 10° seat cushion to the horizontal, which can keep a low level of the lumbar spinal loads and lumbar muscle forces. This study could be used to explain the association between drivers’ sitting posture and the lumbar load change, and provide a reference for the prevention of low back pain.

     

Congenital lumbar hernia and bilateral renal agenesis

We report a new case of congenital lumbar hernia. This is first case reported of congenital lumbar hernia and bilateral renal agenesis. We review literature and describe associated malformations reported that would be role out in every case of congenital lumbar hernia.     

A morphological adaptation of the thoracic and lumbar vertebrae to lumbar hyperlordosis in young and adult females

The lumbar shape in females is thought to be unique, compensating for lumbar hyperlordosis. Yet, the morphological adaptation of various vertebral parameters in the thoracic and lumbar spine to this unique posture in young and adult females has only been partially addressed in the literature. Our aim was to investigate the gender association to vertebral shape in the thoracic and lumbar spine as a possible adaptation to lumbar hyperlordosis in young and adult females. A three-dimensional digitizer was used to measure the vertebral body sagittal wedging, relative spinous process thickness, and relative interfacet width at the T1–L5 level. Two hundred and forty complete, non-pathological skeletons of adults and 32 skeletons of young individuals were assessed. Three major results were found to be independent of age and ethnicity: (a) VB sagittal wedging in females was significantly less kyphotic than males from T9 to L2 (T11 excluded) with a cumulative mean difference of 8.8°; (b) females had a significantly relatively thinner lumbar spinous processes and (c) females had a relatively wider superior interfacet distance (T9–T10 and L1–L4) than males. We conclude that the combination of less kyphotic VB wedging in the lower thoracic and upper lumbar vertebrae, relatively greater interspinous space and larger interfacet width in the lumbar spine in females are key architectural elements in the lumbar hyperlordosis in females and may compensate for the bipedal obstetric load during pregnancy.