How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systematic Review

Background

MRI is the gold standard for evaluating the relationship of disc material to soft tissue and neural structures. However, terminologies used to describe lumbar disc herniation and nerve root compression have always been a source of confusion. A clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers is vital for patient care and future research.

Questions/purposes

Through a systematic review of the literature, the purpose of this article is to describe lumbar disc terminology and comment on the reliability of various nomenclature systems and their application to clinical practice.

Methods

PubMed was used for our literature search using the following MeSH headings: “Magnetic Resonance Imaging and Intervertebral Disc Displacement” and “Lumbar Vertebrae” and terms “nomenclature” or “grading” or “classification”. Ten papers evaluating lumbar disc herniation/nerve root compression using different grading criteria and providing information regarding intraobserver and interobserver agreement were identified.

Results

To date, the Combined Task Force (CTF) and van Rijn classification systems are the most reliable methods for describing lumbar disc herniation and nerve root compression, respectively. van Rijn dichotomized nerve roots from “definitely no root compression, possibly no root compression, indeterminate root compression, possible root compression, and definite root compression” into no root compression (first three categories) and root compression (last two categories). The CTF classification defines lumbar discs as normal, focal protrusion, broad-based protrusion, or extrusion. The CTF classification system excludes “disc bulges,” which is a source of confusion and disagreement among many practitioners. This potentially accounts for its improved reliability compared with other proposed nomenclature systems.

Conclusions

The main issue in the management of patients with lumbar disc disease and nerve root compression is correlation of imaging findings with clinical presentation and symptomatology to guide treatment and intervention. Although it appears that the most commonly supported nomenclatures have strong interobserver reliability, the classification term “disc bulges” is a source of confusion and disagreement among many practitioners. Additional research should focus on the clinical application of the various nomenclatures.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3674-y) contains supplementary material, which is available to authorized users.     

Reoperation after lumbar disc surgery in two hundred and seven patients

Purpose

The purpose of this study was to compare the causes and characteristics of reoperations after different primary operations for lumbar disc herniation (LDH).

Methods

Out of a series of 5,280 patients who underwent operations for LDH between 2001 and 2012, 207 patients (135 male and 72 female, mean age 47.7 years) underwent primary and revision operations, which were included in this study. The following clinical parameters were retrospectively assessed: the primary surgical methods, the intervals between primary and revision operations, and surgical findings in the revisions.

Results

In total, 232 lumbar discs underwent reoperations. One hundred and nineteen reoperations were performed after microendoscopic discectomy (MED group), 68 after percutaneous endoscopic lumbar discectomy (PELD group) and 45 after open disc surgery (open group). The locations of revision operations had priority over those of primary surgery, with a moderate correlation (kappa coefficient = 0.533). A total of 46.6 % of reoperations were performed within 0.5 years after primary surgery, and 35.3 % were performed between one and five years. Real recurrent herniation (homolateral herniations at the same level) was significantly more common than other reoperative surgical findings (70.6 % in PELD group, 47.1 % in MED group, 37.8 % in open group). The overall mean interval until revision surgery was 18.9 months (8.1 months in the PELD group vs. 19.7 months in the MED group vs. 33.1 months in the open group, p < 0.01).

Conclusions

For LDH, real recurrent herniation was the most common cause of reoperations, and more reoperations for real recurrent herniations and shorter intervals were found after minimally invasive endoscopic discectomy than after open disc surgery.     

Extracortical plate fixation with new plate inserts and cerclage wires for the treatment of periprosthetic hip fractures

Purpose

Fixation of periprosthetic hip fractures with intracortical anchorage might not be feasible in cases with bulky implants and/or poor bone stock.

Methods

Rotational stability of new plate inserts with extracortical anchorage for cerclage fixation was measured and compared to the stability found using a standard technique in a biomechanical setup using a torsion testing machine. In a synthetic PUR bone model, transverse fractures were fixed distally using screws and proximally by wire cerclages attached to the plates using “new” (extracortical anchorage) or “standard” (intracortical anchorage) plate inserts. Time to fracture consolidation and complications were assessed in a consecutive series of 18 patients (18 female; mean age 81 years, range 55–92) with periprosthetic hip fractures (ten type B1, eight type C-Vancouver) treated with the new device between July 2003 and July 2010.

Results

The “new” device showed a higher rotational stability than the “standard” technique (p < 0.001). Fractures showed radiographic consolidation after 14 ± 5 weeks (mean ± SD) postoperatively in patients. Revision surgery was necessary in four patients, unrelated to the new technique.

Conclusion

In periprosthetic hip fractures in which fixation with intracortical anchorage using conventional means might be difficult due to bulky revision stems and/or poor bone stock, the new device may be an addition to the range of existing implants.     

Comparison of wire and disc leads to activate the expiratory muscles in dogs

Objective

Respiratory complications account for a major cause of morbidity and mortality in subjects with spinal cord injury (SCI) due to paralysis of the expiratory muscles and the consequent inability to generate effective cough. We demonstrated previously that effective cough can be restored in SCI via spinal cord stimulation (SCS) with disc leads positioned on the lower thoracic and upper lumbar spinal cord via laminotomy incisions. In this study, the effectiveness of wire leads, which can be placed using minimally invasive techniques, to activate the expiratory muscles was evaluated.

Design

Animal study.

Setting

Research laboratory.

Animals

Dogs (n = 8).

Interventions

In separate trials, disc and wire leads were inserted onto the dorsal epidural space at the T9, T11, and L1 spinal cord levels. Effects of electrical stimulation with disc, single wire, and two wire leads placed in parallel were compared.

Outcome measures

Airway pressure generation following stimulation with disc and various configurations of wire leads were compared.

Results

Several different configurations of wire leads resulted in airway pressures that were similar to those generated with monopolar stimulation with disc leads (MSDLs). For example, combined monopolar stimulation with parallel wire leads at the T9 + T11 and T9 + L1 levels resulted in airway pressures that were 103.5 ± 6.4 and 101.9 ± 7.0%, respectively, of those achieved with MSDL. Bipolar stimulation with parallel wire leads at T9–T11 and T9–L1 resulted in airway pressures that were 94.2 ± 3.4 and 96.8 ± 5.0%, respectively, of the pressures achieved with MSDL. Other wire configurations were also evaluated, but were generally less effective.

Conclusion

These results suggest that specific configurations of wire leads, which can be placed via minimally invasive techniques, result in comparable activation of the expiratory muscles compared to disc leads and may be a useful technique to restore cough in persons with SCI.     

Is it Time for Cementless Hip Resurfacing?

Background

Metal-on-metal bearing with cemented femoral component and cementless acetabular fixation is the current standard in surface replacement arthroplasty (RSA) of the hip. Because of concerns about the long-term survivorship of cemented stems in conventional hip arthroplasty, it seems logical to achieve cementless fixation on the femoral side with RSA.

Questions/Purposes

The goals of this review were to evaluate clinical and radiological data reported from previously published cementless RSA series. In addition, we intend to review author’s preliminary experience with Conserve Plus cementless devices specifically assessing the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels measured in follow-up.

Methods

A references search was done with PubMed using the key words “cementless hip resurfacing”, “cementless hip resurfacing prosthesis”, and “femoral cementless hip resurfacing”. Additionally, the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels were measured in 94 cementless Conserve Plus^© devices in 90 patients (68 males and 22 females) with a mean age of 41.1 years (18–59). Mean follow-up was 13.1 months (8–16).

Results

No revision was performed during the observed follow-up. Neither radiological signs of loosening nor neck narrowing >10% were evident. Chromium and cobalt levels in whole blood samples rose respectively from 0.53 μg/l (0.1–1.7) to 1.7 μg/l (0.6–2.9) and from 0.54 μg/l (0.1–1.4) to 1.98 μg/l (0.1–2.8).

Conclusions

Cementless “fit and fill” femoral-side fixation, which seems to be potentially evolved and design-related, should be considered for future hip-resurfacing device generations.     

Direct subcutaneous injection of polyethylene particles over the murine calvaria results in dramatic osteolysis

Purpose

The murine calvarial model has been widely employed for the in vivo study of particle-induced osteolysis, the most frequent cause of aseptic loosening of total joint replacements. Classically, this model uses an open surgical technique in which polyethylene (PE) particles are directly spread over the calvarium for the induction of osteolysis. We evaluated a minimally invasive modification of the calvarial model by using a direct subcutaneous injection of PE particles.

Methods

Polyethylene (PE) particles were injected subcutaneously over the calvaria of C57BL6J ten-week-old mice (“injection” group) or were implanted after surgical exposure of the calvaria (“open” group) (n = 5/group). For each group, five additional mice received no particles and served as controls. Particle-induced osteolysis was evaluated two weeks after the procedure using high-definition microCT imaging.

Results

Polyethylene particle injection over the calvaria resulted in a 40 % ± 1.8 % decrease in the bone volume fraction (BVF), compared to controls. Using the “open surgical technique”, the BVF decreased by 16 % ± 3.8 % as compared to controls (p < 0.0001).

Conclusions

Direct subcutaneous injection of PE particles over the murine calvaria produced more profound resorption of bone. Polyethylene particle implantation by injection is less invasive and reliably induces osteolysis to a greater degree than the open technique. This subcutaneous injection method will prove useful for repetitive injections of particles, and the assessment of potential local or systemic therapies.     

Experimental Disc Herniation in the Rat Causes Downregulation of Serotonin Receptor 2c in a TNF-dependent Manner

Background

During recent decades, the knowledge of the pathophysiology of disc herniation and sciatica has drastically improved. What previously was considered a strict biomechanical process is now considered a more complex interaction between leaked nucleus pulposus and the tissue in the spinal canal. An inflammatory reaction, with tumor necrosis factor (TNF) playing an essential role, has been demonstrated. However, the exact mechanisms of the pathophysiology of disc herniation remain unknown.

Questions/purposes

In this study we use an animal model to investigate (1) if and/or how experimental disc herniation affects gene expression in the early phase (24 hours postsurgery) in the dorsal root ganglion; and (2) if TNF inhibition can reduce any observed changes.

Methods

A rat model of disc herniation was used. Twenty rats were evenly divided into four groups: naïve, sham, disc herniation, and disc herniation with TNF inhibition. The dorsal root ganglion of the affected nerve root was harvested 24 hours after surgery and analyzed with a TaqMan Low Density Array^® quantitative polymerase chain reaction assay. Gene expression levels in sham were compared with disc herniation to assess question 1 and disc herniation to disc herniation with TNF inhibition to assess question 2.

Results

Experimental disc herniation caused a decrease in the expression of the serotonin receptor 2c gene (p = 0.022). TNF inhibition was found to reduce the observed decrease in expression of serotonin receptor 2c (p = 0.037).

Conclusions

Our results suggest that a decrease in the expression of the serotonin receptor 2c gene may contribute to the pathophysiology of disc herniation. Further research on its involvement is warranted.

Clinical Relevance

This pilot study gives a brief insight into cellular changes that may contribute to the pathophysiology of disc herniation. This knowledge may contribute to the development of more and better treatment options for patients with disc herniation and sciatica.     

Blood transfusion in patients with sickle cell disease requiring laparoscopic cholecystectomy

Background:

Surgery in patients with sickle cell disease is associated with high morbidity. To reduce this high morbidity, different preoperative transfusion regimens were introduced. However, blood transfusion is associated with problems. This prospective study aims to establish the safety of conducting laparoscopic cholecystectomy without transfusion in sickle cell disease patients.

Methods:

Forty patients (16 males and 24 females; mean age 26.6 years) undergoing laparoscopic cholecystectomy for cholelithiasis were divided into 2 matched groups: Group I “no transfusion” (n=24 patients; 60%) and Group II “transfusion” (n=16; 40%). In Group II, 9 patients (22.5%) received a simple transfusion and 7 (17.5%) a partial exchange transfusion.

Results:

Group II patients had significantly higher levels of Hb-S prior to transfusion. They developed a significantly higher complication rate (25% vs. 0%) and subsequently longer hospital stay (3.9±2 vs. 2.1±1.4). Moreover, there was no significant difference in the complications between the simple transfusion and partial exchange transfusion subgroups.

Conclusion:

Surgery in SCD patients is safe without a preoperative blood transfusion. Moreover, preoperative blood transfusion is associated with significantly higher postoperative complications and longer hospital stay. Hence, a “no transfusion” policy is recommended.     

The Increased Expression of Matrix Metalloproteinases Associated with Elastin Degradation and Fibrosis of the Ligamentum Flavum in Patients with Lumbar Spinal Stenosis

Background

One of the characteristics of spinal stenosis is elastin degradation and fibrosis of the extracellular matrix of the ligamentum flavum. However, there have been no investigations to determine which biochemical factors cause these histologic changes. So we performed the current study to investigate the hypothesis that matrix metalloproteinases (MMPs), which possess the ability to cause extracellular matrix remodeling, may play a role as a mediator for this malady in the ligamentum flavum.

Methods

The ligamentum flavum specimens were surgically obtained from thirty patients with spinal stenosis, as well as from 30 control patients with a disc herniation. The extents of ligamentum flavum elastin degradation and fibrosis were graded (grade 0-4) with performing hematoxylin-eosin staining and Masson''s trichrome staining, respectively. The localization of MMP-2 (gelatinase), MMP-3 (stromelysin) and MMP-13 (collagenase) within the ligamentum flavum tissue was determined by immunohistochemistry. The expressions of the active forms of MMP-2, MMP-3 and MMP-13 were determined by western blot analysis, and the blots were quantified using an imaging densitometer. The histologic and biochemical results were compared between the two conditions.

Results

Elastin degradation and fibrosis of the ligamentum flavum were significantly more severe in the spinal stenosis samples than that in the disc herniation samples (3.14 ± 0.50 vs. 0.55 ± 0.60, p < 0.001; 3.10 ± 0.57 vs. 0.76 ± 0.52, p < 0.001, respectively). The expressions of the active form of MMPs were identified in all the ligamentum flavums of the spinal stenosis and disc herniation patients. The expressions of active MMP-2 and MMP-13 were significantly higher in the spinal stenosis samples than that in the disc herniation samples (both p < 0.05). The expression of active MMP-3 was slightly higher in the spinal stenosis samples than that in the disc herniation samples, but the difference was not statistically significant (p = 0.131). MMP-2, -3, and -13 were positively stained on the ligamentum flavum fibroblasts.

Conclusions

The current results suggest that the increased expression of active MMPs by the ligamentum flavum fibroblasts might be related to the elastin degradation and fibrosis of the ligamentum flavum in the patients who suffer with lumbar spinal stenosis.     

The safety and efficacy of minimally invasive discectomy: a meta-analysis of prospective randomised controlled trials

Purpose

The objective of this study was to compare the safety and efficacy of minimally invasive discectomy (MID) with standard discectomy (SD) and determine whether the use of the MID technique could decrease the recurrence of lumbar disc herniation (LDH) after the surgery.

Methods

In February 2014, a comprehensive search was performed in PubMed, EMBASE, Web of Science, Cochrane Library and the Chinese Biological Medicine Database. Only randomised controlled trials (RCT) that compared MID with SD for the surgical management of LDH were included. These trials were carefully picked out following the inclusion and exclusion criteria. Using the Cochrane Collaboration guidelines, two authors independently extracted data and assessed these trials’ quality. The age of the patients, size of incision, surgical time, blood loss, visual analogue scale (VAS) score after the surgery, hospital stay, disc herniation recurrence, X-ray exposure and surgical costs in these studies were abstracted and synthesised by a meta-analysis with RevMan 5.2.0 software, and the main results (VAS score after the surgery and disc herniation recurrence) of publication bias were examined by Stata 12.0.

Results

Overall, 16 trials involving 2,139 patients meeting our criteria were included and analysed. Comparing MID and SD, the former was more likely to increase disc herniation recurrence [relative risk (RR) = 1.95, 95 % confidence interval (CI) 1.19–3.19, p = 0.008], and it involved a smaller size of incision [mean difference (MD) = −1.91, 95 % CI −3.33 to −0.50, p = 0.008], shorter hospital stay, longer operating time (MD = 11.03, 95 %C I 6.62–15.44, p < 0.00001) and less blood loss (MD = −13.56, 95 % CI −22.26 to −4.87, p = 0.002), while no statistical difference appeared with regard to the age of the patients, VAS score after the surgery, X-ray exposure, hospital stay and surgical costs.

Conclusions

Based on available evidence, MID results in less suffering for patients during the hospital course with a similar clinical efficacy compared to SD. This makes MID a promising procedure for patients with LDH; however, to popularise it greater effort is required to reduce disc herniation recurrence.     

Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.     

Does atlantoaxial dislocation influence the subaxial cervical spine?

Introduction

Previous studies have reported that the alignments of the occipital-cervical and subaxial spine were closely interrelated in asymptomatic individuals; however, none have focused on a population with atlantoaxial dislocation.

Material and methods

From 2007 to 2011, 298 patients with atlantoaxial dislocation and atlas occipitalization were studied. Angles formed between Occiput-C2 and C2–C7 were measured. The relationship between the alignment of the occipital-cervical junction and the subaxial cervical spine was evaluated.

Results

The range of values for the angles measured was as followed: the Occiput-C2 angles were −35.2° to 44.8°, and the C2–C7 angles were −17.4° to 77.8°. Statistically significant negative correlations were observed between the Occiput-C2 and C2–C7 angles.

Conclusion

Anterior dislocations of the atlas are associated with diminished lordosis or even kyphosis of the occipital-cervical junction, and result in compensatory hyperlordosis of the subaxial cervical spine, collectively presenting as a “swan neck” deformity. Atlantoaxial dislocation may influence the global cervical alignment.     

Detecting relevant changes and responsiveness of Neck Pain and Disability Scale and Neck Disability Index

Purpose

To investigate relevant change on the Neck Pain and Disability Scale (NPAD) and Neck Disability Index (NDI) and which questionnaire is the most responsive in patients with non-specific chronic neck pain (CNP).

Methods

Seventy-six patients with non-specific CNP in an outpatient tertiary rehabilitation setting were dichotomized into “improved” and “stable” based on global perceived effect (GPE) scores. To investigate relevant change minimal detectable change (MDC) and minimal important change (MIC) with the receiver operator characteristic (ROC) cut-off point were assessed. Comparison of responsiveness was performed using areas under the ROC curve (AUC) and correlations between change scores of NPAD and NDI, and GPE.

Results

MDC and MIC on NPAD (scale 0–100) were 31.7 and 11.5 points, respectively. MDC and MIC on NDI (scale 0–50) were 8.4 and 3.5 points, respectively. Changes should exceed this MDC or MIC cut-off to be interpreted as relevant. AUC was 0.75 for both NPAD and NDI. Correlations between change scores of NPAD and NDI, and GPE were, respectively, 0.48 (95 % CI 0.29–0.64) and 0.49 (95 % CI 0.30–0.64).

Conclusions

Relevant change on both NPAD and NDI assessed with MDC and MIC resulted in different cut-offs and consequently with different amounts of certainty that the patient is improved. Responsiveness of NPAD and NDI was similar.     

MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures

Purpose

Posterior ligamentous complex (PLC) components have an orderly sequence of rupture. However, it is still unclear how many structures have to be damaged to consider it disrupted. We aim to establish imaging criteria, which can define the complex as competent or incompetent.

Methods

Prospective study of 74 consecutive vertebral acute traumatic fractures, using X-rays and MRI scan (FS-T2-w/STIR sequences). We analyzed the association between MRI signal (intact, edema, disruption) of each PLC component—facet capsules (FC), interspinous ligaments (ISL), supraspinous ligaments (SSL) and ligamentum flavum (LF)—and the variables: AO/TLICS classification, treatment, surgical findings, interspinous diastasis index (IDI), local kyphosis (LVK) and ISS (TLICS) score. χ² test and U Mann–Whitney were used for statistics.

Results

MR images of ISL edema correlated surgically with intact ligaments or laxity, and were associated with 87.5 % of facet distraction, LVK: 11.6º, IDI: 1.2. Images of ISL, SSL or LF disruptions showed in all cases ruptures under surgical examination. Images of SSL disruption associated with LVK: 14.5º, IDI: 1.8. Images of ISL disruption associated with SSL/LF rupture, LVK: 16º, and IDI: 2; while LF disruption showed LVK: 18º, IDI: 1.9.When comparing “competent PLC” (images of facet distraction and ISL edema) with “incompetent PLC” (images of SSL disruption ± ISL or LF disruption) the latest showed more severe scores in every variable (p < 0.001), except neurologic status.

Conclusion

Following PLC rupture sequence, ISL edema with facet distraction seems not to be enough to define a posterior tension band incompetence. It is the further step of SSL rupture what gives the key to PLC incompetence.     

Driving reaction time before and after surgery for lumbar disc herniation in patients with radiculopathy

Purpose

Although patients scheduled to undergo lumbar disc surgery often ask when they are allowed to drive a motor vehicle again, there are no published recommendations on this subject.

Methods

We conducted a prospective study in 46 consecutive patients (mean age 48.9 years) to determine driving reaction time (DRT) before and after surgery in patients with lumbar disc herniation. Of the patients 23 had left-side radiculopathy and 23 right-side radiculopathy. Driving reaction time as well as back and leg pain were evaluated preoperatively, on the day of discharge from hospital and at the 5-week follow-up examination (FU). 31 healthy subjects were tested as controls.

Results

Significant improvement in DRT was seen for both patient samples (p < 0.05). For patients with a right-side radiculopathy preoperative DRT was 664 ms (median, IQR: 241), which was reduced to 605 ms (median, IQR: 189) immediately postoperatively and to 593 ms (median, IQR: 115) at FU. For patients with a left-side radiculopathy DRT was 675 ms (median, IQR: 247) preoperatively, 638 ms (median, IQR: 242) postoperatively and 619 ms (median, IQR: 162) at FU. Pain was moderately correlated to DRT. Control subjects had a driving reaction time of 487 (median, IQR: 116), which differed significantly from patients at all three testing times (p < 0.001).

Conclusion

Our data indicate a positive effect of the surgery on driving ability. Therefore, we would suggest that for both patient samples it is safe to continue driving after hospital discharge. However, patients have to be informed about increased DRT caused by radiculopathy already before surgery.     

Valgus extension femoral osteotomy to treat “hinge abduction” in Perthes’ disease

Purpose

“Hinge abduction” is a complication of Perthes’ disease caused by impingement of the extruded superolateral portion of the femoral head against the lateral lip of the acetabulum. Catterall first described femoral valgus extension osteotomy (VGEO) to treat this condition. We report the results of this operation in 16 cases of Perthes’ disease with “hinge abduction”.

Methods

Sixteen hips in 16 patients affected by Perthes’ disease and “hinge abduction” were operated on at a mean age of 10.1 years and followed up an average of 6.5 years later. Before surgery, the mean Iowa hip score was 44.4 points. Preoperative radiographs were taken with the affected hip in maximum adduction in order to calculate the amount of valgus correction. The osteotomy was performed between the greater and the lesser trochanter, and it was fixed with a hip plate.

Results

All the osteotomies healed uneventfully. At follow-up, no patient complained of pain and hip abduction ranged from 20° to 45°. Four out of the 16 patients had a moderate limp, and 12 had an improvement in gait pattern compared to preoperatively. At follow-up, the Iowa hip score totaled a mean of 83.6 points, with a statistically significant improvement in comparison to the preoperative evaluation. At follow-up, two hips were classified as Stulberg II–III, ten hips as Stulberg III, and four as Stulberg IV.

Conclusions

In our hands, VGEO was an effective procedure to treat “hinge abduction” in severe Perthes’ disease with satisfactory results. The main limitation of our study is its short follow-up.     

A survey of Fellows in the College of Chiropractic Sports Sciences (Canada): their intervention practices and intended therapeutic outcomes when treating athletes

Objective

To compile baseline data regarding the treatment practices and therapeutic outcomes that fellows of the College of Chiropractic Sports Sciences Canada (CCSS(C)) strive for when treating athletes.

Design

Cross-sectional self-report mail out survey of CCSS(C) fellows.

Participants

Current registered fellows of the CCSS(C) as determined by the College at the time of survey distribution.

Results

The majority of questioned fellows believe that they can cause direct and specific improvements in an athlete’s sport performance. The most commonly utilized therapeutic intervention was spinal joint manipulation/mobilization. The most anticipated outcomes following the treatment of athletes with the goal of affecting athletic performance were “changing or improving aberrant body mechanics,” “restoring or improving aberrant muscle function,” and “improving joint function or reducing joint dysfunction.”

Conclusion

The majority of respondent fellows of the CCSS(C) believe their therapy to be effective in enhancing an athlete’s sport performance.     

Ethnic differences in pedicle and bony spinal canal dimensions calculated from computed tomography of the cervical spine: a review of the English-language literature

Purpose

The aims of this study were to review published data on pedicle dimensions and bony spinal canal diameters calculated from CT examinations of the cervical spine through the English-language literature and analyze these data for ethnic disparities and similarities.

Materials and methods

The authors reviewed the literature on “pedicle” and “spinal canal” by conducting a bibliographic search using PubMed, Ovid MEDLINE, and Science Direct from January 1985 to December 2010. After evaluating all of the selected abstracts, we ultimately selected 19 studies involving living subjects: 12 studies on pedicle dimensions and 7 on spinal canal diameters. The four parameters, pedicle width (PW), pedicle transverse angle (PTA), anterior-posterior diameter of the spinal canal (APD), and transverse diameter of the spinal canal (TD), were analyzed at the relevant levels from C3 to C7. In addition, the values for pedicle dimensions and spinal canal diameters in the European/American populations were compared using the data from Asian populations as a baseline.

Results

The smallest mean PW was found at C4 in the male (5.1 mm) and female populations (4.1 mm); the largest mean PW was found at C7 in both male (7.7 mm) and female populations (7 mm). The PW in males was greater than in females at the majority of levels. The smallest mean PTA was found at C7 in both male (33.4°) and female populations (33°); the largest mean PTA was found at C4 in both male (53.2°) and female populations (52.1°). The overall PW, PTA, APD, and TD ratio of European/American to Asian populations was 91.4–98.8, 99.6–106.2, 110.7–122, and 100–108.3 %, respectively.

Conclusion

Although our cervical spine CT data were suggestive of possible ethnic differences in spinal canal morphology, our analysis failed to identify significant ethnic disparity in pedicle dimensions despite potential differences in physique between populations.