Postural Equilibrium in Adolescent Idiopathic Scoliosis

Postural equilibrium has been quantified by stabilometry in 57 patients with adolescent idiopathic scoliosis aged 10-16 years. Treatment was required in 39 cases whereof 18 were placed under observation only. The control group comprised 32 healthy children of the same age. An experimental design was made to vary the degree of difficulty of upright standing in four different test situations. The postural sway was analysed in the sagittal and lateral direction as well as in the area of total sway. The scoliotic patients had a significantly poorer postural control compared with the healthy children in all the tests. The difference was most pronounced in tests in which the proprioceptive functions were most important for maintaining the postural equilibrium. The left convex patients had quantitatively more pronounced reactions than the right convex patients. Patients with small curvatures, i.e., patients placed under observation only, had significantly increased postural sway compared with patients with more severe deformity. This fact, together with findings in patients with double primary curvatures, and the results of the study of brace effects, indirectly indicate the possibility of a postural disequilibrium as a contributory causative factor in adolescent idiopathic scoliosis.     

Zentrale Schmerzverarbeitung bei chronischem Rückenschmerz

Introduction

A study of patients with low back pain (LBP) had revealed altered central pain processing. At an equal pain level LBP patients had considerably more neuronal activation in the somatosensory cortices than controls. In a new analysis of this dataset, we further investigated the differences in central pain processing between LBP patients and controls, looking for possible pathogenic mechanisms.

Methods

Central pain processing was studied by functional magnetic resonance imaging (fMRI), using equally painful pressure stimuli in a block paradigm. In this study, we reanalyzed the fMRI data to statistically compare pain-elicited neuronal activation of both groups.

Results

Equally painful pressure stimulation resulted in a significantly lower increase of regional cerebral blood flow (rCBF) in the periaqueductal gray (PAG) of the LBP patients. The analysis further revealed a significantly higher increase of rCBF in LBP than in HC in the primary and secondary somatosensory cortex and the lateral orbitofrontal cortex (LOFK), elicited by these same stimuli.

Conclusions

These findings support a dysfunction of the inhibitory systems controlled by the PAG as a possible pathogenic mechanism in chronic low back pain.     

Results of surgical treatment of adults with idiopathic scoliosis

The outcome of surgical treatment of idiopathic scoliosis in forty-five adults was studied with special attention to pain, function, self-image, and pulmonary function. All of the patients were more than twenty-five years old at operation and had been followed for more than three years. Every patient who was operated on by one of us (J. E. H.) and who met these criteria was evaluated. The magnitude of the curves averaged 66 degrees. Standardized gradations of pain and function showed improvement over-all, but significant impairment remained. There was a reduction in the levels of peak and constant pain, but no change in the frequency of peak pain after operation. The number of patients who were pain-free after surgery was not increased. Functional impairment due to the scoliosis was lessened, and the ability to perform the common activities of daily living was improved, but no important changes in occupation or recreational activity were recorded. Correlations of pain or function, or both, and the changes in either, were found with only two parameters: age at follow-up and physical occupation. Pulmonary function, as measured, did not change. Eighteen (40 per cent) of the patients had a minor complication and ten (20 per cent), a major complication; there was one death, due to pulmonary embolism, of a patient who was excluded from the series. In view of the high rate of complications, the limited gains to be derived from spinal fusion should be assessed and clearly explained to patients before the procedure is undertaken.     

Insulin-like growth factor I promotes nerve regeneration: an experimental study on rat sciatic nerve

Insulin-like growth factor I (IGF-I; somatomedin C) has previously been demonstrated, with immunohistochemical methods, to accumulate locally at the site of trauma of an injured peripheral nerve. In the experiments reported here a Y-shaped silicone-chamber system was used to test if local infusion of IGF-I had supportive effects on nerve regeneration. The proximal end of a cut sciatic nerve was inserted into one channel of the Y-shaped chamber and the length and growth direction of the regenerating myelinated axons were evaluated after 1 month. When IGF-I (250 micrograms/ml 0.5 microliters/h) was infused into one channel by an osmotic pump, the length of the regenerating axons increased significantly compared to the control groups with no IGF-I added. In some instances the regenerating axons grew towards the osmotic pump. It is concluded that local infusion of IGF-I at appropriate concentration promotes regeneration of a peripheral nerve. It exerts a neuronotrophic but not a clear chemotactic effect.     

Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated with the Milwaukee brace

Ninety-five patients from the Gothenburg Scoliosis Data Base were studied. They met the following criteria: adolescent idiopathic scoliosis, completion of Milwaukee brace treatment before age 20, a minimum follow-up period of 5 years thereafter, minimum age of 22 years at final follow-up examination. Of these, 85 (90%) were examined personally by an independent investigator, including anteroposterior and lateral full-length spinal roentgenograms. The average length of follow-up was 7.5 years (range, 5-12 yrs). These patients who successfully completed the brace treatment program, in their mid-twenties ended up with curves that were of equal size (33 degrees +/- 3 degrees) as when the treatment started (30 degrees +/- 3 degrees). In the sagittal plane, the spines were normal; none exhibited hypokyphosis (less than 20 degrees). Compared with the straight control group and to a previously reported group of operated patients, the brace group functioned at the same level in regard to marriage, child bearing, sports activities, and job performance. Overall back pain was also reported at a normal rate, with low-back pain significantly less frequent than the control group. Ten patients showed an increase of their curves exceeding 5 degrees; eight of these had been pregnant multiple times before age 25. None of the patients pregnant after that age increased their curve size. This study demonstrates that those patients who complete a Milwaukee brace treatment for adolescent idiopathic scoliosis from a functional and social point of view do very well. Early pregnancy is a significant risk factor for progression after maturity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Newest knowledge of low back pain. A critical look.

Scientific scrutiny of the low back problem demonstrates its socioeconomic importance in most industrialized societies. Natural history studies reveal that the prognosis for the low back pain patient is excellent; for those with sciatica and painful spondylolisthesis it is good. It is even relatively good for those older patients with symptoms of spinal stenosis. Although today there is a better understanding of pain, the pathomechanism of low back pain is unknown. However, for patients with sciatica, spondylolisthesis, and spinal stenosis, physicians are beginning to get a better perception of what causes the pain. Psychosocial factors, including insurance benefits, have been demonstrated to be more important than biomechanical workload not only for acute but also for chronic low back pain patients who are unable to work. Orthopedic surgeons must recognize this fact when contemplating operations for patients with ill-defined back syndromes. Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials.     

Chemonucleolysis for sciatica. A critical review

Intradiscal injection of chymopapain for the treatment of sciatica due to disc herniation has been used for more than 25 years, but is still under debate. We review the indications, complications, and clinical results, and discuss the tissue effects of chymopapain. The results following surgical disc removal versus chymopapain injection indicate that surgery with removal of the disc hernia through a small laminotomy remains the documented treatment of choice for patients with proven disc herniation and sciatica in whom conservative treatment has failed.