Spine
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The lumbar intervertebral discs are innervated posteriorly by the sinuvertebral nerves, but laterally by branches of the ventral rami and grey rami communicantes. The posterior longitudinal ligament is innervated by the sinuvertebral nerves and the anterior longitudinal ligament by branches of the grey rami. ⋯ Medial branches supply the multifidus, intertransversarii mediales, interspinales, interspinous ligament, and the lumbar zygapophysial joints. The distribution of the intrinsic nerves of the lumbar vertebral column systematically identifies those structures that are potential sources of primary low-back pain.
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An investigation of the clinical relevance of the location of the intercrestal line in relation to the pattern of disc degeneration in the lower lumbar spine is presented. An analysis of the discograms from 89 symptomatic patients has demonstrated a difference in the incidence of disc degeneration in the L4-5 and L5-S1 disc spaces dependent on the position of the intercrestal line. This difference supports the hypothesis that additional protection will be given to those L5-S1 discs with which high intercrestal lines are associated as compared to those associated with intercrestal lines lying lower down the spine. A corollary of this hypothesis is that for any individual there is an increased likelihood that the L4-5 disc space will undergo degeneration from the influence of normal mechanical stresses before the L5-S1 disc space if the intercrestal line lies comparatively high up the spine.
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Case Reports Comparative Study
The application of pelvic pins in halo-pelvic distraction. An anatomic study.
The application of the pelvic hoop for halo-pelvic distraction, as described by O'Brien, has led to serious abdominal complications. A study of mature Caucasian pelves as compared to the smaller East Indian pelves has shown that in the larger pelvis, when the gluteal tubercle and posterior superior iliac spine are used as landmarks, as advocated by O'Brien, the pins will invariably pass within the soft tissue elements of the inner pelvis instead of being entirely within the bony ilium, as O'Brien noted in the Chinese pelves. On the basis of pelvic measurements and observations, the authors recommend an open technique for passage of the pins.
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Ninety of 120 patients with herniated lumbar discs who received an intradiscal injection of chymopapain achieved successful recovery. Sixteen of the 21 patients who underwent subsequent surgery had a good result. Study of the unsuccessful cases showed that disc sequestration and lateral stenosis were the major organic causes of failure. ⋯ They appear to be a contraindication to chemonucleolysis. Psychogenic pain components and the failure of the enzyme to hydrolyse the nuclear proteoglycans in a few cases were the other two causes of poor results. A survey of postchemonucleolysis computed tomographic scans suggested that, although capable of digesting nuclear material in most cases, chymopapain may also work through an "anti-inflammatory" mechanism.
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Randomized Controlled Trial Clinical Trial
Chymopapain for the treatment of intervertebral disc herniation. A preliminary report of a double-blind study.
Sixty patients with unilateral sciatica resulting from lumbar intervertebral disc herniation were entered into a double-blind study. All patients had failed to respond to conservative management, and the diagnosis had been confirmed by metrizamide myelography. Following a randomized schedule, 30 patients had intradiscal injections of chymopapain and 30 patients had intradiscal injections of an equivalent volume of normal saline solution. ⋯ Six weeks after the injection, 73% of patients treated with chymopapain and 37% of patients treated with saline solution considered that the treatment was successful. The success rate at six months was 80% for patients treated with chymopapain and 57% for saline-injected patients. From the preliminary results of this study, chymopapain is recommended for the treatment of sciatica from intervertebral disc herniation when conservative measures have failed and before disc fragment excision is considered.