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Standardized and validated self-administered outcome-instruments are broadly used in spinal surgery. Despite a plethora of articles on outcome research, no systematic evaluation is available on what actually comprises a good outcome in spinal surgery from the patients' and surgeons' perspective, respectively. However, this is a prerequisite for improving outcome instruments. In performing a cross-sectional survey among spine patients from different European regions and spine surgeons of the SSE, the study attempted (1) to identify the most important domains determining a good outcome from a patients' as well as a surgeon's perspective, and (2) to explore regional differences in the identified domains. For this purpose, a structured interview was performed among 30 spine surgeons of the SSE and 353 spine surgery patients (representing Northern, Central and Southern Europe) to investigate their criteria for a good outcome. A qualitative and descriptive approach was used to evaluate the data. Results revealed a high agreement on what comprises a good outcome among surgeons and patients, respectively. The main parameters determining good outcome were achieving the patients' expectations/satisfaction, pain relief, improvement of disability and social reintegration. Younger patients more often expected a complete pain relief, an improved work capacity, and better social life participation. Patients in southern Europe more often wanted to improve work capacity compared to those from central and northern European countries. No substantial differences were found when patients' and surgeons' perspective were compared. However, age and differences in national social security and health care system ("black flags") have an impact on what is considered a good outcome in spinal surgery.

Study Design: Assessment of age-related macroscopic changes in human lumbar intervertebral discs (IVD) and vertebral bodies., Objectives: To determine the sequence of macroscopic changes during aging/degeneration., Summary of Background Data: Descriptive studies on macroscopic alterations of the IVD during aging/degeneration are readily available, but quantitative analyses are sparse., Methods: A total of 248 mid-/parasagittal sections of lumbar IVD and vertebral bodies from 41 routine autopsies (range, 7 months to 88 years) were semiquantitatively assessed for macroscopic parameters and correlated with age., Results: Nuclear fibrous transformation, anular disorganization, endplate, and vertebral body alterations progress predominantly in the first two and in the fifth to seventh decades. In the third and fourth decade, little progression occurs. Nuclear clefts and anular tears appear later, mostly starting in the second decade, with clefts preceding tear formation. Radial and concentric tears develop similarly over time, whereas rim lesions mostly develop after the sixth decade. Significant differences are observed between upper and lower lumbar spine., Conclusion: Our data show that fibrous nuclear transformation during aging/degeneration precedes cleft formation. The temporal sequence suggests a strong correlation of cleft and tears formation starting with clefts in the second decade. Our results support the hypothesis that disc degeneration starts in the nucleus. Extensive macroscopic alterations already apparent in the second life decade present a challenge to any tissue engineering and repair attempt.

Unlabelled: Spinal injections have an important role in many centers in the diagnostic assessment and treatment of patient with various spinal disorders. In the literature, many studies describe the application, techniques, and potential benefit of spinal infections. It is well accepted morphologic alterations and pain correlate weakly because many imaging findings in patients with spinal symptoms can be found in asymptomatic individuals. Accordingly, one rationale for spinal injections is to provoke or eliminate pain presumably caused by the target spinal structure; this ostensibly allows a physician to make a better assessment of whether a particular morphologic alteration does or does not cause symptoms. Another rationale is to use spinal injections to support conservative treatment in patients who have from nerve root compromise, spinal stenosis, or facet joint osteoarthritis. Despite the widespread use of these spinal injections, their application is based widely on anecdotal experience and evidence that is not evidence based. We highlight the need for prospective randomized trials on the clinical efficiency of spinal injections and stress the importance for future considerations of cost effectiveness to justify their further application., Level of Evidence: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Study Design: A histologic study on age-related changes of the human lumbar intervertebral disc was conducted., Objectives: To investigate comprehensively age-related temporospatial histologic changes in human lumbar intervertebral disc, and to develop a practicable and reliable classification system for age-related histologic disc alteration., Summary of the Background Data: No comprehensive microscopic analysis of age-related disc changes is available. There is no conceptual morphologic framework for classifying age-related disc changes as a reference basis for more sophisticated molecular biologic analyses of the causative factors of disc aging or premature aging (degeneration)., Methods: A total of 180 complete sagittal lumbar motion segment slices obtained from 44 deceased individuals (fetal to 88 years of age) were analyzed with regard to 11 histologic variables for the intervertebral disc and endplate, respectively. In addition, 30 surgical specimens (3 regions each) were investigated with regard to five histologic variables. Based on the semiquantitative analyses of 20,250 histologic variable assessments, a classification system was developed and tested in terms of validity, practicability, and reliability. The classification system was applied to cadaveric and surgical disc specimens not included in the development of the classification system, and the scores were assessed by two additional independent raters., Results: A semiquantitative analyses provided clear histologic evidence for the detrimental effect of a diminished blood supply on the endplate, resulting in the tissue breakdown beginning in the nucleus pulposus and starting in the second life decade. Significant temporospatial variations in the presence and abundance of histologic disc alterations were observed across levels, regions, macroscopic degeneration grades, and age groups. A practicable classification system for age-related histologic disc alterations was developed, resulting in moderate to excellent reliability (kappa values, 0.49-0.98) depending on the histologic variable. Application of the classification system to cadaveric and surgical specimens demonstrated a significant correlation with age ( < 0.0001) and macroscopic grade of degeneration ( < 0001). However, substantial data scatter caution against reliance on traditional macroscopic disc grading and favor a histology-based classification system as a reference standard., Conclusions: Histologic disc alterations can reliably be graded based on the proposed classification system providing a morphologic framework for more sophisticated molecular biologic analyses of factors leading to age-related disc changes. Diminished blood supply to the intervertebral disc in the first half of the second life decade appears to initiate tissue breakdown.

Objective: The objective of our study was to evaluate the usefulness of FDG positron emission tomography (PET) for the differentiation of degenerative and infectious endplate abnormalities in the lumbar spine that were detected on MR imaging., Subjects and Methods: FDG PET was performed prospectively in 30 consecutive patients with substantial endplate abnormalities (craniocaudal diameter of bone marrow abnormalities, > or = 25% of vertebral height) found during MR imaging of the lumbar spine. Both the MR and PET images were evaluated by two experienced musculoskeletal radiologists and two experienced nuclear physicians. The diagnosis of either degeneration with different types of endplate abnormalities or disk-space infection was determined. Clinical follow-up and, in selected cases, bone biopsies with cultures were used as the standard of reference., Results: On the MR images, 25 of the 38 degenerated levels were classified as Modic type I, 13 levels as type II, and none as type III. Five disk-space infections were diagnosed in four patients. MR imaging findings were false-positive at one disk level with type I abnormalities and false-negative at two levels with infection. PET did not show FDG uptake in the intervertebral spaces of any patient with degenerative disease. FDG PET findings were true-positive in all five levels with disk-space infection. The sensitivity and specificity for MR imaging in detecting disk-space infection were 50% and 96%, and were 100% and 100% for FDG PET, respectively (not significant, McNemar test, p = 0.5)., Conclusion: Our findings suggest that FDG PET may prove useful for differentiation of degenerative and infectious endplate abnormalities detected on MR imaging. Even in active (Modic type I) degenerative endplate abnormalities in our series, PET did not show increased FDG uptake.

Objectives: Motor-evoked potentials (MEP) for intra-operative monitoring due to fast charge (fc: 1.0 Coulomb/s) and slow charge (sc: 0.1Coulomb/s) delivery for multipulse transcranial electrical stimulation (TES) were compared., Methods: MEPs due to fc (n=162) and sc stimulation (n=182) were performed in parallel in a prospective study. The fc stimulation technique is characterized by an increased steepness of charge delivery with consequent reduction of stimulus duration of 50 micros compared to 500 micros in sc stimulation. Stimulation charges (C=Coulomb) and MEP parameters during spine surgery were analyzed., Results: MEPs were successfully recorded in 15/18 patients under total intravenous anesthesia. The mean charge to induce intra-operative MEPs (stimulation threshold) was significantly less in fc (0.195 mC) as compared to sc stimulation (0.298 mC). With both stimulation techniques, in all patients without impairment of motor function, MEPs could be recorded and no technique was superior with respect to successful stimulation. The mean MEP latencies, amplitudes and the extent of intra-individual variation of MEP parameters during surgery (shift of latency less than 10%, variability of amplitude less than 50%) were not different with both stimulation techniques., Conclusions: TES with either fc or sc stimulation can be used reliably for intraoperative monitoring. Fc and sc stimulation are comparable with respect to feasibility, intra-individual variability and mean parameters of MEP responses. However, fc stimulation provides a higher stimulation efficiency and requires about 35% less total charge for MEP monitoring.

During the process of degeneration, the intervertebral disc (IVD) shows a progressive and significant reduction in height due to tissue resorption. Intradiscal clefts and tears are major hallmarks of disc degeneration. Matrix-degrading enzymes such as matrix metalloproteinases (MMPs) are assumed to play a pivotal role in disc tissue degradation and resorption. The objective of this study was therefore to investigate the potential role of MMPs in extracellular matrix degradation leading to disc degeneration. This study was conducted on 30 formalin-fixed and EDTA-decalcified complete cross-sections of lumbar IVDs from cadavers of individuals aged between 0 and 86 years. Tissue sections were used for the immunolocalization of MMPs-1, -2, -3 and -9. The number of labeled cells was assessed by morphometric analyses, and was statistically correlated with the formation of clefts and tears, cellular proliferation, granular matrix changes and mucous degeneration. Furthermore, 30 disc specimens obtained during spinal surgery were used for in situ hybridization of MMP-2 and -3-mRNA. In addition, the enzymatic gelatinolytic activity was determined by in situ zymography in autopsy material. Immunohistochemistry showed the intradiscal expression of all four MMPs, which was confirmed by in situ hybridization, providing clear evidence for the synthesis of the enzymes within nucleus pulposus and annulus fibrosus cells. Gelatinolytic enzymatic activity was verified by in situ zymography. IVDs from infants and young adolescents remained almost completely unlabeled for all MMPs tested, while more MMPs-1 and -3 were seen in disc cells of younger adults than in those of a more advanced age; MMP-2 remained unchanged over the adult age periods, and MMP-9 was expressed in only relatively few cells. This pattern significantly correlated with the occurrence of clefts and tears. This correlation was strongest for MMP-1 ( P<0.0001), MMP-2 ( P<0.0017) and MMP-3 ( P<0.0005) in the nucleus, and MMP-1 ( P<0.0001) and MMP-2 ( P<0.038) in the annulus. In parallel, the proliferation of disc cells and matrix degeneration (granular changes and mucous degeneration) were related to MMP expression. Likewise, enzymatic activity was seen in association with cleft formation. Our data suggest that major MMPs play an important role in the degradation of the IVD. This is evidenced by the high correlation of MMP expression with the formation of clefts and tears. These findings implicate a leading function for MMPs in IVD degeneration resulting in the loss of normal disc function, eventually leading to low-back pain.

There have been no previous reports of a spinal subdural haematoma occurring as a complication of spinal surgery. We highlight the pitfalls in the diagnosis and management of a subacute subdural haematoma resulting from a dural tear which occurred as a surgical complication of microdiscectomy.

The diagnostic assessment of the low back pain patient is often unsatisfactory because a clear morphological alteration explaining the patient's symptoms can only be found in 10-20% of the cases. The majority of the patients is suffering from non-specific low back pain. However, the high incidence of benign, self-limiting low back pain leads to the risk of overlooking specific causes such as tumor or infection. Similarly, relevant paresis and bladder and bowel dysfunction must be diagnosed in time. Furthermore, the aim of the diagnostic work-up is to diagnose and treat specific causes of back and leg pain (e.g. disc herniation and spinal stenosis) to avoid chronicity. In the majority of the cases, history and clinical examination alone allow to differentiate between specific and non-specific low back pain and may lead to a further diagnostic work-up by imaging studies.

The diagnostic assessment of low back pain should predominantly be based on history and clinical examination rather than on imaging studies. The problem of diagnostic imaging in low back pain is related to the high rate of asymptomatic morphological alterations in the lumbar spine. The diagnosis should therefore not be guided by findings in imaging. The imaging studies (standard radiographs and MRI) should verify the clinically suspected diagnosis and further lead to imaging guided injection studies (e.g. nerve root block, facet joint block, sacro-iliac joint block, provocative discography) to differentiate between symptomatic and asymptomatic morphological alterations. With longlasting local anaesthetics and steroids it is possible to achieve a diagnostic as well as a therapeutic effect.

Purpose: To identify the magnetic resonance (MR) abnormalities of the lumbar spine that have a low prevalence in asymptomatic patients and thus determine the findings that are predictive of low back pain in symptomatic patients., Materials and Methods: Sagittal T1-weighted and sagittal and axial T2-weighted MR images were obtained in 60 asymptomatic volunteers aged 20-50 years. The MR images were evaluated with regard to intervertebral disk abnormalities, end plate abnormalities, and osteoarthritis of the facet joints by two musculoskeletal radiologists independently., Results: Disk bulging or disk protrusion was found in 42 (14%) and 48 (16%) of the intervertebral spaces in 37 (62%) and 40 (67%) subjects, respectively. High-signal-intensity zones were found commonly (in 23 [7.7%] and 25 [8.3%] of the intervertebral spaces in 19 (32%) and 20 (33%) subjects, respectively). Disk extrusions were less common (in 11 [3.7%] and 11 [3.7%] of the intervertebral spaces in 11 (18%) and 11 (18%) subjects, respectively). There were no disk sequestrations. A nerve root compression in a single intervertebral space was diagnosed by one reader. End plate abnormalities were found in two (0.7%) and six (1.9%) of the intervertebral spaces in two (3%) and six (10%) subjects, respectively. No severe osteoarthritis was diagnosed by either reader., Conclusion: In patients younger than 50 years, disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints are rare and, therefore, may be predictive of low back pain in symptomatic patients.

Low back pain is a very common but benign and, in general, self-limiting disease indicating that only a small proportion of patients will require sophisticated imaging studies. Recent studies have highlighted the fact that a simple relationship of structural abnormalities to low back pain is impossible because similar alterations can be found in symptomatic as well as in asymptomatic individuals. these findings question our current criteria for the diagnosis of low back pain disorders with regard to their discriminative power in differentiating diseased and non-diseased individuals. Structural abnormalities demonstrated by imaging studies should therefore only be interpreted in the light of the clinical findings. This review shows that only a few studies contribute to our understanding of the clinical efficacy of imaging studies in the evaluation of low back pain disorders. There is an absolute need for comprehensive, well conducted studies on the impact of specific imaging modalities on diagnosis and treatment of lumbar spinal disease.

Continuing controversy over the use of pedicular fixation in the United States is promoted by the lack of governmental approval for the marketing of these devices due to safety and efficacy concerns. These implants have meanwhile become an invaluable part of spinal instrumentation in Europe. With regard to the North American view, there is a lack of comprehensive reviews that consider the historical evolution of pedicle screw systems, the rationales for their application, and the clinical outcome from a European perspective. This literature review suggests that pedicular fixation is a relatively safe procedure and is not associated with a significantly higher complication risk than non-pedicular instrumentation. Pedicle screw fixation provides short, rigid segmental stabilization that allows preservation of motion segments and stabilization of the spine in the absence of intact posterior elements, which is not possible with non-pedicular instrumentation. Fusion rates and clinical outcome in the treatment of thoracolumbar fractures appear to be superior to that achieved using other forms of treatment. For the correction of spinal deformity (i.e., scoliosis, kyphosis, spondylolisthesis, tumor), pedicular fixation provides the theoretical benefit of rigid segmental fixation and of facilitated deformity correction by a posterior approach, but the clinical relevance so far remains unknown. In low-back pain disorders, a literature analysis of 5,600 cases of lumbar fusion with different techniques reveals a trend that pedicle screw fixation enhances the fusion rate but not clinical outcome. The most striking finding in the literature is the large range in the radiological and clinical results. For every single fusion technique poor and excellent results have been described. This review argues that European spine surgeons should begin to back up the evident benefits of pedicle screw systems for specific spinal disorders by controlled prospective clinical trials. This may prevent forthcoming medical licensing authorities from restricting the use of pedicle screw devices and dictating the practice of spinal surgery in Europe in the near future.

From 1984 to 1988, 70 consecutive lumbar and lumbosacral spine fusions enhanced with translaminar facet joint screws were performed for segmental degenerative disease. Twenty patients had partial decompression of central stenosis, 15 concomitant discectomy, and 19 lateral nerve root decompression. The mean time to fusion was 4.5 months (range 2-7 months). At followup (average 45 months; range 24-74 months) 98.5% were judged to have solid fusion. Satisfactory results were observed in 84% of cases, 91% without previous surgery and 75% after previous discectomy. Supplementation of posterolateral fusion by translaminar facet screws significantly improved time to fusion, fusion rate, and clinical outcomes with no significant increased complications.

This series includes 59 consecutive patients, 51 of whom had a minimum follow up of 2 years. The diagnosis was mechanical instability in 39, deformity in 11, and infection or tumor in 9 patients. The overall clinical results of the total group were good or fair in 88% of the patients. Pseudarthrosis occurred twice. We had on postoperative infection, one persistent and two reversible neurological complications. We found 13 broken screws and one rod breakage which had no clinical relevance. None of these asymptomatic complications required revision. The internal fixator has a great potential of correction in scoliotic and kyphotic deformities of the spine. It has not been shown to have the same potential in spondylolisthesis. A combined anterior and posterior stabilisation is needed in severe spondylolisthesis. We have found the internal fixator to provide satisfactory stability to allow fusion and good clinical results with a low rate of relevant complications.