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PubMed1991

Magnetic resonance imaging of temporomandibular joint after surgical treatment of internal derangement.

Sagittal and coronal surface coil magnetic resonance imaging was performed on 21 patients who about 2 years earlier had surgery for temporomandibular joint internal derangement. Surgical procedure included disk repositioning (23 joints) and diskectomy (seven joints). At the time of reimaging, 20 joints showed recurrence of pain and 10 joints were asymptomatic. Extensive fibrous tissue was seen in the joint space and in the joint capsule in 13 of the 20 painful joints, whereas minimal fibrous tissue in the lateral capsule wall was seen in 3 of the 10 nonpainful joints. Fibrous tissue was surgically confirmed in 10 of the painful joints. Disk displacement was seen in 11 of the 23 joints that had surgical disk repositioning. Disk displacement was seen in both painful (9/17) and nonpainful joints (2/6). It was concluded that magnetic resonance imaging is an excellent method for postoperative imaging of the temporomandibular joint and that attention should be directed to the presence or absence and extension of the fibrous tissue in the joint space and in the joint capsule.

Adolescent↗

PubMed1983

Posterolateral approach to ruptured median and paramedian cervical disk.

The trend toward anterior diskectomy for median and paramedian cervical disk rupture has tended to obscure progressive development of the posterolateral approach to these lesions. Modifications of surgical technique from the classic posterior approach have allowed direct access to these lesions, provided for satisfactory decompression of the spinal cord, especially when there is associated spondylosis, and avoided all of the disadvantages of anterior disk surgery. Of 28 patients operated on since 1950, 26 have had significant preoperative myelopathy or myeloradiculopathy. Two patients with obvious spinal cord compression and massive myelographic defects had no neurologic deficit. Improvement has been observed in every patient; 16 patients have had full recovery, and 8 others have had minor residual symptoms and asymptomatic signs. Although four patients have been lost to follow-up, they were all seen at least once after operation. No instance of increased deficit has been seen postoperatively, in contrast to the author's experience with spondylotic myelopathy. Postoperative contrast studies, which have now been performed on eight patients, confirm satisfactory excision of these lesions and decompression.

Cervical Vertebrae↗

PubMed1989

Lumbar disk compliance and degeneration.

Comparison between 242 intradiscal pressure/volume recordings and corresponding diskograms (performed at the same occasion) has shown a significant (p less than 0.01) correlation between disk compliance and the degree of diskographic degeneration. Intradiscal pressure/volume testing is a simple, reliable, and risk-free procedure that should precede every diskogram and be incorporated into the preoperative diagnostic routine of patients undergoing chemonucleolysis or percutaneous diskectomy.

Adolescent↗

PubMed1989

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.

Humans↗

PubMed2005

The prevalence of osteoarthrosis in cases of advanced internal derangement of the temporomandibular joint: a clinical, surgical and histological study.

INTRODUCTION: The articular disk has a central role in the pathology of internal derangement of the Temporomandibular Joint (TMJ). What is less clear is the role of osteoarthrosis in the development of internal derangement. The aim of this study is to determine the prevalence of osteoarthrosis in cases of advanced and recalcitrant TMJ internal derangement that were treated by diskectomy. MATERIALS AND METHODS: This study involved 22 joints in 18 patients who underwent surgery for the treatment of advanced and recalcitrant internal derangement of the TMJ. All patients included in the study failed to respond to at least 6 months of pre-operative conservative treatment and the clinical diagnoses of advanced TMJ internal derangement were confirmed on pre-operative MRI's. Tissue specimens were obtained from all 22 joints for histopathology. The specimens included articular disks that were excised from all 22 joints which were found to have severely displaced and deformed disks that were judged to be irreparable at the time of surgery. Also included were eight tissue samples from the mandibular condyles that were judged to be diseased on pre-operative tomograms and at the time of surgery. All samples were prepared in serial sections in the standard way and examined under light microscopy by two experienced Oral Pathologists. RESULTS: There were 22 specimens of articular disk examined together with 8 specimens from the mandibular condyle. All 22 joints (100%) showed histological evidence of disk pathology and eight of the 22 joints (34.4%) were found to have condylar pathology. The most common disk pathology was hyalinization indicative of disk degeneration (12/22). The most common condylar pathology found was articular surface degeneration indicative of osteoarthrosis (8/22). CONCLUSION: The clinical and radiological diagnoses of advanced TMJ internal derangement correlated with histological findings of degeneration and inflammation of the articular disk in all 22 specimens. The 8 specimens obtained from the condylar head showed histological features consistent with osteoarthrosis. This study showed that osteoarthrosis and internal derangement were found to co-exist in the same joint in about one-third of cases. The fact that osteoarthrosis was not found in all cases suggests that perhaps the widely held view that subclinical osteoarthrosis may lead to pathologic tissue responses in the form of internal derangement will need to be re-examined.

Adolescent↗

PubMed2005

A prospective comparison of thoracoscopic vs open anterior instrumentation and spinal fusion for idiopathic thoracic scoliosis in children.

BACKGROUND/PURPOSE: The management of scoliosis in children has been evolving. Anterior release, diskectomy, and anterior instrumentation and spinal fusion (AISF) may be of benefit compared with a combined anterior and posterior or a posterior-only approach. Because thoracoscopic AISF (TAISF) has the potential benefit of muscle sparing, superior cosmesis, and less pain, the authors decided to prospectively compare this newer technique with open AISF (OAISF) to evaluate whether the 2 approaches were equivalent. METHODS: All children with idiopathic thoracic scoliosis undergoing AISF at a single center were prospectively examined. One hundred fifty-five children who had a minimum of 1-year follow-up were included in the study. Descriptive statistics are reported as means and SDs. Groups were compared using the independent-samples t test with Levene's test for equality of variances; a 2-tailed P value of .05 or less was considered significant. RESULTS: Open AISF was performed in 114 patients and TAISF was performed in 41; there were 126 girls and 29 boys. Mean age at surgery was similar (14 +/- 3 vs 14.3 +/- 1.5 years; P = .5), as was weight (54.2 +/- 19 vs 54.6 +/- 23 kg; P = .9). There were no differences in preoperative thoracic curves (48.5 degrees +/- 14 degrees vs 49.8 degrees +/- 7 degrees; P = .6) or in the number of vertebral levels instrumented (7.7 +/- 1.3 vs 7.6 +/- 0.7; P = .7). Operative time was shorter with OAISF (383 +/- 65 vs 508 +/- 98 minutes; P < .01), and there was less estimated blood loss (924 +/- 724 vs 1218 +/- 747 mL; P = .03). The OAISF group took longer to extubate (1.4 +/- 1.2 vs 1 +/- 0.3 days; P = .03) and had slightly greater chest tube drainage (1710 +/- 730 vs 1639 +/- 515 mL; P = .5). At the 1-year follow-up, the thoracic curves were similar (17.5 degrees +/- 8 degrees vs 15.2 degrees +/- 7.5 degrees; P = .1) and percentage correction of thoracic curves was also similar (64% vs 69%). CONCLUSIONS: Thoracoscopic AISF is safe and effective in correcting idiopathic childhood scoliosis. Correction of deformity with TAISF is equivalent to OAISF, although it takes longer and has more blood loss. However, it spares cutting muscle, uses smaller skin incisions, and appears to have superior cosmesis.

Adolescent↗

PubMed1997

[Bilateral sciatica: a predictive sign of extradural hematoma after lumbar disk herniation].

The authors analyse five cases, in order to recognize a sensitive early clinical feature of extradural haematoma following lumbar diskectomy. Neither time delay (time from surgery to the suspicion of the diagnosis) nor pain intensity (a subjective factor which might be obtunded by an analgesic drug) are valuable features. The only reliable predictive sign is bilateral sciatica, which occurred in all cases, before the diagnosis was confirmed by a sensitive and motor deficit in the lower limbs.

Adult↗

PubMed1994

Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint.

This prospective 1-year follow-up investigated the efficacy of temporomandibular joint lysis and lavage in relation to arthroscopic diagnoses. The study comprised 42 patients. Clinical evaluation was performed before surgery and at regular intervals up to 1 year postoperatively. Diagnostic arthroscopy and immediately subsequent lysis and lavage were performed under local anesthesia in all patients. Only unilateral upper compartment arthroscopies were executed. The results were evaluated according to the 1984 criteria of the American Association of Oral and Maxillofacial Surgeons. Osteoarthrosis was diagnosed arthroscopically in 30 joints (71%), 21 of which (70%) had more pronounced changes. Synovitis, mainly of a mild, localized type, was diagnosed in 39 joints (93%). More pronounced synovitis was found arthroscopically in 12 (31%). Adhesions were found in 20 joints (48%) and were significantly correlated with joints displaying osteoarthrosis (P < 0.001). The overall success rate for arthroscopic lysis and lavage was 50% (21/42 joints). The best response to lysis and lavage was in joints with arthroscopic diagnosis of pronounced synovitis (8/12 joints; 67%). All 21 joints regarded as unsuccessful were operated with diskectomy without implants. The success rate at 1-year follow-up was 18 joints (86%).

Adolescent↗

PubMed1988

Bite force after temporomandibular joint surgery.

Bitings were recorded bilaterally on 5 different submaximal and maximal force levels on 12 patients (7 women and 5 men) who had earlier been subjected to TMJ surgery (10 diskectomies and 2 condylectomies). The maximal bite force was relatively low for the recorded sample with mean values of 7.8 Kp and 8.3 Kp for operated and non-operated sides, respectively. The strongest forces were recorded after condylectomy. There was a wide range between the individual recordings on all levels and the differences increased with the force and were largest at maximal bite force level. No significant differences in bite force between operated and non-operated sides could be found for any of the force levels. The ability to discriminate between different force levels was better on the higher levels. The almost comparable results of the recordings of bite force on the operated and the non-operated sides may be an effect of functional interaction within the masticatory system and be an expression of the essentially improved function after the surgical treatment.

Adult↗

PubMed1992

Percutaneous nucleotomy with CT and fluoroscopic guidance.

Automated percutaneous diskectomy was performed with use of computed tomographic (CT) and fluoroscopic monitoring. Degenerative disease of the intervertebral disk was treated with local administration of anesthesia and use of a nucleotome. One hundred ten patients with neurologic symptoms and morphologic changes of one segment were selected for treatment. Previous conservative therapy had been unsuccessful. Patients with completely prolapsed and sequestered fragments of herniated disks ("uncontained disk"), narrow intervertebral spaces, posterior osteophytes, diseased facet joints, and spinal stenoses were not considered candidates for percutaneous nucleotomy (PNT). After PNT, 82% of the patients had complete remission of their neurologic symptoms; Lasègue sign was negative or improved in 92%. In 18% (20 patients), the symptoms did not improve sufficiently; 11% (12 of 110) of these patients underwent surgical nucleotomy. There were no serious complications, in particular, no injuries to vital structures (nerves, thecal sac, arteries, veins), except for one case of spondylodiskitis. Guiding PNT with CT and fluoroscopy provides a safe procedure with good clinical results. The addition of CT has shortened the operation but increased over-all procedure time. In the future, a shift to outpatient treatment may offset the additional time and cost of including CT guidance.

Adult↗

PubMed1997

Short-term effect of fresh disk allograft on the osteoarthrotic sheep temporomandibular joint.

UNLABELLED: The aim of this experimental study is to evaluate the effect of fresh disk allograft on the osteoarthrotic temporomandibular joints in four sheep. STUDY DESIGN: Bilateral osteoarthrosis was induced in the sheep's temporomandibular joint. Three months later, unilateral diskectomy and fresh disk allograft repair were performed, with the contralateral joint being left as a control. At 6 months after the initial procedure, 3 months after the repair, the four sheep were sacrificed. RESULTS: It was found that the operated joint was fibrously repaired without ankylosis, whereas the control joint showed progressive disease. One grafted disk survived, but the other three were perforated and displaced. CONCLUSION: Fresh disk allograft does temper progression of the disease in the early stages.

Animals↗

PubMed1999

The role of the disk in sheep temporomandibular joint ankylosis.

OBJECTIVE: The purpose of this study was to determine the role of the disk in intraarticular ankylosis of the temporomandibular joint. STUDY DESIGN: Twelve adult sheep were divided into 2 groups. In group 1, removal of the temporal and condylar articular surfaces was performed on the right temporomandibular joint and the disk was maintained; in group 2, removal of the articular surfaces and diskectomy were performed on the right temporomandibular joint. One sheep from each group was killed just after surgery and 5 sheep from each group were killed at 3 months. The joints were examined radiologically, macroscopically, and histologically. The range of jaw movements was recorded preoperatively and at sacrifice. RESULTS: Each of 2 sheep in group 2 had lost 4% of their body weight by 3 months; all of the other sheep maintained or increased their weight. The range of jaw motion to the right was significantly lower in group 2 than in group 1 (P<.01). In group 1, fibrous repair of the articular surface and regeneration of the condylar head was seen. In group 2, each of the joints showed a total fibrous ankylosis with some calcification. There was a statistically significant difference in radiologic score between the groups (P<.0001). Histologic scores for group 1 demonstrated significantly lower scores on the degree of ankylosis scale and degree of calcification scale (P<.0001). CONCLUSIONS: This study showed that the presence of the disk prevented the development of fibrous intraarticular ankylosis of the temporomandibular joint.

Animals↗

PubMed2003

Synovial osteochondromatosis accompanying an ossified articular disk in the temporomandibular joint: a case report.

A 51-year-old woman was referred for pain in the right temporomandibular joint (TMJ) and the trismus. Conventional radiography showed a radiopaque area in the disk, which suggested calcification. At surgery, multiple, round-to-ovoid cartilagenous nodules were found in the joint cavity. Synovectomy and diskectomy were carried out via a pre-auricular incision to remove the nodules. Examination under light microscopy confirmed the diagnosis of synovial osteochondromatosis (SOC). The disk contained a large ossified mass. To our knowledge, this is the first reported example of SOC accompanied by ossification of a large part of the disk.

Chondromatosis, Synovial↗

PubMed2006

GTP cyclohydrolase and tetrahydrobiopterin regulate pain sensitivity and persistence.

We report that GTP cyclohydrolase (GCH1), the rate-limiting enzyme for tetrahydrobiopterin (BH4) synthesis, is a key modulator of peripheral neuropathic and inflammatory pain. BH4 is an essential cofactor for catecholamine, serotonin and nitric oxide production. After axonal injury, concentrations of BH4 rose in primary sensory neurons, owing to upregulation of GCH1. After peripheral inflammation, BH4 also increased in dorsal root ganglia (DRGs), owing to enhanced GCH1 enzyme activity. Inhibiting this de novo BH4 synthesis in rats attenuated neuropathic and inflammatory pain and prevented nerve injury-evoked excess nitric oxide production in the DRG, whereas administering BH4 intrathecally exacerbated pain. In humans, a haplotype of the GCH1 gene (population frequency 15.4%) was significantly associated with less pain following diskectomy for persistent radicular low back pain. Healthy individuals homozygous for this haplotype exhibited reduced experimental pain sensitivity, and forskolin-stimulated immortalized leukocytes from haplotype carriers upregulated GCH1 less than did controls. BH4 is therefore an intrinsic regulator of pain sensitivity and chronicity, and the GTP cyclohydrolase haplotype is a marker for these traits.

Adult↗

PubMed1998

Surgery for cervical myelopathy in geriatric patients.

OBJECTIVE: The number of geriatric patients seeking surgical treatment for cervical myelopathy is steadily increasing. Although anecdotal experiences have been good, insufficient data exists in the spine literature concerning this particular group. We decided to review our experience to determine efficacy of surgical management and examine our morbidity with this select group. METHODS: We undertook a retrospective review of all surgical procedures for nontraumatic cervical myelopathy performed at Mt Sinai Medical Center and Jackson Memorial Medical Center between January 1 1987 and June 1 1992, in patients older than 70 years of age (33 men and 18 women). RESULTS: A total of 53 cervical surgical procedures were performed in 51 patients (nine expansile laminoplasties, 20 anterior cervical diskectomies and fusion and 24 decompressive posterior laminectomies). The average hospital stay was 7.7 +/- 3.4 days. Twenty-one (41%) patients required inpatient rehabilitation; the remaining 30 patients received outpatient rehabilitative therapy. The major morbidity rate was 3.9%, and the minor morbidity rate was 5.8%. Perioperative medical complications included cardiac arrhythmias, hypertensive episodes, atelectasis, confusion, urinary dysfunction and hyponatremia. All of these complications resolved except in one patient. The perioperative mortality rate was 2%. Office follow-up was performed for a mean of 11.1 +/- 2.5 months postoperatively. Comparison of preoperative and postoperative functional status was performed using Nurick's criteria as described in the literature. At follow-up, 60.8% of the patients had improvement in their myelopathic symptoms, especially in regard to gait; 33.3% were stabilized and 5.9% had worsened neurological function. CONCLUSION: This study demonstrates that corrective surgical procedures for significant nontraumatic cervical myelopathy in the geriatric population may be performed safely, that is, with acceptable risk of morbidity and reasonable expectation for clinical improvement.

Aged↗

PubMed2007

Minimal access thoracic surgery in the pediatric population.

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

Anesthesia, Closed-Circuit↗

PubMed1996

Thoracoscopic Surgery of the Spine.

Anterior approach to the thoracic spine has been limited by the morbidity of a thoracotomy. By a thoracoscopic approach, a majority of thoracic spine procedures can now be performed from the anterior approach including diskectomy for herniation, release for correction of spinal deformity and corpectomy for tumor. Although experience is limited and results still short term, the thoracoscopic approach appears to be a promising one for the treatment of thoracic spine disease.

Journal Article↗

PubMed1992

Vascular injury related to lumbar disk surgery.

The authors report a case of left common iliac artery injury, as a complication of diskectomy, in a 57 year-old male patient, with herniated disk at L4-L5. A review shows that L4-L5 disk space is the most common site for this rare complication of lumbar disk surgery.

Hemorrhage↗