The role of laparoscopic biopsies in lumbar spondylodiscitis.

The infection of an intervertebral disk is a serious condition. The diagnosis often is elusive and difficult to make. It is imperative to have appropriate microbiologic specimens before the initiation of treatment. We report the case of a 51-year-old woman with lumbar spondylodiscitis caused by infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging (MRI) scan confirmed the diagnosis, but computed tomography (CT)-guided fine-needle biopsy did not yield adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. We believe that this minimally invasive procedure should be performed when CT-guided fine-needle biopsy fails to yield a microbiologic diagnosis in spondylodiscitis.

Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison.

Object Recent years have been marked by efforts to improve the quality and safety of pedicle screw placement in spinal instrumentation. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement. Methods Ninety-five patients suffering from degenerative disease and requiring elective lumbar instrumentation were included in the study. The robot cohort (Group I; 55 patients, 244 screws) consisted of an initial open robot-assisted subgroup (Subgroup IA; 17 patients, 83 screws) and a percutaneous cohort (Subgroup IB, 38 patients, 161 screws). In these groups, pedicle screws were placed under robotic guidance and lateral fluoroscopic control. In the fluoroscopy-guided cohort (Group II; 40 patients, 163 screws) screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The primary outcome measure was accuracy of screw placement on the Gertzbein-Robbins scale (Grade A to E and R [revised]). Secondary parameters were duration of surgery, blood loss, cumulative morphine, and length of stay. Results In the robot group (Group I), a perfect trajectory (A) was observed in 204 screws (83.6%). The remaining screws were graded B (n = 19 [7.8%]), C (n = 9 [3.7%]), D (n = 4 [1.6%]), E (n = 2 [0.8%]), and R (n = 6 [2.5%]). In the fluoroscopy-guided group (Group II), a completely intrapedicular course graded A was found in 79.8% (n = 130). The remaining screws were graded B (n = 12 [7.4%]), C (n = 10 [6.1%]), D (n = 6 [3.7%]), and E (n = 5 [3.1%]). The comparison of "clinically acceptable" (that is, A and B screws) was neither different between groups (I vs II [p = 0.19]) nor subgroups (Subgroup IA vs IB [p = 0.81]; Subgroup IA vs Group II [p = 0.53]; Subgroup IB vs Group II [p = 0.20]). Blood loss was lower in the robot-assisted group than in the fluoroscopy-guided group, while duration of surgery, length of stay, and cumulative morphine dose were not statistically different. Conclusions Robot-guided pedicle screw placement is a safe and useful tool for assisting spine surgeons in degenerative spine cases. Nonetheless, technical difficulties remain and fluoroscopy backup is advocated.

Strain-induced stabilization of new magnetic spinel structures in epitaxial oxide heterostructures.

We report here on the growth of NiFe2O4 epitaxial thin films of different thickness (3 nm ¿ t ¿ 32 nm) on single crystalline substrates having spinel (MgAl2O4) or perovskite (SrTiO3) structure. Ultrathin films, grown on any of those substrates, display a huge enhancement of the saturation magnetization: we will show that partial cationic inversion may account for this enhancement, although we will argue that suppression of antiparallel collinear spin alignment due to size-effects cannot be excluded. Besides, for thicker films, the magnetization of films on MAO is found to be similar to that of bulk ferrite; in contrast, the magnetization of films on STO is substantially lower than bulk. We discuss on the possible mechanisms leading to this remarkable difference of magnetization.

Generation and validation of a normative, age-specific reference curve for lumbar spine trabecular bone score (TBS) in French women.

Age-related changes in lumbar vertebral microarchitecture are evaluated, as assessed by trabecular bone score (TBS), in a cohort of 5,942 French women. The magnitude of TBS decline between 45 and 85 years of age is piecewise linear in the spine and averaged 14.5 %. TBS decline rate increases after 65 years by 50 %. INTRODUCTION: This study aimed to evaluate age-related changes in lumbar vertebral microarchitecture, as assessed by TBS, in a cohort of French women aged 45-85 years. METHODS: An all-comers cohort of French Caucasian women was selected from two clinical centers. Data obtained from these centers were cross-calibrated for TBS and bone mineral density (BMD). BMD and TBS were evaluated at L1-L4 and for all lumbar vertebrae combined using GE-Lunar Prodigy densitometer images. Weight, height, and body mass index (BMI) also were determined. To validate our all-comers cohort, the BMD normative data of our cohort and French Prodigy data were compared. RESULTS: A cohort of 5,942 French women aged 45 to 85 years was created. Dual-energy X-ray absorptiometry normative data obtained for BMD from this cohort were not significantly different from French prodigy normative data (p = 0.15). TBS values at L1-L4 were poorly correlated with BMI (r = -0.17) and weight (r = -0.14) and not correlated with height. TBS values obtained for all lumbar vertebra combined (L1, L2, L3, L4) decreased with age. The magnitude of TBS decline at L1-L4 between 45 and 85 years of age was piecewise linear in the spine and averaged 14.5 %, but this rate increased after 65 years by 50 %. Similar results were obtained for other region of interest in the lumbar spine. As opposed to BMD, TBS was not affected by spinal osteoarthrosis. CONCLUSION: The age-specific reference curve for TBS generated here could therefore be used to help clinicians to improve osteoporosis patient management and to monitor microarchitectural changes related to treatment or other diseases in routine clinical practice.

Iowa Interstate Rest Area Stabilization Ponds, September 1979

This report is presented in two parts . P a r t I takes a new look at the design of rest area stabilization ponds after nearly 10 years' experience with some of the existing ponds and in the light of new design standards issued by Iowa DEQ. The Iowa DOT is embarking on improvements t o the ponds a t some of the r e s t areas. These improvements may include installation of drainage tile around the ponds to lower the water table below the pond bottom, sealing of the ponds with bentonite clay to reduce the infiltration to limits recently established by Iowa DEQ, and the enlargement of the ponds installation of aeration equipment t o increase the pond capacity. As the Iowa DOT embarks on this improvement program, it behooves them t o make only the improvements that are absolutely necessary to achieve waste water treatment goals. These ponds are subject to an extremely seasonal load and thus the ordinary standards used for pond design are not appropriate. Thus, Part I of the report presents a rationale for design and operation of the ponds which is deemed appropriate for t h e i r unique seasonally loaded character. Part I1 of the report looks a t the feasibility of using wind power for the aeration of the ponds, if and when aeration is deemed necessary.

Ponction lombaire [Lumbar puncture]

La ponction lombaire (PL) est un geste fréquent en médecine interne, en particulier dans les services d'urgences. Dans cet article, nous présentons une description détaillée de ce geste en donnant quelques conseils pratiques pour sa réussite, la gestion des cas difficiles et la prévention des complications. Nous abordons aussi des questions pratiques comme l'indication à une imagerie cérébrale avant le geste et la mobilisation après la PL. La connaissance des indications, des détails de la procédure ainsi que des complications potentielles et de leur prise en charge constitue la base pour une information complète à donner au patient. Lumbar puncture (LP) is a procedure frequently performed by internists. The aim of this article is to describe in detail the procedure, to give some practical advices to always succeed in doing a lumbar puncture and to discuss the most frequent complications, how to prevent them and how to treat them. We will also answer some frequently asked questions, such as indications to perform neuroimaging before a lumbar puncture, or patient mobilisation after LP. Knowledge of these points is key to give a complete information to the patients and obtain an informed consent

Influence of the morphology of the dural sac on surgical decision making in lumbar spinal stenosis

Introduction: Surgical decision making in lumbar spinal stenosis (LSS) takes into account primarily clinical symptoms as well as concordant radiological findings. We hypothesized that a wide variation of operative threshold would be found in particular as far as judgment of severity of radiological stenosis is concerned. Patients and methods: The number of surgeons who would proceed to decompression was studied relative to the perceived severity of radiological stenosis based either on measurements of dural sac cross sectional area (DSCA) or on the recently described morphological grading as seen on axial T2 MRI images. A link to an electronic survey page with a set of ten axial T2 MRI images taken from ten patients with either low back pain or LSS were sent to members of three national or international spine societies. Those 10 images were randomly presented initially and re-shuffled on a second page including this time DSCA measurements in mm2, ranging from 14 to 226 mm2, giving a total of 20 images to appraise. Morphological grades were ranging from grade A to D. Surgeons were asked if they would consider decompression given the radiological appearance of stenosis and that symptoms of neurological claudication were severe in patients who were otherwise fit for surgery. Fisher's exact test was performed following dichotomization of data when appropriate. Results: A total of 142 spine surgeons (113 orthopedic spine surgeons, 29 neurosurgeons) responded from 25 countries. A substantial agreement was observed in operating patients with severe (grade C) or extreme (grade D) stenosis as defined by the morphological grade compared to lesser stenosis (A&B) grades (p<0.0001). Decision to operate was not dependent on number of years in practice, medical density in practicing country or specialty although more neurosurgeons would operate on grade C stenosis (p<0.005). Disclosing the DSCA measurement did not alter the decision to operate. Although 20 surgeons only had prior knowledge of the description of the morphological grading, their responses showed no statistically significant difference with those of the remaining 122 physicians. Conclusions: This study showed that surgeons across borders are less influenced by DSCA in their decision making than by the morphological appearance of the dural sac. Classifying LSS according to morphology rather than surface measurements appears to be consistent with current clinical practice.

Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience.

The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group.

Test-retest reliability of thermal quantitative sensory testing on two sites within the L5 dermatome of the lumbar spine and lower extremity.

INTRODUCTION: Quantitative sensory testing (QST) is widely used in human research to investigate the integrity of the sensory function in patients with pain of neuropathic origin, or other causes such as low back pain. Reliability of QST has been evaluated on both sides of the face, hands and feet as well as on the trunk (Th3-L3). In order to apply these tests on other body-parts such as the lower lumbar spine, it is important first to establish reliability on healthy individuals. The aim of this study was to investigate intra-rater reliability of thermal QST in healthy adults, on two sites within the L5 dermatome of the lumbar spine and lower extremity. METHODS: Test-retest reliability of thermal QST was determined at the L5-level of the lumbar spine and in the same dermatome on the lower extremity in 30 healthy persons under 40 years of age. Results were analyzed using descriptive statistics and intraclass correlation coefficient (ICC). Values were compared to normative data, using Z-transformation. RESULTS: Mean intraindividual differences were small for cold and warm detection thresholds but larger for pain thresholds. ICC values showed excellent reliability for warm detection and heat pain threshold, good-to-excellent reliability for cold pain threshold and fair-to-excellent reliability for cold detection threshold. ICC had large ranges of confidence interval (95%). CONCLUSION: In healthy adults, thermal QST on the lumbar spine and lower extremity demonstrated fair-to-excellent test-retest reliability.

Stabilization of soil hydraulic properties under a long term no-till system

The area under the no-tillage system (NT) has been increasing over the last few years. Some authors indicate that stabilization of soil physical properties is reached after some years under NT while other authors debate this. The objective of this study was to determine the effect of the last crop in the rotation sequence (1st year: maize, 2nd year: soybean, 3rd year: wheat/soybean) on soil pore configuration and hydraulic properties in two different soils (site 1: loam, site 2: sandy loam) from the Argentinean Pampas region under long-term NT treatments in order to determine if stabilization of soil physical properties is reached apart from a specific time in the crop sequence. In addition, we compared two procedures for evaluating water-conducting macroporosities, and evaluated the efficiency of the pedotransfer function ROSETTA in estimating the parameters of the van Genuchten-Mualem (VGM) model in these soils. Soil pore configuration and hydraulic properties were not stable and changed according to the crop sequence and the last crop grown in both sites. For both sites, saturated hydraulic conductivity, K0, water-conducting macroporosity, εma, and flow-weighted mean pore radius, R0ma, increased from the 1st to the 2nd year of the crop sequence, and this was attributed to the creation of water-conducting macropores by the maize roots. The VGM model adequately described the water retention curve (WRC) for these soils, but not the hydraulic conductivity (K) vs tension (h) curve. The ROSETTA function failed in the estimation of these parameters. In summary, mean values of K0 ranged from 0.74 to 3.88 cm h-1. In studies on NT effects on soil physical properties, the crop effect must be considered.

Optimization of Soil Stabilization with Class C Fly Ash, January 1987

Previous Iowa DOT sponsored research has shown that some Class C fly ashes are ementitious (because calcium is combined as calcium aluminates) while other Class C ashes containing similar amounts of elemental calcium are not (1). Fly ashes from modern power plants in Iowa contain significant amounts of calcium in their glassy phases, regardless of their cementitious properties. The present research was based on these findings and on the hyphothesis that: attack of the amorphous phase of high calcium fly ash could be initiated with trace additives, thus making calcium available for formation of useful calcium-silicate cements. Phase I research was devoted to finding potential additives through a screening process; the likely chemicals were tested with fly ashes representative of the cementitious and non-cementitious ashes available in the state. Ammonium phosphate, a fertilizer, was found to produce 3,600 psi cement with cementitious Neal #4 fly ash; this strength is roughly equivalent to that of portland cement, but at about one-third the cost. Neal #2 fly ash, a slightly cementitious Class C, was found to respond best with ammonium nitrate; through the additive, a near-zero strength material was transformed into a 1,200 psi cement. The second research phase was directed to optimimizing trace additive concentrations, defining the behavior of the resulting cements, evaluating more comprehensively the fly ashes available in Iowa, and explaining the cement formation mechanisms of the most promising trace additives. X-ray diffraction data demonstrate that both amorphous and crystalline hydrates of chemically enhanced fly ash differ from those of unaltered fly ash hydrates. Calciumaluminum- silicate hydrates were formed, rather than the expected (and hypothesized) calcium-silicate hydrates. These new reaction products explain the observed strength enhancement. The final phase concentrated on laboratory application of the chemically-enhanced fly ash cements to road base stabilization. Emphasis was placed on use of marginal aggregates, such as limestone crusher fines and unprocessed blow sand. The nature of the chemically modified fly ash cements led to an evaluation of fine grained soil stabilization where a wide range of materials, defined by plasticity index, could be stabilized. Parameters used for evaluation included strength, compaction requirements, set time, and frost resistance.

Interspinous distraction in lumbar spinal stenosis: a neurophysiological perspective.

STUDY DESIGN: Prospective neurophysiological study. OBJECTIVE: To identify and quantify the neurophysiological effects of interspinous distraction during spine surgery for lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: Interspinous devices have been introduced as an alternative treatment of LSS in selected patients aiming at obtaining indirect decompression. Nevertheless, there is no data on the immediate neurophysiological effect of distraction. METHODS: Thirty patients with LSS undergoing decompression (14 at single level, 16 at multiple levels) were enrolled, resulting in a total of 48 levels to be analyzed. Before decompression, calibrated incremental distraction simulating interspinous device implantation of 8, 10, 12, 14, and 16 mm was performed. Intraoperative motor evoked potentials were acquired before any distraction, during distraction at each incremental value and after bilateral decompression. We evaluated relative changes of motor evoked potentials normalized to hand muscles and related them to the number of affected levels, LSS radiological severity based on the A to D grading, lordosis, and disc height. RESULTS: For single-level disease, 8-mm distraction and open decompression yielded similar improvement in motor evoked potentials not only in levels with morphological grades A or B, but also in levels with morphological grades C or D (i.e., severe or extreme stenosis) (P = 0.32). In contrast, distraction superior to 8 mm was less effective (P ≤ 0.05). In multiple-level stenosis, decompression was significantly more effective than any degree of distraction (P < 0.001). No correlation of those results to disc height or lordosis was observed. Using χ trend test to analyze the effect of distraction, a linear trend favoring moderate over severe stenotic morphology was observed (P = 0.0349). CONCLUSION: Interspinous distraction of 8 mm is sufficient to replicate electrophysiological improvements obtained during full decompression even in severe single-level stenosis but not in multilevel disease. Interspinous distraction has therefore an immediately measurable neurophysiological effect. Level of Evidence: 4.