Association between facet joint osteoarthritis and the Oswestry Disability Index

AIM:To investigate the correlation of facet joint osteoarthritis(FJOA) at lumbar levels L4/L5 and L5/S1 and the Oswestry Disability Index(ODI).METHODS:The study involved lumbar MRIs of 591 patients with a mean age of 47.3 years.The MRIs of the lumbar spine were performed on a 1.5 Tesla scanner(Magnetom Avanto,Siemens AG,Erlangen,Germany) using a dedicated receive only spine coil.After initial blinding,each dataset was evaluated by 2 board certified radiologist with more than 5 years experience in musculoskeletal imaging.In total 2364 facet joints were graded.Degenerative changes of the facet joints were evaluated according to the 4-point scale as proposed by Weishaupt et al Functional status was assessed using the ODI.The index is scored from 0 to 100 and interpreted as follows:0%-20%,minimaldisability; 20%-40%,moderate disability; 40%-60%,severe disability; 60%-80%,crippled; 80%-100%,patients are bedbound.Spearman’s coefficient of rank correlation was used for statistical analysis,with significance set at P 【 0.05.RESULTS:In total 2364 facet joints at lumbar levels L4/5 and L5/S1 were analysed in 591 individuals.FJOA was present in 97%(L4/L5) and 98%(L5/S1).At level L4/5(left/right) 17/15(2.9%/2.5%) were described as grade 0,146/147(24.7%/24.9%) as grade 1,290/302(49.1%/51.1%) as grade 2 and 138/127(23.4%/21.5%) as grade 3.At level L5/S1(left/right) 10/11(1.7%/1.9%) were described as grade 0,136/136(23.0%/23.0%) as grade 1,318/325(53.8%/55.0%) as grade 2 and 127/119(21.5%/20.1%) as grade 3.Regarding the ODI scores,patients’ disability had a minimum of 0% and a maximum of 91.11% with an arithmetic mean of 32.77% ± 17.02%.The majority of patients(48.39%) had moderate functional disability(21%-40%).There was no significant correlation between FJOA and ODI on both sides of lumbar level L4/5 and on the left side of lumbar level L5/S1.A weak positive correlation was evaluated between ODI and FJOA on the right side of lumbar level L5/S1.CONCLUSION:The missing correlation of FJOA and ODI confirms our clinical experience that imaging alone is an insufficient approach explaining low back pain.Clinical correlation is imperative for an adequate diagnostic advance in patients with low back pain.

Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms

AIM To assess the correlation of lateral recess stenosis(LRS) of lumbar segments L4/5 and L5/S1 and the Oswestry Disability Index(ODI).METHODS Nine hundred and twenty-seven patients with history of low back pain were included in this uncontrolled study.On magnetic resonance images(MRI) the lateral recesses(LR) at lumbar levels L4/5 and L5/S1 were evaluated and each nerve root was classified into a 4-point grading scale(Grade 0-3) as normal,not deviated,deviated or compressed.Patient symptoms and disability were assessed using ODI.The Spearman's rank correlation coefficient was used for statistical analysis(P < 0.05).RESULTS Approximately half of the LR revealed stenosis(grade 1-3;52% at level L4/5 and 42% at level L5/S1) with 2.2% and 1.9% respectively reveal a nerve root compression.The ODI score ranged from 0%-91.11% with an arithmetic mean of 34.06% ± 16.89%.We observed a very weak statistically significant positive correlation between ODI and LRS at lumbar levels L4/5 and L5/S1,each bilaterally(L4/5 left:rho < 0.105,P < 0.01;L4/5 right:rho < 0.111,P < 0.01;L5/S1 left:rho 0.128,P < 0.01;L5/S1 right:rho < 0.157,P < 0.001).CONCLUSION Although MRI is the standard imaging tool for diagnosing lumbar spinal stenosis,this study showed only a weak correlation of LRS on MRI and clinical findings.This can be attributed to a number of reasons outlined in this study,underlining that imaging findings alone are not sufficient to establish a reliable diagnosis for patients with LRS.

Magnetic resonance imaging-based interpretation of degenerative changes in the lower lumbar segments and therapeutic consequences

Intervertebral disc degeneration and facet joint osteoarthritis of the lumbar spine are, among others, wellknown as a cause of low back and lower extremity pain. Together with their secondary disorders they set a big burden on health care systems and economics worldwide. Despite modern imaging modalities, such as magnetic resonance imaging, for a large proportion of patients with low back pain(LBP) it remains difficult to provide a specific diagnosis. The fact that nearly all the lumbar structures are possible sources of LBP, may serve as a possible explanation. Furthermore, our clinical experience confirms, that imaging alone is not a sufficient approach explaining LBP. Here, the Oswestry Disability Index, as the most commonly used measure to quantify disability for LBP, may serve as an easy-toapply questionnaire to evaluate the patient's ability to cope with everyday life. For therapeutic purposes, among the different options, the lumbar facet joint intraarticular injection of corticosteroids in combination with an anaesthetic solution is one of the most frequently performed interventional procedures. Although widely used the clinical benefit of intra-articular steroid injections remains controversial. Therefore, prior to therapy, standardized diagnostic algorithms for an accurate assessment, classification and correlation of degenerative changes of the lumbar spine are needed.

Enteroclysis:Current clinical value

AIM: To retrospectively analyze changes in clinical indication, referring medical specialty and detected pathology for small bowel double-contrast examinations. METHODS: Two hundred and forty-one (n = 143 females; n = 98 males; 01.01.1990-31.12.1990) and 384 (n = 225 females; n = 159 males; 01.01.2004-31.12.2010) patients underwent enteroclysis, respectively. All exami- nations were performed in standardized double-contrast technique. After placement of a nasojejunal probe distal to the ligament of Treitz, radiopaque contrast media followed by Xray negative distending contrast media were administered. Following this standardized projections in all four abdominal quadrants were acquired. Depending on the detected pathology further documentation was carried out by focused imaging. Examination protocols were reviewed and compared concerning requesting unit, indication and final report. RESULTS: Two hundred and forty-one examinations in 1990 faced an average of 55 examinations per year from 2004-2010. There was an increase of examinations for gastroenterological (33.6% to 64.6%) andpediatric (0.4% to 7.8%) indications while internal (29.0% to 6.0% for inpatients and from 16.6% to 9.1% for outpatients) and surgical (12.4% to 7.3%) referrals significantly decreased. 'Follow-up of Crohn’s disease' (33.1%) and 'bleeding/tumor search' (15.1%) represented the most frequent clinical indications. A total of 34% (1990) and 53.4% (2004-2010) examinations yielded pathologic findings. In the period 01.01.2004 -31.12.2010 the largest proportion of pathological findings was found in patients with diagnosed Crohn’s disease (73.5%), followed by patients with abdominal pain (67.6% with history of surgery and 52.6% without history of surgery), chronic diarrhea (41.7%), suspected Crohn’s disease (39.5%) and search for gastrointestinal bleeding source/tumor (19.1%). The most common pathologies diagnosed by enteroclysis were 'changes in Crohn’s disease' (25.0%) and 'adhesions /strictures' (12.2%). CONCLUSION: 'Crohn’s disease' represents the main indication for enteroclysis. The relative increase of pathologic findings reflects today’s well directed use of enteroclysis.

Does therapist's attitude affect clinical outcome of lumbar facet joint injections?

AIM: To investigate if the clinical outcome of intraarticular lumbar facet joint injections is affected by the therapist's attitude. METHODS: A total of 40 patients with facet jointassociated chronic low back pain were randomly divided into two groups. All patients received computed tomography-guided, monosegmental intra-articular facet joint injections. Following the therapeutic procedure, the patients of the experimental group(EG) held a conversation with the radiologist in a comfortable atmosphere. During the dialog, the patients were encouraged to ask questions and were shown four images. The patients of the control group(CG) left the clinic without any further contact with the radiologist. Outcome was assessed using a pain-based Verbal Numeric Scale at baseline, at 1 wk and at 1, 3, and 6 mo after first treatment. RESULTS: The patient demographics showed no differences between the groups. The patients of the EG received 57 interventional procedures in total, while the patients of the CG received 70 interventional procedures. In both groups, the pain scores decreased significantly over the entire observation period. Compared to the CG, the EG showed a statistically significant reduction of pain at 1 wk and 1 mo post-treatment, while at 3 and 6 mo after treatment, there were no significant differences between both groups. CONCLUSION: Our results show a significant effect on pain relief during the early post-interventional period in the EG as compared to the CG. The basic principle behind the higher efficacy might be the phenomenon of hetero-suggestion.

Mesenteric myolipoma

The authors report on a case of benign myolipoma(synonym lipoleiomyoma) which was first described in 1991. The benign soft tissue tumor is composed of smooth muscle and adipose tissue and occurs sporadically in different locations. In the available literature cases were described retroperitoneal, spinal, orbital and subcutaneous and mostly have been discovered in females. Characteristically myolipomas are very large at diagnosis and reach diameters of 7 to 30 cm particularly in peritoneal or retroperitoneal localization. The sometimes enormous size leads to a displacing growth pattern which ultimately leads to the clinical symptoms. The patients often complain of nonspecific, mostly painless abdominal or thoracic pressure. Bordered by an intact capsule the tumors show no signs of malignancy and in the available literature there is no evidence of metastatic seeding. To the best of our knowledge the presented case is the first description of a diffuse mesenteric myolipoma in a male individual. In this article, we present the multidetector computed tomographic image characteristics, macroscopic appearance and histopathological findings.