St. Mary's Medical Center

Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty. A total of 9482 patients (3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement) were evaluated prospectively from September 1996 through June 1997. Of those patients, 4409 (46 percent [57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement]) had a blood transfusion. Two thousand eight hundred and ninety patients (66 percent) received autologous blood, and 1519 patients (34 percent) received allogenic blood. Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood. Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood; however, inefficiencies in the procedures for obtaining autologous blood were identified. Sixty-one percent (5741) of the patients had predonated blood for autologous transfusion, but 4464 (45 percent) of the 9920 units of the predonated autologous blood were not used. Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units. Of the 5741 patients who had predonated blood, 503 (9 percent) needed a transfusion of allogenic blood. The frequency of allogenic blood transfusion varied with respect to the type of operative procedure (revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions) and with a baseline hemoglobin level of 130 grams per liter or less. Transfusion of allogenic blood was also associated with infection (p < or = 0.001), fluid overload (p < or = 0.001), and increased duration of hospitalization (p < or = 0.01). These latter findings warrant further evaluation in controlled studies.

BACKGROUND: Hepatic ischemia reperfusion is one the main causes for graft failure following transplantation. Although, the molecular events that lead to hepatic failure following ischemia reperfusion (IR) are diverse and complex, previous studies have shown that excessive formation of reactive oxygen species (ROS) are responsible for hepatic IR injury. Cerium oxide (CeO2) nanoparticles have been previously shown to act as an anti-oxidant and anti-inflammatory agent. Here, we evaluated the protective effects of CeO2 nanoparticles on hepatic ischemia reperfusion injury. METHODS: Male Sprague Dawley rats were randomly assigned to one of the four groups: Control, CeO2 nanoparticle only, hepatic ischemia reperfusion (IR) group and hepatic ischemia reperfusion (IR) plus CeO2 nanoparticle group (IR+ CeO2). Partial warm hepatic ischemia was induced in left lateral and median lobes for 1h, followed by 6h of reperfusion. Animals were sacrificed after 6h of reperfusion and blood and tissue samples were collected and processed for various biochemical experiments. RESULTS: Prophylactic treatment with CeO2 nanoparticles (0.5mg/kg i.v (IR+CeO2 group)) 1 hour prior to hepatic ischemia and subsequent reperfusion injury lead to a decrease in serum levels of alanine aminotransaminase and lactate dehydrogenase at 6 hours after reperfusion. These changes were accompanied by significant decrease in hepatocyte necrosis along with reduction in several serum inflammatory markers such as macrophage derived chemokine, macrophage inflammatory protein-2, KC/GRO, myoglobin and plasminogen activator inhibitor-1. However, immunoblotting demonstrated no significant changes in the levels of apoptosis related protein markers such as bax, bcl2 and caspase 3 in IR and IR+ CeO2 groups at 6 hours suggesting necrosis as the main pathway for hepatocyte death. CONCLUSION: Taken together, these data suggest that CeO2 nanoparticles attenuate IR induced cell death and can be used as a prophylactic agent to prevent hepatic injury associated with graft failure.

STUDY DESIGN: A prospective, randomized, multicenter, Food and Drug Administration-regulated Investigational Device Exemption clinical trial. OBJECTIVE: To evaluate the safety and effectiveness of the ProDisc-L (Synthes Spine, West Chester, PA) lumbar total disc replacement compared to circumferential spinal fusion for the treatment of discogenic pain at 1 vertebral level between L3 and S1. SUMMARY OF BACKGROUND DATA: As part of the Investigational Device Exemption clinical trial, favorable single center results of lumbar total disc replacement with the ProDisc-L have been reported previously. METHODS: Two hundred eighty-six (286) patients were treated on protocol. Patients were evaluated before and after surgery, at 6 weeks, 3, 6, 12, 18, and 24 months. Evaluation at each visit included patient self-assessments, physical and neurologic examinations, and radiographic evaluation. RESULTS: Safety of ProDisc-L implantation was demonstrated with 0% major complications. At 24 months, 91.8% of investigational and 84.5% of control patients reported improvement in the Oswestry Low Back Pain Disability Questionnaire (Oswestry Disability Index [ODI]) from preoperative levels, and 77.2% of investigational and 64.8% of control patients met the > or =15% Oswestry Disability Index improvement criteria. Overall neurologic success in the investigational group was superior to the control group (91.2% investigational and 81.4% control; P = 0.0341). At 6 weeks and 3 months follow-up time points, the ProDisc-L patients recorded SF-36 Health Survey scores significantly higher than the control group (P = 0.018, P = 0.0036, respectively). The visual analog scale pain assessment showed statistically significant improvement from preoperative levels regardless of treatment (P < 0.0001). Visual analog scale patient satisfaction at 24 months showed a statistically significant difference favoring investigational patients over the control group (P = 0.015). Radiographic range of motion was maintained within a normal functional range in 93.7% of investigational patients and averaged 7.7 degrees. CONCLUSIONS: ProDisc-L has been found to be safe and efficacious. In properly chosen patients, ProDisc-L has been shown to be superior to circumferential fusion by multiple clinical criteria.

Background: Previous studies have shown that virtual reality (VR) is effective in reducing acute and chronic pain both in adults and in children. Given the emergence of new VR technology, and the growing body of research surrounding VR and pain management, an updated systematic review is warranted. Purpose: The purpose of this systematic review is to compare the effectiveness of VR in reducing acute and chronic pain in adults. Data Sources: A search was conducted in three databases (PubMed, CINAHL, Trip) using standardized search terms. Study Selection: Twenty experimental and quasi-experimental trials published between January 2007 and December 2018 were included based on prespecified inclusion and exclusion criteria. Pain intensity was the primary outcome. Data Extraction: We extracted data and appraised the quality of articles using either the PEDro or Modified Downs and Black risk of bias tools. Data Synthesis: The majority of studies supported the use of VR to reduce acute pain both during the procedure and immediately after. Numerous studies found VR reduced chronic pain during VR exposure but there is insufficient evidence to support lasting analgesia. There was considerable variability in patient population, pain condition and dosage of VR exposure. Limitations: Due to heterogeneity, we were unable to perform meta-analyses for all study populations and pain conditions. Conclusions: VR is an effective treatment for reducing acute pain. There is some research that suggests VR can reduce chronic pain during the intervention; however, more evidence is needed to conclude that VR is effective for lasting reductions in chronic pain. Keywords: virtual reality, analgesia, acute, chronic, pain management, adult

OBJECTIVES: To examine the impact of an interdisciplinary, collaborative practice intervention involving a primary care physician, a nurse, and a social worker for community-dwelling seniors with chronic illnesses. METHODS: A concurrent, controlled cohort study of 543 patients in 18 private office practices of primary care physicians was conducted. The intervention group received care from their primary care physician working with a registered nurse and a social worker, while the control group received care as usual from their primary care physician. The outcome measures included changes in number of hospital admissions, readmissions, office visits, emergency department visits, skilled nursing facility admissions, home care visits, and changes in patient self-rated physical, emotional, and social functioning. RESULTS: From 1992 (baseline year) to 1993, the two groups did not differ in service use or in self-reported health status. From 1993 to 1994, the hospitalization rate of the control group increased from 0.34 to 0.52, while the rate in the intervention group stayed at baseline (P= .03). The proportion of intervention patients with readmissions decreased from 6% to 4%, while the rate in the control group increased from 4% to 9% (P=.03). In the intervention group, mean office visits to all physicians fell by 1.5 visits compared with a 0.5-visit increase for the control group (P=.003). The patients in the intervention group reported an increase in social activities compared with the control group's decrease (P=.04). With fewer hospital admissions, average per-patient savings for 1994 were estimated at $90, inclusive of the intervention's cost but exclusive of savings from fewer office visits. CONCLUSIONS: This model of primary care collaborative practice shows potential for reducing utilization and maintaining health status for seniors with chronic illnesses. Future work should explore the specific benefit accruing from physician involvement in the collaborative practice team.

STUDY DESIGN: This study analyzed the clinical history, physical examination, diagnostic studies, and operative and histologic findings in 19 patients with lumbar intraspinal synovial and ganglion facet cysts evaluated and treated over a 10-year period. OBJECTIVES: The results were correlated to provide a greater understanding of lumbar facet cysts and rationale for conservative or surgical treatments. SUMMARY OF BACKGROUND DATA: The 19 patients included 13 women and 6 men ranging in age from 38 to 79 years. 84.4% of the patients presented with radicular pain. 26.3% had significant motor deficit. 68.4% of the facet cysts were found at L4-L5, 21.1% at L5-S1, 5.2% at L1-L2, and 5.2% at L2-L3. METHODS: The clinical history and findings on physical examination, standard radiography, myelography, computed tomography-myelography, facet arthrography, post-facet arthrograph computed tomography, magnetic resonance imaging with and without contrast, and computed tomography scans were reviewed. RESULTS: Bilobed cysts were found on both dorsal and ventral aspects of the involved facet joints within and outside of the spinal canal on facet arthrography, computed tomography, magnetic resonance imaging, and at the time of surgery in more than 60% of the patients. Significant facet degeneration was found in 75% of standard radiographs, and on all of the magnetic resonance imaging and computed tomography scans. In six patients, symptoms improved with rest, medication, and bracing. Epidural corticosteroid injections provided short-term relief in three out of four patients. Facet corticosteroid injections provided good relief in one, partial relief in one, and no relief in one patient. Surgical decompression in eight patients resulted in three excellent, four good, and one fair outcome. CONCLUSIONS: Most of the lumbar intraspinal facet cysts were associated with significantly degenerated facet joints. Patients with intraspinal facet cysts may respond to conservative treatments if there is no significant neurologic deficit. Surgical decompression and removal of large facet cysts usually are successful in relieving symptoms.

STUDY DESIGN: Measurement of the kinematics of the lumbar spine after insertion of an interspinous spacer in vitro. OBJECTIVES: To understand the kinematics of the instrumented and adjacent levels due to the insertion of this interspinous implant. SUMMARY OF BACKGROUND DATA: An interspinous spacer (X Stop, SFMT, Concord, California) has been developed to treat neurogenic intermittent claudication by placing the stenotic segment in slight flexion and preventing extension. This restriction of motion by the interspinous implant may affect the kinematics of levels adjacent to the instrumented level. METHODS: Seven lumbar spines (L2-L5) were tested in flexion-extension, lateral bending, and axial rotation. Images were taken during each test to determine the kinematics of each motion segment. The interspinous implant was placed at the L3-L4 level, and the test protocol was repeated. RESULTS: The flexion-extension range of motion was significantly reduced at the instrumented level. Axial rotation and lateral bending ranges of motion were not affected at the instrumented level. The range of motion in flexion-extension, axial rotation, and lateral bending at the adjacent segments was not significantly affected by the implant. CONCLUSIONS: The implant does not significantly alter the kinematics of the motion segments adjacent to the instrumented level.

STUDY DESIGN: Measurement of intradiscal pressure was performed after placement of an interspinous implant in a cadaver model. OBJECTIVE: To understand the likelihood of accelerated adjacent-level disc degeneration as a result of the implant. SUMMARY OF BACKGROUND DATA: An interspinous implant has been developed to treat lumbar neurogenic claudication secondary to spinal stenosis that places the stenotic segment in slight flexion and prevents extension. Previous biomechanical studies demonstrated that fusing one level may significantly increase the intradiscal pressures at adjacent levels. Moreover, clinical studies have reported an increased incidence of adjacent-level degeneration after lumbar spinal fusion. METHODS: Eight cadaver lumbar specimens (L2-L5) were loaded in flexion, neutral, and extension. A pressure transducer measured intradiscal pressure and annular stresses during each of the three positions at each of the three disc levels. An appropriately sized implant was placed at L3-L4, and the pressure measurements were repeated. RESULTS: The pressures at the adjacent discs were not significantly affected by the interspinous implant insertion. There was a significant decrease in intradiscal pressure at the L3-L4 disc in the posterior annulus and nucleus in the neutral and extended positions. CONCLUSIONS: The implant does not significantly change the intradiscal pressures at the adjacent levels, yet it significantly unloads the intervertebral disc at the instrumented level in the neutral and extended positions. On the basis of the current findings, it does not appear that the implant causes accelerated disc degeneration at the adjacent levels.

STUDY DESIGN: This study reviewed 62 consecutive patients with chronic disabling low back pain who were treated with disc excision and posterior lumbar interbody fusion. Outcomes of treatment results were evaluated by a follow-up evaluation. OBJECTIVE: To evaluate the efficacy of the surgical treatment of patients with chronic disabling low back pain resulting from internal disc derangements that does not respond to nonoperative treatments. SUMMARY OF BACKGROUND DATA: Chronic and disabling low back pain that persists for more than 6 months and does not respond to all known modalities of nonoperative treatment represents a difficult problem. No sufficient information exists in the literature regarding the efficacy of any specific treatment method for this group of patients. METHODS: During a 7-year period between 1984 and 1990, 62 consecutive patients were treated with disc excision and posterior lumbar interbody fusion. The clinical outcomes were evaluated by postoperative follow-up questionnaire, and the fusion result was evaluated by x-ray studies of the lumbosacral spine. RESULTS: Approximately 87% of the 62 patients responded properly to the follow-up evaluation. Eighty-nine percent of the patients had satisfactory results, 93% returned to work, and a successful fusion was obtained in 94% of the patients.

To provide guidance to clinicians about best preventive and therapeutic practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each form of acute altitude illness that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2010 and subsequently updated as the WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness in 2014.

The PRECICE(®) Intramedullary Limb Lengthening System (Ellipse Technologies Inc., CA, USA) is a remotely controlled, magnetically driven, implantable limb lengthening intramedullary nail system. It has both CE mark and US FDA clearance for its first- (2011) and second-generation (2013) implants. It is indicated for the treatment of limb length discrepancy and short stature. It has been used worldwide in over 1000 cases. Its reported and published results in over 250 cases has been excellent with less pain and lower complication rates than with external fixation methods or previous implantable nail systems.

Thrombotic complications of vascular disease are the leading cause of morbidity and mortality in most industrialized countries. Despite this, safe and effective drugs targeting these complications are limited, especially in the chronic setting. This is because of the complexity of thrombosis in both arteries and veins, which is becoming increasingly evident as numerous factors are now known to affect the fate of a forming thrombus. To fully characterize thrombus formation in these settings, in vivo models are necessary to study the various components and intricate interactions that are involved. Genetic manipulations in mice are greatly facilitating the dissection of relevant pro- and antithrombotic influences. Standardized models for the study of thrombosis in mice as well as evolving techniques that allow imaging of molecular events during thrombus formation are now available. This review will highlight some of the recent developments in the field of thrombosis using mouse models and how these studies are expanding our knowledge of thrombotic disease.

STUDY DESIGN: Seventeen consecutive patients underwent laparoscopic instrumented interbody fusions using custom-designed delivery instrumentation and "BAK" fusion cages; both are manufactured by Spinetech and the former was developed by the authors. The cases were performed at two spine centers under Food and Drug Administration investigational device evaluation clinical trials. OBJECTIVES: We expect this approach will maintain a high fusion rate with diminished hospitalization time, recovery time, patient discomfort, and expense. The rehabilitative aspects of the procedure are a great improvement over traditional fusion approaches. SUMMARY AND BACKGROUND DATA: Extraordinary advances in many endoscopic surgical fields have resulted in many endoscopic surgical fields have resulted in lowered morbidity, expense, and suffering associated with their open surgery counterparts. The authors have developed prototype of delivery instruments for the current laparoscopic fusion cage delivery system. METHODS: The procedure is performed transperitoneally with carbon dioxide insufflation to enable video-assisted visualization through a 10-mm endoscope. Three 10-mm incisions and one 13- to 20-mm incision are required for one-level procedures. Two hollow titanium-threaded interbody implants are packed with autologous bone and inserted into the diseased interspace. RESULTS: Seventeen patients, with an average follow-up period of 8 months and a range of 6-12 months, underwent the procedure. There were 14 single-level fusions and three two-level fusions, all involving L4-S1 levels. There were two cases that required conversion to open procedures without sequelae; two patients had remote donor site wound infections eradicated with incision and drainage and antibiotics, and one patient required subsequent posterior spinal decompression because of a displaced endplate fracture. Average hospital stay was an average of 2 days, excluding two patients with complications and very prolonged stay. CONCLUSIONS: Although this procedure is associated with a long learning curve, the technique, once mastered, is effective and advantageous over current approaches to lumbar fusion. Operative time and hospital stay are expected to decrease with future instrumentation development and surgeon experience.

Polysaccharide-K (polysaccharide-Kureha; PSK), also known as krestin, is a unique protein-bound polysaccharide, which has been used as a chemoimmunotherapy agent in the treatment of cancer in Asia for over 30 years. PSK and Polysaccharopeptide (PSP) are both protein-bound polysaccharides which are derived from the CM-101 and COV-1 strains of the fungus Coriolus versicolor by Japanese and Chinese researchers, respectively. Both polysaccharide preparations have documented anticancer activity in vitro, in vivo and in human clinical trials, though PSK has been researched longer and has therefore undergone more thorough laboratory, animal and clinical testing. Several randomized clinical trials have demonstrated that PSK has great potential as an adjuvant cancer therapy agent, with positive results seen in the adjuvant treatment of gastric, esophageal, colorectal, breast and lung cancers. These studies have suggested the efficacy of PSK as an immunotherapy or biological response modifier (BRM). BRMs potentially have the ability to improve the "host versus tumor response," thereby increasing the ability of the host to defend itself from tumor progression. The mechanisms of biological response modification by PSK have yet to be clearly and completely elucidated. Some studies suggest that PSK may act to increase leukocyte activation and response through up-regulation of key cytokines. Indeed, natural killer (NK) and lymphocyte-activated killer (LAK) cell activation has been demonstrated in vivo and in vitro, and recent genetic studies reveal increased expression of key immune cytokines in response to treatment with PSK. An antimetastatic action of PSK has also been demonstrated and is perhaps attributed to its potential to inhibit metalloproteinases and other enzymes involved in metastatic activity. PSK has also been shown to cause differentiation of leukemic cells in vitro, and this effect has been attributed to induction of differentiation cytokines. PSK has further been shown to have antioxidant capacity which may allow it to play a role as a normal tissue chemo- and radio-protector when used in combination with adjuvant or definitive chemotherapy and/or radiotherapy in the treatment of cancer, while it may also enable it to defend the host from oxidative stress. Interestingly, studies have also shown that PSK may actually inhibit carcinogenesis by inhibiting the action of various carcinogens on vulnerable cell lines. This action of PSK may play a role in preventing second primary tumors when an inducing agent, such as tobacco or asbestos, is suspected and may also prevent second malignancies due to the carcinogenic effects of radiotherapy and cytotoxic chemotherapy. Another very important aspect of chemoimmunotherapy, in general is that it may be used on debilitated patients such as those with AIDS and the elderly who might otherwise be denied potentially helpful adjuvant cytotoxic chemotherapy. Further determination of the mechanisms of these anti-cancer, immunostimulating and biological response modifying effects of PSK as well as of other protein-bound polysaccharides is certainly warranted. Indeed, with modern cellular and molecular biology techniques, a better understanding of the specific molecular effects of PSK on tumor cells as well as leukocytes may be determined. Much of the research that has been done on PSK is outlined in this paper and may serve as a foundation toward determining the mechanisms of action of this and other protein-bound polysaccharides in the treatment of cancer. This information may open new doors in the development of novel strategies for the treatment of malignancies using adjuvant immunotherapy in combination with surgery, chemotherapy and/or radiotherapy.

alpha-Fetoprotein (AFP) is frequently used as a diagnostic marker for hepatocellular carcinoma (HCC). Most available data concerning AFP come from studies of patients with chronic hepatitis B or other chronic liver diseases of mixed etiologies. Limited data concerning the diagnostic value of AFP for hepatitis C virus (HCV)-related HCC have to date come only from Asian and European studies, and results are conflicting. There may be significant differences in AFP levels depending on racial backgrounds and etiologies of primary liver disease. We conducted a multicenter, retrospective, case-control study of 163 HCC patients with HCV infection and 149 control patients with HCV-related cirrhosis. The positive likelihood ratios for AFP at 0 to 20, 21 to 50, 51 to 100, and 101 to 200 ng/mL were 0.46, 1.31, 1.15, and 6.90, respectively. No controls had AFP greater than 200 ng/mL. The sensitivity of AFP for the diagnosis of HCC in African Americans with HCV infection was lower than that of patients of all other ethnic groups combined (57.1% vs. 81.6% for AFP > 10 ng/mL, P =.02, and 42.9% vs. 66.0% for AFP > 20 ng/mL, P =.05). The area under the receiver operating characteristics curve was 0.81 for non-African Americans but only 0.56 for African Americans. In conclusion, AFP greater than 200 ng/mL can be used to confirm HCC in patients with HCV-related cirrhosis and a hepatic mass. However, AFP is insensitive for the diagnosis of HCC in African Americans.

STUDY DESIGN: A retrospective review of prospective data of all patients undergoing extreme lateral interbody fusion (XLIF) for degenerative disease of the lumbar and thoracic spine. OBJECTIVES: To compare between obese and nonobese patients, the incidence of early complications and predictive factors affecting complication rate. SUMMARY OF BACKGROUND DATA: XLIF is a 90-degree off midline approach that allows for large graft placement, excellent disk height restoration, and indirect decompression at the stenotic motion segment. As the psoas muscle is traversed, the lumbosacral plexus is protected by the use of automated electrophysiology through dynamic discrete evoked electromyogram thresholding. Exposure is achieved with an expandable split-blade retractor, which allows for direct illuminated visualization facilitating discectomy and complete anterior column stabilization by using a large load-bearing implant that rests on the dense ring apophysis bilaterally. METHODS: A retrospective chart review of a prospectively compiled database of all patients treated with the XLIF procedure between October 2006 and July 2008 was completed. Early complications were defined as any adverse events occurring within the first 3 months of the index procedure. The National Institute of Health Guidelines for defining obesity relating to body mass index were used. RESULTS: Out of 432 patients, 313 have complete data: 156 obese, 157 nonobese. The ages, comorbidities, earlier surgeries, and diagnoses were equivalent. There were no transfusions and no infections. Complications were minimal and about the same in each group. CONCLUSIONS: Unlike traditional open lumbar fusion procedures, minimally invasive surgery (XLIF) has no greater risk of complication in the obese patient.

This randomized clinical trial evaluated the efficacy of injections of a dextrose-glycerine-phenol connective tissue proliferant into the posterior ligaments, fascia, and joint capsules to treat chronic low back pain. Seventy-nine patients with chronic low back pain that had failed to respond to previous conservative care were randomly assigned to receive a double-blind series of six injections at weekly intervals of either Xylocaine/saline solution or Xylocaine/proliferant into the posterior sacroiliac and interspinous ligaments, fascia, and joint capsules of the low back from L4 to the sacrum. Patients were observed with a visual analog, disability, and pain grid scores, and with objective computerized triaxial tests of lumbar function for 6 months following conclusion of injections. Pretreatment imaging tests with either magnetic resonance imaging (MRI) or computed tomography (CT) scans were performed in all patients. Thirty of the 39 patients randomly assigned to the proliferant group achieved a 50% or greater diminution in pain or disability scores at 6 months compared to 21 of 40 in the group receiving lidocaine (p = 0.042). Subjective parameters measured at 6 months posttreatment improved (p < 0.001) overall in both the treatment and control group compared to baseline. Improvements in visual analog (p = 0.056), disability (p = 0.068), and pain grid scores (p = 0.025) were greater in the proliferant group. Objective testing of range of motion, isometric strength, and velocity of movement showed significant improvements in both groups following treatment but did not favor either group. The MRI and CT scans showed significant abnormalities in both groups, but these did not correlate with subjective complaints and were not predictive of response to treatment.

In degenerative lumbar spine disease, recent studies have supported the clinical usefulness of discography, especially when used with computed tomography (CT) scanning. The role and capabilities of magnetic resonance imaging (MRI) scanning are currently evolving and being defined. This study reviews a series of patients with prolonged disabling symptoms who had normal MRI scans and abnormal discography. Discograms and discogram-CT scans may at times allow detection of clinically correlative and significant pathology (usually annular disruptions) not suggested by MRI scanning. This fact should be considered in patients with normal MRI scanning and continuing unexplained symptomatology.

One hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years. Eighty-four per cent of the knees were affected by osteoarthrosis. Graded according to the knee-rating system of the Hospital for Special Surgery, there were eighteen excellent, fifty-three good, eighteen fair, and eleven poor results. At the most recent follow-up, twenty-nine knees (29 per cent), nine of which were affected by rheumatoid arthritis, were still painful in the patellofemoral area. The height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively. Small patients who had osteoarthrosis were exceptionally free of pain, regardless of sex, age, or level of activity. It seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain, are more than 160 centimeters tall, weigh more than sixty kilograms, and have advanced changes in the patella at the time of the operation.

X-STOP is the first interspinous process decompression device that was shown to be superior to nonoperative therapy in patients with neurogenic intermittent claudication secondary to spinal stenosis in the multicenter randomized study at 1 and 2 years. We present 4-year follow-up data on the X-STOP patients. Patient records were screened to identify potentially eligible subjects who underwent X-STOP implantation as part of the FDA clinical trial. The inclusion criteria for the trial were age of at least 50 years, leg, buttock, or groin pain with or without back pain relieved during flexion, being able to walk at least 50 feet and sit for at least 50 minutes. The exclusion criteria were fixed motor deficit, cauda equina syndrome, previous lumbar surgery or spondylolisthesis greater than grade I at the affected level. Eighteen X-STOP subjects participated in the study. The average follow-up was 51 months and the average age was 67 years. Twelve patients had the X-STOP implanted at either L3-4 or L4-5 levels. Six patients had the X-STOP implanted at both L3-4 and L4-5 levels. Six patients had a grade I spondylolisthesis. The mean preoperative Oswestry score was 45. The mean postoperative Oswestry score was 15. The mean improvement score was 29. Using a 15-point improvement from baseline Oswestry Disability Index score as a success criterion, 14 out of 18 patients (78%) had successful outcomes. Our results have demonstrated that the success rate in the X-STOP interspinous process decompression group was 78% at an average of 4.2 years postoperatively and are consistent with 2-year results reported by Zucherman et al previously and those reported by Lee et al. Our results suggest that intermediate-term outcomes of X-STOP surgery are stable over time as measured by the Oswestry Disability Index.