BACKGROUND: It is often difficult to determine the cause of low back pain (LBP) in the patients with lumbar disc herniation. The herniated disc has long been thought to be an important cause of the patient's complaint about LBP and sciatica. Whether the adjacent degenerative disc results in LBP needs further confirmations. OBJECTIVE: This study sought to determine whether the degenerative disc adjacent to the herniated disc in patients with LBP and radicular pain can result in discogenic LBP, as assessed by provocative discography, and to report the outcomes of the residual LBP when adjacent symptomatic disc were treated with methylene blue after microendoscopic discectomy. METHODS: Twenty lumbar disc herniation patients complaint about LBP and radicular pain underwent provocative discography. There was one degenerative herniated disc with one or more adjacent degenerative discs in their MRI. Provocative discography was performed on all degenerative discs and at least one normal disc for control. The severity of LBP and leg pain of all patients was assessed using visual analog scale before discography. All patients underwent microendoscopic discectomy at herniated level, and intradiscal injection of methylene blue was given at painful adjacent level in five patients after microendoscopic discectomy. RESULTS AND CONCLUSION: Discographies were performed on 64 discs of 20 patients, from L2-3 to L5-S1. There were 11 discs satisfying the positive response criteria, including 6 in degenerative segment adjacent to the herniated disc and 5 in the herniated disc that induced corresponding radiculopathy. The leg pains were evidently improved in all patients, while LBP was partially improved after microendoscopic discectomy. Six patients with symptomatic adjacent degenerative disc still had evident LBP, influencing their daily living. Five of them received intradiscal injection of methylene blue treatment and the LBP was relived. One patient refusing to the treatment still complained the LBP. Results evidenced that accompanying LBP for many LDH patients may come from the degenerative levels adjacent to the herniated disc.

Objective To analyze the causes of the complications of one-stage surgical management for spinal tuberculosis and its countermeasures.Methods From May 1997 to December 2008,116 patients with spinal tuberculosis underwent operations.Among them,6 were in cervical vertebra,3 in cervicothoracie vertebra,29 in thoracic vertebra,37 in thoracolumbar vertebra.29 in lumbar vertebra and 12 in hmbrosacrum vertebra.All cases underwent the anterior and/or radical debridement,decompression,autogenous bone grafting or radical debridement,decompression,autogenous bone grafting and internal fixation.The causes of the complications of surgical management and the countermeasures were analyzed.Results One hundred and ehven cases were followed upfor an average of(3.86±2.16)years(range 6 months to 12 years).The rate of complication was 13.5%(15/111).Recurrent spinal tuberculosis occarred in 5 cases,internal fixation loosened in 1 case,rupture of the external iliac vein occurred in 2 cases,lateral ventral syndrome in 1 case,venous embolism of the lower extremity in 1 csse,reactional psychosis in 2 cases,pneumatothorax in 2 cases and femoral nerve irritating syndrome in 1 case.Among the recurrent cages,2cases with anterior debridement and 2 cases with posterior debridement underwent anterior operation again andgot good results, 1 case with anterior debridement gave up the reoperafion.Other cases relieved after conservative therapy.Conclusions Standardized anti-tuberculosis thempy is fundamental for preventing the recurrence of tuberculosis.Correct approach for the operation and thorough radical debddement are the key points for preventing the recurrence of tuberculosis.Good and effective therapy surround the operation is helpful for preventing the recurrence of tuberculosis.

[Objective]This study was designed to construct a recombinant adenovirus vector contains LMP-1 gene,and investigate the osteoinductive activity of MSC which were transfected recombinated adenoviral vector carrying LMP-1 gene.[Methods]Total RNA was extracted from mt osteoblast and the LMP-1 gene was acquired by RT-PCR,the LMP-1 gene and entry vector pENTR/D-TOPO were used to create the entry clone with the directional TOPO clone technology,then the entry clone and the expression vector were used to create the expression clone throush the LR recombination reaction.The adenovirus expression clone was linearized by PacI and transfected to the 293A cell line to harvest a high titer.Ad-LMP-1 was infected into the 3rd passage MSC,the expression of LMP-1 was detected by Western blot.The osteogenic activity of MSC was evaluated by the expression of collagen Ⅰ,ALP,osteocalcin and the formation of bone nodule.[Result]The LMP-1 gene was successfully acquired and confirmed,the entry clone and the expression clone were both verified by enzymes digestion,and the expression clone was further confirmed by sequenced.The expression of LMP-1 was detected successfully in MSC.The increasing expression of collagen Ⅰ,osteocalcin.ALP and bone nodule were observed by comparing to the control group.[Conclusion]Gateway technology not only make construction of the pAd-LMP-1 recombination adenovirus vector simple and fast,but also get a high transfection efficacy in MSC.LMP-1 gene can induce the osteoblast differention of MSCs,and improve its osteogenic activity.The adenovirus vector is reliable to be used in further gene therapy research.

Objective To study the incidence and prognosis of avascular necrosis after talus fracture. Methods A retrospective survey was performed in 12 patients ( 13 feet) with talus fractures admitted into hospital from July 2004 to November 2009 to analyze necrosis rate, ankle function recovery and disability rate. According to Hawkin' s classification system, there were two patients with type Ⅰ feet, four with type Ⅱ feet, five with type Ⅲ feet and two with type Ⅳ feet. Results All patients were followed up for average period of 19.6 months (range 11-52 months). Avascular necrosis was detected in eight feet, of which one foot was treated with ankle fusion, one with subtalar arthrodesis and one with bone implantation. The other five feet had good ankle and subtalar function, with no collapse or osteoarthritis. According to Maryland foot score, the result was excellent in eight patients, good in two, fair in one and failure in two, with excellence rate of 77%. Conclusion The incidence of avascular necrosis after talus fracture is related to the location and energy of trauma. However, the function prognosis of the talus shows no correlation with necrosis.

Objective To explore the indications of anterior and posterior approach operations for unstable thoraco-lumbar fractures coupled with neurologic deficits and prevention of intraoperative and postoperative complications. Methods We investigated 107 consecutive eases of thoraco-lumbar fractures coupled with spinal cord injury who had been operated on from January 2000 to December 2006.Their average age was 37.8(range.17 to 78) years old. They were 71 males and 36 females. Anterior approach was selected for 46 cases and posterior approach for 61 cases according to their McCormack grades. By the Frankle system for neurologie deficits, 7 cases were graded as A,16 as B,39 as C and 45 as D. Fracture height vecoveries before and after surgery were analyzed statistically. Kyphotic deformity was assessed on lateraJ radiographs using the Cobb method. Results The mean follow-up of 97 cases was 2.8(range,0.5 to 6) years. In both groups. All the cases gained at least 1 grade improvement except those with Frankle grade A. The mean kyphotic angles before operation, after operation and at the latest follow-up were 23.7°,10.6°and13.1°respectively, with significant differences(P＜0.01),in the anterior approach group, while 16.3°,8.4°and 11.7°respectively, with significant differences(P＜0.01),in the posterior approach group. Some complications, such as deficit of cutaneous nerve of thigh, appeared in the 2 groups. Conclusions In treatment of unstable thoraco-lumbar fractures coupled with neurologic deficits, the anterior approach may be better than the posterior approach. The posterior approach can be applied for the cases with less than 7 points in McCormack index. Correct selection of operative approach, careful operation and good rehabilitation after operation are necessary for the prevention of complications.

[Objective]To study the intervertebral disc degeneration induced by bilateral zygopophysial joint resection in New Zealand rabbits.[Method]Forty-five New Zealand rabbits were randomly divided into 3 groups:group A,L_(4) and L_(5) inferior articular processes were en bloc excised,L_(5) and L_(6) superior articular processes were retained;its L_(6、7) and L_(3、4) as self-control group B;L_(3) to L_(7) paravertebral muscles were stripped and took L_(4、5),C_(5、6) as control group C.At one,two,four and eight months postoperatively,anterior-posterior and lateral X-ray film abnormal signs,including intervertebral space wedging,osteophyma formation at the edge of vertebral body and cartilage end plate celcification,were examined and counted.[Result]In the group C,cartilage end plate calcification,seldom intervertebral space narrowing,rare osteophyma formation at the edge of vertebral body and no lumbar spinal kyphosis were found in some rabbits.In the group A,cartilage end plate calcification began to found in the early stage on the L_(4、5) and L_(5、6),as time went on to the 8~(th) month postoperatively,almost all rabbits were found intervertebral space narrowing,osteophyma formation of vertebral space narrowing,osteophyma formation of vertebral body and cartilage end plate calcification.Conform kyphosis of L_(5、6) were also occurred at some rabbits.There was significant difference between group A and group C,but no difference with group B.[Conclusion]Radiological changes of L_(5、6) intervetevbral disc degeneration can be induced by excision of L_(5) and L_(6) zygopokhysial joint of rabbit.

[Objective]To study whether intervertebral disk degeneration can be induced by destroying bilateral zygapophysial joints of New-Zealand rabbit.[Method]Thirty male New-Zealand rabbits were randomly divided into operation group on the bone and operation group on the soft tissue.In operation group on the bone,L4 and L5 inferior articular processes were en bloc excised,L5 and L6 superior articular processes were retained.In the operation group on the soft-tissue,Only L3 to L7 paravertebral muscles were stripped.In operation group on the bone,L4、5 and L5、6 intervertebral disks acted as experimental group;L3、4 and L6、7 acted as self-control group.In the operation on the soft tissue,L4、5 and L5、6 acted as experimental control group.One,two,four and eight months post-operation,histological and ultrastructure organizations of intervertebral disks of New-Zealand rabbits were performed.[Result]The normal rabbit discs formed a very complex system,with an outer anulus fibrosus surrounding a central nucleus pulposus in which collagen fibers aligned parallelly and intervertebral disk cells distributed evenly.Collagen fibers derangly aligned and intervertebral disk ceils declined with time post-operation.At the end of four months post-operation,many degenerative cells were found in the study group,which features as irregular cell contours,swelling chondrosome,rough endoplasmic reticulum,and condense nucleus located in the cellular nucleus.Eight months after operation,many dead cells were found.Cytolysosomes increased,cellular nucleus became twisted,rough endoplasmic reticulums swelled,and chondrosome became vacuolization.Dead intervertebral disk cells were located in nidi which were made of multilayer degenerative collagen fibers.[Conclusion]Histological changes of intervertebral disk degeneration can be induced by destroying L4、5 and L5、6 zygapophysial joints of New-Zealand rabbit.

[Objective]To study hIGF-1 gene expression on intervertebral disk degeneration.[Method]Twenty-four male New-Zealand rabbits IVDD models were made according to reference and randomly divided into Ad/CMV-hIGF-1,hIGF-1 growth factor and PBS group.Twenty five microlitre the second generation Ad/CMV-hIGF-1(T=80?109 PFU/L),hIGF-1 growth factor(100 ?g/L)and PBS were respectively injected into L4、5,L5、6 intervertebral disk under fluoroscopic guidance.One,two,four and eight weeks post-operation,rabbits were sacrificed,intervertebral disk samples were harvested.Total proteins of equal mass intervertebral disks were extracted,isolated in SDS-polyacrylamide gel electrophoresis(SDS-PAGE)and transferred to polyvinylidene difluoride(PVDF)Millipore.The hIGF-1 growth factor expression were indentified with Western blot.[Result]The hIGF-1 interest protein existed at 7.6 kilo-Dalton.At one week after injection,its expression quantities were almost equal between Ad/CMV-hIGF-1 and hIGF-1 growth factor group.At two week after injection,it obviously declined in hIGF-1 growth factor group.At four week after injection,it still expressed in Ad/CMV-hIGF-1 group.At eight week after injection,it did not express in three groups.[Conclusion]Ad/CMV-hIGF-1 successfully infects degenerative intervertebral disk.In Ad/CMV-hIGF-1 group,the hIGF-1 gene expression lasts longer than that in hIGF-1 growth factor group.

[Objective]To study the role of hIGF-1 gene on collagen type Ⅱ expression of degenerative intervertebral disk.[Method]Twenty-four male New-Zealand rabbits intervertebral disk degenerontion(IVDD) models were done according to reference and randomly divided into Ad-CMV-hIGF-1,hIGF-1 growth factor and PBS group.Twenty five microlitre the second generation Ad/CMV-hIGF-1(T=80?109 PFU/L),hIGF-1 growth factor(100 ?g/L)and PBS were respectively injected into L4、5,L5、6 intervertebral disk under fluoroscopic guidance.One,two,four and eight weeks post-operation,rabbits were sacrificed,intervertebral disk samples were harvested.Total proteins of equal mass intervertebral disks were extracted,isolated in SDS-Polyacrylamide gel electrophoresis(SDS-PAGE)and transferred to polyvinylidene difluoride(PVDF)Millipore.The hIGF-1 growth factor expression were indentified with Western blot.Collagen type Ⅱ gene fragments were amplified with RT-PCR,and relative expression was done with GAPDH as intern control.[Result]The hIGF-1 interest protein existed at 7.6 Kilo-Dalton.At one week after injection,its expression quantities were almost equal between Ad/CMV-hIGF-1 and hIGF-1 growth factor group.At two week after injection,it obviously declined in hIGF-1 growth factor group.At four week after injection,it still expressed in Ad/CMV-hIGF-1 group.At eight week after injection,it did not express in theree groups.Collagen type Ⅱ mRNA relative expressions increased significantly from one to four weeks after injection,declined slightly at the end of eight weeks in Ad/CMV-hIGF-1 group.However,they appeared to decrease continuously in the other two groups with time.At the corresponding phases,those in PBS group were the lowest.[Conclusion]Ad/CMV-hIGF-1 could successfully infect degenerative intervertebral disk.The hIGF-1gene expression could last four weeks and could stimulate collagen type Ⅱ synthesis in Ad/CMV-hIGF-1 group.

[Objective]To determine whether discectomy resulted in improvement in low back pain(LBP)associated with lumbar disc herniation. [Method]Two hundred and one consecutive single-level lumbar discectomy were followed up,one hundred patients underwent microendoscopic discectomy(MED group) and 101 patients were treated with conventional open discectomy(COP group).Outcomes were assessed using Visual Analog Scale(VAS) and patient satisfaction.The changes in LBP were compared between the MED group and COP group.The effects of severity of low back pain before surgery on the improvement of back and leg pain were also determined.The mean duration of follow-up was 45 months.[Result]The mean VAS leg pain significantly decreased from 70.02?15.80 before operation to 7.73?12.13 at final follow-up.A significant improvement was also noted in LBP,the mean VAS LBP score was 43.61?26.18 before surgery and 16.89?14.73 at the time of final follow-up.The important improvement in LBP and leg pain was seen in 70.1%～78.1% and 97.0% patients respectively.Improvements in back pain and leg pain were correlated(r= 0.1656,P=0.0304).The rate of important improvement of low back pain was greater in MED group than in COP group.The rate of important improvement in LBP was similar in the patients of a preponderance of LBP,a preponderance leg pain and an equivalence of LBP and leg pain,the patients with a preponderance of LBP showed a lower rate of important improvement in leg pain than the others.[Conclusion]Discectomy for relief of sciatica of lumbar disc herniation provides effective relief of LBP.The MED is more likely effective as a surgery way to relief LBP.Furthermore,it certified that the severe LBP maybe a negatively predictive factor for the follow-up outcome of leg pain.