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PubMed1985

[Superior facet syndrome--findings on metrizamide CT myelography].

Sciatica caused by root entrapment in the lateral recess was named superior facet syndrome by Epstein in 1972. Few reports on this subject based on large numbers of cases have been documented to date. Of the patients with sciatica, 32 patients were diagnosed to have root entrapment at the lateral recess L5 or/and S1 lumbar spine. Out of 32 patients, 20 patients were operated on and the lateral entrapment was recognized in all of surgical cases. Neuroradiological findings, especially of metrizamide CT (met. CT), were documented in detail. Thirty two patients were classified in three types according to radiological findings. They were congenital or developmental, degenerative, and combined type, respectively, Fourteen cases belonged to the congenital type, 13 to the degenerative and 5 to the combined type. Each group had the mean ages of 23.4, 53.8, and 36.8 years old, respectively. Of 32 cases the entrapment occurred in 47 L5 roots and 11 S1 roots. There was no remarkable laterality. In operation the unroofing of the lateral recess were done and the sciatica subsided postoperatively in all of surgical cases. Met. CT revealed extreme medial protrusion of the superior articular joint in 18 of 24 cases (75%) and none filling of the root in the lateral recess in 21 of 24 cases (87.5%). In the degenerative type, met. CT showed some degenerative changes that were hypertrophy or deformity of the articular joints and spur formation of the vertebral body.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1984

[Lumbosciatica caused by spondylolisthesis. Results of the surgical treatment by facetolaminectomy and interbody arthrodesis by the posterior approach in a series of 66 cases].

66 patients with spondylolisthesis were reviewed after surgical procedure with a follow-up period of more than a year postoperatively. The indication for the operation was disabling sciatica in all patients. 4 patients had undergone prior excision of the herniated disc. All the patients underwent a removal of the loose posterior element as suggested by the Gill procedure and intervertebral body fusion using a posterior surgical approach. The surgical procedures with only one regressive neurological complication are described. The results are considered from a clinical and anatomo-radiological point of view. In this series 86.5 percent of 66 patients became sciatica-free. 62 percent of the total series rated the end result as excellent or good. 92.4 percent of the patients demonstrated bony fusion between the two grafted vertebrae. The benefits of posterior laminectomy with interbody fusion are also attractive for spondylolisthesis with sciatica.

Adolescent↗

PubMed1993

[Nociceptive flexion reflex of the leg. Use after surgical treatment of herniated disk].

In patients suffering from acute sciatica due to herniated disk Lasegue's manoeuvre inhibits the leg flexion nociceptive reflex (RIII reflex) in either the ipsilateral or the contralateral limb. This is thought to be due what is called "diffuse noxious inhibitor control" modulating the activity of a group of convergent spinal neurons. The purpose of this study was to determine whether surgical resection of the herniated disk in patients suffering from sciatica might relieve this so-called "counter-irritation". Among 10 patients whose sciatica resulted from herniated disk, the decrease in amplitude of the RIII response observed when Lasegue's manoeuvre is applied disappeared in 7 patients, 6 to 8 days after surgical resection of the herniated disk. These results suggest that this test might be a useful tool for postoperative prediction of radicular compression.

Adult↗

PubMed1997

Sciatic pain and piriformis syndrome.

Between 70% and 80% of the population of the world experience low back pain at some time during their lives. A subgroup of patients who experience back pain also experience sciatic pain as well, with a majority of these patients seeking evaluation from their primary care clinician. One relatively new differential diagnosis to be considered when evaluating the patient with sciatica is piriformis syndrome. Piriformis syndrome has been documented for more than 50 years. Yet its diagnosis still remains confusing at times. Using a case study for the purpose of illustration, this article outlines signs and symptoms of sciatica, as well as differential diagnoses to be considered when examining a patient with sciatica. Piriformis syndrome, diagnostic tests to be performed, treatment, education, and follow-up of the patient with piriformis syndrome are all discussed in detail. Finally, implications for primary care clinicians are presented.

Adult↗

PubMed1998

Manipulative therapy in lower back pain with leg pain and neurological deficit.

OBJECTIVE: To discuss a case of sciatica associated with lower back pain that originates in a disc. We discuss the use of manipulative therapy as a conservative approach and compare it with other conservative methods and with surgery. CLINICAL FEATURES: The patient suffered from lower back and left leg pain that had increased in severity over a 6-day period. There was decreased sensation in the dorsum of the left foot and toes. Computed tomography demonstrated the presence of a small, contained disc herniation. INTERVENTION AND OUTCOME: The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care. CONCLUSION: We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.

Chiropractic↗

PubMed1998

Long-term outcome of patients suffering from clinical instability after microsurgical treatment of lumbar disc herniation.

A total of 39 patients suffering from clinical instability of the lumbar spine after microdiscectomy were evaluated for their long-term outcome. Included there were 21 (54%) male and 18 (46%) female patients with a mean age of 55 years. All had been operated on for a virgin single-level lumbar disc herniation between the years 1985-1989 and they were evaluated for the presence of lumbar instability in 1991. Clinical signs and symptoms of segmental instability were then detected in all patients, with the symptom of "apprehension" positive in 30. During the follow-up, 2 (5%) patients had been treated by lumbar spondylodesis. At the time of the present investigation, both of them gave the information that their low back pain and sciatica had diminished as compared to the prediscectomy situation; both were retired. The symptom of "apprehension" was negative in both. Of the remaining 37 patients, low back pain had completely recovered in 4 (11%) and diminished in 23 (62%) patients, while in 9 (24%) patients, back pain had remained unchanged and become worse in 1 (3%). Further, sciatica had completely recovered in 4 (11%) and diminished in 23 (62%) patients, while in 7 (19%) patients, sciatica had remained unchanged and become worse in 3 (8%). Only 14 (38%) of these patients were able to work. However, evaluated by the Oswestry Index, the overall outcome in daily activities had significantly improved in all 37 patients since 1991 (p = 0.01). The symptom of "apprehension" was now positive in 26 patients. A significant correlation was observed between the positivity of this test and the persistence of low back pain (p = 0.02) and a poor outcome in daily activities (p < 0.0001). Comfirming earlier observations, the findings of this study support the concept that patients with postoperative lumbar instability have a poor prognosis. Further studies are needed to define the optimal treatment for this problematic patient group.

Adult↗

PubMedDate not supplied

How emergency physicians approach low back pain: choosing costly options.

To determine ways in which emergency physicians approach the diagnosis and treatment of the common presenting complaint of low back pain, responses of emergency physicians to a questionnaire dealing with three hypothetical patients with different types of low back pain were taken from a stratified national random sample of eight medical specialties. For severe acute (with and without sciatica) or chronic low back pain, physicians were asked which tests and consultants they would use in pursuit of the diagnosis, and which treatments and specialty referrals they would recommend in each of the three scenarios. For diagnosis in the acute cases (pain less than 1 week), up to 22% of emergency physicians recommended computed tomography (CT scan) and 36% recommended magnetic resonance imaging (MRI). Specialist consultation would be sought for 61% of the acute sciatica patients, 32% of the acute nonsciatica patients, and 47% of the chronic patients. In approaching treatment, over 75% of emergency physicians would advise bedrest for an average of 3.5 to 4.5 days. Between 16% and 40% suggested physical therapy for the acute patients. Referrals to surgical specialists (orthopedist or neurosurgeon) were highest (81%) for acute sciatica, compared with 52% for chronic low back pain, and 41% for acute nonsciatic low back pain. In conclusion, given that most cases of acute low back pain resolve with minimal intervention, diagnostic imaging, laboratory testing, and early specialist consultation favored by many emergency physicians would add little except expense to understanding its etiology. For treatment, emergency physician recommendations for bedrest were longer than necessary and, for physical therapy, of no proven benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed2001

Low levels of nitric oxide (NO) in systemic sclerosis: inducible NO synthase production is decreased in cultured peripheral blood monocyte/macrophage cells.

OBJECTIVE: To investigate nitric oxide (NO) production and inducible NO synthase expression by cultured peripheral blood mononuclear cells (PBMC) in patients with systemic sclerosis (SSc). METHODS: Eighteen patients with SSc were compared with two control groups: 16 patients with rheumatoid arthritis (RA) and 23 patients with mechanical sciatica. Nitrate was determined by fluorimetry in plasma and by spectrophotometry in supernatants. Inducible NO synthase (iNOS) was detected in cultured PBMC by immunofluorescence, immunoblotting and flow cytometry with or without treatment of the cells with interleukin (IL) 1beta+ tumour necrosis factor alpha (TNF-alpha), IL-4 or interferon gamma (IFN-gamma) from day 1 to day 5. RESULTS: NO metabolite concentrations were lower in SSc patients (mean+/-s.e.m. 34.3+/-2.63 micromol/l) than in RA (48.3+/-2.82 micromol/l; P<0.02) and sciatica (43.3+/-5.24 micromol/l; P<0.03) patients. iNOS was detected in cultured monocytes in all three groups but induction occurred on day 1 in RA, day 2 in sciatica and only on day 3 in SSc, whatever the stimulus. CONCLUSIONS: The concentrations of NO metabolites are decreased in SSc patients and the metabolism of these compounds in PBMC is altered. Low levels of NO, a vasodilator, may be involved in vasospasm, which is critical in SSc. This may have therapeutic implications.

Adult↗

PubMed2003

Correlation of low back pain with functional status, general health perception, social participation, subjective happiness, and patient satisfaction.

STUDY DESIGN: A cross-sectional and epidemiologic study investigated low back pain. OBJECTIVE: To assess the correlation among outcome measures for low back pain, including sciatica, according to a proposed low back pain-related model. SUMMARY OF BACKGROUND DATA: Various outcome measures are used in low back pain research: pain, functional status, generic health status, and patient satisfaction. Correlation among these measures has been unclear. METHODS: For this study, 816 subjects (369 men and 447 women; average age, 62 years) who underwent an adult medical examination. The patients were interviewed concerning their personal background, severity of low back pain and sciatica, functional status, general health perception, social participation, subjective happiness, and patient satisfaction. The correlation among these measures was analyzed systematically using path analysis based on a low back pain-related model hypothesizing that low back pain and sciatica worsen functional status and general health perception and then affect social participation, subjective happiness, and patient satisfaction. RESULTS: Restriction of functional status was found to be the most closely correlated with severity of low back pain. A decrease in physical health was most closely correlated with restriction of function. Social participation, subjective happiness, and patient satisfaction were closely correlated with physical health status. There was a significant correlation among outcome measures concerning physical health, which was consistent with a low back pain-related model. CONCLUSIONS: The outcome measures concerning physical health in this study were found to be correlated significantly, consistent with the proposed low back pain-related model.

Adult↗

PubMed1992

Low back pain and disability in 14-year-old schoolchildren.

In this cross-sectional prevalence study in 1503 14-year-old Finnish schoolchildren (n = 1503) low back pain was found to be the third most common form of pain interfering with schoolwork or leisure time during the past 12 months. The lifetime cumulative incidence of low back pain was 30% and that of sciatica 1.8%. Of the 417 pupils who had experienced low back pain at some time, 39% had suffered during the past month; 65% recovered in one month from the last pain episode, while 35.2% of those reporting disabling low back pain during the past year were aware of recurrent or continual pain. Thus, 7.8% (n = 107) of the whole population could be classified as "low back pain chronics": 86% of the low back pain chronics had trouble with at least one of the daily activities listed, most commonly with sitting at school. Excluding pain in the extremities or sciatica, girls reported various pains more commonly than boys. Moreover, girls reporting recurrent low back pain had more trouble with their daily activities due to pain than boys (p < 0.001), even though the recovery from the last pain episode took the same time in boys and girls. The pupils who had had sciatica at some time, in addition to recurrent low back pain, had more trouble with the 10 daily activities than others with recurrent low back pain (p = 0.014).

Activities of Daily Living↗

PubMed2006

Cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in the treatment of lumbar disc herniation: a prospective randomised controlled trial [ISRCTN51857546].

BACKGROUND: Open discectomy is the standard surgical procedure in the treatment of patients with long-lasting sciatica caused by lumbar disc herniation. Minimally invasive approaches such as microendoscopic discectomy have gained attention in recent years. Reduced tissue trauma allows early ambulation, short hospital stay and quick resumption of daily activities. A comparative cost-effectiveness study has not been performed yet. We present the design of a randomised controlled trial on cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in patients with lumbar disc herniation. METHODS/DESIGN: Patients (age 18-70 years) presenting with sciatica due to lumbar disc herniation lasting more than 6-8 weeks are included. Patients with disc herniation larger than 1/3 of the spinal canal diameter, or disc herniation less than 1/3 of the spinal canal diameter with concomitant lateral recess stenosis or sequestration, are eliglible for participation. Randomisation into microendoscopic discectomy or conventional unilateral transflaval discectomy will take place in the operating room after induction of anesthesia. The length of skin incision is equal in both groups. The primary outcome measure is the functional assessment of the patient, measured by the Roland Disability Questionnaire for Sciatica, at 8 weeks and 1 year after surgery. We will also evaluate several other outcome parameters, including perceived recovery, leg and back pain, incidence of re-operations, complications, serum creatine kinase, quality of life, medical consumption, absenteeism and costs. The study is a randomised prospective multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 2 years. DISCUSSION: Currently, open discectomy is the golden standard in the surgical treatment of lumbar disc herniation. Whether microendoscopic discectomy is more cost-effective than unilateral transflaval discectomy has to be determined by this trial.

Adult↗

PubMedDate not supplied

[Percutaneous automated lumbar nucleotomy].

The results of percutaneous automated lumbar nucleotomy in the treatment of lumbar disc herniation were assessed in a series of 39 patients. The technique consists of mechanical decompression of the herniated intervertebral disc without total excision. Only one-space discs were treated by this method. Sciatica was the predominant clinical symptom in 30 cases, and lumbar pain in 9 cases. Good to very good results were obtained in 70% of patients with sciatica and in 55% of patients with lumbar pain. After 4 cases of nucleotomy performed after failure of nucleolysis were excluded, the proportion of very good results rose to 77% in sciatica. Conversely, it seems that a number of failed nucleotomies can be treated by nucleolysis. Nucleotomy is very well tolerated and deserves to be used as first-line treatment of single and radiologically well documented lumbar disc herniations.

Adult↗

PubMed1989

[The surgical treatment of lumbar canal stenosis].

In a retrospective study of the results, 2 and 4 years after operation, of 52 cases of narrow lumbar canal, the most frequent preoperative symptoms were low back pain (82.7%), neurogenic claudication (61.5%) and sciatica (61.5%). 21 patients had a herniated disk in addition to the narrow canal. Sciatica was more frequent in this group than in narrow lumbar canal alone, where neurogenic claudication was more frequent. All patients underwent decompressive laminectomy, most often at level L4-L5. No spondylodesis was required. After 4.9 months, 84% of the patients were improved or cured. After more than 2 years 90% of the patients were cured of low back pain and 92% were cured of sciatica, but 22% were still under limitation in walking.

Adult↗

PubMed1993

[Herniation of a lumbar disk in the elderly. Results of chemonucleolysis].

The purpose of this study was to evaluate the outcome after chymopapain chemonucleolysis in elderly patients with low back pain and sciatica due to lumbar disc herniation without concomitant stenosis, unresponsive to conservative therapy. In the 42 study patients, aged 60 years or older, clinical manifestations were similar to those usually seen in younger patients. Evidence of nerve root tension, including a positive straight-leg raising test seen in 67% of our patients, proved valuable for outruling sciatica due to bony impingement. Outcome was favorable in 78% of cases after a mean follow-up of 2.5 years. This findings is consistent with previous studies performed without age restrictions. Chemonucleolysis had no adverse effects. Despite the biochemical changes which occur in the aging disc, chemonucleolysis is an effective tool for the treatment of sciatica due to disc herniation in elderly patients.

Aged↗

PubMed2006

Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.

CONTEXT: Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial. OBJECTIVE: To assess the efficacy of surgery for lumbar intervertebral disk herniation. DESIGN, SETTING, AND PATIENTS: The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks. INTERVENTIONS: Standard open diskectomy vs nonoperative treatment individualized to the patient. MAIN OUTCOME MEASURES: Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status. RESULTS: Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes. CONCLUSIONS: Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000410.

Adult↗

PubMed2005

Hepatitis C virus infection in psoriatic arthritis.

OBJECTIVE: To evaluate the prevalence of hepatitis C virus (HCV) infection in patients with psoriatic arthritis (PsA), compared with patients affected by non HCV-related rheumatic degenerative disorders. METHODS: One-hundred consecutive subjects with PsA, and a statistically comparable group of 100 consecutive patients with peripheral osteoarthritis (OA) or sciatica due to L4-L5 or L5-S1 herniated disc were tested for HCV infection with a third-generation microparticle enzyme immunoassay (MEIA). Positive cases were submitted to a third-generation recombinant immunoblot assay (RIBA) confirmatory test. Comparison between the HCV prevalence obtained in the 2 enrolled groups was performed using Fisher's exact test. RESULTS: Anti-HCV antibodies were found with the MEIA method, in 1 patient with PsA, and in 4 patients with OA or sciatica. The RIBA method confirmed MEIA results in all positive patients. The difference in HCV prevalence detected in the PsA group and in the control group was not statistically significant (P = 0.68). Furthermore, HCV prevalence in PsA patients was lower than the ones reported in different geographic areas of Italy. CONCLUSION: Our present report does not confirm previous data that indicated an increased prevalence of HCV in PsA patients, and as a consequence, does not sustain a possible trigger role of HCV in cases of PsA. The absence of clinical or instrumental resources that consent a definite differential diagnosis between PsA and HCV-related arthritis was outlined and analyzed.

Arthritis, Psoriatic↗

PubMed1985

Autotraction in lumbar disc herniation. A myelographic study before and after treatment.

Autotraction is a method of diminishing lower back pain and sciatica in which the patient stretches himself on a specially designed traction table. The pulling force ranges between 400-800 N. Clinical results are encouraging and the method can be recommended as a temporary treatment especially in lumbago with sciatica. The influence on a herniated disc is discussed with respect to the suggestion that autotraction will diminish the herniation. In this study myelographic examination revealed that herniation was the same in location and size before and after autotraction. However, there was a marked clinical improvement in all patients but one.

Adult↗

PubMed2001

[MRI diagnosis of intervertebral disk disease].

Magnetic resonance imaging (MRI) is the leading diagnostic procedure for disk pathology and has overtaken other imaging modalities in frequency of use. However, one must be cautious not to overinterpret small abnormalities that are also frequent in asymptomatic subjects. There is conflicting evidence about the correlation of high-intensity zones with clinical symptoms. Bulging disks and protrusions are a common finding in asymptomatic individuals, whilst extrusions are almost always accompanied by back pain and sciatica. In patients with back pain or sciatica, MRI is indicated after failure of conservative management or neurological deterioration. Contrast-enhanced MRI is well suited to differentiate a recurrent disk extrusion from epidural fibrosis. In all cases suspicious of tumor or infection, MRI is indicated as a first-line investigation. The indications and pitfalls of the state of the art of MRI are delineated in this article.

Adolescent↗