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PubMed1997

Disc protrusion in the child. Particular features and comparison with neoplasms.

Lumbar intervertebral disc herniation, although common in adults, is infrequent in the young, and especially in patients under 17 years old. In this work we review clinical data pertaining to two pediatric groups of patients whose main complaint was low back pain and/or sciatica, trying to identify factors that might contribute to their earlier referral and to the differential diagnosis of protruded disc and spinal neoplasm in this population. Group A comprises 17 youngsters diagnosed as having lumbar herniated nucleus pulposus and group B, 16 children with neoplasms of the lower thoracic and lumbosacral regions. Both groups were similar in sex distribution and symptoms of pain and numbness. However, there was a striking difference in age at presentation. No patient in group A was younger than 11 years, while most of those in group B were in their first decade of life (P = 0.018). The classic clinical onset in the children with herniated discs started with low back pain and sciatica, as in the children with neoplasms, although in subgroup B leg pain tended to be bilateral. The usual examination findings in both groups were spinal rigidity and sensory loss, but motor weakness and impaired reflexes were found to be more frequent in the group with spinal growths (P = 0.02). Children with lumbosacral neoplasms also tended to present with atypical symptoms (acute onset, intracranial hypertension, subarachnoid hemorrhage and abdominal pain), while this was the exception in the group with herniated discs. Plain radiographs of the pediatric spine showed that X-ray examination is still a good tool for diagnosing spinal growths compared with their scant utility in disc herniations (P = 0.001). During the survey we were impressed by the children's apparent good tolerance to pain, which is probably due to the lack of the emotional component of pain in adults and explains their delayed referral for neurosurgical consultation. However, all modalities of treatment seemed to be effective in children, chemonucleolysis and surgery being extraordinarily effective in this age group. Accordingly, we see no reason for long-term conservative therapy in children with lumbar and sciatic pain; on the contrary, we believe these patients should be offered earlier neurosurgical treatment.

Adolescent↗

PubMed1998

Sacroiliac joint dysfunction in patients with imaging-proven lumbar disc herniation.

A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy.

Adult↗

PubMed1998

Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months' follow-up.

We evaluated three different conservative treatment methods for acute low-back pain patients in groups following a manual therapy programme, an intensive training programme, or a general practitioner programme, the latter serving as the control group. Patients aged 19-64 years on sick leave for low-back pain with or without sciatica were included in a prospective randomised study evaluating outcomes such as impairment, pain, functional disability, socio-economic disability and satisfaction with the treatment or explanations. Evaluation by unbiased observers was performed at 1, 3 and 12 months. The three treatment groups were comparable at baseline. With regard to satisfaction, the patients in the manual therapy programme and those in the intensive training programme were more satisfied with the treatment than those in the general practitioner programme at all follow-ups. With regard to the explanations of current low-back pain episodes, the patients in the manual therapy programme were more satisfied than those in the general practitioner programme at all follow-ups. The manual therapy programme group were also more satisfied with the explanations than those in the intensive training programme at the 1-month follow-up. However, no differences were revealed between the groups with respect to outcomes on measures of impairment, pain, functional disability or socioeconomic disability. All three study groups showed rapid improvement. After 1 month a significant improvement was noted in all outcome values compared with the values on entry to the study. Within the limitations discussed in our study, it is concluded that (1) patients sick listed with acute low-back pain, with or without sciatica, will be significantly improved after 1 month regardless of conservative treatment programme; (2) they will be more satisfied with the treatment if they are referred to a manual treatment programme or a training treatment programme; (3) they will be more satisfied with the explanations of the acute low-back problem if they are referred to one of the above groups, especially the manual treatment group; (4) they will not show any other differences with respect to subjective and objective variables, either at short-term or at long-term follow-ups.

Acute Disease↗

PubMed1996

Pediatric lumbar disc surgery: 20 patients under 15 years of age.

BACKGROUND: Patients in their first or second decades of life who present with back pain without sciatica or painless scoliosis have been found to have a central lumbar disc protrusion. This study was elected to determine the difference between pediatric and adult disc symptomatology, surgical findings, and the results of surgery. METHODS: Review of office and Children's Hospital records from 1958 through 1995 yielded a total of 60 patients under the age of 20 years who had lumbar discectomy by the author. Twenty were under the age of 15. This group is reported herein. All but 3 have been followed for up to 20 years. RESULTS The youngest was a boy 10 years and 8 months at operation. Only 20% complained initially of sciatic pain; 60% had it by the time of surgery; 20% never had it. The offending disc was at L5-S1 in 75%. The disc protrusion was central in 75%; no disc had ruptured. The posterior spinal ligament had ossified in the protruded position in 40%. Computed tomography (CT) scans were particularly useful. Significant antecedent trauma was present in 45%. Sixty percent were males. There was a family history of disc disease in 60%. The whereabouts of 3 of the 20 patients is unknown; their operations were 20-36 years ago. CONCLUSIONS: Lumbar disc disease in the first 2 decades may be missed because of the absence of sciatica. Once diagnosed, conservative therapy for as long as 2 years has failed. Lumbar discectomy in children under 15 years was safe in all cases and known to be successful in 88%.

Adolescent↗

PubMed1990

Transient and chronic neurological complications of fast neutron radiation for adenocarcinoma of the prostate.

The records of 132 patients participating in clinical trials using fast neutron (n = 94), mixed neutron and photon (n = 16), or conventional photon (n = 22) irradiation for primary management of prostatic cancer were retrospectively reviewed to assess treatment-related neurological complications. With a median follow-up of 14 months (range 1 to 101 months), 31/132 patients (26 neutron, 3 mixed beam, 2 photon) have experienced either sciatica beginning during or shortly after treatment, or diminished bladder or bowel continence that developed at a median time of 6.5 months following treatment. Sciatica responded to oral steroids and was usually self-limited, whereas sphincter dysfunction appears to be permanent. Pre-treatment risk factors for complications included a history of hypertension, diabetes, cigarette smoking or peripheral vascular disease, with 81% of affected patients having one or more risk factors compared with 55% of unaffected patients (p = 0.01). Seven patients have moderate (5) or severe (2) residual problems, all in the cohorts receiving neutrons (6/7) or mixed beam therapy (1/7).

Adenocarcinoma↗

PubMed1994

Sciatic entrapment neuropathy associated with an anomalous piriformis muscle.

Piriformis syndrome is an often overlooked cause of sciatica that typically responds to intramuscular local anesthetic and steroid injection. In this report, our patient presented with sciatica that responded poorly to epidural steroid injection and only transiently to piriformis injection. Surgical exploration of the sciatic nerve revealed a fascial constricting band around the nerve as well as a piriformis muscle lying anterior to the nerve. This unusual anatomical relationship between the piriformis and the sciatic nerve has not been previously described in the literature. Subsequent sectioning of the anomalous muscle and the constricting band yielded complete resolution of our patient's symptoms.

Adult↗

PubMed1994

Bipartite piriformis muscle: an unusual cause of sciatic nerve entrapment.

The sciatic nerve usually emerges below the piriformis muscle; however, variations of the relationship between the sciatic nerve and piriformis muscle are occasionally encountered. In a 28-year-old woman with sciatica, entrapment of the sciatic nerve by a bipartite piriformis muscle was found. She was treated by dissection of the lower head of the piriformis muscle and restitution of the normal anatomical relationship between the nerve and piriformis muscle. Sciatica resolved postoperatively.

Adult↗

PubMedDate not supplied

Diagnosis and management of posttraumatic piriformis syndrome: a case study.

OBJECTIVE: The aim of this study is to describe the clinical management of a young male patient with sciatica symptoms that developed after an avulsion of the ischial tuberosity. This is a rare injury, but complications may occur. CLINICAL FEATURE: A 19-year-old patient developed sciatica 6 months after a football injury. The patient described his symptoms as a shooting pain from the buttock to the lateral part of the foot, along the back of his thigh and calf, sometimes accompanied by paresthesia. Physical examination showed restricted hip range of motion and a positive Bonnet's test. X-ray analysis revealed a bony overgrowth of the right ischial tuberosity. INTERVENTION AND OUTCOME: A treatment plan was designed to decrease the pain level, increase sacroiliac and lumbar joint mobility, and augment muscular extensibility. The patient received 20 treatments over a period of approximately 3 months. Complete recovery was observed 5 months later. CONCLUSION: Although many differential diagnoses were contemplated, it is most likely that changes in muscular tension and gait pattern, resulting from the ischial tuberosity avulsion, contributed to overuse of the piriformis muscle leading to a piriformis syndrome.

Adult↗

PubMed2006

Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain.

Although lumbar radicular pain is the most common chronic neuropathic pain syndrome, there have been few randomized studies of drug treatments. We compared the efficacy of morphine (15-90 mg), nortriptyline (25-100 mg), their combination, and a benztropine "active placebo" (0.25-1 mg) in patients with chronic sciatica. Each period consisted of 5 weeks of dose escalation, 2 weeks of maintenance at the highest tolerated doses, and 2 weeks of dose tapering. The primary outcome was the mean daily leg pain score on a 0-10 scale during the maintenance period. Secondary outcomes included a 6-point ordinal global pain relief scale, the Beck Depression Inventory (BDI), the Oswestry Back Pain Disability Index (ODI) and the SF-36. In the 28 out of 61 patients who completed the study, none of the treatments produced significant reductions in average leg pain or other leg or back pain scores. Pain reduction, relative to placebo treatment was, 14% for nortriptyline (95% CI=[-2%, 30%]), 7% for morphine (95% CI=[-8%, 22%]), and 7% for the combination treatment (95% CI=[-4%, 18%]). Mean doses were: nortriptyline alone, 84+/-24.44 (SD) mg/day; morphine alone, 62+/-29 mg/day; and combination, morphine, 49+/-27 mg/day plus nortriptyline, 55 mg+/-33.18 mg/day. Over half of the study completers reported some adverse effect with morphine, nortriptyline or their combination. Within the limitations of the modest sample size and high dropout rate, these results suggest that nortriptyline, morphine and their combination may have limited effectiveness in the treatment of chronic sciatica.

Adult↗

PubMed1976

Variations in size of the bony lumbar canal in patients with prolapse of lumbar intervertebral discs.

Prolapse of the lumbar intervertebral disc is one of the commonly accepted causes of low back pain. Most patients respond well to conservative treatment, but some may not respond at all. Though the reason for this variation is not clearly understood, it is felt that a developmentally narrow spinal canal might have some relation to the persistence of backache and sciatica. The canal was therefore measured at each of the lumbar vertebral level by a method described by Jones and Thomson (1969) in 100 consecutive patients operated upon for prolapsed lumbar intervertebral discs, in 100 normal patients for comparison. This method does not give direct measurements of the bony spinal canal but provides a ratio of the size of the canal to the adjacent vertebral body. We found a trend towards the presence of a narrower than normal lumbar canal in patients with prolapsed lumbar intervertebral discs. It is concluded that in patients with prolapsed lumbar intervertebral discs necessitating operation, the canal tends to be narrower than normal, and such narrowing enhances the effect of any disc protrusion leading to severe symptoms of backache and sciatica.

Adolescent↗

PubMed2004

Treatment of herniated lumbar disc by intradiscal and intraforaminal oxygen-ozone (O2-O3) injection.

MATERIAL: We report our experience between May 1996 and May 2003 with 2200 patients affected by low back pain or sciatica due to herniated disk treated by intradiscal and intraforaminal oxygen-ozone injection. The patients received medical and physical therapy before treatment for at least 2 months; the patients with conus-cauda syndrome and hyperalgesic sciatica were excluded. We never performed discography before the treatment that was performed under CT guidance or fluoroscopy. CT provided monitoring of gas distribution in the disk and epidural space. RESULTS: No side effects were recorded at short and long-term follow-up. Clinical results were evaluated with the modified McNab method showing an 80% success rate and 20% failure rate in 1750 patients followed up to 6 months while the success rate dropped down at 75% and failure increased at 25% in 1400 followed up to 18 months. CT showed reduction in the size of the herniated disk in only 63% of the followed patients (420 patients). The failure has been mostly related to: calcified herniated disk; spinal canal stenosis; recurrent herniated disk with epidural fibrosis; small descending herniated disk at the level of the lateral recess.

Adolescent↗

PubMed1991

[Accidental epidural injection of hypertonic sodium chloride solution].

Twenty ml of 20% hypertonic saline were accidentally injected into the epidural space of a 53-year-old man with lumbar backache and sciatica. This resulted in severe thoracolumbar pain, which disappeared after he received by the same route 20 ml of 1% lidocaine and 40 ml distilled water. Three months later, the sciatica had almost all disappeared; there remained no motor deficit. A literature survey helped to explain the signs described. Further cases of accidental epidural injections of other drugs are discussed.

Humans↗

PubMed2004

[Radicular low back pain: is there a relationship between the treatment regimen and outcome?].

OBJECTIVE: To identify a possible relationship between the non-surgical treatment regimen and outcome. METHODS: In a sample of 170 patients with sciatica due to a herniated disk the intensity of a conservative multimodal inpatient treatment in a neurological department was extracted. The outcome was examined using two prospective cohorts (183 patients). These results were compared with published data from orthopaedic inpatient rehabilitation in Germany. RESULTS: The neurological inpatient treatment regimen was more intense than the orthopaedic inpatient rehabilitation, especially with regard to physiotherapy. In contrast, physical therapy was applied more often in orthopaedic rehabilitation. A better short-term outcome with regard to pain intensity was found after multimodal conservative treatment. CONCLUSIONS: Further studies are needed to compare different treatment regimens in patients with sciatica.

Cohort Studies↗

PubMed2001

Psychological screening in the surgical treatment of lumbar disc herniation.

The specific use of psychological screenings to determine appropriateness for lumbar discectomy surgery and predict outcomes is not well understood. Data from spine surgery as a whole are not likely generalizable to the patient with a significant disc herniation considering surgery. As opposed to most "back pain syndromes," acute and subacute sciatica from disc hemiation has a very high chance of dramatic and lasting improvement with surgery. Recent studies have shown standard psychometric tests used as preoperative screening in this situations fail to predict outcomes in most subgroups. Data from the author's institution suggest severe emotional distress in those patients coming to early surgical intervention does not correlate with adverse outcomes. However, the same psychometric profile in those patients with chronic sciatica pain and disability does predict worse outcomes compared with chronic pain in less emotionally distressed patients. The data suggest that the ability to rapidly relieve pain in the case of disc herniation may limit the morbid effects of psychological distress seen in many back pain syndromes. With prolonged pain and emotional distress, however, adverse and possibly self-perpetuating psychological and social changes may significantly decrease the impact of disc surgery.

Diskectomy↗

PubMed1999

Diagnosis and prognosis in lumbar disc herniation.

In a prospective 2-year followup study of 160 consecutive patients undergoing primary surgery for suspected lumbar disc herniation, the authors studied the diagnostic and prognostic factors by using stepwise logistic regression analysis. When the different factors were entered in the same order as presented clinically, history and pain analysis contained most of the predictive information available. When all factors were entered simultaneously in the computations, the following factors (in order of relative importance) predicted relief of sciatica after 2 years: rupture of the anulus (as opposed to bulging disc or negative exploration), no preoperative comorbidity, and male gender. The following factors predicted return to work at 2 years: no preoperative comorbidity, duration of sciatica less than 7 months, education or vocational training in addition to compulsory school, age younger than 41 years, male gender, and no previous nonspinal surgery. Return to work does not seem to be a valid result parameter in lumbar disc surgery. The most important physical signs were root tension tests and lumbar range of motion, whereas neurologic signs were of secondary importance. Many people have asymptomatic herniations, and today supersensitive diagnostic imaging is widely available. Thus, the importance of clinical evaluation has increased, and most of the relevant information can be obtained by listening to the patient. A simple anamnesis apparently is a good alternative to psychologic tests in surgical triage.

Absenteeism↗

PubMed1991

Cyst of the ligamentum flavum: report of six cases.

Six cases of cyst of the ligamentum flavum with compression of a lumbar nerve root are reported. All patients exhibited recurrent back pain and sciatica. Investigation included computed tomography, myelography, or both. The correct diagnosis was reached before operation in only half the patients. High-resolution computed tomography performed in the four last patients outlined the cystic lesion with its low-density center. Surgical excision was performed in all patients. Microscopic examination showed a dense fibrous cyst arising from the ligamentum flavum. The lumen contained myxoid or necrotic material, but no epithelial lining. Cysts of the ligamentum flavum must be considered in the differential diagnosis of causes of sciatica. A firm radiological diagnosis may, at present, still require myelography combined with high-resolution computed tomography. Differentiation from synovial or ganglion cysts of the spine is discussed.

Aged↗

PubMed1978

Repeat surgery after disc excision.

Sixty patients requiring repeat surgery after lumbar disc excision are reviewed. Thirty-one had had their initial surgery performed by the authors and represent a 5.9% frequency of repeat surgery after initial laminectomy for sciatica. Of the 60 patients, 49 suffered recurrent radicular pain, 20 suffered from back pain, and 8 had other problems (infection, extradural cysts, etc.). In patients with recurrent sciatica, perineural fibrosis and recurrent herniation were the most common problems; those patients with the latter pathologic condition responded most favorably to repeat surgery. Of 520 patients who had undergone disc excision, only 9 required secondary fusion.

Adult↗

PubMedDate not supplied

Anterior spinal fusion or deranged lumbar intervertebral disc.

Ninety-seven patients who underwent anterior interbody fusion for lumbar disc derangement were examined two to 15 years after the operation. Complete relief of back pain was obtained in 60% and of sciatica in 85%; marked improvement of back pain was obtained in 29% and of sciatica in 10%. The fusion rate was 63% and was only slightly correlated with symptomatic improvement. Many complications were encountered, most of which were transient.

Adolescent↗