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PubMed1989

Percutaneous removal of herniated lumbar discs. 50 cases with ten-year follow-up periods.

L4-L5 herniated discs documented by myelogram were removed percutaneously from 50 patients, under local anesthesia and X-ray control, and the patients were followed for ten years. Forty-three patients (86%) had relief of sciatica and sensory deficit. However, only one out of eight patients who had had motor neurological deficit had return of normal power and relief of sciatica from this procedure. The best clinical results were in those patients who felt improvement and relief of pain in the leg at the time of the removal of the disc material. The best clinical results were in patients with a major bulge of the disc and decompression of the nerve root. Patients with sequestration of the disc do not uniformly respond well to this procedure. There were no significant complications. Percutaneous excision of herniated L4-L5 lumbar discs, under local anesthesia, is a safe and valid procedure to reduce patient morbidity and hospital stay, and it does not prejudice the outcome of a formal laminectomy if it should fail.

Adult↗

PubMed1986

[Double-blind study of the treatment of disc lumbosciatica by chemonucleolysis].

A randomized, double-blind study was made of 39 patients with discolumbar hernias that were unresponsive to medical treatment. They were treated either by nucleolysis with chymopapain (4 000 U of discase), or by discography followed by injection of distilled water as a placebo. After one month, treatment was found to be successful in 55% of cases undergoing nucleolysis and in 26% of cases receiving the placebo. The results after 3 months were 65% and 42%. respectively. After one month, the intensity of lumbar pain decreased by 44% on average in the group treated by chymopapain, and by 0% in the placebo group. Radicular pain decreased by 53% in the first group and by 26% in the placebo group, and improvement in Lasègue's sign was 51% and 20%, respectively. Analgesic treatment was reduced in patients treated by chymopapain: 65% of patients in the first group report some or much improvement in their sciatica, whereas this figure was 26% in the placebo group (p less than 0.02). Contralateral sciatica was observed in 3 patients of the placebo group. The average give in the disc one month after nucleolysis was 34% in the chymopapain group and 27% in the placebo group, without correlation with the clinical result. On average, patients were monitored for one year after nucleolysis, and during this year 6 patients from the chymopapain group were operated upon, compared with 10 patients from the placebo group. Although these results are at the limit of statistical significance because of the number of patients studied, they confirm the innocuousness and effectiveness of chymopapain in the treatment of discolumbar hernias.

Adult↗

PubMed1988

Computed tomography as the primary radiological examination of lumbar spine.

A series of 235 patients examined by lumbar CT because of sciatica or other low back disorder was studied. The need of additional examinations and correlations to surgical findings were evaluated. Inadequate information was the cause of additional examination, mostly myelography in 20 patients (8.5%). It was concluded that lumbar CT is a suitable first examination of the lumbar spine in sciatica and low back pain. The indications to complementary myelography and its benefit are discussed.

Adolescent↗

PubMed1982

[Lumbosciatica and nerve root anomalies].

The authors report 3 cases of lumbar pain and sciatica where operation revealed the existence of abnormalities in the distribution of L5 and S1 roots. In one case, the L5 root was not recognised within fibrous tissue also surrounding S1 and S2 and histological examination of this "fibrosis" led to the identification of nerve structures. Development of postoperative L5 paralysis showed that the L5 root was contained within the tissue non-individualised, consisting of multiple rootlets. In the other two cases the L5 and S1 roots arose from a common trunk. There was an associated herniated disc in all three cases. A review of the literature revealed the rarity of such abnormalities, as well as the fact that they were not recognised before surgery. They are difficult to recognise, even at the time of operation. The prognosis is less good than in typical lumbar pain and sciatica, essentially because of surgical difficulties of the disc curettage.

Adult↗

PubMed1982

[Cystic dilatations of the subarachnoid space at the lumbo-sacral level. Clinical and therapeutic aspects].

The cystic dilation of the sub-arachnoidal space individualised by Tarlov in 1938, may be integrated in the diagnosis of non discal surgical sciatica. The classification proposed by Lazorthes sumes up the eventualities encountered at the lombo-sacral level. The clinical study of five personal observations and the analysis of literature enable the establishment of a clinical picture evoking the anomaly. It would appear that the affection is characterised by lumbago or lumbo-sciatica, the attacks separated by free intervals. In an acute period the algia lessens in the Trendelenbourg position. A significant sign would be the pain on moving the sacrum. Among the complementary examination the radiographic study of the sacrum with tomographies is indisplusable, the diagnosis is based on the radiography of spinal nerve roots with late time in a vertical position. Medico-surgical treatment is in order, it gives a favorable result when surgical criteria have respected: invalidating evolutive algia with or without a clear sign of deficiency. The surgical result is essentially conditioned by a strict indication.

Adult↗

PubMed1980

Back and leg complaints in relation to muscle strength in young men.

Back and leg complaints were studied by using a questionnaire and medical examination in 183 male conscripts and relating the results to background variables, anthropometry, the isometric strength of large muscle groups, and endurance running. A history of sciatica was reported by 8%, lumbago by 13%, back injury by 13% and low back insufficiency by 63%. Weak trunk extensors were associated with a history of sciatica, weak trunk flexors with back injuries and with current backache at work/exercise. Weak leg extensors showed associations with a history of low back insufficiency and of sick leave due to the back and with current hip pain. Men with a history of lumbago and of hip and knee complaints performed poorly during 12 min of running. Back and leg complaints were more frequent in men with high socio-economic status, who engaged in little physical activity, or who were obese. The questionnaire and strength measurements proved suitable for studying low back syndrome in its early stages.

Adult↗

PubMedDate not supplied

[Sciatic foramina radiculalgia. Apropos of 16 cases].

Over a period of six years, the authors have seen sixteen cases of foraminal sciatica with an L5 topography which possesses the following unusual clinical features: long history of back pain with a grumbling course and without any acute episodes, progressive sciatica without any predisposing factors, paresthesiae particularly on standing with normal amipaque saccoradiculography and unresponsive to medical treatment. The operative finding in all of these patients was a disc compression in the intervertebral foramen (hernia, disc residue or softened disc), which was frequently associated with factors reducing the calibre of the foramen: abnormal position of the root and lowering of the pedicular roof caused by lumbosacral disc degeneration. This multi-factorial compression therefore required, depending on the case, curettage of the disc or a localized annulectomy combined with a facettectomy. The long term results of the operation can be considered to be favourable, in view of the long history of root pain (an average of 4 years) which largely explains the incomplete nature of the post-operative success.

Adult↗

PubMedDate not supplied

[Irradiation of the patient and its costs in the usual diagnostic procedures for disk hernia. Radiculography, spinal phlebography and tomodensitometry].

Three methods are currently employed for the diagnosis of sciatica due to disc lesions: radiculography, spinal phlebography, and computed tomography. Though their indications vary according to the author, it seemed worthwhile to compare radiation delivered by each of them, because of the often young age of the patients. Dosimetric studies using a Rando Phantom enabled calculation of doses to the skin, spinal cord, and gonads. Results indicated that low doses were delivered by the scanner, relatively high doses by spinal phlebography, and intermediate doses by radiculography. These findings suggest that the initial examination preoperatively in cases of simple sciatica due to herniated disc should be a CT scan whenever possible. Phlebography, on the contrary, and particularly in young women, should be used only exceptionally, as a result of the high doses delivered to the ovaries even during technically simple explorations.

Adult↗

PubMed1994

Neurinoma of the cauda equina misdiagnosed as prolapsed lumbar disk. Report of three cases.

The authors report three cases of neurinoma of the cauda equina initially misdiagnosed as prolapsed lumbar disk. Computed Tomography failed to reveal the tumour, while showing evidence of disk-degenerative patology and being thus misleading. Similar cases are reported in literature. After a thorough analysis of the causes of such an apparently gross error, it is concluded that the main source of pitfalls arises from neglecting those typical clinical features differentiating prolapsed disk from oncogenetic sciatica. When oncogenetic sciatica is suspected Computed Tomography is inappropriate and even misleading, while the elective investigation is Magnetic Resonance.

Adult↗

PubMed1993

[Osteosarcoma of the sacrum. Apropos of a case in a 14 year-old girl].

The authors report a case of sacral osteosarcoma, which is a rare and dreaded tumor. Sciatica was the first manifestation. Patients with refractory sciatica and normal plain films and computed tomography studies of the lumbar spine should undergo magnetic resonance imaging to look for a sacral lesion.

Adolescent↗

PubMed1996

Forceful epidural injections for the treatment of lumbosciatic pain with post-operative lumbar spinal fibrosis.

OBJECTIVE: To evaluate the efficacy of forceful epidural corticosteroid injections in lumbosciatic pain ascribed to post-operative lumbar spinal fibrosis. METHOD: Randomized controlled study comparing forceful injections via the sacral hiatus of 125 mg prednisolone acetate + 40 ml saline (treatment group) and injections via the same route of 125 mg prednisolone acetate alone (control group). Results were compared after six and 18 months. The main evaluation criterion was a subjective assessment of overall efficacy done by the patient using a seven-level scale. RESULTS: After six months, the proportion of patients who were relieved of their sciatica was significantly higher in the forceful injection group (n = 29; 45%) than in the control group (n = 31; 19%) (p = 0.03). Success rates for low back pain were 29% and 6% in the forceful injection and control groups, respectively. Among secondary efficacy criteria, nerve root pain evaluated on a visual analog scale and by Schöber's index showed significantly greater improvement in the forceful injection group than in the control group. After 18 months, results were still in favor of the forceful injection group, with success rates of 39% for the sciatica and 31% for the low back pain. The proportion of patients who returned to work was similar in the two groups. CONCLUSION: Although mediocre overall, the results of forceful epidural corticosteroid injections are better than those of simple epidural injections of a corticosteroid alone. Given the paucity of effective treatments for lumbosciatic pain apparently due to postoperative fibrosis, forceful injections should be given a place in the treatment of this condition.

Adult↗

PubMed1996

Evaluation of outcome following lumbar discectomy.

AIM: To assess the outcome of patients who underwent lumbar discectomy for sciatica as determined by return to work, residual functional disability and self reported pain measures. METHODS: Ninety seven patients who had undergone L4-5 or L5-S1 discectomies for sciatica were reviewed 20 months after surgery. Variables assessed were: gender; length of preoperative time off work and compensation claims for treatment. Outcome was determined by current earning capacity, residual pain level and the Oswestry disability questionnaire. RESULTS: The length of preoperative sick leave had a significant effect on all outcome measures of function, pain, ability to return to full time work and current compensation status. Those patients who had more than 6 months sick leave prior to operation were less likely to have a favourable outcome. CONCLUSION: While chronicity of symptoms does not negate the indications for discectomy, the results suggest that the duration of preoperative leave needs to be considered prior to operation.

Analysis of Variance↗

PubMed1996

The piriformis syndrome.

Piriformis syndrome is an often misdiagnosed cause of sciatica, leg, or buttock pain, and disability. The sciatic nerve may be compressed within the buttock by the piriformis muscle, with pain increased by muscular contraction, palpation, or prolonged sitting. A thorough medical history and physical examination are essential to proper diagnosis. Diagnostic testing may be used to differentiate piriformis syndrome from other causes of sciatica, lower extremity weakness, and pain. This article reviews the pathophysiology and management of piriformis syndrome.

Buttocks↗

PubMed1997

[Value of peroperative endoscopy in treating giant lumbosacral meningocele].

Lombosacral meningocele may be responsible for sciatica, low backache, cauda equina syndrome according to their localization and size. When they are symptomatic, the surgical purpose is to close the communication between the meningeal sac and the cyst. For giant meningocele, acute localization of the communication may be difficult. In such cases, peroperative endoscopy may be useful. We present a case of sciatica related to a giant meningocele extended from L2 to S2. MRI, CT scan and myelography were unable to localize the communication. We used peroperative endoscopy for direct visualization of the communication in order to minimize the surgical approach. An intrathecal nerve root was found strangulated in the communication suggesting an original kind of nerve root suffering. The communication was only closed. The patient made an uneventful recovery with complete relief of symptoms. Magnetic resonance imaging 3 months later showed a significant decrease of the meningocele without any further radicular compression.

Adult↗

PubMed1998

[Back pain. Experimental studies are successful].

Recent experimental studies performed at the Dept of Orthopaedics at Gothenburg University have systematically assessed the basic pathophysiological mechanisms behind sciatica due to disc herniation. It has hereby been seen that the epidural presence of nucleus pulposus may induce structural and functional injury of the adjacent nerve roots similar in magnitude to those induced by mechanical deformation. By increasing the knowledge of the substances and mechanisms leading to this nucleus pulposus-induced nerve injury it may be assumed that sciatica to a certain extent may be treated by specific pharmacologic agents in the future, in combination with existing treatment modalities.

Female↗

PubMedDate not supplied

[Surgery of lumbar disk hernia: historical perspective].

Although the clinical picture of discogenic sciatica is well known already in the ancient world, it is not until 1933 that WJ Mixter and JS Barr provide the correct pathogenetic interpretation and suggest surgery as the treatment of choice. The work of the American Authors was however based on the knowledge acquired during the previous centuries starting with Domenico Cotugno, who first suggested the neurogenic nature of sciatica (1764) and later with the neurologists of the french school Valleix, Lasègue, Dejerine, Sicard who elucidated the semeiology and debated in detail the etiopathogenesis of the condition. The german pathologists Schmorl and Andrae (1927-29) are to be credited for their contribution to the pathology of intervertebral disc, recognizing the frequency and degenerative (not neoplastic) nature of nucleus pulposus herniation. Surgery of disc herniation starts with Oppenheim and Krause (1909). Mixter and Barr used laminectomy and a transdural route although a more limited approach to the spinal canal had already been proposed by the italian Bonomo (1902), unknown to many. Love, of the Mayo Clinic (1937-39) introduced the extradural/interlaminar approach while Caspar and Yasargil (1977) applied the concepts of microsurgery to the procedure. The latest advances are represented by percutaneous and endoscopic techniques.

Animals↗

PubMed2000

Surgery for lumbar disc prolapse.

OBJECTIVES: The primary rationale for surgery for disc prolapse is to relieve nerve root irritation or compression due to herniated disc material. Claims of the merits of alternative surgical procedures are made without clear evidence about clinical outcomes. The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Medline, Embase, Biosis, Dissertation Abstracts, Index to UK Thesis, and reference lists of the retrieved articles up to March 1997 and we corresponded with experts. SELECTION CRITERIA: Randomised and quasi-randomised trials of the surgical management of lumbar disc prolapse. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary. MAIN RESULTS: Twenty-seven trials were found. There were methodological weaknesses in many of the trials. Sixteen of the 27 trials were of some form of chemonucleolysis. Ten trials compared different surgical techniques, although only one of these compared surgical discectomy with conservative management. Surgical discectomy produced better clinical outcomes than chemonucleolysis with chymopapain, and chemonucleolysis produced better clinical outcomes than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy. Three trials failed to show a significant reduction in scar formation or improved clinical outcomes by inserting an inter-position membra ne to cover the spinal dura after discectomy. Three trials of percutaneous discectomy provided moderate evidence that it produces poorer clinical outcomes than standard discectomy or chymopapain. We found no published randomised trials of laser discectomy. REVIEWER'S CONCLUSIONS: Chemonucleolysis is more effective than placebo and it is less invasive but less effective than surgical disectomy. Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear.

Diskectomy↗

PubMed2002

Use of a prevention index to identify industries at high risk for work-related musculoskeletal disorders of the neck, back, and upper extremity in Washington state, 1990-1998.

BACKGROUND: The prevention of work-related musculoskeletal disorders such as carpal tunnel syndrome and low back disorders has been a focus of international prevention efforts including regulation. This study examines workers compensation claims in Washington State to provide baseline data from which to assess the need and the effects of prevention activities. METHODS: Washington State Fund workers compensation claims for general and selected specific hand/wrist, elbow, shoulder, and back disorders in 1990-1998 as well as general self-insured compensable (four or more lost workdays) claims data were examined. Payroll hours were used to calculate claims incidence rates per 10,000 full-time equivalent employees (FTEs). We created a prevention index (PI) to rank industries by averaging the ranks of their number of claims and their claims incidence rate. The focus was on non-traumatic soft tissue musculoskeletal disorders (NTST-MSDs). RESULTS: Between 1990-1998, there were 392,925 State Fund accepted claims for NTST-MSDs of the neck, back, and upper extremity resulting in $2.6 billion in direct costs and 20.5 million lost workdays. The average claims incidence rate (CIR) was 355 NTST-MSDs per 10,000 FTEs. The NTST-MSD CIR decreased significantly less than that for all other claims (P = 0.05) but the CIR for upper extremity NTST-MSDs did not significantly decrease over the study period. There were no significant changes in the CIRs for sciatica (4.9 per 10,000 FTEs) and rotator cuff syndrome (15.3 per 10,000 FTEs), whereas the CIR for epicondylitis (10.6 per 10,000 FTEs) increased and for carpal tunnel syndrome (24.5 per 10,000 FTEs) decreased significantly over the study period. Based on the prevention index, the top five industries for combined State Fund and Self-Insured Compensable NTST-MSDs were Trucking and Courier Services (SIC 421), Nursing Homes (SIC 805), Masonry (SIC 174), Air Transportation (SIC 451), and Residential Construction (SIC 152). Using Washington Industrial Classes (WIC), temporary workers in assembly and administrative services were also high on the prevention index. CONCLUSIONS: NTST-MSDs continue to be a large and costly problem in Washington State. While the incidence rates for some NTST-MSDs are decreasing, the overall rate is not decreasing as fast as the rate for all other claims. In some cases, the rate is stable (sciatica, rotator cuff syndrome) or increasing (epicondylitis). Heavy manual handling and repetitive work characterize the industries with the highest risk.

Adult↗