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PubMed1997

[Acute lumbar disk displacement with nerve root compression. Indications for peridural steroid injection].

The rationale and indication, but also the efficacy and limitation of lumbar epidural corticosteroid injection in patients suffering from acute lumbosacral radicular pain are explained. Epidural administration of corticosteroids with longterm effect and bupivacaine by a translumbar approach in patients suffering from acute low back pain and sciatica causes an immediate, persistent pain relief and a more prompt regression of nerve root compression compared to patients just treated by bed rest and analgesics. The state of the art is based on recent meta-analyses and the understanding of the pathophysiology of discal hernia which includes inflammation. Contemporary concepts and data from recent reviews are summarized to elucidate current recommendations and suggestions for the management of patients with acute sciatica. The postulate of an application performed by an experienced anaesthesiologist is stressed. Advantages of this invasive form of therapy include reduction of addictive analgesic drugs, decreased time of absolute immobilisation, respectively strict bed rest, and of hospitalisation.

Acute Disease↗

PubMedDate not supplied

Herniated intervertebral disc without pain.

The diagnosis of herniated intervertebral disc is often made in cases of radicular pain in the low back, the neck, or sciatica or brachialgia. Practitioners often call upon radiologic imaging to confirm this diagnosis. But on radiologic examination, such a herniation may consist of a bulge, protrusion, prolapse, extension, extrusion or sequestration of this disc. We define and illustrate these terms from the literature. We then review the radiologic studies of normal controls, who have never had sciatica, brachialgia or pain in the low back or neck. In over one-quarter of these controls, studies using the plain x-ray, CT scan, myelogram, and MRI show various radiologic signs of a herniated intervertebral disc. We therefore recommend that practitioners should not exclusively rely on radiologic imaging to confirm the clinical diagnosis of a herniated intervertebral disc.

Aging↗

PubMed1997

[Spinal diseases in the nursing profession--a cross-sectional study].

A cross-sectional study on the profession-specific prevalence rates of back pain symptoms was conducted including N = 3332 nurses as the exposed group and N = 1720 office clerks as a control group. Only participants who had never changed from an exposed to an unexposed profession or vice versa, were included for the results presented here. Severity of symptoms was assessed, dividing into low back pain on the one hand, and lumbago-sciatica/sciatica on the other; frequency of pain episodes was measured using lifetime- and point-prevalence, in all these four combinations of severity and frequency the prevalence rates among nurses were clearly and significantly higher. Multivariate analyses revealed that profession is the most important risk factor among many others that were tested. Estimation of the prevalence rate for the heaviest symptom, the point-prevalence of lumbago-sciatica/sciatica, showed that about 4 out of 5 cases among nursing staff can be attributed to their profession. On the background of this high attributable risk the acceptance rate for LBP diseases of suspected occupational origin among nursing staff by statutory occupational health insurance bodies appears much too low.

Adult↗

PubMed2005

Role of magnetic resonance imaging in lumbar spondylosis.

OBJECTIVE: To assess the frequency of various MRI findings in patients with lumbar spondylosis and determine their association with symptoms of patients. DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Radiology Department,The Aga Khan University Hospital, Karachi, from January to December, 2002. PATIENTS AND METHODS: The study included 120 patients who presented with low back and leg pain. Segmental classification system was used to classify the pain distribution. All patients underwent lumbar MRI using 1.5 T-scanner. MRI scans was evaluated for magnitude and location of nerve compression, disc extrusion and the nature of nerve and thecal sac deformation in the central canal, lateral recess and intervertebral foramen at each spinal level. Statistical analysis was performed using computer program SPSS (Version; 10). Chi-square test was also used to determine significance of association between degree of compression, duration of symptoms, site of pain and presence of weakness and numbness. Independent samples test (Levenes test) and Chi-square test were used to determine the significance of associations between age, gender, chronicity of symptoms and MRI findings. A p-value of <0.05 was considered to indicate statistically significant association. RESULTS: The study included 120 patients, the age range was 22 to 88 years (mean 47 years). Twenty-three patients had acute pain of less than 2 months, 40 patients had recurrence of previous symptoms within past 2 months and 57 patients had chronic pain. Disc herniation was most frequent finding seen in 107 patients (89%). Eighty-eight patients (73%) had MRI evidence showing some degree of nerve or thecal sac compression. Severe nerve compression was present in 48 patients (40%). Disc extrusion was present in 22 patients (18%). There was no significant association between segmental distribution of symptoms and presence of anatomic impairment. However, severe nerve compression and disc extrusion were significantly associated with pain distal to the knees. CONCLUSION: The presence of disc extrusion or ipsilateral severe nerve compression at one or multiple side is strongly associated with distal leg pain. There should be a correlation between patient symptoms and signs of sciatica and imaging demonstration of nerve root compression before invasive therapy is undertaken.

Adult↗

PubMed1984

Muscular hypertrophy after chronic radiculopathy.

In four patients, calf muscular hypertrophy developed after the onset of sciatica. Hypertrophic muscles were weak and showed electromyographic signs of denervation. In all cases, calf muscle biopsy showed striking hypertrophy of type 1 and, especially, type 2 muscle fibers. This hypertrophy was associated with other signs indicating a neurogenic lesion. Muscle hypertrophy is a rare finding in neurogenic lesions. Stretch and exercise of muscle are probably the causative factors.

Adult↗

PubMed2006

Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort.

CONTEXT: For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care. OBJECTIVE: To compare the treatment effects of diskectomy and usual care. DESIGN, SETTING, AND PATIENTS: Prospective observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003. INTERVENTIONS: Standard open diskectomy vs usual nonoperative care. MAIN OUTCOME MEASURES: Changes from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version). RESULTS: Of the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7). CONCLUSIONS: Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000410.

Adult↗

PubMed1996

Application of outcomes research in occupational low back pain: the Maine Lumbar Spine Study.

Outcomes research represents an expansion of traditional clinical research to include issues of cost and quality of care in usual clinical practice, emphasizing outcomes that matter most to patients. In low back disorders, outcomes research has focused on the lack of reliable information to support much of clinical practice and has demonstrated marked variability in the treatment of these common problems. The Maine Lumbar Spine Study represents an example of an outcomes research study to investigate the treatment of patients with sciatica in usual clinical practice. Because low back symptoms are a frequent cause of occupational disability, Workers' Compensation patients were explicitly oversampled. Baseline features were significantly different in those patients who were receiving Workers' Compensation versus those who were not. Efforts to compare outcomes by disability status need to control for these differences. Whereas most Workers' Compensation patients were still receiving disability compensation regardless of treatment at 6 months, patients who were treated surgically were more likely to have come off disability and returned to work than nonsurgically treated patients. Long-term follow-up is necessary to determine whether these differences persist.

Adult↗

PubMed2000

Multiple peripheral nerve compressions related to malignantly transformed hereditary multiple exostoses.

Autosomal dominantly transmitted hereditary multiple exostoses is an uncommon disorder consisting of multiple projections of bone capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on flat bones. Sarcomatous transformation occurs in 1-25% of patients. We report a 33-year-old man with sciatica, previously diagnosed as hereditary multiple exostoses, presenting with multiple peripheral nerve compressions. Electrodiagnostic studies showed profound axon-loss multiple neuropathies involving the sciatic, superior gluteal, and inferior gluteal nerves. Magnetic resonance imaging of the left pelvis showed a large mass in the sacral area that was suggestive of a chondrosarcoma. An open intralesional excision biopsy confirmed chondrosarcoma transformed from chondromatosis. Excision of the lesion was effective in eliminating the impingement of nerves and retarding progressive osseous growth. We suggest that malignant transformation be suspected in cases with focal compression neuropathy of patients known to have multiple exostoses. Osteochondroma as a possible cause for compression neuropathy is discussed.

Adult↗

PubMed2000

Sensitivity and specificity of dural sac and herniated disc dimensions in patients with low back-related leg pain.

Narrow spinal canals or herniated discs can be associated with leg pain. However, it is not known whether quantitative measurements of the spinal canal or herniated disc are sensitive and specific for low back-related leg pain. The size and cross-sectional area of the dural sac and any herniated discs were measured from magnetic resonance imaging examinations of 22 asymptomatic individuals and 44 patients with sciatica. The sensitivity and specificity of these measurements were determined. In this small population of patients, a dural sac anteroposterior (AP) diameter of 10.2 mm at the L3-4, L4-5, or L5-S1 vertebral levels was 74% sensitive and 74% specific for leg pain. Based on measurements in symptomatic patients, a herniated disc with an AP diameter of approximately 3 mm was over 95% sensitive and 95% specific. However, if the AP diameters of herniated discs in symptomatic patients were compared with similar measurements in asymptomatic controls, the most sensitive and specific threshold value was 6.8 mm. These findings must be confirmed in a larger population before they are applied clinically. J. Magn. Reson. Imaging 2000;12:439-443.

Adolescent↗

PubMed1987

Functional disability due to back pain. A population-based study indicating the importance of socioeconomic factors.

Using national survey data, we examined correlates of disability due to low back pain in 1,516 persons who had back pain. Greater education level correlated significantly (P less than 0.001) with fewer disability days (i.e., days of activity limitation, absence from work, confinement to bed, or reduced housework), even after controlling for severity, sciatica, occupation, and age. Findings in men differed from those in women; education level was a strong correlate for men only. For work absenteeism, low income was a stronger correlate than education. These data support the importance of social factors in the prognosis of some musculoskeletal diseases.

Absenteeism↗

PubMed1988

Degenerative spondylolisthesis, synovial cyst of the zygapophyseal joints, and sciatic syndrome: report of two cases and review of the literature.

Two cases of sciatica secondary to nerve root compression by a "synovial cyst" of a zygapophyseal joint are described. In light of these 2 cases and on reviewing the literature, it appears that zygapophyseal joint osteoarthritis with degenerative (or articular) spondylolisthesis can be a predisposing factor to the formation of such synovial expansions and, consequently, the cause of nerve root compression. The coexistence of a lumbar degenerative spondylolisthesis with a radicular syndrome should therefore encourage early investigation by computed tomography scan, so that conservative treatment would not be unnecessarily prolonged.

Adult↗

PubMed1999

The relative contributions of interpersonal and specific clinical skills to the perception of global clinical competence.

BACKGROUND: The objective structured clinical examination (OSCE), an established instrument for evaluating resident competence, was used to test the hypothesis that faculty assessment of clinical competence in residents at various levels of training may be influenced more by general skills as a physician and less by competency in the actual skills being specifically tested. In this study, advantage was taken of the anticipated observation that general surgery residents did not demonstrate improvement in their ability to perform a focused neurological assessment over time. METHODS: An OSCE, which was administered to 56 general surgery residents at all levels of training, included the assessment of a specific clinical neurosurgical problem (sciatica). Univariate and multivariate analyses were used to evaluate the relationship between the global faculty judgment of competent or noncompetent and the other performance measures that were applied. RESULTS: At different levels of training, there was no observed difference in the specific skills being tested; nevertheless, junior and senior residents were more likely than incoming interns to be judged "competent" and received better evaluations of how well they introduced themselves to the patient. The competence judgment correlated significantly with all of the other performance measures, including the skills being tested. CONCLUSIONS: The perception of competence is not solely dependent upon the particular skills under scrutiny. General competence does not guarantee competence in each specific skill set of a medical specialty.

Clinical Competence↗

PubMed2005

CT-guided oxygen-ozone treatment for first degree spondylolisthesis and spondylolysis.

Aim of this study was to assess the therapeutic outcome of CT-guided periganglionic infiltration of oxygen-ozone and injection of the gas mixture into the lysis points in patients with first grade spondylolisthesis and spondylolysis. We selected 18 patients presenting with low back pain and sciatica resistant to physical and medical management with a radiological diagnosis of spondylolisthesis and spondylolysis subsequently confirmed on CT scan. Following CT-guided bilateral periganglionic O2-O3 infiltration and injection into the lysis points, 15 patients (83.3%) obtained a complete remission of pain. None of the patients reported pain recurrence at clinical follow-up visits one, three and six months after treatment. Oxygen-ozone therapy administered in this way is even more effective than CT-guided periganglionic infiltration alone as it has an additional anti-inflammatory and analgesic effect on the nerve structures in the neural arch, namely Luschka's recurrent nerve.

Adult↗

PubMed1990

Acute bleeding into a filum terminale ependymoma.

We present a case of a 63-year-old male patient who was admitted to our hospital due to an acute compression syndrome of the cauda equina. He had complained about a sciatica for at least one year. CT-diagnosis appeared to be negative, whereas a lumbar myelogram revealed a complete block at L2/3. Emergency surgery was performed, and an ependymoma of the filum terminale was removed into which it had bled massively. The case is compared to the literature findings. These relate ependymomas in the described region with acute onset more often to symptoms caused by subarachnoid bleeding. Mechanical and/or histopathological factors are discussed as the cause of acute bleeding. Spinal ependymomas represent a rare event compared to other neurosurgical diseases. Even more seldom are tumors of this kind causing an acute cauda equina compression syndrome.

Acute Disease↗

PubMed1994

Lumbar disc degeneration and segmental instability: a comparison of magnetic resonance images and plain radiographs of patients with low back pain.

We analyzed disc space height, angular displacement, tilting movement, and horizontal displacement in 109 patients with low back pain and/or sciatica, on plain radiographs of the lumbar spine. These parameters were compared with the grade of disc degeneration as evaluated by magnetic resonance imaging with the aim of studying lumbar segmental instability. Disc space height decreased in proportion to the grade of disc degeneration. Angular displacement was significantly less with severe disc degeneration, accompanied by a tendency to stabilization of the motion segment. Tilting movement and horizontal displacement did not correlate with the grade of disc degeneration. Lumbar segmental instability was recognized at all levels even in individuals who appeared to be normal or to have mild disc degeneration. The incidence of lumbar segmental instability at the L3-4 level was significantly higher in patients with normal discs or mild disc degeneration. At the L4-5 and L5-S levels it did not differ between different grades of disc degeneration.

Adolescent↗

PubMed1997

Distribution and incidence of degenerative spine changes in patients with a lumbo-sacral transitional vertebra.

The purpose of this prospective study was to determine the overall incidence and distribution of lumbo-sacral degenerative changes (i.e. disc protrusion or extrusion, facet degeneration, disc degeneration, nerve root canal stenosis and spinal stenosis) in patients with and without a lumbo-sacral transitional vertebra (LSTV). The study population consisted of 350 sequential patients with low back pain and/or sciatica, referred for medical imaging. In all cases CT scans of the lumbo-sacral region were obtained. In 53 subjects (15%) and LSTV was found. There was no difference in overall incidence of degenerative spine changes between the two groups. We did find, however, a different distribution pattern of degenerative changes between patients with and those without an LSTV. Disc protrusion and/or extrusion occurred more often at the level suprajacent to the LSTV than at the same level in patients without LSTV (45.3% vs 30.3%). This was also the case for disc degeneration (52.8% vs 28%), facet degeneration (60.4% vs 42.6%) and nerve root canal stenosis (52.8% vs 27.9%). For spinal canal stenosis there was no statistically significant difference between the two categories. In conclusion, our findings indicate that an LSTV does not in itself constitute a risk factor for degenerative spine changes, but when degeneration occurs, it is more likely to be found at the disc level above the LSTV.

Case-Control Studies↗

PubMed1993

Clinical instability of the lumbar spine after microdiscectomy.

A total of 190 patients treated microsurgically for a virgin single level lumbar disc herniation were examined physically after a mean follow-up period of 3 years (range 21-68 months). Included were 99 (52%) men and 91 (48%) women with a mean age of 42 years. During the observation period, sciatica had completely recovered or markedly diminished in 172 (90%) patients, and 142 (75%) patients had returned to work. However, as many as 29% of the patients occasionally suffered from low back pain. Clinical examination revealed various signs and symptoms of segmental instability of the lumbar spine in 22% of the surgical patients. There was a significant association between postoperative instability and unsatisfactory long-term outcome: of the 42 patients with instability, 62% suffered from low back pain and 45% were on sick leave or retired because of the back, while the corresponding numbers for those patients without instability were 20% and 8%, respectively (p < 0.0001). Moreover, the mean value of the Oswestry index in instability patients was as high as 34% (SD 12), indicating moderate disability, whereas a significantly (p = 0.0001) lower Oswestry Index 16% (SD 13), indicating minimal disability, was detected in patients without instability.

Activities of Daily Living↗

PubMed1993

Microsurgical treatment of lumbar disc herniation: follow-up of 237 patients.

We have reviewed retrospectively the results of 237 consecutive patients who underwent microsurgical discectomy for a virgin lumbar disc herniation. Included were 128 (54%) mean and 109 (46%) women, with the mean age of 42 years. Intra-operatively, protrusion was found in 60 (25%) patients, prolapse in 127 (54%) patients and sequestration in 50 (21%) patients. The median post-operative follow-up time was 2 years. During the observation period, sciatic pain had completely recovered or markedly diminished in 218 (92%) patients, and 187 (79%) patients had returned to work. The mean duration of preoperative sciatica was 3.8 months in those patients who finally returned to work. In contrast, it was as long as 6.3 months in those patients who lost their working capacity as a consequence of low back pain. The patients operated on for a prolapse or a sequestrum recovered better than those who underwent surgery for a protrusion. Of the patients operated on for a protrusion, 68% returned to work, while 76% of those operated on for a sequestrum and 85% of those operated on for a prolapse returned to work during the follow-up. Difference was seen also in the occupational outcome: only 37% of the patients operated on for a protrusion reported to manage their work well, while 47% of those with a prolapse and 58% of those with a sequestrum managed well. Surgical complications were infrequent in this study. Dural tear appeared in 10 (4%) patients and post-operative discitis in 4 (1.7%) patients. Of all patients, 9 (4%) required re-operation for a true recurrent disc.

Activities of Daily Living↗