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PubMed2006

[Extragenital endometriosis leading to piriformis syndrome].

We report on a 44-year-old woman with a history of sciatica fluctuating with her menstrual cycle and going back over 10 years; ultimately it was present continuously and became disabling. Over the years the patient developed ipsilateral foot-drop, a sensory disorder in the lateral aspect of the lower limb and back of the foot, and atrophy of the gluteus muscle. MRI confirmed the suspicion of extragenital endometriosis, which had caused piriformis syndrome by compression with consequent damage to the sciatic and inferior gluteal nerves. After hormonal therapy had been tried without success, the endometrioma was excised to relieve the pressure on the nerves, and the diagnosis was confirmed histopathologically. The motor deficit remained up to the 15 months since surgery, but the patient is now free of pain.

Adult↗
PubMed1996

[Sacral intradural arachnoid cysts as the cause of lumbar syndrome].

In two female individuals (37 and 47 years old) sacral intradural arachnoid cysts caused low back pain and sciatica for several years until the correct diagnosis was established by MR imaging. Both patients had micturition disturbances (pollakisuria). In both cases a sacral laminectomy was carried out and the dorsal border of the cyst wall was resected (marsupialisation) after evacuation of xanthochrome fluid. Neither cysts showed any communication with the subarachnoid space. Postoperatively the patients were free of complaints; pollakisuria disappeared within 2-4 weeks.

Adult↗
PubMed2007

[Minimally invasive injection therapy in lumbar syndromes].

Minimally invasive injection therapy is an effective approach for the treatment of sciatica with less complications. This therapy is a sufficient option in cases without absolute indications for operation.The paper describes in detail the different injection techniques like spinal nerve analgesia, epidural dorsal/perineural injections, vertebral joint infiltrations, and radiculographies.

Analgesics↗
PubMed1996

Optimising the image of the intradural nerve root: the value of MR radiculography.

We evaluated the additional value of MR radiculography for increasing the sensitivity and specificity of MRI with regard to nerve root compression in patients with sciatica. The single slices of a heavily T2-weighted oblique coronal image set were reformatted with a maximum intensity projection protocol. This image resembles a classical contrast radiculogram and shows the intradural nerve root and its sleeve. In 43 patients studied with a standard MRI examination there was a need for further assessment of nerve root compression in 19 (44%). In 13 (68%) of these, MR radiculography made a definite verdict possible.

Dura Mater↗
PubMed1997

The action of prostaglandin E2 and triamcinolone acetonide on the firing activity of lumbar nerve roots.

Sciatica, due to lumbar disc herniation, is understood electrophysiogically to be an ectopic firing originating from a nerve root. The recent concept of chemical radiculitis implies the involvement, not only of mechanical compression, but also of chemical mediators which contribute to the generation of ectopic firing. The present study demonstrates that prostaglandin E2, a chemical mediator of inflammation, provoked the ectopic firing of nerve roots in a canine in vitro model which indicates that it may play a part in the irritation of nerve roots. In contrast, triamcinolone acetonide suppressed the firing induced by prostaglandin suggesting that steroids may be effective in the treatment of root symptoms.

Action Potentials↗
PubMed1998

Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT.

The aim of this study was to investigate the correlation of vertebral dimensions with somatometric parameters in patients without clinical symptoms and radiological signs of central lumbar spinal stenosis. One hundred patients presenting with low back pain or sciatica were studied with CT. In each of the L3, L4 and L5 vertebra three slices were taken with the following measurements: 1. Slice through the intervertebral disc: (a) spinal canal area; (b) interarticular diameter; (c) interligamentous diameter. 2. Slice below the vertebral arcus: (a) dural sac area; (b) vertebral body area. 3. Pediculolaminar level: (a) anteroposterior diameter and interpedicular diameter of the spinal canal; (b) spinal canal area; (c) width of the lateral recesses. The Jones-Thomson index was also estimated. The results of the present study showed that there is a statistically significant correlation of height, weight and age with various vertebral indices. The conventional, widely accepted, anteroposterior diameter of 11.5 mm of the lumbar spinal canal is independent of somatometric parameters, and it is the only constant measurement for the estimation of lumbar spinal stenosis with a single value. The present study suggests that there are variations of the dimensions of the lumbar spinal canal and correlations with height, weight and age of the patient.

Adult↗
PubMed2001

CT-guided injection of botulinic toxin for percutaneous therapy of piriformis muscle syndrome with preliminary MRI results about denervative process.

Piriformis muscle syndrome (PMS) is a cause of sciatica, leg or buttock pain and disability. The pain is usually increased by muscular contraction, palpation or prolonged sitting. The aim of our paper was to evaluate the feasibility of CT-guided percutaneous botulinic toxin (BTX) injection for the purpose of PMS treatment. Thirty patients suffering from PMS, suspected with clinical and electrophysiological criteria, after imaging examinations excluding other causes of sciatic pain, resulted positive at the lidocaine test and were treated by intramuscular injection of BTX type A under CT guidance. The follow-up (12 months) was performed with clinical examination in all cases and with MR 3 months after the procedure in 9 patients to evaluate the denervative process entity of the treated muscle. In 26 cases relief of symptoms was obtained after 5-7 days. In 4 patients an insufficient relief of pain justified a second percutaneous treatment which was clinically successful. No complications or side effects were recorded after BTX injection. The MR examination showed a signal intensity change of the treated muscle in 7 patients due to the denervative process of PM, whereas in the remaining 2 cases only an atrophy of the treated muscle was detected. Larger series are necessary to confirm these MRI preliminary results. The CT-guided BTX injection in the PMS is an emergent and feasible technique that obtains an excellent local therapeutic effect without risk of imprecise inoculation.

Adult↗
PubMed2003

Lumbar disc herniation in early childhood: case report and literature review.

INTRODUCTION: Lumbar disc herniation is a common condition in adults, uncommon in adolescents and exceptional below the age of 10 years. CASE REPORT: We report on a 6-year-old boy who presented with low-back pain and sciatica after having sustained an injury in a rear-end automobile accident. Due to our limited experience with protruded discs in this age group, we decided to be conservative initially. However, the persistence of incapacitating pain prompted surgical treatment. Operative findings consisted of a torn annulus, attached at one end to the cartilaginous plate, which formed a major portion of the extruded L5-S1 disc. DISCUSSION: A search of the literature yielded only four cases of lumbar disc (L4-5) protrusions in patients aged 9 years or younger. The child described here is one of the youngest patients with a lumbar disc rupture to be reported in the literature, and the first with an L5-S1 traumatic herniation.

Child↗
PubMed2002

Thermal quantitative sensory testing in lumbar disc herniation.

The most frequent clinical presentation of sciatica suggests injury of sensor root fibers alone. To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbosacral disc herniations, 36 men and 30 women with L4/5 or L5/S1 disc herniations underwent thermal QST of the L4, L5, and Si dermatomes. For both levels of disc herniation, there was a significant difference for all temperature modalities, i.e., cold, warmth and heat pain, between all dermatomes as well as between the side of the herniated disc and the corresponding asymptomatic side. However, the proportion of herniated discs classified correctly was only 48% in patients with disc herniations at the L4/5 level, while it was 71% at the L5/S1 level. We conclude that thermal QST measurements reflect and document sensory dysfunction in patients with lumbosacral disc herniation. The method offers a new means both to study the time course of a spontaneous recovery of sensory dysfunction and to evaluate the result of different treatment options. However, thermal QST seems to have the same poor predictive value for identifying the anatomic location of a herniated lumbar disc as conventional electrophysiologic methods.

Adult↗
PubMed2002

Patient-oriented assessment of back pain in pregnancy.

Back pain is a common symptom in women during the last period of pregnancy. Only a few studies using validated patient-oriented tools have been undertaken on this topic. We report on a multicenter study on back pain in women during the last period of pregnancy, which involved seven Italian institutions. Seventy-six women in their 8th and 9th months were studied using the Italian validated version of the Roland questionnaire -- a disease-specific patient-oriented tool for low back pain. Sixty-two percent of the women had gone through at least one previous pregnancy, and clinical data concerning both the period before all pregnancies and the period before the current pregnancy were acquired. The study found that 31% of the women had no back pain symptoms (Roland score 0), 40% scored from 1 to 4, 21% scored from 5 to 10, and 8% scored more than 10. With regard to the predictive factor, history of back pain and sciatica before the pregnancy were found to be associated with occurrence of back pain symptoms during pregnancy. Unexpectedly, our results showed that male sex of the fetus seems to be related to occurrence of back pain symptoms during pregnancy. However, back pain was not associated with having gone through previous pregnancies, nor was the Roland score related to the weight before pregnancy or to increment of weight during pregnancy. Evaluation of the patient's perspective made it possible to identify predictive factors for occurrence of back pain, thereby furnishing important information for the clinical approach to pregnancy.

Adult↗
PubMed2002

Dorsal root sensitivity to interleukin-1 beta, interleukin-6 and tumor necrosis factor in rats.

The release of inflammatory cytokines caused by a disrupted disc may play a critical role in pain production at nerve endings, axons, and nerve cell bodies. Herniated disc tissue has been shown to release inflammatory cytokines such as interleukin-1 beta (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor (TNF), and other algesic chemicals. This study was designed to characterize the effects of these proinflammatory cytokines on the somatosensory neural response at the dorsal root level in rats. It is hypothesized that their effects on nerve endings in disc and adjacent tissue contribute to low-back pain, and the effects on dorsal root axons and ganglia contribute to radiculopathy and sciatica. Surgically isolated sacral dorsal roots were investigated by electrophysiologic techniques. IL-1beta, IL-6, or TNF (100 ng, each) were applied onto the dorsal roots. Neural responses and mechanosensitivity of the receptive fields were evaluated over time. The results showed that 3 h after each cytokine application, the neural activity was statistically decreased. The mechanical sensitivity of the receptive fields increased at 90 min following IL-1beta or TNF application, and returned to normal more than 3 h after IL-1beta application. IL-1beta, IL-6, and TNF may be neurotoxic to dorsal root axons. Furthermore IL-1beta and TNF may sensitize the peripheral receptive fields. This study suggests that dorsal roots may be impaired by these proinflammatory cytokines.

Action Potentials↗
PubMed2003

Conjoined lumbosacral nerve roots: current aspects of diagnosis.

Conjoined lumbosacral nerve roots (CLNR) are the most common anomalies involving the lumbar nerve structures which can be one of the origins of failed back syndromes. They can cause sciatica even without the presence of a additional compressive impingement (such as disc herniation, spondylolisthesis or lateral recess stenosis), and often congenital lumbosacral spine anomalies (such as bony defects) are present at the "conjoined sheaths". This congenital anomaly has been reported in 14% of cadaver studies, but myelographic or computed tomographic studies have revealed an incidence of approximately 4% only. Diagnostic methods such as magnetic resonance imaging (MRI) are helpful for determination of the exact anatomical relations in this context. We present five typical cases of conjoined nerve roots observed during a 1 year period, equivalent to 6% of our out-patients without a history of surgical treatment on the lumbar spine. In all cases with suspicious radiological findings MRI or lumbar myelography combined with CT and multiplanar reconstructions is recommended.

Adolescent↗
PubMed2005

Revision of a Charité artificial disc 9.5 years in vivo to a new Charité artificial disc: case report and explant analysis.

This report describes a case of one-level total disc replacement (TDR) of L5-S1 requiring revision at 9.5 years following the index surgery due to polyethylene failure caused by high oxidation. Primary revision strategies for TDR include instrumented posterolateral fusion, or 360 degrees fusion with replacement of the prosthesis with cages or allograft bone. A revision of a TDR with a similar prosthesis has not been described in the literature. An active 42-year-old female underwent TDR with a Charité artificial disc. She remained active and pain free for 9.5 years before presenting with moderate low-back pain and sciatica. Radiographic studies confirmed a fragmented polyethylene core. The failed prosthesis was revised to a new Charité disc with the patient again active and pain free for 6 months following surgery. Chemical and physical analysis of the core indicated high oxidation due to gamma sterilization in air; a process changed to gamma sterilization in nitrogen in 1998 to meet industry standards. No evidence of wear debris was noted. Revision of an artificial disc with an artificial disc can be performed safely and adequately with the Charité disc prosthesis as an alternative to fusion necessitated by a device failure. An anterior revision approach carries significant risk and should only be performed by surgeons experienced in anterior lumbar surgery.

Adult↗
PubMed2005

Lumbar disk herniation with contralateral symptoms.

The aim of the study is to determine if leg pain can be caused by contralateral lumbar disk herniation and if intervention from only the herniation side would suffice in these patients. Five patients who had lumbar disk herniations with predominantly contralateral symptoms were operated from the side of disk herniation without exploring or decompressing the symptomatic side. Patients were evaluated pre- and postoperatively. To our knowledge, this is the first reported series of such patients who were operated only from the herniation side. The possible mechanisms of how contralateral symptoms predominate in these patients are also discussed. In all patients, the shape of disk herniations on imaging studies were quite similar: a broad-based posterior central-paracentral herniated disk with the apex deviated away from the side of the symptoms. The symptoms and signs resolved in the immediate postoperative period. Our data clears that sciatica can be caused by contralateral lumbar disk herniation. When operation is considered, intervention only from the herniation side is sufficient. It is probable that traction rather than direct compression is responsible from the emergence of contralateral symptoms.

Adult↗
PubMed2004

Indomethacin blocks the nucleus pulposus-induced effects on nerve root function. An experimental study in dogs with assessment of nerve conduction and blood flow following experimental disc herniation.

Inflammatory mechanisms have been suggested to be involved in the basic pathophysiologic events leading to nerve root injury after local application of nucleus pulposus. To assess if these nucleus pulposus-induced effects could be blocked by anti-inflammatory treatment, 41 dogs were exposed to either incision of the L6-7 disc to induce experimental disc herniation with (n=12) or without (n=14) indomethacin treatment per os (5 mg/kg per day), and no incision with (n=5) or without (n=10) indomethacin. Intraneural blood flow and nerve conduction velocity were assessed after 7 days to evaluate the degree of nerve injury. Disc incision induced a reduction in nerve root and dorsal ganglion blood flow as well as nerve function, similarly to previous studies. However, simultaneous treatment with indomethacin efficiently blocked the negative effects on both blood flow and nerve conduction but had no effects per se. The present study thus indicates that inflammatory mechanisms may be of relevance in the pathophysiology of nucleus pulposus-induced nerve root injury and thereby also for sciatica.

Animals↗
PubMed2000

Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation.

This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted.

Adolescent↗
PubMed2000

Tethered cord syndrome in adults.

BACKGROUND: The tethered cord syndrome (TCS) consists of an abnormally low conus medullaris tethered by a thickened filum terminale or various forms of spinal dysraphism. The adult variant of the syndrome seems not to be as rare as once thought. METHOD: This study includes 11 patients with a TCS. Clinical, radiological findings and outcome were reviewed in these adult patients with TCS. FINDINGS: The patients ranged in age from 18 to 34 years (mean 24.09 years). There were 7 men and 4 women. The presenting symptoms in order of frequency were as follows: low back pain radiating to legs, urinary complaints, weakness in legs and impotence. All patients had magnetic resonance imaging scans. Physical exercise in 8, birth delivery in 1 and carrying heavy objects in 1 patient were determined as the precipitating factors. No precipitating factor could be defined in one of the patients. All patients were operated on, except for one. None of the patients worsened after surgery. INTERPRETATION: The patients presenting with low back pain and sciatica responded to surgery better than those with sphincter problems.

Adolescent↗