1/20. Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. role of the posterior longitudinal ligament.Among unusual abnormalities of the lumbar spine reported since the introduction of Computed tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
2/20. The significance of low back pain in older adults.A retrospective study of the practice of an orthopedic surgeon at a university teaching hospital was done to evaluate the significance of low back pain in older adults. All 259 patients in a 3-year period 50 years of age and over whose presenting complaint was low back pain or sciatica or both were identified and classified by final diagnosis. A comparison was similarly identified and classified. Systemic disease, particularly cancer, was much more prevalent in the older group. It was demonstrated that a simple screening routine consisting of measuring the erythrocyte sedimentation rate and serum concentrations of alkaline phosphatase and calcium would identify all cases of unsuspected malignant disease--that is, at least one of the values would be abnormal in every case.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
3/20. The role of HLA B27 in the diagnosis and management of low-back pain and sciatica.Present diagnostic criteria for ankylosing spondylitis (AS) lean heavily on the x-ray examination, but there is much dispute as to its efficacy, especially in mild or early cases. Determinations of the HLA B27 histocompatibility antigen appear to define the population at risk far better than any other means. Of 31 patients who had the HLA B27 antigen, all had negative latex fixation tests and axial polyarthritic complaints (seronegative spondyloarthropathy or rheumatoid variant). Three had Reiter's syndrome and one had ulcerative colitis. Of the remaining 27 patients, nine had definite AS, 11 had probable AS, and seven had possible AS. Eleven of the 27 underwent at least one invasive spinal procedure (myelogram, laminectomy, fusion, facet denervation) before a diagnosis of AS was made.- - - - - - - - - - ranking = 4keywords = sciatica (Clic here for more details about this article) |
4/20. A malignant peripheral nerve-sheath tumour responding to chemotherapy.A malignant peripheral nerve-sheath tumour developed in the right S1 nerve root in a man aged 30 causing back pain and sciatica. CT and MRI revealed a destructive tumour of the sacrum invading the retroperitoneal space. The tumour was not resectable with an adequate margin. Chemotherapy, consisting of high-dose ifosfamide followed by a combination of vincristine, doxorubicin and cyclophosphamide, was given with success. Malignant peripheral nerve-sheath tumours are thought to respond weakly to chemotherapy, but the response in our patient was complete.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
5/20. Spinal tumors in coexisting degenerative spine disease--a differential diagnostic problem.The clinical presentation of spinal tumors is known to vary, in many instances causing a delay in diagnosis and treatment, especially with benign tumors. Neck or back pain and sciatica, with or without neurological deficits, are mostly caused by degenerative spine and disc disease. Spinal tumors are rare, and the possibility of concurrent signs of degenerative changes in the spine is high. We report a series of ten patients who were unsuccessfully treated for degenerative spine disease. They were subsequently referred for operative treatment to our department, where an initial diagnosis of a tumor was made. Two patients had already been operated on for disc herniations, but without long-lasting effects. In eight patients the diagnosis of a tumor was made preoperatively. In two cases the tumor was found intraoperatively. All patients showed radiological signs of coexisting degenerative spine disease, making diagnosis difficult. MRI was the most helpful tool for diagnosing the tumors. A frequent symptom was back pain in the recumbent position. Other typical settings that should raise suspicion are persistent pain after disc surgery and neurological signs inconsistent with the level of noted degenerative disease. Tumor extirpation was successful in treating the main complaints in all but one patient. There was an incidence of 0.5% of patients in which a spinal tumor was responsible for symptoms thought to be of degenerative origin. However, this corresponds to 28.6% of all spine-tumor patients in this series. MRI should be widely used to exclude a tumor above the level of degenerative pathology.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
6/20. Efficacy of etanercept delivered by perispinal administration for chronic back and/or neck disc-related pain: a study of clinical observations in 143 patients.OBJECTIVE: documentation of the clinical results obtained utilizing perispinal etanercept off-label for treatment-refractory back and neck pain in a clinical practice setting. research design AND methods: The medical charts of all patients who were treated with etanercept for back or neck pain at a single private medical clinic in 2003 were reviewed retrospectively. patients were treated if they had disc-related pain which was chronic, treatment-refractory, present every day for at least 8 h, and of moderate or severe intensity. patients with active infection, demyelinating disease, uncontrolled diabetes, lymphoma or immunosuppression were excluded from treatment with etanercept. Etanercept 25 mg was administered by subcutaneous injection directly overlying the spine. Visual Analogue Scales (VAS, 0-10 cm) for intensity of pain, sensory disturbance, and weakness prior to and 20 min, 1 day, 1 week, 2 weeks, and 1 month after treatment were completed. Inclusion criteria for analysis required baseline and treatment VAS data. MAIN OUTCOME MEASURES: Before and after treatment VAS comparisons for intensity of pain, sensory disturbance, and weakness. RESULTS: 143 charts out of 204 met the inclusion VAS criteria. The 143 patients had a mean age of 55.8 /- 14, duration of pain of 9.8 /- 11 years, and an initial Oswestry Disability Index of 42.8 /- 18, with 83% having back pain, 61% sciatica, and 33% neck pain. 30% had previous spinal surgery, and 69% had previously received epidural steroid injections (mean 3.0 /- 3). The patients received a mean of 2.3 /- 0.7 doses of perispinal etanercept separated by a mean interval of 13.6 /- 16.3 days. The mean VAS intensity of pain, sensory disturbance, and weakness were significantly reduced after perispinal etanercept at 20 min, 1 day, 1 week, 2 weeks, and 1 month with a p < 0.0001 at each time interval for the first dose in this patient population. CONCLUSIONS: Perispinal etanercept is a new treatment modality which can lead to significant clinical improvement in selected patients with chronic, treatment-refractory disc-related pain. Generalizability of the present study results is limited by the open-label, uncontrolled methodology employed. Based on this and other accumulating recent studies, etanercept may be useful for both acute and chronic disc-related pain. Further study of this new treatment modality utilizing double-blind placebo controlled methodology is indicated. NOTE: This treatment method is protected by multiple patents awarded to Edward Tobinick MD, including U. S. patents 6 015 557; 6 177 077; 6 419 944; 6 537 549 and Australian patent 758 523.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
7/20. Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina.Midline prolapse of a disc causing compression of the cauda equina is rare but needs urgent diagnosis and surgical treatment. The onset of bladder and rectal paralysis with saddle anaesthesia should be viewed with a high index of suspicion in a patient with backache and sciatica. Eight cases were seen over a period of five years, and they fell into three clinical groups. Group I patients presented with a sudden onset without any previous symptoms related to the back. Group II patients had a history of recurrent episodes of backache and sciatica, the latest episode resulting in involvement of the cauda equina. The group III patient was indistinguishable from one with a tumour as he presented with backache and sciatica slowly progressing to paralysis of the cauda equina. The prolapse was at the disc between L5 and S1 vertebrae in 50 per cent of the patients, most of whom did not have any limitation of straight leg raising. Urgent myelography and equally urgent removal of the disc within two weeks of the onset of the symptoms resulted in almost complete motor and bladder recovery within five months after the operation in most cases. However, recovery of sensation and sexual function was incomplete even four years after the operation.- - - - - - - - - - ranking = 3keywords = sciatica (Clic here for more details about this article) |
8/20. 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.- - - - - - - - - - ranking = 2keywords = sciatica (Clic here for more details about this article) |
9/20. Lumbar intraspinal synovial cysts. Recognition and CT diagnosis.The lumbar intraspinal synovial cyst is an uncommon cause of low-back pain or "sciatica." However it is important to recognize these cysts so that correct surgical management is offered to the patient. Intraspinal synovial cysts can be accurately diagnosed by computed tomography (CT). The authors report ten cases of lumbar intraspinal synovial cysts (LISC) that highlight the clinical and radiologic features.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
10/20. Allergic or pseudoallergic reaction following epidural steroid deposition and skin testing.A 46-year-old female with a history of low back pain and sciatica was referred for evaluation for epidural steroid injection. Following appropriate history, physical examination and laboratory testing, an epidural injection was performed using triamcinolone diacetate (Aristocort Intralesional (R), Lederle Pharmaceuticals) and lidocaine. Despite good pain relief, the patient presented one week later to a hospital emergency room with signs and symptoms consistent with a delayed allergic or pseudoallergic reaction. Subsequent skin testing, performed one month following the epidural injection, with the same drug precipitated the onset of an accelerated but similar reaction 12 hours later. To our knowledge, this is the first known report of allergic or pseudoallergic reactions following epidural steroid deposition and subsequent skin testing in the medical literature.- - - - - - - - - - ranking = 1keywords = sciatica (Clic here for more details about this article) |
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