Acute Radiculopathy Research Articles

Pain intensity, spine structure, and body composition in patients with acute discogenic lumbar radiculopathy

ObjectiveThis study aimed to compare the pain intensity, spine structure, and body composition according to functional disability levels in patients with acute discogenic lumbar radiculopathy (DLR). MethodsA total of 118 women (n = 83) and men (n = 35) patients with acute DLR (mean age: 51.87 ± 13.38 years) were included in the study. The function ability was measured with the Oswestry Disability Index, pain intensity was measured with the Visual Analogue Scale, spine structure was measured with the Spinal Mouse® device, and body composition was measured with the Bioelectrical Impedance Analysis System. ResultsPatients with mild functional disability levels had significantly lower activity (p˂.001) and night pain intensity (p = 0.001) than patients with moderate, severe, and completely functional disability levels, and patients with completely functional disability levels had significantly higher rest pain intensity (p = 0.005) than patients with mild, moderate, and severe functional disability levels. Patients with mild functional disability levels had significantly better spine check scores (p = 0.001), posture (p = 0.005), and mobility (p = 0.003) than patients with moderate, severe, and completely functional disability levels. Patients with mild functional disability levels had significantly lower fat percentage (p = 0.032), and higher basal metabolic rate (p = 0.024) than patients with moderate, severe, and completely functional disability levels. ConclusionPain intensity, spinal structure, and body composition of acute DLR patients differ greatly according to their functional disability levels. Although it is known that the level of functional disability of patients is a result of the severity or prognosis of the disease, performing different treatment methods aimed at decreasing the functional disability level of patients by health professionals may be important in terms of coping with the disease.

A Case Report of Korean Medicine Treatment Focused on Acupotomy Therapy for Acute Cervical Radiculopathy Presenting with Shoulder Pain

A Case Report of Korean Medicine Treatment Focused on Acupotomy Therapy for Acute Cervical Radiculopathy Presenting with Shoulder Pain

Post-traumatic hemorrhage in a large sacral Tarlov cyst causing acute radiculopathy

Symptomatic Tarlov cysts (TCs) are an under-recognized clinical entity that should be considered in the differential for lower back pain. These are more common in women and can also be a cause of pelvic pain. Hemorrhagic TCs have been rarely reported in the literature, with symptoms ranging from lower back pain and radiculopathy to symptoms of cauda equina syndrome. We report on a female patient in her 50s who presented with radicular symptoms as a consequence of TC hemorrhage. Magnetic resonance imaging is the gold standard investigation, and this showed post-traumatic hemorrhage causing irritation of the sciatic nerve. Hemorrhagic TC is an important differential to consider in the setting of acute radicular pain, and the symptoms can be resolved with conservative management.

Treatment of unilateral cervical facet fractures without evidence of dislocation or subluxation: a narrative review and proposed treatment algorithm.

Isolated cervical spine facet fractures are often overlooked. The primary imaging modality for diagnosing these injuries is a computed tomography scan. Treatment of unilateral cervical facet fractures without evidence of dislocation or subluxation remains controversial. The available evidence regarding treatment options for these fractures is of low quality. Risk factors associated with the failure of nonoperative treatment are: comminution of the articular mass or facet joint, acute radiculopathy, high body mass index, listhesis exceeding 2 mm, fragmental diastasis, acute disc injury, and bilateral fractures or fractures that adversely affect 40% of the intact lateral mass height or have an absolute height of 1 cm.

Efficacy of epidural infiltration in the management of pain and disability due to acute and subacute lumbosacral radiculopathy

Background and ObjectiveEpidural infiltrations are used for treatment of low back pain and sciatica. Linked to lumbar radiculopathy (lumbosacral radicular syndrome). This study evaluates the efficacy of epidural infiltration by different routes to reduce pain intensity, disability and return to work. MethodsIs a prospective observational study in one hundred consecutive patients sent to pain unit for severe lumbo-sacral radiculopaty. We analyze the efficacy on pain relief (Visual Analogue Scale) and funcional status at two weeks, one month, and three months after epidural injection of local anesthetics and esteroids with differents approachs (interlaminar, caudal and transforaminal). ResultsNinety nine patients (46.5% men, 53.5 women) were finally enrrolled in the study. Mean age was 57.47 ± 11.1 years. The caudal approach was used in 58.6% patients, 23.2% transforaminal approach, and 18.2% interlaminar approach. A significant pain relief was found in all times studied (EAV 7.48 ± 1.5 basal; 6.2 ± 0,9 at 15 days; 6.3 ± 1.2 at one month; 6.15 ± 1.3 at 3 months, p < 0.05). Transforaminal approach was superior to caudal or interlaminal. Seventy percent in time off work patients returned to work after epidural inyections. ConclusionsEpidural local anesthetics with esteroids injections for lumbo-sacral radiculopathy were effective for low back pain, improved functional status and promoted return to work. Transforaminal approach is superior to others.

CCR2 monocytes as therapeutic targets for acute disc herniation and radiculopathy in mouse models

Back pain and radiculopathy caused by disc herniation are major health issues worldwide. While macrophages are key players in disc herniation induced inflammation, their roles and origins in disease progression remain unclear. We aim to study the roles of monocytes and derivatives in a mouse model of disc herniation. Using a CCR2-CreER; R26R-EGFP (Ai6) transgenic mouse strain, we fate-mapped C-C chemokine receptor type 2 (CCR2) expressing monocytes and derivatives at disc herniation sites, and employed a CCR2RFP/RFP mouse strain and a CCR2-specific antagonist to study the effects of CCR2+ monocytes on local inflammatory responses, pain level, and disc degeneration by immunostaining, flow cytometry, and histology. CCR2+ monocytes (GFP+) increased at the sites of disc hernia over postoperative day 4, 6, and 9 in CCR2-CreER; Ai6 mice. F4/80+ cells increased, and meanwhile, CD11b+ cells trended downward. Co-localization analysis revealed that both GFP+CD11b+ and GFP+F4/80+ constituted the majority of CD11b+ and F4/80+ cells at disc hernia sites. Fluorescence activated cell sorter purified GFP+ cells exhibited higher cytokine expressions than GFP- cells. Inhibition of CCR2 signaling reduced infiltration of monocytes and macrophages, alleviated pain, maintained disc height, and reduced osteoclast activity in adjacent cortical bone for up to 1 month. Our findings suggest that circulating CCR2+ monocytes play important roles in initiating and promoting the local inflammatory responses, pain sensitization, and degenerative changes after disc herniation, and thus may serve as therapeutic targets for disc herniation induced back and leg pain.

Spinal arteriovenous malformation with a calcified nodule: illustrative case.

This article describes a rare case of cervical spinal arteriovenous malformation (AVM) mimicking a neurogenic spinal tumor. A 22-year-old female presenting with a C6-7 AVM with a calcification nodule experienced new-onset acute right upper radiculopathy associated with extradural compression of the spinal cord. Note that spinal AVMs with a calcified nodule are rare. Endovascular embolization is generally used to relieve the symptoms of AVM; however, this procedure cannot relieve cord compression, particularly in cases complicated by calcified nodules. This article discusses treatment options. Decompression surgery is preferable to endovascular embolization because it alleviates symptoms while preventing cord compression and minimizing the risk of recurrence.

Case Report: Langerhans cell histiocytosis involving the cervical spine in an adult patient

Langerhans Cell Histiocytosis (LCH) is a typically benign disorder that affects infants predominately, with adult occurrence being uncommon. We discuss the case of a 22-year-old guy who visited our clinic complaining of three months of acute nape pain and upper limb radiculopathy. Notably, the patient had no history of trauma, fall injuries, or tuberculosis. Radiological tests identified a single osteolytic lesion within the C3 vertebral body. The lesion was removed, an anterior C3 corpectomy and discectomy were performed, and the patient's spine was reconstructed with a titanium cage and plating. The patient's nape discomfort and radiculopathy vanished almost instantly after surgery. A definitive diagnosis of LCH was confirmed through histological examination. This case report illustrates the unusual and uncommon occurrence of LCH at the C3 vertebral body, for which fusion surgery was the only viable therapeutic option. The patient's recovery from radiating pain following the surgical procedure demonstrates the effectiveness of the intervention. LCH in the cervical spine is rather rare, but it is nevertheless important to be aware of the possibility of developing it.

Peripheral nervous system involvement accompanies central nervous system involvement in anti-glial fibrillary acidic protein (GFAP) antibody-related disease.

Glial fibrillary acidic protein (GFAP) is expressed by astrocytes in the central nervous system (CNS), but also by immature and regenerative Schwann cells in the peripheral nervous system (PNS). GFAP antibodies (GFAP-Abs) in cerebrospinal fluid (CSF) have been mainly described in patients with meningoencephalomyelitis. We aimed to study PNS symptoms in patients with CSF GFAP-Abs. We retrospectively included all patients tested positive for GFAP-Abs in the CSF by immunohistochemistry and confirmed by cell-based assay expressing human GFAPα since 2017, from two French reference centers. In a cohort of 103 CSF GFAP-Abs patients, 25 (24%) presented with PNS involvement. Among them, the median age at onset was 48years and 14/25 (56%) were female. Abnormal electroneuromyography was observed in 11/25 patients (44%), including eight isolated radiculopathies, one radiculopathy associated with polyneuropathy, one radiculopathy associated with sensory neuronopathy, and one demyelinating polyradiculoneuropathy. Cranial nerve involvement was observed in 18/25 patients (72%). All patients except one had an associated CNS involvement. The first manifestation of the disease concerned the PNS in three patients. First-line immunotherapy was administered to 18/24 patients (75%). The last follow-up modified Rankin Scale was ≤ 2 in 19/23 patients (83%). Patients with PNS involvement had significantly more bladder dysfunction than patients with isolated CNS involvement (68 vs 40.3%, p = 0.031). PNS involvement in GFAP-Abs autoimmunity is heterogeneous but not rare and is mostly represented by acute or subacute cranial nerve injury and/or lower limb radiculopathy. Rarely, PNS involvement can be the first manifestation revealing the disease.

Alpha-Lipoic Acid, Palmitoylethanolamide, Myrrh, and Oxygen-Ozone Therapy Improve Pharmacological Therapy in Acute Painful Lumbosacral Radiculopathy due to Herniated Disc

BACKGROUND: Neuropathic mechanisms largely contribute to radicular Low Back Pain (LBP) and an increase in oxidative stress is recognized as one of the possible causes of nerve damage, inducing axonal degeneration and myelin degradation of nerve fibers. OBJECTIVES: We investigated whether a combination of nutraceutical supplements and oxygen-ozone (O2-O3) therapy might reduce disability and improve clinical effects of pharmacological therapy in patients with acute radicular LBP. STUDY DESIGN: This is a prospective, open-label, comparative observational study approved by the Institutional Review Board of the Sapienza University of Rome (RS 6285/2021). SETTING: Physical Medicine and Rehabilitation Unit of Sant’Andrea Hospital. METHODS: Within the scope of this study, 62 patients with acute radicular LBP diagnosed with disc herniation were assigned into 4 groups. The first group was assigned pharmacological therapy (n = 16), the second group was assigned pharmacological therapy and nutraceutical supplements (n = 15), the third group was assigned pharmacological therapy and O2-O3 therapy (n = 15), and the fourth group was assigned pharmacological therapy, nutraceutical supplements, and O2-O3therapy (n = 16). All patients who participated in the study were evaluated at the beginning of the study, 2 weeks, and 4 weeks (T2) after the beginning of treatment using the Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), and 12-item Short-Form Health Survey. Opioid analgesic intake was noted from baseline to end of treatment (T2). RESULTS: In each group was observed a statistically significant difference for all measures compared to the baseline. At the T2 evaluation time between groups for the Mann-Whitney U test, a statistically significant difference was found: in the ODI scale between groups B and A (P = 0.004), groups C and A (P &lt; 0.001), and groups D and A (P &lt; 0.001); in the NRS-11 between groups B and A (P = 0.017), groups C and A (P = 0.002), and groups D and A (P &lt; 0.001); in the 12-item Physical Component Summary score between groups B and A (P = 0.003), groups C and A (P = 0.002), and groups D and A (P &lt; 0.001), while no significant differences between groups were observed in the 12-item Mental Component Summary score. The average days of opioid usage were similar in the 4 groups (8.33 in group A, 8.33 in group B, 8.33 in group C, and 8.75 in group D). However, the percentage of patients requiring adjuvant opioid therapy differed remarkably: 60% in group A, 40% in group B, 20% in group C, and 25% in group D. LIMITATIONS: A small number of patients were recruited, and we did not perform long-term follow-up. CONCLUSIONS: This study supports a multimodal approach combining nutraceutical supplements and O2-O3 therapy with pharmacological therapy in the treatment of acute radicular LBP secondary to disc herniation. The combination of neurotrophic and antioxidant therapies represents an etiopathogenetic approach, not purely symptomatic, that reduces symptomatology and avoids progression of the nerve damage. KEY WORDS: Low back pain, lumbar radicular pain, neuropathic pain, herniated disc, alpha lipoic acid, palmitoylethanolamide, myrrh, oxygen-ozone therapy, ozone, nutraceuticals

Are modular pedicle screws associated with a high complication rate following posterior spinal fixation?

Modular pedicle screws have a separate head that can be intraoperatively assembled to the inserted shank. The aim of this study was to report associated intra- and post-operative complications and reoperation rates of posterior spinal fixations with modular pedicle screws at a single center. A retrospective, institutional chart review was performed on 285 patients who underwent posterior thoracolumbar spinal fusion with modular pedicle screw fixation between January 1, 2017, and December 31, 2019. The primary outcome was failure of the modular screw component. Other measures recorded were length of follow-up, other complications, and need for additional procedures. There were 1,872 modular pedicle screws (average 6.6 per case). There were no (0.0%) screw head dissociations at the rod screw junction. There was 20.8% overall complication rate (59/285) with 25 reoperations: 6 due to non-union and rod breakage, 5 for screw loosening, 7 for adjacent segment disease, 1 for acute postoperative radiculopathy, 1 for epidural hematoma, 2 for deep surgical-site infections, and 3 for superficial surgical-site infections. Other complications included superficial wound dehiscence [8], dural tears [6], non-unions not requiring reoperation [2], lumbar radiculopathies [3], and perioperative medical complications [5]. This study demonstrates that modular pedicle screw fixation has reoperation rates similar to those previously reported for standard pedicle screws. There was no failure at the screw-head junction, and no increases in other complications. Modular pedicle screws present an excellent option to allow surgeons to place pedicle screws without the risk of extra complications.

Factors of lumbosacral radiculopathy chronicity

Assessment of chronic factors of acute lumbosacral radiculopathy is an urgent problem due to the disease impact on the quality of life of patients, possible loss of work capacity and disability. The aim of the work is to identify chronicity factors of acute compressive lumbosacral radiculopathy depending on the severity of degenerative-dystrophic changes in the spine and pathomorphological changes in the zone of disc-radicular conflict based on complex clinical-neurological, neuro-orthopedic, neuroimaging, neurophysiological and statistical methods of examination. Materials and methods. 100 patients with acute lumbosacral radiculopathy were examined. The patients were divided into two groups: 45 patients with radiculopathy and both discogenic pathology and stenotic process in the spinal canal and/or lateral openings, and 55 patients with radiculopathy developed secondary to a pathology between the vertebral disc at the level of one vertebromotor segment. All the patients underwent neurological, neuroorthopedic, neurophysiological examinations. The study was conducted in two stages – 3–7 days and one months after the disease onset. Results. On the basis of comprehensive clinical, neuroimaging, neurophysiological examinations and statistical processing of the obtained data, factors affecting the chronicity of acute compressive lumbosacral radiculopathy were identified: age (rs = 0.25, P = 0.012), sex (rs = 0.25, P = 0.012), pain syndrome severity according to the VAS (rs = 0.25, P = 0.011), the presence of a neuropathic component of pain according to the PainDETECT questionnaire (rs = 0.74, P &lt; 0.001), biomechanical disorders of the spine during the Schober test (rs = -0.41, P &lt; 0.001), lateroflexion (rs = -0.30, P = 0.003), extension (rs = 0.28, p = 0.004), damage to Aβ fibers (rs = -0.36, P = 0.009), Aδ-fibers (rs = -0.38, P = 0.006), C-fibers (rs = -0.37, P = 0.008), allodynia (rs = 0.38, P &lt; 0.001), hyperalgesia (rs = -0.24, p = 0.014), muscular-tonic syndrome index (rs = 0.26, p = 0.008), the presence of lumbar canal stenosis (rs = 0.42, P &lt; 0.001), spondyloarthrosis (rs = 0.22, P = 0.028), spondylolisthesis (rs = 0.20, P = 0.047). Conclusions. The conducted study has revealed the main factors contributing to the development of acute lumbosacral radiculopathy chronicity. The presence of a neuropathic component of pain in the mechanism of pain syndrome development in the acute period of the disease and the involvement of C-fibers in the pathological process in the late stages of the disease are among the important markers contributing to the disease prolongation. Assessment of the factors that determine the chronicity of the course in the acute period of the disease allows to prescribe complex differential therapy at the early stage of the disease.

Iatrogenic contralateral foraminal stenosis following lumbar spine fusion surgery: illustrative cases.

Lumbar spine fusion is the mainstay treatment for degenerative spine disease. Multiple potential complications of spinal fusion have been found. Acute contralateral radiculopathy postoperatively has been reported in previous literature, with unclear underlying pathology. Few articles reported the incidence of contralateral iatrogenic foraminal stenosis after lumbar fusion surgery. The aim of current article is to explore the possible causes and prevention of this complication. The authors present 4 cases in which patients developed acute postoperative contralateral radiculopathy requiring revision surgery. In addition, we present a fourth case in which preventive measures have been applied. The aim of this article was to explore the possible causes and prevention to this complication. Iatrogenic foraminal stenosis of the lumbar spine is a common complication; preoperative evaluation and middle intervertebral cage positioning are needed to prevent this complication.

Postoperative bone graft migration into the thecal sac and shifting down to the lower level after an endoscopic lumbar interbody fusion: a case report

BackgroundPostoperative bone graft migration (PBGM) is a fairly rare spinal postoperative complication. Its occurrence after endoscopic surgery has rarely been reported in the literature so far. This is a case report of a 52-year-old male occurring PBGM into the thecal sac in the 8th days after an endoscopic lumbar interbody fusion (ELIF), which can make surgeons more minded with such serious rare complication after BGM.Case PresentationA 52-year-old male patient, underwent a L4-5 ELIF, presented with an acute radiculopathy on right leg and urinary incontinence in the 8th postoperative day. An emergency lumbar Computed Tomography(CT scan) and Magnetic Resonance Imaging (MRI) demonstrated bone graft migration into the thecal sac at the L4-5 level, and shifting down to the lower level. The revision surgery was performed at once successfully. Finally, the patient got well managed before discharge.ConclusionSupported by this case report, we believe that PBGM into the thecal sac is a rare but horrible complication of ELIF. However, too much volume of bone graft and its posterior placement are more prone to developing this complication. Finally, we are not sure that the outcome presented in this study will be repeated in future cases.

Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case

Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment. The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion. This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Cytokines and neoangiogenesis parameters in young patients with acute discogenic lumbosacral radiculopathy

Introduction. Discogenic lumbosacral pain in young people has a complex and multicomponent pathogenesis. Evidence of the content of cytokines and neoangiogenesis factors in patients with acute discogenic lumbosacral radiculopathy are deficiency and often contradictory. Objective: to evaluate the cytokine and neoangiogenesis parameters in the blood of young patients with acute discogenic lumbosacral radiculopathy.Materials and methods. The study involved 49 patients (27 (55.1%) men and 22 (44.9%) women) with a mean age of 36 [27; 45] years with acute lumbosacral pain caused by degenerative changes in the spine and signs of compression of the spinal nerves, according to MRI. The control group consisted of 17 healthy individuals (10 (58.8%) men and 7 (41.2%) women) with a mean age of 33 [25; 41] years. The level of C-reactive protein was measured by an automatic biochemical analyzer Konelab 30Iprime (ThermoFisher, Finland). The levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), vascular endothelial growth factor A (VEGF-A) in blood were determined by enzyme-linked immunosorbent assay (ELISA) on a plate ELISA analyzer Real-best (Russia) using reagent kits Cloud-Clone Corp. (USA, China).Results. Patients with acute discogenic lumbosacral radiculopathy, compared with the control group, has an increase in the levels of C-reactive protein (11.2 [7.1; 15.3] vs. 4.2 [3.5; 4.9] mg/ml; р = 0.011), TNF-α (23.1 [16.8; 29.5] vs. 9.7 [6.9; 12,5] pg/ml; р = 0.001), IL-1β (4.7 [3.1; 6.3] vs. 3.2 [2.3; 4.1] pg/ml; р = 0.041), IL-6 (11.2 [6.1; 16.3] vs. 4.5 [3.1; 5.9] pg/ml; р = 0.007), IL-8 (30. [21.9; 48.8] vs. 20.5 [8.5; 32.6] pg/ml; р = 0.023) and VEGF-A (318 [260; 570] vs.168 [100; 240] pg/ml; р = 0.002).Conclusion. The obtained results confirm the importance of pro-inflammatory factors and indicators of neoangiogenesis in the development of acute discogenic lumbosacral radiculopathy in young patients.

248 Ultrasound-Guided Transgluteal Sciatic Nerve Block in Emergency Department Patients With Sciatic Radiculopathy: A Multicenter Prospective Study

Acute-on-chronic pain secondary to sciatica is a common emergency department (ED) presentation and often leads to loss of work, decreased function, and emotional distress. The transgluteal sciatic nerve block (TGSNB) is used by anesthesiologists for chronic, acute, and perioperative sciatic nerve pain. The objective of this study is to assess the efficacy and safety of ED performed TGSNB for acute sciatic radiculopathy.

Anterior Transpsoas Approach for Removal of Cement Leakage after Sacroplasty.

Sacroplasty is a minimally invasive treatment option for severe pain due to sacral insufficiency fracture. Cement leakage is a known risk of sacroplasty. Despite the elevated risk to the L5 nerve root and lumbosacral trunk from cement leakage anterior to the sacral ala, there are no reports regarding surgical management of this complication. We describe an anterior retroperitoneal transpsoas approach to the sacral ala to remove cement leakage causing acute L5 radiculopathy in a 57-year-old gentleman who had undergone sacroplasty for sacral insufficiency fracture (Denis zone 1). The approach provides rapid and excellent visualization of the sacral ala without manipulation of the iliac vessels. We recommend that surgery be considered in a timely fashion, to utilize neuromonitoring, and that surgeons be aware of the considerable variability of the neurologic structures that will be encountered, which is described in this technical note.

Lumbar Compression Fracture Following Assault

A patient was referred to physical therapy after traumatic assault and resultant fall to the ground with symptoms of acute onset lumbar radiculopathy. Based on presentation and skillful use of imaging guidelines, the therapist referred them back to the physician for imaging of the hip and lumbar spine. This facilitated an appropriate course of management of fracture, resulting in recovery of prior level of function. JOSPT Cases 2022;2(3):159–161. doi:10.2519/josptcases.2022.10983

Rhizotomy and endoscopic discectomy for chronic low back pain and acute radiculopathy in a stiff-person syndrome - case report

INTRODUCTION: Stiff Person Syndrome (SPS) is a rare neurological disorder, first described in 1956 by Moersch and Woltman. The clinical picture has an insidious onset of classic findings of episodic painful spasms, hyperreflexia, axial muscle stiffness, progressing slowly to the proximal limb muscles. Painful hyperlordosis due to lumbar spine stiffness is a diagnostic characteristic of SPS. CASE REPORT: Male, 69 years old, with SPS for 40 years, referred by the neurologist to the spine surgeon because of failure to conservative management of chronic low back pain, progressively acute leg and gait impairment. Physical examination is difficult to perform in SPS because it triggers spasms. MRI presented zygoapophyseal joint, intervertebral discs and muscle degeneration, including a L4L5 cranial migrated herniated disc. Once there were no other effective ways to manage his axial and radicular pain, it was decided to perform percutaneous transforaminal endoscopic discectomy for L4L5 decompression, L3 to S1 dorsal ganglion root medial branch ablative radiofrequency rhizotomy to relieve facet pain and L2 dorsal sensory ganglion pulsed radiofrequency rhizotomy for modulation of chronic low back pain. One year postoperative follow up, the patient has showed improvement in the VAS and SF-36. CONCLUSION: Chronic pain reported by a patient must be addressed in the biological, psychological and social dimensions. Understanding the multidimensionality of the factors involved with pain allows planning less aggressive and highly efficient strategies in uncommon and off label patients, as in the case of SPS.